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RAPPAHANNOCK AREACOMMUNITY SERVICES BOARD

HEALTH AND SAFETY POLICY

Reviewed April 2019

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Table of ContentsI: HEALTH AND SAFETY POLICY..............................................................................................................4

HEALTH AND SAFETY PLAN.................................................................................................................4

Health and Safety Committee....................................................................................................................5

II: TRAINING PROCEDURES....................................................................................................................5

Topic: First Aid/CPR/AED............................................................................................................5

Topic: Universal Precautions.........................................................................................................5

Topic: Fire Safety/Evacuation Procedures...................................................................................6

Topic: Incident Reporting..............................................................................................................6

Topic: Safe Management of Violent Behavior..............................................................................6

Topic: Lifting Techniques...............................................................................................................6

Topic: Emergency Preparedness...................................................................................................6

III: INFECTION CONTROL PLAN ……………………………………………………………………...7

Infection Control Practices ……………………………………………………………………………...7

Hand washing..........................................................................................................................................8

Gloves.......................................................................................................................................................8

Plastic Aprons.........................................................................................................................................8

Red Biohazard Bags...............................................................................................................................9

Sharps Containers..................................................................................................................................9

Ventilation Devices..................................................................................................................................9

First Aid and CPR..................................................................................................................................9

Spills of blood or other body fluids.....................................................................................................10

Laundry.................................................................................................................................................10

Disinfection of reusable consumer equipment...................................................................................10

Infant services.......................................................................................................................................10

Kitchen tasks..........................................................................................................................................10

General Housekeeping.........................................................................................................................10

Medication areas...................................................................................................................................11

Disposal of infectious waste.................................................................................................................11

Collection of laboratory specimens.....................................................................................................11

Needle safety..........................................................................................................................................11

Additional Precautions ..…………………………………………………….……….………………11

Exposure ……………………………………………………………………………………………….13

VI: UNIVERSAL PRECAUTIONS POLICY...........................................................................................13

Hand washing........................................................................................................................................13

Gloves.....................................................................................................................................................14

Plastic Aprons.......................................................................................................................................14

Red Biohazard Bags.............................................................................................................................14

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Sharps Containers................................................................................................................................14

Ventilation Devices...............................................................................................................................14

Specific Universal Precaution Procedures..............................................................................................15

General Contact by Persons Served....................................................................................................15

First Aid and CPR................................................................................................................................15

General Housekeeping.........................................................................................................................15

Spills of blood or other body fluids.....................................................................................................15

Laundry.................................................................................................................................................15

Disinfection of reusable consumer equipment...................................................................................15

Infant services.......................................................................................................................................16

Kitchen tasks.........................................................................................................................................16

Disposal of infectious waste.................................................................................................................16

Collection of laboratory specimens.....................................................................................................16

Needle safety..........................................................................................................................................16

Medication areas...................................................................................................................................17

V: EMERGENCY RESPONSE PLAN......................................................................................................17

VI: EMPLOYMENT RELATED INJURIES............................................................................................17

VII: INCIDENT REPORT POLICY..........................................................................................................17

VIII: MANDATED REPORTING POLICY.............................................................................................17

IX: PHYSICAL ENVIRONMENT POLICY............................................................................................19

X: EMERGENCY DRILL POLICY..........................................................................................................20

XI: RACSB FALLS RISK POLICY...........................................................................................................21

XII: EMERGENCY INTERVENTION POLICY....................................................................................22XIII: FIREARMS AND WEAPONS: …………………………………………………………………....22

XIV: PROCEDURES FOR HOME/COMMUNITY BASED OUTREACH SERVICES....................23

XV: USE OF TOBACCO PRODUCTS......................................................................................................23

XVI: ILLICIT/LICIT DRUG USE POLICY............................................................................................24

XVII: RISK MANAGEMENT POLICY AND PROCEDURES.............................................................24

XVIII: WORKPLACE VIOLENCE PREVENTION POLICY...............................................................28

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HEALTH AND SAFETY POLICIES

I: HEALTH AND SAFETY POLICY

The prevention of accidents, injuries, and communicable diseases is achieved through management of the working environment and through careful attention to procedure by staff. It is further recognized that accidents, injuries, and communicable diseases can be limited by:

Management exercising its authority to institute and maintain protocols and procedures to reduce likelihood of accidents, injuries, and communicable diseases;

Staff exercising responsibility in following through with established procedures of training and operation;

Properly trained and supervised employees conducting their operations in accordance with instructions;

Assistance from safety programs that provide training and awareness in safety measures and first aid care.

It is further recognized that the medical needs of individuals served will be addressed within the scope and level of services provided by the Rappahannock Area Community Services Board (RACSB). An individual’s medical care needs will be addressed per program specific policies and procedures when deemed appropriate.

HEALTH AND SAFETY PLAN

It is the intention of RACSB to provide a safe and comfortable environment for its employees and the individuals served by RACSB. To meet this end, the following actions will be taken:

Health and Safety Committee meetings will be held at least quarterly; Group and individual safety training will be provided to staff and employees; Regular safety inspections will be made of all work areas and deficiencies will be

corrected; All safety rules and regulations, accident plans, disaster plans, and evacuation routes

will be posted in appropriate locations at each site as determined by the Health and Safety Committee;

All employees and contracted staff will be screened annually for tuberculosis; All staff will be offered the Hepatitis B vaccination per OSHA standards; All staff are expected to be aware of and to understand all policies, regulations, and

safety plans at all times.

Failure to comply with these requirements will result in corrective action.

Staff will have immediate access to First Aid equipment and supplies at all locations, per licensing requirements of the Virginia Department of Behavioral Health and Developmental Services. As noted on the facility checklist, the first aid kit shall at a minimum include: a thermometer, saline solution, adhesive bandadages, sterile gauze, tweezers, an instant ice-pack, adhesive tape, first-aid cream, and antiseptic soap. Choking/CPR sign must be located near the First Aid kit. A CPR face guard or mask shall be readily accessible.

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Health and Safety Committee

The Health and Safety Committee provides the leadership to implement environmental health and safety policies and to regulate safety training at RACSB. Reviews and recommendations of all accidents and safety-related incidents will be handled through this Committee. Implementation of the Health and Safety Committee recommendations will be initiated by management approval. The Health and Safety Committee will consist of representatives of various facilities operated by RACSB, including the five outpatient clinics. A chairperson will be elected from among the representatives.

The basic agenda for each meeting will be as follows: Review of minutes from previous meeting; Review and analysis of inspection and drill reports; Review and analysis of incident reports, workers’ compensation claims, and accident

reports; and Review of in-service training and program needs.

II: TRAINING PROCEDURES

PURPOSE: To assure that all RACSB employees are properly trained in various health and safety topics to assure that staff and individuals are able to conduct business in a safe environment, the following training will be provided:

Topic: First Aid/CPR/AEDTrainer: CPR and Training SolutionsFrequency: Classes held at the Ronald W. Branscome Building, 600 Jackson Street,

Fredericksburg, VA 22401 or other RACSB site. All new employees are trained in First Aid/CPR/AED within their first week of employment during new employment orientation.. Arrangements may be made for employees to obtain training on an individual basis at off-site locations through the Red Cross. An AED is present in The Sunshine Lady House for Mental Health Wellness & Recovery, RACSB’s Residential Crisis Stabilization program, and in the 3 ICF-IID programs located at Ross Drive, Lucas Street, Wolfe Street, and RAAI 750 Kings Highway. Only employees trained in its use will be permitted to utilize the AED.

Attendees: Each RACSB facility should have a minimum of one CPR/First Aid certified employee on-site during business hours. Employees seen as most likely to serve this function will be given priority with regard to training. Priority will also be given to persons who work with individuals in residential, day support, or medical capacities. All staff should be encouraged to obtain the training and will be accommodated as space permits. First Aid kits are supplied to staff that routinely transport individuals and are available to be signed out by staff.

Topic: Universal PrecautionsTrainers: Immediate supervisor, facility coordinator/supervisor/manager, and

administrative personnelFrequency: At time of employment and annually thereafter.Attendees: All employees will receive training in universal precautions at the time of

orientation. Training will be verified on the employee orientation form, which will be forwarded to the Human Resource Office within 15 days of employment. The training should include procedures on dealing with blood borne pathogens as

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well as information about the location of protective supplies and the universal precautions procedure manual. All employees will receive periodic training on universal precautions in accordance with OSHA standards.

