Person Served
What are the protocols regarding identifying and reporting abuse related to persons served?
x.12.1.2
Abuse protocol related to person served.
Do staff and volunteers have access to policy and procedures manual? x.13.2
yes, access to policies and information required to ensure safe delivery of service.
Are the facilities and equipment used by the person served inspected on a regular basis?
x.16.2
There is a practice of regular inspections.
What are the values, beliefs and treatment models used within the program?
x. 1.3
1. Staff will be able to briefly describe the values, beliefs, and treatment approaches used within the program.
2. Ensure what is said is consistent with pre-site documentation
Describe the role you play and the contributions you provide to realize the organization’s:
What are the policies and procedures to support the right of the family, legal guardian or parents of person served to speak to supervisors, staff?
x. 7.2
Policies and procedures to support the right of the family, legal guardian or parents of persons served to speak to supervisors, staff, and to the person served with reasonable notice, unless prohibited by court order.
Do any staff in the organization need to know specialized training to meet your person served needs here?
yes, Any specialized training requirements for staff, contractors, and volunteers (skill development, specific treatment approaches , adaptive equipment, changes in practices, changes in legislation, etc.)
Are you aware of any time an injury has occurred as a result of a restraint? If so, describe the process that occurred?
x.19.8
1. Document the incident
2. Review of the incident by program manger
3. Ensure medical care is provided.
How many staff are required to be present when persons served are sleeping (e.g., during an overnight shift, etc.)?
x.11.10
At least 1 awake staff is required for:
1. Any person served who requires active care during the night, as identified in the care plan.
2. Programs with more than 12 person served presently enrolled.
What is addressed within the Quality Improvement plan?
What kind of rights is explained to support the person served within the program?
x.8.1
1. Supports available through the program
2. Access to aboriginal/cultural resource person
3. confidentiality
4. Involvement in future planning
5. Grievance/ conflict resolution (verbal/written)
6. Access to advocate
7. Discontinuance of service (options exercised)
8. Well being and safety
9. Other rights that apply
Tell us about the kinds of training the organization provides to you in the following areas
1. Aboriginal/ cultural
2. Diversity training
3. Outcome and quality improvement
x.12.3, x.12.5, x. 12.6, x.12.8, x.12.9, x.12.10
4. Self-harm
5. Restrictive procedures
6. Crisis intervention
7. Other opportunities- additional staff developmental training/workshops/ conferences
1. Describe current practice (examples) of the training they are provided
2. Document all training not done or is done outside of timelines.
In your experience how would you describe the level of safety of the buildings. properties and the facilities used to deliver services? How are safety hazards addressed?
x.16.3
1. Describe that the buildings, properties, and facilities are safe.
2. Describe how safety hazards are addressed in a timely manner
What is the population that your program serves? Can you describe the types of services and issues you address within the program?
x.11.1
1. Definition of PS
2. A description of services provided and issues that are addressed.
What is included in the risk management plan?
1. Risks identified on the risk register that are likely to happen or would have a severe impact on the organization
2. Proactive and reactive measures used to mitigate the identified risks
3. Persons or positions responsible for managing identified risks
4. Communication methods
5. Monitoring and evaluation of the effectiveness of the risk management plan
6. Informing all personnel of their role in managing risks
When a person served comes into the program how do you measure their needs and strengths to determine how to best provide services?
x.7.40
1. Staff are able to describe the pre/post measurement tool used within the program.
2. Staff can identify who is responsible to perform these measurements (i.e. Keyworker, clinician, etc.)
3. staff can define when these measures are done intake and discharge.
What are your written policies and procedures regarding the use of tobacco and tobacco products?
1. Tobacco use by personnel, persons served, and guests on the organization’s grounds and within program spaces
2. Tobacco use in vehicles operated or contracted by the organization
3. Harm reduction strategies to address smoking and smoking cessation programs
4. Ceremonial uses of tobacco
Describe the safe practices that are in place to identify and use toxic or flammable materials? How is this material disposed of?
x.16.4
1. Describe the practice of:
a. Kept in original marked container
b. Locked storage
c. separate from food/medication
d. Flammable material- monitored access to
2. Disposal is done in a safe and eco- friendly manner.
Describe the process used to screen potential person served for the program?
x.11.3
Describe the matching process used to ensure the admission of appropriate person served into the program.
Describe your quality improvement activities. How do you engage your staff in this process?
1. Defining the roles and responsibilities at all levels of the organization
2. Involving various personnel from all levels of the organization
3. Incorporating current practice research on service delivery to improve organization services
4. Involving persons served and stakeholder groups
5. Recognizing quality improvements achieved by personnel
How are persons served discharged or graduate from the program?
x.13.3, x. 13.4, x. 13.5
1. Defined the process to respond to planned and unplanned discharges.
2. Describe the exit criteria
3. Describe activities to support transition from program
4. Explain what follow-up services they offer
Does staff ever work alone? Are there any safety precautions in place? What supports are provided after hours?
Would the program be able to admit a person with an infectious disease? If so, what would be considered?
x.22.1
If they do admissions they should be able to describe the following:
1. Risk of transmission
2. Ability of program/staff to make reasonable accommodation.
3. Ability of PS to protect themselves
4. Ability of PS to contain the spread of infectious disease.
5. Risk of PS becoming infected with another disease.
What is the timeline when the initial meeting should occur?
x.11.4
Within ten days of entering the program.
How does the Organization involve the community in activities which allow for feedback to support the development of policy?