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Policy Risk management is an attempt to identify and manage threats that could negatively impact the agency. Mid-Ohio Psychological Services, Inc addresses risk by establishing policies, procedures and safeguards to ensure adequate insurance coverage, awareness and honesty among personnel, screening new personnel, developing a plan for coping with disaster, managing physical safety and infection control, and computer information security. The safety of programs will be monitored for significant risk and/or loss including pending lawsuits, loss of grants or other funding; maintaining safe staffing levels; adherence to federal and sate requirements; and reporting reviewing, and monitoring of significant loss to the program and governing authority as determined in the risk management plan. Mid-Ohio Psychological Services Inc. will protect the agency from unnecessary risk in the following manner: Procedures General Safety Any incidents or injuries occurring on Mid-Ohio Psychological Services, Inc. grounds, whether by staff or public, will be immediately reported to the Executive Director or the Clinical Director in the absence of the Executive Director and dictated in the Incident Reporting Policy. Any safety hazards will be reported in the same manner. Each report will be investigated by the Executive Director or their designee. A written report will be made of the action taken and any follow up necessary to prevent future accidents. All new employees will be given a safety orientation. All employees will be given follow-up in-service education at least yearly. People Mid-Ohio Psychological Services Inc. protects the agency, employees, board members, volunteers, clients, and the general public by doing background investigations on all new employees of the agency. Background checks will include contacting previous employers, verifying education and licensing information, contacting references, requesting a Bureau of Criminal Identification and Investigation report, and checking the county courts records. The agency also maintains up to date personnel policies and procedures that included acceptable behaviors for agency employees and background investigations, which can be viewed with all agency personnel policies and procedures. The agency does substance testing for all new employees and any employees who exhibit reasonable suspicion of drug use. Complete details of this testing policy can be located in the Substance Testing Policy and Procedures. The agency requires that all employees fill out a conflict of interest statement annually or when significant changes occur. Complete details can be located in the Conflict of Interest Policy and Procedures. In addition, the agency transfers risk by maintaining proper insurance coverage on the following areas:
Property Mid-Ohio Psychological Services Inc. protects the agency’s property including building, facilities, equipment, and material by having secure locks throughout the building, covering windows in order to obscure the contents of the building from outside, and storing items in secured filing cabinets. In addition, fire doors protect the building from total loss in the case of a fire. Monthly fire and safety inspections are conducted to safeguard against loss due to preventable causes. Building The building or buildings, which house the Mid-Ohio Psychological Services, Inc. will meet or exceed all applicable federal, state, and local codes as well as be in compliance with the provisions of the 1981 edition of the LIFE SAFETY CODE of the National Fire Protection Association unless equivalent methods of protection are provided. Access will be available to handicapped individuals. Restrooms will be equipped with grab bars. All storage areas and stairwells are to remain clean and uncluttered. Physical Security Mid-Ohio Psychological Services Inc. controls physical access to the building at all times, by leaving all entrances to the building secured except the front entrances that are staffed by an employee when clients are in the building. Access to computers is controlled through security passwords and the use of access profiles. The distribution of keys is controlled through one employee so that access to different areas of the building can be controlled. Income Mid-Ohio Psychological Services Inc. protects the agency’s income in many ways, including distributing duties, so that there is a paper chain for all payments that are received by the agency. This includes writing receipts that are sequentially number for all payments. Employees posting payments to the accounts receivable may not make out the deposits for the agency. Two different employees maintain the accounts receivable and the accounts payable. The agency has obtained a line of credit to protect the agency from cash shortages. Further information concerning the segregation of duties can be found in the Financial Management Policy and Procedures. Funding available for services is always monitored closely; any significant changes in funding streams will be reported to the Board of Directors. The agency bills services to private insurance and agencies whenever possible. The agency pursues grant funding whenever possible. Goodwill Mid-Ohio Psychological Services Inc. protects the goodwill of the agency by holding all staff accountable for the behavior they exhibit on behalf of the agency. The agency participates in press releases on information that is important in the community. Reporting and Action Mid-Ohio Psychological Services Inc. requires that any fraud, waste, wrong doing or suspicious activities be reported to the Administrative Coordinator or Executive Director immediately. The Executive Director will investigate all complaints within three days and resolve them accordingly. Any conditions that might have an adverse effect on the agency will be reported to the Board of Directors. If the Executive Director or Administrative Coordinator are involved in the activity that is being reported, then the report should be made to the agency’s Board President. Any employee who participates in "whistle blowing" is legally protected against being fired for making a report. "Whistle blowing" is when an employee reports and illegal act to someone outside the company. It must be reported to a government or law enforcement agency. Anyone reporting such activities will be protected against any retaliation by any