TABLE OF CONTENTS
Employee Code of Conduct .........................................................................................................................
4
Employee Recruitment and Selection Policy Sample .....................................................................
10
Internet & Email Access Policy .................................................................................................................
13
Cellphone Procedures ..................................................................................................................................
19
Sample Smoking Policy ...............................................................................................................................
23
Sample Substance Use Policy ..................................................................................................................
25
Sample Health & Safety Manual .............................................................................................................
30
Sample Workplace Harassment Policy ................................................................................................
50
Grievance Procedure Company Policy ..................................................................................................
52
Employee Progressive Discipline Policy Template ..........................................................................
55
Company Social Media Policy for Employees ....................................................................................
59
Contractor Management Policy ..............................................................................................................
62
Company Data Protection Policy .............................................................................................................
64
Template for Policy and Procedure Review Log ...............................................................................
67
Use of ICT Facilities & Devices Policy Template ..............................................................................
70
Fiscal Policies & Procedures .....................................................................................................................
72
Work Health Policy Template ....................................................................................................................
84
Sample Maintenance Policy ......................................................................................................................
87
Sample Shared Governance Policy and Procedure .........................................................................
98
Recovery/Return to work Procedure Template ................................................................................
101
Email Monitoring Policy .............................................................................................................................
105
Incident Management Policy ...................................................................................................................
115
Social Media Policy .....................................................................................................................................
147
Fixed Asset Policy & Procedures ...........................................................................................................
150
Product Management Framework White Paper .............................................................................
156
Market Research Policies and Procedures .......................................................................................
172
Sample Customer Service Policy ...........................................................................................................
174
Survey Policy and Procedures ................................................................................................................
176
New Product Development ......................................................................................................................
182
Generic Shipping Policy Template .......................................................................................................
205
Child Protection Policy and Procedure Template ..........................................................................
207
Sample Infection Control Policy ............................................................................................................
213
Parent Issues and Concerns Policy ......................................................................................................
219
Home Care Policy .........................................................................................................................................
222
Injection Safety Policies and Procedures Template ....................................................................
477
Promising Policies and Practices for Organizations ....................................................................
479
Vaccine Management Standard Operating Procedure (SOP) Template .............................
498
Emergency Response Procedures ........................................................................................................
504
Sick Bay Policy and Arrangements ......................................................................................................
664
Livestock Truck Emergencies Policies and Procedures .............................................................
666
Grant Management Policies and Procedures ..................................................................................
675
Sample Financial Management Policy and Procedures .............................................................
678
Mental Health Policy ..................................................................................................................................
704
Anti-Money Laundering/Anti-Terrorism Financing Policies and Procedures ....................
735
Accounting Policies and Procedures ..................................................................................................
739
Payment Card Security Policy and Procedures ..............................................................................
766
Billing and Collections Policy and Procedures ...............................................................................
770
Office Security Policy ................................................................................................................................
774
Network Firewall Implementation Policy ..........................................................................................
781
Information Security Policy ....................................................................................................................
786
Information Security Program ...............................................................................................................
862
Sample Data Security Policies ..............................................................................................................
881
Safeguarding Nonpublic Customer Information ...........................................................................
888
Employee Code of Conduct
Your Employee Code of Conduct is one of the most important parts of your Employee Handbook. We
created a code of conduct template to help you communicate your expectations to your employees in a
clear and tactful manner.
Download this Code of Conduct for Employees template in .doc format by clicking on the link at the
bottom of this page.
Keep in mind that this template is not a legal document and may not take into account all relevant local
or national laws. Please ask your attorney to review your finalized policy documents or Handbook.
Contents:
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Dress code
Cyber security and digital devices
○ Internet usage
○ Cell phone
○ Corporate email
○ Social media
Conflict of interest
Employee relationships
○ Fraternization
○ Employment of relatives
Workplace visitors
Solicitation and distribution
Employee Code of Conduct template
As an employee, you are responsible to behave appropriately at work. We outline our expectations here.
We can’t cover every single case of conduct, but we trust you to always use your best judgement.
Reach out to your manager or HR if you face any issues or have any questions.
Dress code
Our company’s official dress code is [Business/ Business Casual/ Smart Casual/ Casual.] This includes
[slacks/ loafers/ blouses/ boots.] However, an employee’s position may also inform how they should
dress. If you frequently meet with clients or prospects, please conform to a more formal dress code. W e
expect you to be clean when coming to work and avoid wearing clothes that are unprofessional (e.g.
workout clothes.)
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As long as you conform with our guidelines above, we don’t have specific expectations about what types
of clothes or accessories you should wear.
We also respect and permit grooming styles, clothing and accessories that are dictated by religious
beliefs, ethnicity or disability.
Cyber security and digital devices
This section deals with all things digital at work. We want to set some guidelines for using computers,
phones, our internet connection and social media to ensure security and protect our assets.
Internet usage
Our corporate internet connection is primarily for business. But, you can occasionally use our connection
for personal purposes as long as they don’t interfere with your job responsibilities. Also, we expect you
to temporarily halt personal activities that slow down our internet connection (e.g. uploading photos) if
you’re asked to.
You must not use our internet connection to:
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Download or upload obscene, offensive or illegal material.
Send confidential information to unauthorized recipients.
Invade another person’s privacy and gain access to sensitive information.
Download or upload pirated movies, music, material or software.
Visit potentially dangerous websites that can compromise our network and computers’ safety.
Perform unauthorized or illegal actions, like hacking, fraud or buying/selling illegal goods.
Cell phone
We allow use of cell phones at work. But, we also want to ensure that your devices won’t distract you
from your work or disrupt our workplace. We ask you to follow a few simple rules:
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Use your cell phone in a manner that benefits your work (business calls, productivity apps,
calendars.)
Keep personal calls brief and use an empty meeting room or common area so as not to disturb
your colleagues.
Avoid playing games on your phone or texting excessively.
Don't use your phone for any reason while driving a company vehicle.
Don’t use your phone to record confidential information.
Don’t download or upload inappropriate, illegal or obscene material using our corporate internet
connection.
Also, you must not use your phone in areas where cell phone use is explicitly prohibited (e.g.
laboratories.)
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Corporate email
Email is essential to our work. You should use your company email primarily for work, but we allow
some uses of your company email for personal reasons.
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Work-related use. You can use your corporate email for work-related purposes without
limitations. For example, you can sign up for newsletters and online services that will help you in
your job or professional growth.
Personal use. You can use your email for personal reasons as long as you keep it safe, and
avoid spamming and disclosing confidential information. For example, you can send emails to
friends and family and download ebooks, guides and other safe content for your personal use.
Our general expectations
No matter how you use your corporate email, we expect you to avoid:
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Signing up for illegal, unreliable, disreputable or suspect websites and services.
Sending unauthorized marketing content or emails.
Registering for a competitor’s services, unless authorized.
Sending insulting or discriminatory messages and content.
Spamming other people’s emails, including your coworkers.
In general, use strong passwords and be vigilant in catching emails that carry malware or phishing
attempts. If you are not sure that an email you received is safe, ask our [Security Specialists.]
Social media
We want to provide practical advice to prevent careless use of social media in our workplace. We
address two types of social media uses: using personal social media at work and representing our
company through social media.
Using personal social media at work
You are permitted to access your personal accounts at work. But, we expect you to act responsibly,
according to our policies and ensure that you stay productive. Specifically, we ask you to:
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Discipline yourself. Avoid getting sidetracked by your social platforms.
Ensure others know that your personal account or statements don’t represent our
company. For example, use a disclaimer such as “opinions are my own.”
Avoid sharing intellectual property (e.g trademarks) or confidential information. Ask your
manager or PR first before you share company news that’s not officially announced.
Avoid any defamatory, offensive or derogatory content. You may violate our company’s antiharassment policy if you direct such content towards colleagues, clients or partners.
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Representing our company through social media
If you handle our social media accounts or speak on our company’s behalf, we expect you to protect our
company’s image and reputation. Specifically, you should:
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Be respectful, polite and patient.
Avoid speaking on matters outside your field of expertise when possible.
Follow our confidentiality and data protection policies and observe laws governing copyrights,
trademarks, plagiarism and fair use.
Coordinate with our [PR/Marketing department] when you’re about to share any major-impact
content.
Avoid deleting or ignoring comments for no reason.
Correct or remove any misleading or false content as quickly as possible.
Conflict of interest
When you are experiencing a conflict of interest, your personal goals are no longer aligned with your
responsibilities towards us. For example, owning stocks of one of our competitors is a conflict of interest.
In other cases, you may be faced with an ethical issue. For example, accepting a bribe may benefit you
financially, but it is illegal and against our business code of ethics. If we become aware of such
behaviour, you will lose your job and may face legal trouble.
For this reason, conflicts of interest are a serious issue for all of us. We expect you to be vigilant to spot
circumstances that create conflicts of interest, either to yourself or for your direct reports. Follow our
policies and always act in our company’s best interests. Whenever possible, do not let personal or
financial interests get in the way of your job. If you are experiencing an ethical dilemma, talk to your
manager or HR and we will try to help you resolve it.
Employee relationships
We want to ensure that relationships between employees are appropriate and harmonious. We outline
our guidelines and we ask you to always behave professionally.
Fraternization
Fraternization refers to dating or being friends with your colleagues. In this policy, “dating” equals
consensual romantic relationships and sexual relations. Non-consensual relationships constitute sexual
violence and we prohibit them explicitly.
Dating colleagues
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If you start dating a colleague, we expect you to maintain professionalism and keep personal
discussions outside of our workplace.
You are also obliged to respect your colleagues who date each other. We won’t tolerate sexual jokes,
malicious gossip and improper comments. If you witness this kind of behavior, please report it to HR.
Dating managers
To avoid accusations of favoritism, abuse of authority and sexual harassment, supervisors must not date
their direct reports. This restriction extends to every manager above an employee.
Also, if you act as a hiring manager, you aren’t allowed to hire your partner to your team. You can refer
them for employment to other teams or departments where you don’t have any managerial or hiring
authority.
Friendships at work
Employees who work together may naturally form friendships either in or outside of the workplace. We
encourage this relationship between peers, as it can help you communicate and collaborate. But, we
expect you to focus on your work and keep personal disputes outside of our workplace.
Employment of relatives
Everyone in our company should be hired, recognized or promoted because of their skills, character and
work ethic. We would not like to see phenomena of nepotism, favoritism or conflicts of interest, so we
will place some restrictions on hiring employees’ relatives.
To our company, a “relative” is someone who is related by blood or marriage within the third degree to
an employee. This includes: parents, grandparents, in-laws, spouses or domestic partners, children,
grandchildren, siblings, uncles, aunts, nieces, nephews, step-parents, step-children and adopted
children.
As an employee, you can refer your relatives to work with our company. Here are our only restrictions:
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[You must not be involved in a supervisory/reporting relationship with a relative.]
[You cannot be transferred, promoted or hired inside a reporting relationship with a relative.]
[You cannot be part of a hiring committee, when your relative is interviewed for that position.]
If you become related to a manager or direct report after you both become employed by our company,
we may have to [transfer one of you.]
Workplace visitors
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If you want to invite a visitor to our offices, please ask for permission from our [HR Manager/ Security
Officer/ Office Manager] first. Also, inform our [reception/ gate/ front-office] of your visitor’s arrival.
Visitors should sign in and show identification. They will receive passes and will be asked to return them
to [reception/ gate/ front-office] once their visit is complete.
When you have office visitors, you also have responsibilities. You should:
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Always tend to your visitors (especially when they are underage.)
Keep your visitors away from areas where there are dangerous machines, chemicals,
confidential records or sensitive equipment.
Prevent your visitors from proselytizing your colleagues, gathering donations or requesting
participation in activities while on our premises.
Anyone who delivers orders, mail or packages for employees should remain at our building’s reception
or gate. If you are expecting a delivery, [front office employees/ security guards] will notify you so you
may collect it.
Solicitation and distribution
Solicitation is any form of requesting money, support or participation for products, groups, organizations
or causes which are unrelated to our company (e.g. religious proselytism, asking for petition signatures.)
Distribution means disseminating literature or material for commercial or political purposes.
We don’t allow solicitation and distribution by non-employees in our workplace. As an employee, you
may solicit from your colleagues only when you want to:
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Ask colleagues to help organize events for another employee (e.g. adoption/birth of a child,
promotion, retiring.)
Seek support for a cause, charity or fundraising event sponsored, funded, organized or
authorized by our company.
Invite colleagues to employee activities for an authorized non-business purpose (e.g. recreation,
volunteering.)
Ask colleagues to participate in employment-related activities or groups protected by law (e.g.
trade unions.)
In all cases, we ask that you do not disturb or distract colleagues from their work.
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Employee Recruitment and Selection Policy Sample
This Employee Recruitment and Selection Policy template is ready to be tailored to your company’s
needs and should be considered a starting point for setting up your recruiting policies.
Policy brief & purpose
Our employee recruitment and selection policy describes our process for attracting and selecting
external job candidates. This recruitment policy sample can serve as a rubric that our recruiters and
hiring managers can use to create an effective hiring process.
We are committed to our equal opportunity policy at every selection stage. Hiring teams should aim for a
well-planned and discrimination-free hiring process.
Scope
This recruitment and selection policy applies to all employees who are involved in hiring for our
