Life Changes, Inc. Policy & Procedure. [REV. 3/2025]

By signing below, I confirm that I have received a copy of the Life Changes, Inc. Policy & Procedure Manual and have been oriented to the Board of Directors-approved policies and procedures.

Life Changes, Inc. is a 501(c)3 not-for-profit charitable organization offering faith-based, recovery infused, family style, living facilities. The organization is a Level Il Sober Living Home as defined by the National Alliance for Recovery Residence. We believe in the unique ability of every client we serve. We are dedicated to empowering each client to achieve their life vision. Many times, our clients are simply drifting through life - allowing life to happen to them rather than creating a life that works for them. Through a strong foundation of recovery, a sense of community, useable life skills, workforce development activities, support, and guidance that nurture growth and development, these men and women can and do become the individuals they were destined to be. We applaud their every achievement!

The target population of Life Changes are adults suffering from an addictive disorder, homeless or at imminent risk of becoming homeless, suffer from a mental health disorder, are seeking relief from an abusive situation, are the victims of human trafficking and/or are reentering society after a period of incarceration. Life Changes, Inc. was founded in 2011 to provide an independent (not affiliated with any treatment center, hospital, institution, or specific religion) faith-based sober living home for women. Life Changes quickly saw the need for services for men and opened additional residential facilities for the male population in 2015.

Recognizing that individuals who have completed an addictions treatment program, recently released from incarceration, are seeking escape from an unhealthy lifestyle, or have aged out of foster care are not always ready for independent living, Life Changes was prompted to develop a comprehensive program for individuals who have little to no support or guidance.Life Changes is a community-based, recovery oriented, transitional living environment, which provides shelter, referrals for comprehensive resources using self-help, group/individual counseling, and targeted therapy. Through onsite services and comprehensive resources, the program provides residents Peer Recovery Support Services and the opportunity to further their education, obtain employment, incorporate new life skills, and develop positive support systems before facing the world on their own. Life Changes, Inc's staff encourages residents to function in as many social areas as possible, and assists residents, when necessary, in areas where they may be experiencing difficulties. The organization was founded on a holistic approach tailored to meet specific needs. Life Changes has now moved toward an integrated evidence-based and evidence-enhanced philosophy to ensure consistent and measurable outcomes. This is accomplished using the same approach but uses evidence-based and evidence-enhanced programming to guide planning for success.

Organizational Assessment Policy The Life Changes Board of Directors will assess, no less often than every two years, the organization's performance and effectiveness, and future actions required to achieve its mission. The Board of Directors will accomplish this through the development and/or annual review of its Strategic Plan. Conflict of Interest and Nepotism Life Changes, Inc's Board of Directors firmly believes that no individual (staff, volunteer, or Board member) should benefit personally or professionally from decisions of the Board. Nor should they benefit from the activities of the organization at the expense of the greater good of Life Changes, Inc. Therefore, all Board members must disclose any conflicts of interest. Board members that incur potential conflicts of interest must excuse themselves from discussion and voting on the matter. The remaining members of the board will determine how to manage the potential conflict. To avoid conflicts of interest and to achieve high ethical standards, no member of the Board may hire or cause to be hired, or supervise, any relative or other close relations. Hiring decisions (employees and consultants) will be based on the organization's need and the individual's knowledge, experience, and ability. Systems of Controls/Integrity of the Program 1.Life Changes, Inc. will adhere to the proposed Strategic Plan, reviewing quarterly at each Board Meeting. All client data will be entered in the Client Resource Management system, and/or any system required by licensure entities, and will be reviewed and studied by the CEO, Administrative Director, and Programs Committee during regularly scheduled meetings. Data collection will be consistent with meeting any compliance and/or grants/contract requirements regarding state and national outcomes measures as well as goals and objectives of the program. 3.The Client Resource Management system contains, but is not limited to demographics, completion status, employment status, location of any substance use disorder and/or mental health treatment. Life Changes, Inc. will seek training and technical assistance on an as needed basis from any governing entities to ensure compliance is met. Mandated Reporting Life Changes, Inc. will provide Treatment Episode Data Set (TEDS) to SAPTA on a monthly basis in a format determined by the Division. Governing Body 1.The Board of Directors will review and approve an annual budget to carry out the objectives of Life Changes, Inc. 2.The Governing Body will appoint a qualified administrator with authority and responsibilities appropriate to the requirements of the program. Political Activity 1.Life Changes, Inc. follows policies established by the State of Nevada relative to the political activities of employees. Therefore, while on duty or within any period during which they are expected to perform services for which they receive compensation, employees of Life Changes, Inc. shall not: a.Take any active part in managing a campaign for political office or otherwise engage in political office or activity; or b.Otherwise use the authority of their position or utilize Life Changes, Inc. supplies or vehicles to secure support for or oppose any candidate, party or issue in a partisan election involving candidates for office or party nomination or affect the results thereof. 2.No employee, volunteer, Board or Committee member shall promise rewards, threaten loss of job, or coerce any employee of Life Changes, Inc. to support or contribute to any political candidate, or party.

Public Information 1.Requests for information from the news media will be directed to the CEO. 2.All staff appearances made as a representative of Life Changes, Inc. before public bodies or statements to the media must be made only with prior approval by the CEO. 3.Each employee of Life Changes, Inc. is encouraged to remember that he or she is a representative of the agency whether on or off the job. Public statements of any kind reflect upon the agency and, as a result, influence what people think of Life Changes, Inc. Crisis Plan 1.In the event of a crisis the CEO shall have the sole responsibility for media statements. 2.In the absence of the CEO, the designee shall assume the administrative responsibilities and/or utilize the Board of Directors for assistance. 3.An evacuation/crisis plan shall be posted at each facility. This posting shall include a mutual meeting place for all clients and staff, as well as emergency contact numbers. General Operating Guidelines In accordance with NAC. 449.154913 the Administrator of Life Changes, Inc. shall ensure that: 1.Alcohol or drugs are not allowed on the premises of any Life Changes, Inc. facility. 2.The policies, procedures and rules established by the governing body are carried out. 3.Each client, staff, board member and volunteer comply with those policies, procedures, and rules. 4.The facility provides an environment that will facilitate the reintegration of the clients of the facility into the community; and 5.The operation of the facility is not compromised by a client, staff, board member or volunteer who violates policies, procedures, or rules of the facility. Annual Report 1.The program will submit an annual report in writing to the Board of Directors to review and evaluate. The annual report will consist of at least the following: a.Organizational activities Programs C.Fiscal health d.Goals e.Long term strategic plan f.The Board of Directors shall use the annual report to modify and improve the program. Code of Ethics and Conduct and Standards of Professional Practice Life Changes, Inc. is a private, non-profit organization whose purpose is "Providing safety, shelter and support to at-risk adults in the community." Life Changes, Inc. is proud to have representatives who maintain an excellent reputation for conducting business activities with integrity, fairness, and in accordance with the code of professional ethics and standards of professional practice, as listed below. The standards listed below are subject to any employee, volunteer, board member or representative of Life Changes, Inc. Violation of any standards or conduct requirements listed in this approved policy will result in immediate termination 1.Employees, board members and volunteers shall act according to the highest standards and values of Life Changes, Inc. 2.Employees, board members and volunteers shall be responsible for advocating adherence to all applicable laws and regulations when representing Life Changes, Inc. 3.Employees, board members and volunteers shall neither seek nor accept fees for services rendered as a representative of Life Changes, Inc. Any fees will be determined and billed through the Life Changes administrative offices and will only be collected or billed by an authorized representative. 4.The primary interest of all employees, board members and volunteers shall be to serve our resident population. Employees, board members and volunteers shall effectively disclose all conflicts of interest; such disclosure does not preclude or imply ethical impropriety. 5.Employees, board members and volunteers shall adhere to the principle that all information created by or on behalf of Life Changes, Inc. is the property of Life Changes, Inc. and shall not be transferred or removed. 6.Employees, board members and volunteers shall not disclose privileged information to unauthorized parties. 7.Employees, board members and volunteers shall keep client information confidential. This includes all information in all forms (written, verbal, electronic, and computerized) during and after service with the organization. 8.Employees, board members and volunteers shall take care to ensure that all publications and informational materials are accurate and correctly reflect Life Change's values and mission. 9.Employees, board members and volunteers shall, to the best of their ability, ensure that contributions are used in accordance with donors' intentions. 10.Employees, board members and volunteers shall ensure, to the best of their ability, proper stewardship of charitable contributions and grants, including timely reports on the use and management of funds, and explicit consent by the donor or grantor before altering the conditions of a gift or grant. 11.Employees, board members and volunteers' actions shall reflect concern for the interests and well-being of individuals affected by those actions. 12.Employees, board members and volunteers shall ensure their actions do not negatively impact the wellbeing of the client. 13. Employees, board members and volunteers shall not exploit any relationship with a donor, prospect, client, volunteer, or fellow co-worker to the benefit of the employee. 14. Employees, board members and volunteers shall not exploit a client through sexual or non-sexual means and shall not engage in sexual activities with clients. 15. Employees, board members and volunteers shall not engage in personal relationships with a client of the Life Changes program at any time. Failure to comply with this policy will result in immediate termination. Specifically, employees, board members or volunteers shall not provide special favors, one-on-one time outside the scope of their duties, gifts, rides, private dinners, or any activity that could be construed as inappropriate conduct and that does not fall specifically within the scope of their assigned duties. 16.Employees, board members and volunteers shall not engage in personal relationships with a client for a minimum of two years after a client has left the program. Specifically, employees, board members or volunteers shall not provide special favors, one-on-one time outside the scope of their duties, gifts, rides, private dinners, or any activity that could be construed as inappropriate conduct and that does not fall specifically within the scope of their assigned duties. All the above notwithstanding, employees, board members and volunteers shall comply with all applicable local, state, provincial and federal civil and criminal laws. Employees, board members and volunteers should avoid the appearance of any criminal offense or professional misconduct. Adopted from the Ethical Standards established by the National Society of Fundraising Executives. Quality Assurance Plan - Performance Outcome Measures Life Changes, Inc. is committed to improving the quality of the services provided by the program which addresses, without limitation, operational services, human resources, fiscal services, and clinical outcome measures; and ensures the integrity of the program will be maintained. Life Changes, Inc. strives to provide the highest quality of care for its clients that will allow them to pursue a meaningful and productive life, substance free. To meet this goal, Life Changes, Inc. has developed a well-defined Quality Assurance Plan that continually monitors and reviews its services and programs to ensure the integrity, goals and mission of the agency are met and Life Changes, Inc. follows all Federal and State regulations. Life Changes, Inc. will establish a Quality Improvement Group comprised of the Executive Committee of the Board of Directors and the CEO to continually review, evaluate, and update this plan. The group also develops and implements systems, policies and procedures for the identification, collection, and analysis of performance measurement data; educates and trains the leadership and staffas to the quality improvement plan and their respective responsibilities in carrying out the plan.

Life Changes, Inc. will make a copy of the plan established available to a funden or licensing entity when requested. When new procedures/changes are developed they will be presented to the Board of Directors for approval. If approved, they will be documented and distributed to all employees. Once changes have been made, their effectiveness on the overall performance of the agency will be monitored to ensure they are meetings the goals of the program. This plan will be ongoing and proactive. As Life Changes, Inc. continues to grow, the pursuit of quality care will remain a basic tenant of its operations.

Cultural Competency and Diversity Policy Pursuant to NRS 449.101 Life Changes, Inc. is committed to fostering diversity, inclusion, and cultural competency. Life Changes, Inc. will seek and develop resources so that all board members, employees, and volunteers are provided the opportunity to develop a greater awareness and sensitivity to the needs of persons served, stakeholders and communities. Cultural competency is an awareness of, respect for, and attention to the diversity of the people with whom Life Changes, Inc. interacts (persons served, families, staff, community providers and other stakeholders) that is reflected in attitudes, organizational structures, policies, employee training and supports. Life Changes, Inc. seeks to ensure sensitivity, demonstrate accommodation and cultural competency in working with individuals from diverse cultural groups. The organization will not discriminate in the admission of, or provision of services to, a patient/resident based wholly or partially on the actual or perceived race, color, religion, national origin ancestry, age, gender, physical or mental disability, sexual orientation, gender identity of expression or human immunodeficiency virus status of the patient/resident or any person with whom the patient/resident associates. Pursuant to NRS 449.0302 Life Changes, Inc. will adhere to any other cultural competency requirements prescribed by regulations and shall post prominently in all facilities and on the organization website the following statement: "Life Changes, Inc. does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status." Any resident who has experienced prohibited discrimination may file a complaint with the Division. Nevada Department of Health and Human Services, Division of Public and Behavioral Health |Bureau of Health Care Quality and Compliance 727 Fairview Dr., Suite E |Carson City, NV 89701 www.dhhs.nv.gov or www.dpbh.nv.gov o Nevada Department of Health and Human Services, Division of Public and Behavioral Health Bureau of Behavioral Health Prevention and Wellness Substance Use Prevention, Treatment and Recovery 4126 Technology Way, Suite 200, Carson City, NV 89706 Gender, Pronouns, and Preferred Name Policy Life Changes, Inc. is committed to fostering an environment of inclusiveness and supporting employees, volunteers, board members and clients preferred forms of self-identification. With this principle in mind, this policy provides definitions for, and uses of, legal sex (gender), gender identify, pronouns and preferred name recorded. Legal Sex (Gender) Employees, volunteers, board members and clients must designate their legal sex during the onboarding process. Life Changes, Inc. is required to collect legal sex (gender) to comply with federal reporting requirements. Possible legal sex (gender) designations are as follows: Female, Male. Gender Identity Employees, volunteers, board members and clients may designate their gender identity and it may be different from their legal sex (gender Providing gender identity information is optional and entirely voluntary. The possible gender identity designations are as follows: Female, Male, Non-Binary, Prefer Not to Disclose, N/A. Gender Pronouns Employees, volunteers, board members and clients may designate pronouns they wish to use. The preferred pronoun will be displayed in the Life Changes Client Resource Management roster or the internal staff, volunteer, board member roster. Providing pronoun information is optional and entirely voluntary. Employees, volunteers, board members and clients may add, edit, or remove their pronouns at any time. The possible gender pronoun designations are as follows: He/Him/His, She/Her/Hers, They/Them/Theirs, No Preference, Prefer Not to Disclose, N/A. Preferred Name Except when the use of an individual's legal name is required by law or policy, employees, volunteers, board members and clients will be identified by the preferred name they have designated, unless this name is associated with illegal activity (gang name, street name, prison yard name

Legal Sex Designation Gender Identity Gender Pronouns Preferred Name Legal Name Inclusion Life Changes, Inc. will make reasonable accommodations in providing statements, notices, and information for residents who: Are unable to read. Are blind or visually impaired. Have communication impairments; or Do not read or speak English or any other language in which the statements, notices and information are written.

The sex that is indicated on government issued ID, such as a passport, driver's license of social security registration A person's inner sense of being man, woman, both, or neither. Gender identity may or may not be expressed outwardly and may or may not correspond to one's physical characteristics. Words that people use to refer to other people, typically instead of using their names. An alternative to the individual's legal name as designated by the individual in the Life Changes, Inc. system(s The name an individual uses for official governmental documents, such as licenses, passports, and tax forms.

Life Changes, Inc. will assign an appropriate employee, volunteer, or board member to assist individuals in understanding statements, notices, and information either through direct assistance or seeking outside assistance.

SECTION 2 - EMPLOYMENT REQUIREMENTS AND PERSONNEL CLASSIFICATION

Drug Free Workplace Act 1.The unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in Life Changes, Inc. 2.There is an ongoing drug-free awareness program in place to inform employees about: a.The dangers of drug abuse in the workplace. b.Life Changes, Inc. policy of maintaining a drug-free workplace. Specifically, employees of Life Changes, Inc., must not report for work impaired by use of alcohol or another drug, except when medical allowances must be made. C.The prohibition against drug use/possession/trafficking in the workplace. d.Any available referrals for drug counseling, rehabilitation, and employee assistance programs. e.The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace.