employee or officer of the agency. This means that the employee cannot be fired or mistreated for reporting the activities. The employee’s agency relationship should remain the same as it was prior to reporting the activity. Electrically Powered Equipment All electrically powered equipment will be inspected at least quarterly to insure that it does not pose an electrical hazard during its intended use. Frayed or damaged electrical cords will be replaced. Any equipment deemed potentially dangerous by the Safety and Infectious Control Committee will be labeled and locked up until it can be repaired or discarded. Heating, Ventilating, and Air Conditioning The heating, ventilating, and air conditioning system (HVAC) will be inspected and serviced monthly according to the owners manual. Inspections and servicing will be documented in writing and reported to the Safety and Infection Control Committee. In the event of failure of the HVAC, the building's owner will be notified of the problem and servicing requested. Infection Control Whenever it comes to the attention of the agency that a client has a reportable communicable or contagious disease, the Executive Director or their designee will contact the County Health Department. Whenever it comes to the attention of the agency that an employee or contract person of the agency has a reportable communicable or contagious disease, the County Health Department will be contacted by the Executive Director or their designee. A list of the communicable diseases that must be reported can be found in Chapter 3701-3 of the Ohio Administrative Code (OAC). A copy of this rule is attached to this policy. The Executive Director and the Clinical Director of the agency are to be informed whenever a staff member of the agency learns that an employee or client has a reportable communicable or contagious disease. Clinicians will address prevention and the control of communicable diseases with identified clients as appropriate. All new employees are instructed in the importance of the infection control and personal hygiene and in their responsibility in the infection control program. Every employee will receive follow up in-service education in the infection prevention and control. The following safety measures will be taken; liquid anti-bacterial soap will be used for hand washing, the agency will provide toilet seat covers for use in all restrooms, rubber gloves will be provided for maintenance staff to use when cleaning the building, and bleach based cleaning products will be used whenever possible. Agency staff will use universal precautions. Hazardous Material All caustic materials including cleaning supplies will be maintained in appropriate, well marked containers which are to be stored in a locked room. All caustic materials are to be stored and disposed of in accordance with local codes and ordinances. Medication Handling Mid-Ohio Psychological Services, Inc. will not store or distribute medication. Seclusion & Restraint Mid-Ohio Psychological Services, Inc. will not employ methods of seclusion or restraint. Law enforcement and/or emergency personnel will be summons in the event that a safety emergency occurs. Staff should remove themselves from the situation if they feel unsafe. Weapons and Drugs In the event that a client or employee brings illicit drugs or weapons into the agency they will be asked to remove them from the premises immediately. An employee will immediately be sent for substance testing according to the agency’s personnel policies and procedures. Weapons within the agency are a violation of the agency’s posted concealed weapons signs, therefore the incident will be reported to the Executive Director and local law enforcement and an MUI form will be completed. If licit drugs are required to be taken during the time and employee or client is required to be at the agency they will be asked to keep the drugs in their direct possession in a discrete manner. Tobacco Use Mid-Ohio Psychological Services does not prohibit clients or employees from the use of tobacco products, however use is prohibited within the agency buildings. The agency provides areas for use at building exits. The agency also provides can for proper disposal of used products. The agency provides an open policy regarding tobacco use within privately owned vehicles used by the agency staff. It is expected that staff and clients are respectful to each others wishes regarding tobacco use within vehicles. Fire Suppression and First Aid In Vehicles Operated for Agency Business All vehicles operated for the course of agency business will contain secured fire suppression and first aid equipment. Fire Suppression and First Aid In Agency Facilities All facilities operated for the course of agency business will contain fire suppression and first aid equipment, including light exit signs. Documentation and Debriefing Incident are documented using a Major Unusual Incident reporting form. These forms are maintained by the Administrative Coordinator and reported to the Fairfield County ADAMH Board when warranted. The incidents are reported to all staff in monthly QA reports. The agency’s supervisors and Executive Director provide debriefing for staff directly involved in the incident and this is documented on the MUI form. Emergency Plans Fire Drill Instructions All personnel should adopt a positive attitude toward fire safety. Fire hazards should be reported to the executive director. Periodic discussions will be held pertaining to fire safety. In case of a real fire existing during bad weather conditions, entrance should be requested for the clients and staff to any business in the vicinity. All fire drills will be documented using the Fire Drill Report form and will be included in the monthly QA report. Fire In the event of a real or simulated fire, the receptionist will:
A master fire exit map will be maintained and posted in appropriate areas. Building inspections and fire extinguishers will be inspected/serviced by a certified fire authority annually. All fire exit doors are to be unlocked and clearly marked. Fire drills will be held quarterly. Bomb threats Bomb threats are usually received in written form or by telephone. All threats should be taken seriously. In the event of a real or simulated bomb threat, staff members will:
Drills will be held annually. Natural Disasters Tornados Tornadoes generally occur during the spring and summer. The agency staff will monitor weather information on the local radio stations and listen for tornado sirens. In the event of a real or simulated tornado, staff members will:
Tornado drills will be conducted annually. Severe Thunderstorms and Flooding Severe Thunderstorms can produce lightning, hail, heavy rain (which may cause flash flooding), strong winds and tornadoes. The National Weather Service considers a thunderstorm severe if it has:
Flooding is normally the result of heavy rains or run off from thawing ice. If the basement of the agency should begin flooding, efforts will be made to protect anything in danger of damage. Electrical circuits will be shut off to the area. Agency staff will monitor weather information on local radio stations. If the weather becomes severe, clients will be asked to wait until the storm has passed to leave the building. Agency staff should move themselves and clients away from direct window areas to interior walls to avoid injury if windows should break. All non-essential electrical equipment should be turned off or unplugged to avoid damage or conduction of lighting in the event the building was struck. For agency staff who are driving in an area that is experiencing heavy storms or flooding, they should pull onto the shoulder of the road way from away from any objects that could fall on the vehicle and come to a complete stop. They should then turn on their emergency lights and wait for the rain to subside. Keep windows rolled up and try not to touch any metal inside the vehicle. In no case should a driver drive through a high water area. When flooding occurs the agency premises should be checked for damage before employees or clients are allowed to return. The structure should be inspected along with gas lines and damage to electrical and plumbing systems. Severe Winter Storm Severe Winter Storms can manifest in a variety of ways to include freezing temperatures, high winds, heavy snowfall, sleet or freezing rain. The agency staff will monitor weather conditions using local radio stations. The agency will maintain snow removal equipment in the form of shovels and salt. Agency staff who are driving in an area that is experiencing a severe winter storm should avoid areas that have not been cleared and that may present a danger of getting stuck or disabled. The agency will be closed if the county issues a snow level emergency of a three. Power Failures Power failures can happen for multiple reasons including but not limited to weather, transformer failure or accidents involving lines or poles. In the event of a real or simulated power failure, staff members will:
Power failure drills will be conducted annually. Medical Emergencies In the event of a real or simulated medical emergency, staff members will:
Instructions to call 911 will be posted throughout the agency buildings and medical emergency drills will be conducted annually. Safety During Violent or Other Threatening Situations Violent or threatening situations can include civil disturbances or enemy attacks. Due to the unknown nature of these attacks, decisions regarding the best interest of employees and clients would need to be made at the time of the incident. All staff members will undergo training on disaster and evacuation procedures. The agency will maintain a log of disaster and evacuation procedures which include:
Gas Leak If agency staff become aware of or suspect a gas leak, the building effected will be evacuated. The fire department and local gas utility will be called. Windows in the building will be opened to increase ventilation. Any sources that pose a potential for ignition will be removed. Essential Services The fact that the agency's services are provided in multiple buildings maintaining essential services during or after a emergency situation would be possible. All services provided by the agency are essential to the clients served, so an effort would be made to maintain all services by relocating services to agency buildings that were unaffected. All system's records can be restored and run through the Columbus office if necessary. In the event that the entire Lancaster site was unavailable, the agency is within five minutes of the Fairfield County ADAMH Board and essential functions such as notifying clients of cancelled appointments could be done from this location using reports generated by the agency's system. Client emergencies could handled from this location or through staff that maintain offices outside of the agency at the Fairfield County Municipal Court and Fairfield County Job and Family Services. In the event that the buildings that house the Columbus office become unusable, essential functions can be handled through the Lancaster office. There are multiple office buildings at the the location of the Columbus office, so client services could be resumed relatively quickly using borrowed space from the property managers and agency equipment from the Lancaster office. In the event that essential services could not be restored within a day or two, the agency would make arrangements with other ADAMH Board system providers for referrals and records releases with authorization from the clients. Emergency services at Fairfield Medical Center would be utilized for any client's developing crisis during this time. QUARTERLY RISK MANAGEMENT ACTIVITIES A. The following risk management activities will occur quarterly and will be included in the Quarterly QA Report. a. Progress toward plan objectives b. Activities concerning potential hazardous working conditions/physical plant conditions/fire/safety considerations i. Review the monthly QA Safety and Infection Control Form c. Monitoring of significant financial losses i. Review the monthly Agency Service Budget ii. Review any funding contracts due for renewal d. Monitoring of all major unusual incidents – reporting /reviewing i. Review the MUI section of the QA report for any re-education needs e. Communication to/from QA/QI coordinator/committee i. Address any areas of concern in the monthly QA Committee Meeting B. Action recommended to the Governing Authority – Changes in policies/procedures/program etc. a. Communicate any suggestions for changes to the Administrative Coordinator and Executive Director so changes can be taken to the Board C. Use of the findings for improvement of the program/corrective action plan D. Status of corrective action taken last quarter
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