FSHOP 215-4

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					OPERATING PROCEDURE                                                    Florida State Hospital
NO. 215-1                                                              Chattahoochee, Florida
                                                                       August 7, 2009


                                              Safety

                   RESIDENT HEALTH AND SAFETY PLAN / COMMITTEE

1. Purpose: To promote the health and safety of residents, review and evaluate the quality of
resident safety measures used by Florida State Hospital, and assist in the implementation of the
facility resident health and safety plan.

2. Training Requirements: Unit Directors, Department Heads, and all direct services staff will
be trained on this operating procedure upon hire into the position during Worksite Education and
by their supervisor each time the operating procedure is revised. Resident Safety Committee
members will be trained when appointed to the committee.

3.   References:

     a. 42 Code of Federal Regulations Part 482.21, Condition of participation: Quality
Assessment and Performance Improvement Program. NOTE: This is equivalent to the Florida
State Hospital Total Quality Management - Quality Delivery System.

     b.   Florida Statutes 395.1012 Resident Safety.

4.   General:

     a. The Hospital Resident Health and Safety Officer is the Administrative Assistant I within
Risk Management which is appointed by the Administrator.

    b. The Resident Health and Safety Plan is part of the overall Hospital Total Quality
Management Quality Delivery System process (see the Attachment for relationship).

     c. The Resident Health and Safety Committee evaluates the hospital’s collection,
processing, and evaluation of resident health and safety information with hospital wide
departmental and specialized committees (see the Attachment).

5.   Responsibilities:

     a. All Hospital Unit Directors and Department Heads will be aware of the Hospital
Resident Health and Safety Plan and Committee. All efforts should be taken to correct any
resident health and safety concerns within the current hospital processes (see the Attachment).
Issues or concerns not resolved by this process should be documented and forwarded to the
attention of the Hospital Resident Safety Officer/Office of Risk Management.

     b.   The Hospital Resident Safety Officer will:


This operating procedure supersedes: Operating Procedure 215-1, dated December 16, 2008
Office of Primary Responsibility: Office of Risk Management
Distribution: Florida State Hospital Computer Network Users
Operating Procedure 215-1                                                            August 7, 2009


          (1)   chair the Resident Health and Safety Committee;

         (2) ensure the Resident Health and Safety Committee meets once per quarter or
more frequently as needed;

       (3) convey management's views and other committee actions to committee
members in order to exchange information;

          (4)   track all actions requiring follow-up to ensure applicable closure to concern;

          (5)   ensure minutes of meetings are prepared and maintained.

     c.   The Resident Health and Safety Committee will:

          (1)   meet once per quarter or more frequently as needed;

          (2) promote the health and safety of residents, review and evaluate the quality of
resident safety measures used by the hospital, and assist in the implementation of the Hospital
Health and Safety Plan (see the Attachment);

          (3) seek input from and distribute information to all applicable units, departments,
and disciplines in order to establish and assess processes and systems that may impact
resident health and safety at this facility. Ensure there are no unreasonable impediments that
might hinder efforts to promote and complement resident safety.

         (4) Membership: The Resident Health and Safety Committee shall consist of at
least the following standing members (which mostly represents other applicable hospital
committees). The committee shall call upon other knowledgeable medical and/or professional
staff members as needed to participate in committee meetings that relate to their
departments/units and/or discipline.

                (a)   Resident   Health    and   Safety     Officer / Resident   Safety   Committee
Chairperson;

                (b)   Operations and Facilities Director;

                (c)   Nursing Management Team Chairperson or designee;

                (d)   Infection Control Committee Chairperson or designee;

                (e)   Pharmacy and Therapeutics Committee representative;

                (f)   Resident Advocacy Office Representative ;

                (g)   Quality Assessment Environmental Specialist representative; and

                 (h) One person shall also be included who is neither employed by, contracted
with, nor practicing in the Hospital. This person will be appointed by the Hospital Administrator.

  (Signed original on file in Central Health Information Services)

DIANE R. JAMES                                   Attachment
Hospital Administrator                             Hospital Resident Health and Safety Plan

                                                 2
Operating Procedure 215-1                                                      August 7, 2009




                SUMMARY OF REVISED, ADDED OR DELETED MATERIAL
The major change to this procedure is the deletion that the Resident Health and Safety Officer
will be a “Licensed Health Care Risk Manager.” There is no mandated requirement (Florida
Statutes) that this position must be a “licensed person,” however, must be appointed and the
Administrative Assistant I position in Risk Management is charged with this responsibility. The
Attachment was updated.