3.Reasonable accommodations to any disabled employee requiring medical treatment. 4.It is required that each employee provide a signed verification of the statement required by paragraph (a), such verification will be placed in the personnel file. 5.As a condition of employment, any employee must notify the employer in writing of any criminal drug statute conviction for a violation occurring in the workplace no later than five calendar days after such conviction. 6.Life Changes, Inc. will notify any certification agency or funder and any other federal funding source in writing within ten (10) calendar days after receiving notice under subparagraph (d) from an employee or otherwise receiving actual notice of such conviction. 7.One or more of the following actions will be taken within thirty calendar days of receiving notice under subparagraph (e) with respect to any employee who is so convicted: 8.Taking appropriate personnel action against such employees, up to and including termination. 9.Requiring such employees to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency. 10.[Public Law 100-690 Title V, Subtitle D, 41 USC 701 et seq.] 11.Upon arrival all Life Changes, Inc. clients will be assessed for physical limitations, and/or disabilities. Clients will be accommodated, according to individual needs, to the area of the facility that provides A.D.A. accommodation, as applicable. Affirmative Action 1.Affirmative Action is defined as specific, result oriented programs designed to materially increase the participation throughout the workforce, both volunteer and staff, of individuals who, in the past, may have been deprived of such as opportunity, especially minorities and women. 2.It is understood that in accepting federal funds, failure to enforce the Affirmative Action Policy may result in termination of the federal contract. 3.The following procedures regarding staff selection will be in effect: a.Appropriate advertising will be done to recruit the best qualified candidate. b.The following information and data shall be placed in the advertisement: i. List opening for job available. ii.List salary, qualifications required, and brief job description. iii.List dates when filing closes and state the date for any exam to be given and nature of exam, e.g., oral, written, or performance. If iv.a position is funded by federal or state funding agencies, the position is subject to annual review and renewal. V. A statement shall be included that agency hires without regard to race, creed, color, national origin, age sex or physical disability. 4.No elected or appointed Corporate Officer, Board Member, Committee Member, or member of their family may be employed by or receive a salary from Life Changes, Inc. without specific approval of the Board of Directors. Equal Opportunity Employer (EOE) 1.It will be the responsibility of Life Changes, Inc., in accordance with Title I of the Housing and Community Development Act of 1974 and 1977, and other related federal regulations, to ensure equal opportunity in employment without regard to race, creed, color, national origin, age, sex, or physical disability. 2.Equal opportunity within Life Changes, Inc. shall include all employment practices, not limited to hiring, recruiting, promotion, demotion, transfer, lay-off, termination, training, and compensation practices. At Will Employment Employment at Life Changes, Inc. is strictly an "at-will" arrangement that either the employee or the Company may terminate at any time, for any reason, (with or without just cause), and with or without previous notice. Nothing in this policy or any other Life Changes, Inc. document shall create a promise, a contract, or any other enforceable commitment to the contrary, and noofficer, employee, or agent of the Company has authority to make any promise or commitment contrary to what is stated in this paragraph - except for the Board of Directors of Life Changes, Inc. and then, only if the promise or commitment is in writing, duly authorized by a majority vote of the Board of Directors and signed by the President and Secretary of the Board. Employee Assistance Program ¹ Life Changes Inc. recognizes that a wide variety of problems not directly associated with one's job can affect an employee's job performance. In many instances, employees overcome such personal problems independently and the effect on job performance is negligible. In other instances, supervisory motivation or guidance helps to return an employee's job performance toacceptable level. In some cases, however, neither the efforts of the employee nor the supervisor has the desired effect of resolving the employee's problem, nor does the unsatisfactory performance persist over a period, either constantly or intermittently. Life Changes Inc. believes it is in the interest of the employee, the employee's family, and the agency to provide an Employee Assistance Program (EAP) to assist employees with personal problems. Key elements of Life Changes Inc.'s policy underlying the EAP are: 1.A belief that almost any human problem can be successfully treated provided it is identified in its early stages and a referral is made to an appropriate source of care. This applies whether the problem is physical illness, mental or emotional illness, financial, legal, marital, or family distress, alcoholism, drug abuse, etc. An assurance to employees that if such personal problems are the cause of unsatisfactory job performance, they will receive careful consideration and assistance in resolving the problem in an effective and confidential manner. 3.An assurance to employees that their jobs, future, and reputations will not be jeopardized by utilizing EAP. 4.An assurance that all employee records will be preserved in the highest degree of confidence. 5.Encouragement for employees to seek counseling voluntarily when they have problems which affect job performance. An employee wishing to utilize Life Changes Inc. EAP should contact their immediate supervisor for referral services. If the employee has a personal problem the employee will be referred to an appropriate professional for assessment and follow-up. Life Changes Inc. reserves the right to mandate participation of an employee in the EAP program, as a condition of continued employment, if there is good cause to believe the employees personal problems are significantly impairing employee workplace performance. Sexual Harassment It is the policy of Life Changes Inc. to ensure that the workplace is free of any form of sexual harassment. Sexual harassment is a form of sex discrimination which is unlawful under state and federal statutes. This statement is intended to make all employees sensitive to the matter, to advise them of their behavioral obligations and to inform them of their equal employment opportunity rights. You should be aware that Life Changes Inc. considers sexual harassment a profoundly serious offense. As such, the CEO is directed to consider harsh disciplinary sanctions, including termination, even for first time offenders. Under the Equal Employment Opportunity Commission's guidelines, unwelcome sexual advances, requests for sexual favors, and other verbal and physical conduct of a sexual nature are unlawful: a.When submission to such conduct is made a term or condition of employment. b.When submission to, or rejection of, such conduct by an individual is used as the basis for employment decisions affecting that individual. When such conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creates an intimidating, hostile, or offensive working environment.

1 State of Nevada, Employee Handbook, August 1995

following steps: a.Document the occurrences of harassment. b. Report the alleged discrimination to the Attorney General, your CEO, the Board of Directors or equal employment officer. d.Document any reprisals. An employee may submit a grievance in accordance with the procedure outlined in Grievance and Appeals or file a complaint with the Nevada Equal Rights Commission in accordance with NRS 613.405. Discrimination Life Changes, Inc. does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identify or expression of HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identify, or expression of HIV status. Americans With Disabilities Act The Americans with Disabilities Act (ADA) of 1990 is a civil rights act prohibiting discrimination against individuals with disabilities in employment, public services and transportation, public accommodations, and telecommunications. To be considered disabled under the ADA, a person must have a physical or mental impairment that limits one or more major life activities, or have a record of such impairment, or be regarded as having such impairment. Additionally, to be covered by the ADA, persons with disabilities must be otherwise qualified for the job, program, or activity to which they seek access.

Confront the harassen and make it clear that the conduct is unwelcome. Document this confrontation.

Under the employment provisions of the Act, it is discriminatory not to make reasonable accommodation to the known physical or mental disabilities of applicants or employees with disabilities. Employers are not required to provide accommodations that would impose an undue hardship on the operation of their business. The ADA requires that employment decisions involving persons with disabilities be made based on whether they can perform the job's essential functions, with or without accommodation. It seeks to delay consideration of medical or disability-related information until a conditional job offer has been made to the best qualified applicant. Personnel 1.The Board of Directors delegates to the CEO the power of establishing qualifications for other staff positions, selecting staff to fill these positions and the application of personnel practices. 2.It is the intent of the organization to retain only authorized workers. All new hires must provide proof of identify and work eligibility in accordance with U.S. Immigration Regulations. New employees must complete and sign IRS Form I-9 and produce both proof of identity and right to work within three working days of hire. Failure to comply will result in termination of employment Employee Classifications The categories of personnel of Life Changes, Inc. are: 1)Permanent: a person, who is off probation, has regularly scheduled hours and is not temporary. 2)Full time: a person who is regularly scheduled to work no less than 64 hours per pay period up to 80 hours per pay period but no more than 40 hours per week. 3)Part time: a person who is regularly scheduled to work less than 64 hours per pay period. 4)Casual Labor: a person who works as needed on an on-cal basis. 5)Contract: a person employed through a letter of agreement or contract which clearly specifies the nature and amount of services to be provided and the terms of compensation. 6)Probationary: all employees shall be considered probationary for the first ninety (90) days of employment, and such employees may be terminated at the discretion of the supervisor, with input from the CEO, without formally specified cause within the probationary period. The probationary period may be extended or reinstated by the employee's supervisor with input from the CEO. Laid-Off/Terminated Employees A laid-off or terminated employee ceases to receive or accrue any employee benefits, except as required by federal and state law. Rehired Employees A rehired employee is considered a new employee from the date of rehire or return with respect to employee benefits. All rehired employees are subject to approval by the CEO of the organization. Exempt/Non-Exempt Employees Exempt employees are exempt from overtime provisions of the federal and state wage and hours laws. Salaried employees, including managers and other high-level personnel, are exempt under these laws. Non-exempt employees are entitled to overtime compensation, whether salaried or hourly, if the job classification and duties are not exempt from the overtime provisions of the federal and state wage and hour laws. Recruitment Process 1.Life Changes, Inc. will make every reasonable effort to publicize employment opportunities utilizing free employment websites, as well as posting in various recovery and mental health-oriented locations. 2.Life Changes, Inc. will post employment opportunities on the social media site. 3.Life Changes, Inc. will adhere to the EOE policy as described in this manual. Process of Selection The process of selection for employees/volunteers of Life Changes, Inc. is as follows: 1.The Board of Directors selects the CEO. 2.All Life Changes, Inc. staff/volunteers are selected by the CEO. Supervisory staff for an open position may interview potential staff and provide options/recommendations to the CEO. The CEO has the deciding vote on all hiring activities. Process of Termination 1.The Board of Directors may terminate the CEO 2.Dismissal/termination of Life Changes staff/volunteers is the sole responsibility of the CEO. Supervisory staff may request dismissal/termination of a staff/volunteer with documented cause. 3.While operating as an At-Will employer, Life Changes, Inc. encourages management to dismiss employees based upon reasonable cause with complete documentation in place in the employee/volunteer file. Termination of Employment The following are the conditions under which an employee may be terminated:

1.Resignation--The term "resignation" refers to the voluntary termination of employment on the part of the employee. In the event of resignation, it is requested the CEO or employee's immediate supervisor receive a written notice fifteen days prior to the actual date of separation giving the reasons for leaving. 2.Reduction in Force --The term "reduction in force" refers to termination of employment by the agency for reasons beyond the control of the employee and bears no relation to job performance or conduct. Should the agency be unable to continue an employee (who has rendered satisfactory service) in his/her current position, because of budget cuts, reorganization, discontinuance, or curtailment of area of service, and is unable to offer some other mutually satisfactory assignment, the employee shall be released. Notification of release shall be given to the employee in writing by the CEO. An employee released from employment (excluding temporary employees and layoffs) shall receive his/her payment for the balance of accrued annual vacation along with salary earned through the date of release. 3.Dismissal--The term "dismissal" refers to termination of employment by the agency. Authority to dismiss shall rest in the CEO. In cases where the termination is not acceptable to the employee, s/he may follow the Grievance and Appeal procedure. Authority to dismiss the CEO shall rest in the Board of Directors. An employee dismissed by the agency may be released without notice and shall receive payment within the time prescribed by law or regulation for the balance of his/her accrued annual leave and any salary which has been earned through the date of termination. Reasons warranting dismissal, include, but are not limited to those listed in the section "Disciplinary Action." 4.An evaluation memo on each employee may be, upon leaving the job, prepared by the employee's immediate supervisor (based on work performance), and included in the employee's personnel record for future reference. Disciplinary Action 1.Disciplinary action will be taken when indicated by an employee's on-the-job performance. Disciplinary action may include: a.Documented counseling. b.Documented warning. C.Documented reprimand. d.Suspension without pay. e.Continuation or reinstatement of probationary period. f.Demotion. Termination g. 2.Necessary disciplinary action shall be taken whenever the employee's actions include, but are not limited to, any of the following deficits: a.Failure to maintain satisfactory and harmonious working relationships with clients, Life Changes, Inc. staff, and/or the public. b.Unsatisfactory work performance. C.Failure to satisfy the conditions of employment. d.Absence without prior notification within 45 minutes of shift. e.Dishonesty, theft, failure to answer application form truthfully, altering records and timecards. f.Failure to abide by CFR 42 part 2 and HIPAA requirements. g.Behavior that is detrimental and in opposition to the projects of the agency. h.Willful disregard of policies, procedures, and supervision. i.Negligence and/or fraud in the performance of duties. Inefficiency or incompetence in the performance of duties. j. k.Careless, negligent, or improper use of Life Changes, Inc. property. I.Failure to hold or maintain the proper degrees, certificates or licenses required either by law or the qualifications of the position held. m.Habitual failure to report for duty at the assigned time and place. n.Absence without approved leave. O.Two or more documented warnings for the same offense, within one year's time. p.Two or more documented reprimands for the same offense, within one year's time. q.Reporting for work impaired or under the influence of alcohol or other drugs, (Allowances will be made to provide reasonable accommodation to any documented disability an employee may have which requires medical treatment r.Insubordination, which is defined as refusal to comply with a direct request from a superior when that request is consistent with policies and procedures of Life Changes, Inc. For the CEO, insubordination includes refusal to comply with a direct request from the Board of Directors or the Board's designated spokesperson. Performance Evaluations 1.Informal evaluation of an employee's work is a continuous process. 2.All new employees will be provided with a formal evaluation at the end of their six months of employment. 3.All employees shall be subject to an evaluation by the CEO annually. 4.The chairperson of the board will annually evaluate the CEO. 5.Formal evaluations will be in written form prepared by the CEO or the employee's immediate supervisor. Such evaluations will relate to the position performance expectations as described in the position's job description classification. 6.The completed and signed Performance Appraisal shall be reviewed and filed in the employee's personnel folder. 7.An unsatisfactory Performance Appraisal can result in withholding of merit increases or advancement as well as termination. Grievance And Appeals 1.It is the policy of Life Changes, Inc. to ensure that all employees receive fair and equitable treatment. We support employee-supervisor relations by encouraging communication and reconciliation of work-related problems. The grievance procedure is available for expressing legitimate dissatisfaction without fear of criticism. All clients, participants and staff have the right to appeal any decision without threat or reprisal. 2.If an employee is dissatisfied by any action of Life Changes, Inc., and is unable to resolve the situation through informal discussions with the supervisor, s/he may file a written grievance and be assured there will be no adverse consequences for doing so. The provisions of the grievance procedure to all employees are described below. a.Should any employee believe he or she has grievances, it should be presented in written form and discussed with his/her immediate supervisor or designee. The immediate supervisor shall respond to the grievance, in written form, within ten working days. b.Should the grievance be with the employee's immediate supervisor, the employee may file the grievance with the immediate supervisors supervisor. C.If the grievance is not resolved, to the employee's satisfaction, with the immediate supervisor or designee, the employee may present the grievance to the CEO or designee, d.If the grievance is not resolved to the employee's satisfaction by the CEO or designee, the employee may appeal to the Board of Directors in writing. The Board of Directors shall consider the matter at its next regularly scheduled meeting which the employee may attend. The action taken by the board shall be final. Personnel Files Personnel files are the property of Life Changes, Inc. and may not be removed from the premises without written authorization of the CEO. The employee has the right to inspect his/her personnel file at reasonable times, at a reasonable place, and on reasonable notice. Employees may request copies of signed documents related to their service to Life Changes. A personnel file will be kept for all paid and volunteer staff positions. Personnel files will be kept in electronic format in a confidential secure drive. Personnel records are provided to payroll services and these documents are stored in the organizations confidential secure online accounting system. Access to personnel files is restricted to the following: 1.Board of Directors Personnel Committee

Administrative Director/H.R. 3.

4.Direct supervisor 5.Payroll services may have limited access and may only view documents required to process financial matters. 6.Representatives of regulatory agencies conducting audit evaluation or investigation 7.Legal counsel for Life Changes. 8.Disclosure upon order of court of competent jurisdiction 9.Any party to the extent necessary for appropriate Life Changes, Inc. response to any action brought by the employee. 10.Disclosure to parties other than the foregoing may be made only with written consent of the employee. Personnel files shall contain: 1.Application for employment and/or resume. 2.Verification of references. 3.Verification of education/training 4.Evaluations of performance in employment 5.Documentation of any personnel actions taken. 6.Documentation evidencing the employee's entitlement to remain and work in the United States (IRS Form I-9) 7.If an employee provides care services requiring a license or certification, a copy of the document authorizing the employee to do so under state law. 8.A copy of employee's job description signed by the employee/volunteer 9.Signed confidentiality and HIPAA privacy and confidentiality agreement 10.Signed ethics and confidentiality policy 11.Records of annual vacation and personal convenience leave, both as to time accrued and time expended.

e.Signature of employee upon completion of applicable training/orientation Wages & Merit Increases 1.The Board of Directors shall set the annual salary for the CEO. 2.The CEO shall set all staff salaries. 3.The CEO and executive staff will be reviewed quarterly for merit bonuses. 4.Merit increases may be allowed based on the employee's job performance, pending funding availability. Pay Periods 1.There shall be twenty-six annual pay periods. 2.Payday shall be on the Friday following the close of the pay period. 3.For bookkeeping purposes, salaries shall be computed per the approved salary schedule. 4.Salaried employees shall receive twenty-six equal payments. 5.Hourly employees shall receive pay based on hours worked.

