Emmaus Home of Virginia

Policy and Procedures Manual

Area: Administrative Services Policy: 12 VAC35-105-520 Page of

Title: Health and Safety Management Issued: Revised:

Focus: Risk Management

Policy:

Emmaus Home of Virginia will ensure compliance with all relevant laws, regulations, and
industry standards pertaining to risk management, resident care, and facility operation.
This policy shall involve a comprehensive approach using a Risk Tracking Tool to identify,
assess, mitigate, and monitor risks associated with the operation of the facility and the safety and
well-being of its residents, staff, and visitors.

Procedures:

The risk manager shall monitor the effectiveness of risk mitigation measures that
ensures compliance with relevant laws, regulations, and industry standards. In addition
to completing training approved by DBHDS, he or she is responsible for the risk
management function. This may involve analyzing trends, soliciting feedback from
stakeholders, and implementing changes to enhance safety and effectiveness.

He or she shall implement our policy using the group home’s Risk Tracking Tool. Audits,
inspections, and reviews are conducted quarterly and annually to verify compliance and
identify areas for improvement by continuously improving our home’s risk management
processes and procedures.

He or she may conduct training sessions, workshops, and drills to ensure that staff
members are prepared to respond effectively to safety protocols and emergency
response plans.

A. The provider shall designate a person responsible for the risk management function who
has completed department approved training, which shall include training related to risk
management, understanding of individual risk screening, conducting investigations, root
cause analysis, and the use of data to identify risk patterns and trends.
B. The provider shall implement a written plan to identify, monitor, reduce, and minimize
harms and risk of harm, including personal injury, infectious disease, property damage or
loss, and other sources of potential liability.
Emmaus Home of Virginia
Policy and Procedures Manual
C. The provider shall conduct systemic risk assessment reviews at least annually to identify
and respond to practices, situations, and policies that could result in the risk of harm to
individuals receiving services. The risk assessment review shall address at least the
following:
1. The environment of care;
2. Clinical assessment or reassessment processes;
3. Staff competence and adequacy of staffing;
4. Use of high risk procedures, including seclusion and restraint; and
5. A review of serious incidents.
D. The systemic risk assessment process shall incorporate uniform risk triggers and
thresholds as defined by the department.
E. The provider shall conduct and document that a safety inspection has been performed at
least annually of each service location owned, rented, or leased by the provider.
Recommendations for safety improvement shall be documented and implemented by the
provider.
F. The provider shall document serious injuries to employees, contractors, students,
volunteers, and visitors that occur during the provision of a service or on the provider's
property. Documentation shall be kept on file for three years. The provider shall evaluate
serious injuries at least annually. Recommendations for improvement shall be documented
and implemented by the provider.
Emmaus Home of Virginia
Policy and Procedures Manual

Group homes typically have specific policies and procedures in place to manage risks associated
with the care and support they provide to residents. Here's an outline of some common elements
you might find in a group home's risk management policy and procedures:

1. **Risk Assessment and Identification**: Regular assessments are conducted to identify

potential risks within the group home environment. This includes evaluating risks related to
health and safety, resident behaviors, staff interactions, facility maintenance, and external
factors.

2. **Documentation and Reporting**: Procedures are established for documenting and reporting
any incidents, accidents, or near-misses that occur within the group home. This documentation is
crucial for analyzing trends, identifying areas for improvement, and ensuring compliance with
regulations.

3. **Staff Training and Education**: Staff members receive comprehensive training on risk
management protocols, including how to identify potential risks, respond to emergencies, and
mitigate hazards. Ongoing education ensures that staff members remain up-to-date on best
practices.

4. **Emergency Response Plans**: Group homes have detailed emergency response plans in
place to address a variety of scenarios, such as medical emergencies, natural disasters, or
incidents involving aggressive behavior from residents. These plans outline specific roles and
responsibilities for staff members and provide guidance on evacuation procedures,
communication protocols, and coordination with external agencies.
Emmaus Home of Virginia
Policy and Procedures Manual

5. **Safety Measures and Equipment**: The group home is equipped with safety features and
equipment to minimize risks and ensure the well-being of residents and staff. This may include
security cameras, fire extinguishers, first aid kits, emergency call systems, and specialized
equipment for residents with disabilities.

6. **Medication Management**: Policies and procedures govern the storage, administration, and
documentation of medications to reduce the risk of errors or adverse reactions. Staff members
are trained in medication management protocols, and regular audits may be conducted to ensure
compliance with medication policies.

7. **Behavioral Management Plans**: For residents with behavioral challenges or mental health
conditions, individualized behavior management plans are developed to address specific triggers,
de-escalation techniques, and strategies for promoting positive behavior. Staff members receive
training on implementing these plans effectively.

8. **Quality Assurance and Continuous Improvement**: Group homes engage in regular quality
assurance activities to monitor the effectiveness of their risk management strategies and identify
opportunities for improvement. This may involve conducting internal audits, soliciting feedback
from residents and families, and benchmarking against industry standards.

9. **Compliance with Regulations**: Group homes adhere to relevant regulations and standards
governing the provision of care and support services, such as those established by government
agencies or accrediting bodies. Compliance efforts encompass areas such as licensing
requirements, staff-to-resident ratios, health and safety standards, and privacy regulations.

10. **Communication and Collaboration**: Effective communication and collaboration among

staff members, residents, families, and external stakeholders are essential for identifying and
addressing risks proactively. Group homes foster a culture of transparency, open communication,
and teamwork to ensure that everyone is invested in maintaining a safe and supportive
environment.

These are just some of the key elements you might expect to find in a group home's risk
management policy and procedures. Each group home may have variations based on factors such
as the specific needs of their residents, the regulatory environment in which they operate, and
their organizational values and priorities.