Topic: Fire Safety/Evacuation ProceduresTrainer: Immediate supervisor, administrative personnel, Local Fire Inspector, facility

coordinator/supervisor/managerFrequency: At time of employment and other times, as deemed necessaryAttendees: All employees will receive training in fire safety and the evacuation procedures

specific to their work site from their immediate supervisor within seven days of employment. Supervisors will verify the training on the employee orientation form, which will be forwarded to the Human Resource Office within 15 days of employment. Supervisors will verify the training on the employee orientation form, which will be forwarded to the Human Resource Office within 15 days of employment. (If this is program specific orientation form, it is due within 30 days of hire date) Fire inspections will be conducted annually at each facility, and the information gained from this review will be shared with staff by the coordinator/supervisor/manager of the facility at subsequent staff meetings.

Topic: Incident ReportingTrainer: Immediate supervisor, local human rights/consumer affairs advocate, Quality

Assurance CoordinatorFrequency: At time of employment and other times as deemed necessaryAttendees: All employees will receive training in reporting incidents that result in injury to

staff or individuals receiving services or highlight a potential health risk and/or safety concern. The training will include information about incidents involving individuals receiving services as well as those potentially involving Workers’’ Compensation claims, i.e. an injury to an employee. Training will also include the agency human rights plan. Training will take place during new employee orientation and training forms will be forwarded to the Human Resource Office within 15 days of employment.

Topic: Safe Management of Violent BehaviorTrainer: Immediate supervisor and RACSB staff trained in Therapeutic Options for select

employeesFrequency: At time of employment and annually thereafterAttendees: All employees will be instructed at the time of employment in relationship

building techniques and how to help individuals manage escalating behavior. The training will include facility specific procedures for avoiding confrontations, sounding an alarm, and summoning law enforcement personnel. Additional training by qualified professionals will be made available to appropriate staff on an annual basis.

Topic: Lifting TechniquesTrainer: RACSB staffed trained in lifting techniques, for select employees. Frequency: At time of employment and other times as deemed necessary.Attendees: Select employees who deliver direct care

Topic: Emergency PreparednessTrainer: Administrative personnel, immediate supervisor Frequency: At time of employment; annuallyAttendees: All employees will be instructed in procedures to prepare for potential

emergencies that could impact their program.

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The above trainings should be considered a minimum training guide, and other health and safety trainings will he conducted on an as needed basis. The training plan will be reviewed annually by the Health and Safety Committee.

III: INFECTION CONTROL PLAN

An infection control plan puts together various practices which, when used appropriately, restrict the spread of infection. A breach in infection control practices promotes potential transmission of infection from individual to staff, other individuals, family member, and stakeholders. It is therefore important for all staff, individuals, their family members, friends, and stakeholders who come in close contact with others to adhere to the infection control guidelines. It is also imperative for management to ensure implementation of the infection control plan in facilities.

The general objective of this plan is to provide administrators and staff with the tools to implement infection precaution and control effectively in order to protect themselves and others from the transmission of infections. The ultimate responsibility for prevention and control of infection rests with the staff.

The specific objectives of these guidelines are to provide directions and information in relation to: Facilities, equipment, and procedures necessary to implement standard and additional

precautions for control of infections Cleaning, disinfecting, and reprocessing of reusable equipment Waste management Protection of staff from transmissible infections Infection control practices in special situations

The goal of the infection control plan is to reduce the risk of infections spreading to staff, individuals, family members, and stakeholders.

Since medical history and examination alone cannot reliably identify all persons served with blood-borne pathogens, it is the policy of RACSB that the Center for Disease Control recommendations for universal blood and body fluid precautions be used in the care of all individuals. Employees are to consider all individuals potentially infected with blood-borne pathogens and, therefore, adhere rigorously to infection-control precautions for minimizing the risk of exposure to blood and bodily fluids of all individuals.

Particular care needs to be taken in the management of individuals known to have active infections. It must be remembered that infection will not always be detected; complete safety is contingent on following the appropriate level of precautions.

Management staff should be oriented on the importance of the infection control plan. Staff should be equipped with requisite knowledge, skills, and attitudes for good infection control practices. All employees will be trained in the universal precautions outlined in this policy within 30 days of their employment. Other trainings related to infection control will be conducted on an as needed basis.

Infection Control Practices

Infection control practices can be grouped in two categories

(1) standard precautions;

(2) additional precautions.

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Employees who come in contact with the following items, which are considered to be infectious wastes, shall use appropriate barrier protection:

Blood and body fluids, such as urine, vomit, feces, and semen; Articles grossly soiled with blood or body fluids; Sharps or needles, syringes, razors, etc.; Laboratory waste, such as specimens, cultures, etc.

This plan requires the use of the following protective equipment and abiding by the following protocols by all employees:

Hand washing

Keeping hands clean through hand hygiene is one of the most important steps we can take to avoid getting sick and spreading germs to others. Many diseases and conditions are spread by not washing hands with soap and clean running water. If soap and water are unavailable, use an alcohol-based hand sanitizer that contains at least 60% alcohol to clean hands. Regular hand washing, particularly before and after certain activities, is one of the best ways to remove germs, avoid getting sick, and prevent the spread of infections to others.

Correct hand washing techniques are to be used by all personnel in order to maintain sanitary conditions. Employees should wash their hands:

After handling soiled articles; After each visit to the toilet; After using and discarding a tissue or handkerchief used for a cough or a

sneeze; Before starting work; Before preparing meals; Before and after eating meals; Prior to applying gloves and after glove removal; and Before and after preparing medications.

Hands should be washed above the wrists, using soap and cleaning well between the fingers and under nails. Hands should be rinsed and dried thoroughly with a paper towel, and the paper towel should be used to turn off the faucet before being discarded.

Gloves

Gloves must be worn when appropriate in accordance with the universal precautions specified in this policy. All facilities shall ensure that disposable, non-sterile gloves shall be available in first-aid area, in areas where cleaning supplies are kept, in kitchen areas, in laboratory areas, and other areas where injections and venipuncture are performed or where exposure to blood or body fluids may take place.

Plastic Aprons

In the unlikely event that splashing is anticipated, disposable plastic aprons shall be worn to prevent soiling of clothing with blood or body fluids. All facilities shall have disposable plastic aprons available in first-aid areas, in laboratory areas or other areas where injections and venipuncture are performed, in the areas where cleaning supplies are stored, and in other

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appropriate areas. It is recommended that aprons be worn when cleaning incontinent individuals, cleaning large spills of blood or body fluids, and when doing venipuncture.

Red Biohazard Bags

All facilities shall ensure that containers for the collection of infectious waste are located in the first-aid areas, kitchen areas, laboratory areas, or other appropriate locations. Containers for infections waste shall be lined with red plastic bags approved for biohazard waste disposal. All waste material in which blood is visible to the eye should be disposed of in these hazardous waste containers. When the containers are three-quarters full, they shall be closed and secured and taken to the central collection area located at the Jackson Street Clinic where a nurse will remove for disposal. The central collection container will be emptied at reasonable intervals by the refuse company, which serves RACSB through contract and which collects waste when notified by RACSB staff.

Sharps Containers

Each facility is to ensure that a sharps container is available in all areas where injections and venipuncture are performed. Syringes, with the needle intact, are to be placed in the sharps container. When full, the sharps containers are to be sealed and placed in the central collection container, which is lined with a red biohazard bag. Disposal of the contents will proceed as outlined above for other hazardous waste.

Ventilation Devices

To minimize the need for emergency mouth-to-mouth resuscitation, all facilities shall ensure that ventilation devices are available in first aid areas. Ventilation devices are equipped with disposable baffles. If visible blood is apparent on a used baffle, it should be placed in a red biohazard bag for disposal.

It is the responsibility of each facility coordinator/supervisor, manager to ensure the availability of the protective equipment and cleaning supplies described in this policy. All staff should understand the limitations of protective equipment and be on guard against a sense of security not warranted by the equipment being used for that purpose. For example, gloves offer no protection against needle-stick injuries.