Job Descriptions 1.Job descriptions will accurately reflect the situation of employment 2.Each position will have a job description and will include a.Position title b.Duties and responsibilities C.Qualifications required d.Positions supervisor

a.Work in excess of established hours is not authorized unless specific written authorization is received from the CEO and documented in the employee's permanent file. Staff Training 1.Employees will be granted leave with pay to attend job-related training or exams at the discretion of their supervisor. 2.The CEO may approve training-related expenses such as annual license fees and applicable continuing education units for license/certified staff. Additional Employment 1.Employees who wish to maintain outside employment may do so only after submitting a written plan to their supervisor for how conflict of interest with Life Changes, Inc. and its clients will be avoided. 2.Employees who take outside employment must not allow that employment to interfere with their established schedule or job duties for Life Changes. Approval for continued outside employment shall be contingent upon consistent implementation of the written plan. Leave Requests/Supervisory Structure Staff supervisors are responsible for screening and preparing recommendations on all staff requests for time off, vacation leave, other types of leave, and any other planned absence from the job. The employee's supervisor and/or the CEO must approve all requests for planned absences from the job. An "Employee Request for Leave" form must be submitted to employee's supervisor for approval, input into computer and filed in employee file. Promotions And Demotions 1.When there is a vacancy in a higher-level position, affirmative action policies will be followed. 2.An employee may be demoted or transferred to a lower classification in the following instances: a.At his/her own request. b.For unsatisfactory work. C.During reduction in the work force. d.At any time, for any reason, during the initial 120 days of a promotion. New Staff Orientation 1.If possible, the outgoing staff member will train and assist the new employee after proper notice is given. In cases of unexpected openings, the immediate supervisor will train and assist the new employee. New employees be oriented to their position and assignment location, will complete all onboarding documentation and training including, but not limited to 1) confidentiality policy, cultural competency, and Code of Conduct Personal Conduct 1.All employees, board members and volunteers of Life Changes, Inc. will conduct themselves in a professional, business-like manner. 2.Inappropriate or unprofessional conduct between the clients, staff, board members or volunteers may result in immediate termination of the employee, board member or volunteer. 3.Staff, board members or volunteers may not engage any Life Changes, Inc. client in a close personal relationship and may not engage in such a relationship with a former Life Changes, Inc. client for a minimum of two years after the clients discharge from the program. Failure to comply with this policy will result in immediate termination. 4.All personnel, board members and volunteers are encouraged to participate in ongoing personal growth programs consisting of spiritual, emotional, and/or physical aspects while employed at Life Changes, Inc. Due to the stress levels incurred while working with this special population, the suggestion is to assist the employee, board member or volunteer in

maintaining his/her balance and health while working with the clients. The client may resist immersing his/herself in a program for growth when the person working with the client is not a role model of self-care and self-discipline. 5.Board members are encouraged to chair 12-step meetings at Life Changes, Inc. 6.Board members and staff that are in a 12-step program are discouraged from sponsoring clients as this special relationship can conflict with the board/staff relationship. 7. Under no circumstances is a board member to approve a special situation. Board-Staff Relations 1.The CEO is responsible to the Board of Directors for administration of the program. a.The CEO may assign a designee to act in her stead in her absence. 2.Directives to any staff/volunteer member are to be channeled through this CEO who is responsible for overall coordination of staff activities. Dress Code 1.Professional appearance is tremendously important at Life Changes, Inc. All employees are expected to dress in a manner suitable to a professional organization and maintain good personal hygiene. 2.There may be special events or occasions throughout the year when employees may dress in attire different from stated policy. These occasions will be communicated to all employees as they arise. For events and special occasions employees are expected to dress in a dignified manner. 3.Employees who reside in a Life Changes, Inc. facility may dress more casually. 1.Apparel with gang, drug or alcohol logos or provocative apparel is not allowed at any time. 2.The undergarments must be worn at all times. 3.For House Managers or House Managers significant others, residing in a facility with clients of the opposite gender, it is essential to wear appropriate clothing, undergarments at all times. If wearing nightclothes, a cover-up is required. 4.As with administrative staff, short shorts/skits, plunging necklines and other inappropriate apparel are not allowed. 4.For employees and volunteers representing Life Changes in the community or administrative offices, business casual apparel is acceptable. The following professional dress code is to be followed. 1. Tops 1.No low-cut tops showing cleavage. 2.No spaghetti straps. For sleeveless apparel, the straps must be a minimum of two inches wide and bra straps are to covered. 3. No tank tops. 4. No tops with gang, drug, or alcohol logos. 5.No tops showing belly or excess skin. 6.Tops should be appropriate for a business environment for both men and women. 2. Bottoms 1.Short shorts or cut-offs are not to be worn. 2.Shorts/Skirt should be two inches or less above the knee in both the front and back to be considered a professional look for the workplace. 3.Clothing must not have raged hems, or excessive rips. 4. No sagging or excessively tight pants. 5.Pants should be appropriate for the business environment for both men and women. 3.Other 1.No visible underwear meaning: 1.No bra straps may be showing. 2.No pants sagging past underwear. 2. Apparel is not to be excessively tight. 3. Make-up and jewelry are to be kept to a minimum.

Confidentiality All employees, contractor, and/or volunteers of Life Changes, Inc. shall adopt to the confidentiality standards set forth in 42 C.F.R. Part 2, 45 C.F.R. Parts 160, 162 and 164, NRS 458.055 and any other applicable confidentiality laws pertaining to the services provided by the program. In the event of a conflict in the confidentiality requirements set forth in42 C.F.R. Part 2, 45 C.F.R. Parts 160, 162 and 164, NRS 458.055 and any other applicable confidentiality laws, the more restrictive law will apply. (HIPAA) Health Insurance Portability Accountability Act, (45 CFR, Parts 160-164) Effective April 14, 2011, Life Changes, Inc., a covered entity and declared a "Business Associate" shall adhere to policies and procedures governing protected health information (PHI) as follows: 1.The Administrative Director shall be the designated Privacy Officer for Life Changes, Inc. 2.The Privacy Officer will conduct employed and contractual staff training as required by state and federal guidelines and will inform all staff of any changes that occur. 3.Life Changes, Inc. will ensure all clients are informed how their protected health information will be used and retain a signed copy of the acknowledgment in the client file. 4.Life Changes, Inc. will ensure that all employees of Life Changes, Inc., including contractual staff, have signed the Privacy and Confidentiality Agreement. This agreement will be retained in the employees/contractual staff's file. HIPAA Violations & Penalties Life Changes, Inc. may impose penalties or sanctions on any employee who violates privacy policies and procedures. Please review HIPAA section in the manual. In general, penalties or sanctions for privacy policy and procedure violation may include one or more of the following: 1.Verbal warning and/or written warning, training session. 2.Suspension. 3.Termination. 4.Involvement of local, state, or federal law enforcement agencies. 5.Civil and/or criminal penalties. Contractors, Consultants, Volunteers and 1099 Staff Contractors, consultants, volunteers and 1099 staff may have access to confidential information concerning clients only to the extent required to perform requested duties. These individuals must sign and agree to comply with confidentiality agreements required by 42 C.F.R. Part 2, C.F.R. Parts 160, 162 and 164. Signed agreements will be maintained in the confidential personnel file of each party.

Employee, volunteers and board members of Life Changes, Inc. shall maintain the confidentiality of personally identifiable information concerning the sexual orientation of a patient/resident, whether the patient/resident is transgender or has undergone a gender transition and the human immunodeficiency virus status of the patent/resident and take reasonable actions to prevent the unauthorized disclosure of such information.

EIC/Worker's Compensation 1.All employees of Life Changes, Inc. are covered by workers compensation. If an employee is injured in the course of employment (or contracts an occupational disease), he/she is entitled to medical attention and treatment under workers compensation. Employees will be paid for lost time as provided by workers compensation. 2.When an employee is injured on the job or contracts an occupational disease, he or she must report it immediately to his/her immediate supervisor who will be responsible for filing a report with the CEO. 3.When an employee is eligible to receive workers compensation, he or she may select from two (2) options: a. He or she may take the two-thirds pay offered by workers compensation which is 2/3 of regular gross earnings and non-taxable, leaving accrued leave time undisturbed. b.He or she may use his/her accumulated P.T.O. along with the workers' compensation payment until such leave is exhausted. Holidays 1.All regular, full-time employees qualify for holiday benefits. 2.Regular, part-time (less than 32 hours per week), and all relief (on-call) employees are ineligible for Holiday Benefits. 3.Life Changes, Inc. will observe Ten (10) paid holidays each year in accordance with the following schedule: Official Dates Name of Approved Holiday 1New Years Day January 1 2Washington's Birthday (Presidents Day)3rd Monday of February 3Memorial Day Last Monday in May 4July 4 Independence Day 5Labor Day1st Monday in September 5.5Nevada Day 1/2 DayLast Friday in October 6.5November 11th Veteran's Day 8.5 Thanksgiving & Family DayLast Thursday & Friday in November 10Christmas Eve (1/2/ day) & Christmas DayDec. 24th (1/2 day) & Dec. 25th An employee may forgo an established paid holiday once annually to be taken on their birthday. This must be requested/approved in writing prior to said holiday. 4.Employees will utilize the holiday benefit on the actual day it falls on unless the holiday falls on an employee's regularly scheduled day off or the needs of the organization require the employee to be on duty. 5.Should an employee be unable to take time off for a paid holiday, they may bank the holiday for a period of six weeks. After six weeks, if the holiday is not used, it will be lost. 6.Employees may not bank more than two holidays at any given time. Overtime 1.In accordance with Nevada Overtime Laws hourly employees who work overtime will be compensated per state law. 2.Executives, administrators, and other professionals earning at least $455 per week are considered exempt and are not paid overtime under Section 13(a1) of the Fair Labor Standards Act. a.A position is classified as Executive if the position includes full-time responsibility in the management of two or more employees. In this instance, the position is salaried. b.A position is classified as Administrative if the primary duty is non-manual work related to business operations, management policies, or administrative training. The job must be salaried to fulfill the requirements, and no more than 20% of job duties must not fit into the categories described above. C.A position is classified as Professional if the primary duties require advanced knowledge and extensive education, including artists, certified teachers, and skilled computer professional. The job must be salaried, primarily intellectual and the employee is expected to use discretion and judgement. No more than 20% of the time is to be spent doing activities not directly related to the duties described above. 3.Any employee not classified as described above is an hourly employee and is eligible for overtime pay. 4.Non-exempt employees who work more than 40 hours in a week are paid overtime at a rate of 1/2 their normal wage. a.In accordance with Nevada Labor Law, overtime pay applies for workers earning less than $12.38 per hour or $10.39 with health benefits. Note this rate is current as of 2023 and is subject to change as Nevada minimum wage changes. Vacation Time & Sick Time 1.All relief (on-call) employees are not eligible for Paid Vacation, Sick time, or Holiday pay. 2.Regular, full-time employees' (32 hours per week or more) paid time off shall be pro-rated based on the number of regularly scheduled hours worked per week. a. For example, an employee regularly scheduled for 40 hours per week will get 100% of allocated time off. An employee regularly scheduled for 32 or less hours per week will earn time off in accordance to their approved schedule. 1.For example, an employee scheduled for 20 hours per week, will earn 50% of a regular full-time employees vacation and sick time benefits. 3.The accrual rate by which paid time off is determined is based upon your start date and the following table: Length of ServiceHours/Days 40 hrs per week (100% FTE) Paid Time Off 1 3 years10 days80 hrs. 96 hrs. 4 5 years12 days 6 10 years15 days120 hrs. 11-12 years17 days136 hrs. 13+ years160 hrs. 20 days 4.No Employee is eligible for accrued paid vacation time off until one full year of regular full-time employment. Unpaid leave is at the discretion of the CEO. 5.Paid Vacation Time Off may be granted in units of from one-half (1/2) day minimum to a maximum of ten days, not including holidays. 6.No more than the maximum allowed paid time off may be accrued from the anniversary of the employee's start date. 7.Vacation time must be used within a one-year period from the date it was awarded. Any time not used after the one-year period will be forfeited. 8.Pay in lieu of annual vacation will not be granted other than at the time of termination of employment. 9.If any holiday observed by the agency falls within an employee's paid vacation time off, the employee will not be charged with a day of paid time off. 10.Paid Time Off will be taken only at a convenient time approved by the CEO. 11.All relief (on-call) employees are not eligible for Paid Vacation, Sick time, or Holiday pay. Sick Leave Sick leave shall be pro-rated based on the number of regularly scheduled hours worked per week. a.A full time employee (64 (or more) hours per pay period) shall be granted 40 hours of paid sick leave. b.Part time employees shall be granted sick leave in accordance with the number of approved hours they work. 12.5 days of sick pay will be granted upon completion of an employee's probationary period and will be renewed each year on the anniversary date.

13. Sick time not utilized by the employee's anniversary date will be forfeited. Mental Health Day A Mental Health Day is a day off work where an employee can invest in self-care and recover from a potential mental health issue, including burnout. This is a "no-questions asked" day off when an employee needs it. Self-care is vitally important in the workplace and knowing when self-care is needed is important for success in the workplace. Life Changes, Inc. will do what is necessary to cover your workload and no judgement or penalty will be given against an employee who chooses to take a Mental Health Day. 1.Employees may request one Mental Health Day per quarter without a written notice from a physician or mental health provider. 2.A Mental Health Day does not require pre-planning. However, the employee is required to notify the supervisor within one hour of their regular start time. 3.A Mental Health Day is not an additional paid time off day in and of itself. An employee may choose to use eligible vacation or sick leave. If the employee chooses not to use their eligible time, this will be considered a non-paid day. 4.An employee who takes a Mental Health Day is required to return to their regular schedule the following day. The Mental Health Day hours cannot be "made up" by overtime work. A Mental Health Day is taken for a reason and Life Changes chooses not to further exacerbate the situation through overtime work. Rest Breaks 1.Per Nevada Revised Statutes section 608.019, employers are required to provide employees a paid ten-minute (10) rest break for every four hours (approximately) of continuous work. At Life Changes, you have been given the courtesy of one paid 15-minute break every four hours. a.An employee must work between 4 and 7.45 hours to receive one paid 15-minute break. b.An employee must work between 8 and 10 hours to receive two paid 15-minute breaks. C.For example: "Mary is a part-time receptionist who works from 9 am to 1 pm during the week and from 10 am to 1 pm on Saturdays. Since she works four continuous hours during the week, she is entitled to a 10-minute break (15 minutes at Life Changes But, since she works only three hours on Saturdays, she is not entitled to any breaks on that day." 2.Lunch Breaks - per the above-mentioned statute, employers are required to provide employees who work an eight-hour shift with a meal break of 30 minutes. Unlike rest breaks, Nevada Labor Law does not require these lunch breaks to be paid. a.Because a 30-minute lunch break is required by law, all Life Changes employees who work a minimum of an eight-hour shift are required to take a 30-minute, unpaid lunch break and are required to clock out for this lunch break. b.If an employee works less than an eight-hour day, they are not required to take a lunch break. Civil Leave 1.If an employee is required to attend a court session as part of his/her job, no leave is required. 2.When an employee is required to appear in a legal action, to which he or she is a party and Life Changes Inc. is not a co-respondent, he or she must take Paid Time Off or leave without pay. 3.If an employee is selected for jury duty, no leave is required. However, any monetary compensation earned while serving on jury duty must be released to Life Changes, Inc., upon return to work. Family & Medical Leave under Family Medical Leave Act (FMLA) The FMLA entitled eligible employees to take job-protected leave for specific family and medical reasons with a continuation of all company benefits under the same terms and conditions as if the employee had not taken leave. Eligible employees are entitled to: Up to twelve workweeks of leave in a 12-month period for: the birth of a child and to care for the newborn child within one year of birth. the placement with an employee of a child for adoption or foster care and to care for the newly placed child within one year of placement. to care for the employee's spouse or domestic partner, son, daughter, or parent who has a serious health condition. a serious health condition that makes the employee unable to perform the essential functions of his or her job. any qualifying exigency arising out of the fact that the employee's spouse or domestic partner, son, daughter, or parent is a military member on covered active duty; or Up to twenty-six workweeks of leave during a single 12-month period to care for a covered servicemember (including covered veterans) with a serious injury or illness if the eligible employee is the servicemember's spouse or domestic partner, son, daughter, parent, or next of kin. An "eligible employee" is an employee who: Has been employed by the company for at least 12 months; and Has a worked a minimum of 1,250 documented hours during the 12-month period immediately preceding the first day of leave. Military Leave 1.Military leave without pay will be granted to employees who are members of the National Guard or military reserve units. Such employees shall be entitled to leave without pay for one period of up to fifteen (15) days in any one calendar year when ordered to report for duty for annual training or other purposes. 2.Military leave may be extended beyond 15 days at the discretion of the CEO 3.Requests for military leave without pay shall be made to the employee's supervisor who shall determine whether such leave is to be authorized and who shall clear the matter with the CEO. 4.If military leave without pay is granted, the employee may be paid for accrued vacation leave and any salary earned. Leave Without Pay for Other Reasons 1.Leave without pay may be granted for reasons other than those listed at the discretion of the CEO. Absenteeism The Fair Labor Standards Act (FLSA) does not require payment for time not worked, such as vacations, sick leave or federal or other holidays. These benefits are matters of agreement between an employer and an employee and are based on the policy and procedure of the company. Life Changes' attendance policy is created by the Board of Director's and enforced by the CEO. The FLSA does not regulate attendance. This includes implementing disciplinary measures for violation of the attendance policy. Each employee is allowed a certain number of days off from work (typically paid), at the employee's discretion (subject to requirements for advance notice and other procedures necessary to allow the employer to staff properly Progressive discipline is used when the employee exceeds the number of allowed absences as described in the "excessive absenteeism" policy below.

