Audit

H. Health and Safety

1. The organization maintains a healthy and safe environment.

2. The organization implements written procedures to promote the safety of:

a. Persons served

b. Personnel

3. Person served receive education designed to reduce identified physical risks.

4. Personal receive documented competency-based training:

a. Both:

(1) Upon hire.

(2) At least annually

b. In the following areas:

(1) Health and safety practices

(2) Identification of unsafe environmental factors

(3) Emergency procedures

(4) Evacuation procedures, if appropriate

(5) Identification of critical incidents

(6) Reporting of critical incidents

(7) Medication management, if appropriate.

(8) Reducing physical risks

(9) Workplace violence

5. There are written emergency procedures:

a. For:

(1) Fires

(2) Bomb threats

(3) Natural disasters

(4) Utility failures

(5) Medical emergencies

(6) Violent or other threatening situations

b. That satisfy:

(2) Practice is appropriate for the locale

c. That address, as follows:

(1) When evacuation is appropriate

(2) Complete evacuation from the physical facility.

(3) When sheltering in place is appropriate

(4) The safety of all persons involved

(5) Accounting for all persons involved

(6) Temporary shelter, when applicable

(7) Identification of essential services

(8) Continuation of essential services

(9) Emergency phone numbers

(10) Notification of the appropriate emergency authorities

6. The organization has evacuation routes that are:

a. Assessable

b. Understandable to:

(1) Person served

(2) Personnel

(3) Other stakeholders, including visitors

7. Unannounced tests of all emergency procedures:

a. Are conducted at least annually:

(1) On each shift

(1) At each location

b. Include complete actual or simulated physical evacuation drills.

(1) Areas needing improvement

(2) Actions to be taken

(3) Results of performance improvement plans

(4) Necessary education and training of personnel

d. Are evidenced in writing, including the analysis.

8. There is immediate access to:

a. First aid expertise

b. First aid equipment

c .First aid supplies

d. Relevant emergency information on the:

(1) Persons Served

(2) Personnel

9. The organization has written procedures regarding critical incidents that include:

a. Prevention

b. Reporting

c. Documentation

d. Remedial action

e. Timely debriefings conducted following critical incidents

f. The following critical incidents if appropriate:

(1) Medication errors

(2) Use of seclusion

(3) Use of restraint

(4) Incidents involving injury

(5) Communicable disease

(6) Infection control

(7) Aggression or violence

(8) Use an unauthorized possession of weapons

(9) Wandering

(10) Elopement

(11) Vehicular accidents

(12) Bio-hazardous accidents

(13) Unauthorized use and possession of legal or illegal substances

(14) Abuse

(15) Neglect

(16) Suicide and attempted suicide

(17) Sexual assault

(18) Other Sentinel events

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

a. At least annually:

b. That addresses:

(1) Causes

(2) Trends

(3) Actions for improvement

(4) Results of performance improvement plans

(5) Necessary education and training or personnel

(6) Prevention of reoccurrence

(7) Internal reporting requirements

(8) External reporting requirements

11. The organization implement procedures:

a. For:

(1) Infection prevention

(2) Infection control

b. That include:

(1) Training regarding:

(a) Infections

(b) Communicable diseases

(2) Appropriate use of standard or universal precautions

(3) Guidelines for addressing these procedures with:

(a) Person served

(b) Personnel

(c) Other stakeholders

12. When transportation is provided for person served there is evidence of:

a. Appropriate licensing of all drivers

b. Regular review of driving records of all drivers

c. Insurance covering:

(1) Vehicles

(2) Passengers

d.Safety features and vehicles

e.Safety equipment

f. Accessibility

g.Training of drivers regarding:

(1) The organizations transportation procedures

(2) The unique needs of person served

h. Written emergency procedures available in the vehicles

i. Communication devices available in the vehicles

j. First aid supplies available in the vehicles

k. Maintenance of vehicles owned or operated by the organization according to manufacturers’ recommendations

l. If services are contracted, review of the contract is at least annually against elements a. through k. of this standard.

13. Comprehensive health and safety inspections:

a. Are conducted:

(1) At least annually

(2) By a qualified external authority

b. Result in a written report that identifies:

(1) The areas inspected

(2) Recommendations for areas needing improvement

(3) Actions taken to respond to the recommendations

14. Comprehensive health and safety self-inspections:

a. Are conducted at least semiannually on each shift

b. Result in the written report that identifies

(1) The areas inspected

(2) Recommendations for areas needing improvement

(3) Actions taken to respond to the recommendations

15. If applicable, there are written procedures concerning hazardous materials that provide for sale:

a. Handling

b. Storage

c. Disposal

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.