First Aid and CPR

This type of contact by persons served requires the use of universal precautions, including:1. Disposable gloves shall be available in all facility first-aid areas. Gloves should be

worn for touching blood and body fluids. Hands shall be washed immediately after gloves are removed.

2. In the event that gloves are not immediately available, hands and other skin surfaces shall be washed immediately and thoroughly if contaminated with blood or other body fluids.

3. In the event that a person served requires CPR or resuscitation, staff should use ventilation devices (e.g., rescue-masks). These devices shall be available in all facility first aid areas. Ventilation device baffles must never be reused.

4. Red biohazard bags shall be available in all facility first aid areas. Used soiled gloves, ventilation devices, and dressings must be disposed of in these biohazard bags.

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Spills of blood or other body fluids

In the event of spills of blood or other body fluids, clean-up procedures will be instituted immediately . Universal precautions must be taken to avoid exposure. Disposable gloves shall be worn when cleaning up such fluids. A plastic apron should be worn when splashing of fluids may occur.Using paper towels, all extraneous materials should be removed. If blood is visible in the fluid, the towels should be discarded in a red biohazard bag. The area of the spill should be covered with an EPA approved germicide solution (1: 10 bleach/water solution) for several minutes and then wiped dry.

Laundry

Transmission of infection through normally soiled laundry is unlikely; however, soiled laundry is to be handled as little as possible. Each residential person served is responsible for collection and handling of his/her personal soiled laundry. In the event that a resident requires assistance with his/her laundry, staff are to wear gloves and hold soiled laundry away from their body as much as possible. Staff may also elect to wear a disposable plastic apron when handling soiled linen.Soiled laundry stored for cleaning or pick up by laundry service is to be placed in covered containers that prevent leakage.

Disinfection of reusable consumer equipment

Some equipment, such as toys and play mats, are reusable. These items must be disinfected prior to reuse. Used items shall be placed in a covered container pending disinfection. To disinfect, used items shall be sponged off using an EPA approved disinfectant (1: 10 bleach to water solution) and allowed to air dry.

Infant services

As transmission of various infections through saliva, urine, and feces is possible, it is recommended that disposable gloves be worn when exposure to these infectious substances is anticipated (e.g., when changing diapers, assisting with feeding). Changing tables, feeding tables, and other environmental surfaces in the infant services area shall be cleaned with an EPA approved disinfectant/detergent.

Kitchen tasks

Staff and persons served shall wear disposable gloves when handling dirty dishes. All dishes, with the exception of large items, are to be sterilized (washed in the dishwasher), not hand washed. Those items requiring hand washing shall be thoroughly washed, using dish detergent and hot water. Counters and other environmental surfaces within the kitchen do not require extraordinary attempts to disinfect. An EPA approved disinfectant/detergent is suitable for cleaning these surfaces. While not a source of transmission of blood-borne pathogens, eating utensils shall not be shared without sterilization, as this is a source of transmission of other infectious agents.

General Housekeeping

Environmental surfaces, such as walls, floors and other surfaces are not associated with the transmission of infection to consumers or health care workers. Therefore, extraordinary attempts to disinfect or sterilize these environmental surfaces are not necessary.

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Disinfectant/detergent formulas registered by the EPA will be used for cleaning. Disposable gloves shall be worn when cleaning, but used gloves do not need to be placed in biohazard bags unless soiled with blood or other bodily fluids containing visible blood.

Medication areas

All employees distributing oral medications shall maintain good personal hygiene. Dispensing counters, counting trays, and other environmental surfaces in the medication area shall be cleaned with an EPA approved disinfectant/detergent. It is not necessary to wear protective equipment when distributing oral medications. Disposal of infectious waste

Each facility shall have a collection area where generated infectious waste shall be collected to be transported to a central collection container at the 600 Jackson Street location. From there, the contents will be transported for incineration or other method of disposal in accordance with local ordinance. When collecting individual biohazard bags and sharps containers for placement in a central collection area, staff shall wear disposable gloves. Used gloves not soiled with visible blood may be disposed of in any suitable trash receptacle and do not need to be placed in biohazard bags. The contents of the filled central collection container will be sealed in accordance with the procedures and requirements of the contracting collection service.Collection of the waste will occur as needed and will be initiated by contacting the RACSB Procurement Specialist, who will arrange for pickup of the waste.

Collection of laboratory specimens

As the blood and body fluids of all consumers should be considered infectious, all specimens of blood and body fluids shall be put in well-constructed containers with secure lids to prevent leaking during transport. All persons processing blood and body fluids shall wear gloves.Implementation of universal blood and body fluid precautions for all consumers eliminates the need for warning labels on specimens.

Needle safety

Needles and syringes must be handled in a manner which promotes safety and infection control. Prior to administering an injection, hands must be washed and gloves applied. After completing an injection or venipuncture, the contaminated syringe, with the needle intact and uncapped, shall be placed in a sharps box, which is to be located in any area in which injections or venipuncture takes place. The needle should not be broken off at the hub under any circumstances. After any injection or venipuncture, hands must be washed thoroughly after glove removal. Staff performing venipuncture may elect to wear a disposable plastic apron. Used gloves and aprons may be placed in ordinary trash receptacles, unless visibly stained with blood, in which case they should be placed in a red biohazard bag. When the sharps box is full, it shall be sealed and disposed of in containers supplied by the disposal service. Any employee receiving a needle stick injury must immediately report the incident to their supervisor and complete an incident report form. Staff performing acupuncture should follow safety guidelines taught during acupuncture training.

Additional Precautions

Additional precautions include:

Airborne precautions;

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Droplet precautions; and

Contact precautions.

Airborne precautions are designed to reduce the transmission of diseases spread by the airborne route.

Airborne transmission occurs when droplet nuclei are disseminated in the air. These particles can remain suspended in the air for long periods of time, especially when bound on dust particles. Diseases which spread by this mode include open/active pulmonary tuberculosis (TB), measles, chicken pox, pulmonary plague and hemorrhagic fever with pneumonia.

The following precautions need to be taken:

Implement standard precautions.

Place patient in a single room that has specific airflow pressure

Keep doors closed.

Anyone who enters the room must wear a special, high filtration, particulate respirator mask.

Limit the movement and transport of the individual from the room for essential purposes only; the individual should wear a mask.

Diseases, which are transmitted by droplets, include pneumonias, pertussis, diphtheria, influenza type B, mumps, and meningitis. Droplet transmission occurs when there is adequate contact between the

mucous membranes of the nose and mouth or conjunctivae of a susceptible person. Droplets are usually generated from the infected person during coughing, sneezing, or talking.

The following precautions need to be taken:

Implement standard precautions.

Place patient in a single room (or in a room with another patient infected by the same pathogen).

Wear a surgical mask when working within 1-2 meters of the individual. Place a surgical mask on the individual if transport is necessary.

Usual contact by persons served at RACSB is limited to contact equivalent to casual, social contact (e.g., hand shaking) and, therefore, does not require any precautions. Even in residential facilities, normal contact (e.g., sharing restrooms, dining together) does not require precautions.

Diseases typically transmitted by contact include colonization or infection with multiple antibiotic resistant organisms, enteric infections, and skin infections.

The following precautions need to betaken: Implement standard precautions. Place patient in a single room (or in a room with another patient infected by the

same pathogen). Consider the epidemiology of the disease and the patient population when determining patient placement.

Wear clean, non-sterile gloves when entering the room. Wear a clean, non-sterile gown when entering the room if substantial contact with the

individual, environmental surfaces, or items in the individual’s room is anticipated. Limit the movement and transport of the individual from the room; the individual should be

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moved for essential purposes only. If transportation is required, use precautions to minimize the risk of transmission.

ExposureShould an exposure incident occur involving staff, an individual, the individual’s family member, or stakeholder, initial first aid processes should be followed (clean the wound, flush eyes, or other mucous membrane) and then contact should be made to the immediate supervisor of the program or other management staff. If the exposure involves a staff member, the supervisor should advise staff to follow the process for a work related injury. If the exposure is to an individual receiving services, staff should take the necessary steps to ensure the individual’s health and safety. The staff member should document the routes of exposure and how the exposure occurred by completing an incident report. If the staff member is unable to complete the incident report, the supervisor or designee should complete the incident report instead.