Policy and disciplinary action for excessive absenteeism: "Excessive absenteeism is defined as any absence exceeding the number of allowed/accrued sick time and/or (5 days/year), vacation time (1, 2, 3 weeks/year depending on duration of employment) off per year. a.First offense - written counseling and warning that continued excessive absenteeism will lead to subsequent disciplinary action.

b.Second offense written counseling session and warning that continued excessive absenteeism will lead to termination. C.Third offense termination.

Uncompensated Absences/Time Off: 1.At the sole discretion of the CEO, an employee who uses all their accrued sick time before the end of a calendar year, may request an additional (1) day off per year, at his/her own expense (unpaid time off 2.No employee may request uncompensated time off for vacation when no vacation time has yet been accrued. In the case of employees who use all accrued vacation time, no additional time off uncompensated or otherwise will be allowed. Leave Requests and Records 1.All requests for leave must be submitted no less than ten (10) working days in advance of the requested leave period. 2.Cases of absenteeism due to illness, Employee Leave Request Leave form must be completed on the first day of return to duty. 3.Other requests for leave must be submitted as soon as possible. 4.Each employee may request an accounting of their accrued leave and vacation time. Travel Requests All 1.employees who expect to travel out of the area for Life Changes, Inc. on official business must submit a formal request for authorization for such travel at least two (2) weeks in advance unless lack of timely notice from sponsoring agency or organization clearly prevents said notice. 2.Travel Request forms are to be submitted to the employee's immediate supervisor who will make his/her recommendation for consideration by the CEO. 3.Following approval by the CEO, travel requests and arrangements for hotel accommodation will be handled by the CEO. Expense Reimbursement 1.It is the policy of Life Changes, Inc. to reimburse employees/volunteers and members of the Board of Directors and its committees for expenses incurred because of agency business or related activities. 2.All employees and members of the Board of Directors who incur business-related expenses shall complete a "Reimbursement Request" complete with receipts. 3.Employees may be advanced the state per diem rate for necessary expenses determined by the travel/conference schedule. 4.Additional travel expenses, with the necessary receipts or vouchers must be submitted to the CEO not later than five working days after the conference. 5.If, in the course of official duties, the CEO directs you to use your own personal vehicle, reimbursement will be made at the current rate authorized by the State Administration and published in the State Administrative Manual. If you use your private automobile for personal convenience when conducting agency business, you will receive one-half of the authorized rates. 6.The CEO may approve reimbursement for other types of business-related expenses when, in his/her judgment, they are in the best interest of the agency. Quality Management and Improvement 1.Informal monitoring of employee and/or contractual staff job performance will be conducted on an ongoing basis by the CEO, or employee's immediate supervisor, no less often than annually, Formal evaluations will take place at the end of a 90-day probationary period for new employees, six months, and annually thereafter. A copy will be maintained in the employee's confidential file. 2.Clients of Life Changes, Inc. will privately complete a satisfaction survey on a quarterly basis prior to discharge. All results will be reviewed by the CEO to measure, assess, and improve staff and program performance. 3.Any complaints received at Life Changes, Inc. regarding any employee and/or contractual staff will be investigated by the CEO. a.CEO will document said complaints in employee/contractual/volunteen staff file and hold a meeting with employee/contractual/volunteen staff for whom the complaint is against. b.CEO and employee/contractual/volunteen staff will devise a solution in writing within ten (10) days of said meeting. C.CEO will follow up with employee/contractual/volunteen staff within 30 days of said complaint d.Should employee/contractual/volunteen staff not follow through with solution arrived at upon first meeting, disciplinary action will be taken as detailed in personnel section of policy manual.

Section 3 Fiscal Financial Records-Internal Controls Life Changes, Inc. is committed to accurate accounting and reporting in accordance with Generally Accepted Accounting Principles (GAPP This commitment is reflected in our accounting policies and procedures. We strive to attain accuracy and efficiency with every document we handle. Efficiency will be achieved as we are committed to maximizing the percentage of dollars spent directly on programs benefiting our clients and the community. To this end, our internal controls are designed to maintain a balanced cost/benefit ration, achieving timely and low-cost accuracy. Life Changes, Inc. honors donors, grant, and contract restrictions spending the dollars we receive on the specific business each donor has designated. Our Chart of Accounts is structured to require specific classes and categories, recognizing separation between Operating and Capital income/expenditures. These distinctions are required for each item of income and expense and are part of our requirements for every transaction. This promotes accurate transaction processing in accordance with funding restrictions. The CEO must keep financial records of the program. The records must be prepared in accordance with accepted accounting principles which are consistently applied. The CEO shall consult with the Administrative Director to see that the above has been conducted. The CEO will stay in compliance with policies and procedures. No state or federal monies may be used by the program to pay for any political activities of the program. 2.Policies and Procedures prohibit the use of block grant funds to provide needle exchange. LifeChanges, Inc. shall provide for a financial review, financial statement as requested by funding agencies and/or, an independent audit pursuant to Title 2 Code of Federal regulations 200.501, "A Non-Federal entity that expends $750,000 or more during the non-Federal entity's fiscal year in Federal awards must have a single or program-specific audit conducted for that year in accordance with the provisions of this part." (Rev. 12/2017) 4.Life Changes, Inc. shall keep accurate and current data on. a.A general ledger of cash disbursements. A payroll ledger. C.A journal of cash disbursements. d.A journal of other receipts, if appropriate. e.A journal of non-monetary disbursements, if appropriate; and f.The records of checking, savings, and other accounts at financial institutions. g.All grant funds will be coded to the appropriate grant source, when applicable, in the accounting system to match the budget submitted to the funder. h.All grant reimbursement requests will have backup documentation with monthly reimbursement requests. Internal Controls Internal Controls are the policies, procedures, forms, methods, rules, and practices required to meet our organization objectives. The goal of Internal Controls is: 1.Effective and efficient operations 2.Reliable reporting 3.Compliance with regulations Internal Controls define the way we conduct business and are applicable to all employees of the organization. Additional Overview Information 1.The fiscal year of Life Changes, Inc. begins on January 1 and ends on December 31 each calendar year. 2.All funds received by Life Changes, Inc. shall be credited to Life Changes, Inc. and placed in a depository approved by the Board of Directors. 3.All checks drawn by Life Changes, Inc. that are less than $5,000.00 require the signature of the Board President/CEO or of an authorized Board Member. Checks drawn over $5,000.00 require prior approval by the Board of Directors. 4.All checks and cash received by Life Changes, Inc. are handled according to the policy described below. 5.Checks or electronic payments shall be issued for all bills owed by Life Changes, Inc. within the provision of the budget adopted by the Board of Directors. 6.The accounts of Life Changes, Inc. shall, when requested by the Board of Directors, receive an annual audit review by an Independent Certified Public Accountant, and the signed certificate of said accountant shall appear on the copy of the audit review report to be sent to Life Changes, Inc. 7.A copy of the proposed Life Changes, Inc. operating budget for the following year shall be submitted to a combined meeting of the Finance Committee and the Executive Committee and then, upon these Committee's motion, will be recommended to the Board of Directors for approval each year at the annual January board meeting. 8.No state or federal monies may be used by the program to pay for any political activities of the program. Policy Statement It is Life Change's policy to ensure that adequate and appropriate funding is identified prior to committing the organization to funding obligations with respect to the acquisition of Capital Assets and/or to incurring contractual obligations. For the purposes of this policy, Capital Assets are defined as any asset that has a useful life of more than one year and a value of more than $5,000. Examples include, but are not limited to, building structures, technology equipment, software, furniture, fixtures, and equipment. Contractual obligations include, but are not limited to, leases, software maintenance agreements, equipment maintenance agreements, consulting agreements, insurance policies, building permits, and employment contracts. Financial Authority for Capital Asset Acquisition 1.Board President/CEO may authorize up to $5,000, according to pre-approved budget guidelines for projects. 2.The CEO, under the written direction of the Finance Committee, may authorize expenditure of more than $10,000. Incoming Monies-Accounts Receivable 1.Individual client service fees/savings monies shall be charged in a fair and equitable manner. 2.LifeChanges, Inc. shall assign a separate three (3) part numbered receipt book to each staff person charged with the collection of monies. 3.Client fees shall be collected on a weekly basis. 4.Client fees shall be recorded in the three (3) part receipt book. The following information shall be reflected on the receipt: a.Date b.Client name C.Amount paid d.Signature of staff person receiving payment. 5.Each copy in the three (3) part receipt book shall be distributed as follows: a.Original to client (white) b.2nd copy to accompany payment (yellow) C.3rd copy to remain in receipt book. (pink) 6.A voided receipt shall include all three parts (white, yellow & pink) and must contain an explanation of reason for void, signed by the person holding responsibility for the receipt book and all 3 parts stapled together in the receipt book. 7.Receipts containing errors will have one line drawn completely through the error and will be initialed by staff. 8.The staff person whose signature is on the receipt is responsible for ensuring monies are turned in weekly. Failure to submit all received money will result in the staff being fiscally responsible for missing money. 9.Client fees in check or money order form shall be endorsed at the time of receipt with 'for deposit only' and the above procedures followed.

10.Life Changes, Inc. will ensure electronic client statements are available when requested. Other Incoming Monies/Accounts Receivable 1.Immediately upon receiving a check, the CEO shall endorse it with "for deposit only." 2.The check is to be receipted into the system using correct codes so that monies are not co-mingled. 3.The check is then deposited into the Life Changes, Inc. bank account, by the CEO, within three (3) days of receipt.

Bank Deposits-Revenues 1.All agency income shall be deposited in company safe the week monies are received 2.Deposits into the company bank accounts shall occur when checks and cash reach a total of $5,000. More frequent deposits may occur based on the financial needs of the organization. 3.The Administrative Director shall enter the deposit in the QuickBooks program based on the receipts 4.All monies collected are to be turned into the CEO the week they are received. Monies are to be placed in the fee receipt envelope, the yellow copy of the receipt is to be matched with the funds received, and the front of the envelope accurately completed. 5.Any discrepancies in fees will only be adjusted based on a verified original receipt and verification in QuickBooks accounting system. Bank Account 1.The CEO and Board Treasurer are the only people with access to the program bank accounts. Bank Statements/Reconciliation 1.The CEO shall provide the Administrative Director, monthly, with an electronic record of the bank statement for all accounts. 2.The Administrative Director will reconcile statement in Quick Books. 3.The Administrative Director shall submit reconciled bank documents to the CEO and Board Treasurer via email. 4.The CEO, Board Treasurer and Administrative Director are the only people who shall have access to the bank statement and the QuickBooks accounting system. 5.The Board President may request access when needed for budgeting or planning purposes. 6.The Administrative Director and Board Treasurer shall prepare financial reports for Board review quarterly and at year end. Personnel & Payroll 1.The Administrative Director shall submit payroll amounts no later than noon on the Monday prior to payday. In the absence of the Administrative Director, the CEO will submit the payroll. a.Payroll email is to be sent to the payroll company for processing and cc'd to the CEO. 2.All employees must submit a bi-weekly Daily Activity Report timesheet on the Monday prior to payroll to be paid. Daily Activity Reports will be maintained in each employee folder. a.Daily Activity Reports (Timesheets) are to be completed daily and shall include any mileage or reimbursements incurred each day. b.Failure to complete a Daily Activity Report as required may result in the employee not being credited for the hours worked. C.The Life Changes internal payroll department is authorized to process payroll solely for the hours claimed at the close of each pay period. d.Any hours claimed after the close of a pay period must be submitted to the full Personnel Committee, accompanied by a detailed explanation for the failure to report the hours in a timely manner. All 3.payroll information is confidential. The CEO, Board Treasurer and Administrative Director are the only people who shall have access to the payroll file. 4.Upon receipt, the CEO and the Administrative Director will review all payroll information. Client Service Fees/Sliding Scale/Health Insurance Payments 1.Life Changes, Inc. shall maintain separate fiscal records & receipts for each client. 2.No client will be denied services based on their ability to pay. When grant/contract funds are available for billing transitional bed nights, no client will be charged rent. Rather, the client will be required to maintain a savings account as evidenced by proof of a deposit slip with a local bank. 3.Insurance Billing - All clients will be assessed for Medicaid health insurance eligibility to assist in paying for housing fees. If the client is deemed eligible, Life Changes, Inc. staff coordinate billing with Medicaid company and will assist any new clients with the application process. When services are covered or partially covered by a third party, Life Changes, Inc. will work directly with the third party on the client's behalf (with signed release and consent Client fiscal records/receipt shall include the following information: a.First and Last Name of client. b.Date of payment, amount paid and dates of coverage. C.Indicate method of payment, whether paying by cash, check and/or money order. d.The receipt will be signed by staff collecting fees and submitted for deposit weekly. 4.Clients will receive an original (white) copy of the receipt. Client Service Fee Record and Documentation 1.Payment of client service fees will be discussed with each client prior to intake into the residential facility. 2.Prior to intake it will be determined if the client is eligible for alternative funding or if the client is to be fiscally responsible. a.Should it be determined the client is fiscally responsible a clear explanation of any fees charges will be provided. 3.The clients bed space will be charged weekly from the date of their intake for seven days. Should the client discharge prior to a full seven days, their fees will be pro-rated. 4.Any and all payment made by or on behalf of the client shall be recorded in the client electronic record. 5.The client electronic records are available for the client to review upon request. Paying Bills by Check-Purchasing & Expenditures 1.The program shall maintain a checking account for the purpose of paying bills. 2.The CEO and/or Board Treasurer shall be the Authorized signer on the checking account and shall complete the authorized signer form required by the bank. 3.Each request for payment must be accompanied by an invoice. No payment will be made without back-up documentation. 4.The CEO shall review and approve all invoices prior to payment. 5.The CEO shall generate a check and Administrative Director shall indicate in writing on all invoices "paid," write check number and date of payment on invoice. 6.The CEO shall ensure all payments are accurate, copy the required documentation for grant reimbursement, mail all payments and accurately file all invoices. Check Writing 1.The program shall maintain a checking account for the purpose of paying bills. 2.The CEO and Board Treasurer shall be the "Authorized Signers" on the checking account and the authorized signer form required by the bank will be completed. In the absence of the CEO, check signing duties will default to the Board Treasurer. 3.The CEO and/or Administrative Director shall review, initial, and authorize all invoices prior to payment. 4.The CEO or Board Treasurer shall generate check and indicate in writing on all invoices "paid," write check number, date of payment, amount paid and include appropriate grant/contract code when applicable.

