R03-502 Program Environment and Safety

A. A licensee shall develop, implement and comply with written policies and procedures for the safety and protection of all individuals within the program environment that include:

1. A disaster plan that addresses disaster preparedness, planning, response and recovery during any emergency that may include fire, flood, tornado, severe weather, earthquakes, medical emergencies, power failures, bomb threats, terrorist threats, acts of violence, prolonged loss of heat, light, water, chemical exposure, unusual fumes, and gas leaks,

2. An emergency plan to meet the physical needs of clients, staff, and visitors in the event of disruption caused by injury, death, or arrest,

3. Designation of a staff member to ensure that disaster and emergency plans are kept up to date,

4. That the Department of Social and Rehabilitation Services is notified within 24 hours or the next business day immediately following an emergency that disrupts client services for more than 48 hours, and

5. An annual review and update of their internal disaster plan.

1. Review in Policy and Procedure Manual. 3. Verify staff member assigned to update. 5. Verify disaster plan updated by signature.

 

B. A licensee shall develop policy for use of tobacco products at the facility to include the following:

1. For programs providing services to adults, tobacco use is prohibited inside the facility and may be permitted outside in a designated area, and

2. For programs providing services to minors, tobacco use is prohibited on the premises by minors.

Review in Policy and Procedure Manual. Verify location of posted signs.

 

C. A licensee shall:

1. Ensure compliance with federal, state and local fire and safety regulations, codes, and statutory requirements,

2. Provide annual documentation on the program premises of the working order for fire extinguishers and smoke detectors,

3. Obtain an annual fire and safety inspection conducted by the state fire marshal or local authorities,

4. Maintain a copy of the fire and safety inspection report on the premises with any subsequent correspondence regarding deficiencies,

5. Maintain current HIV and STI reference materials on site,

6. Maintain a safe, clean environment free from rodents and insects,

7. Ensure client confidentiality at all times unless disclosure is authorized by law and court order, and

8. Keep refuse in covered containers.

2. Verify by reviewing the fire inspection report. 6. Tour facility and verify a safe clean environment. 8. Verify covered containers in kitchens, food preparation areas, bathrooms and outdoors.

 

D. In addition to meeting the requirements for (C) (1-8) residential programs shall:

1. Conduct, on an annual basis, quarterly fire and tornado drills and document the: a. Number of staff, b. Number of clients, c. Date of the drill, and d. Time the drill was initiated and completed,

2. Maintain fire and tornado drill documentation at the program for a period of 12 months,

3. Provide areas or rooms that afford privacy and are sufficient to accommodate the treatment services and activities stated in the program description such as individual or group counseling,

4. Provide adequately equipped, clean, well-maintained and ventilated client bathrooms that ensure privacy,

5. Provide client sleeping quarters that include individual beds that are:

a. In good repair,

b. Free of odors,

c. Free of stains,

d. Free of infestation, and

e. Equipped with clean bedding, such as pillow, linens, blanket or bedspread that are in good condition,

6. Dispose of medical waste in accordance with the guidelines of the Centers For Disease Control,

7. Keep chemicals a minimum of 6 inches off of the floor, 48 inches away from food, and 72 inches away from heat sources such as hot water heater pilot lights,

8. Keep working thermometers in refrigerators and freezers at all times, with refrigerators maintaining a temperature at or below 41 degrees Fahrenheit and frozen foods maintained in a frozen state, and

9. Ensure that foods which have been removed from the original container are a. Placed in a spill proof container, b. Labeled, c. Dated, and d. Stored no less than 24 inches off of the floor, and

10. Develop, implement, and comply with policies regarding animals on the premises.

1. Review and verify drill logs are complete with elements 1 a-d and are maintained for 12 months. 4 - 9. Tour facility and verify conditions of bathrooms, bedrooms, beds, red medical waste containers, chemical storage, refrigerators and freezers, working thermometers, and appropriate food storage. 10. Review of policy and procedure manual and verify compliance.

 

E. A licensee shall post conspicuously on the premises the following information:

1. Emergency evacuation routes,

2. Emergency telephone numbers for the fire, police and poison control,

3. The location at the program where inspection reports are available for review, and

4. For a residential treatment programs, the days, times, and locations within the program a client may receive visitors and telephone calls.

Verify the posted locations of R03-502 1-4.