Hubbert Homes — Staff Workflow Diagram
Hubbert Homes

Staff Workflow Diagram

🔒 HIPAA Compliant Ritten + Pear Suite

Staff Roles & System Access

All staff handling PHI follow HIPAA minimum-necessary standards. EHR entry (Ritten) is restricted to the VA. CHW uses Pear Suite as primary documentation. Housing Coordinator is the central operational hub bridging clinical and non-clinical staff.

⚠️
HIPAA Note: PHI may only be shared on a need-to-know basis using secure channels. Drug test results route directly to the VA — non-clinical staff receive failed-test notification only, with no clinical detail. All incident and health-related records are entered into EHR by the VA only.
👤
CEO / Executive Director
Clinical · Final Decision Authority
  • Final approval: all intake decisions (approve / waitlist / reject)
  • Reviews CEO-tagged CRM items before deciding
  • Final approval: all discharge decisions
  • Immediate authority for safety/serious misconduct discharge
  • Clinical and operational compliance oversight
Ritten Pear Suite Ritten (CRM)
🩺
Community Health Worker (CHW)
Clinical
  • Receives warm handoff from Housing Coordinator upon move-in
  • Conducts intake assessment & develops assembly/care plan
  • Documents all client notes in Pear Suite (primary system)
  • Notifies Housing Coordinator + Lead Residents of updates
  • Collaborates with Housing Coordinator on less-serve discharge recommendations
  • Documents Kaiser client notes in Charm (Kaiser clients only)
Pear Suite (primary) Charm (Kaiser)
📋
Clinical Consultant
Clinical
  • Clinical oversight and guidance to care team
  • Supports CHW with complex case review
  • Reviews clinical documentation as needed
Pear Suite Charm (Kaiser)
🏠
Housing Coordinator
Hybrid · Central Coordination
  • Reviews intake applications; documents written recommendation with reasons
  • Manages Ritten (CRM) for all final intake decisions
  • Notifies all applicants of status in writing
  • Coordinates door code creation prior to move-in
  • Performs warm handoff to CHW upon client move-in
  • Receives failed drug test notification from VA only
  • Adds incident reports to Ritten (non-clinical)
  • Delivers written notice to clients for incidents and discharge
  • Initiates discharge for service/rule violations
  • Collaborates with CHW on less-serve discharge recommendations
Ritten (CRM) Ritten (Non-Clinical)
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Virtual Assistant (VA)
Non-Clinical · EHR Data Entry
  • Receives drug test results directly; records all results in Ritten
  • Notifies Housing Coordinator of failed tests only (no clinical detail)
  • Notifies CHW of failed drug tests
  • Uploads client intake documents into Pear Suite upon admission
  • Manually duplicates CHW Pear Suite notes into Ritten
  • Updates EHR upon discharge
Ritten (EHR) Pear Suite
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Lead Residents
Non-Clinical · On-Site
  • First responders to on-site incidents
  • Report incidents to Housing Coordinator
  • Receive operational updates from CHW (no PHI)
  • Receive failed drug test notification from Housing Coordinator
  • Drug test updates by form
Form-based updates Email
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Administrative Assistant
Non-Clinical · Administrative
  • Manages grievance submissions and tracking
  • Manages maintenance requests and follow-up
Ritten (EHR) Ritten (Non-Clinical)

Intake Workflow

From referral through move-in, care plan, and dual-system setup. CEO makes all final admission decisions. CRM is auto-populated on form submission. Warm handoff to CHW occurs on move-in day.

