Risk management is an attempt to identify and manage threats that could negatively impact the agency. Mid-Ohio Psychological Services, Inc addresses risk by establishing policies, procedures and safeguards to ensure adequate insurance coverage, awareness and honesty among personnel, screening new personnel, developing a plan for coping with disaster, managing physical safety and infection control, and computer information security.
The safety of programs will be monitored for significant risk and/or loss including pending lawsuits, loss of grants or other funding; maintaining safe staffing levels; adherence to federal and state requirements; and reporting reviewing, and monitoring of significant loss to the program and governing authority as determined in the risk management plan.
Mid-Ohio Psychological Services Inc. will protect the agency from unnecessary risk in the following manner:
Any incidents or injuries occurring on Mid-Ohio Psychological Services, Inc. grounds, whether by staff or public, will be immediately reported to the Executive Director or the Operations Director in the absence of the Executive Director and dictated in the Incident Reporting Policy. Any safety hazards will be reported in the same manner. Each report will be investigated by the Executive Director or their designee. A written report will be made of the action taken and any follow up necessary to prevent future accidents. All new employees will be given a safety orientation. All employees will be given follow-up in-service education at least yearly.
Mid-Ohio Psychological Services Inc. protects the agency, employees, board members, volunteers, clients, and the general public by doing background investigations on all new employees of the agency. Background checks will include contacting previous employers, verifying education and licensing information, contacting references, requesting a Bureau of Criminal Identification and Investigation report, and checking the county courts records. The agency also maintains up to date personnel policies and procedures that included acceptable behaviors for agency employees and background investigations, which can be viewed with all agency personnel policies and procedures.
The agency does substance testing for all new employees and any employees who exhibit reasonable suspicion of drug use. Complete details of this testing policy can be located in the Substance Testing Policy and Procedures.
The agency requires that all employees fill out a conflict of interest statement annually or when significant changes occur. Complete details can be located in the Conflict of Interest Policy and Procedures.
In addition, the agency transfers risk by maintaining proper insurance coverage on the following areas:
- Malpractice Insurance for all clinical staff
- Physical Injury/Property Insurance for all visitors and staff
- Board of Directors Insurance for all board members
- Blanket Bond for the entire agency
Mid-Ohio Psychological Services Inc. protects the agency’s property including building, facilities, equipment, and material by having secure locks throughout the building, covering windows in order to obscure the contents of the building from outside and storing items in secured filing cabinets. In addition, fire doors protect the building from total loss in the case of a fire. Monthly fire and safety inspections are conducted to safeguard against loss due to preventable causes.
The buildings which house the Mid-Ohio Psychological Services, Inc. will meet or exceed all applicable federal, state, and local codes as well as be in compliance with the provisions of the 1981 edition of the LIFE SAFETY CODE of the National Fire Protection Association unless equivalent methods of protection are provided. Access will be available to handicapped individuals. Restrooms will be equipped with grab bars. All doorways, storage areas and stairwells are to remain clean and uncluttered.
Mid-Ohio Psychological Services Inc. controls physical access to the building at all times, by leaving all entrances to the building secured except the front entrances that are staffed by an employee when clients are in the building. Access to computers is controlled through security passwords and the use of access profiles. The distribution of keys is controlled through one employee so that access to different areas of the building can be controlled.
Mid-Ohio Psychological Services Inc. protects the agency’s income in many ways, including segregation of duties, so that there is a paper chain for all payments that are received by the agency. This includes writing receipts that are sequentially number for all payments. Employees posting payments to the accounts receivable may not make out the deposits for the agency. Two different employees maintain the accounts receivable and the accounts payable. The agency has obtained a line of credit to protect the agency from cash shortages. Further information concerning the segregation of duties can be found in the Financial Management Policy and Procedures.
Funding available for services is always monitored closely; any significant changes in funding streams will be reported to the Board of Directors. The agency bills services to private insurance and agencies whenever possible. The agency pursues grant funding whenever possible.
Mid-Ohio Psychological Services Inc. protects the goodwill of the agency by holding all staff accountable for the behavior they exhibit on behalf of the agency. The agency participates in press releases on information that is important in the community.
Reporting and Action
Mid-Ohio Psychological Services Inc. requires that any fraud, waste, wrong doing or suspicious activities be reported to the Operations Director or Executive Director immediately. The Executive Director or their designee will investigate all complaints within three days and resolve them accordingly. Any conditions that might have an adverse effect on the agency will be reported to the Board of Directors.
If the Executive Director or Operations Director are involved in the activity that is being reported, then the report should be made to the agency’s Board President.
