SAFE AND THERAPEUTIC ENVIRONMENT PLAN
Compliance Checklist
Principles of the Safe & Therapeutic Environment Plan
Clear policy of zero tolerance for workplace violence managers, supervisors, employees, recipients & visitors advised of policy
Employees encouraged to promptly report incidents & injuries
Employees encouraged to suggest ways to reduce or eliminate risks
include information on the facility's policies and procedures regarding
components of the plan delineated in C)3) of the directive
Oversight of Developmental and Implementation of Plan Team designated
all stakeholder represented
Components of the Safe & Therapeutic Environment Plan
Data Analysis (including frequency & cause)
an analysis of recipient injuries by treatment area using facility data
information on staff injuries from OIRS System and/or ARS system
an analysis of injuries by work area & job title using facility data
After reviewing the injury data above, the assessment should focus on work areas experiencing the greatest risk, using the following tools:
staff & recipient focus groups
surveys
environmental audits
Additionally, an evaluation of organizational policies, procedures and practices to ensure they are supportive
Hazard Prevention and Control
(Design of measures through engineering or administrative and work practices to prevent or control identified hazards and incorporate them into plan. Delineate responsibilities and timeframes.)
Suggested improvement areas are:
Clinical/Interpersonal
Environmental
Organizational
Trauma Response
Trauma Response Policy in place
Personnel designated to coordinate and provide services to employees
Does it require:
provision of emotional support
provision of related information, including referral information
accompanying employee home or to medical facilities,
as necessary
assistance in dealing with the criminal justice system
Medical Management Program
The following practices/procedures should be in place:
encouragement of staff and recipients to report all injuries and incidents
appropriate investigation
referral for appropriate medical and psychological treatment
assistance with Worker's Compensation claims, alternate duty
assignments, and other return-to-work issues
Plan stipulates policy and procedures are in compliance with
Section 7.21(b) of MHL; OMH Policy Directives QA 510,
QA 520 and QA 530; and JCAHO Standard EC-1.4.
Training
The following mandates should be included:
all inpatient staff who interact with service recipients trained in PMCS
all non-inpatient direct care staff trained in crisis management training appropriate to their community roles.
clinical staff periodically instructed in restraint and seclusion, including
techniques of application and laws, regulations, policies and procedures
governing use
appropriate training for personnel assigned to trauma response in post-
incident debriefing methodologies and hospital procedures
Plan Submittal and Evaluation
Written plan submitted to Division of Operations, Bureau of Employee
Relations and Bureau of Capital Operations
At least annual evaluation, to include:
review of injury rates and other objective markers, worker's and
recipient's satisfaction with the program's progress and an
examination of measures taken to improve safety
adjustments to program based on evaluation
Annual evaluation report to Division of Operations, Bureau of
Employee Relations and Bureau of Capital Operations
Identified opportunities to improve safety may be addressed through
its Performance Improvement Programs
This page last updated 04/10/07