RACSB programs will develop contingency plans specific to the illness or infection for those individuals residing in residential programs that may be diagnosed with infections that have the potential to be spread to other individuals residing in the program. The contingency plan will be reviewed by the Residential Coordinator or their designee.

Incident reports will be reviewed for action plans related to exposure.

IV: UNIVERSAL PRECAUTIONS POLICY Since medical history and examination cannot reliably identify all persons served with blood- borne pathogens, it is the policy of RACSB that the Center for Disease Control recommendations for universal blood and body fluid precautions be used in the care of all individuals. Employees are to consider all individuals as potentially infected with blood-borne pathogens and, therefore, adhere rigorously to infection-control precautions for minimizing the risk of exposure to blood and body fluids of all individuals.

All employees will be trained in the universal precautions outlined in this policy within 30 days of their employment.

Employees who come in contact with the following items, which are considered to be infectious wastes, shall use appropriate barrier protection:

Blood and body fluids, such as urine, vomit, feces, and semen; Articles grossly soiled with blood or body fluids;Sharps or needles, syringes, razors, etc; Laboratory waste, such as specimens, cultures, etc

This policy requires the use of the following protective equipment and protocols by all employees:

Hand washing Correct hand washing techniques are to be used by all personnel in order to maintain sanitary conditions. Employees should wash their hands:

After handling soiled articles; After each visit to the toilet; After using and discarding a tissue or handkerchief used for a cough or a

sneeze; Before starting work;

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Before preparing meals; Before and after eating meals; Prior to applying gloves and after glove removal; and Before and after preparing medications.

Hands should be washed above the wrists, using soap and cleaning well between the fingers and under nails. Hands should be rinsed and dried thoroughly with a paper towel, and towel should be used to turn off the faucet before being discarded.

Gloves Gloves must be worn when appropriate, in accordance with the universal precautions specified in this policy. All facilities shall ensure that disposable, non-sterile gloves shall be available in first- aid area, in areas where cleaning supplies are kept, in kitchen areas, in laboratory areas and other areas where injections and venipuncture are performed or where exposure to blood or body fluids may take place.

Plastic Aprons In the unlikely event that splashing is anticipated, disposable plastic aprons shall be worn to prevent soiling of clothing with blood or body fluids. All facilities shall have disposable plastic aprons available in first-aid areas, in laboratory areas or other areas where injections and venipuncture are performed, in the areas where cleaning supplies are stored, and in other appropriate areas. It is recommended that aprons be worn when cleaning incontinent individuals, cleaning large spills of blood or body fluids, and when doing venipuncture.

Red Biohazard Bags All facilities shall ensure that containers for the collection of infectious waste are located in the first-aid areas, kitchen areas, laboratory areas or other appropriate locations. Containers for infections waste shall be lined with red plastic bags approved for biohazard waste disposal. All waste material in which blood is visible to the eye should be disposed of in these hazardous waste containers. When the containers are three-quarters full, they shall be closed and secured and taken to the central collection area located at the Jackson St. facility where a nurse will remove for disposal. The central collection container will be emptied at reasonable intervals by the refuse company, which serves RACSB through contract and which collects waste when notified by RACSB staff.

Sharps Containers Each facility is to ensure that a sharps container is available in all areas where injections and venipuncture are performed. Syringes, with the needle intact, are to be placed in the sharps container. When full, the sharps containers are to be sealed and placed in the central collection container, which is lined with a red biohazard bag, and disposal of the contents will proceed as outlined above for other hazardous waste.

Ventilation Devices To minimize the need for emergency mouth-to-mouth resuscitation, all facilities shall ensure that ventilation devices are available to first aid areas. Ventilation devices are equipped with disposable baffles. If visible blood is apparent on a used baffle, it should be placed in a red biohazard bag for disposal.

It is the responsibility of each facility coordinator/supervisor, manager to ensure the availability of the protective equipment and cleaning supplies described in this policy. All staff should understand the limitations of protective equipment and be on guard against a sense of security not warranted by the equipment being used for that purpose. For example, gloves offer no protection against needle-stick injuries.

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Specific Universal Precaution Procedures:

General Contact by Persons Served Usual contact by persons served at RACSB is limited to contact equivalent to casual, social contact (e.g., hand shaking) and, therefore, does not require any precautions. Even in residential facilities, normal contact (e.g., sharing restrooms, dining together) does not require precautions.

First Aid and CPR This type of contact by persons served does require use of universal precautions, including:

5. Disposable gloves shall be available in all facility first-aid areas. Gloves should be worn for touching blood and body fluids. Hands shall be washed immediately after gloves are removed.

6. In the event that gloves are not immediately available, hands and other skin surfaces shall be washed immediately and thoroughly, if contaminated with blood or other body fluids.

7. In the event that a person served requires CPR or resuscitation, staff should use ventilation devices (e.g., resuci-masks). These devices shall be available in all facility first aid areas. Ventilation device baffles must never be reused.

8. In the event that a ventilation device is not immediately available, CPR or resuscitation should proceed without protection.

9. Red biohazard bags shall be available in all facility first aid areas. Used soiled gloves, ventilation devices and dressings must be disposed of in these biohazard bags.

General Housekeeping Environmental surfaces, such as walls, floors and other surfaces are not associated with the transmission of infection to consumers or health care workers. Therefore, extraordinary attempts to disinfect or sterilize these environmental surfaces are not necessary. Disinfectant/detergent formulas registered by the EPA will be used for cleaning. Disposable gloves shall be worn when cleaning, but used gloves do not need to be placed in biohazard bags unless soiled with blood or other bodily fluids containing visible blood.

Spills of blood or other body fluids In the event of spills of blood or other body fluids, clean-up procedures will be instituted at once. Universal precautions must be taken to avoid exposure. Disposable gloves shall be worn when cleaning up such fluids. A plastic apron may be worn when splashing of the fluids may occur.Using paper towels, all extraneous materials should be removed. If blood is visible in the fluid, the towels should be discarded in a red biohazard bag. The area of the spill should be covered with an EPA approved germicide solution (1: 10 bleach/water solution) for several minutes and then wiped dry.

Laundry Transmission of infection through normally soiled laundry is unlikely; however, soiled laundry is to be handled as little as possible. Each residential person served is responsible for collection and handling of his/her personal soiled laundry. In the event that a resident requires assistance with his/her laundry, staff are to wear gloves and hold soiled laundry away from their bodies as much as possible. Staff may also elect to wear a disposable plastic apron when handling soiled linen.Soiled laundry stored for cleaning or pick up by laundry service is to be placed in covered containers that prevent leakage.

Disinfection of reusable consumer equipment Some equipment, such as toys and play mats, are reusable. These items must be disinfected prior

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to reuse. Used items shall be placed in a covered container pending disinfection. To disinfect, used items shall be sponged off using an EPA approved disinfectant (1: 10 bleach to water solution) and allowed to air dry.

Infant services As transmission of various infections through saliva, urine and feces is possible, it is recommended that disposable gloves be worn when exposure to these infectious substances is anticipated (e.g., when changing diapers, assisting with feeding). Changing tables, feeding tables and other environmental surfaces in the infant services area shall be cleaned with an EPA approved disinfectant/detergent.

Kitchen tasks Staff and persons served shall wear disposable gloves when handling dirty dishes. All dishes, with the exception of large items, are to be sterilized (washed in the dishwasher), not hand washed. Those items requiring hand washing shall be thoroughly washed, using dish detergent and hot water. Counters and other environmental surfaces within the kitchen do not require extraordinary attempts to disinfect. An EPA approved disinfectant/detergent is suitable for cleaning these surfaces. While not a source of transmission of blood-borne pathogens, eating utensils shall not be shared without sterilization, as this is a source of transmission of other infectious agents.

Disposal of infectious waste Each facility shall have a collection area where generated infectious waste shall be collected to be transported to a central collection container at the 600 Jackson Street location. From there, the contents will be transported for incineration or other method of disposal in accordance with local ordinance. When collecting individual biohazard bags and sharps containers for placement in a central collection area, staff shall wear disposable gloves. Used gloves not soiled with visible blood may be disposed of in any suitable trash receptacle and do not need to be placed in biohazard bags. The contents of the filled central collection container will be sealed in accordance with the procedures and requirements of the contracting collection service.Collection of the waste will occur as needed and will be initiated by contacting the RACSB Procurement Specialist, who will arrange for pickup of the waste.

