South Arkansas Regional Health Center. Written Plan for Health, Safety and the Environment of Care

Transcription

1 South Arkansas Regional Health Center Written Plan for Health, Safety and the Environment of Care Introduction South Arkansas Regional Health Center is committed to providing a therapeutic, safe, healthy and pleasant environment for the consumers, staff and visitors of the center through the development, implementation and on-going monitoring of South Arkansas Regional Health Center, Inc. s facilities, vehicles, equipment and supplies. This plan includes the following: Staff orientation Surveillance and monitoring of the safety and cleanliness of the environment Evacuation plans and procedures for handling emergencies Infection Control First aid Incident reporting The planning, development, revision, implementation, monitoring, and evaluation of the Center s Health, Safety and Environment of Care Plan takes into consideration external and internal standards of care reflective of our center s practice designed to enhance the safety and appearance of facilities, reasonable protection against loss exposure and the prevention of hazards and the control of infection in the physical environment. The scope of this written plan includes the appropriate planning and design of a system of care that is consistent with the mission of South Arkansas Regional Health Center, Inc., and includes the following types of initiatives and activities: 1. Orientation and the education of staff with regard to their individual and collective role in ensuring a provision of a safe, healthy, and clean environment. 2. Promote and facilitate an agency-wide awareness that our environment impacts both the individuals served by South Arkansas Regional Health Center Inc., the staff working directly and indirectly with the clients served, and visitors to the Center. 3. Analysis of findings, subsequent recommendations and /or corrective action, as appropriate and necessary, and subsequent identification and strategies for improving the practices, activities and processes stated herein. 1

2 Implementation The Director of Quality Improvement will maintain responsibility for the preparation, implementation, monitoring, evaluation and reporting on the activities or problems encountered with the Health, Safety and Environment of Care Plan. All staff has an individual and collective role in contributing to and the monitoring of the maintenance of a clean, safe and healthy environment. The Program Director of each specific geographic location retains the autonomy, independence and authority to ensure that the maintenance and cleanliness of the facility is maintained on a day-to-day basis. The majority of S.A.R.H.C. facilities contract with an external cleaning service to provide on-going cleaning, sanitation, and other related services to its facilities. These services include the inspection, maintenance and replacement of lights, particularly with respect to Exit Lighting and Emergency Lighting in the respective facilities. In response to consumer, customer and particularly, staff input, emergency plan testing/ implementation will take into consideration the least disruption possible with the scheduled day-to-day activities of the agency, including appointments between staff and clients. Accordingly, tests of our emergency plans may typically commence during times of either low patient volume, cancellation of appointments, lunch time, staff meeting times, and the like. Any situation(s) or circumstances that naturally occur throughout the year, at any of our geographic locations relative to emergency disaster drill activities may be considered a test of the respective plan. In the event of an actual medical emergency, only those situations requiring medical attention above and beyond the attention of the agency nurse will be considered as a test, providing there is a subsequent submission of an Incident Report Form according to procedure. An annual test or drill schedule will be developed by the Director of Quality Improvement and given to the Program/Unit Director or designee at the beginning of each year. Each location will be responsible for completing tests/drills as assigned monthly. Otherwise, in the event that the Program Director or designee has not initiated a specific test of the emergency plan nor has had an actual situation constituting a test, the Director of Quality Improvement will inform the Program Director or designee, during the last quarter of the year, so as to ensure a minimal annual testing of all plans unless otherwise required by licensure, regulation, or law. The process of reporting will consist primarily of the identification of any relevant or significant deviation from expectations or anticipated levels of performance associated with the components of this plan. In the event issues or problems associated with the provisions of this plan or its implementation remain unresolved, the Director of Quality Improvement will report the situation or circumstances to the Management team for further input and resolution. 2