Any employee who participates in “whistle blowing” is legally protected against being fired for making a report. “Whistle blowing” is when an employee reports and illegal act to someone outside the company. It must be reported to a government or law enforcement agency.
Anyone reporting such activities will be protected against any retaliation by any employee or officer of the agency. This means that the employee cannot be fired or mistreated for reporting the activities. The employee’s agency relationship should remain the same as it was prior to reporting the activity.
Electrically Powered Equipment
All electrically powered equipment will be inspected at least quarterly to insure that it does not pose an electrical hazard during its intended use. Frayed or damaged electrical cords will be replaced. Any equipment deemed potentially dangerous by the Safety and Infectious Control Committee will be labeled and locked up until it can be repaired or discarded.
Heating, Ventilating, and Air Conditioning
The heating, ventilating, and air conditioning system (HVAC) will be inspected and serviced monthly according to the owner’s manual. Inspections and servicing will be documented in writing and reported to the Safety and Infection Control Committee. In the event of failure of the HVAC, the building’s owner will be notified of the problem and servicing requested.
Whenever it comes to the attention of the agency that a client has a reportable communicable or contagious disease, the Executive Director or their designee will contact the County Health Department. Whenever it comes to the attention of the agency that an employee or contract person of the agency has a reportable communicable or contagious disease, the County Health Department will be contacted by the Executive Director or their designee. A list of the communicable diseases that must be reported can be found in Chapter 3701-3 of the Ohio Administrative Code (OAC). A copy of this rule is attached to this policy.
The Executive Director of the agency is to be informed whenever a staff member of the agency learns that an employee or client has a reportable communicable or contagious disease. Clinicians will address prevention and the control of communicable diseases with identified clients as appropriate.
All new employees are instructed in the importance of the infection control and personal hygiene and in their responsibility in the infection control program. Every employee will receive follow up in-service education in the infection prevention and control. The following safety measures will be taken; liquid anti-bacterial soap will be used for hand washing, the agency will provide toilet seat covers for use in all restrooms, rubber gloves will be provided for maintenance staff to use when cleaning the building, and bleach based cleaning products will be used whenever possible. Agency staff will use universal precautions.
All caustic materials including cleaning supplies will be maintained in appropriate, well-marked containers which are to be stored in a locked room. All caustic materials are to be stored and disposed of in accordance with local codes and ordinances.
Prescription Medication Handling
Mid-Ohio Psychological Services, Inc. will not store or distribute medication. If prescription drugs are required to be taken during the time and employee or client is required to be at the agency they will be asked to keep the drugs in their direct possession in a discrete manner.
Seclusion & Restraint
Mid-Ohio Psychological Services, Inc. will not employ methods of seclusion or restraint. Law enforcement and/or emergency personnel will be summoned in the event that a safety emergency occurs. Staff should remove themselves from the situation if they feel unsafe.
Weapons and Drugs
In the event that a client or employee brings illicit drugs or weapons into the agency they will be asked to remove them from the premises immediately. An employee with Alcohol or illicit substances will immediately be sent for substance testing according to the agency’s personnel policies and procedures. Weapons within the agency are a violation of the agency’s posted concealed weapons signs, therefore the incident will be reported to the Executive Director and local law enforcement and an MUI form will be completed.
Mid-Ohio Psychological Services does not prohibit clients or employees from the use of tobacco products; however use is prohibited within the agency buildings. The agency provides cans for proper disposal of used tobacco products at entrances of the agency.
The agency provides an open policy regarding tobacco use within privately owned vehicles used by the agency staff. It is expected that staff and clients are respectful to each other’s wishes regarding tobacco use within vehicles.
Fire Suppression and First Aid In Vehicles Operated for Agency Business
All vehicles operated for the course of agency business will contain secured fire suppression and first aid equipment.
Fire Suppression and First Aid In Agency Facilities
All facilities operated for the course of agency business will contain fire suppression and first aid equipment, including lighted exit signs.
Documentation and Debriefing
Incidents are documented using a Major Unusual Incident reporting form. These forms are maintained by the Administrative Coordinator and reported to the county ADAMH Board with jurisdiction when warranted. The incidents are reported to all staff in monthly QA reports. The agency’s supervisors and Executive Director provide debriefing for staff directly involved in the incident and this is documented on the MUI form.
Fire Drill Instructions
All personnel should adopt a positive attitude toward fire safety. Fire hazards should be reported to the executive director. Periodic discussions will be held pertaining to fire safety. In case of a real fire existing during bad weather conditions, entrance should be requested for the clients and staff to any business in the vicinity. All fire drills will be documented using the Fire Drill Report form and will be included in the monthly QA report.
In the event of a real or simulated fire, the receptionist will:
- Call 911 to report the fire.
