Policy and Procedure Manual

Transcription

1 Policy and Procedure Manual Environment of Care (EC) Table of Content EC-01 EC-02 EC-03 EC-04 EC-05 EC-06 EC-07 EC-08 EC-09 EC-10 EC-11 EC-12 EC-13 EC-14 EC-15 EC-16 EC-17 EC-18 EC-19 EC-20 EC-21 EC-22 TN EC-23 TN EC-24 TN Environment of Care Program Smoking Fire Safety Devices & Systems Fire Plan Shelter in Place Plan Evacuation Plan Weapons Possession or Bomb Threat Security Utilities Management Plan Risk & Safety Assessment Vehicle Use & Driver Safety Management & Disposal of Bio-Hazardous Waste Handling & Storage of Hazardous Materials Cleaning Schedules Decoration of Rooms Kitchen Safety Meal Planning Food Preparation Storage of Food and Supplies Labeling of Stored Food Temperature Monitoring Animal Facility Access & Resident Supervision Animal Facility Emergency & Evacuation Plan Riding of Horses

2 SUBJECT: ENIVORNMENT OF CARE PROGRAM Page 1 of 1 ISSUE DATE: June 30, 2002 REVIEWED/REVISION DATE: March 31, 2014 POLICY NO. EC-01 PROGRAM: All POLICY: The facility shall have an Environment of Care Program to insure the identification, development, implementation and review of security and safety policies and procedures for all departments and services. PROCEDURE: 1. The Environment of Care Program shall be developed by the Safety Officer and Compliance Manager and reviewed annually by the management team. This program will include a review of the Fire Plan, Evacuation Plan, and Shelter in Place Plan, Utilities Management Plan, Security, Management of Hazardous Materials, Animal Facility Emergency & Evacuation Plan, and Infection Control Plan. 2. Mandatory to the safety plan are the following points: A. Establishment of a safety committee which contains multi-disciplinary members who have diverse training and/or experience to develop, implements, and maintain a comprehensive organization wide environment of care program. B. The Executive Administrator appoints a Safety Officer and Risk Manager, responsible for carrying out the functions of the environment of care program. C. The Safety Officer is the chairperson of the Safety Committee, which includes the Management Team. D. The committee does an annual review of the Environment of Care Program and all of it components and a monthly review of any health and safety issues that arise. E. Immediate actions are to be taken when conditions exist that pose an immediate threat to life or health or pose a threat of damage to equipment or building. 3. Documentation of all meetings is through minutes, which must demonstrate evidence of information exchange and consultation between the management team/safety committee on the various safety programs. 4. Conclusions, recommendations and actions of the Safety Committee are evaluated annually.

3 SUBJECT: SMOKING Page 1 of 1 ISSUE DATE: June 30, 2002 REVIEW/REVISION DATE: March 31, 2014 POLICY NO. EC-02 PROGRAM: All POLICY: It is the policy of RHG to provide a healthy environment in which residents and staff live and work. In line with this, no smoking is permitted within the facility. PROCEDURE: 1. Residents are allowed to keep in their possession lighters and/or matches for outside smoking. This right may be restricted by any staff for the safety of the environment. 2. Smoking will be permitted by residents only in designated areas on the grounds. The only such designated areas in Florida are in the back patio, in the backyard; in either covered or uncovered areas. The only area at Tennessee where smoking is permitted is in the designated smoking area on the concrete floored portion of the porch area at the south end of the building on the main level. Smoking in resident rooms or anywhere within the building is strictly prohibited. Ashtrays in the outside Smoking area shall be made of suitable noncombustible materials. 3. Smoking in the front of the building is prohibited. 4. Residents are only permitted to smoke within constraints of treatment team recommendations. 5. The smoking policy shall be provided to each new resident and visitor at the center and to all new staff at orientation. 6. Smoking by employees, visitors, interns or volunteers is prohibited on RHG property or vehicles. 7. Employees and interns are not to smoke in front of residents on outings, appointments or any other company errand.

4 SUBJECT: FIRE SAFETY DEVICES STYSTEMS Page 1 of 1 ISSUE DATE: June 30, 2002 REVIEWED/REVISION DATE: March 31, 2014 POLICY NO. EC-03 PROGRAM:ALL POLICY: RHG shall use and maintain safety devices throughout the facilities to insure the safety of residents, staff, visitors and property from fire and products of combustion. PROCEDURE: 1. All safety devices shall comply with State and Federal regulations. Should there be any question as to the use of any device in connection with resident safety; the Fire Chief will be contacted for his decision. These decisions shall be documented by the Safety Officer/Facilities Manager. 2. At the beginning of each shift, staff shall review the current census of residents, admissions and discharges at each location in order to ensure resident identification in all areas of the facility. Any staffing changes will be noted in the census log. Residents, who seek day treatment services, will sign in and out of the census log. 3. (RT) Facilities shall be electrically monitored and have a manually operated fire alarm system, which automatically transmits an alarm to the appropriate fire department. 4. (RT) Preventative maintenance and testing of the fire alarm system shall be done on an annual basis. 5. (RT) The automatic sprinkler systems are to be connected to the fire alarm system and must also be scheduled for preventative maintenance on a quarterly basis (FL) or semi-annual basis (TN). 6. (RT) The Ansul hood in each kitchen will be inspected semi-annually. 6. All Facility buildings are to have an evacuation plan posted in a conspicuous place. 7. Fire extinguishers are installed in all locations in accordance with the proper fire authorities and are inspected a monthly basis and serviced on an annual basis for preventative maintenance. 8. Egress lighting will be tested monthly and batteries will be replaced annually. 9. Smoke detectors will be tested quarterly and batteries will be replaced annually. 10. (TN) Water Storage tanks will have water supplies tested daily and tanks will be inspected annually. Water low and high alarms will be tested semi-annually. Documentation will be maintained.