Collection of laboratory specimens As the blood and body fluids of all consumers should be considered infectious, all specimens of blood and body fluids shall be put in well-constructed containers with secure lids to prevent leaking during transport. All persons processing blood and body fluids shall wear gloves.Implementation of universal blood and body fluid precautions for all consumers eliminates the need for warning labels on specimens.

Needle safety Needles and syringes must be handled in a manner which promotes safety and infection control. Prior to administering an injection, hands must be washed and gloves applied. After completing an injection or venipuncture, the contaminated syringe, with the needle intact and uncapped, shall be placed in a sharps box, which is to be located in any area in which injections or venipuncture takes place. The needle should not be broken off at the hub under any circumstances. After any injection or venipuncture, hands must be washed thoroughly after glove removal. Staff performing venipuncture may elect to wear a disposable plastic apron. Used gloves and aprons may be placed in ordinary trash receptacles, unless visibly stained with blood, in which case they should be placed in a red biohazard bag. When the sharps box is full, it shall be sealed and disposed of in containers supplied by the disposal service. Any employee receiving a needle stick injury must immediately report the incident to their supervisor and complete an incident report form.

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Medication areas All employees distributing oral medications shall maintain good personal hygiene. Dispensing counters, counting trays and other environmental surfaces in the medication area shall be cleaned with an EPA approved disinfectant/detergent. It is not necessary to wear protective equipment when distributing oral medications.

V: EMERGENCY RESPONSE PLAN RACSB seeks to enact appropriate responses within the agency for its consumers and employees in the event of potential or actual disasters. Disasters that could conceivably impact the operation of the agency have been identified, and drills are regularly conducted to practice responses to fires, storms, threats, power failures, and medical emergencies. Fire drills should be conducted across all shifts over the course of a tri-monthly rotating basis. All other drills should be conducted at least once each year. For 24 hour programs, drills are conducted at least annually on each shift.Written procedures to be followed during drills and during any actual disaster are individualized to meet the needs of the various RACSB facilities. Procedures are provided to each employee and retained in the policy and procedure manuals. Training on these procedures is provided during employee orientation and annually thereafter by program supervisors. At a minimum, the written procedure will identify the individual responsible for initiating the emergency response, the process for notifying others who might be affected by the emergency, any necessary evacuation procedures, and the process for obtaining assistance in resolving the crisis situation. As part of the drill process, information regarding how essential services would continue to be provided in case of an evacuation should also be documented as follows: “If this was an actual emergency that required evacuation, individuals receiving services would be transported to: (naming the location for transportation by RACSB vehicles). For day support and outpatient services, the ability to continue to provide services will be assessed and responded to accordingly. For 24 hour programs, services will continue at an alternative location. Such services will include the provision of food and appropriate medication management services.”

The results of each drill are documented by the facility coordinator/supervisor/manager and reviewed by the Executive Director (or designee) and the Health and Safety Committee.

VI: EMPLOYMENT RELATED INJURIES All accidents must be reported to the supervisor immediately. In the event of a work related accident, the Employer’s Accident Report must be obtained from management and completed (available on the intranet) and staff must contact VML in case of injury. VML will provide staff with medical advice. Medical expenses will be considered when this form is completed prior to treatment and in accordance with the Workers’ Compensation laws of the State of Virginia.

RACSB has a form available for employees that lists medical facilities where they can obtain medical services for work related injuries. Employees are asked to choose from the facilities listed and submit the form to their supervisor.

VII: INCIDENT REPORT POLICY Documentation of incidents that result in concern for the health and safety of individuals receiving services through Rappahannock Area Community Services Board (RACSB) programs provide an essential mechanism for evaluating the overall safety and risk management plan at

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RACSB. Reportable incidents should include the following: physical and verbal aggression; injuries to individuals served or staff; property damage; situations that may cause a safety risk for individuals served and/or staff such as exposure to a communicable disease, lack of infection control or exposure to bio hazardous materials; health concerns; introduction of a weapon and/or illicit (or licit) substances into any facility or program; vehicular accidents; elopement or wondering of an individual receiving services while receiving services; abuse, neglect, sexual assault, suicide or attempted suicide, medication noncompliance; medication errors; any use of seclusion or restraint; death of an individual enrolled in services; as well as any sentinel event. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, (loss of limb or function) or serious risk thereof. Sentinel events include those in which other agencies are called out of health and safety concern of an individual receiving RACSB services (i.e. filing of APS or CPS reports).

Timely reporting of incidents is necessary in order to gain an accurate account of details as well as to implement needed corrective measures. The appropriate information should be entered into the electronic incident report tracking system by the employee directly involved (or to whom it has been reported by a consumer) as soon as possible following an incident. Incidents which occur or are reported prior to 4:00PM must be submitted prior to 5PM on the date of discovery. Incident reports for incidents occurring or reported after 4:00PM must be received by 12:00 PM the next day.

The incident report should include a detailed description of the incident, a list of the persons involved in and witnessing the incident, corrective action taken and any recommendations to prevent a reoccurrence.

Consequently, employees are encouraged to report any situation involving violations of program rules, injury to individuals receiving RACSB services or staff, damage to RACSB property or any work-related irregularity which might bear on the safety of RACSB employees and individuals receiving services.Incident report data will be reviewed at least quarterly by the Health and Safety Committee, in order to identify trends and opportunities to mitigate risk. Recommendations stemming from that review will be forwarded to the Executive Director.

In addition a Managed Care Organization (MCO) Critical Incident Report (CIR) Form must be completed if the individual is a CCC Plus or Medallion 4 member and the incident is one of the following: serious injury requiring medical attention, health concern requiring medical attention, hospitalization, suspected abuse, neglect or exploration, medication error, suicide attempt requiring medical attention, suicide, elopement from a 24 hour staffed program or death.

All reportable incidents should be reported as soon as possible after the incident, by completed the electronic incident report form in the Incident Report Tracker System (unless a power or internet outage prevents access), and any other necessary documentation such as the MCO CIR Form, so that any incidents that meet the Department of Behavior Health and Developmental Services’ (DBHDS) definition of serious injury or allegations of human rights allegations can be entered into DBHDS Computerized Human Rights Information System (CHRIS) database within 24 hours of discovery of the incident and/or the MCO CIR Form can be submitted to the appropriate managed care organization.

Reportable deaths and injuries are those that occur during the time an individual is receiving services in an RACSB program or in a program in which we have contracted to deliver services. Reports to DBHDS should be made through RACSB’s Quality Assurance Office via DBHDS’ Computerized Human Rights Information On-line system (CHRIS).

The immediate Supervisor and/or Program Coordinator should review the electronic version of

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the incident report form and the MCO CIR. If appropriate, timely debriefings will be held following emergency situations. It is the responsibility of the program supervisor to ensure notification to the relevant case coordinator/case manager of incident that involves an individual receiving RACSB Support Coordination or Case Management services. Incidents that are serious in nature and/or entered into CHRIS are forwarded to the Program Director and the Executive Director for review.

All data collected on the electronic incident report form will be stored in the Incident Tracker System, maintained by the Quality Assurance and IT Department.

For incidents involving an employment-related injury or illness of an RACSB staff member, the RACSB Notice of Employment Related Injury or Illness form should be completed by the employee’s immediate supervisor and forwarded to the Program Director for comment. The original of the form will then be maintained in the Personnel Office, with a copy being returned to the employee’s worksite.

Incidents that involve peer to peer aggression need to be reported through the Incident Tracker System. Peer to peer aggression is defined in DBHDS Human Rights Regulations as “a physical act, verbal threat, or demeaning expression by an individual against or to another individual that causes physical or emotional harm to that individual. Examples include hitting, kicking, scratching, and other threatening behavior. Such instances may constitute potential neglect.” Peer to peer incidents are may be reported in CHRIS as neglect allegations and are investigated accordingly.

Incidents involving a complaint of a possible human rights violation (e.g., allegations of harm, abuse, neglect, exploitation or discrimination) should be reported immediately to the supervisor and to the Office of Consumer Affairs. If the consumer affairs advocate is unavailable, the report should be made to the Director of Compliance and Human Rights/Corporate Compliance Officer. The procedures to be followed in reporting such complaints are outlined in the Human Rights Plan, available at all worksites through the intranet.