company. It refers to all potential job candidates.
Policy elements
What is the recruitment and selection process?
Generally, hiring teams could go through the following steps:
1. Identify need for an opening
2. Decide whether to hire externally or internally
3. Review the job description and compose a job ad
4. Select appropriates sources (external or internal) for posting the opening
5. Decide on the selection stages and possible timeframe
6. Review resumes in company database/ATS
7. Source passive candidates
8. Shortlist applications
9. Proceed through all selection stages
10. Run background checks
11. Select the most suitable candidate
12. Make an official offer
Stages may overlap. Hiring managers may remove/add steps as appropriate. The first five stages are
mandatory in every hiring process.
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Posting jobs internally
Hiring managers can post a job opening internally before starting recruiting external candidates. If they
decide to post internally, they can:
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Set a deadline for internal applications
Communicate their opening through newsletters, emails, word-of-mouth or an Applicant Tracking
System’s automated emails
Creating job descriptions
Hiring managers can create job ads based on full job descriptions of each role. Job ads should be clear
and accurately represent the open position. They should include:
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A brief description of our company and mission
A short summary of the role’s purpose
A list of responsibilities
A list of requirements
How to apply
The job ad’s style should be consistent with our company’s unique voice. It should be addressed to ‘you’
in a polite and engaging tone. Jargon, complicated phrases and gender-specific language should be
avoided.
Employee selection stages
Our company has a standard hiring process that may be tweaked according to a role’s requirements.
Our standard process involves:
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Resume screening
Phone screening
Assignment
Interview
Hiring managers may choose to add/remove stages depending on the role they’re hiring for. For
example, they can add the following selection stages/methods:
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Assessment centers
Group interviews
Competency/Knowledge or other selection tests
Referrals Evaluation
In most cases, the stages of resume screening and interview are compulsory.
Interview feedback
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Recruiters/ hiring managers should always inform candidates they interviewed that they decided to
reject them. Leaving candidates in the dark can be damaging to our employer brand.
Also, we encourage hiring managers to send interview feedback to candidates. They should first though
check with HR to make sure they won’t invite legal action. Being brief, respectful and keeping feedback
job-related are the general rules for writing feedback emails to candidates.
Revoked offers
In case when a formal has to be revoked, the hiring manager and human resources department should
draft and sign an official document. This document should include a legitimate reason for revoking the
offer. Legitimate reasons include:
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Candidate is proved to not be legally allowed to work for our company at a specific location
Candidate has falsified references or otherwise lied about a serious issue
Candidate doesn’t accept the offer within the specified deadline (deadline must have been
included in the offer letter)
Hiring managers and HR must notify the candidate formally as soon as possible.
Disclaimer: This policy template is meant to provide general guidelines and should be used
as a reference. It may not take into account all relevant local, state or federal laws and is not
a legal document. Neither the author nor Workable will assume any legal liability that may
arise from the use of this policy.
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INTERNET AND EMAIL ACCESS
POLICY
www.hwca.com
Internet and Email Access PPolicy
olicy
In order to protect the firm, its employees, customers and suppliers, all members of staff
should be given a copy of the firm’s policy regarding acceptable use of IT resources –
particularly internet, email access, and data protection policies. It may also be necessary to
have a separate Bring Your Own Device (BYOD) policy covering the use of personal devices
and to what extent (if any) these are permitted to connect to corporate information
systems.
Any such policies should form part of the contract of
employment - to the extent that any breaches of the
policy could result in disciplinary action, and in some
cases even dismissal.
Having an acceptable use policy not only helps protect
the organisation’s exposure to rogue software, legal
action, and loss of corporate/personal data but can also
help in disputes with employees.
Personal phones, personal headsets and
use of social networks
Firms may wish to include references to the use of
personal phones, personal headsets and social
networking. The use of these or restrictions on the use of
these will very much depend on the working
environment.
Email
Model policy statement
Employees need to be wary of the content of all emails
they may send. One email sent without thought as to the
potential repercussions can have unintended
consequences for both the employee and organisation.
To minimise these kinds of potential problems, employers
should consider setting out a policy statement for all
employees embracing internet and email access.
Illegal material
A suggested policy statement is shown below which you
may find useful as a starting point.
Due to the uncensored nature of the material on the
internet, there are a large number of websites which
contain offensive, obscene and illegal (in the UK)
material. Employees should not access such sites.
Policy and scope
Viruses and phishing
The company/firm (delete as appropriate) sees the
internet and the use of email as an important business
tool.
Innocent looking websites and emails have been used to
tempt users to download material which has been found
to contain a virus, or to disclose company, or personal
confidential data they would not normally impart.
Staff are encouraged to enhance their productivity by
using such tools - but only in accordance with the
guidelines set out in this document.
The internet is largely unregulated and uncensored and
we have a duty of care to protect the security of the
company’s/firm’s internal information, our customers, our
suppliers and our employees from malevolent, obscene
and illegal material.
www.hwca.com
Monitoring - Optional paragraphs 1
With this in mind, the company/firm reserves the right to
monitor emails and internet sites visited on an employee
basis. However, this will only be performed where there is
a suspicion of behaviour which breaches the company’s
‘email and internet access’ policy.
Staff under surveillance will be informed, by
management, that they are being monitored.
Covert monitoring will only be performed in exceptional
circumstances and only when sanctioned by a senior
officer(s) of the company/firm.
and must not interfere with the person’s job
responsibilities. Private use must not disrupt IT systems or
harm the company/firm’s reputation.
You should exercise caution in any use of the internet
and should never rely on information received or
downloaded without appropriate confirmation of the
source.
Access to the internet and email
All/The following users have access to the internet and
email from all/the following PCs...
Personal use
Monitoring - Optional paragraphs 2
With this in mind, the company/firm reserves the right to
monitor email and internet traffic. However, individual
users will not be identified in the monitoring process.
It will be assumed that all staff understand and agree to
the policies unless a director (partner) is notified
otherwise. Any exceptions are to be appended to the
employee’s contract of employment and signed by a
director (partner) and the employee.
All the company’s/firm’s resources, including computers,
access to the internet and email are provided solely for
business purposes.
The purpose of this policy is to ensure that you
understand to what extent you may use the computer(s)
owned by the company/firm for private use and the way
in which access to the internet should be used within the
company/firm, to comply with legal and business
requirements.
This policy applies to all employees of the company/firm
and failure to comply may lead to disciplinary action in
line with the Disciplinary Procedure. In addition, if your
conduct is unlawful or illegal you may be personally liable.
The internet may not be accessed for personal use during
normal hours of employment. Occasional use for personal
reasons is allowed outside working hours, however the
restrictions set out in ‘Browsing/downloading material’
(below) must be adhered to.
Personal emails may not be sent/received unless in an
emergency and with prior authority from a manager.
[Optional paragraph on Personal use of mobile phones,
personal headsets and social networking]
Emails and email attachments
Emails must conform to the same rules as issuing
correspondence on the company’s/firm’s headed paper.
Optional sentence - Emails must be authorised by either a
director/partner (or manager).
Emails must not contain controversial statements/
opinions about organisations or individuals. In particular,
racial or sexual references, disparaging or potentially
libellous/defamatory remarks and anything that might be
construed as harassment should be avoided.
Emails must not contain offensive material.
General principles
Emails containing a virus must not knowingly be sent.
A computer and internet access is provided to you, to
support the company’s/firm’s activities.
Emails coming from an unknown source must not be
opened but disclosed to management (see Disclosure).
Private use of computers and the internet is permitted
subject to the restrictions contained in this policy. Any
private use is expected to be in the employee’s own time
Emails sent externally, must contain the company’s/firm’s
disclaimer (see sample below)
www.hwca.com
Emails (sent and received) must be stored in the
appropriate client files and use the same naming
conventions which are used to store letters and other
correspondence.
• persistent downloading of illegal/obscene/offensive
material
Browsing/downloading material
Disciplinary
Only material from bona fide business, commercial or
governmental websites should be browsed/downloaded.
A breach of any of the policies is a disciplinary matter.
No other material should be browsed/downloaded. This
specifically includes games, screensavers, music/video
and illegal, obscene or offensive material.
Laptops/portables and portable media
devices
• loss of corporate data or loss of machines and devices
containing corporate data
Illegal activities will also be reported to the relevant
authorities.
Inappropriate use
• Laptops are liable to be inspected by authorities
particularly if travelling by air/sea/rail, both within and
outside the UK. Where an employee has a company’s/
firm’s laptop they must ensure that it does not
knowingly contain illegal material.
Computers are a valuable resource to our business but if
used inappropriately may result in severe consequences
to both you and the company/firm. The company/firm is
particularly at risk when you have access to the internet.
The nature of the internet makes it impossible to define
all inappropriate use. However you are expected to
ensure that your use of computers and the internet
meets the general requirements of professionalism.
• Laptops containing corporate data should be
encrypted.
Specifically, during any use of the computer or internet
you must not:
b) Using laptops/portables on remote connections
• copy, upload, download or otherwise transmit
commercial software or any copyrighted materials
belonging to the company/firm or other third parties
a) TTra
ravvelling with laptops/portables
• Company’s/firm’s laptops may be used for email/
internet use without being connected to the
corporate server. Appropriate security software to
allow such access and to control viruses, should be
installed.
c) Using portable media de
devices
vices
• Portable media devices include USB drive, CDs, DVDs
etc
• Where these contain confidential corporate or
personal data, the data contained on these devices
should be encrypted.
Disclosure
Employees have a duty to report the following to
management:
• use any software that has not been explicitly approved
for use by the company/firm
• copy or download any software or electronic files
without using virus protection measures approved by
the company/firm
• visit internet sites or download any files that contain
indecent, obscene, pornographic, hateful or other
objectionable materials
• make or post indecent, obscene, pornographic, hateful
or otherwise objectionable remarks, proposals or
materials on the internet
• reveal or publicise confidential or proprietary
information (including personal data) about the
company/firm, our employees, clients and business
contacts.
• suspect emails/email attachments/websites
• obscene/illegal material found on a PC
• persistent use of the internet for personal reasons
www.hwca.com
The following activities are expressly forbidden:
• the deliberate introduction of any form of computer
virus
• seeking to gain access via the internet to restricted
areas of the company’s/firm’s computer system or
another organisation’s or person’s computer systems
or data without authorisation or other hacking
activities
• downloading corporate information onto portable
media devices (such as USB drive or CD) unless
management has expressly approved this activity
• uploading personal/private information (for example
music, films or photographs) from portable media
devices (such as USB drive or CD) onto a local or
network drive, unless management has expressly
approved this activity.
Monitoring
At any time and without notice, we maintain the right
and ability to examine any systems and inspect and
review any and all data recorded in those systems. Any
information stored on a computer, whether the
information is contained on a hard drive, computer disk
or in any other manner may be subject to scrutiny by the
company/firm. This examination helps ensure compliance
with internal policies and the law. It supports the
performance of internal investigations and assists the
management of information systems.
In order to ensure compliance with this policy, the
company/firm may employ monitoring software to check
on the use of the internet and block access to specific
websites to ensure that there are no serious breaches of
the policy. We specifically reserve the right for authorised
personnel to access, retrieve, read and delete any
information that is created by, received or sent as a result
of using the internet, to assure compliance with all our
policies. Such monitoring will be used for legitimate
purposes only.
Sample eMail disclaimer
This email and all attachments it may contain are
confidential and intended solely for the use of the
individual to whom it is addressed. Any views or opinions
presented are solely those of the author and do not
necessarily represent those of [the company/firm]. If you
are not the intended recipient, be advised that you have
received this email in error and that any use,
dissemination, printing, forwarding or copying of this
email is strictly prohibited.
Please contact the sender if you have received this email
in error.
Companies Act 2006 emails and
websites
Changes to Company law mean that, every company
must include their company registration number, place of
registration and registered office address on corporate
forms and documentation (this includes emails and
websites).
In particular, all external emails must include this
information - whether as part of the corporate signature
or as part of the corporate header/footer.
How we can help
We will be more than happy to provide you with
assistance in formulating an acceptable use policy, or if
any additional information is required.
For information of users: This material is published for the information of clients. It provides only an overview of the regulations in force at the date of publication, and no action
should be taken without consulting the detailed legislation or seeking professional advice. Therefore no responsibility for loss occasioned by any person acting or refraining from action
as a result of the material can be accepted by the authors or the firm.
www.hwca.com
POLICIES & PROCEDURES
Acquisition and Use of Cell Phones, Smart Phones &
Home Internet Access for University Employees
Policy No.: 900-16 Procedures
Effective: 6/30/12
PROCEDURES:
These procedures apply to all University employees authorized by the President or division Vice President to
receive reimbursement for use of portable equipment and/or electronic communication equipment as a
condition of employment under Policy #900-16. The President or division Vice Presidents are hereafter
referred to as “authorizers.”
These procedures may be revised and are subject to change. Employees will be notified when revisions are
made.
General Information Regarding Cell Phones and Smartphones:
1. Multiple monthly cell phone service plans are available to meet the anticipated business needs of the
university divisions.
2. Employees authorized to have a state purchased phone may contact Purchasing and Contract
Administration to obtain information on discounted plans available for university cell phones. For a
current list of CSUN cell phone service plans with estimated costs please contact Purchasing and
Contract Administration.
3. Smartphone devices are cell phones that support applications such as email, calendaring, Internet
access, and read-access to office documents and PDF files. IT has reviewed and tested a variety of
Smartphone devices and has listed those Smartphones that appear compatible with the university
email and calendar system. IT has also identified Smartphones that did not test well in our CSUN
environments.
4. The current list of CSUN IT-tested Smartphone devices. The list of CSUN IT-tested Smartphones will be
periodically reviewed and revised as necessary to reflect vendor changes.
OPTION ONE: University-owned Device or University-paid Service:
1. Wireless Device/Service Use Agreement:
When a university-owned wireless device or service is assigned to an authorized employee, The
Wireless Device/Service Use Agreement should be completed and signed by the authorizer. The form
should then be submitted to Purchasing and Contract Administration. Purchasing and Contract
Administration will acquire the necessary device/service and will assist departments with information
on contracts for these devices/services.
2. Accounting Guidelines/Process:
a. Monthly statements will be sent by Accounts Payable to the authorized employee’s approver
for review.
b. When monthly service plan charges exceed the approved amount, the employee’s authorizer
may certify to Accounts Payable that the excess was due to the conduct of university business,
otherwise the employee must reimburse the University for the excess amount.
c. Personal use of a university-owned device/service will result in the employee being required to
reimburse the university for all personal charges on the device and may result in full taxation of
the service. (Note: Frequent reimbursements or business related overages will generate a
review of the agreement by the authorizer to determine whether the service plan should be
changed or usage reduced.) A reimbursement from the employee will be treated as an
abatement of cost, using the same chartfields used by Accounts Payable to record the original
cost. The Department Deposit Transmittal Form must be completed and delivered to Accounts
Payable before the employee’s reimbursement is deposited.
3. University-owned equipment used at employee’s home:
a. Requires the approval of the Off-Campus Home User Permit by an authorizer. Once the form is
signed it should be submitted to Asset Management.
b. The Permit for home use does not expire, but will be reviewed annually by the authorizer.
c. The authorizer will notify Accounts Payable if the nature of the employee’s responsibilities
change and the employee is no longer authorized. The authorizer will also notify Accounts
Payable when an employee transfers to another department, and will complete a
Separation/Clearance Form when employment has been terminated.
OPTION TWO: Employee-owned Device or Employee-paid Service:
1. Maximum Reimbursements:
a. Maximum amounts are based on the levels defined in the policy. Maximum reimbursements
may be revised and are subject to change. Employees will be notified when revisions are made.
b. The amount of expense reimbursement for cell phone or Smartphone service fees is the lesser
of the following amounts or the actual monthly amount charged to the employee by their
provider:

Level 1: $75

Level 2: $25
c. The amount of expense reimbursement for Smartphone data charges is the lesser of the
following amounts or the actual monthly amount charged to the employee by their provider:

Level 1: $50

Level 2: $0
d. The amount of expense reimbursement for Smartphone purchase is limited to level 1 usage and
is the lesser of $100 plus applicable taxes, or the actual cost incurred by the employee.
2. Exceptions/Changes:
a. Any exceptions to the expense reimbursement amounts require approval by an authorizer.
b. Option Two does not require the authorized employee to identify the personal or business use
of the device/service.
c. Any supplemental changes made by the authorized employee (e.g., changes in phone numbers)
are the employee’s responsibility. Purchasing and Contract Administration can assist authorized
employees with transferring their existing university-owned cell phone number to an
employee-owned device. The transfer of university numbers to an employee phone number is
subject to approval by an authorizer.
3. Reimbursement Process:
a. Ongoing reimbursement to an authorized employee for university business use of a personal
device or service plan requires the following:
· Approval of the Wireless Device/Service Reimbursement Form by an authorizer. The
form is should be submitted to Accounts Payable.
· Verification by the authorizer that the authorized employee is incurring the charges
reimbursed by the university.
· The employee shall make available to the university, upon request, records of the
business calls necessary to comply with applicable laws and regulations, including but
not limited to the California Public Records Act. However, the employee may redact any
personal information from the records provided. The employee agrees to retain cell
phone bills for thirty (30) days from the date of receipt of said bills by the employee.
· The authorizer will notify Accounts Payable if the nature of the employee’s
responsibilities change and the employee is no longer authorized to receive
reimbursement. The authorizer will also notify Accounts Payable when an employee
transfers to another department, and will complete a Separation/Clearance Form when
employment has been terminated.
· The employee must reimburse the university for any payments under this type of
agreement that occurred after the employee ceased to be authorized for
reimbursement or ceased to incur the cost.
4. One-time reimbursement to an authorized employee for university business use of a personal device
or service plan requires the following steps:
a. Reimbursement under $50 will be processed through the University Cash Services petty cash
system. Complete the Petty Cash Reimbursement Request Form . Reimbursement exceeding
$50 will be processed through Accounts Payable for issuance of a reimbursement check.
b. An authorizer can determine if a regular reimbursement plan is appropriate for an employee
who requires frequent reimbursement for business use of personal devices/services.
5. Vehicle Safety:
a. The University cares about employee personal safety and is committed to doing everything
possible to prevent workplace accidents and provide a safe working environment. Employees
should be aware of and comply with all state and local traffic laws while using a cellular device
and operating a vehicle.
6. Implementation:
a. These procedures will be implemented immediately upon the President’s approval of the policy
for all employees who are not receiving reimbursements or utilizing university owned phones
defined in the policy.
b. These procedures will be phased in for all existing employees currently receiving
reimbursements or utilizing university owned phones and implemented per the following
schedule:
MPP Employees – No later than July 1, 2012
Represented Employees – No later than January 1, 2013
Sample smoking policy
Black, bold text provides the minimum requirements needed to comply with the
smoke free legislation. Additional green text is for organisations who wish to introduce
additional restrictions on smoking, such as removing smoking breaks or adopting smoke free sites.
SMOKING POLICY
Smoking policy for [name of organisation]
Effective from [date]
INTRODUCTION
Second hand smoke is a known health hazard. In 2004, the Government's Scientific
Committee on Tobacco and Health reported that the increased risk to non-smokers of
lung cancer from exposure to second hand smoke was 24% and the increased risk of
heart disease 25%.
In provisions made under the Health Act 2006, all enclosed and substantially enclosed
workplaces and public places will be legally required to be smoke free.
The following policy has been adopted by [name of organisation] to take all possible
steps to protect employees from second hand smoke exposure and to comply with
legislative requirements.
1. THE POLICY
1.1
From [date] smoking is prohibited in [name of organisation]'s premises and on the
surrounding grounds, including the car park. Smoking is also prohibited in company
vehicles used by more than one person, and in private vehicles if a passenger is
carried. This applies to employees whether employed directly by [name of
organisation], through an agency, by a contractor or other organisation, and
visitors [include any other users]. [Specify any outdoor areas provided for
smokers if applicable.]
1.2
Employees who wish to smoke may do so in their own time during lunch
breaks. Employees will not be permitted to smoke whilst carrying out their duties and
responsibilities for [name of organisation].
1.3
The sale of tobacco will be prohibited in all [name of organisation]'s premises.
2. THE POLICY FOR THIRD PARTY PREMISES
2.1
Employees required to visit other premises not covered by smoke free legislation as
part of their duties (ie, domestic premises) should advise the visitee when arranging a
visit of [name of organisation]'s smoking policy. Although [name of organisation] has a
duty of care to protect its employees it cannot control the smoking policy on these
premises. Employees should agree that the visitee arrange for a non-smoking area to
be provided for the duration of the visit. Where this is not possible, employees should
ask the visitee to refrain from smoking inside the premises or in the meeting area for
one hour before the visit and that the visitee not smoke during the duration of the
visit.
2.2
In circumstances where it is not possible to arrange a visit beforehand, employees
should seek advice from their line manager, who should take all reasonable steps to
protect them from exposure to second hand smoke.
3. IMPLEMENTATION AND ENFORCEMENT OF THE POLICY
3.1
Managers will be responsible for the promotion and maintenance of the policy by
their staff. Managers will receive training and guidance regarding their
responsibilities in relation to the policy and enforcement of it.
3.2
Employees should inform the appropriate manager of anyone who fails to
comply with the policy.
3.3
Employees not complying with the policy will be referred to Occupational
Health/their manager for support subject to the usual disciplinary procedure.
3.4
Visitors not adhering to the policy will be asked to comply or leave the premises
or site.
3.5
All job applicants will be made aware of the policy via application packs, where a
requirement to abide by it will be part of the person specification. Applicants will be
reminded of the policy at interview stage.
3.6
A copy of the policy will form part of new employees' induction packs. Training
and guidance on enforcing the policy will from part of new managers' induction
process.
4. SUPPORT FOR THOSE WHO SMOKE
4.1
[Name of organisation] recognises that smoking is an addiction and that the smoking
policy will impact on smokers' working lives. [Name of organisation] wishes to support
employees who want to stop and help individuals adjust to this change. [Name of
organisation] will give each employee who smokes, and wishes to stop, four hours
paid time off to seek professional help from the local NHS Stop Smoking Service, their
GP or other recognised method of smoking cessation.
4.2
[Name of organisation]'s Occupational Health department/manager/owner will provide
smoking cessation support/information on free local NHS stop smoking services.
5. REVIEW OF THE POLICY
The policy will be reviewed by [appropriate reviewer/review group] six months after the
date of implementation and then 12 months from the date of implementation.
(Please replace this image with your company logo)
(Disclaimer: This document is for illustrative purposes only. Please carefully adapt it your unique business and check
with your legal counsel before use.)
Company Name Substance Use Policy
Policy purpose
Company name is committed to providing a safe and healthy working environment for our employees,
contractors, clients and visitors (hereinafter referred to as ‘employees’ for simplicity). Employees under
the influence of impairment-causing substances, such as drugs or alcohol, can pose serious health
and safety risks to themselves and those around them.
The purpose of this policy is to provide guidance to our employees and managers on substance
management in the workplace so that we may maintain a safe workplace where all employees are
treated fairly and with respect.
Policy Overview
Here are the general terms of our workplace substance use policy:
1. The use, sale, purchase, transfer or possession of any illegal substances that cause
impairment, or any legal, non-medically authorized substances that cause impairment is
strictly prohibited in our workplace. Refer to the Substance Classification Chart at the end of
this policy for more information.
2. Employees are not permitted to work while impaired by any substance.
3. We recognize that substance dependency is a serious medical issue. Employees who are
experiencing substance abuse or dependency challenges are encouraged to disclose these
challenges to a member of HR immediately so that Company name may initiate the
accommodation analysis process. Employees will not be negatively impacted by doing so.
4. Employees who occupy a safety-sensitive position (defined later in this policy) are required to
disclose the use of impairment-causing substances to a member of HR so we may conduct a
risk-assessment.
5. There are some cases where the consumption of legal, impairment causes substances (such
as alcohol) will be permitted at work events. Employees are expected to exercise reasonable
professional judgement when consuming substances during these times.
Employees in Safety-Sensitive Positions
Safety-sensitive positions are those in which impairment due to drugs or alcohol could result in direct and
significant risk of injury to the employee, others, or the environment. Examples include truck drivers,
heavy equipment operators, or individuals dealing with hazardous chemicals.