5 SUBJECT: FIRE PLAN Page 1 of 7 ISSUE DATE: June 30, 2002 REVIEWED/REVISION DATE: July 31, 2014 POLICY NO. EC-04 PROGRAM: All POLICY: The facility shall have a fire plan and program to insure the safety of the patients, employees and visitors of the facility. To enhance the safety of all stakeholders, Pasadena Villa minimizes the risk of fire whenever possible, exits will be free and unobstructed, exits will be marked with egress lighting and fire response equipment is available at all times. PROCEDURE: 1. The Safety Committee shall be responsible for writing a Fire Plan for implementation at the facility. 2. This plan shall address: A. Use and function of fire alarm and detection systems, containment and the protection of lives including transfer to areas of refuge, evacuation plans and fire extinguisher equipment. B. Concise, pre-established, documented plans to be implemented during a disaster. C. The frequency of fire drills FL: at least annually for each shift worked, minimum of quarterly system wide TN: at least 1 per Month and 2 Sleep Time Drills per Year. D. Fire Drills focus on the evacuation of all individuals in a timely and orderly fashion. E. At least 50% of fire drills are unannounced. E. Staff requirements and designation of roles and functions. F. Methods of providing appropriate training to staff. 3. The Fire Plan is implemented, evaluated and documented annually. Documentation is to include problems identified during implementation, corrective actions taken and staff participation. 4. Documentation of fire drill compliance and critique of response is provided to the Safety Committee/Management Team.

6 Use of Fire Alarm at Pasadena Villa: Fire Plan: Florida The fire alarm at Pasadena Villa is monitored at all times by CMS Monitoring. All activations of the fire alarm system result in automatic transmission to CMS, and from CMS to the fire department. The fire evacuation routes shall be posted throughout each facility. At least four fire extinguishers shall be available at all times. All fire extinguishers shall be inspected and date tagged at least annually. The fire alarm system and/or smoke detectors monitor smoke in all resident rooms, offices and common areas. When the system detects smoke, the fire alarm will sound, which consists of very loud audio in conjunction with strobe light visual alarms. Once the alarm sounds, Pasadena Villa staff shall immediately go to the control panel to determine where the fire or smoke has been detected. The fire alarm shall be activated either manually at a manual pull station, or by the smoke alarm system. There are four manual pull stations in the facility and approximately thirty smoke detection devises. Once a staff member or resident visually sees a fire, he/she shall pull the nearest manual pull station. This will automatically transmit an emergency signal to the fire system monitoring company, CMS. CMS will then immediately call to confirm the emergency and notify the fire department for dispatch. In the event of a fire drill or false alarm (either by pull station or some other means); staff will call CMS prior to activation of the fire alarm to inform CMS of the drill. The staff must also silence the alarm and reset the system. Transmission of Alarm to Fire Department from Pasadena Villa Once the fire alarm is activated, the fire system monitoring company will confirm the emergency and notify the fire department. If the alarm was a false alarm, staff shall notify the fire alarm system monitoring company, and transmission to the fire department will be voided. CRH and other step down facilities The Community Residential homes, apartments and rental houses are all equipped with residential smoke detectors in all resident rooms, offices and common areas. When the system detects smoke, the fire alarm will sound, which consists of very loud audio in conjunction with strobe light visual alarms. At least one fire extinguisher shall be available at all times. All fire extinguishers shall be inspected monthly and date tagged at least annually.