VIII: MANDATED REPORTING POLICY

All employees, interns and volunteers of RACSB shall adhere to Virginia Mandated Reporting requirements. Virginia law defines a mandated reporter as an individual who is licensed, certified or registered by health regulatory board, a mental health services provider, or any person employed with or contracted with a public or private agency or facility working with adults in an administrative, supportive or direct care capacity. As a mandated reporter, you are required to immediately report situations in which there is suspicion that an adult or child, receiving services, may have been abused, neglected or exploited, or is at risk of being abused, neglected or exploited.

It is the policy and the responsibility of RACSB employees to report all allegations of abuse, neglect, and exploitation to the appropriate Department of Social Services in which the incident occurred, to their supervisor or program coordinator, the Office of Consumer Affairs, and the Director of Compliance and Human Rights.

All reported incidents must be documented on the RACSB Incident Report form. The immediate supervisor, the Program Director and the Executive Director, should review the completed form.

IX: PHYSICAL ENVIRONMENT POLICY All buildings and installed equipment shall be inspected and approved by the local Building

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Official when required by regulation and documented by a Certificate of Occupancy in accordance with the proposed licensed purpose.

Annually, at least one comprehensive inspection will be conducted by a competent authority external to RACSB at all sites that are owned, rented, or leased by RACSB. These inspections may include the following: a review of emergency warning systems and emergency response plans and equipment, means of safe egress, the operation and use of machinery, the handling and storage of materials, to include the safe and effective management of bio hazardous materials, inspections of walking and working surfaces, inspections of the electrical system, provisions for health and sanitation in regards to food preparation, inspections of utility systems, including ventilation, illumination noise and air contaminants of the working environment and the provision of fire protection in accordance with applicable federal, state and local fire safety requirements.Written results of these inspections will be maintained in the RACSB safety manual. This documentation must include the identification of the areas covered, recommendations for improvements, and a corrective action plan that will be implemented for any deficiencies noted in the review. External fire inspections will be conducted at all sites on an annual basis.

On a monthly basis, each outpatient clinic and residential program will be inspected by RACSB staff to assure the presence and proper functioning of emergency safety equipment, including alarm systems, lighting, extinguishers, and first aid/universal precaution supplies. These inspections will be documented on the facility checklist.

Accessibility in the event of an emergency will also be evaluated. In addition, routine maintenance concerns will be addressed, and the staffing patterns will be assessed for appropriately trained personnel to respond in the event of emergencies. The results of these self- inspections will be forwarded to the Executive Director or designee, along with a plan for correcting any deficiencies identified in the review.

As of January 2013, the inspection and maintenance check of medical equipment, including personal medical equipment and devices was added to this inspection procedure. Personal medical equipment devices include, but are not limited to, glucose monitors and catheters.

Personal medical equipment will be inspected by an RACSB staff person at a minimum of a quarterly basis. These quarterly inspections will assess the operating function of the devices and the sanitation of the devices.

X: EMERGENCY DRILL POLICY At least once a year each portion of the emergency plan must be tested. Fire drills are required quarterly. It is required that all other drills be completed on a rotating basis, every quarter.Drills will be conducted to test the adequacy of the emergency response procedures. These drills

should emphasize practicing the appropriate response for a variety of emergency situations that might be encountered at the worksite. These emergencies should include but are not necessarily limited to fires, bomb threats, natural disasters, utility failures, threats of violence in the workplace, and medical emergencies. At least once a year, as part of the drill process, a review should occur regarding emergency preparedness.Drills should include complete evacuation of the building when this response would be appropriate to the emergency, as well as a review of the plan for temporary shelter, an accounting for the safety of persons involved, and a review of the procedures for insuring the identification and continuation of essential services, when applicable.

As part of the drill process, information regarding how essential services would continue to be provided in case of an evacuation should also be documented as follows: “If this was an actual

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emergency that required evacuation, individuals receiving services would be transported to:(naming the location for transportation by RACSB vehicles). For day support and outpatient services, the ability to continue to provide services will be assessed and responded to accordingly. For 24 hour programs, services will continue at an alternative location. Such services will include the provision of food and appropriate medication management services.”

For emergency evacuations to be conducted annually at all residential and community housing sites that are staffed 24 hours per day, 7 days per week, must be conducted once on each shift for a minimum of three times a year at that site. Evacuations may be simulations or may include actual involvement of the persons served. Opportunities should be available during the drills to practice the evacuation of staff and persons served with disabilities that would conceivably be present and might not be able to exit the building without special assistance during an actual emergency. Information that may be needed during an emergency, including the names of staff members certified in CPR and first aid, emergency first aid procedures, and emergency contact information for staff and persons served should be readily available during relevant drills.

An assessment of each drill should be documented. A report and plan to remedy any problems encountered during the drill will be forwarded to the Executive Director (or designee).

XI: RACSB FALLS RISK POLICY All individuals enrolled in services with RACSB shall have a Falls Risk Assessment. This assessment shall be conducted upon admission, annually, and as changes occur with input from the individual/parent/guardian. The staff person responsible for updating the individual services plan is responsible for updating the Falls Risk Assessment.

The Assessment shall consist of eight conditions designed to evaluate if a person served is at risk of falling. The eight conditions listed are the following:

1) History of falls;

2) Dizziness, imbalance, unsteady gait;

3) Weakness, drowsiness;

4) Confusion, disorientation;

5) Impaired memory, judgment;

6) Ambulatory devices used;

7) Intoxicated; withdrawing from drugs or alcohol;

8) Impaired vision.

Falls Prevention Plan must be included in the ISP if History of Falls or if 4 of the 7 other conditions apply.

Listed below are some suggested guidelines from the Virginia Department of Behavioral Health and Developmental Services Fall Risk Assessments – Interpretive Guidelines.

Some suggested Prevention/Management plans could address such things as: Staff, client, and/or family education about fall risks, medication side effects & food/drug

interactions, adequate and balanced nutrition. What kind of assistance is to be provided to an individual who is a fall risk; i.e., since

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‘assisting’ an individual may increase fall risk. Before assisting, assess coordination & balance.

Use, when appropriate, of assistive devices.

Some suggested ways of reducing fall risks in the environment:

In residential, clients should be placed in beds that allow exiting from their strongest side, also evaluate environment for placement of furniture, access to the bathroom, avoid slippery rugs and have night lights,

Placing personal items within easy reach. Ensuring a safe environment—clean up spills, clutter, electrical cords, also evaluate environment for placement of furniture, access to the bathroom, slippery rugs.

Additional Suggestions from RACSB staff:

Refer to appropriate services (i.e. Medical providers) Physical assistance using crisis intervention techniques. Use of safety equipment (i.e. bars, step up stools, non-slip mats in bathtubs.

XI: EMERGENCY INTERVENTION POLICY It is the policy of RACSB that behavior management will not include the use of seclusion or restraint. If it is determined that an individual is an immediate risk of harm to self or others, or has become aggressive or assaultive, staff will immediately call 911, and then proceed to use verbal skills to deescalate the situation until assistance arrives on the scene.

During the first month of employment, all direct service staff will receive training in the use of therapeutic responses to deescalate a potentially dangerous situation and contributing causes to threatening behavior and how interpersonal skills impact the situation. Emergency situations in which physical contact may be used include the appropriate way to release self from an individual’s grasp, or defensive moves if an individual attempts physical contact and as a means of self-protection.

An Incident Report should be completed for all episodes in which 911 had to be contacted or when an incident required de-escalation from a particular behavior or aggressive or assaultive actions. A description of the incident, the preceding behaviors, and the outcome will be documented in the record of the individual. The incident report form is not to be kept in the individual’s record.

XII: FIREARMS AND WEAPONS Weapons are not allowed in any RACSB facility. The term “weapon” includes but is not limited to knives and firearms. Objects which have no logical purpose other than to inflict injury will be considered weapons. However, for the purpose of this policy, a weapon may be any implement capable of inflicting bodily harm and which is used or worn in a threatening manner, as deemed by staff.