                                              3
                                                                                              HOSPITAL RESIDENT HEALTH & SAFETY PLAN


                                           Adverse                                      Resident                                                          Resident
                                          Incidents                                    Grievances                                                          Events
                                                                                                                                                                             Hospital Attorney
                                                               Risk Management                           Resident                Risk Management
                                                                                                         Attorney
                                                                                                                                                                                      Resident Advocacy
                                                                                                                          FSHOP 75-1 Resident Events / Injuries
                                                              CODE 15 (AHCA)                                             FSHOP 10-1 Critical Events
                                   Hospital                   Resident Notification
                                   Attorney                                                                               FSHOP 155-10 High Risk Residents                           FSHOP 10-1 Critical Events
                                                              Sexual Misconduct (DOH)                                    Emergency Room Reports
                                                              Annual Report (AHCA)                                                                                                   FSHOP 140-1 Abuse Process
                                                                                                                          Close-the-Loop Process                                       Management Review Process
                                    Quality                                                                               Adverse Events                                             Sexual Misconduct
                                 Assessment &                                                                             Trends / Analysis                                             Reporting
                                                                                   Resident                               Monthly/Quarterly Reports to Units
                                   Planning                                                                           
                                                                                   Advocacy                                Analysis of Events
                                                                                                                          Risk Assessments                                            Quality Improvement Services
                                                                                                                          Sexual Misconduct Reporting
                                 FSHOP 155-22
                                                                                                                          FSHOP 10-9 Workplace Violence
                                 Seclusion & Restraints
                                                                                                                             Awareness and Prevention                                         Risk Management Data
                                                                                  FSHOP 155-6                                                                                                Performance Improvement &
                                                                                     Resident Issue                                                                                               Planning
                                Quality Service Planning                                                                                 Hospital Committees
                                                                                     Resolution System                                                                                        Resident Satisfaction
                                                                                  FSHOP 140-1                                                                                                Staff Satisfaction
                                FSHOP 151-7 Assessments                              Abuse Process                                       Mortality                                           FSHOP 155-22
                                                                                  Resident Government /                                 P&T                                                    Seclusion and Restraints
                                                                                     Safety Committee                                    Infection Control                                   FSHOP 151 -7 Assessments
                                     Resident Advocacy                            Resident Satisfaction                                 Unit / Department / Resident                        FSHOP 155-10 High Risk
                                                                                  Outcome of Tracking                                       Health & Safety Committees                           Management
                                                                                  Trends / Analysis
                                          Abuse Process                          Monthly /
                                          FSHOP 10 - 1                                                                                                  Security
                                                                                     Quarterly Reports
                                      
                                             Critical Events
                                           Security                                                                                                Security Investigations
                                                                                                                                                                                                Hospital Health &
                                                                                                                                                                                                  Safety / Risk
                                                Resident Attorney                      Resident Health & Safety Rights Programs
                                                                                                                                                                                                 Administrator
                                Resident Advocacy Office                                QA Performance Improvement Plan
                                                                                        FSHOP 30-1 Rights and
                                                                                           Responsibilities of Residents and
                            Resident Issue Resolution System                               Staff for Treatment at FSH
                                                                                        FSHOP 155-6                                                                                              Governing Board /
Operating Procedure 215-1
Attachment




                                                                                           Resident Issue Resolution System                            Staff Development
                                                                                                                                                                                                Senior Leadership Team
                                        Resident                                        FLAC / Abuse Processes                                        Training Programs
                                     Ward Government                                    FSHOP 155-10 High Risk Residents
                                       Committee                                        FSHOP 155-1 Access to Grounds /                              Risk Management                           Strategic Plan
                                                                   Risk                    Form Resident Orientation Checklist                           Pre-Service                           Monthly Performance Report
                                                                Management              Resident Satisfaction Survey                                    Annual                                Close-the-Loop Processes
                                                                                        DCF Pamphlet 155-2 Your Rights &                                Problem Areas                             (Resident and Staff)
                                                                                           Responsibilities in Florida’s                                                                        Problem Areas
                                                                   Incident                Mental Health Facilities                                                                             Health & Safety Monthly Reports
                                                                   Reports              De-Escalation / Safety Plan
                                            Resident                                    Resident Response System / Card          Education and                      Summary
                                          Health & Safety      Resident Health &        Family / Friend Immediate                  Training                          Reports
                                                                 Safety Officer           Response System for Safety Concerns

				
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