DPD Risk Management/Safety Plan
The 2006 Plan incorporates progress of the 2005 Plan and Analysis of the Risk Drivers that comprise Risk Management outlined in Section IV.
Risk management is the development of procedures that mitigate risk to an acceptable level. The stakeholders, the board and all tiers within the agency have a role to play in risk management.
The Director of Training and Safety will oversee all aspects of risk management, training, and safety under the guidance of the executive director who has the ultimate responsibility for risk management. All staff are asked for input and for continual observation and recommendations.
III. Scope of DPD Plan
· On-going identification of all risks and causes:
Ongoing identification of risks will be obtained by seeking input from Department Heads at monthly CQI Meetings, staff meetings, and oversight by the Director of Training and Safety.
· Analysis of impact:
Analysis of impact and consequences of each risk identified will be conducted by the Director of Training and Safety. Risks which lead to the most significant consequences and those which have the highest probability of occurring will be priority and will be the first business of the Director of Training and Safety. They will remain the highest priority until such time and the risk is deemed acceptable or the priority of the task is changed in consultation of the executive director.
· Identification of Risk Drivers:
The analysis and identification of risk drivers will be formally evaluated and updated in the DPD annual operational plan.
· Risk Response Strategies:
The Director of Safety and Training is responsible to continually and proactively assess facility needs and risk factors regarding operations of the organization. The potential improvements and risks identified are analyzed in terms of the potential impact and consequences and the probability of occurrence. Where possible the impact analysis should include the potential financial impact.
· Risk response evaluation and correction:
Generally the Director of Safety and Training is responsible for overseeing the response and correction. Options are weighed at regular supervision meetings with the executive director.
· Reporting and on-going monitoring procedures:
The DPD will identify risks by reviewing the activities at CQI meetings, department head meetings and activities of the Director of Safety and Training. The DPD will work cooperatively and regularly communicate with the Diocese of Paterson Insurance Department on Risk Management. The DPD will have an outside Formal Risk Management Audit at least every five years. The Board of Trustees will be updated on the Risk Management Activities of the DPD at least annually.
IV. The identification and analysis:
The identification component has been completed in the 2005 plan. The analysis of the underlying risk drivers that are associated with the business of the DPD will be addressed here in the 2006 plan to identify specifics in each are including how each is measured if applicable.
· Disaster Planning – The DPD disaster plan has been in existence since 2003. The plan is designed to incorporate specific areas such as identifying Disaster recovery Team, coordinating with state and local governments, coordination and communication, Evacuation, treatment of medical emergencies, and individual planning for each program
· Evacuation Planning and Fire Drill Analysis– the DPD utilizes the DPD evacuation system to monitor every resident in their evacuation ability. The DPD also evaluates the evacuation data on the program as a whole. In 2004, each program had their own evacuation plan with scattered information in each plan. Today, each program has the same information and the document for each program is uniform. All plans are monitored more efficiently and changed each year or when a resident moves on or out of the program.
· Facility Systems Monitoring – The DPD has been universally monitoring facilities since 2003 in the following areas, fire inspections with local fire marshals, Fire extinguisher management, Use group licenses, Dryer vent cleaning, Sprinkler system monitoring, mold inspections, OSHA reviews, Generator system tests, State boiler inspections, and expired medication reminders.
· Water Safety for pool use and pool maintenance – With the start of the 2006 swim season, the DPD now requires that anyone swimming in the pool sign a hold harmless agreement before thy are allowed to swim. This includes residents, staff, volunteers, families and children. No child is allowed in the swimming area or allowed to swim without the presence of a legal guardian.
· Staff Training, DPD will continue to offer Strategies that work, Agency mission and philosophy, CPR, First Aid, Universal Precautions, Preventing Abuse and Neglect, Protecting Gods Children, Medication Administration, and Overview of Developmental Disabilities for every employee. The DPD will also offer as many in-service trainings and seminars, external trainings and conferences and continue to provide continuing education through the Rutgers University Certificate program in developmental disabilities.
· Medication Issues - The DPD now has two years worth of data on medication analysis including the number of doses given annually, error rates, individual program stats and is monitoring errors by having staff fill out an error form and analyzing the trends from the responses. The DPD has also streamlined its staff discipline process for medication errors.
· Incident Report Investigations – The DPD successfully monitors all incidents and accidents and reviews all trends on a monthly, quarterly and yearly basis. These results are shared with the board, the CQI committee and program directors to share with their staff.
· Policy and procedures application – The DPD successfully was able to move all of its policies and procedures into electronic format on our intranet using microsoft sharepoint. As of the April 2006 inspection of Gruenert Center by the NJ Office of Quality Management, Gruenert Center policies and procedures have also been moved to electronic format. The DPD is now in the process of moving all policies and procedures to a web-based format in order for all employees to view them at anytime even from home.
· HIPPA – The DPD respects the privacy of individuals and complies with all laws as governed by the State of NJ. The DPD role is that of a “business partner” with DDD regulating the guidelines to comply with HIPAA.
· Key Management – the DPD has been able to manage the over 327 keys it has for all of its facilities and vehicles in case of an emergency and for better efficiency of key management.
· Overnight Safety Analysis – In 2004, the DPD had some issues with overnights falling asleep. The DPD decided to conduct random overnight checks on the overnight shift which identified issues in several programs. Although effective, DPD did not have the man power to continue these checks and with the aid of TC-1 – (Swipe Cards for punching in and out), the DPD now requires overnight staff to punch in on an hourly basis. This has been very effective.
· Workman’s Comp and Disability The DPD continues to monitor workman’s comp and disability claims and assures that the residence is a safe place to live and work.
· Food Preparation and Handling – This was an issue identified by staff as an area where the DPD was lacking. In 2005, the DPD was able to hire a nutritionist on a part time basis to visit each program regularly an give advice to the menu planners, shoppers and staff that prepare the food to provide healthier life styles for our residents The DPD also has a proposal into the State of NJ for immediate funding to include a full time nutritionist.
The risk management analysis and plan will be reviewed annually as part of the strategic planning cycle and whenever a significant change occurs to a risk driver or a new activity or function is introduced. The risk responses of the DPD will be documented within the Risk Management Plan. This will include a summary of management's responses to the risks identified together with an analysis of any gaps between responses and the risks identified.