3 Staff Orientation Employee orientation to the agency consists of familiarizing with the provisions contained herein. All new employees are informed of the key components of this plan and provided a copy for their reference. On-going training is provided during staff inservices to address changes to procedures and/or maintain knowledge of current safety information. All Fire Extinguishers are inspected monthly to ensure they are charged and current on inspection. Agency owned and operated vehicles are inspected on a monthly basis by a designated staff member with the results forwarded to the Director of Quality Improvement. This ensures that our vehicles driven by staff and transporting clients are properly maintained and are safe. Any indicated or necessary repairs are expeditiously implemented via the Program Director at each geographic location. All of our Life Safety Maintenance Agreements are closely monitored and tested on at least an annual basis by Electronic Alarm Company at all the El Dorado sites and Simplex at the Magnolia and Camden sites. This includes testing of fire alarm systems; smoke detection systems, and other alarm systems. The Department of Health reviews and inspects kitchen and cooking facilities at Hope House on an annual basis. Our fire suppression equipment at all geographic Hope Fire Extinguisher and a designated staff inspect locations on an annual basis monitors all fire suppression equipment for an appropriate level of charge on a monthly basis. The New Hope building in Camden is rented and Metropolitan Fire Extinguisher Company inspects the fire suppression equipment. State Child Care Licensing officials conduct periodic inspections of the children s outpatient program at West Grove Academy. Staff are instructed to observe and review the emergency evacuation routes posted in all facilities while paying particular attention to the location of fire suppression devices, first aid supplies, emergency exits, and existence of emergency contact numbers located on each evacuation plan. Additionally posted are lists of staff that are trained in CPR and First Aid and these lists are located at all geographic locations. Staff is informed of the Center s policy on safety with particular attention focused on the agency s commitment to promote and protect the safety of staff, our clients, and visitors. Therapist s or case managers who are likely to provide service in the community, in homes, schools or other similar places outside of the traditional office setting are instructed to always be aware of a means of safe egress. Case managers typically offer services in homes and they are generally paired with another case manager for the initial period of their employment with the agency. The key attributes of infection control, specifically, the use of universal precautions is stressed. Staff members are informed as to the availability of nursing staff (at all geographic locations) and their ability to answer any questions they may have and/or assist in any manners related to the health provisions of this plan. 3

4 Surveillance and Monitoring Internal Environmental Audits Internal environmental surveillance activities will continue to be conducted on a quarterly basis by the Director of Quality Improvement or designee. Typically, these activities consist of observation, discussion, replacement, and/or correction as appropriate and relevant to the following: 1. Overall presentation of the environment in terms of cleanliness. 2. Proper location, storage and access to first aid supplies. 3. Location and limited/restricted access and exposure to Biohazardous Waste Material. 4. Location, Confidentiality, Storage, Inventory of and restricted access to medications. 5. Clear access to fire suppression / protection equipment. 6. Fire suppression / protection equipment checked. 7. Clear means of safe egress in the event of necessary evacuation and posting of evacuation exits, location of fire extinguishers, emergency contact numbers, and CPR/First Aid trained staff. 8. Proper confidentiality, storage, and security of medical / administrative records. 9. Posting of information critical to consumer care including but not limited to client rights and responsibilities, HIPAA guidelines, All Concealed Weapons Prohibited signs, and No Smoking Signs. 10. Posting of State and Federal labor laws. External Environmental Audits As previously referenced, S.A.R.H.C. arranges for a yearly external authority review, inspection, testing, and replacement, if necessary, of several components related to the health and safety of our environment including but not limited to the following: 1. All fire suppression located at our facilities and vehicles are inspected, repaired or replaced, as appropriate by Hope Fire Extinguisher Company with the exception of the New Hope day treatment program facility in Camden which is the responsibility of the landlord. This facility is rented and the owner contracts with Metropolitan Fire Extinguisher Company. 2. All emergency warning devices, means of egress, emergency plans. handling and storage of materials. An external compliance/safety officer inspects walking and working surfaces, electrical systems, ventilation, illumination, noise, and air contaminants yearly. 3. Electronic Alarm Company in El Dorado and Simplex in Magnolia and Camden provide on-going monitoring, maintenance, and annual inspections of the alarm system and ensures compliance with state, provincial and local fire safety requirements. 4