- Alert the occupants of the building that there is an evacuation in progress using the intercom system.
- Insure that all clients have left the room, turn off lights to the room, close the door to the room, and follow clients from the building. If the assigned exit is blocked. The staff should direct clients to the nearest exit and/or safest exit regardless of previous assignment.
- Insist that there be no talking or horseplay at any time during the entire procedure.
- Take the daily scheduler to the outside assembly area and call the roll.
- If any client or staff member is missing, report it immediately to the fire marshal or executive director.
- No one will return to the building until given permission by the fire inspector or an agency supervisor.
A master fire exit map will be maintained and posted in appropriate areas. Building inspections and fire extinguishers will be inspected/serviced by a certified fire authority annually. All fire exit doors are to be unlocked and clearly marked. Fire drills will be held quarterly.
Bomb threats are usually received in written form or by telephone. All threats should be taken seriously. In the event of a real or simulated bomb threat, staff members will:
If a threat is phoned in, the personnel taking the call should get as much information as possible from the caller
- Where the bomb is located
- When the bomb will go off
- What type of bomb it is
- Listen and try to identify any background noises such as traffic.
- Listen for voice characteristics, speech pattern, accents etc
- Do not hang up
- The fire department should be called immediately, if possible have another staff member call while on the telephone.
- All personnel should look around the area for anything suspicious, if anything is located, the Executive Director or Administrative Coordinator should be notified immediately.
- The building will then be evacuated to the rear of the building using the fire exit plan.
- People will return to the building only after safety personnel (fireman, police officer, etc) give permission.
Drills will be held annually.
Tornadoes generally occur during the spring and summer. The agency staff will monitor weather information on the local radio stations and listen for tornado sirens. In the event of a real or simulated tornado, staff members will:
- Announce “Attention, Attention, This is a tornado alert.” All staff assists persons in your work area to an interior area away from doors & widows using the intercom system.
- Take flashlights that staff have in their desks.
- Close curtains and blinds in their work areas.
- Close all doors (leaving them unlocked)
- Assist clients and visitors to the nearest interior room way from doors and windows or to a basement if accessible. At the Franklin County office, employee’s and client’s will go to the ground floor of the building to the hallway away from windows and doors.
- Review a roster of clients to make sure everyone is accounted for.
- Everyone should sit on the floor and cover their heads with their arms.
- For agency staff who are driving in an area that is experiencing tornadoes, they should seek shelter in the nearest building.
- All persons will wait until officials have indicated that it is safe to return to the main floor and proceed with business.
Tornado drills will be conducted annually.
Severe Thunderstorms and Flooding
Severe Thunderstorms can produce lightning, hail, heavy rain (which may cause flash flooding), strong winds and tornadoes. The National Weather Service considers a thunderstorm severe if it has:
Wind Gusts in excess of 58 miles per hour
Hail ¾ in diameter or larger
Flooding is normally the result of heavy rains or run off from thawing ice. If the basement of the agency should begin flooding, efforts will be made to protect anything in danger of damage. Electrical circuits will be shut off to the area. Agency staff will monitor weather information on local radio stations. If the weather becomes severe, clients will be asked to wait until the storm has passed to leave the building. Agency staff should move themselves and clients away from direct window areas to interior walls to avoid injury if windows should break. All non-essential electrical equipment should be turned off or unplugged to avoid damage or conduction of lighting in the event the building was struck.
For agency staff who are driving in an area that is experiencing heavy storms or flooding, they should pull onto the shoulder of the road way from away from any objects that could fall on the vehicle and come to a complete stop. They should then turn on their emergency lights and wait for the rain to subside. Keep windows rolled up and try not to touch any metal inside the vehicle. In no case should a driver drive through a high water area. When flooding occurs the agency premises should be checked for damage before employees or clients are allowed to return. The structure should be inspected along with gas lines and damage to electrical and plumbing systems.
Severe Winter Storm
Severe Winter Storms can manifest in a variety of ways to include freezing temperatures, high winds, heavy snowfall, sleet or freezing rain. The agency staff will monitor weather conditions using local radio stations. The agency will maintain snow removal equipment in the form of shovels and salt. Agency staff who are driving in an area that is experiencing a severe winter storm should avoid areas that have not been cleared and that may present a danger of getting stuck or disabled. The agency will be closed if the county issues a snow level emergency of a three.
Power failures can happen for multiple reasons including but not limited to weather, transformer failure or accidents involving lines or poles. In the event of a real or simulated power failure, staff members will:
- Shut off all electrical equipment to avoid damage when power is restored.
- Move themselves and clients to areas that are lit by natural light to avoid injury from falls.