Employees in these roles are required to disclose impairment or the use of any substances that
could cause impairment at work to a member of HR immediately.

Employees who have used these substances prior to work but are scheduled to work and may
still be impaired must also notify HR immediately.

Once disclosed, Company name will conduct a risk assessment to ensure the employee is able to
complete their duties in a safe manner.

Company name may request additional information from a physician to complete this
assessment.

An employee’s failure to disclose or failure to cooperate with the risk assessment may result in
disciplinary action, up to and including termination of the employment with cause.
Substance abuse and dependency
Company name acknowledges that substance abuse or dependency are a serious medical, social,
employment issue. Under Human Rights Legislation, substance dependencies are protected and
recognized as a disability and considered to be prohibited grounds of discrimination.

Any employee who is struggling with substance abuse or dependency will receive support and
accommodation from the company provided that they notify a member of HR.

Employees will not be negatively impacted for notifying a member of HR of a substance abuse
or dependency issue.

If an employee discloses a substance abuse or dependency issue after they have violated a
company policy, they may still be subject to disciplinary action for the policy violation alone,
not the dependency issue.
Accommodation
Under the Canadian Human Rights Act, Company name is committed to protecting individuals in the
workplace from discrimination on the basis of medical need.
If any employee is experiencing substance dependency issues or is required to use medical substances
that cause impairment while at work (including medical cannabis with THC content), company name will
accommodate the employee, to the point of undue hardship, so that they may continue to do their jobs.
To initiate the accommodation process:





The employee must disclose the substance use to a member of HR and make a formal request
for accommodation
Company name will begin an accommodation analysis to determine the extent of accommodation
required
Employees will not be negatively impacted if they disclose a substance abuse or dependency
issue.
Company name will work with the employee and, if appropriate, the employee’s treating physician
or medical provider to devise an individualized treatment and accommodation plan
Company name will provide accommodation to the point of undue hardship
Policy Procedure and Discipline
Company name will not tolerate any unsafe behaviour or negligence in the workplace, including
impairment in the workplace.
Employees are encouraged to contact a member of HR with any questions or concerns regarding
substance use at work.
Company name will investigate and deal with all complaints or incidents related to substance use at work
in a fair, respectful, and timely manner.
Information provided about an incident or about a complaint will not be disclosed except as necessary to
protect workers, to investigate the complaint or incident, to take corrective action or as otherwise required
by law.
Any employee who fails to comply with this policy to who engages in illegal activities such as selling drugs
or alcohol in the workplace will be subject to disciplinary action, up to and including the termination of
their employment with cause.
For any further information or assistance, please contact a member of HR.
Approved by:
[Signature]
[Name]
[Date]
Substance Classification Chart
The following table explains how Company name classifies and treats different substance types in the
workplace:
Substance type
Use in the workplace
Disclosure requirements
Legal, nonmedical
substances
No employee may use, sell,
purchase or transfer these
substances on company
property.
All employees must disclose
substance abuse or dependency
issues to initiate the accommodation
analysis process.
No employee may be
impaired while working.
Employees in safety-sensitive
positions must disclose possible
impairment before working.
Ex: alcohol,
recreational
cannabis
Employees may be
permitted to consume
these substances at
company-sanctioned social
events, provided they
exercise reasonable
professional judgement.
Illegal, nonmedical
substances that
cause impairment
No employee may use, sell,
purchase, possess or
transfer these substances
on company property.
All employees must disclose
substance abuse or dependency
issues to initiate the accommodation
analysis process.
Ex: recreational
drugs such as
cocaine, heroin
No employee may be
impaired while working.
Employees in safety-sensitive
positions must disclose possible
impairment before working.
Medicallyauthorized
substances that
cause
impairment, used
with a
prescription
Medically-authorized
substances are allowed on
company property.
All employees must disclose
substance abuse or dependency
issues to initiate the accommodation
analysis process.
Ex: medical
cannabis with THC
content
No employee may be
impaired while working.
Employees in safety-sensitive
positions must disclose possible
impairment before working.
Employees who are not in safetysensitive positions are not required
to disclose use outside of the
workplace.
Prescription
drugs that cause
impairment, used
illegally
Prescription
drugs or medical
substances that
do not cause
impairment, used
legally
Ex: medical CBDbased cannabis
No employee may use, sell,
purchase, possess or
transfer these substances
on company property.
All employees must disclose
substance abuse or dependency
issues to initiate the accommodation
analysis process.
No employee may be
impaired while working.
Employees in safety-sensitive
positions must disclose possible
impairment before working.
Permitted at work, provided
they are used legally and
responsibly
Employees who are not in a safetysensitive position are not required to
disclose prescription-drug or
medication use to the company
provided they are not impaired at
work.
If any employee in a safety-sensitive
position is unsure if their medication
may cause impairment, they must
inform HR to initiate a riskassessment.
OCCUPATIONAL HEALTH
AND SAFETY
POLICY AND PROCEDURES MANUAL
Table of Contents
Health and Safety Policy........................................................................... 3
Occupational Health and Safety ............................................................... 4
In Workplaces ........................................................................................... 4
Duties of Workers ............................................................................... 4
What the law requires ......................................................................... 4
Duties Of Your Employer ..................................................................... 4
Your Responsibilities ........................................................................... 4
Your Rights ........................................................................................ 4
Your Right To Know ............................................................................ 5
Your Right To Participate ..................................................................... 5
Committees Have Duties To:................................................................ 5
Your Right To Refuse .......................................................................... 6
Add Contact Information Here: ............................................................ 8
Responsibilities ......................................................................................... 9
Warehouse and Delivery Staff .............................................................. 9
Warehouse Supervisor......................................................................... 9
Sales Staff and Suppliers ..................................................................... 9
Safety Officer ................................................................................... 10
Branch Manager................................................................................ 10
Duties ...................................................................................................... 10
Branch Manager................................................................................ 10
Safety Officer ................................................................................... 10
Critical Injury Protocol ........................................................................... 15
Accident Investigation Policy ................................................................. 16
Environmental Policy .............................................................................. 18
Acknowledgement & Agreement Receipt ..............................................19
Forward
Your Company Name is committed to the Health and Safety of all our employees.
The purpose of the Health and Safety policies and procedures is to guide and
direct all employees to work safely and prevent injury, to themselves and others.
All employees are encouraged to participate in developing, implementing, and
enforcing Health and Safety policies and procedures. All employees must take all
reasonable steps to prevent accidents and never sacrifice safety for expedience.
Our goal is to eliminate or minimize hazards that can cause accidents.
It is company policy that all employees be given a copy of the policies manual
and be familiar with its contents.
This policy will be reviewed annually.
Together we can achieve a safe and happy work environment.
Health & Safety Manual
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Health and Safety Policy
Your Company Name is committed to the goal of providing and maintaining a
healthy and safe working environment, with a view to continuous improvement.
This goal is only achievable by adherence to established objectives striving to
exceed all obligations under applicable legislation, and by fostering an
enthusiastic commitment to health, safety and the environment within Your
Company Name personnel, contractors and visitors.
In particular:
ƒ
Management, working in cooperation with the Joint Health and Safety
Committee, will strive to take all reasonable steps to reduce workplace
hazards to as low as reasonably achievable.
ƒ
Supervisors and managers are held accountable for the health and
safety of all employees under their supervision. This includes
responsibility for applicable training and instruction, appropriate followup on reported health and safety concerns, and implementation of
recommended corrective action. This accountability is integrated into
the performance appraisal system.
ƒ
Supervisors, workers and visitors are expected to perform their duties
and responsibilities in a safe and healthful manner, and are accountable
for the Health and Safety of themselves and others.
ƒ
Your Company Name is committed to providing all necessary training
and instruction to ensure that appropriate work practices are followed
on the job, and to promote their use off the job.
ƒ
If necessary, Your Company Name will take disciplinary action where
individuals fail to work in a healthy and safe manner, or do not comply
with applicable legislation or corporate policies and procedures.
Health, safety, the environment and loss control in the workplace are everyone’s
responsibility. Your Company Name expects that everyone will join in our
efforts to provide a healthy and safe working environment on a continuous day
to day basis. Only through the dedication and efforts of all individuals can Your
Company Name succeed in providing a healthy safe working environment.
Health & Safety Manual
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Occupational Health and Safety In Workplaces
Duties of Workers
Occupational Health and Safety and You
One of your most important responsibilities is to protect your Health and Safety
as well as that of your co-workers. This booklet will discuss some of your duties
under the occupational Health and Safety legislation and help you to make your
workplace safer and healthier.
What the law requires
Workplaces under the jurisdiction are governed by your provincial legislation.
The legislation places duties on owners, employers, workers, suppliers, the selfemployed and contractors, to establish and maintain safe and healthy working
conditions. The legislation is administered by your provincial legislation. Your
officials are responsible for monitoring compliance.
Duties Of Your Employer
Your employer is responsible for providing you with safe and healthy working
conditions. This includes a duty to protect you from violence, discrimination and
harassment. You must cooperate with your employer in making your workplace
safe and healthy.
Your Responsibilities
You must also comply with the legislation. You have responsibilities to:
ƒ
protect your own Health and Safety and that of your co-workers;
ƒ
not initiate or participate in the harassment of another worker; and
ƒ
co-operate with your supervisor and anyone else with duties under
the legislation.
Your Rights
The legislation gives your three rights:
ƒ
ƒ
the right to know the hazards at work and how to control them;
the right to participate in Occupational Health and Safety; and
Health & Safety Manual
Page 4 of 20
ƒ the right to refuse work which you believe to be unusually dangerous.
You may not be punished for using these rights. An employer can be required
to legally justify any action taken against a worker who is active in Health and
Safety.
Your Right To Know
The Act requires your employer to provide you with all the information you
need to control the hazards you face at work. For example, chemicals at the
workplace must be listed. You are entitled to review this list. Your employer
must train you to safely handle the chemicals you will work with. If you are
inexperienced, you must receive an orientation which includes;
ƒ
What to do in a fire or other emergency;
ƒ
First aid facilities;
ƒ
Prohibited or restricted areas;
ƒ
Workplace hazards; and
ƒ
Any other information you should know.
You must also be supervised closely by a competent supervisor.
Your Right To Participate
You have the right to become involved in occupational Health and Safety.
The legislation encourages employers and workers to work together to
maintain a healthy and safe workplace. Employers at workplaces with (ten or
more – consult your provincial act) workers must set up an occupational
health committee of employer and worker representatives.
Committees Have Duties To:
ƒ
Regularly inspect the workplace;
ƒ
Conduct accident investigations;
ƒ
Deal with the Health and Safety concerns of employees;
ƒ
Investigate refusals to work;
Health & Safety Manual
Page 5 of 20
ƒ
Meet at least (four times a year – consult your provincial act); and return
minutes of each meeting to the Division.
Committee members are entitled to five days (consult your provincial legislation) of
unpaid educational leave each year to take occupational Health and Safety courses.
They may attend courses provided by the Division without loss of pay or benefits.
Certain types of workplaces with less than (ten – consult your provincial act)
employees must have a worker Health and Safety representative. The representative
must be selected by the workers at the workplace. He or she has many of the
responsibilities of an occupational health committee.
Your Right To Refuse
You have the right to refuse to do work which you believe is unusually dangerous.
The unusual danger may be to you or to anyone else. An unusual danger could
include such things as:
ƒ
ƒ
ƒ
a danger which is not normal for your occupation or the job;
a danger under which you would not normally carry out your job; and/or
a situation for which you are not properly trained, equipped or experienced.
To exercise this right, use the following guidelines.
Once you believe that the work you have been asked to do is unusually
dangerous, you should inform your supervisor. Make sure that the supervisor
understands that you are refusing to do the disputed job for health and
safety reasons. Work with the supervisor to attempt to resolve the problem.
If the problem cannot be resolved by the supervisor to your satisfaction, and
no worker health and safety representative or occupational health committee
exists at the workplace, your supervisor should phone the Division and ask for
advice. You also have the right to contact the Division at any time.
The supervisor has the right to assign you to other work (at no loss in pay or
benefits) until the matter is resolved.
Do not leave the site without the permission of your employer.
If a committee exists at the workplace, contact your local representative and
ask for help. Your supervisor should contact the co-chairpersons and ask
them to investigate. They will try to resolve the matter. If they cannot
resolve the matter to your satisfaction, they will convene for an emergency
Health & Safety Manual
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committee meeting. The committee will investigate and prepare a report on
the refusal.
You have the right to continue to refuse until:
ƒ
measures have been taken to satisfy you that the job is now safe to
perform; or
ƒ
Your occupational health committee has investigated and ruled
against your refusal.
If the committee rules against your refusal, you have the right to appeal the
ruling to an occupational health officer. The officer will investigate and
prepare a report on the disputed work. If you disagree with the decision of
the officer, you may appeal to the director of the Division.
An employer cannot assign another worker to do the disputed job unless the
replacement worker is advised in writing:
ƒ
of the refusal and the reasons for it;
ƒ
of the reasons why the employer believes that there placement
worker can do the disputed job safely;
ƒ
that the replacement worker also has the right to refuse; and
ƒ
of the steps to follow when exercising this right.
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Contact Information
Add your office address information & contact telephone numbers here.
Health & Safety Manual
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Responsibilities
Our safety program is the responsibility of all levels of company employees. The
chain of responsibility is as follows.
1) Warehouse staff and delivery driver report to the warehouse supervisor.
2) Warehouse supervisor, sales staff and suppliers report to the safety
officer.
3) Safety officer reports to the branch manager.
4) All employees are responsible for the health and safety of all visitors or
contractors brought on site by them, and to insure that they are aware of
and follow all company safety rules and procedures at a minimum.
Warehouse And Delivery Staff
Warehouse and delivery people are accountable to the warehouse supervisor for
ensuring that all aspects of Occupational Health & Safety policy are followed.
Employees must take an active roll in protecting and promoting their health,
safety and accident prevention. You must not perform activities that jeopardize
your health and safety or that of others.
Warehouse Supervisor
The warehouse supervisor is accountable to the safety officer and is responsible
for ensuring the Occupational health & safety policy is followed. They must
provide leadership in all aspects of Health and Safety including developing policy
and procedure. They are also responsible for ensuring proper procedures are
followed in the lacquer areas for pouring, mixing and storing flammable
products.
Sales Staff And Suppliers
Sales staff is accountable to the safety officer for ensuring that Occupational
Health & Safety policies are followed. They are responsible for all aspects of
health and safety in their area of the office and sample areas.
Suppliers are accountable to the safety officer for providing WHMIS and MSDS
(Material Safety Data Sheets) sheets for all hazardous products supplied by
them.
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Safety Officer
The safety officer is accountable to the branch manager and is responsible for
Occupational Health & Safety performance for all employees in their branch at
all levels.
The safety officer must provide leadership in all aspects of health and safety
activities at work or otherwise. The safety officer must take an active roll in all
aspects of safety, within their branch.
Branch Manager
The branch manager is responsible for the health and safety of all employees
within their branch. The branch manager must ensure all policies and
procedures are followed according to Occupational Health & Safety.
Duties
Branch Manager
1) Ensure that all reasonable steps are taken to prevent accidents.
2) Ensure that standards and procedures are developed and maintained.
3) Be familiar with the Occupational Health & Safety act and any revised
regulations and ensure they are followed.
4) Ensure that all employees are instructed in the procedures and
requirements of Occupational Health & Safety.
5) Review accident reports, safety audits and other related material relative
to health or safety.
Safety Officer
1. Ensure that all reasonable steps are taken to prevent accidents.
2. Be familiar with Occupational Health & Safety act, the company policy and
any other legislation pertaining to health or safety.