5 4. The Arkansas Department of Health performs unannounced inspections of our Community Integration Program (Hope House) to ensure sanitation provision with regard to food preparation, eating areas, and air contaminants. In addition, the Arkansas Department of Health also provides an inspection on a yearly basis in order to issue a required license to operate a food service. The license is retained and posted by the respective facility. Evacuation Plans / Procedures in Event of Emergency In the event of a catastrophe, natural disaster, or other similar type situation whereby the health or safety of our staff or clients may be potentially placed at risk for a period of time, the following alternatives are available. Staff and consumers in our community integration programs have access to agency vehicles to transport if necessary. Agency vehicles are available at almost all geographic locations and are utilized in the event of any emergency situation. The majority of these consumers are transported to and from the programs by the agency as a means to assist them in receiving the services they need. For the children at West Grove Academy, a school bus is used in transporting consumers to and from the program and remains available at the center for transport. Emergency lighting and battery-operated radios are available at each location. Drill Captains are assigned in each work area to ensure on-site leadership for drills and in case of an actual emergency. All other essential services required by our consumers, at any geographic location, can be provided at and by another geographic location. Emergency services are available twenty-four hours a day, seven days a week, regardless of weather, for crisis intervention and psychiatric assistance In the event of a fire, either the emergency alarm system will be activated or an announcement will commence over the intercom system informing all staff to immediately evacuate the building according to procedure. Safety Procedure (SA-002) RACE = R = Rescue A= Alarm C= Contain E= Extinguish/Evacuate 1. R Rescue Is always the priority for the safety of our clients, staff and visitors. a. All staff, clients, and visitors should exit the building in a calm fashion via the closest exit immediately available and as identified on the Evacuation Plan for each respective building. Do not use elevator in evacuation of building during a fire. b. All available staff members are responsible for escorting clients from the premises. Particular attention should be focused upon children and those who may have any disabilities or needs. 5

6 c. Clients, staff and visitors are to report to the most convenient area of assembly that is at least 50 feet away from the physical structure of the building affected and check in with their assigned captain. 2. A Alarm a. In the event of an actual fire or fire alarm, staff should pull fire alarm if it is not already sounding and leave the building through the nearest fire exit. The alarm will contact the emergency services. Once safely out of the building, staff can call 911 to give more details regarding location of the fire in the building, etc. 3. C Contain a. Drill Captains and senior staff members will be the last ones out of the building following verification that all clients, staff and visitors are evacuated from the building. b. Drill Captains and other senior staff shall will, to the best of their ability as safety allows, ensure that all internal doors and windows are closed. 4. E Extinguish / Evacuate a. In the event that the fire is small and has not yet spread beyond its original point of origin, staff may attempt to extinguish and bring the fire under control. b. Locate nearest fire extinguisher and follow the directions on the extinguisher. Stand five feet from the fire. Use the PASS procedure in extinguishing a fire. P= Pull the Pin. A= Aim nozzle at the bottom of the fire S = Squeeze the handle S = Sweep at the base of the fire. c. If staff attempts to contain the fire, always position yourself with your back to the closest available exit. d. Evacuate the building, utilizing the closest exit as shown on the nearest evacuation route sign. Clients and staff will report to assigned drill captains to account for the safety of all. Clients, staff or visitors may re-enter the building only after it has been determined by officials or seen by senior staff, as appropriate, that the fire has been contained and it is determined that the building is safe to enter. 6

