Behavioral Health Standard 1.H – Health and Safety

1.H.1

The organization maintains a healthy and safe environment.

  • Health & Safety Plan
  • Facility Environmental Inspections Procedure

1.H.2

The organization has written procedures to promote the safety of:

  1. Persons served.
  2. Personnel.
  • Health & Safety Plan

1.H.3

Persons served receive education designed to reduce identified physical risks.

  • Health & Safety Plan

1.H.4.a-b

Personnel receive documented competency-based training:

  1. At orientation in the following areas:
    1. Health and safety practices.
    2. Identification of unsafe environmental factors.
    3. Emergency procedures.
    4. Evacuation procedures, if appropriate.
    5. Identification of critical incidents.
    6. Reporting of critical incidents.
    7. Medication management, if appropriate.
    8. Reducing physical risks.
    9. Workplace violence.
    10. Both:
      1. Upon hire.
      2. Annually.
  2. At least annually in the following areas:
    1. Health and safety practices.
    2. Identification of unsafe environmental factors.
    3. Emergency procedures.
    4. Evacuation procedures, if appropriate.
    5. Identification of critical incidents.
    6. Reporting of critical incidents.
    7. Medication management if appropriate.
    8. Reducing physical marks.
    9. Workplace violence.
  • Health & Safety Plan

1.H.5.a.1-6.b.c.1-10

There are written emergency procedures:

  1. For:
    1. Fire.
    2. Bomb Threats.
    3. Natural Disasters.
    4. Utility Failures.
    5. Medical Emergencies.
    6. Violent or other threatening situations.
  2. That satisfy:
    1. The requirements of the applicable authorities.
    2. Practices appropriate for the locale.
  3. That address, as follows:
    1. When evacuation is appropriate.
    2. Complete evacuation from the physical facility.
    3. When sheltering in place is appropriate.
    4. The safety of all persons involved.
    5. Temporary shelter, when applicable.
    6. Identification of essential services.
    7. Continuation of potential services.
    8. Emergency phone numbers.
    9. Notification of the appropriate emergency authorities.
  • Fire protocol and fire safety
  • Bomb threats procedure
  • Thunderstorms and Tornados
  • Utility failures
  • Outing medical emergencies / workplace violence
  • Health & Safety plan
  • Individualized Emergency Plan for each facility

1.H.6

The organization has evacuation routes that are:

  1. Accessible.
  2. Understandable to:
    1. Persons served.
    2. Personnel.
    3. Other stakeholders, including visitors.
  • Drill Narrative Procedure
  • Drill Schedule / Analysis

1.H.7.a-d

An unannounced test of each emergency procedure:

  1. Is conducted at least annually:
    1. On each shift.
    2. At each location
  2. Includes, as relevant to the emergency procedure, complete actual or simulated physical evacuation drill.
  3. Is analyzed for performance that addresses:
    1. Areas needing improvement.
    2. Actions to be taken.
    3. Results of performance improvement plans.
    4. Necessary education & training or personnel
  4. Is evidenced in writing, including the analysis.
  • Health & Safety plan
  • Drill Narrative Procedure
  • Drill Schedule / Drill Analysis

1.H.8.a-d

There is ready access to:

  1. First aid expertise.
  2. First aid equipment.
  3. First aid supplies.
  4. Relevant emergency information on the:
    1. Persons served.
    2. Personnel.
  • Health & Safety Plan

1.H.9.a-f

The organization has written procedures regarding critical incidents that include:

  1. Prevention.
  2. Reporting.
  3. Documentation.
  4. Remedial action.
  5. Timely debriefing conducted following critical incidents.
  6. The following critical incidents:
    1. Medication errors.
    2. use of seclusion.
    3. use of restraint.
    4. incidents involving injury.
    5. Communicable disease.
    6. Infection control.
    7. Aggression or violence.
    8. Use and unauthorized possession of weapons.
    9. Wandering.
    10. Elopement.
    11. Vehicular accidents.
    12. Bio hazardous accidents.
    13. Unauthorized use and possession of illegal substances.
    14. Abuse.
    15. Neglect.
    16. Suicide and attempted suicide.
    17. Sexual assault.
    18. Other sentinel events.
  • Health & Safety Plan
  • Infection Control Plan
  • Critical Incident Analysis

1.H.10.a-b

A written analysis of all critical incidents is provided to or conducted by the leadership:

  1. At least annually.
  2. That addresses:
    1. Causes.
    2. Trends.
    3. Actions for improvement.
    4. Results of performance improvement plans.
    5. Necessary education and training of personnel.
    6. Prevention of recurrence.
    7. Internal reporting requirements.
    8. External reporting requirements.
  • Health & Safety Plan
  • Critical Incident Analysis

1.H.11.a.1-2.b

The organization implements procedures:

  1. For:
    1. Infection prevention.
    2. Infection control.
  2. That include:
    1. Training regarding:
      1. Infections.
      2. Communicable diseases.
    2. Appropriate use of standard or universal precautions.
    3. Guidelines for addressing these procedures with:
      1. Persons served.
      2. Personnel.
      3. Other stakeholders.
  • Health & Safety Plan

1.H.12.a-l

When transportation is provided for persons served there is evidence of:

  1. Appropriate licensing of all drivers.
  2. Regular review of driving records of all drivers.
  3. Insurance covering:
    1. Vehicles.
    2. Passengers.
  4. Safety features in vehicles.
  5. Safety equipment.
  6. Accessibility.
  7. Training of drivers regarding:
    1. The organization’s transportation procedures.
    2. The unique needs of the persons served.
  8. Written emergency procedures available in the vehicles.
  9. Communication devices available in the vehicles.
  10. First aid supplies available in the vehicles.
  11. Maintenance of vehicles owned or operated by the organization according to the manufacturers recommendations.
  12. If services are contracted, a review of the contract at least annually against elements a-k of this standard.
  • a-e: Health & Safety Plan
  • f: Accessibility Plan
  • g: Statement of Understanding
  • h: Outing Medical Emergencies / Workplace Violence
  • i: Staff Cell Phone Allowance
  • j: Health & Safety Plan
  • k: Vehicle Repair Log

1.H.13.a-b

Comprehensive health and safety inspections:

  1. Are conducted:
    1. At least annually/
    2. by a qualified external authority.
  2. Result in a written report that identifies:
    1. The areas inspected.
    2. Recommendations for areas needing improvement.
    3. Actions taken to respond to the recommendations.
  • Health & Safety Plan
  • Annual Survey from DHSR, MCO, Health Department, Fire Department.

1.H.14.a-b

Comprehensive health and safety self inspections:

  1. Are conducted at least semi annually on each shift.
  2. Result in a written report that identifies:
    1. The areas inspected.
    2. Recommendations for areas needing improvement.
    3. Actions taken to respond to the recommendations.
  • Facility Environmental Inspections

1.H.15

If applicable, there are written procedures concerning hazardous materials that provide for safe:

  1. Handling.
  2. Storage.
  3. Disposal.
  • N/A