Bad Debt Policy 1.Upon discharge from Life Changes, Inc. transitional living program, clients will be required to meet with the resident manager to set a payment schedule for any outstanding fees. 2.The resident manager shall come to an agreement, in writing, concerning timely payment of fees. It is not the intent of Life Changes, Inc. to impose a financial hardship on any client, any reasonable payment will be agreed upon. However, Life Changes, Inc. maintains that payment of outstanding fees must be made in a reasonable amount of time. If 3.a client fails to honor his/her agreement within 30 days of time of discharge, the bill will be forwarded to a collection agency. 4.If no payment is made by the end of the fiscal year the outstanding monies will be written off as bad debt within the agency budget. 5.All paperwork regarding outstanding fees will be forwarded to the client's parole or probation officer, when applicable.

Financial Security-Monitoring Standards It shall be the responsibility of the CEO to ensure all monies are appropriately accounted for. Should a discrepancy or questionable expenditure arise the CEO shall immediately contact the Board Treasurer with documentation regarding the expenditure. Should the discrepancy or questionable expenditure involve the CEO the Board of Directors will be consulted immediately. A system of checks and balances is in place to ensure monies are treated, recorded, and deposited in a manner to protect the integrity of the program and staff as follows:

1.Life Changes Inc. shall utilize a money bag for storage of all checks and cash brought into the organization. The money bag shall be placed in the locked area when not in use. 2.At no time shall cash or checks be left unsecured. The 3.transitional living facility shall have a locked cabinet on premises. All client service fees shall be placed in the locked cabinet. When money changes hands within the organization, the staff person receiving the cash shall initial and date they have received the money. Financial Review/Audit Preparation/Grants/Contracts 1.The CEO shall cause to have a paper trail of all income and expenditures on an ongoing basis. 2.The CEO and/or Administrative Director shall conduct quarterly internal audits of all expenditures. 3.The CEO and/or Administrative Director shall conduct quarterly internal audits of all grant/contract funding backup documentation. 4.All electronic fiscal grant/contract files shall include the request for reimbursement, a copy of the received check and/or direct deposit notice. 5.As new fiscal procedures are created the requirements of Title 2 Code of Federal regulations 200.501 regulating requirements for a single audit shall be the primary concern.

Credit/Debit Cards Credit/Debit cards shall be maintained in the name of Life Changes. Inc., The Board of Directors shall assign responsibility for correct usage of the credit/debit card to the CEO. Only those persons authorized shall have access to the credit/debit cards. 1.All credit/debit card transactions must receive prior approval from the CEO. 2.All credit/debit card transactions shall be accompanied by a legible receipt. 3.Replacement of lost credit/debit card receipts shall be the responsibility of the person making the transaction. If a duplicate receipt is used the receipt must be marked "original receipt lost, duplicate copy." 4.If a lost credit/debit card receipt cannot be replaced, it shall be the responsibility of the person making the transaction to reimburse the company for the charge. 5.The CEO or Administrative Director shall assign proper coding to the credit/debit card slip. 6.Final approval of all credit/debit card transactions shall be with the CEO. 7.Misuse of the company credit/debit card and/or continuous lost credit/debit card receipts shall result in removal from the approved list of authorized users and/or disciplinary action. Purchases/Procurement 1.The CEO is the sole individual allowed to make purchases using any form of payment that belongs to Life Changes, Inc., unless otherwise authorized by the Board of Directors. 2.The CEO is approved to obligate Life Changes, Inc. up to $1,000.00 beyond any budget category without Board approval. 3.Any purchase by the CEO over $5,000.00 must be brought to the Board of Directors for approval. 4.A minimum of three bids will be acquired to find the most competitive, cost-effective price and to ensure impartiality. Retention Of Records 1. All fiscal records will be kept for a minimum of seven (7) years in a locked and secured area or if electronic, must adhere to cyber security practices. Inventory Control - Supplies/Equipment 1. On a monthly basis, all departments will take inventory of supplies and submit an electronic request for supplies. All food storage areas will be clean, orderly, and temperature maintained at appropriate levels. 2.On an annual basis, each department will review the complete inventory list of equipment that pertains to their department/facility. All obsolete items will be deleted from the list. All new equipment will be added to the list, including description, serial number (if applicable), cost or value, if donated and location. Food Stamps/Medicaid Application 1.All client admissions into Life Changes, Inc. will be assessed for Food Stamp/Medicaid Eligibility. Those found to be eligible will fill out a Food Stamp/Medicaid Application during the transitional living admission process. 2.Life Changes, Inc. staff will clearly explain the benefits of the different types of Medicaid. At no time will Life Changes staff choose the type of Medicaid an individual will receive. All new applications will be given to the Welfare Division Case Worker within 24 hours. Gift Acceptance Policy 1.Unrestricted, outright gifts are acceptable in any amount. Cash 2. a.Life Changes, Inc. accepts cash, checks, money orders, MasterCard, and Visa. b.All checks should be made payable to Life Changes, Inc. and should not be made payable to an employee or volunteer for credit to Life Changes, Inc. C.All checks are deposited in the ordinary course of business. No employee is authorized to delay deposit. 3.Publicly Traded Securities a.Life Changes, Inc accepts securities, which are traded on the New York Stock Exchange, American Stock Exchange, NASDAQ, or other readily available markets. The gift of any securities with market restrictions must be approved by the Treasurer. b.Securities accepted by Life Changes, Inc. are sold as soon as practicable, unless it is decided by the Board to hold the securities as investments of Life Changes, Inc. Life Changes, Inc. shall convert the securities into cash and then reinvest that money into a cash-like, fully liquid, principally protected vehicle that provides a small yield to fight the effects of inflation, unless otherwise voted upon by the Board d.To maximize tax-saving benefits to the donor, it is advised that donors transfer appreciated securities directly to Life Changes, Inc. instead of selling the securities and gifting the proceeds. To maximize their capital loss deductions, donors are advised to sell depreciated securities and gift the proceeds to Life Changes, Inc. The donor is responsible for contacting his/her financial professional to inform him/her of the desire to transfer shares of securities to Life Changes, Inc.Life Changes, Inc. staff may assist in the gift process by contacting the financial professional to ensure the transaction takes place in as short a time as possible. Securities are recorded and valued the date they are deposited in Life Changes, Inc.'s account.

i. The value of a gift of security is derived from the meaning of the high and low prices per share on the date of the gift. ii. For bonds donated, accrued interest is also included in the gift amount. The Life Changes, Inc. gift acceptance committee considers gifts of real property, both improved and unimproved (e.g., detached single-family residences, condominiums, apartment buildings, rental property, commercial property, farms, acreage, etc, including gifts subject to a retained life estate, only after a thorough review of the criteria for acceptance set forth below under the direction and supervision of the Board 1.The minimum acceptable fair market value for a gift of real property is $50,000. Property must be readily marketable and have a clear title capable of being insured by a reputable title company at regular rates unless it is otherwise decided by the Board of Directors. a.Full interests, partial interests, and remainder interests in real property are all acceptable. Remainder interests are contracts. In the case of such gifts, the donor is expected to agree to pay all property taxes, maintenance expenses, and any property indebtedness. b.Assets may be given outright, serve as the corpus of a trust arrangement, or in the case of a personal residence, be given with the right of lifetime tenancy by the donor and/or the donor's spouse. C.Criteria for Acceptance of Real Property i.Market value and marketability-The gift acceptance committee must receive a current appraisal of the fair market value of the property and interest in the property Life Changes, Inc. would receive if the proposed gift were approved. The development & communications director informs the donor that, if the gift is completed, the IRS requires an appraisal made within 60 days of the date of the gift and that it is Life Changes, Inc.'s policy to dispose of all gifts of real estate, other than property which Life Changes, Inc. wishes to retain, as expeditiously as possible. Thus, regardless of the value placed on the property by the donor's appraisal, Life Changes, Inc. attempts to sell at a reasonable price considering current market conditions. ii.Potential environmental risks-All proposed gifts of real property, including gifts from estates, must be accompanied by an environmental audit performed at the donor's expense. The only permitted exception to this requirement is for residential property that has been used solely for residential purposes for a significant (at least twenty-year) period. In cases where this exception applies and no environmental audit is undertaken, the donor/executor may be required to execute an environmental indemnity agreement. Even in the case where an environmental audit is submitted, the donor may be required to sign an environmental indemnity agreement. iii.Limitations and encumbrances-The existence of all mortgages, deeds of trust, restrictions, reservations, easements, liens, and other limitations of record must be disclosed. No gift of real estate is accepted until all mortgages, deeds of trust, liens, and other encumbrances have been discharged, except in very unusual cases where the fair market value of Life Changes, Inc.'s interest in the property, net of all encumbrances, is substantial. iv.Carrying costs-The existence and amount of any carrying costs, including but not limited to, property owners' association dues, country club membership dues and transfer charges, taxes, and insurance, must be disclosed by the donor prior to acceptance of the property by Life Changes, Inc. V.Title information-A copy of any title information in the possession of the donor, such as the most recent survey of the property, a title insurance policy, and/or an attorney's title opinion, must be furnished. vi.Additional considerations include the following: 1.Type of real property and location 2.Purpose of the gift (e.g., endowment, unrestricted) 3.Any potential Life Changes, Inc. use 4.Any special arrangements requested by the donor concerning disposition (e.g., price considerations; time duration prior to disposition; potential buyers; or realtors/brokers with whom the donor would like Life Changes, Inc. to list the property, etc vii. The execution and delivery of a deed of gift or other appropriate conveyance completes the gift. The costs associated with the conveyance and delivery of the gift, including but not limited to, recording fees and, if deemed necessary by the Board, a current survey, title insurance, and/or an attorney's title opinion, are the donor's responsibility. Section 4 - Housing Policies Non-Discrimination Policy Life Changes, Inc., offers transitional housing and/or sober living for clients who need clean and sober, supportive housing while engaging in behavioral health or other supportive services. It will be the responsibility of Life Changes, Inc, in accordance with Title I of the Housing and Community Development Act of 1974 and 1977, and other related federal regulations, to ensure that no client will be denied services due to race, creed, color, national origin, age, sexual orientation, or physical disability. All housing services will be operated in accordance with Life Changes, Inc.'s policies and procedures including the written protocols of the Board of Directors, Organizational Management, Fiscal, Personnel and Health and Safety protocols. Housing Services Defined Sober Living is a type of temporary housing for people who are homeless or at risk of homelessness. It aims to help them move to permanent housing within 24 months or less. All housing services provide supportive services such as supervision, life skills education, Peer Recovery Support Services and medical/behavioral health care referrals. SAPTA Certified Transitional Housing services consist of a supportive living, drug free environment for individuals who are receiving outpatient substance abuse treatment through a SAPTA Certified Intensive Outpatient Level 2.1 or Outpatient Level 1 program and who are without appropriate living alternatives. Clients seeking Transitional Housing must sign a Release of Information (ROI) between the SAPTA Certified Treatment Agency and Life Changes, Inc. to disclose information specific to the client's level of care, admission, continued stay and discharge. Ongoing communication, to ensure the highest level of success for the client, will be authorized for the period of time the client is engaged in Life Changes Transitional Housing services.

Individuals admitted to Transitional Housing services must be concurrently admitted to a Level 1 Outpatient or Level 2.1 Intensive Outpatient program per an assessment. The American Society of Addiction Medicine (ASAM) 6-dimensional assessment must be reviewed to ensure there is sufficient risk in Dimension 6: Recovery Environment. The individual remains in Level 1 or Level 2.1 and ASAM Dimensional reviews reveals continued risk in the Recovery Environment. The individual does not require a higher level of care. The individual needs a higher level of care per ASAM Dimensional review and is transferred. The individual has gained stable/supportive housing/recovery environment and no longer needs Transitional Housing. Limitation on Number of Admissions In accordance with NAC 449.154917, Life Changes, Inc. shall only admit the number of residents to the facility for which it is licensed. Criteria for Admission Screening/Referrals Life Changes, Inc. facilities maintains at least one on-site manager and a 24-hour per day, seven days per week, on call person. The CEO, or her designee, will be responsible for screening potential clients and determining their eligibility for transitional VS sober living services. Eligibility includes the following criteria: 1.Assessing where Life Changes, Inc. meets the client's current need. For example, just housing VS. housing and substance abuse counseling or peer recovery support services.

a.Should substance abuse counseling be required, the client will be referred to a community agency licensed in this practice with which Life Changes, Inc. holds a memorandum of understanding (MOU b.The specific needs of the applicant will determine which facility the applicant is eligible for. Assessing client's readiness to change. 3.Willingness to participate in peer recovery support services when deemed necessary through an individualized client care plan 4.Client must agree to fully engage in services whether it be as a Transitional Housing or Sober Living client and comply with all Life Changes program requirements. 5.The client must be physically able to obtain employment within fourteen (14) days, attend the referenced workforce development activities and pay program fees or have a funding source that will pay housing costs for the client. a.Clients who are not medically cleared to work but have documented proof of such and a third-party payee source are eligible for housing services. 6.Client must not have a criminal conviction of arson, a sex offense or violence against a minor, senior, or disabled person. 7.Client must be able to self-evacuate and be ambulatory to care for personal needs and hygiene. 8.The client must sign a written contract for services which details the requirements of the facility. 9.Prior to entry, a prospective client must complete an application for residential services. Theapplication will be reviewed by the Client Care Coordinator to determine eligibility and appropriateness of the applicant for residential services. a. b.The Client Care Coordinator may consult executive staff to determine eligibility. 10.Referrals for Sober Living or Transitional Housing include area treatment providers, social services, criminal justice entities, other community-based organizations and/or self- referrals. 11.Any referrals made on behalf of the client will include follow-up by the Client Care Coordinator to ensure client engagement. Additional Recruitment Procedure It is the policy of Life Changes, Inc. to notify area treatment centers and other community-based organizations via telephone and email regarding bed availability. Additionally, Life Changes, Inc.'s website has an application for potential clients to complete and a public computer lab on-site at the Life Changes administrative offices. Admission Client Files It is the practice of Life Changes, Inc. to maintain HIPAA compliant electronic records of all current and past clients. In accordance with NAC 49.154943, each client record will include the following: 1.Signed Contract for Residency 2.Release of Information for contract with treatment providers and/or any other entity that may require contact (e.g., criminal justice entity, vocational rehabilitation worker, prior treatment providers, etc 3.Name and telephone numbers of the vendors, medical/mental health professionals, criminal justice entities and others that provide services for the client. 4.Formal or informal write-ups or disciplinary actions 5.Discharge status including any special conditions for readmission. 6.Signed HIPAA policy. 7.Signed orientation to the program rules and regulations. 8.Client picture 9.Rights as a resident form 10.Full name, address, and date of birth 11. Name and contact information for emergency contact. 12. List of program rules signed by the client. 13. Case notes 14.Other Storage of Clinical Records 1.All client records shall be held in a HIPAA compliant electronic file which requires password access. 2.All client records shall be in an electronic format and paper files will not be utilized. 3.Electronic records shall have redundant external backups held in two separate locations in secure safes with limited access. Staff Access 1.Staff may have access to the clinical records only to the extent required to perform their assigned job duties. 2.If a person on staff has prior knowledge that may interfere with the treatment of a client, arrangements can be made for separate secure storage of the client record to ensure that the staff person is denied access to it. Client Access 1.Any client of Life Changes, Inc., may gain access to their file, providing the staff is present. Staff should inquire as to what items the client needs to view and may not hand over the entire client file. It is also acceptable for the client to receive copies from his/her file at a charge of ten cents per copy. 2.Each client of Life Changes, Inc. shall be required, as a condition of admission and continued service, to provide Life Changes, Inc. with a signed client consent to disclose identifying client information to the Washoe County Health District if a communicable disease must be reported in compliance with state law. 42 CFR, part 2 and 45 CFR do not make exception to the general rule requiring client consent in this circumstance. Confidentiality & Releasing Client Identifying Information The general rule in 42 CFR, part 2 is that identifying client information may be released only with signed client consent in a format containing the requisite elements specified in 42 CFR, part 2. Additionally, all clients will be informed of 45 CFR, the HIPAA, "Privacy and Confidentiality Notice" and how their information will be used/disclosed. Clients will have a signed copy of the Privacy and Confidentiality Notice in their case file. 1.Standard Consent Form: The standard, i.e., restricted, and revocable" consent form shall be used whenever the client and Life Changes, Inc. wish to share identifying client information with any party other than those providing criminal justice supervision. Areas not applicable will be lined out and initialed by clients and/or staff. 2.Release of Information in a Criminal Justice Context: "i.e., Unrestricted and irrevocable" shall be used only for exchange of identifying client information with those providing criminal justice system supervision. Areas not applicable will be lined out and initialed by clients and/or staff. Release of Identifying Client Information in the Absence of Signed Client Consent: Reporting of Neglect or Abuse of Minor Children: In the event that a staff person has reasonable suspicion of neglect or abuse of a minor child, a report shall be made to the proper authorities for investigation independent of whether the client has provided consent for such a report. Such a report in the absence of signed client consent is authorized by 42 CFR, part 2 and 45 CFR, only for the initial report. Any subsequent communication with the proper authorities in which identifying client information is disclosed may be made only with signed client consent or the order of the court with proper jurisdiction. a.If the suspected neglect or abuse occurred in Nevada and the report is being made during normal business hours, the report is to be made to the Division of Child and Family Services, Reno Field Office at 775-785-8600. b.If the suspected neglect or abuse occurred in Nevada and the report is being made after normal business house or if the suspected neglect or abuse occurred outside of Nevada, the report is to be made to law enforcement personnel in the area where the abuse is suspected to have occurred.