CEO Housing Coordinator VA CHW - - - Automated
1
Intake Form Submitted Auto
Referral partner or applicant completes the intake form. Ritten (CRM) is automatically updated with intake form data upon submission — no manual entry required.
📌 Applies to both Ritten and Pear Suite programs. Auto-population ensures consistent, timestamped records from the moment of referral.
2
Housing Coordinator Reviews & Recommends Housing Coord. Ritten (CRM)
Housing Coordinator reviews the application in Ritten (CRM) and prepares a written recommendation with documented reasons: approve, waitlist, or reject.
📌 All three outcomes require a written reason on file for fair housing compliance. Reasons are documented before CEO is tagged — never after.
3
CEO Tagged in Ritten (CRM) for Final Decision CEO Required Ritten (CRM) Tag
Housing Coordinator tags CEO in Ritten (CRM). CEO reviews the recommendation and documented reasons before making the final admission decision. No communication goes to the applicant until CEO decides.
⚠️ CEO tag is mandatory — do not skip. This step protects the organization and creates an audit trail for every admission decision.
CEO Decision — Three Outcomes
✅ Approved
  • Housing Coordinator notifies applicant in writing
  • Client creates door code prior to move-in
  • VA uploads intake docs into Ritten (EHR)
  • Client moves in
  • Housing Coordinator performs warm handoff to CHW
⏳ Waitlisted
  • Housing Coordinator notifies applicant in writing
  • CRM status updated to Waitlist
  • Re-evaluated when bed becomes available
❌ Rejected
  • Housing Coordinator notifies applicant in writing
  • Reason documented in CRM (fair housing record)
  • CRM status updated to Rejected
4
VA Uploads Intake Docs to Ritten VA Ritten EHR PHI
Upon confirmed move-in, VA uploads all intake documentation into Ritten. Client is activated as a current resident in the EHR. Applies to both Ritten and Pear Suite program tracks.
📌 VA is the sole staff member who enters data into Ritten. No other staff should upload directly to EHR.
5
Warm Handoff: Housing Coordinator → CHW Housing Coord. CHW
On move-in day, Housing Coordinator formally introduces the client to the CHW and transfers care coordination responsibility. The handoff is the trigger for clinical engagement to begin.
📌 The warm handoff should occur in person or by phone on move-in day. Housing Coordinator confirms the handoff is complete before closing out the intake workflow.
6
CHW Conducts Intake Assessment & Care Plan CHW Pear Suite
CHW meets with the client to complete the intake assessment and develop an individualized assembly/care plan. All documentation is entered in Pear Suite. CHW then notifies Housing Coordinator and Lead Residents of the completed plan.
📌 After completing the care plan in Pear Suite, CHW notifies the VA. VA manually duplicates the notes into Ritten to maintain dual-system records. See CHW Notes tab for full documentation flow.

Drug Testing Workflow

Test results are PHI and route directly to the VA for EHR entry. Non-clinical staff receive failed-test notification only — never the full results. This preserves HIPAA minimum-necessary standards throughout.

🔒
HIPAA Minimum-Necessary: Drug test results are protected health information. Only the VA receives full results. Housing Coordinator and Lead Residents are notified of failed tests only — no substance name, level, or clinical detail is shared with non-clinical staff.
1
Drug Test Administered
Client drug test is conducted per program policy. Results are treated as PHI from this point forward.
2
Witness / Administrator Completes Form Lead Resident Housing Coord. CEO
Whoever witnesses or administers the test — Lead Resident, Housing Coordinator, or CEO — completes a single documentation form. No duplicate forms. These roles have no direct EHR access; form is the only record they maintain.
📌 One form per test, completed by the person present. Form-based records only — no Ritten or Pear Suite access for these roles.
3
Results Sent Directly to VA VA PHI
Test results route directly to the VA — not through the Housing Coordinator or Lead Residents. VA is the sole recipient of full clinical test results.
4
VA Records All Results in Ritten VA Ritten EHR
VA enters the drug test results into Ritten — both passed and failed. This is the official system of record for all test data.
Result Outcome
✅ Passed
  • Recorded in Ritten by VA
  • No further notification required
  • Housing Coordinator and Leads are not notified
❌ Failed
  • VA notifies CHW (clinical follow-up)
  • VA notifies Housing Coordinator: failed result only
  • No clinical details shared (HIPAA minimum-necessary)
  • Housing Coordinator notifies Lead Residents
  • Program consequence policy applied

Incident Reporting Workflow

Incidents escalate from any on-site staff to the Housing Coordinator, who documents in Ritten (non-clinical) and delivers written notice to the client.

1
Incident Occurs On-Site Any Staff
Any staff member present witnesses or is notified of an incident. Staff must immediately document the incident using at least one of the following: video recording, photograph, or written account. Documentation is submitted alongside the incident report.
📌 At least one form of documentation is required — video, photo, or written account. The documenting staff member notifies the Housing Coordinator with the documentation attached.
2
Housing Coordinator Updates EHR Housing Coord. Ritten (Non-Clinical)
Housing Coordinator receives the incident report and documentation and enters the incident into Ritten (non-clinical). This creates the official record of the incident.
📌 Include: incident date, time, nature of incident, client identifier, and attached documentation (video, photo, or written account).
3
Housing Coordinator Issues Written Notice to Client Housing Coord. Written Notice
Housing Coordinator prepares and delivers formal written notice to the client(s) involved. Notice outlines what occurred and any resulting actions or consequences. A copy is retained on file.
📌 Written notice is required for all formal incidents. Retain a copy. This is separate from any verbal communication at the time of the incident.