7 Response to Fire Alarm Response to the fire alarm shall follow by evacuation procedures as shown on the posted facility evacuation diagrams. When the fire alarm is activated, staff shall immediately go that area and confirm whether a fire indeed exists, or if it is a false alarm. If it is a false alarm, the staff shall call the fire system monitoring company to avert a transmission to the fire department and reinstate the alarm monitoring. All staff and residents will continue with daily schedule. In the event of a false alarm, the Facilities Manager will complete a fire alarm report to be kept on file. In the event of a fire drill, the Facilities Manager will complete a fire drill report to be kept on file. These reports are reviewed by the Safety Committee annually. If there is indeed a fire, staff shall immediately evacuate the building. Isolation of Fire If the fire is located within a room in which a door may be closed, staff shall immediately close such door to isolate the fire. Staff shall then locate and activate the nearest fire extinguisher and apply to the base of any visible flames. In the event that the fire is determined to be small enough to be safely approached with a fire extinguisher, staff shall use a fire extinguisher to attempt to get the fire under control. In the event it is determined that attempting to use a fire extinguisher would pose more danger then benefit, staff shall not attempt to contain the fire using the fire extinguisher. Evacuation of Fire Area If a fire has been identified in any building, staff shall try to remain calm and use the R.A.C.E. approach: Rescue residents and/or other individual from immediate danger. Activate the alarm by pulling the nearest alarm box. Contain the fire by closing all doors, windows and other accesses. Extinguish the fire with an extinguisher. Staff shall immediately evacuate residents to the safe area, which is designated as the grassy knoll in front of Pasadena Villa, adjacent safe yard at Lake Highland CRH and Summerlin Avenue CRH. Residents shall be directed toward one of the three designated and marked emergency exits. The nurse (Lead RCC at night) will take the MAR, visitor sign in sheet and daily census and staffing notebook to verify that all individuals have evacuated the building. Emergency phone lists will be located in the Daily Census and Staffing binder. Once evacuated to the front parking lot, the nurse or Clinical Services manager (Lead RCC at night) will account for

8 all residents, visitors and staff. The Clinical Services Manager or designee will notify the Executive Administrator member of any missing, injured or deceased persons via cell phone. If an alternate meeting place is needed for safety, staff and residents will meet in the parking lot directly next door to Pasadena Villa. Residents and staff shall remain in the safe area until the fire department has declared an all clear. Fire Drills & Trainings Fire Drills will be preformed at least annually for each shift worked in order to ensure staff and residents are prepared for disasters. Fire Drills will be coordinated by the Facilities and Fleet Manager or Safety Officer and scheduled with the Clinical Program Manager. Resident in-services will be completed quarterly to cover fire prevention and evacuation procedures. Staff will be trained at General Orientation and annually by the Safety Officer. Staff inservices will cover: how and when to operate the fire alarm, fire extinguishers, fire sprinklers, fire prevention, building evacuation and management of facility emergencies.

9 Fire Plan: Tennessee Use of Fire Alarm at Pasadena Villa s Smoky Mountain Lodge: The fire alarm at Smoky Mountain Lodge is monitored at all times by Fleenor Security. All activations of the fire alarm system result in automatic transmission to Fleenor Security, and from Fleenor Security to the fire department. The fire evacuation routes shall be posted throughout each facility. At least seventeen fire extinguishers shall be available at all times. All fire extinguishers shall be inspected and date tagged at least annually. The fire alarm system and/or smoke detectors monitor smoke in all resident rooms, offices and common areas. When the system detects smoke, the fire alarm will sound, which consists of very loud audio in conjunction with strobe light visual alarms. Once the alarm sounds, Pasadena Villa staff shall immediately go to the control panel to determine where the fire or smoke has been detected. The fire alarm shall be activated either manually at a manual pull station, or by the smoke alarm system. There are manual pull stations at each exit in the facility and approximately forty smoke detection devises. Once a staff member or resident visually sees a fire, he/she shall pull the nearest manual pull station. This will automatically transmit an emergency signal to the fire system monitoring company, Fleenor. Fleenor will then immediately call to confirm the emergency and notify the fire department for dispatch. In the event of a fire drill or false alarm (either by pull station or some other means), staff will call Fleenor prior to activation of the fire alarm to inform Fleenor of the drill. The staff must also silence the alarm and reset the system. Transmission of Alarm to Fire Department from Pasadena Villa s Smoky Mountain Lodge Once the fire alarm is activated, the fire system monitoring company will confirm the emergency and notify the fire department. If the alarm was a false alarm, staff shall notify the fire alarm system monitoring company, and transmission to the fire department will be voided. Response to Fire Alarm Response to the fire alarm shall follow by evacuation procedures as shown on the posted facility evacuation diagrams. When the fire alarm is activated, staff shall immediately go that area and confirm whether a fire indeed exists, or if it is a false alarm.

