TARRY HOUSE, INC.

 

Subject:  Risk Management Policy & Procedure       

 

Procedure Number:  M.L.10

Site: Tarry House and Respite

 

Issued By: Executive Director

Effective: 04/23/02

Approved By: The Board of Trustees

Revised:  12/10/02; 8/01/05; 8/28/06; 1/27/09

Reference Policy:  H.S. 01: H.R. 01

Reviewed: 12/10/04; 8/01/05; 8/28/06; 8/10/07; 1/27/09

 

Standards Reference:

CARF: Section 1.G.

ODMH: 5122-30-12

 

   I.           Purpose

 

To minimize the risks associated with providing services by utilizing several policies & techniques to limit risk exposure and minimize losses to the agency and the persons served.

 

 II.           Policy

 

It is the policy of Tarry House, Inc. to assess for potential and actual risk to the persons served, to personnel (Staff, Board Members & Volunteers), to the service delivery environment and facilities/equipment.  To that end, the agency will identify exposures, analyze the potential severity of losses and implement measures to avoid or reduce the potential losses and monitor the effectiveness of and make adjustments to measures implemented.  Implementation of this policy shall be the responsibility of the Executive Director.

 

III.           Procedure

 

A. Identify Potential Loss Exposure

 

1. Loss of primary funding source

2. Major injury, loss of life substantiated claim of abuse & neglect involving persons served by Tarry House.

3. Person served misconduct (criminal activity).

4. Personnel misconduct (staff, volunteers, Board Members)

5. Personnel injury/loss of life (on the job)

6. Loss of partial or entire use of facility due to natural disaster, fire, essential utilities

7. Loss of licensure

8. Liability issues surrounding the use of agency vehicles

9. Disclosure of Protected Health Information

 

B. Analyze Loss Exposure

 

1. Yearly

2. Daily

3. Occasional (based on historical experience)

4. Minimal

5. Minimal

6. Minimal

7. Yearly

8. Daily

9. Daily

 

C. Potential techniques to handle exposure

 

  1. Development of alternative funding sources for Tarry House, Inc.
  2. Facility is staffed 24-hrs a day.  Staff will complete hourly rounds to check the condition of clients and facility.  Weekly and    monthly safety checks are completed as assigned.  Staff will be trained on Abuse and Neglect policy at least annually.
  3. Tarry House screens all persons referred for services for a history of violent and/or criminal behavior..
  4. Tarry House conducts pre-employment criminal background checks and drug and alcohol screening.  Tarry House may also perform random drug and alcohol screening on employees.  Employees receive training on all relevant policies and procedures.  Liability insurance is maintained.
  5. All staff receives training on health and safety policy as part of orientation and on an annual basis.  Staff also receives training for First Aid/CPR and Crisis Intervention.
  6. Tarry House conducts fire drills, disaster drills, emergency evacuation drills and inspections of the facilities and essential equipment by experts.  Property and casualty insurance maintained.  A smoke free environment is maintained.
  7. Tarry House maintains state licensure for its Respite and Recovery facilities through State Department of Mental Health surveys every two years.  Tarry House maintains standards of care.
  8. Staff members are expected to maintaining a valid Ohio Driver License and remain insurable by the organization’s auto insurance carrier.  The organization’s secretary will ensure that copies current drivers licenses and proof of auto insurance are kept on file.
  9. Tarry House implements and trains on confidentiality policies that meet all current ODMH, CARF and HIPAA standards.

 

D. Implementation Plan

 

Tarry House, Inc. developed a Risk Assessment Plan in August of 2006.  The plan will be monitored and the results are to be reported to the full Board of Trustees on an annual basis. Tarry House, Inc. has a comprehensive plan in place to monitor the safety and security of the persons served at all times. Persons served are expected to sign in & out when entering or exiting the facility, designating their whereabouts.  Staff is required to conduct hourly rounds and complete documentation on the location and status of all persons served, as well as the condition of the facility.  The agency vehicles will be checked to ensure safe operation every time the vehicles are used as well as a more thorough check by the maintenance worker monthly. All personnel also function as advocates for the persons served and are on watch for any incidents of abuse or neglect.  Persons served are also trained on community safety, personal security and use of community resources.

 

Major & minor unusual incidents are handled accordingly by staff as expected through supervision and training.  Individual assessments are completed for all persons admitting to a history of violent behavior.  Individual behavior contracts are implemented when indicated with the consent of the person served.  Local law enforcement officials are involved when necessary.

 

Tarry House, Inc. developed and implemented a Corporate Compliance Plan and has appointed a Corporate Compliance Officer. This plan provides an avenue by which all personnel can report staff or board misconduct and have it investigated and action taken. It also provides for a non-reprisal reporting atmosphere.  Also, there is a comprehensive ethics policy in place, which outlines proper staff and board member conduct. Staff is trained on the ethics policy on an annual basis.

 

Staff training on health and safety, fire safety, psychiatric emergencies, rights, abuse and neglect, medication monitoring and crisis intervention is conducted on either an annual or semi-annual basis. There is also a requirement that all Tarry House staff proving direct services to those served maintain certification in CPR and First Aid.  Tarry House employees are covered by Workers’ Compensation and Casualty Insurance. Tarry House facilities are covered by property insurance. Board members, volunteers and employees are covered by professional liability insurance.  All insurance policies are reviewed on an annual basis for adequacy.  The Board of Trustees approves all insurance on an annual basis.

 

Tarry House applies for re-certification of its license to provide “other” mental health services with the Ohio Department of Mental Health every three (3) years.  A survey is conducted every two (2) years to ensure compliance with ODMH residential standards. In conjunction with the survey all facilities inspections are completed on an annual basis with local, county and state controlling entities. Tarry House is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).  Tarry House is expected to maintain this Accreditation.

 

E.  Monitoring

 

The primary monitoring of the agency’s potential loss exposure will be the responsibility of the Executive Director and Board of Trustees, although all staff is expected to be involved as needed to limit risk to the organization. The Executive Director and the Board of Trustees shall meet on an annual basis and monitor information collected on the following areas:  Incident reports, employee accident/injury reports, financial reports, pre-employment criminal background checks, pre-employment and random drug and alcohol testing results, all fire, disaster and emergency drills, staff training compliance, agency transportation policy compliance, bed utilization, employee driver’s license checks and agency insurance coverage.  The Executive Director and the Board of Trustees shall use this information in order to make decisions that will reduce or eliminate the agency’s loss exposure. They will then monitor the effectiveness of decisions made and make adjustments as necessary.

 

 

 

 

_____________________________                                                                         ______________________________

    Executive Director                                                                                                                     Date