7 In the event of an actual fire, an Incident Report will be filed with the Director of Quality Improvement. Any associated reports conducted by local authorities will be attached upon receipt. DO: Remain calm keep your head clear and think. Know your evaluation route to the closest available exit. Know where the fire extinguishers are located and how to use them. Never attempt to manage a fire that is bigger than you are. Get help immediately, initiate the alarm system and call 911. Leave the lights on, even in a fire area. Follow the evacuation procedure in the event you are not going to attempt to contain. DON T Do not ever shout FIRE! Do not pull the pin on the fire extinguisher until you get to the area of the fire. Do not turn the fire extinguisher upside down. Do not attempt to manage a fire bigger than you. Do not attempt to use the elevator. DURING A FIRE Feel a door before you attempt to open it. If it is hot, do not open the door. If the door feels cool, do not stand up to open it, kneel down and close the door behind you after exiting. Stay low and close to the floor in an area filled with smoke. Leave the lights on and disconnect other electrical appliances or equipment if possible. If you must go through a smoke filled area, try to place a wet cloth, or piece of clothing over your nose and mouth. In the event of a tornado watch or warning: An announcement will commence over the intercom system informing all staff to immediately assist all clients according to procedure. (SA-005) Tornado Watch 1. During a tornado watch keep tuned to the local radio or TV stations. If the weather service shows radar screening, you can readily see where the storms are headed. 7

8 2. Check outdoors, as appropriate, and indoors for any objects, which may become airborne in the event of high winds and secure them as needed. a. Outside objects may include lawn chairs, metal trays, ashtrays, etc. b. Inside objects may include drinking glasses or other objects made of glass such as vases, mirrors, trays, bottles and other sharp objects. c. Check to ensure drapes/ blinds are closed to help stop flying glass. d. Reassure clients. Tornado Warning 1. In the event of a tornado warning is issued: a. Move clients and staff into a hallway of the lowest floor and away from windows and doors. Sit on the floor with your back against the wall. b. All rooms with windows attached to a hallway should have doors closed. c. Remain calm, reassure clients and don t panic. d. Remain in hallway until notified that the Tornado Warning has ended. In the Event of a Bomb Threat 1. Any and all threats are to be treated as a serious threat of harm to the well being of our staff, clients and visitors. Bomb threats may be in the form of a telephone call, note, correspondence including fax, , etc. 2. The staff person receiving the bomb threat should: a. Remain Calm. b. Obtain as much information as possible by prolonging the call or the conversation with the person verbalizing the bomb threat. Try to ascertain the exact location of the suspected bomb, the type of explosive, the time it will explode, what it looks like and why it was placed. 3. The staff person receiving the threat should attempt to notify a nearby staff who can immediately call the 911 emergency telephone number or call 911 after the call ends. 8

9 4. The staff person who calls 911 should notify the Program Director and the Executive Director immediately. 5. The Program Director or Executive Director may order evacuation. A recommendation to evacuate may also be given by the police department, local law enforcement agency, or fire department. In the case of evacuation, the evacuation procedure should be followed. 6. Clients, staff or visitors may re-enter the building after it has been determined by officials or by senior staff, as appropriate, that the building is safe to enter. In the event of a earthquake An announcement may commence over the intercom system informing all staff to immediately assist clients according earthquake procedure. However, given that there may likely be no warning whatsoever, as in the case of a tornado, staff are to inform and assist clients to secure a position beneath a sturdy desk or table and stay away from windows, glass doors, or other glass objects. In case of a severe medical emergency Any available doctor, nursing staff, or certified CPR/First Aid staff should be called immediately to the scene. Nearby staff should immediately call 911 and take all necessary precautions to divert clients from the vicinity. The Executive Director, Program Director and the Medical Director should be notified as quickly as possible. Family members or the designed emergency contact person listed for the individual will be notified by S.A.R.H.C. personnel as soon as possible. The staff member who initiated care for the client is to complete an incident report. In the event of a power failure There is an emergency lighting system that will be activated and will provide enough light for and allow safe egress and evacuation of the building, if necessary. Flashlights are available in the event no other lighting system is working or available. If needed, Clients will be transported home from community integration programs. Extended loss of power may require the Center to temporarily close, in which case, public service announcements will be provided on radio and television and emergency on-call services will continue to be available for crisis intervention. 9