10 If it is a false alarm, the staff shall call the fire system monitoring company to avert a transmission to the fire department and reinstate the alarm monitoring. All staff and residents will continue with daily schedule. In the event of a false alarm, the Facilities Manager will complete a fire alarm report to be kept on file. In the event of a fire drill, the Facilities Manager will complete a fire drill report to be kept on file These reports are reviewed by the Safety Committee annually. If there is indeed a fire, staff shall immediately evacuate the building. Isolation of Fire If the fire is located within a room in which a door may be closed, staff shall immediately close such door to isolate the fire. Staff shall then locate and activate the nearest fire extinguisher and apply to the base of any visible flames. In the event that the fire is determined to be small enough to be safely approached with a fire extinguisher, staff shall use a fire extinguisher to attempt to get the fire under control. In the event it is determined that attempting to use a fire extinguisher would pose more danger then benefit, staff shall not attempt to contain the fire using the fire extinguisher. Evacuation of Fire Area If a fire has been identified in any building, staff shall try to remain calm and use the R.A.C.E. approach: Rescue residents and/or other individual from immediate danger. Activate the alarm by pulling the nearest alarm box. Contain the fire by closing all doors, windows and other accesses. Extinguish the fire with an extinguisher. Staff shall immediately evacuate residents to the safe area, which is designated as the mailboxes at the bottom of Wonderland Lane. Residents shall be directed toward the closest designated and marked emergency exits. Staff nurse or manager will take the visitor sign in sheet and daily census and staffing notebook to verify that all individuals have evacuated the building. Emergency phone lists will be located in the Daily Census and Staffing binder. Once evacuated to the Safe Spot; the middle of the driveway, the staff nurse or designee will account for all residents, visitors and staff. The staff nurse or manager will notify the emergency on call staff member of any missing, injured or deceased persons via cell phone. Residents and staff shall remain in the safe area until the fire department has declared an all clear..

11 Fire Drills Fire Drills will be performed at least monthly at different times in order to ensure staff and residents are prepared for disasters. There will be at least 2 Sleep Time Drills per year. Fire Drills will be coordinated by the Facilities Manager and scheduled with the Clinical Program Manager. Staff will be trained at General Orientation and annually by the Safety Officer. Staff inservices will cover: how and when to operate the fire alarm, fire extinguishers, fire sprinklers, fire prevention, building evacuation and management of facility emergencies.

12 SUBJECT: SHELTER IN PLACE PLAN Page 1 of 6 ISSUE DATE: March 31, 2012 REVIEWED/REVISION DATE: March 31, 2014 Policy No. EC-05 PROGRAM: ALL POLICY: It is the policy of RHG to plan for severe weather year round at each location. The shelter in place plan will serve as a plan for weather emergencies year round but take into account the severe weather seasons associated with the geography of each of its locations. This plan will also be implemented for emergencies that affect the geographic area immediately surrounding the facility such as wild fire, outside civil disturbance, or outside utilities failure (if authorities have not evacuated the area). Staff will be trained annually on the shelter in place plan and responsibilities assigned to Management staff to coordinate and execute in the event of inclement weather or other emergency. Inclement weather may include; hurricanes, tornados, ice or snow storms. PROCEDURE: An annual Hazard Vulnerability Analysis to assess the most likely hazards will be completed by the Compliance Manager and Safety Manager and be submitted to the Management Team with an inventory of internal assets for emergency management. When emergencies arise, the Executive Administrator will determine whether staff and residents will shelter in place or evacuate the building and communicate/initiate the shelter in place plan with management team and the Governing Board. Updates from local emergency management officials will be monitored by the Management Team and any updates/changes will be directed by the Executive Administrator or designee. The Executive Administrator will terminate the shelter in place plan and begin resuming normal business function based on input from the Governing Board, the management team, and local emergency management authorities. Florida Plan: The Facility Manager and/or Executive Administrator will monitor weather reports for the potential of inclement weather (Tornado/Hurricane). In the event that local authorities determine a weather emergency is likely, the Facility Manager/Safety Officer with the Administrator/Risk Manager will coordinate notification and assignment of duties as needed to ensure the safety of staff and residents as well as communication with resident families. Food: The facility will keep a minimum of 4 day supply of non-perishable food on site in case of emergency. The facility has an additional contract with the food service provider to deliver food and water prior to and after a storm. The Guest Services Manager and/or Culinary Manager will coordinate staffing and food supply prior to the storm. Water: The residential facility has 200+ gallons of potable water available that is replenished daily. Each location has gallons of potable water available. Water is available for food preparation and drinking should there be an issue with the city water supply.