Introduction of a weapon to any RACSB facility by anyone other than a law enforcement officer acting in an official capacity is against agency policy and must be reported on an incident report form. Unauthorized possession of a weapon by a consumer within a RACSB facility will be grounds for denial of services. If it is determined that a threat does exist, procedures as addressed in the Bodily Injury/ Bomb Threat Policy will be followed (site specific). If an imminent threat to others does not exist, the person will be asked to leave the building. The immediate supervisor

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must be notified as soon as possible, but within 24 hours, after the incident has occurred.XIII: PROCEDURES FOR HOME/COMMUNITY BASED OUTREACH SERVICES A: Threats/Violence - The following procedures apply to situations where threats or violence occurs against staff while providing Home/Community Based outreach services:

1. Staff must be certified in Therapeutic Options (Therops).2. Whenever possible, the immediate supervisor must be informed of staff schedule for

visits, and have access to the address and phone number of clientele for whom services are being rendered.

3. Staff will carry an emergency call list with them.4. Staff have the option to check out an RACSB cell phone, or utilize their own in case

of an emergency.

Upon entering the residence of a consumer, or facility where services are to be provided, staff will immediately check for means of egress. If the staff person feels threatened in any way, staff should seek to exit the premises as soon as possible. Therops procedures should be used in an attempt to de-escalate the situation.

If a weapon was involved during the encounter, staff needs to call 911 as soon as it is safe to do so. In the case of threats of bodily harm, staff may use their discretion in calling 911. RACSB Emergency Services will be notified in either case.

An Incident Report and notification to the supervisor need to take place within 24 hours of the incident. The staff person may contact their supervisor immediately to process the incident and seek input.Any incident relating to the operation of the facility which results in serious injury or death shall be investigated by the person in charge of the facility, appropriately reported to local authorities, and immediately reported to the RACSB Director of Compliance and Human Rights.

A written report of the incident shall be completed and kept on file by the facility, Quality Assurance, and made available for review by authorized personnel.

B: Transporting - Staff that routinely transports individuals served by RACSB must have a valid Virginia driver’s license. Emergency kits are available for anyone that transports a person served by the agency. Emergency kits will be assigned to Mental Health Residential Services staff. These kits include written emergency procedures as well as cell phones, flares, first aid supplies, and fire extinguishers.

If in the event that an employee is involved in an automobile accident while transporting a person served, the Human Resources Handbook policy regarding insurance coverage will apply. Driving records are reviewed on an ongoing basis.

XIV: USE OF TOBACCO PRODUCTS Use of any tobacco products (smoking, chewing, etc.) or electronic nicotine delivery devices is not permitted within facilities or vehicles operated by RACSB at any time. Smoking, electronic nicotine delivery devices, and tobacco products will not be permitted to be used in RACSB parking lots or on RACSB property.

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VX: ILLICIT/LICIT DRUG USE POLICY RACSB is a drug-free workplace, and the use of illicit drugs within the context of its programs or their presence on any property operated by RACSB is prohibited. Any person found to be selling, distributing and/or using illicit drugs on the premises will be subject to corrective action, including possible discharge from services. Any drugs confiscated from a consumer will be treated as an “unknown” medication and will be given to the medical services staff for disposal.All surplus or expired medication, controlled and uncontrolled, will be disposed of by destroying the medication in the presence of at least one witness according to RACSB policy. The medication disposal form will be completed and forwarded to the administrative supervisor for review and storage.

Any employee suspected of using illicit drugs on the premises will be asked to submit to a drug screen. If illicit drugs are confiscated from an employee, the proper authorities will be notified.

Over-the-counter or prescribed medications will be permitted only for the personal use of the person served for whom they are intended. It is the responsibility of this individual to make certain that such medications remain in their possession at all times while in RACSB facilities, and any indication that such medications are being distributed to other persons served by the agency will subject the owner to corrective action, including possible discharge from services.

XVI: RISK MANAGEMENT POLICY AND PROCEDURES

The purpose of the Risk Management Plan (RMP) is to support the mission and vision of Rappahannock Area Community Services Board (RACSB) as it pertains to clinical risk and safety of individuals served, employees, and visitors. The RMP includes a view of potential business, operational, and property risk.

The RMP philosophy of RACSB is that risk management is everyone’s responsibility. Teamwork and participation among management, volunteers, and staff are essential for an efficient and effective RMP. The RMP will be implemented through the coordination of multiple organizational functions and the activities of multiple offices.

The focus of the RMP is to provide an ongoing, comprehensive and systematic approach to reducing risk exposure. Risk Management activities include identifying, investigating, analyzing and evaluating risk followed by implementation of the most appropriate method for correcting, reducing, and mitigating risk.

Goal Continuously improve safety and minimize or prevent errors and events that result in

harm through proactive risk management activities.

Mitigate the negative effects of errors and events when they do occur.

Minimize losses to RACSB overall by proactively identifying, analyzing, and preventing risks.

Threat Levels:

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The organization outlines the levels of risk threats for the Risk management plan as follows: Low Risk: Managed by routine procedures Medium Risk: Routine procedures with specific management responsibility High Risk: Routine procedures with Senior Management Attention

Components of the Risk Management Program The RACSB Risk Management Program will include the following components:

A Risk Manager, the Director of Compliance and Human Rights, assigned by the Executive Director.

A Risk Management Plan to identify, monitor, reduce, and minimize risks and potential risks associated with injury, infectious disease, property damage or loss, harm to individuals being served and other sources of potential liability;

The Health and Safety Committee that coordinates activities designed to result in reduction of risk and loss and continuously improves the quality of care and facilities;

A Risk Assessment, that is conducted at least annually, to identify and respond to practices, situations, and policies that could result in the risk of harm to individuals being served before problems occur;

Ongoing Monitoring and Data Analysis of harm and potential harm to identify and promptly respond to risk of harm to individuals receiving services;

Safety Inspections that are performed, by external agencies, at least annually at each service location owned, rented, or leased by RACSB. External agencies or resources include, but are not limited to, Local or State Fire Marshall/Inspector; Department of Social Services, Department of Behavioral Health and Developmental Services; independent elevator Inspection Services; Department of Medical Assistance Services; independent fire extinguisher inspection; and suppression system inspection;

Documentation of all aspects of the Risk Management Program, including employee training, serious injuries, annual review of data, safety inspections, ongoing monitoring and actions taken to reduce risk.

Health and Safety Committee

The Health and Safety Committee will coordinate activities designed to result in reduction of risk and loss and continuously improve the quality of care. The Committee will function as follows:

1. Identify and assess risks, develop a plan with interventions, actions and systems to control risk, conduct periodic evaluations to assess results of actions and reformulation of planning.

2. Assess the exposure of RACSB to loss in the following causation areas:

People: This area is defined as "acts" or behaviors that may expose the organization to loss and liability. Appropriate areas for assessment would include incident reports, code of

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conduct standards and violations, safety standards, reports, consumer rights and grievance complaints, satisfaction and perception surveys and purchasing/fiscal practices.

Organization: This area is defined as the policies, procedures, and legal guidelines that the organization is legally responsible to follow. Appropriate areas for assessment would include a review of adherence to policies and procedures, a review of federal and state safety, fiscal, third party, and clinical guidelines compared to actual practices, and a review of current industry standards of care compared to actual practices.

Physical Environment: This area is defined as the conditions that exist within the organizations structures. Appropriate areas for assessment would include the physical structures in which services are provided, equipment used throughout the organization, health and safety reports, incident reports, maintenance reports, and the tools for maintaining and transmitting information.

Reporting Incidents All employees, volunteers, contractors and interns are required to report any serious event on the Incident Report Form.

All new employees, volunteers, contractors and students are required to complete an incident report training course during orientation. This training includes when to complete an incident report, how to complete an incident report, and results of failure to report a serious injury or incident.

Annual Proactive Risk Assessment RACSB conducts an annual Proactive Risk Assessment to identify and evaluate the potential for adverse impacts of direct and indirect services processes, buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of the, individuals served, staff, and visitors. More in-depth analyses are performed on identified, hazards and proposed changes to new or existing processes.

The goal of a proactive risk assessment is to reduce the likelihood of or mitigate the impact of incidents or other negative experiences that have the potential to result in injury, accidents, or other loss to the individuals served, visitors, staff or the assets of the organization.

The Proactive Risk Assessment is conducted by the Risk Manager and Leadership staff.