10 In the event of an agitated/combative Client S.A.R.H.C. services, programs and/or staff do not use seclusion, restraint or other therapeutic intervention techniques or procedures to control the combative behavior of clients; such as therapeutic holds or physical interventions in the therapeutic setting, onsite or off-site. In dealing with an agitated or combative client, staff will: Approach the client in a calm, confident, direct, matter-of-fact, non-threatening manner. Expectations and/or limits must be reasonable and clearly and slowly communicated to the client. Let the client know of appropriate choices that are open to him/her. Offer the client assistance in resolution of the issue or in modifying his/her anger or behavior in an acceptable manner. If possible, other staff members should make an effort to clear all individuals away from the immediate area for the protection of all. In the event that it appears that verbal re-direction and/or de-escalation is not having the desired effect, the affected staff or other staff may call Code 1000 and give the location of the code over the intercom for additional manpower. For those sites where an intercom system is not available, staff is to call the front office and the co-worker who answers is responsible for spreading the Code 1000 information to other staff members. All available and able staff members will go to the location of the code to provide assistance. If the situation warrants, either 911 should be called or the local law enforcement agency. An incident report is to be filled out and forwarded through the appropriate channels per incident reporting procedure. Special treatment interventions or any other type of intrusion or intrusive procedure such as involuntary administration of medication or emergency medication or inappropriate touching for the purpose of searching the consumer is strictly prohibited. In the event of a Client with a Weapon Any and all concealed weapons are prohibited inside SARHC property and or property rented by SARHC unless carried by law enforcement during the performance of their duties. Signs stating All Concealed Weapons Prohibited are posted at each entrance. In the event that a client reveals he or she has a weapon, staff will remain calm and speak calmly to the client and ask the client to leave the facility. In the event that a client refuses to leave or if staff feels immediately threatened, the affected staff may call a Code 22 followed by the location. For those sites where an intercom system is not available, staff is to call the front office and the co-worker who answers is responsible for spreading the Code 22 information to other staff members. In addition, any available staff member who is in a safe place is to call

11 Staff will keep clients and visitors out of the indicated area and assist them as needed in securing a safe position away from the announced location. Staff will remain in the safe location until notified by authorities that the situation has been resolved. Once the situation is resolved, an incident report is to be filled out and forwarded through the appropriate channels per operational procedure. Vehicle Plan South Arkansas Regional Health Center provides transportation, as appropriate and available, in center-owned or leased vehicles, for those in need as a result of disability or inability to provide their own transportation in order to attend scheduled appointments, actively participate in their treatment regimen, or as otherwise deemed appropriate by the supervisor or Program Director. Vehicle operators must be appropriately licensed with a valid Driver's License and have an appropriate driving record. All Vehicle Operators will receive training for emergency or urgent circumstances and situations. All operators shall be trained in First Aid in case a medical emergency should arise and other qualified medical personnel are not available. Operators will be familiar with and have access to emergency procedures to use in case of an accident, flat tire, oil leak, gas leak or other potentially dangerous situations. Emergency situations shall be immediately reported to supervising personnel and subsequently referred to the Program Director and/or Executive Director, as appropriate. In case of an accident, ensure all passengers are safe, comfortable and unharmed. If passengers have minor injuries that the operator is trained to handle, then appropriate first aid will be given. If injuries are severe, proper medical authorities should be notified along with notification to the Program Director and the Executive Director. The operator shall not admit fault to anyone but will contact and cooperate with authorities. Names, addresses, phone number, driver's license number and insurance company (including policy number) of the parties involved shall be exchanged. An Incident Report should be filed immediately upon return to work or as soon thereafter as possible. All paperwork collected at the accident scene should be submitted, along with the incident report, to the Program Director and/or Executive Director. In case of a flat, the operator should ensure all passengers are unharmed and safe. The operator should immediately notify supervising staff so that arrangements for auxiliary transportation may be arranged and the appropriate service may be contacted to conduct the necessary repair(s). In case of oil leak, gas leak or any other potentially dangerous situation, the operator and passengers should evacuate the vehicle immediately. Designated South Arkansas Regional Health Center personnel should be notified. Knowledgeable personnel will 11