13 The Facility Manager will work with the on site Manager and culinary staff to ensure that water is used efficiently (1 gallon per person/per day) in the event that water service is interrupted. Shelter: The facility will provide shelter to Pasadena Villa Network of Service residents only during severe weather emergencies. Residents in apartments, rental houses and other semiindependent living are provided shelter during inclement weather emergencies. The Clinical Services Manager will coordinate the transportation and shelter of residents during storms. They will work with local authorities and the Management Team to determine safety of transportation and when emergent shelter is appropriate. The Facility Manager will check the grounds for any objects such as lawn chairs, trays, rakes, hoses, or other items which may become dangerous if blown about in high winds. All such objects shall be moved to the storage shed or indoors. If the storm is in close proximity, the hurricane shutters attached to all windows shall be closed, and shall remain closed until an all clear has been declared by the Executive Administrator. In the event that the building needs to be evacuated during a weather emergency, staff and residents will evacuate to the assigned Special Needs Emergency Shelter: Devereux. Medications will be transported in a locked container to the shelter location. Medications: The Facility will ensure that an adequate supply of current medications is available for residents within 24 hours prior to a major storm. The Nurse Manager or designee will work with the attending MD and nursing staff to coordinate delivery or pick up of resident medication prior to storm arrival. The Nurse Manager will make available all pharmacy phone numbers for pharmacies used by residents for coordination of care. The Nurse Manager will ensure that all Medication Administration Records are up to date and loaded into the electronic medical record for remote access should the need arise. The Nursing staff will evaluate content of First Aid supplies/kits in the facility prior to storm arrival to ensure that there is are adequate, currently dated supplies. Staffing: Per the Employee Handbook, staff is expected to continue to show up for scheduled shifts during any emergency. The scheduled time and assignment may be adjusted as needed for safety of residents and staff. Staff must be available by phone for coordination. The Human Resource Representative will work with the Management Team to determine staffing needs and to communicate with employees via the employee phone list. Human Resource Representative will ensure that the emergency contact information of employees is up to date. The Human Resource Representative will contact employees by phone, text or when the emergency management plan has been initiated. Non-clinical staff may be reassigned as needed to ensure resident care and safety by the Clinical Services Manager. Utilities: The facility will ensure that all Management Team Members are trained on the location of utility shut offs in the event of a weather emergency. Staff will be familiar with: Fire Panel operation, Electrical panel operation, Generator location, Hurricane shutter manual operation, water main shut off valve and any other necessary utility function.

14 The Facility Manager or designee will be responsible to annually train Management Team Members on the location of utilities and the operation of auxiliary power sources (automatic generators). The Facility Manager will inspect the auxiliary power source and operation of hurricane shutters monthly from May through November. The facility has two propane powered automatic electrical generators, which will immediately restore power during a power outage. However, in the event of a facility-wide power outage, the staff shall contact the Facility Manager and Executive Administrator and the Orlando Utilities Commission to alert them of the outage. Also, additional staff shall be called in to ensure the safety and increased monitoring of the residents. Phone service is available through landline, cell phone and internet (if available). Staff is provided with a landline phone in the event of a power outage. Supplies: The Facility will make available storm supplies and update their inventory annually prior to Hurricane Season. The Facility Manager will ensure that the weather radio is in good working condition and that staff members are training on its use at all times. The Facility Manager will ensure that at least one flashlight and batteries are available for staff within 24 hours of storm arrival. The Facility Manager will ensure that a corded phone is available to staff and residents in case of power loss. They will verify the location within 24 hours of storm arrival. The Facility Manager will ensure that additional building supplies are available as needed for storm preparation. (tarps, tape, rope). The Facility Manager will coordinate staff to fill all vehicles with gasoline within 24 hours of storm arrival. Communication: Out of state locations (TN) will have access to electronic records for resident emergency contact information. The Clinical Services Manager at Smoky Mountain Lodge will communicate with families in the event of an emergency with daily updates. Psychotherapist will be responsible for confirming emergency contact phone information for resident families within 48 hours of predicted storms. The Human Resource Representative will confirm employee phone contact information and distribute updated employee phone lists within 48 hours of predicted storms. The Executive Administrator will be onsite and will be the point person for staff and managers. Clinical Support: Clinical services may be altered or modified as needed by the resident milieu and under the direction of the Clinical Services Manager. Medications will continue to be administered on the same schedule with any alterations in schedule under the direction of the Psychiatrist and Nurse Manager. Health needs will be addressed by nursing staff. Admissions will be suspended during an emergency. Safety and Security: Residents will be required to stay within the building during a shelter in place emergency. Residents may leave accompanied by a staff member and under the direction of the Clinical Services Manager Only. Staff and residents will remain inside and transportation will cease per the recommendation of local authorities.

15 Residents of other levels of care will shelter in place at Pasadena Villa. Staff will continue to monitor the census of staff and residents in the building to ensure that all are accounted for daily. Tennessee Plan: The Facility Manager and/or Clinical Services Manager will monitor weather reports for the potential of inclement weather (Tornado/Ice & Snow). In the event that local authorities determine a weather emergency is likely, the Facility Manager/Safety Officer with the Clinical Services Manager will coordinate notification and assignment of duties as needed to ensure the safety of staff and residents as well as communication with resident families. Food: The facility will keep a minimum of 4 day supply of food on site in case of emergency. The facility has an additional contract with the food service provider to deliver food and water prior to and after a storm. The Guest Services Manager and/or Culinary Manager will coordinate staffing and food supply prior to the storm. Water: The facility has gallons of potable water available that is replenished daily. This water is available for food preparation and drinking should there be an issue with the city water supply. The Facility Manager will work with the on site Manager and culinary staff to ensure that water is used efficiently (1 gallon per person/per day) in the event that water service is interrupted. Shelter: The facility will provide shelter to Pasadena Villa Network of Service residents only during severe weather emergencies. Residents in apartments, rental houses and other semiindependent living will be provided shelter during inclement weather emergencies. The Clinical Services Manager will coordinate the shelter of residents during storms. They will work with local authorities and the Management Team to determine when emergent shelter is appropriate. The Facility Manager will check the grounds for any objects such as lawn chairs, trays, rakes, hoses, or other items which may become dangerous if blown about in high winds. All such objects shall be moved to the storage area or indoors. If the storm is in close proximity, staff and residents will move away from windows and toward interior rooms. In the event that the building needs to be evacuated during a weather emergency, staff and residents will evacuate to the assigned Special Needs Emergency Shelter through TEMA. Medications will be transported in a locked container to the shelter location. Medications: The Facility will ensure that an adequate supply of current medications is available for residents within 24 hours prior to a major storm. The Nurse Manager or designee will work with the attending MD and nursing staff to coordinate delivery or pick up of resident medication prior to storm arrival. The Nurse Manager will make available all pharmacy phone numbers for pharmacies used by residents for coordination of care.