Reporting of Elder Abuse & Exploitation: Nevada law requires that neglect, abuse, or exploitation of the elderly be reported to the proper authorities, 42 CFR part 2 and 45 CFR do not make exception to its general rule in this circumstance. Accordingly, if a staff person has reasonable suspicion that any elderly person is subject to neglect, abuse or exploitation, a report shall be made to the proper authorities in one of the following manners: Anonymously, to ensure that no person's status as a client is disclosed; or after having sought and obtained, in a timely manner, order from a court of proper jurisdiction. Medical Emergencies: In the event of a medical emergency, identifying client information may be released to authorized medical personal to the extent required for proper care of the client. 42 CFR, part 2 and 45 CFR provide an exception to the general rule in this circumstance. Crimes on Program Premises, Crimes Against Program Staff, or Threats to Commit Such Crimes: In the event of crimes on program premises, crimes against program staff or threats to commit such crimes a report to law enforcement shall be made independent of client consent. 42 CFR, part 2 and 45 CFR provide an exception to the general rule in this circumstance. Audit & Evaluation: Agencies conducting audit and evaluation activities who have regulatory authority over the agency may be provided access to identifying client information for the purposes of audit and evaluation if such agencies provide Life Changes, Inc. with written assurance required by 45 CFR, part 2. No written authorization is required under 45 CFR, parts 160-1647. Research Activities: Identifying client information may be released to entities conducting bonafide research in the absence of signed client consent if such entities have developed research protocols which have been made subject to the scrutiny required by 42 CFR, part 2 and have provided Life Changes, Inc. written assurance required by 45 CFR, part 2. No written authorization is required under 45 CFR, parts 160-164. Tarasoff Warnings If Life Changes, Inc. staff have good cause to believe that a client may kill or seriously injure an identified victim, staff shall notify law enforcement and shall make a good faith effort to warn the intended victim. If the danger to others appears to be the product of a mental disorder, the medical emergency protocol shall be followed and a Tarasoff warning issued only if the protocol fails to resolve the dangerousness. 42 CFR, part 2 does not make exception to its general rule in this circumstance, however, it is the position of Life Changes, Inc. that the greater good principal applies, and that the injury incurred upon the client by inappropriate disclosure of identifying client information is far less that the potential injury to the potential victim. Staff of Life Changes, Inc. who invokes the "Tarasoff Warning" protocol shall make every effort to confer with a member of upper management prior to invoking. Should the situation be an emergency, staff shall rely on his/or her best judgment and fully document the situation, the steps taken to notify upper management, the process of notifying law enforcement and the intended victim on a Critical Incident Report Form. The completed form must be immediately forwarded to the staff person's immediate supervisor who will in turn forward the information to the Board President/CEO within 120 minutes of the incident. Subpoena & Court Orders: A subpoena signed by a judge may order that identifying client information be produced in court. A subpoena by any other party only requests such a production and does not require it. It does not require nor authorize the release of such information to any party after its production in court. Only a subpoena combined with a special court order will be honored. A subpoena alone does not warrant disclosure. In any event, subpoenaed identifying client information shall only be released with written consent of the client. A client's written authorization is required under both Confidentiality Laws and HIPAA 45 CFR, parts 160, 162 and 165 when releasing any information to law enforcement agencies. Release Pursuant to a Qualified Service Organization Agreement (QSOA):2F3/ QSOA established between Life Changes, Inc. and another organization or party is recognized by HIPAA to be sufficient in nature and not also require a signed "Business Associate Agreement: Release of HIV Seropositive Related Information: Information identifying a client's HIV seropositive status - whether it is positive or negative - is subject to confidentiality protection more stringent than the general confidentiality standards of 42 CFR, part 2, but inclusive of 45 CFR. Such information will be released only: 1.With SAPTA approved signed separate and explicit consent from the client. Such a consent must: a.Be on a separate consent to release information form (e.g., a consent to release information form allowing release of "intake assessment, discharge summary and HIV/AIDS information" would result in release only of intake a discharge summary) b.Explicitly allow release of HIV seropositive information (e.g., consent to release "treatment records" would not allow release of HIV seropositive information) C.Contain the required elements of consent to release information according to the standards of 42 CFR, part 2 and 45 CFR. 2.Upon order of a court with competent jurisdiction. 3.While providing regulatory agencies exercising their audit function access to clinical records. 4.When release of HIV seropositive information is required during compliance with Nevada communicable disease reporting requirements. Communicable Disease Life Changes, Inc. clients will be offered testing for communicable diseases in cooperation with a local community agency qualified to conduct such testing. Clients are not required to disclose the results of these tests except in the case of TB. If the entity providing the testing does not provide pre and post counseling, Life Changes, Inc. will provide this service at no charge to the client. AIDS/HIV Disease: No applicant to Life Changes, Inc. will be asked to take an HIV test to enter or receive treatment. Any client who chooses to be tested for HIV can request off-site testing services. Upon entering treatment, all clients will be informed of the off-site testing services available. The results of the test will be given privately and in person to the client by the testing entity nurse. The client is not required to disclose the results of the test. However, upon request by the client, Life Changes, Inc. staff will refer the client to appropriate resources to improve the quality of life for the HIV positive client. No prospective, current, or past client of Life Changes, Inc. will be denied services due to being HIV positive. No client or staff member will be treated differently due to suspicion or knowledge that he/she is HIV positive or has AIDS.

2 Duty to warn means that the staff person must verbally tell the intended victim that there is a foreseeable danger of violence. Duty to protect implies a therapist determining that his or her patient presents a danger of violence to another and an obligation to use reasonable care to protect the intended victim against danger (Harvard Mental Health Letter, 2008, January This may entail a warning, police notification, or other necessary steps. 3 A qualified service organization (QSO) means a person or organization that: 1) provides services to a [Part 2] program, such as data processing, bill collecting, dosage preparation, laboratory analyses, or legal, medical, accounting or other professional services or services to prevent or treat child abuse or neglect, including training on nutrition and child care and individual and group therapy, and 2) has entered into a written agreement with a program under which that person a) acknowledges that in receiving, storing, processing or otherwise dealing with any patient records from the programs, it is fully bound by these regulations; and b) if necessary, will resist in judicial proceedings any efforts to obtain access to patient records, except as permitted by these regulations. Where a Part 2 program has entered a QSOA with an entity that provides any of the covered services, and where the information exchanged is needed to provide the covered services, patient consent is not required. (42 CFR § 2.11)

Other Communicable Disease: No prospective, current, or past client of Life Changes, Inc. will be denied services on the grounds of having been diagnosed as having TB, Hepatitis, STD, or other communicable diseases. However, if a client's medical condition prevents him/her from participating in any activity that is a program requirement (e.g., attendance of group therapy sessions) he/she will be required to postpone admission until he/she is medically stable enough to participate in all program requirements. All clients who have Hepatitis B will need written orders from the Northern Nevada HOPES and/or their personal physicians, at the time the diagnosis is confirmed, that delineate the proper procedure to be followed to prevent the spread of infection to others. All clients having a positive TB skin test be referred to an appropriate health provider to receive an x-ray and will need written confirmation from an appropriate health provider, T.B. Nurse, or the client's personal physician, that the disease is no longer contagious before admission and/or readmission to the program. If a client cannot receive an x-ray immediately, or the next business day, an incident report will be written and concerned local, and state entities will be notified. Communicable Disease Education: All clients will receive formal education on the transmission, symptoms, and treatment of T.B., Hepatitis, HIV, and other common STD's. These formal education presentations will be presented quarterly. In addition to formal education presentations, the issue of educating clients about communicable disease will be addressed, by Life Changes, Inc. staff members, during counseling sessions and/or other program activities whenever and wherever it is appropriate to do SO. All staff members will be provided with education relative to Hepatitis B and the Hepatitis B vaccine, in accordance with OSHA regulations. Life Changes, Inc. staff members will encourage and promote safe sex practices, including abstinence from sexual activity, as a form of preventing communicable diseases. However, staff members will refrain from making moral or value judgments about clients based on the client's past sexual activities or choice of sexual lifestyle. Client Cooperation in Preventing the Spread of Communicable Disease: Clients who have been diagnosed as having a communicable disease and refuse to follow the medical procedures that are recommended by Life Changes, Inc., Northern Nevada HOPES and/or the personal physician - both in terms of treatment of their own disease and avoiding the infection of others only will be discharged for non-compliance with program rules when all avenues have been exhausted. In the interest of confidentiality, the treatment record of any client who is discharged for non-compliance with medical recommendation for treatment of the HIV/AIDS disease will state simply "non-compliance of program rules in terms of refusal to follow medical advice" with no mention of the specific disease for which the client was being treated. Universal Precautions Procedures All staff members of Life Changes, Inc. will observe the standard UNIVERSAL PRECAUTIONS for protection against occupational exposure to HIV/AIDS and other communicable diseases. These include: 1.Treatment of all bodily fluids, blood and blood-borne pathogens are to be treated as potentially infectious. a.Immediate clean-up of all spills of blood with diluted bleach (use at least nine parts water, 1-part bleach) b. Placement of potentially infected waste impervious bags. Disposal of bags must be in accordance with guidelines set forth by Life Changes, Inc. for disease control. C.Use of protective equipment, including use of pocket masks when resuscitation of a client becomes necessary. d.Following appropriate methods for sterilization, disinfecting, and general housekeeping. e.Use of gloves by staff members during the handling of bodily fluids. f.Washing of hands, after gloves are removed, with a 10% bleach solution. The 2. ProgramManager is responsible for ensuring that all clients have documented Tuberculosis (TB) test results in their files within the required time frame. a.Clients with a positive TB skin test will be referred to Reno Diagnostic Center, Renown Clinic, or another appropriate medical facility for an X-ray. If an applicant tests positive for TB, they must provide an X-ray report from an approved medical facility before intake. Additionally, admission requires written confirmation from the Washoe County Health Department TB Nurse or the client's personal physician verifying that the disease is no longer contagious. b.If a client cannot receive an X-ray immediately or by the next business day, an incident report will be filed, and SAPTA, along with the Washoe County Health Department, will be notified. (Revised 2/26/2025) 3.The Program Director will complete a contagious risk assessment with each client and will encourage clients who fall into high-risk categories to take the HIV/AIDS test. Community-Based Outreach Model Life Changes, Inc. will provide outreach services directly and/or enter into cooperative agreements with other agencies which provide similar services. Life Changes, Inc. will use the National Institute on Drug Abuse's (NIDA's) Community-Based Outreach Model as the foundation for developing its program. In adhering to 45 C.F.R. Part 96.126, Life Changes, Inc. 's outreach efforts will include all the following: 1.Electing, training and supervising outreach workers. 2.Contracting, communicating, and following up with high-risk substance abusers, their associates, and neighborhood residents, within the constraints of Federal and State confidentiality requirements, including 42 C.F.R. Part 3.Promoting awareness among injecting drug abusers about the relationship between injecting drug abuse and communicable diseases such as HIV. 4.Recommend steps that can be taken to ensure that HIV transmission does not occur; and 5.Encouraging entry into treatment. Retention Of Records 1.Life Changes, Inc. will retain client records for a minimum of seven (7) years after the client's discharge unless the chief of the bureau and the state health officer specifically authorize disposition at an earlier time. 2.In case of demise of the agency, all client files will be transferred to the appropriate State agency or destroyed under the direction of said State agency.

Clinical Records of Clients 1.Ensure that a record is maintained for each client. The record must include:

a.Identification information. The name, age, gender, race, ethnicity, and permanent address of the client. i.Past medical and social history. ii.Copies of initial and periodic examinations. iii. Evaluations and progress notes. iv. A review and any revisions of each plan of treatment. If b.services are funded by an outside entity, an evaluation of the financial status of the client is sufficient to determine eligibility for such services. C.Any consent to release information which satisfies the requirements set forth in 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164. d.The source of any referral to the program. e.The original plan of care for the client and all revisions to the plan of care. f. The plan of care, stated in quantifiable terms, outlines goals to be accomplished through individually designed activities, therapies, and treatments. The plan of care will state what service or person is responsible for the treatment or services to the client. g. h.Entries will be made describing the services and referrals rendered, self-administered medications, and any symptoms or other indications of illness or injury, including the date, time and action taken regarding each incident

2. Anyadditional information that should be taken into consideration during the planning of care, determination of appropriate referrals and determination of any need for coordination of care 3.Documentation of any discussion with the client concerning the results of the needs assessment, appropriate referrals, and any barriers to care. 4.The date, type, and duration of any contact with the client, and any services provided to the client. 5.Documentation of any: a.Incident that may cause imminent danger to the health and safety of the client, other clients or staff, or persons outside the treatment program. b.Problem involving the client. C.Infraction of the rules of the treatment program by the client; and d.Sign or symptom of illness or injury of the client. e.Documentation in support of services that the care program provides to the client, including, without limitation, any: i.Correspondence concerning the client; and ii. Results of a test conducted on the client, including, without limitation, any test conducted by a laboratory. If 6.the client is transferred to a different location or provided a different service, including a service provided by the same operator, a copy of the case note made at the time of transfer which includes, without limitation: i.Diagnosis of the client at the time of admission or intake. ii. The response of the client to the care plan. iii. iv.Recommendations for persons who will be providing care to the client. 7.After the client is discharged from the program: a.Documentation that a copy of the plan for continuing care of the client, including, without limitation, any referrals given to the client, was provided to the client before discharge, if possible. 8.A copy of the notification, which was signed by the client, indicating: a.The procedure for the client to register a complaint and to appeal a decision by the program concerning a complaint. b.The requirements for the confidentiality of client information set forth in 42 C.F.R. Part 2, 45 C.F.R. Parts 160, 162 and 164 and any other applicable federal or state laws governing the confidentiality of client information for the service provided; and C.Any other rights of the client that are specified by the Division. 9.Ensurethestaff readily has access to the client records to the extent authorized pursuant to 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164. that 10.Maintain a system for the maintenance and protection of client information which satisfies the requirements set forth in 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164, including, without limitation, requirements for: a.Adequate provisions to prevent unauthorized access or theft of any form of a record of a client. b.The locked storage of paper records. C.Adequate provisions for a system of backup of records maintained in a computer system in case of a failure of the primary system. d.Retention of the records of each client for not less than 6 years after the client is discharged from the treatment program, to be made available as required pursuant to 45 C.F.R. Parts 160, 162 and 164; and e.Appropriate methods to destroy records of clients as required by federal regulation. 11.Ensure that each client has access to their records as required pursuant to 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164.