12 assess the vehicle. Passengers may need to be transported by another vehicle. The Executive Director should be notified of the situation. Warning Signs, available in each van, should be placed in the road, behind and in front of the van, if the van is blocking traffic for any reason. Hazard lights, located on the instrument panel, should also be activated. Vehicle inspections are conducted monthly by designated staff. Documentation of inspections and corrective action are forwarded to the Director of Quality Improvement. The following items are checked during inspection: tire pressure, brake fluid, oil level, filters, antifreeze level, spare tire condition, content of first aid kit, fire extinguisher, emergency phone numbers, seatbelts in working order, lights, road warnings/hazard equipment, current insurance coverage and the Center's Vehicle Plan. Infection Control It is the policy of South Arkansas Regional Health Center to promote and provide a safe, supportive, and healthy environment within which all consumers, external customers and staff are provided the opportunity to individually and collectively participate in the prevention and control of infection or communicable disease. The purpose of the South Arkansas Regional Health Center infection control program is to provide an educational/training framework and programs designed as such to adhere to guidelines established by Federal, State, local health authorities and additionally include best practices through established procedure(s) relative to identifying and minimizing or reducing the associated risks and incidence in preventing the spread of endemic/epidemic infections and communicable disease. The scope of the South Arkansas Regional Health Center infection control program includes the following areas: 1. Prevention/Control of Infection & Communicable Disease 2. Biomedical-Infectious Material/Waste 3. First Aid Method of Implementation: South Arkansas Regional Health Center has established a system, mechanism and process designed to educate & train both consumers and staff, and to monitor/evaluate identified risk(s) associated with the prevention and control of infection and communicable disease; consisting of, but not limited to the following: 12

13 1. Staff Orientation At orientation staff is given information a copy of the Infection Control Plan which is reviewed with them. This plan includes: A. General Principles of Infection Control B. Universal Precautions C. Occupational Exposure D. Voluntary Availability of Hepatitis B Vaccine 2. Consultation & In-Service Training Any relevant trends pertaining to the review and monitoring of reported incidents involving infection control or any significant issues that arise will either be discussed on an on-going basis during clinical staffing or may be included as scheduled topics for in-service training. The nursing staff on duty at each location of service delivery will be able to identify and assist other staff with on-going consultation in regard to infection control issues. A. General Principles of Infection Control 1. Sources of Infection: Any individual is a potential source of infection that comes into contact with consumers, staff, or visitors who have an active disease or who are carriers (colonized by an infectious agent but who have no evidence of disease). Other sources include a person s own endogenous flora, fomites (inanimate objects in the environment which are contaminated), or the reservoir the environment in which the agent of infection is found. 2. Modes of Escape from Reservoir: Respiratory tract, gastrointestinal tract, open lesions, mechanical escapes (includes insects) and blood. 3. Modes of Transmission: Infectious diseases are transmitted via three major types of transmission; contact, airborne and bloodborne. Generally speaking, the determination of the mode of transmission assists in the identification of the proper precautions to be taken. Major Types of Transmission: a. Contact (3 Types) 13