3. Ensure all policies and legislation is followed by all levels of employees.
4. Ensure safety meetings are held and minutes are recorded, posted and
filed accordingly to Occupational Health & Safety regulations.
5. Ensure all accidents are reported and investigated.
Health & Safety Manual
Page 10 of 20
6. Ensure MSDS sheets are provided for all hazardous materials delivered to
the workplace and are readily available for employees to review.
6) Review all MSDS and advise/train employees in the safe use, storage and
transportation of controlled or dangerous products including what to do in
case of an accidental spill or emergency.
7. Ensure employees are instructed in the procedures and requirements of
Occupational Health & Safety.
8. Review all accidents and near misses to determine root and basic causes,
with suggestion/implementation of changes to prevent re-occurrence.
9. Ensure all employees are trained in WHMIS (Workplace Hazardous
Material Information System)
All Other Staff
1) Comply with all Company Procedures, Safety Policy and requirements of
Occupational Health & Safety.
2) Be responsible for working safely and carrying out their duties with skill
and care as to not cause accidental injury to themselves, fellow
employees or the general public.
3) Immediately report all injuries, near misses or potential hazards to their
supervisor.
4) Know the location of all fire extinguishers, fire alarms or other warning
devices.
5) Ensure all personal safety equipment is being used properly.
6) Never engage in horse play or tomfoolery.
7) Maintain clean and orderly work area.
8) When in doubt…. ASK
Suppliers
1) Provide MSDS for all hazardous material shipped to our warehouse.
2) Ensure all reasonable steps are taken to prevent an accident.
3) Be familiar with Occupational Health & Safety act.
Health & Safety Manual
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General Safety Rules
1)
All accidents, injuries or near misses, regardless of their nature, shall be
promptly reported to the safety officer.
2)
Clothing shall be appropriate to the duties being performed. Long pants,
a clean neat shirt and steel toed shoes are the minimum requirements.
3)
Hard hats and safety vests are provided for all warehouse staff and must
be worn at all times in the warehouse, loading or unloading of vehicles in
the yard.
4)
Running is not permitted except in extreme emergencies.
5)
Smoking is not permitted in any part of the warehouse or office. You may
only smoke in designated areas.
6)
Visitors and customers are to be escorted by staff while on company
property.
7)
Hand tools are to be used for their intended purpose only.
8)
Only licensed personnel may operate forklifts or other warehouse
equipment and must wear a seatbelt while doing so.
9)
Riding on equipment is prohibited except where designated for operator.
10)
Horseplay, fighting or tomfoolery is strictly prohibited on Your Company
Name premises.
11)
All spacers are to be of equal proportion and undamaged. Damaged
spacers are dangerous.
12)
Open lifts are to be stored on the floor or in assigned bunks. Do not stack
an open lift; this act will result in disciplinary action up to and including
dismissal. All lumber lifts must be banded.
13)
Only solid spacers are to be used on lumber products, no particle board
spacers.
14)
All bunked products will be placed securely in the bunks.
15)
All spills will be immediately cleaned up and reported.
16)
Drawers and filing cabinets will be kept closed when not in use.
17)
Filing cabinet drawers are to be filled from the bottom up or the cabinet is
to be securely fastened /anchored.
18)
Lifts and clutter will be cleaned up before the end of your workday.
19)
Aisles are to be kept clear at ALL times.
20)
Do not unload a truck alone under any circumstances, if someone can not
help you then wait or call someone else for help. (Applies on and off Your
Company Name property).
Health & Safety Manual
Page 12 of 20
Safety Tips
1) If you are not sure…..ask.
2) Follow instructions and don’t take chances.
3) Wear your personal safety equipment.
4) Never operate equipment you have not been trained for.
5) Keep your work area clean.
6) Stay clear of forklifts while they are being operated.
7) Avoid injury by lifting correctly. If it’s heavy ask for help. Max weight to
be lifted is 75lbs.
8) Make sure the job can be done safely.
9) DO NOT unload a truck alone.
Portable Ladders
Portable ladders must be secured against movement and placed on a base that is
stable; the base of an inclined portable ladder is to be no further from the base
of the wall or structure than ¼ of the height to where the ladder contacts the
wall or structure.
Pallets & Storage Racks
All employees must ensure that pallets used to transport or store
materials/containers are loaded, moved, stacked, arranged and stored in a
manner that does not create danger to workers.
Your Company Name must ensure that racks used to store materials or
equipment are designed, constructed and maintained to support the load placed
on them and are placed on firm foundations that can support the load.
Employees must report any damage to a storage rack to the manager as quickly
as is practical. All managers and employees must take all reasonable steps to
prevent storage racks from being damaged to the extent that their integrity as a
structure is compromised.
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First Aid
An employer must ensure that the first aiders at a work site have successfully
completed a first aid training course approved by a Director of Medical Services
and hold a valid certificate in first aid. (consult with your local medical services)
An employer must keep record at the site of workers who are first aiders and
post these names where they are accessible by all employees.
Every branch must have a first aid kit on site; each kit must contain the
following: (see your Provincial legislation)
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
n)
o)
p)
q)
10 antiseptic cleansing towelettes, individually packaged
25 sterile adhesive dressings, individually packaged
10 - 10cm X 10cm sterile gauze pads, individually packaged
2 - 10cm X 10cm sterile compress dressings, with ties individually
packaged
2 - 15cm X 15cm sterile compress dressings, with ties, individually
packaged
2 conform gauze bandages – 75mm wide
3 cotton triangular bandages
5 safety pins - assorted sizes
1 pair of scissors
1 pair of tweezers
125mm x 4.5 m of adhesive tape
1 crepe tension bandage – 75mm wide
1 resuscitation barrier device with a one-way valve
4 pairs of disposable surgical gloves
1 first aid instruction manual (condensed)
inventory of kit contents
1 waterproof waste bag
Accident And Near Miss Reporting
The following protocol must be followed.
1) All employees must immediately report any occupational injury, accident
or near miss to the safety officer or their supervisor.
2) Supervisors must immediately tend to injuries and then report them to
the safety officer.
3) Branch managers must immediately discuss the incident with the safety
officer and injured persons.
Health & Safety Manual
Page 14 of 20
The purpose of this procedure is to comply with Occupational Health & Safety
act, workers compensation board and to determine the cause of the accident and
make recommendations to prevent further re-occurrence. All reports of injury
must be filed.
If an injury occurs a record must be kept and include the following:
a)
b)
c)
d)
e)
f)
g)
h)
name of worker
name and qualifications of person giving first aid
a description of illness or injury
the first aid given to the worker
the date and time the illness or injury
the date and time the illness or injury was reported
where at the work side the incident occurred
the work-related cause of the incident, if any
The employer must retain the records kept for 3 years from the date the incident
is recorded. A person who has custody of records must ensure that no person
other than the worker has access to a workers records unless:
a) the record is in a form that does not identify worker
b) the worker has given written permission to the person
c) the Director of Medical Services or a person authorized by the director
requires to be produced under the act.
An employer must give a worker a copy of the records pertaining to the worker if
the worker asks for a copy.
Critical Injury Protocol
First and foremost, always take whatever measures are required to provide
proper care of an injured worker.
If a critical injury has occurred and the worker has been cared for, the branch
manager, safety officer and W.C.B must be notified. The appropriate report
must be completed as soon as possible; this is to ensure that important details
are not forgotten.
A critical injury is an injury that….
1) Places life in jeopardy
2) Produces unconsciousness
Health & Safety Manual
Page 15 of 20
3) Results in substantial loss of blood
4) Involves the fracture of a leg or arm, but not a finger or toe
5) Involves the amputation of a leg, arm, hand or foot, but not a finger or
toe.
6) Consists of burns to major portion of the body.
7) Causes loss of sight in an eye.
Accident Investigation Policy
All accidents that result in injury or property damage or that could have resulted
in serious injury or property damage (near miss) must be thoroughly
investigated.
The investigation must determine the cause of the incident so that appropriate
action can be taken to prevent recurrence.
The safety officer shall be responsible for conducting the investigation. The
investigation report shall be completed as soon as possible after the incident and
reported to the branch manager. The safety officer and appropriate supervisor
shall determine what steps are to be taken to prevent recurrence.
Any disputes arising from the investigation will be investigated and arbitrated by
the branch manager.
Alcohol And Drug Policy
It is the responsibility of all employees to ensure an alcohol and drug free
environment. If there is any awareness or suspicion that any employee, supplier
or visitor is under the influence of illegal narcotics or alcohol, will be removed
from the premises immediately.
Should an employee report to work while under the influence of such
substances, the employee will be taken home either in a cab or by the Branch
Manager.
This is a zero tolerance policy
Health & Safety Manual
Page 16 of 20
Disciplinary Action
Careless work and irresponsible behaviour directly affect the quality of health
and safety in the workplace. Even absenteeism influences safety by placing more
duties on fellow employees.
The following instances shall be cause for verbal or written warning and possible
dismissal.
1)
2)
3)
4)
5)
6)
7)
8)
9)
Absenteeism without cause
Health and safety violations
Poor conduct or misconduct
Theft
Sexual harassment
Racial discrimination
Carelessness
Wilful damage to company property
Drug or alcohol use
Compliance with company and legislative safety standards is necessary to
maintain a safe and healthy work environment. As with any program non
compliance issues must be dealt with.
The following is a guideline for disciplinary actions for safety infractions based on
seriousness of the offence.
*First offence, employee will be given a documented verbal warning
*Second offence, employee will be given a written warning and a one day
suspension.
*Third offence, employee may be suspended or terminated (suspension or
termination to fit seriousness of the offence).
Hazard Warning Signs
When ever possible, warning signs will be displayed where a potential hazard
may cause injury. Warning signs must be strictly adhered to.
Warning signs must be posted where hazards exist and must not be removed
unless hazard has been controlled.
Health & Safety Manual
Page 17 of 20
Environmental Policy
Your Company Name is Committed to the Protection of the Environment for
Present and Future Generations. All Employees Are Responsible for
incorporating into Their Planning and Work the Actions Necessary to Fulfill this
Commitment.
Your Company Name Will Meet These Responsibilities by Endeavouring to
Provide the Resources for Continuing To:
ƒ
Design and manage our operations to meet or surpass applicable
environmental laws.
ƒ
Work in partnership with customers, suppliers, trade associations and
government agencies to promote the environmentally safe handling and
disposition of materials and products.
ƒ
Acquire knowledge and technologies to improve the environmentally
save efficient use of our processes and products.
ƒ
Formulate and implement effective environmental emergency response
systems.
ƒ
Involve our employees in our environmental programs and keep them
informed of our performance.
ƒ
Promote employee awareness of this policy and enhance their
capabilities to implement this policy.
Health & Safety Manual
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Acknowledgement & Agreement Receipt
Date ___________________________
I, ____________________________, hereby acknowledge receipt of the
Your Company Name “Occupational Health & Safety Manual”.
I have read, understand and agree to the terms of employment and will
carry out and abide by the operational procedures and rules as outlined
therein.
I agree:
To adhere to all company policies and procedures.
To the use of safety equipment, at all times, which is required by my safe
work procedures and by my clients.
That government and client regulations shall be complied with at all times.
That I am responsible and accountable for my health and afety
performance.
Employee’s Signature:
_______________________________________________
Manager, Your Company Name : _______________________________
This page is to be forwarded to head office at time of signing.
Health & Safety Manual
Page 19 of 20
Workplace harassment policy sample
This Workplace Harassment Policy template is ready to be tailored to your company’s needs and
should be considered a starting point for setting up your employment policies. A Workplace Harassment
Policy may also be referred to as an Anti-Harassment, Employee Harassment, Sexual Harassment
or Racial Harassment Policy.
Policy brief & purpose
Our anti-harassment policy expresses our commitment to maintain a workplace that's free of
harassment, so our employees can feel safe and happy. We will not tolerate anyone intimidating,
humiliating or sabotaging others in our workplace. We also prohibit wilful discrimination based on [age,
sexual orientation, ethnicity, racial, religion or disability.]
Scope
This workplace harassment policy applies to all employees, contractors, public visitors, customers and
anyone else whom employees come into contact with at work. For more details on how to recognize,
report and deal with sexual harassment and harassment from outside our company, please refer to our
sexual harassment policy and our third party harassment policy.
Policy elements
What is the definition of harassment in the workplace?
Harassment includes bullying, intimidation, direct insults, malicious gossip and victimization. We can’t
create an exhaustive list, but here are some instances that we consider harassment:
●
●
●
●
●
[Sabotaging someone’s work on purpose.]
[Engaging in frequent or unwanted advances of any nature.]
[Commenting derogatorily on a person’s ethnic heritage or religious beliefs.]
[Starting or spreading rumors about a person’s personal life.]
[Ridiculing someone in front of others or singling them out to perform tasks unrelated to their job
(e.g. bringing coffee) against their will.]
Sexual harassment is illegal and we will seriously investigate relevant reports. If an employee is found
guilty of sexual harassment, they will be terminated.
How to address harassment
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If you’re being harassed, whether by a colleague, customer or vendor, you can choose to talk to any of
these people:
●
●
●
Offenders. If you suspect that an offender doesn’t realize they are guilty of harassment, you
could talk to them directly in an effort to resolve the issue. This tactic is appropriate for cases of
minor harassment (e.g. inappropriate jokes between colleagues.) Avoid using this approach with
customers or stakeholders.
Your manager. If customers, stakeholders or team members are involved in your claim, you
may reach out to your manager. Your manager will assess your situation and may contact HR if
appropriate.
HR. Feel free to reach out to HR in any case of harassment no matter how minor it may seem.
For your safety, contact HR as soon as possible in cases of serious harassment (e.g. sexual
advances) or if your manager is involved in your claim. Anything you disclose will remain
confidential.
Disciplinary Consequences
Punishment for harassment depends on the severity of the offence and may include counseling,
reprimands, suspensions or termination.
Disclaimer: This policy template is meant to provide general guidelines and should be used
as a reference. It may not take into account all relevant local, state or federal laws and is not
a legal document. Neither the author nor Workable will assume any legal liability that may
arise from the use of this policy.
Further reading:
●
Sexual Harassment (Equal Employment Opportunity Commission)
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Grievance procedure company policy
This Grievance Procedure policy sample is ready to be tailored to your company’s needs and should
be considered a starting point for setting up your employment policies.
Policy brief & purpose
Our grievance procedure policy explains how employees can voice their complaints in a constructive
way. Supervisors and senior management should know everything that annoys employees or hinders
their work, so they can resolve it as quickly as possible. Employees should be able to follow a fair
grievance procedure to be heard and avoid conflicts.
The company encourages employees to communicate their grievances. That way we can foster a
supportive and pleasant workplace for everyone.
Scope
This policy refers to everyone in the company regardless of position or status.
Policy elements
Grievance definition
We define grievance as any complaint, problem or concern of an employee regarding their workplace,
job or coworker relationships.
Employees can file grievances for any of the following reasons:
●
●
●
●
Workplace harassment
Health and safety
Supervisor behavior
Adverse changes in employment conditions
This list in not exhaustive. However, employees should try to resolve less important issues informally
before they resort to a formal grievance.
Employees who file grievances can:
●
●
●
Reach out to their direct supervisor or HR department
File a grievance form explaining the situation in detail
Refuse to attend formal meetings on their own
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●
Appeal on any formal decision
Employees who face allegation have the right to:
●
●
●
Receive a copy of the allegations against them
Respond to the allegations
Appeal on any formal decision
The company is obliged to:
●
●
●
●
●
●
●
Have a formal grievance procedure in place
Communicate the procedure
Investigate all grievances promptly
Treat all employees who file grievances equally
Preserve confidentiality at any stage of the process
Resolve all grievances when possible
Respect its no-retaliation policy when employees file grievances with the company or external