(Added to NAC by Bd. of Health by R120-04, eff. 10-5-2004; A by R104-14, 10-27-2015)

Itis the policy of Life Changes, Inc. to comply with the standards of 42 CFR, part 2, and 45 CFR with the sole exception of Tarasoff warnings as specified below. Information which identifies a client's HIV seropositive status - whether positive or negative - is subject to confidentiality protection more stringent than the requirements of 42 CFR, part 2 as specified below. Client Safety Procedures 1.A fire drill will be held monthly, and a report of the results will be submitted to the administrative offices and held on site. 2.The Onsite Manager will conduct quarterly checks of all smoke alarms. All bedroom doors containing self-closing devices will remain closed when the room is unoccupied or during sleeping hours. 3.At least one first aid kit will be maintained at the facility and be accessible to all people. 4.The Onsite Manager will complete an "incident report" form any time a client, while on LIFE CHANGES, INC. premises, is involved in any incident, no matter how minor,has thator might have in the future, an impact on the physical well-being of the client. The written report must be submitted to the administrative offices for review within 24 hours. 5.All employees with direct client contact will be provided with CPR training on a bi-annual basis and a copy of the CPR certification will be placed in the employee file. 6.If the facility is rendered unsafe because of fire or other disaster, the evacuation plan will be followed to lead all clients and staff to safety. After everyone is safely out of the facility, 911 will be called to contact the appropriate agency. 7.Appropriate outside agencies, such as the Salvation Army, Gospel Mission, Red Cross, etc., will be contacted to arrange for temporary shelter for transitional living clients. 8.Monthly evacuation drills will be conducted at the facility under staff supervision on a regular basis. The Onsite Manager will log the results of such drills. Client Health & Hygiene 1.No client will share personal toiletry items, such as: razors, toothbrush, comb, clippers, towels, bar soap, etc. Power Of Attorney 1.A client or participant of Life Changes, Inc. is forbidden to grant power of attorney to Life Changes, Inc. or any member of it's staff. Emergency Health/Medical Services 1.In the event of a medical emergency on facility premises, dial 911 and request assistance. 2.An incident report shall be completed and forwarded to Board President/CEO within 120 minutes. 3.In the event of a medical emergency, the consent of client is not required to disclose identifying client information to authorized medical personnel to the extent required for appropriate care of the client. Critical Incident(S) Reporting 1.As required by NAC 458.279, the Board President/CEO, will notify the Board of Directors, regulatory agencies and/or funders, when applicable, of an incident that may cause imminent danger to the health and safety of the staff of the program, a client of the program or a visitor to the program. 2.Management onsite at the time of the critical incident will notify their immediate supervisor of an incident that may cause imminent danger to the health and safety of the staff of the program, a client of the program or a visitor to the program. Onsite management will treat any incident out of the ordinary as a critical incident and will report such to their immediate supervisor. The Program and/or Clinical Director will immediately notify the Board President/CEO of such incident.

Policy:It is the policy of Life Changes, Inc. that all critical incidents will be reported immediately to the Board President/CEO or designee. The Board President/CEO will be responsible for notifying applicable local or state entities who in turn will be responsible for notifying the Division Administrator or Deputy Administrator of the Division of Public and Behavioral Health:

The Division Administrator will report any high profile or unusual incidents to the Director of the Department of Health and Hum Services. The Division Administrator or Deputy Administrator will be responsible for determining what constitutes high profile or unusual incidents. Purpose/Reference: Life Changes, Inc. Board of Directors and staff have the responsibility of ensuring the safety and interests of all its clients, employees, volunteers, and visitors as a "high priority" by immediately responding to and addressing any critical incidents described within this policy and responding appropriately to remediate or rectify them. All individuals who are actively receiving services from Life Changes, Inc. will be required to complete a report in the event of a critical incident. All critical incidents will be reported on a Critical Incident Reporting Form. Definitions & Reporting Codes: The letters in parenthesis at the end of each category are data entry codes. Critical incidents are categorized as follows:

1.Suicide (S): Deliberately self-inflicted death of a person receiving services. 2.Death (D): Death of a person receiving services not caused by suicide or death of an employee during working hours. 3.Suicide Attempt/Threat (SA): Act committed by a person receiving services to cause their own death or a plausible statement that they intend to hurt themselves. The threat of suicide does not need to be reported to a funding source but must be included in an internal incident report. 4.Assault/Violence/Threat (AV): Instances in which a person receiving services assaulted someone or is assaulted or a person receiving services makes or receives threats of harm or violence. 5.Abuse/Neglect (AN): Abuse is defined as any willful infliction of pain or injury upon a person receiving services by anyone else. This includes, but is not limited to: a.Rape, sexual assault, or sexual exploitation of the client. b.The use of any type of aversive intervention i. Except as otherwise provided in NRS 433.54863F4, a violation of NRS 433.549.4F5 C.The use of physical, chemical, or mechanical restraints or the use of seclusion in violation of federal law. 6.Eloped/Missing/AWOL (A): Any person receiving services who is missing from the program's facility. People receiving services who are discharged against medical advice (AMA) are not considered eloped. 7.Injury/Illness (I): A physical injury or illness incurred while a person is under the supervision of a program that is serious enough to require medical attention or admission to an acute care hospital. Any accident occurring during employment that results in the hospitalization of three or more employees must be reported to OSHA within 8 hours after the accident is reported to any agent or employee of the employer, per NRS 618.378. 8.Legal/Criminal (L): A person receiving services is suspected or accused of committing a crime or program staff contact with law enforcement or media regarding alleged criminal activity by a person receiving services. Also, reports in the media regarding alleged client criminal activity. 9.HIPAA (H): If there has been a breach or a HIPAA violation, this shall be noted in the incident report and state funders HIPAA privacy officer will be notified immediately following receipt of the report. 10.Other: Any event that adversely affects, or has the potential to affect, the health and safety of a person receiving services, provider staff, or volunteers who are on-site for any purpose that does not fall into one of the other categories above. This includes, but is not limited to, the following examples: a.Evacuation, fires, floods, hazardous materials events. b.Property damage. C.Sexual acting out that does not meet the definition of abuse. d.Potential media events; and e.Potential agency liability issues.

Procedures: In the event of a critical incident, involving one or more clients, staff or volunteers, Life Changes, Inc. staff will be following the reporting procedure set forth below: 1.All State or Federally Funded Programs: All critical incident events will be reported using the designated reporting codes above on the Critical Incident Reporting Form. A typed report on the form detailing information regarding the client/program participant and a detailed description of the event, including names of witness(es), will be e-mailed, or faxed to pertinent local or state entities as soon as possible, but in no case later than the end of the first working day after the incident occurs. This policy/procedure does not preclude the normal course of documentation in client files. 2.During and outside of normal business hours Life Changes, Inc. Board President/CEO or designee will notify the Board of Director either verbally or through electronic correspondence and the appropriate local or state entity within 30 minutes of becoming aware of any critical incident that may be considered high profile or of media interest. 3.Local and state entities will determine if a formal investigation of the incident is warranted and will determine how the investigation should be conducted. If a decision is made by the Division Administrator or Deputy Administrator to have the investigation completed by staff outside of its agency, the Division Administrator will appoint the investigators. A types and detailed report of the investigation, along with recommendations, will be forwarded to the Agency Director and a final report will be forwarded to the Division Administrator or Deputy Administrator within ten (10) working days of the investigation being assigned. Investigators will follow established protocols and procedures in completing their report. Within five (5) days of receipt of the investigation report, the Agency will forward the investigation report to the Board President/CEO of the reporting program with a request for a Corrective Action Plan. The incident may be closed at the time an investigation has commenced, in which case all correspondence, corrective action, and follow-up will be focused on the results of the investigation. 4.If a formal investigation is not warranted, a follow-up report will be sent to the Agency ten (10) working days after the initial incident report. Follow-up reports will be forwarded by pertinent state or local entities to the Division as requested by the Division Administrator or Deputy Administrator until closure of the incident is appropriate. 5.In the event of a client death, a copy of the coroner's report will be requested by pertinent local or state entities. If the client's death was due to other than natural causes, a detailed description of the client's service history will be included in the initial incident report, and a formal death review will be requested. A copy of all incident reports of client deaths will be forwarded to the appropriate Medical Director and the Division of Public and Behavioral Health's (DPBH) Medical Director. After consultation between the two, the DPBH Medical Director will make the decision if further information or a more in-depth review is necessary.

4 NRS 433.5486 Use of physical, mechanical or chemical restraint on consumer by facility authorized in certain circumstances. Notwithstanding the provisions of NRS 433.549 to 433.5503, inclusive, to the contrary, a facility may use or authorize the use of physical restraint, mechanical restraint or chemical restraint on a person with a disability who is a consumer if the facility is: 1. Accredited by a nationally recognized accreditation association or agency; or 2. Certified for participation in the Medicaid or Medicare Program, only to the extent that the accreditation or certification allows the use of such restraint. (Added to NRS by 1999, 3230; A 2011, 420) NRS433.549 Use of physical, mechanical, or chemical restraint on consumer by person employed by facility prohibited; exceptions. A person employed by a facility, or any other person shall not: 1. Except as otherwise provided in NRS 433.5493, use physical restraint on a person with a disability who is a consumer. 2. Except as otherwise provided in NRS 433.5496 and 433.5499, use mechanical restraint on a person with a disability who is a consumer. 3. Except as otherwise provided in NRS 433.5503, use chemical restraint on a person with a disability who is a consumer. (Added to NRS by 1999, 3231; A 2001, 2744; 2011, 420)

In the event of an employee death or an accident, which results in the hospitalization of three or more employees during working hours, the appropriate program director will notify ASHA within eight (8) hours of the death or accident, per NRS 618.378. 1.The decision to notify law enforcement of any client incident will be made by the provider's CEO. If law enforcement agencies are to be notified, the notification must occur within 24 hours of the incident. In the event of stolen property from a state agency, law enforcement must be notified immediately. If confidential information, such as a client's name, is disclosed to law enforcement agencies, a formal denial of rights form must be filed at the time such notification occurs. 2.The provider CEO may request assistance from DPBH, through SAPTA, for assistance in briefing staff involved in residential death, other unusual death, or critical incident of high profile or unusual circumstances. SAPTA will notify the Division and Division staff trained in debriefing will be utilized to meet with program staff and conduct the debriefing. The debriefing will take place no more than five (5) days after the incident occurs. The debriefing is intended to provide support to staff involved in difficult or unusual incidents. 3.Suicides or high profile/unusual deaths will be reported by pertinent local or state entities to the Division, the Mental Health Commission, and to the Department at the closure of the incident. Detection Of Complications/Conditions Life Changes, Inc. staff will monitor all clients for the early signs of complications common among drug abusers. Safeguarding Client's Records Client's records shall be held in a restricted area, in a cabinet, a file, or other type of container that can be locked or in a computer system where access is limited with a password. Managing & Safeguarding Client's Money & Property Clients are informed that Life Changes, Inc. staff will not take custody or be responsible for a client's money or property at the time of admission. Clients are further informed that they will be responsible for the safeguarding of their money and property while living at Life Changes, Inc. Clients are advised not to bring any large sums of money onto the premises and that they should open a bank account to safeguard their money. In addition, clients are advised not to bring property of any great value onto the premises. To do otherwise could be counterproductive to our attempts to achieve responsibility, discipline, social stability, and the coping skills necessary for independent living. Medication Monitoring Applicants, who are stable on medication maintenance for the treatment of an opioid use disorder, including FDA approved medications, will not be denied services. The following protocol will be followed: 1.All over the counter medication is self-monitored and Life Changes, Inc. is not responsible for client medications. 2.Prescription medication to which a client must have immediate access (e.g., asthma inhalers, nitroglycerine tables, etc will be retained in the client's possession. 3.Clients must take medication as prescribed. 4.All other prescription medication will be secured in a safe location by the House Leader/Manager and the following medication monitoring protocol implemented: a.Medication stored in a safe location by the House Manager must be clearly marked and retrieved only by residents. b.Client will be provided with access to medication on a case-by-case basis. C.Staff will document the type and quantity of medications relinquished to the client's custody, and the client will initial the medication log. d. Medications must be taken as prescribed, unless there is a written notification from the physician that the dosage has been changed. Documentation will be attached to the medication log. e.There will be a separate medication log for each client. f.All medication counts shall be done by the client under the observation of staff. g.All expired medications or medications left in the custody of Life Changes, Inc. thirty (30) or more days, after the client leaving the program, shall be turned in to CEO for disposal. h.CEO, or her designee will conduct quarterly inspections of the medication storage area and medication logs and will document the inspection. i.Any adverse reaction by a client to a medication must be documented in a client's file and reported to staff. a.Client will self-administer medication, and this will be observed by a staff person who has been oriented to the program policies and procedures of self-administration of prescription medication. 5.Upon suspicion of abuse of medication, Life Changes, Inc. reserves the right to refer a client for urinalysis testing. 6.In the instance of illness, staff MUST be notified. Residents must disclose to the physician that they are in recovery from substance abuse and should not be prescribed narcotic drugs. Client Rights Clients of Life Changes, Inc. have the following rights: 1.Not to be abused, neglected, or exploited by another resident or any other person visiting the facility. 2.To speak to any person who advocates for your rights. 3.To be treated with dignity and respect. 4.To enjoy a facility environment that is a safe and comfortable haven for you. 5.To interact socially with other residents. 6.To make your own decisions consistent with facility rules. 7.To vote. Client Grievance It is the policy of Life Changes, Inc. to treat each client with due respect, courtesy and with dignity. However, if a client has concerns about the services they are receiving, they have the right to voice their concerns through the grievance process and shall not be subject to retribution or any other adverse consequences for doing so. All clients, participants and staff have the right to appeal any decision with threat or reprisal. 1.The client is to speak to the Resident Manager and explain the problem. If a solution acceptable to the client is not found, the client is to submit a signed written grievance to the CEO at with the words "client grievance" in the subject line. The grievance will be presented at the next regularly scheduled staff meeting. The response to the client will be presented in writing within five working days of the meeting. 2.If the response does not resolve the matter to the client's satisfaction, client may have a personal interview with the CEO within 3 days of requesting the interview. 3.If the interview does not resolve the grievance to the client's satisfaction, the client may have an interview with the Board of Directors for consideration at their next regularly scheduled meeting. The client may attend the meeting of the Board of Directors and discuss the grievance with the board. 4.The board may discuss the merits of the grievance in executive session and shall act on the grievance in the form of a board resolution, which shall be communicated to the client. The decision of the board is final. 5.Should the client have further concerns, the client may address their concerns to the organizations licensing entity. a.Nevada Department of Health and Human Services Division of Public and Behavioral Health Bureau of Health Care Quality and Compliance 72 Fairview Dr. Suite E, Carson, City, NV 8970, or b.Nevada Department of Health and Human Services Division of Public and Behavioral Health Bureau of Behavioral Health Prevention and Wellness

Substance Use Prevention, Treatment and Recovery 4126 Technology Way, Suite 200, Carson City, NV 89706

6.Life Changes, Inc. shall maintain a log that lists: a.All complaints with the facility that are filed. b.The actions taken by the facility to investigate and resolve the complaint; and C.If no action was taken, an explanation as to why no action was taken. 7.The telephone number of the CEO and contact information in 5.a. will be conspicuously posted on the premises of the facilities. Discharge It is the policy of Life Changes, Inc. to require two individual staff members to agree on the terms of discharge for everyone. Approval for all discharges is to be finalized by the CEO. All documentation as described below is required to be completed in a timely manner and placed in the file. Discharges are to be staffed with the CEO. In the event of the absence of the CEO, she may assign a designee to act in her stead. Life Changes, Inc. operates a residential component and provides wrap around services through an outside agency. The residential component is appropriate for at risk individuals who need housing and a structured living environment. Discharge from the residential component does not constitute discharge from wrap around services. Life Changes, Inc. strives to return each client to the community as clean and sober individuals capable of becoming an asset to the community, their families, and the workforce. It is our goal to empower each client of the program to grow both spiritually and intellectually and learn tools to become responsible individuals. There are four specific incidents when a client may be discharged from the program. At no time will Life Changes, Inc. discharge or transfer a client of the facility based on discrimination against a client for the source of payment for the services provided. 1.Successful Discharge: A successful discharge from Life Changes, Inc. is indicated by a client's ability to be self-supporting, obtain independent housing or transfer to another appropriate facility, completion of intake assessment plan, creation of aftercare plan and continued sobriety. Client may be discharge from residential housing when all residential goals are met. 2.Administrative Involuntary Discharge. It is the philosophy of Life Changes, Inc. that all clients have the right to a safe, stable, and therapeutic environment in which to pursue treatment, maintain recovery and residency. Any client who compromises this right may be subject to discharge from the program. A client may be terminated from the program if two program staff (including the CEO) determine that a client poses an immediate and substantial risk of physical or emotional harm to other clients, program personnel, volunteers, or property. Staff must collectively determine the clients continued stay would not be conducive to a safe, stable, and therapeutic environment; the client may be immediately discharged. a.Violation of, but not limited to, the following may be cause for immediate discharge. Following appropriate investigation and documentation, staff collectively determines if the violation is severe enough to require immediate discontinuation of services. i.Violence or threats of violence (to self or others ii. Entering the facility under the influence of mind- or mood-altering chemicals including alcohol. Must be documented through a urinalysis and/or Breathalyzer. iii.A positive urinalysis or Breathalyzer for mind- or mood-altering chemicals. iv.Possession of mind-altering chemicals (includes prescription and non-prescription drugs and alcohol V.Substantial non-compliance with program rules. b.Staff may determine collectively that a client's continuous non-compliance with program policies and protocols presents reasonable cause for discharge. i.Examples: 1.Violation of stated and posted program rules. 2.Non-compliance with program policies 3. Non-compliance with program contract. a.NOTE: Violation of items listed in Item 3.b.i., ii. And iii. is defined as three or more infractions of any program rule within a 7- day period and must be documented in client file. C. Continuous non-compliance with program rules which extends the 7-day period may result in discontinuation of services. 3.Administrative Voluntary Discharge A client may be given an Administrative Voluntary Discharge in the following circumstances: a.Client chooses to leave prior to program completion. Administrative Discharge Procedure An administrative discharge requires a 30-day restriction before a client can reapply for services. Other conditions for re-admission may be required (for example, completion of residential treatment, proof of employment, paying outstanding program fees A client wishing readmission to the program must have the approval of two staff members.

