Title Page
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Conducted on
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Prepared by
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Location
H. Health and Safety
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1. The organization maintains a healthy and safe environment.
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2. The organization implements written procedures to promote the safety of:
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a. Persons served
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b. Personnel
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3. Person served receive education designed to reduce identified physical risks.
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4. Personal receive documented competency-based training:
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a. Both:
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(1) Upon hire.
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(2) At least annually
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b. In the following areas:
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(1) Health and safety practices
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(2) Identification of unsafe environmental factors
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(3) Emergency procedures
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(4) Evacuation procedures, if appropriate
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(5) Identification of critical incidents
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(6) Reporting of critical incidents
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(7) Medication management, if appropriate.
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(8) Reducing physical risks
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(9) Workplace violence
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5. There are written emergency procedures:
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a. For:
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(1) Fires
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(2) Bomb threats
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(3) Natural disasters
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(4) Utility failures
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(5) Medical emergencies
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(6) Violent or other threatening situations
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b. That satisfy:
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(2) Practice is appropriate for the locale
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c. That address, as follows:
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(1) When evacuation is appropriate
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(2) Complete evacuation from the physical facility.
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(3) When sheltering in place is appropriate
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(4) The safety of all persons involved
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(5) Accounting for all persons involved
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(6) Temporary shelter, when applicable
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(7) Identification of essential services
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(8) Continuation of essential services
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(9) Emergency phone numbers
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(10) Notification of the appropriate emergency authorities
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6. The organization has evacuation routes that are:
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a. Assessable
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b. Understandable to:
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(1) Person served
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(2) Personnel
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(3) Other stakeholders, including visitors
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7. Unannounced tests of all emergency procedures:
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a. Are conducted at least annually:
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(1) On each shift
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(1) At each location
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b. Include complete actual or simulated physical evacuation drills.
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(1) Areas needing improvement
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(2) Actions to be taken
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(3) Results of performance improvement plans
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(4) Necessary education and training of personnel
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d. Are evidenced in writing, including the analysis.
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8. There is immediate access to:
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a. First aid expertise
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b. First aid equipment
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c .First aid supplies
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d. Relevant emergency information on the:
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(1) Persons Served
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(2) Personnel
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9. The organization has written procedures regarding critical incidents that include:
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a. Prevention
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b. Reporting
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c. Documentation
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d. Remedial action
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e. Timely debriefings conducted following critical incidents
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f. The following critical incidents if appropriate:
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(1) Medication errors
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(2) Use of seclusion
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(3) Use of restraint
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(4) Incidents involving injury
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(5) Communicable disease
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(6) Infection control
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(7) Aggression or violence
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(8) Use an unauthorized possession of weapons
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(9) Wandering
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(10) Elopement
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(11) Vehicular accidents
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(12) Bio-hazardous accidents
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(13) Unauthorized use and possession of legal or illegal substances
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(14) Abuse
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(15) Neglect
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(16) Suicide and attempted suicide
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(17) Sexual assault
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(18) Other Sentinel events
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10. A written analysis of all critical incidents is provided to or conducted by the leadership:
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a. At least annually:
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b. That addresses:
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(1) Causes
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(2) Trends
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(3) Actions for improvement
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(4) Results of performance improvement plans
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(5) Necessary education and training or personnel
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(6) Prevention of reoccurrence
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(7) Internal reporting requirements
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(8) External reporting requirements
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11. The organization implement procedures:
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a. For:
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(1) Infection prevention
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(2) Infection control
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b. That include:
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(1) Training regarding:
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(a) Infections
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(b) Communicable diseases
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(2) Appropriate use of standard or universal precautions
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(3) Guidelines for addressing these procedures with:
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(a) Person served
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(b) Personnel
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(c) Other stakeholders
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12. When transportation is provided for person served there is evidence of:
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a. Appropriate licensing of all drivers
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b. Regular review of driving records of all drivers
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c. Insurance covering:
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(1) Vehicles
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(2) Passengers
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d.Safety features and vehicles
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e.Safety equipment
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f. Accessibility
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g.Training of drivers regarding:
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(1) The organizations transportation procedures
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(2) The unique needs of person served
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h. Written emergency procedures available in the vehicles
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i. Communication devices available in the vehicles
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j. First aid supplies available in the vehicles
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k. Maintenance of vehicles owned or operated by the organization according to manufacturers’ recommendations
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l. If services are contracted, review of the contract is at least annually against elements a. through k. of this standard.
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13. Comprehensive health and safety inspections:
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a. Are conducted:
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(1) At least annually
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(2) By a qualified external authority
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b. Result in a written report that identifies:
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(1) The areas inspected
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(2) Recommendations for areas needing improvement
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(3) Actions taken to respond to the recommendations
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14. Comprehensive health and safety self-inspections:
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a. Are conducted at least semiannually on each shift
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b. Result in the written report that identifies
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(1) The areas inspected
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(2) Recommendations for areas needing improvement
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(3) Actions taken to respond to the recommendations
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15. If applicable, there are written procedures concerning hazardous materials that provide for sale:
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a. Handling
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b. Storage
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c. Disposal