16 The Nurse Manager will ensure that all Medication Administration Records are up to date and loaded into the electronic medical record for remote access should the need arise. The Nursing staff will evaluate content of First Aid supplies/kits in the facility prior to storm arrival to ensure that there is are adequate, currently dated supplies Staffing: Per the Employee Handbook, staff is expected to continue to show up for scheduled shifts during any emergency. The scheduled time may be adjusted as needed for safety of residents and staff. Staff must be available by phone for coordination. The Human Resource Representative will work with the Management Team to determine staffing needs and to communicate with employees via the employee phone list. Human Resource Representative will ensure that the emergency contact information of employees is up to date. The Human Resource Representative will contact employees by phone, text or when the emergency management plan has been initiated. Non-clinical staff may be reassigned as needed to ensure resident care and safety by the Clinical Services Manager. Utilities: The facility will ensure that all Management Team Members are trained on the location of utility shut offs in the event of a weather emergency. Staff will be familiar with: Fire Panel operation, Electrical panel operation, Generator location, water main shut off valve and any other necessary utility function. The Facility Manager will be responsible to annually train Management Team Members on the location of utilities and the operation of auxiliary power sources (automatic generators). The Facility Manager will inspect the auxiliary power source monthly. The facility has a propane powered automatic electrical generators, which will immediately restore power during a power outage. However, in the event of a facility-wide power outage, the staff shall contact the Facility Manager and Clinical Services and the Sevier County Utilities System to alert them of the outage. Also, additional staff shall be called in to ensure the safety and increased monitoring of the residents. Phone service is available through landline, cell phone and internet (if available). Staff is provided with a landline phone in the event of a power outage. Supplies: The Facility will make available storm supplies and update their inventory annually prior to severe weather seasons (Winter & Spring). The Facility Manager will ensure that the weather radio is in good working condition and that staff members are training on its use at all times. The Facility Manager will ensure that at least one flashlight and batteries are available for staff within 24 hours of storm arrival. The Facility Manager will ensure that a corded phone is available to staff and residents in case of power loss. They will verify the location within 24 hours of storm arrival. The Facility Manager will ensure that additional building supplies are available as needed for storm preparation. (tarps, tape, rope) The Facility Manager will coordinate staff to fill all vehicles with gasoline within 24 hours of storm arrival. Communication: Out of state locations (FL) will have access to electronic records for resident emergency contact information.

17 Psychotherapist will be responsible for confirming emergency contact phone information for resident families within 48 hours of predicted storms. The Human Resource Representative will confirm employee phone contact information and distribute updated employee phone lists within 48 hours of predicted storms. The Clinical Services Manager will be onsite and will be the point person for staff and managers. Clinical Support: Clinical services may be altered or modified as needed by the resident milieu and under the direction of the Clinical Services Manager. Medications will continue to be administered on the same schedule with any alterations in schedule under the direction of the Psychiatrist and Nurse Manager. Health needs will be addressed by nursing staff. Admissions will be suspended during an emergency. Safety and Security: Residents will be required to stay within the building during a shelter in place emergency. Residents may leave accompanied by a staff member and under the direction of the Clinical Services Manager Only. Staff and residents will remain inside and transportation will cease per the recommendation of local authorities. Staff will continue to monitor the census of staff and residents in the building to ensure that all are accounted for daily.