CHW Notes & Dual-System Documentation

CHW documentation system depends on the client's health plan. Kaiser clients are documented in Charm; all other clients in Pear Suite. All notes are duplicated into Ritten by the VA.

ℹ️
Dual-System Policy: Charm or Pear Suite is the CHW's primary documentation system depending on health plan. Ritten is updated by the VA only. If records ever conflict, Charm or Pear Suite (whichever applies) is the source of truth.
1
CHW Documents Client Notes CHW
CHW completes all client notes, progress updates, and care plan documentation. System used depends on the client's health plan:
Health Plan — System Selection
🏥 Kaiser Client → Charm
  • CHW documents in Charm (Kaiser-required platform)
  • Covers: intake assembly plan, progress notes, care coordination, clinical observations
📋 All Other Clients → Pear Suite
  • CHW documents in Pear Suite (primary platform)
  • Covers: intake assembly plan, progress notes, care coordination, clinical observations
2
CHW Notifies Housing Coordinator & Lead Residents CHW Housing Coord. Leads
After completing documentation, CHW notifies the Housing Coordinator and Lead Residents of relevant updates. Operational context only is shared with non-clinical staff — clinical PHI stays within clinical channels.
📌 Leads receive information on a strict need-to-know basis. Example: "Client X completed care plan session" is appropriate. Clinical assessment details are not shared.
3
VA Duplicates Notes into Ritten VA Ritten EHR PHI
VA manually transcribes or uploads the CHW's notes from Charm (Kaiser) or Pear Suite (all others) into Ritten. This synchronizes both systems and maintains a complete EHR record for CalAIM and partner reporting.
📌 VA completes duplication promptly after CHW notification. Flag any discrepancies to the CHW immediately — do not resolve conflicts unilaterally. Source system is always the source of truth.

Discharge Workflow

CEO makes all final discharge decisions. Three tracks depending on the nature of the situation. All discharges follow the same notification and documentation chain after CEO approval.

Three Discharge Tracks — All Require CEO Final Decision
⚠️ Service / Rule Violations
  • Housing Coordinator initiates
  • Documents reasons in writing
  • Submits recommendation to CEO for final decision
📉 Less-Serve / Step-Down
  • Housing Coordinator + CHW collaborate
  • Joint written recommendation to CEO
  • CEO makes final decision
🚨 Safety / Serious Misconduct
  • Housing Coordinator initiates immediately
  • CEO has immediate decision authority
  • Can bypass full collaborative review process

After CEO decision — all three tracks follow the same notification and documentation chain below.

1
Discharge Initiated with Written Recommendation Housing Coord.
Housing Coordinator (and CHW for less-serve) prepares a discharge recommendation with documented reasons and submits to CEO for review. No action is taken before CEO decides.
📌 Documented reasons are required before escalation to CEO. This protects the organization in any grievance, legal review, or partner audit.
2
CEO Final Decision CEO Approval Required
CEO reviews the recommendation and documentation. CEO approves, modifies, or denies the discharge. For safety/serious misconduct, CEO may decide immediately. For all other discharges, written recommendation review is required.
⚠️ No communication goes to the client until CEO has made a final decision. CEO decision is the authorization to proceed.
3
Housing Coordinator Issues Written Discharge Notice Housing Coord. Written Notice
Upon CEO approval, Housing Coordinator prepares and delivers formal written discharge notice to the client. Notice includes reason for discharge, effective date, and any applicable next steps or referrals.
📌 Written notice is legally required. Retain a copy. Include: discharge date, reason, any applicable appeal rights, and referral to other services where appropriate.
4
Housing Coordinator Updates EHR Housing Coord. Ritten (Non-Clinical)
Housing Coordinator records the discharge in Ritten (non-clinical) — including discharge date, reason, and disposition. Client record is updated to discharged status.
📌 EHR should reflect the discharge before the client's move-out date where possible. This ensures accurate records for CalAIM, partner reporting, and any future referrals.