14 1) Direct Personal Contact between a susceptible individual and an infected person. 2) Indirect Personal Contact by a susceptible individual with a contaminated article resulting in hand to mouth, hand to skin, or mucous membrane transfer of the infectious agent. 3) Droplet Contact by a susceptible individual with a transmissible organism by way of the conjunctive, nose or mouth. b. Airborne: Transmission of a microorganism either in droplet nuclei (dried droplets) or re-suspended dust. Droplet nuclei refers to those particles whose characteristics allow them to be transmitted more than several feet and can remain suspended in the air for long periods of time. They become disseminated and are either inhaled or deposited on the skin and/or mucous surfaces. c. Bloodborne: 1) Transmission of microorganisms that are present in human blood and cause disease in humans, such as, Hepatitis B and Human Immunodeficiency. 2) Personnel with exudative lesions or weeping dermatitis should refrain from all direct consumer care and from handling patient care equipment until the condition is resolved. 3) Precautions should be taken to prevent injuries caused by needles, scalpels, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. Resistance to pathogenic microorganism(s) varies markedly and depends on several factors or conditions such as: age, sex, genetic constitution, immune system status, nutritional status, general physical, mental and emotional health; presence of any underlying disease (diabetes, lymphoma, leukemia, neoplasia), or treatment with certain anti-microbial, corticosteroids, irradiation, or immunosuppressive agents. B. Universal Precautions Universal Precautions as defined by the Centers for Disease Control and Prevention, are a set of precautions designed to prevent transmission of human 14

15 immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other blood borne pathogens. Universal precautions involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker s skin or mucous membranes to potentially infective materials. In addition, under universal precautions, it is recommended that all health care workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices. All employees should take precautions to prevent injuries caused by needles during disposal. To prevent needle stick injuries, needles should not be recapped by hand, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes and needles, and other sharp items should be placed in puncture-resistant containers for disposal. The puncture-resistant containers are located in the nurse s office. These containers are collected and disposed of by Commodore Medical Services. Gloves should be worn when anticipating touching blood, tissue, body fluids containing visible blood, mucus membranes, or the non-intact skin of individuals Gloves should also been worn when anticipating touching or any contact with surfaces soiled with any bio-hazard substance or material. 1. Change gloves between patient contacts. Hands should be washed immediately after gloves are removed. 2. Hands and other skin surfaces should be washed immediately or as soon as patient safety permits if contaminated with blood or body fluids requiring universal precautions. 3. Do not wash or disinfect surgical/examination gloves for reuse. Washing the surface may cause enhanced penetration of liquids through undetected holes in the gloves. Disinfecting and/or cleaning agents may cause deterioration in the surface of the gloves. 4. Use general-purpose utility gloves for housekeeping duties involving potential blood contact and for instrument cleaning and decontamination procedures. Utility gloves may be decontaminated and reused but should be discarded if they are peeling, cracked or discolored, or if they have punctures, leaks, tears or other evidence of deterioration. 5. Staff who have lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment until the condition is resolved. 15

16 Isolation procedures are typically determined by the nurse or doctor depending upon the phase of isolation and type of treatment needed. Isolation may include being separated from the group or being dismissed from treatment until the noted condition stabilizes. Isolation procedures are used on an as needed basis and only as necessary to prevent the spreading of illness, infection or disease. Incident Reporting: (Refer to SA 009) Incident Reports provide a mechanism to be able to identify individually and collectively any trends in any adverse events that either potentially or actually cause injury or harm to any consumer, visitor or member of the workforce. Incident Reports are to be completed in the event of a sentinel event, a bio-hazard accident, use of possession of licit and/or illicit substances, abuse and neglect, suicide or attempted suicide, medication errors, incidents involving injury, exposure to communicable diseases, acts of violence or aggression, elopement, and in any circumstance in which there has been potential or actually harm to any customer, visitor, or employee. The reporting and subsequent analysis of incidents throughout the organization, either onsite or off-site, provides the opportunity to identify any significant trends with the hope of being able to ascertain any cause effect relationships that may be able to be prevented in the future. All incidents should be recorded accurately and completely on the Incident Report Form and submitted to the respective Program/Unit Director for review. The Program/Unit Director forwards the Incident Report From to the Executive Director for review. The Executive Director sends it to the Director of Quality Improvement for review and data collection. The analysis of the organization s incidents are tracked upon receipt by the Director of Quality Improvement. The Director of Quality Improvement prepares an annual summary of the type, nature, frequency, and trends associated with incidents by geographic location and makes recommendations regarding training, internal processes, and/or procedural changes needed. (Refer to Incident Report Summary) 16