18 SUBJECT: EVACUATION PLAN Page 1 of 5 ISSUE DATE: June 30, 2002 REVIEWED/REVISION DATE: March 31, 2014 POLICY NO. EC-06 PROGRAM: All POLICY: RHG has prepared an Evacuation Plan to ensure the safety of residents, staff and visitors in the case the facility is not usable due to disasters such as bomb threats, acts of terrorism, utility and auxiliary utility failure or other natural disasters that impede facility operations. The Executive Administrator will determine when an evacuation of the facility is necessary based on the recommendation of local authorities, integrity of the building and/or the situation at hand; the Executive Administrator will initiate the evacuation plan PROCEDURE: The Safety Office in coordination with the Compliance Manager, the Executive Administrator and Risk Manager will ensure that facilities are disaster ready at all times. Staff training about emergency preparedness will occur at hire and annually. Management Team will review resources, assets and evacuation plans annually; including an evacuation drill. The Human Resource department shall make available to staff an emergency phone list with all administrative and clinical staff for use during emergencies. Human Resources will contact The Safety Officer shall, on a regular basis, visit the National Weather Service website to check on current threats, and shall make updates and/or revisions to this Evacuation Plan as necessary. FLORIDA: Local Evacuation: If the building is no longer safe; staff shall immediately evacuate residents to the safe area, which is designated as the grassy knoll in front of Pasadena Villa, adjacent safe yard at Lake Highland Community Residential Home and Summerlin Community Residential Home. Residents shall be directed toward one of the three designated and marked emergency exits. The Culinary Manager will check each room on the East wing. Once the room is checked, the door will be closed. The Clinical Services Manager will check each room on the West wing. Once the room is checked, the door will be closed. The nurse will take the MAR, visitor sign in sheet and daily census and staffing notebook to verify that all individuals have evacuated the building. Emergency phone lists will be located in the Daily Census and Staffing binder. The Clinical Services Manager will retrieve available vehicle keys. Once evacuated to the front grassy knoll, the nurse or Clinical Services manager will account for all residents, visitors and staff. The Clinical Services Manager will direct staff and residents to all available facility vehicles; noting vehicle assignments on the census. Staff will drive to the local evacuation point. The address will be available in each vehicle glove compartment.

19 Upon arrival, the Clinical Services Manager will account for all residents, visitors and staff. Location: Lakewood; 8400 La Amistad Cove, Fern Park, FL Phone: (407) The Executive Administrator or designee will annually confirm the relationship with the evacuation location and their accessibility should the evacuation plan be initiated. Transit and routes will be provided annually to Management Team members as part of the annual evacuation drill. In the event that there is no space or capability of housing the residents at Lakewood, residents shall be housed, with staff supervision, at the following hotels: Comfort Inn Suites, Orange Avenue, Courtyard by Marriott, Magnolia Avenue. When safe and available, RHG may transfer residents and staff to the Tennessee location for continued treatment. Communication: Out of state locations (FL) will have access to electronic records for resident emergency contact information. Psychotherapist will contact all resident families and give the opportunity to house the resident/relative themselves. Such clients shall be discharged from the facility and readmitted upon return. Residents and families, who wish to transfer to another appropriate RHG program, discharge or transfer to another treatment program will be assisted in doing so. The Human Resource Representative will confirm employee phone contact information and contact employees to update the location of staff and residents and any changes in schedule or assignments daily. The Executive Administrator will communicate with local emergency management authorities about the immediate needs of residents and staff. The Executive Administrator will be onsite and will be the point person for staff and managers. The Executive Administrator will be the sole contact for media, local authority and any third party. Staffing: Per the Employee Handbook, staff is expected to continue to show up for scheduled shifts during any emergency. The scheduled time, location and assignment may be adjusted as needed for safety of residents and staff. Staff must be available by phone for coordination. The Human Resource Representative will work with the Management Team to determine staffing needs and to communicate with employees via the employee phone list. Human Resource Representative will ensure that the emergency contact information of employees is up to date. The Human Resource Representative will contact employees by phone, text or when the emergency management plan has been initiated. Non-clinical staff may be reassigned as needed to ensure resident care and safety by the Clinical Services Manager. Medications: The Medication Administration Record and all resident medications shall be taken in a secure medication container, to be used within the shelter/evacuation location. The Nurse Manager will notify the pharmacy of evacuation location to ensure adequate levels of resident medications during the evacuation. Supplies: Each vehicle is stocked with a First Aid kit that includes personal protective equipment. The Culinary Manager will assist in coordination of food, water, toiletries and other supplies through

20 local vendors with delivery to the evacuation location as needed. Safety and Security: Residents will be supervised by Pasadena Villa staff 24 hours a day. Clinical support: Clinical services may be altered or modified as needed by the resident milieu and under the direction of the Clinical Services Manager. Medications will continue to be administered on the same schedule with any alterations in schedule under the direction of the Psychiatrist and Nurse Manager. Health needs will be addressed by nursing staff. Admissions will be suspended during an emergency City-Wide Evacuation: In the event of a city-wide evacuation, Pasadena Villa will work with local authorities and families to arrange for transportation, discharge or transfer as early as possible. The Executive Administrator and Clinical Services Manager will coordinate individual plans, staff and resident communication. TENNESEE: Local Evacuation: If the building is no longer safe; staff shall immediately evacuate residents to the safe area, which is designated as the mailboxes at the bottom of Wonderland Lane. Residents shall be directed toward one of the three designated and marked emergency exits. The Nurse Manager will check each room on the East wing. Once the room is checked, the door will be closed. The Clinical Services Manager will check each room on the West wing. Once the room is checked, the door will be closed. The Human Resources Representative will check the offices downstairs, once the room is checked, the door will be closed. The nurse will take the MAR, visitor sign in sheet and daily census and staffing notebook to verify that all individuals have evacuated the building. Emergency phone lists will be located in the Daily Census and Staffing binder. The Clinical Services Manager will retrieve available vehicle keys. Once evacuated to the mailboxes, the nurse or Clinical Services manager will account for all residents, visitors and staff. The Clinical Services Manager will direct staff and residents to all available facility vehicles; noting vehicle assignments on the census. Staff will drive to the local evacuation point. The address will be available in each vehicle glove compartment. Upon arrival, the Clinical Services Manager will account for all residents, visitors and staff. Location: Smoky Mountain Stables, 1222 Goose Gap Road, Sevierville, TN The Executive Administrator or designee will annually confirm the relationship with the evacuation location and their accessibility should the evacuation plan be initiated. Transit and routes will be provided annually to Management Team members as part of the annual evacuation drill. In the event that there is no space or capability of housing the residents Smoky Mountain Stables, residents shall be housed, with staff supervision, at the following hotels: Clarion Inn Willow River and Red Roof Inn Pigeon Forge.