The Risk Assessment shall address the following: Environmental risks Timeliness and completeness of clinical assessments/reassessments Staff competence Adequacy of staffing Adherence to federal, state, and local regulatory requirements Reporting and review of serious incidents.

The risk assessment process involves identifying both existing and potential risks. Risks

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are identified through a review of incident reports and other organizational risk assessment. (Such as safety drills and facility checklist.

The Risk Manager annually schedules or monitors the components of risk assessments to include:(a)A review of incidents (b)A walk-through of the physical plant(c)Review of physical plant required inspections (e.g. fire extinguishers) to ensure they

are up-to-date(d)Review of external regulatory (e.g., DBHDS Licensing, CARF, other) agency

findings to identify potential risk areas(e)Record review of timeliness of assessments(f) Review of employment records of all new employees to ensure required

background checks were completed(g)Review of training records to ensure that all staff completed mandatory training.(h)Review of program policies and procedures

The Risk Manager and the Health and Safety Committee evaluate the results. The reports identify risk, the level of each risk, recommendations and specific strategies for improvement for each identified risk. The report with recommendations maybe submitted to Program Coordinators, Program Directors and the Executive Director for review and action.

Action is taken on all identified risks. Action is based on the level of risk, the need for immediate remedial intervention and the resource needs for implementation.

The Risk Plan is reviewed and revised, if needed, at least annually, following the annual risk assessment activities. The revised plan will:

Identify the general Risk Areas. Establish one or more Measures for each Risk Area that describes the specific risk

in objective and measurable terms. Include Thresholds that for each Measure, which signifies when action must be

taken to move the organization towards compliance. Establish the frequency of the review; Assign the individual responsible; and Outline strategies to be implemented to manage the risk.

Actions in Response to Risk Assessment may include:

The development and implementation of new policies and procedures

Development of training for staff

Refresher training for staff

Personnel corrective disciplinary action

Revision of forms

Development of data base to capture specific data elements

Development of reports to increase awareness and reduce errors

Maintenance request

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XVI: WORKPLACE VIOLENCE PREVENTION POLICY

It is the intention of Rappahannock Area Community Services Board to provide a workplace free of violence, and one where all employees participate in violence prevention. The purpose of the Workplace Violence Prevention policy is to provide training, information, and timely response procedures for all employees in an effort to reduce or eliminate potential risks of violence.

All employees should understand the concept of universal precautions for violence, that is, that violence is a realistic possibility but can be avoided or mitigated through preparation. Employees should also understand the importance of a culture of respect, dignity, and active mutual engagement in prevention of workplace violence.

TRAINING

All employees will be instructed at the time of employment and annually thereafter, in the appropriate intervention of individuals that exhibit escalating behavior. The training will include facility specific procedures for avoiding confrontations, sounding an alarm alerting staff to occurring violence, and summoning law enforcement personnel. Additional training by qualified professionals will be made available to appropriate staff on an annual basis.

In addition, during the first month of employment, all direct service staff will receive training in the use of therapeutic responses to deescalate potentially dangerous situations. Staff will likewise learn about contributing factors that can escalate into threatening behavior and how interpersonal skills can impact and influence situations. Emergency situations in which physical contact may be used include appropriately releasing self from an individual’s grasp, or utilizing evasive maneuvers as a means of self-protection if an individual becomes physically aggressive.

Procedures are provided to each employee and retained in the policy and procedure manuals. Training on these procedures is provided during employee orientation and annually thereafter by program supervisors. At a minimum, the written procedure will identify the individual responsible for initiating the emergency response, the process for notifying others who might be affected by the emergency, any necessary evacuation procedures, and the process for obtaining assistance in resolving the crisis.

PROCEDURES FOR HOME/COMMUNITY BASED OUTREACH SERVICES

A: Threats/Violence - The following procedures apply to situations where threats or violence may occur against staff while providing Home/Community Based outreach services:

1. Staff must be certified in Therapeutic Options.2. Whenever possible, the immediate supervisor or designee, must be informed of staff schedule for visits, and have access to the address and phone number of clientele for whom services are being rendered.3. Staff will carry an emergency call list with them. (Program Specific)4. Staff have the option to utilize their own cell phone in case of an emergency.

Upon entering the residence of an individual receiving services or facility where services are to be provided, staff will immediately check for means of egress. If the staff member feels threatened in any way, staff should seek to exit the premises as soon as possible. Therapeutic Options procedures should be used in an attempt to de-escalate the situation.

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If a weapon is involved during the encounter, staff need to call 911 as soon as it is safe to do so. In the case of threat of bodily harm, staff may use their discretion in calling 911. RACSB Emergency Services shall be notified in either case, along with the immediate supervisor or designee

FIREARMS AND WEAPONS

Weapons are not allowed in any RACSB facility and/or premises. The term “weapon” includes but is not limited to knives and firearms. Objects which have no logical purpose other than to inflict injury will be considered weapons. For the purpose of this policy, a weapon may be any implement capable of inflicting bodily harm and which is used or worn in a threatening manner as interpreted by staff.

Introduction of a weapon at any RACSB facility/property by anyone other than a law enforcement officer acting in an official capacity is against agency policy and must be reported on an incident report form. Unauthorized possession of a weapon by a consumer within a RACSB facility/property will be grounds for denial of services. If it is determined that a threat does exist, procedures as addressed in the Bodily Injury/ Bomb Threat Policy will be followed (site specific). If an imminent threat to others does not exist, the person will be asked to leave the building/premises. The immediate supervisor must be notified as soon as possible, but within 24 hours, after the incident has occurred.

INCIDENT REPORTING

Documentation of situations or incidents provides an essential feedback mechanism for evaluating the overall safety plan at RACSB. Reportable incidents should include the following: physical and verbal aggression, any injuries to persons served or staff, property damage, situations that may cause a safety risk for persons served and/or staff such as exposure to a communicable disease, lack of infection control or exposure to bio -hazardous materials, health concerns, introduction of a weapon and/or illicit (or licit) substances into any facility or program, abuse, suicide or attempted suicide. Timely reporting of incidents is necessary to gain an accurate account of details as well as to implement needed corrective measures.

For incidents involving an employment-related injury or illness of an RACSB staff member, the RACSB Notice of Employment Related Injury or Illness form should be completed by the immediate supervisor of the employee and forwarded to the Program Director for comment. The original of the form will then be maintained in the Human Resource Office, with a copy being returned to the worksite of the employee.

Incidents that involve peer to peer conflict need to be reported on the incident report form. Such peer to peer conflict can include: one consumer attacking another consumer by using physical force, allegations of sexual assault including non-consensual sexual advances or suggestions, and verbal threats where the aggressor has the means to carry the threat out.The appropriate form should be completed by the employee directly involved (or to whom it has been reported by a consumer) as soon as possible following an incident, but no later than 24 hours, and should include a detailed description of the incident, a list of the persons involved in and witnessing the incident, corrective action taken, and any recommendations to prevent a reoccurrence.

ASSESSMENTS & INSPECTIONS

It is the policy of the Rappahannock Area Community Services Board (RACSB) to assess for potential and actual risks to persons served, the public, employees, and to the overall working

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service delivery environment (including RACSB facilities). Assessments will result in the development of preventive measures and interventions that will serve to reduce risk and loss within the organization. “Near misses” will also be analyzed to prevent future occurrences.

Annually, at least one comprehensive inspection will be conducted by a competent authority external to RACSB at all sites that are owned, rented, or leased by RACSB. These inspections may include the following: a review of emergency warning systems, emergency response plans, and equipment, as well as a review of the means of safe egress. Written results of these inspections will be maintained in the RACSB safety manual. This documentation must include the identification of the areas covered, recommendations for improvements, and a corrective action plan that will be implemented for any deficiencies noted in the review.

On a monthly basis, each outpatient clinic and residential program will be inspected by RACSB staff to assure the presence and proper functioning of emergency safety equipment including alarm systems, lighting, extinguishers first aid supplies, and universal precautions supplies. These inspections will be documented on the facility checklist form. Accessibility in the event of an emergency will also be evaluated.

Drills will be conducted to test the adequacy of emergency response procedures. These drills should emphasize practicing the appropriate response for a variety of emergency situations that might be encountered at the worksite. These emergencies should include, but are not necessarily limited to, bomb threats, threats of violence in the workplace, and medical emergencies.