- If natural light begins to diminish, the building should be evacuated.
Power failure drills will be conducted annually.
In the event of a real or simulated medical emergency, staff members will:
- Call 911 immediately upon the incident
- Collect pertinent client information regarding the victim of the emergency.
- Notify the client’s emergency contact person or anyone the client requests to be notified.
- Remove all clients and staff not directly involved from the area.
- Complete an MUI form by those involved after the emergency is over.
Instructions to call 911 will be posted throughout the agency buildings and medical emergency drills will be conducted annually.
Safety During Violent or Other Threatening Situations
Violent or threatening situations can include civil disturbances or enemy attacks. Due to the unknown nature of these attacks, decisions regarding the best interest of employees and clients would need to be made at the time of the incident.
All staff members will undergo training on disaster and evacuation procedures.
The agency will maintain a log of disaster and evacuation procedures which include:
- Number of Staff Participating
If agency staff become aware of or suspect a gas leak, the building affected will be evacuated. The fire department and local gas utility will be called. Windows in the building will be opened to increase ventilation. Any sources that pose a potential for ignition will be removed.
The fact that the agency’s services are provided in multiple buildings maintaining essential services during or after an emergency situation would be possible. All services provided by the agency are essential to the clients served, so an effort would be made to maintain all services by relocating services to agency buildings that were unaffected. All system’s records can be restored and run through the Columbus office if necessary.
In the event that the entire Lancaster site was unavailable, the agency is within five minutes of the Fairfield County ADAMH Board and essential functions such as notifying clients of cancelled appointments could be done from this location using reports generated by the agency’s system. Client emergencies could be handled from this location or through staff that maintain offices outside of the agency at Fairfield County Job and Family Services.
In the event that the buildings that house the Columbus office become unusable, essential functions can be handled through the Lancaster office. There are multiple office buildings at the location of the Columbus office, so client services could be resumed relatively quickly using borrowed space from the property managers and agency equipment from the Lancaster office.
In the event that the building that houses the Delaware office becomes unusable, essential functions can be handled through the Lancaster office. The agency uses space in Delaware Job and Family Services, so client services could be resumed relatively quickly using this space.
In the event that the building that houses the Licking office becomes unusable, essential functions can be handled through the Lancaster office. The staff and clients of that site would be redirected to Lancaster or Columbus sites in order to provide services until the building could be repaired or an alternate site could be located.
In the event that the building that houses the Ross office becomes unusable, essential functions can be handled through the Lancaster office. The staff and clients of that site would be redirected to Lancaster or Columbus sites in order to provide services until the building could be repaired or an alternate site could be located.
In the event that essential services could not be restored within a day or two, the agency would make arrangements with other ADAMH Board system providers for referrals and records releases with authorization from the clients. Emergency services at local hospitals would be utilized for any client’s developing crisis during this time.
Sexually Abusive Behavior and Clients
Clients who have been identified as participants in the agency’s Sexually Abusive Behaviors programming must process their sexual experiences in therapy prior to engaging in sexual activity to ensure clients are not engaging in inappropriate contact with each other or engaging in abusive sexual behavior. Staff shall never engage in sexual behavior/contact/conduct/harassment of a client under any circumstance and shall be terminated immediately and reported to the appropriate licensing board if staff does engage in this behavior.
Supervision and Monitoring of Staff
All administrative supervisors are expected to monitor and supervise the actions of their staff to ensure that they perform their duties in a lawful, professional, and ethical fashion that ensures the safety of co-workers and clients on a day-to-day basis. Any behavior that appears to place the safety of clients or co-workers in jeopardy or that represents a violation of legal, professional or ethical standards must be addressed immediately and reported to the Director of Operations and the Executive Director as soon as possible.
QUARTERLY RISK MANAGEMENT ACTIVITIES
A. The following risk management activities will occur quarterly and will be included in the Quarterly QA Report.
- Progress toward plan objectives
- Activities concerning potential hazardous working conditions/physical plantÂ conditions/fire/safety considerations
- Review the monthly QA Safety and Infection Control Form
- Monitoring of significant financial losses
- Review the monthly Agency Service Budget
- Review any funding contracts due for renewal
- Monitoring of all major unusual incidents reporting /reviewing
- Review the MUI section of the QA report for any re-education need
- Communication to/from QA/QI coordinator/committe
- Address any areas of concern in the monthly QA Committee Meeting
B. Action recommended to the Governing Authority Changes in policies/procedures/program etc.
- Communicate any suggestions for changes to the Administrative Coordinator and Executive Director so changes can be taken to the Board
C. Use of the findings for improvement of the program/corrective action plan
D. Status of corrective action taken last quarter