If a client is given an Administrative Discharge, the following procedures must be implemented:

1.Two staff members (including the CEO) must agree that it is in the best interest of the client, the facility, and the community that the client is discharged. 2.If it is deemed the client would be a danger to self, others or the community, the following protocol is in place: a.If under the influence of a mood or mind-altering substance, the client must be immediately relieved of vehicle keys (if applicable b.The Reno Police Department dispatch (775-334-2121) must be immediately contacted. C.CEO must be immediately contacted for those individuals under the supervision of any judicial system, specialty court or the State of Nevada, Department of Parole and Probation. The CEO will determine if Parole and Probation is to be immediately contacted, if not, will report said incident by 9:00 AM the following morning. d.Client must be isolated away from current clients of the program e.Any other necessary precautions to protect the safety of the client, fellow clients, the facility, and the community must be implemented. f.Client must be provided with written referral sheet, which includes instructions to immediately contact the State of Nevada Department of Parole and Probation (if applicable), area treatment providers, social service organizations, and housing options including the homeless shelter. Staff will request a Breathalyzer and Urinalysis test g. i.If the client is unwilling to comply, the refusal must be documented in the client file. ii.If the client complies, a clean, photocopy of the test strip for the Urinalysis must be made. In clients own writing, the following statements must be clearly written, in blue ink, on the photocopy "I, (name of client) attest this photocopy is a true and accurate rendition of the UA I gave on (date) at (time)" Client must sign and date statement. Staff giving UA must witness statement. h.The situation must be treated as a critical incident and a critical incident policy followed. Ifit 3.isdeemed the client is not a danger to self, others, or the community two staff members may collectively agree to the following: i.Item 2.g. above regarding Breathalyzer and Urinalysis test must be followed. ii.If a single room is available and safe alternate housing is not available, client may be provided immediate overnight isolation from other clients to facilitate the ongoing safety of the client and the community. If iii.space is not available onsite at Life Changes, clients must be referred to alternate housing such as the homeless shelter or a self-pay motel. NOTE: At no time will Life Changes be financially responsible for the costs incurred. Death 4. a.If a client expires on Life Changes property, Reno Police Department must be immediately notified.

i.The Executive and Program Directors must be immediately notified. 1.Program staff will be immediately contacted to provide support services for all clients, staff, and volunteers. b.Item 2.c. above regarding notification of State of Nevada Department of Parole and Probation must be followed. C.Fellow clients must be detained away from the scene of the incident. d.If a deceased client is housed in a shared room, the roommate must be immediately moved. e.Within 24 hours, the CEO will provide or arrange for the following services: i.Crisis/grief counseling in group setting ii. Crisis/grief counseling in individual setting iii. Be available to provide or arrange for crisis/grief support to next of kin/significant others, etc. iv. Complete Critical Incident report per policy. V.Provide follow-up supports for individuals as necessary f.A Critical Incident report must be filed within 24 hours and Critical Incident policy followed. g.Discharge Instruction Sheet The Discharge Instruction Sheet will be initiated by residential staff, in the appropriate areas, and completed at the time of discharge. The Discharge Instruction Sheet will be complete with contact information for all aftercare providers. This document will be placed in the client file, provided to the client, with a copy provided to any aftercare service providers. Smoking There shall be no smoking in LIFE CHANGES, INC. facility. Smoking is prohibited except in designated smoking areas only. Safety From Fire Refer to emergency action plan

In accordance with NAC 449.154999 Safety from fire. 449.037), LIFE CHANGES, INC. Shall adhere to the following:

1.The facility will comply with regulations adopted by the State Fire Marshal pursuant to chapter 477 of NRS and any local ordinances relating to safety from fire. 2.A plan for evacuation of clients in case of fire or another emergency shall be: a.Understood by all residents. b.Posted in a common area of the facility. C.Discussed with each resident at the time of his/her admission. 3.At least one portable fire extinguisher must be available at the facility. Any portable fire extinguishers available at the facility must be inspected, recharged, and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections. 4.A written policy on smoking is available and carried out by the facility. The policy must be: a.Developed with the purpose of preventing fires caused by smoking in the facility. b.Posted in a common area of the facility. 5.Smoke detectors installed in a facility must always be maintained in proper operating condition and must undergo a formal test quarterly and an informal test monthly. The results of the tests conducted pursuant to this subsection must be recorded and maintained at the facility. a.Formal tests will include the following: i. Alarm securely mounted ii. No evidence of damage iii. Ventilation holes clean and free of obstructions iv. Signal sounds when test is operated V. Information regarding change of battery or replacement of unit. 6.If an automatic fire sprinkler system is installed in a facility, the system must be inspected: a.Not less than once each calendar quarter by a person who understands the way the system operates and the way the system must be maintained. b.Not less than once each calendar year by a person who is licensed to inspect such a system pursuant to the provisions of chapter 477 of NAC. Client Safety Procedures 1.A fire drill will be held monthly, and a report of the results will be maintained on clip board at facility. The Resident Manager will conduct monthly checks of all smoke alarms and replace batteries as needed but no less often than every six (6) months. All bedroom doors containing self-closing devices will remain closed when the room is unoccupied or during sleeping hours. 2.Life Changes, Inc. will conduct a disaster drill at least annually and will retain a written record of each drill for no less than 12 months after the drill is conducted. 3.Life Changes, Inc. retains a written plan for disasters which outlines procedures for members of the staff and clients to follow in case of fire or another emergency and which provides for meeting the needs of clients if the facility must be evacuated or is destroyed. A copy will be available to all staff in the facility. 4.At least one first aid kit will be maintained at the facility and be accessible to all people, and staff members will have evidence that they have training in the use of first-aid supplies. 5.Resident Manager and/or other staff on duty will complete an "incident report" form every time 911 is called or a client, while on Life Changes, Inc. premises, is involved in any incident, no matter how minor, that has or might have in the future, an impact on the physical wellbeing of the client. Calls made to 911 will be the responsibility of the Resident Manager on duty. The incident must be reported to the CEO via cell phone then a written report submitted no more than 24 hours following an incident. A client may not refuse emergency medical services unless the responding agency verifies that the client's wellbeing is not in jeopardy. 6.All employees with direct client contact will be required to obtain CPR & First Aid training on a bi-annual basis and a copy of the certification will be placed in the employee file. 7.If the facility is rendered unsafe because of fire or other disaster, the evacuation plan will be followed to lead all clients and staff to safety. After everyone is safely out of the program, 911 will be called to contact the appropriate agency. Appropriate outside agencies, such as the Salvation Army, Gospel Mission, Red Cross, etc., will be contacted to arrange for temporary shelter for transitional living clients. Periodic fire and evacuation drills will be conducted at the facility under staff supervision on a regular basis. The Resident Manager on duty will log the results of such drills. Client Health And Hygiene No client will share personal toiletry items, such as (razors, toothbrush, comb, clippers, towels, bar soap, etc Power Of Attorney No client will be asked to grant power of attorney to Life Changes, Inc., or its staff, except to the extent required by the Nevada Board of Pharmacy for the purpose of medication monitoring. Emergency Health/Medical Services 1.In the event of a medical emergency on program premises staff on duty will dial 911 and request assistance. 2.An incident report shall be completed, and the file forwarded to the CEO. 3.In the event of a medical emergency, the consent of client is not required to disclose identifying client information to authorize medical personnel to the extent required for appropriate care of the client.

Detection Of Complications/Conditions Life Changes, Inc. staff will monitor all clients for the early signs of complications common among drug abusers. Drug addiction is a brain disease. Although initial drug use might be voluntary, drugs of abuse have been shown to alter gene expression and brain circuitry, which in turn affect human behavior. Once addiction develops, these brain changes interfere with an individual's ability to make voluntary decisions, leading to compulsive drug craving, seeking and use. The impact of addiction can be far reaching. Cardiovascular disease, stroke, cancer, HIV/AIDS, hepatitis, and lung disease can all be affected by drug abuse. Some of these effects occur when drugs are used at high doses or after prolonged use, however, some may occur after just one use. Critical Incident(S) and Serious Occurrence Policy & Reporting Procedures As required by NAC 458.279, the CEO, will notify the Board of Directors and/or the Substance Abuse Prevention and Treatment Agency (SAPTA) as soon as possible, but in no case later than the end of the first working day after any incident occuring that may cause imminent danger to the health and safety of the staff of the program, a client of the program, a volunteer of the program or a visitor to the program OR may jeopardize the integrity of the operation of the facility. Policy: It is the policy of Life Changes, Inc. that all critical incidents will be reported immediately to the CEO or designee. The CEO will be responsible for notifying the Substance Abuse Prevention and Treatment Agency (SAPTA) who in turn will be responsible for notifying the Division Administrator or Deputy Administrator of the Division of Public and Behavioral Health: The Division Administrator will report any high profile or unusual incidents to the Director of the Department of Health and Human Services. The Division Administrator or Deputy Administrator will be responsible for determining what constitutes high profile or unusual incidents. Purpose/Reference: Life Changes, Inc.'s Board of Directors and staff have the responsibility of ensuring the safety and interests of all its clients, employees, volunteers, and visitors as a "high priority" by immediately responding to and addressing any critical incidents described within this policy, and taking appropriate measures to remediate or rectify them. All individuals who are actively receiving services from Life Changes, Inc. will be required to complete a report in the event of a critical incident. All critical incidents will be reported on a Critical Incident Reporting Form. Definitions and Reporting Codes: The letters in parenthesis at the end of each category are data entry codes. Critical incidents are categorized as follows: 1.Suicide (S) - Deliberately self-inflicted death of a person receiving services. 2.Death (D) Death of a person receiving services not caused by suicide or death of an employee during working hours. 3.Suicide Attempt/Threat (SA) Act committed by a person receiving services in an effort to cause their own death or a plausible statement that they intend to hurt themselves. A threat of suicide does not have to be reported to the Agency, but should be part of the funded program's internal incident report (substance abuse treatment programs should assure that their internal agency policies address this 4.Assault/Violence/Threat (AV) - Instances in which a person receiving services assaulted someone or is assaulted, or a person receiving services makes or receives threats of harm or violence. 5.Abuse/Neglect (AN) - Abuse is defined as any willful infliction of pain or injury upon a person receiving services by anyone else. This includes, but is not limited to: a.Rape, sexual assault, or sexual exploitation of the client; b.The use of any type of aversive intervention; i.Except as otherwise provided in NRS 433.5486, a violation of NRS 433.549 and C.The use of physical, chemical, or mechanical restraints or the use of seclusion in violation of federal law. Any act which meets the standard of practice for care and treatment does not constitute abuse. Neglect means any omission to act that causes injury to a client or that places a client at risk of injury, including, but not limited to, the failure to follow: An appropriate plan of treatment to which the client has consented; The policies of the facility for the care and treatment of clients; and Standard of practice, which means "the skill and care ordinarily exercised by prudent professional personnel engaged in health care." 6.Eloped/Missing/AWOL (A) Any person receiving services who is missing from a funded program's facility. People receiving services who are discharged against medical advice (AMA) are not considered eloped. 7.Injury/Illness (I) A physical injury or illness incurred while a person is under the supervision of a funded program that is serious enough to require medical attention or admission to anacute care hospital. Any accident occurring in the course of employment that results in the hospitalization of three or more employees must be reported to OSHA within 8 hours after the accident is reported to any agent or employee of the employer, per NRS 618.378. 8.Legal/Criminal (L) A person receiving services is suspected or accused of committing a crime, or program staff contact with law enforcement or media regarding alleged criminal activity by a person receiving services. Also, reports in the media regarding alleged client criminal activity. 9.HIPAA (H) If there has been a breach or a HIPAA violation, this shall be noted in the incident report and the Division's HIPPA Privacy Officer will be notified immediately following receipt of the report by SAPTA. 10.Other (O) - Any event that adversely affects, or has the potential to affect, the health and safety of a person receiving services, provider staff, or volunteers who are on-site for any purpose that does not fall into one of the other categories above. This includes, but is not limited to, the following examples: a.Evacuations, fires, floods, hazardous materials events; b.Property damage; C.Sexual acting out that does not meet the definition of abuse; d.Potential media events; and e.Potential agency liability issues. Procedures: In the event of a critical incident involving one or more clients, staff, or volunteers, Life Changes, Inc. staff will follow the reporting procedure set forth below: 1.All SAPTA Funded Programs: All critical incident events will be reported using the designated reporting codes indicated above on the Critical Incident Reporting Form. A typed report on the form detailing information regarding the client/program participant and a detailed description of the event, including the names of witness(es), will be e-mailed or faxed to SAPTA as soon as possible, but in no case later than the end of the first working day after the incident occurs. This policy/procedure does not preclude the normal courseof documentation in client files. 2.During normal business hours the Life Changes, Inc. CEO or designee will verbally notify the Life Changes, Inc. Board of Directors and the SAPTA Division Administrator or designee within 30 minutes of becoming aware of any critical incident that may be considered high profile or of media interest. Outside of regular work hours (Monday-Friday, 8am-5pm), the Exective Director of Life Changes, Inc. or designee will call the SAPTA Division Administrator and leave a recorded message. 3.SAPTA will determine if a formal investigation of the incident is warranted and will determine how the investigation should be conducted. If a decision is made by the Division Administrator or Deputy Administrator to have the investigation completed by staff outside of SAPTA, the Division Administrator will appoint the investigators. A typed and detailed report of the results of the investigation, along with recommendations, will be forwarded to the Agency Director and a final report will be forwarded to the Division Administrator or Deputy Administrator within ten (10) working days of the investigation being assigned. Investigators will follow established protocols and procedures in completing their report. Within five days (5) of receipt of the investigation report, the Agency will forward the investigation report to the CEO of the reporting program with a request for a Corrective Action Plan. The incident may be closed at the time an investigation has commenced, in which case all correspondence, corrective action, and follow-up will be focused on the results of the investigation.

4.If a formal investigation is not warranted, a follow-up report will be sent to the Agency ten (10) working days after the initial incident report. Follow-up reports will be forwarded by SAPTA to the Division as requested by the Division Administrator or Deputy Administrator until closure of the incident is appropriate 5.In the event of a client death, a copy of the coroner's report will be requested by SAPTA. If it appears that the client's death was due to other than natural causes, a detailed description of the client's service history will be included in the initial incident report, and a formal death review will be requested. A copy of all incident reports of client deaths will be forwarded to SAPTA's Medical Director and DPBH's Medical Director. After consultation between the two, the DPBH Medical Director will make the decision if further information or a more in- depth review is necessary. 6.In the event of an employee death or an accident which results in the hospitalization of three or more employees during working hours, the appropriate program director will notify OSHA within eight (8) hours of the death or accident, per NRS 618.378. 7.The decision to notify law enforcement of any client incident will be made by the provider's CEO. If law enforcement agencies are to be notified, the notification must occur within 24 hours of the incident. In the event of stolen property from a State agency, law enforcement must be notified immediately. If confidential information, such as a client's name, is disclosed to law enforcement agencies, a formal denial of rights must be filed at the time such notification occurs. 8.The provider CEO may request assistance from DPBH, through SAPTA, for assistance in briefing staff involved in residential death, other unusual death, or critical incident of high profile or unusual circumstances. SAPTA will notify the Division and Division staff trained in debriefing will be utilized to meet with program staff and conduct the debriefing. The debriefing will take place no more than five (5) days after the incident occurs. The debriefing is intended to provide support to staff involved in difficult or unusual incidents. 9.Suicides or high profile/unusual deaths will be reported by SAPTA to the Division, the Mental Health Commission, and to the Department at the closure of the incident.