21 When safe and available, RHG may transfer residents and staff to the Tennessee location for continued treatment. Communication: Out of state locations (FL) will have access to electronic records for resident emergency contact information. Psychotherapist will contact all resident families and give the opportunity to house the resident/relative themselves. Such clients shall be discharged from the facility and readmitted upon return. Residents and families, who wish to transfer to another appropriate RHG program, discharge or transfer to another treatment program will be assisted in doing so. The Human Resource Representative will confirm employee phone contact information and contact employees to update the location of staff and residents and any changes in schedule or assignments daily. The Clinical Services Manager will communicate with local emergency management authorities about the immediate needs of residents and staff. The Clinical Services Manager will be onsite and will be the point person for staff and managers. The Executive Administrator will be the sole contact for media, local authority and any third party. Staffing: Per the Employee Handbook, staff is expected to continue to show up for scheduled shifts during any emergency. The scheduled time, location and assignment may be adjusted as needed for safety of residents and staff. Staff must be available by phone for coordination. The Human Resource Representative will work with the Management Team to determine staffing needs and to communicate with employees via the employee phone list. Human Resource Representative will ensure that the emergency contact information of employees is up to date. The Human Resource Representative will contact employees by phone, text or when the emergency management plan has been initiated. Non-clinical staff may be reassigned as needed to ensure resident care and safety by the Clinical Services Manager. Medications: The Medication Administration Record and all resident medications shall be taken in a secure medication container, to be used within the shelter/evacuation location. The Nurse Manager will notify the pharmacy of evacuation location to ensure adequate levels of resident medications during the evacuation. Supplies: Each vehicle is stocked with a First Aid kit that includes personal protective equipment. The Guest Services Manager will assist in coordination of food, water, toiletries and other supplies through local vendors with delivery to the evacuation location as needed. Safety and Security: Residents will be supervised by Pasadena Villa staff 24 hours a day. Clinical support: Clinical services may be altered or modified as needed by the resident milieu and under the direction of the Clinical Services Manager. Medications will continue to be administered on the same schedule with any alterations in schedule under the direction of the Psychiatrist and Nurse Manager. Health needs will be addressed by nursing staff. Admissions will be suspended during an emergency City-Wide Evacuation:

22 In the event of a city-wide evacuation, Pasadena Villa will work with local authorities and families to arrange for transportation, discharge or transfer as early as possible. The Executive Administrator and Clinical Services Manager will coordinate individual plans, staff and resident communication.

23 SUBJECT: Weapons Possession or Bomb Threat Page 1 of 1 ISSUE DATE: May 25, 2012 Policy No. EC-07 REVISION DATE: March 31, 2014 PROGRAM: ALL POLICY: All staff, volunteers, contract workers, residents, visitors on anyone else on RHG property are prohibited from possessing firearms, explosives or weapons in the facility, whether or not a federal or state license to possess the same has been issued to the possessors. Exceptions include; commissioned law enforcement or military in performance of their official duties. Tennessee employees may retain a concealed fire arm locked their vehicle per the State of Tennessee law. PROCEDURE: Bomb Threat: If a threat of violence against the facility or persons, either verbally or written; contact the Clinical Services Manager and Executive Administrator immediately. Take every threat seriously. If the bomb threat is called in, respond as calmly as possible. Make an attempt to get more specific information about the bomb s location, components or trigger. Pay close attention to the qualities of the voice, background noises, etc. to aid in identification of the caller. Make an effort to keep the caller on the line as long as possible while signaling other staff to call law enforcement. Document exact working used by caller. When is the bomb going to go off? Where is it right now? What does it look like? What will trigger it? Who put it there? What type of bomb is it? Who made the bomb? If a written threat is received, staff is to save all material including the envelope, packing materials or container. Once you realize it is a threat refrain from further unnecessary handling of the package and contact law enforcement. The Clinical Services Manager will be the point of contact for law enforcement and will initiate evacuation of building if required. Weapons Possession: Anyone possessing a weapon other than those exceptions notes will be asked to remove them from the premises immediately. They may be subject to arrest, discharge and/or disciplinary action.