agencies (e.g. equal employment opportunity committee)
Procedures
Employees are encouraged to talk to each other to resolve their problems. When this isn’t possible,
employees should know how to file a grievance:
1. Communicate informally with their direct supervisor. The supervisor will try to resolve the
problem. When employees want to complain about their supervisor, they should first try to
discuss the matter and resolve it between them. In that case, they’re advised to request an
informal meeting. Supervisors should try to resolve any grievance as quickly as possible. When
they’re unable to do so, they should refer to the HR department and cooperate with all other
procedures.
2. If the grievance relates to a supervisor behavior that can bring disciplinary action (e.g. sexual
harassment or violence), employees should refer directly to the HR department or the next level
supervisor.
3. Accommodate the procedure outlined below
The HR department (or any appropriate person in the absence of an HR department) should follow the
procedure below:
1.
2.
3.
4.
5.
6.
Ask employee to fill out a grievance form
Talk with the employee to ensure the matter is understood completely
Provide the employee who faces allegations with a copy of the grievance
Organize mediation procedures (e.g. arranging a formal meeting)
Investigate the matter or ask the help of an investigator when needed
Keep employees informed throughout the process
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7. Communicate the formal decision to all employees involved
8. Take actions to ensure the formal decision is adhered to
9. Deal with appeals by gathering more information and investigating further
10. Keep accurate records
This procedure may vary according to the nature of a grievance. For example, if an employee is found
guilty of racial discrimination, the company will begin disciplinary procedures.
Disclaimer: This policy template is meant to provide general guidelines and should be used
as a reference. It may not take into account all relevant local, state or federal laws and is not
a legal document. Neither the author nor Workable will assume any legal liability that may
arise from the use of this policy.
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Employee progressive discipline policy template
This Progressive Discipline policy template is ready to be tailored for your company’s needs and should
be considered a starting point for setting up your employment policies.
Policy brief & purpose
Our Progressive Discipline policy outlines the steps we will take to address an employee’s misconduct.
We recognize that people make mistakes and our employees may not always follow our policies closely.
We want to give our employees a chance to correct their behavior when possible and assist them in the
process. We also want to ensure that serious offenses are thoroughly investigated and dealt with.
Scope
This policy applies to all our employees.
Policy elements
Our disciplinary process has six steps of increasing strictness. These steps are:
1.
2.
3.
4.
5.
6.
Verbal warning
Informal meeting with supervisor
Formal reprimand
Formal disciplinary meeting
Penalties
Termination
All these phases are official and managers should document them. HR must also keep records of the
process from step 3 onwards.
Managers should let employees know when they launch a progressive discipline procedure. For
example, pointing out a performance issue is not necessarily a verbal warning and may be part of the
regular feedback an employee receives. If managers judge that a progressive disciplinary process is
appropriate, they must clarify this to their team member and document the step.
Each step may be repeated instead of moving forward to the next step at HR or a manager’s discretion.
For example, a supervisor may choose to have more than one informal meeting with their employees
(step 2) before they ask HR to issue a formal reprimand (step 3.) Managers can make the decision to
repeat a step if they:
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●
●
●
Feel that the step was not properly executed the first time.
See signs of improvement in their employee and want to help them further.
Believe conditions or parameters change enough to make repeating the step necessary.
Explaining the steps
Step 1: When a manager or HR issues a verbal warning to an employee, they should do so privately.
When appropriate, they should provide that employee with a copy of the company policy they violated,
and explain our progressive discipline steps. Supervisors should provide employees with any coaching
or advice they need.
Employees have [two weeks] to correct their behavior before step 2 takes effect.
Step 2: A manager (or HR if appropriate) discusses corrective actions with an employee. Employees
should receive actionable feedback on how to deal with an unintentional violation. They can review
coaching or mentoring methods.
Employees have [a month] to correct their behavior before step 3 takes effect.
Step 3: Employees receive a formal written reprimand. HR should inform them that if they do not correct
their behavior within [one week], step 4 will take effect.
Step 4: Employees will be called in for a formal disciplinary meeting with HR, their Department Head
and/or their supervisor. They will have the chance to explain their side and HR is obliged to investigate.
HR must clarify that this is the final step before an employee is penalized.
Employees must correct their behavior immediately, or step 5 takes effect.
Step 5: This step encompasses any penalties that employees will receive. This usually includes
detraction of certain perks and benefits (as long as they are not mandatory by law.) It may also include
suspension without pay or demotion for serious offenses. We will still provide counseling in this stage if
appropriate (e.g. minor cases of substance abuse.) We will apply this step uniformly and fairly. It will not
result in adverse impact for protected groups.
Employees must correct their behavior within [one month] before step 6 takes effect.
Step 6: Employees who continue to violate our policies, either voluntarily or involuntarily, by this stage
will be terminated. This step will follow an official investigation by HR (or legal authorities when
appropriate) to ensure that terminating an employee is fair. A termination for cause will refer to
employees who were guilty of severe violations or felonies.
How to invoke progressive discipline
The progressive discipline process may begin from a different step, according to the severity of an
employee’s misconduct:
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Performance issues. Procedure starts at stage 1. Examples are:
●
●
●
Absenteeism.
Disregarding deadlines.
Lack of knowledge of Health & Safety standards.
Minor offenses (one-time). Procedure starts at stage 1. Examples are:
●
●
On-the-job minor mistakes.
Breach of dress code or smoking policy.
Serious misconduct/ Repeating an offense for which a progressive discipline procedure already
took place. Procedure starts at stage 3. Examples are:
●
●
●
On-the-job major mistakes.
Rudeness to customers or partners.
Unwillingness to follow Health & Safety standards
Severe violations. Procedure starts at stage 5. Examples are:
●
●
●
Substance abuse.
Offensive behavior.
Retaliation against an employee.
Illegal behavior. Procedure starts at step 6. Examples are:
●
●
●
●
Corruption/ Bribery.
Sexual Harassment.
Workplace Violence.
Embezzlement/Fraud.
HR/Department Heads can skip any of the steps if they believe they are obsolete. For example, if an
employee has received several formal reprimands for the same offense, HR may choose to terminate
them directly. Or an employee may be directly suspended for a short period as a punishment.
This policy is meant to provide general guidelines. Our company reserves the right to treat
circumstances in a different way from that described in this policy. But, we are always obliged to act
fairly and lawfully and document every stage of the progressive discipline process.
Right to appeal
Employees who were not terminated for cause or were not found guilty for illegal behavior may file an
appeal. For example, if an employee thinks they were demoted unfairly, they can bring this issue to the
attention of HR. HR will evaluate the situation and may organize a hearing.
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Preventing progressive discipline
Disciplining an employee is never a pleasant task. For the sake of everyone involved, we will take
actions to prevent the need for disciplinary action. We will:
●
●
●
●
●
●
Communicate our policies and Code of Conduct clearly to all new hires.
Announce any revisions or changes in our policies to all our employees in a formal manner (e.g.
bulletins, newsletters.)
Use frequent employee performance meetings to address issues before they become problems.
Train managers to communicate, enforce and abide by policies.
Train employees in certain policies and procedures.
Establish a culture of respect and collaboration.
Disclaimer: This policy template is meant to provide general guidelines and should be used
as a reference. It may not take into account all relevant local, state or federal laws and is not
a legal document. Neither the author nor Workable will assume any legal liability that may
arise from the use of this policy.
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Company social media policy for employees
This sample Employee Social Media Policy is a good starting point for fleshing out your own policy for
use of social media in the workplace by your employees.
What is a corporate social media policy?
Most of your employees are likely to use one or more social platforms. Whatever they post on their
personal accounts can be a potential risk for your company (e.g. if they share sensitive information).
And, more importantly, using social media at work can affect productivity and focus. This is one of the
reasons you need a company social media policy – to address limitations on what employees can post
and to potentially place restrictions on social media use inside the workplace.
The other reason is your own social media profile; as an organization, you’ll want to have a consistent
voice on your social media and want to avoid posting potentially risky statements or information. A social
media policy for employees can give them the instructions they need to know how to handle corporate
accounts.
How restrictive should my company social media policy be?
Your employees own their social media profiles, so what they post there can’t be restricted by your
organization. You can, however, provide them with reasonable guidelines about what they shouldn’t post
about (e.g. confidential data) and provide any potential disciplinary actions if their posts affect your
company’s image (e.g. hate speech). As far as your own company’s social media accounts are
concerned, you’re entitled to set the rules of posting.
How do I distribute it?
Your social media policy should be part of your employee handbook or live inside your policy database
(e.g. in your HRIS). Make sure all employees have read it, especially those in your social media team.
Of course, remember that this policy is a living document – this is because the social media landscape
changes often, new rules and regulations about privacy are introduced and trends can also play a part
(e.g. the #metoo movement). Make sure you keep up-to-date with changes and think about whether
your company social media policy might need some revamping.
Here’s a simple social media policy template to get you started with the essentials:
Policy brief & purpose
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Our social media company policy provides a framework for using social media. Social media is a
place where people exchange information, opinions and experiences to learn, develop and have fun.
Whether you’re handling a corporate account or using one of your own, you should remain productive
and avoid damaging our organization in any way. This policy provides practical advice to avoid issues
that might arise by careless use of social media in the workplace.
Scope
We expect all our employees to follow this policy.
Also, by “social media”, we refer to a variety of online communities like blogs, social networks, chat
rooms and forums – not just platforms like Facebook or Twitter.
This policy is built around two different elements: one, using personal social media at work and two,
representing our company through social media.
Policy elements
Using personal social media
We [allow] our employees to access their personal accounts at work. But, we expect you to act
responsibly and ensure your productivity isn't affected.
Whether you’re using your accounts for business or personal purposes, you may easily get sidetracked
by the vast amount of available content. So, please restrict your use to a few minutes per work day.
We ask you to be careful when posting on social media, too. We can’t restrict what you post there, but
we expect you to adhere to our confidentiality policies at all times. We also caution you to avoid violating
our anti-harassment policies or posting something that might make your collaboration with your
colleagues more difficult (e.g. hate speech against groups where colleagues belong to). In general,
please:
We advise our employees to:
●
●
●
Ensure others know that your personal account or statements don’t represent our
company. You shouldn’t state or imply that your personal opinions and content are authorized or
endorsed by our company. We advise using a disclaimer such as “opinions are my own” to avoid
misunderstandings.
Avoid sharing intellectual property like trademarks on a personal account without approval.
Confidentiality policies and laws always apply.
Avoid any defamatory, offensive or derogatory content. It may be considered as a violation
of our company’s anti-harassment policy, if directed towards colleagues, clients or partners.
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Representing our company
Some employees represent our company by handling corporate social media accounts or speak on our
company’s behalf. When you’re sitting behind a corporate social media account, we expect you to act
carefully and responsibly to protect our company’s image and reputation. You should:
●
●
●
●
●
●
●
Be respectful, polite and patient, when engaging in conversations on our company's behalf.
You should be extra careful when making declarations or promises towards customers and
stakeholders.
Avoid speaking on matters outside your field of expertise when possible. Everyone should
be careful not to answer questions or make statements that fall under somebody else’s
responsibility.
Follow our confidentiality policy and data protection policy and observe laws on copyright,
trademarks, plagiarism and fair use.
Inform our [PR/Marketing department] when you're about to share any major-impact content.
Avoid deleting or ignoring comments for no reason. They should listen and reply to criticism.
Never post discriminatory, offensive or libelous content and commentary.
Correct or remove any misleading or false content as quickly as possible.
Disciplinary Consequences
We'll monitor all social media postings on our corporate account.
We may have to take disciplinary action leading up to and including termination if employees do not
follow this policy's guidelines. Examples of non-conformity with the employee social media policy include
but are not limited to:
●
●
●
Disregarding job responsibilities and deadlines to use social media at work.
Disclosing confidential information through personal or corporate accounts.
Directing offensive comments towards other members of the online community.
If you violate this policy inadvertently, you may receive a reprimand. We expect you to comply after that,
or stricter disciplinary actions will apply.
Disclaimer: This policy template is meant to provide general guidelines and should be used
as a reference. It may not take into account all relevant local, state or federal laws and is not
a legal document. Neither the author nor Workable will assume any legal liability that may
arise from the use of this policy.
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DOCUMENT NAME: Contractor Management Policy
Contractor Management Policy
Purpose
Skillset Limited (‘Skillset’) acknowledges its legal duty to ensure, so far as is reasonably
practicable, that Workers and other persons at the workplace are not exposed to risks arising from
the business or undertaking. Skillset aims to eliminate the risks, or if that is not reasonably
practicable, minimise the risks so far as is reasonably practicable.
Workers also have responsibilities in connection with managing risks. Workers must comply with this
policy as amended from time to time and any relevant Code of Practice, relevant regulation and/or
State or Territory Codes of Practice, as amended from time to time.
With these duties in mind, this policy endeavours to outline appropriate risk control measures that
must be implemented at work by both Skillset and, where appropriate, Workers.
Commencement of Policy
This Policy will commence from 01/05/2017. It replaces all other Contractor Management policies of
Skillset (whether written or not).
Application of Policy
This Policy applies to workers (employees, agents, contractors (including temporary contractors as
otherwise defined under WHS legislation) of Skillset, collectively referred to in this policy as workers.
This Policy is not limited to the workplace or work hours. This Policy extends to all functions and
places that are work related. For example, work lunches, conferences, Christmas parties and client
functions.
DEFINITION
A contractor is a person, other than an employee, who is engaged to perform work at a workplace
(e.g. a plumber, a carpenter, an electrician, etc).
CONTRACTOR MANAGEMENT
Under the WHS Act 2011, a contractor will be a worker and will now owe the same duties as any
other worker if they are carrying out work in any capacity for a Person Conducting a Business or
Undertaking (PCBU).
A PCBU will owe duties to ensure the health and safety of all workers at work in the business or
undertaking:
a) who are engaged, or caused to be engaged by the PCBU
b) whose activities in carrying out work are influenced or directed by the PCBU.
Page 1 of 2
CONTROLLED DOCUMENT – Printed copies uncontrolled
Version #01
st
Release Date: 1 May 2017
Authorised by: Craig Randazzo
st
Review Date: 1 May 2018
Position: Chief Executive Officer – Skillset
DOCUMENT NAME: Contractor Management Policy
Through implementation of the Contractor Pre-qualification procedure, Skillset is committed to
ensuring that all contractors engaged to perform work at any site will meet the necessary health and
safety requirements while the work is being performed.
Breach of this Policy
All Workers must comply with this Policy at all times. If a Workers breaches this Policy, they may be
subjected to disciplinary action including termination of employment. Agents and contractors
(including sub-contractors and temporary contractors) may have their contracts with Skillset
terminated or not renewed.
Variations
Skillset reserves the right to vary, replace or terminate this policy from time to time.
Associated documents:

Contractor Management Procedure

Workplace WHS Inspection Procedure
Page 2 of 2
CONTROLLED DOCUMENT – Printed copies uncontrolled
Version #01
st
Release Date: 1 May 2017
Authorised by: Craig Randazzo
st
Review Date: 1 May 2018
Position: Chief Executive Officer – Skillset
Company data protection policy
This Company Data Protection Policy template is ready to be tailored to your company’s needs and
should be considered a starting point for setting up your employment policies.
Policy brief & purpose
Our Company Data Protection Policy refers to our commitment to treat information of employees,
customers, stakeholders and other interested parties with the utmost care and confidentiality.
With this policy, we ensure that we gather, store and handle data fairly, transparently and with respect
towards individual rights.
Scope
This policy refers to all parties (employees, job candidates, customers, suppliers etc.) who provide any
amount of information to us.
Who is covered under the Data Protection Policy?
Employees of our company and its subsidiaries must follow this policy. Contractors, consultants,
partners and any other external entity are also covered. Generally, our policy refers to anyone we
collaborate with or acts on our behalf and may need occasional access to data.
Policy elements
As part of our operations, we need to obtain and process information. This information includes any
offline or online data that makes a person identifiable such as names, addresses, usernames and
passwords, digital footprints, photographs, social security numbers, financial data etc.
Our company collects this information in a transparent way and only with the full cooperation and
knowledge of interested parties. Once this information is available to us, the following rules apply.
Our data will be:
●
●
●
●
Accurate and kept up-to-date
Collected fairly and for lawful purposes only
Processed by the company within its legal and moral boundaries
Protected against any unauthorized or illegal access by internal or external parties
Our data will not be:
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●
●
●
●
Communicated informally
Stored for more than a specified amount of time
Transferred to organizations, states or countries that do not have adequate data protection
policies
Distributed to any party other than the ones agreed upon by the data's owner (exempting
legitimate requests from law enforcement authorities)
In addition to ways of handling the data the company has direct obligations towards people to whom the
data belongs. Specifically we must:
●
●
●
●
●
Let people know which of their data is collected
Inform people about how we'll process their data
Inform people about who has access to their information
Have provisions in cases of lost, corrupted or compromised data
Allow people to request that we modify, erase, reduce or correct data contained in our databases
Actions
To exercise data protection we're committed to:
●
●
●
●
●
●
●
Restrict and monitor access to sensitive data
Develop transparent data collection procedures
Train employees in online privacy and security measures
Build secure networks to protect online data from cyberattacks
Establish clear procedures for reporting privacy breaches or data misuse
Include contract clauses or communicate statements on how we handle data
Establish data protection practices (document shredding, secure locks, data encryption, frequent
backups, access authorization etc.)
Our data protection provisions will appear on our website.
Disciplinary Consequences
All principles described in this policy must be strictly followed. A breach of data protection guidelines will
invoke disciplinary and possibly legal action.
Disclaimer: This policy template is meant to provide general guidelines and should be used
as a reference. It may not take into account all relevant local, state or federal laws and is not
a legal document. Neither the author nor Workable will assume any legal liability that may
arise from the use of this policy.
Improve your hiring with Workable - get started with a product tour or a 15-day free trial.
Further reading:
●
●
Data Protection Act of 1998 (UK)
Data protection in United States
Improve your hiring with Workable - get started with a product tour or a 15-day free trial.
Pearson Quality Nominee Resource
Template for policy and procedure review log
Author: VQA Team
Approver: VQA Team
Page 1 of 3
DCL1 – Public
Version 1.1
Date: 26.11.20
This document is intended to provide a template that may be used to capture an overview of all
policies and procedures within a centre
This QN support resource is an example template and its use is not required by Pearson. It has been developed by
the Pearson Vocational Quality Advisors in response to feedback from our Quality Nominee community to be used
solely as support material
Template for policy and procedure review log
Author: VQA Team
Approver: VQA Team
Page 2 of 3
DCL1 – Public
Version 1.1
Date: 26.11.20
Name of Policy
Author: VQA Team
Approver: VQA Team
Version No
Page 3 of 3
DCL1 – Public
Approved to Date
Planned Review Date
Version 1.1
Date: 26.11.20
This Reference Sheet has been developed to complement the Queensland Government Information Standards.
The information contained in this document may be used as additional reference material by Queensland
Government agencies when managing the use of ICT facilities and devices. Agencies should consider the
information provided as reference material and interpret it in the context of their own agency methodologies.
Example Template - Use of ICT Facilities & Devices Policy
1.
PURPOSE
[A general statement emphasising the effective use of the internet and email as business,
communication and education tools]
2.
SCOPE
[Outlines the users and ICT facilities and devices covered by the policy]
3.
LEGAL REQUIREMENTS
[Outlines the relevant legal and statutory compliance requirements].
4.
POLICY STATEMENT
[States the agency’s overall policy in the use of ICT facilities and devices and aligns with
IS38, Cabinet endorsed Policy & Principles Statement and approved Code of Conduct].
5.
SECURITY
[This section should refer to the agency’s security policies which specifically relate to the use
of ICT facilities and devices and highlights specific issues, eg, information classification and
control. Internet and email restrictions should also be reiterated, eg, mailbox size limits]
6.
ACCESS TO ICT F ACILITIES AND D EVICES
[Clearly defines issues surrounding access to the agency’s ICT facilities and devices
including who has access to what]
Page 1 of 2
Example Template for the Use of ICT Facilities and Devices Policy
7.
AUTHORISED AND UNAUTHORISED U SE
[Clearly articulate what activities will be considered authorised and unauthorised, including
examples of such activities]
8.
INTERNET AND EMAIL USE
[Covers etiquette and best practice for Internet and email use]
9.
OWNERSHIP OF MATERIAL
[Outlines that documents, messages, email and correspondence created, received or stored
using the agency’s ICT facilities and devices, are at all times, the property of the agency]
10.
RESPONSIBILITIES AND OBLIGATIONS
[Outlines both agency and employee responsibilities and obligations when using ICT facilities
and devices]
11.
TRAINING
[Outlines how the agency will address training of employees in the use of ICT facilities and
devices. A sample acknowledgement form is attached]
12.
MONITORING
13.
EXTERNAL EMAIL MONITORING
[States the agency’s processes and objectives for monitoring ICT facilities and devices]
14.
DISCIPLINARY PROCEDURES
[Clearly identify disciplinary procedures to deal with unlawful or criminal use of ICT facilities
and devices, indicate that employees have a right of appeal in relation to an agency
undertaking disciplinary action and outlines penalties for misuse]
Page 2 of 2
SAMPLE NPO
Fiscal Policies & Procedures
Approved by the Board of Directors, DATE
SAMPLE NPO Fiscal Policies & Procedures
Table of Contents
Accounting Procedures ................................................................................................... 1
Basis of Accounting ......................................................................................................................................................... 1
Journal Entries ................................................................................................................................................................... 1
Bank Reconciliations ...................................................................................................................................................... 1
Monthly Close ..................................................................................................................................................................... 2
Recordkeeping ................................................................................................................................................................... 2
Internal Controls ............................................................................................................. 2
Lines of Authority............................................................................................................................................................. 2
Conflict of Interest ........................................................................................................................................................... 2
Segregation of Duties...................................................................................................................................................... 3
Physical Security ............................................................................................................................................................... 3
Financial Planning & Reporting ....................................................................................... 3
Budgeting Process ............................................................................................................................................................ 3
Internal Financial Reports ........................................................................................................................................... 4
Audit ........................................................................................................................................................................................ 4
Tax Compliance ................................................................................................................................................................. 4
Exempt Organization Returns ............................................................................................................................... 4
Quarterly/Annual Payroll Reports ...................................................................................................................... 5
Revenue & Accounts Receivable ..................................................................................... 5
Invoice Preparation ......................................................................................................................................................... 5
Revenue Recognition ...................................................................................................................................................... 5
Cash Receipts ...................................................................................................................................................................... 6
Deposits ................................................................................................................................................................................. 6
Expense & Accounts Payable .......................................................................................... 6
Payroll .................................................................................................................................................................................... 6
Time Sheet Preparation & Approval ................................................................................................................... 6
Payroll Additions, Deletions, and Changes ....................................................................................................... 6
Payroll Preparation & Approval ........................................................................................................................... 7
Pay Upon Termination .............................................................................................................................................. 7
Purchases & Procurement ........................................................................................................................................... 7
Independent Contractors ............................................................................................................................................. 7
Invoice Approval & Processing ................................................................................................................................. 7
Cash Disbursements........................................................................................................................................................ 8
Petty Cash ............................................................................................................................................................................. 8
Employee Expense Reimbursements ..................................................................................................................... 8
Travel Expenses ............................................................................................................................................................ 8
Credit Cards .................................................................................................................................................................... 9
Expense Allocations ........................................................................................................................................................ 9
Asset Management ......................................................................................................... 9
Cash Management and Investments ....................................................................................................................... 9
Capital Equipment............................................................................................................................................................ 9
Employee Retirement Accounts ............................................................................................................................... 9
Operating Reserve............................................................................................................................................................ 9
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE
Accounting Procedures
This section covers basic accounting procedures for the organization. The accounting procedures
used by the organization shall conform to Generally Accepted Accounting Principles (GAAP) to
ensure accuracy of information and compliance with external standards.
Basis of Accounting
SAMPLE Policy: The organization uses the accrual basis of accounting. The accrual basis is the
method of accounting whereby revenue and expenses are identified with specific periods of
time, such as a month or year, and are recorded as incurred. This method of recording revenue
and expenses is without regard to date of receipt or payment of cash.
SAMPLE Procedures:
 Throughout the fiscal year, expenses are accrued into the month in which they are incurred.
The books are closed no later than the [DAY/WEEK] after the close of the month. Invoices
received after closing the books will be counted as a current-month expense.
 At the close of the fiscal year, this rule is not enforced. All expenses that should be accrued
into the prior fiscal year, are so accrued, in order to ensure that year-end financial
statements reflect all expenses incurred during the fiscal year. Year-end books are closed no
later than 90 days after the end of the fiscal year.
 Revenue is always recorded in the month in which it was earned or pledged.
Journal Entries
Policy:
Procedures:
 Procedure A
 Procedure B
Bank Reconciliations
SAMPLE Policy: All bank statements will be opened and reviewed in a timely manner. Bank
reconciliation and approval will occur within 30 days of the close of the month.
SAMPLE Procedures:
 All bank statements and cancelled checks will be opened, reviewed and initialed
by the Director of Operations upon receipt.
 Once reviewed, bank statements are submitted to the Office Manager for reconciliation.
 The Executive Director will review and approve reconciliation reports by signing and dating
the report in the upper right hand corner.
Fiscal Policies & Procedures
Page | 1
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE
Monthly Close
Policy:
Procedures:
 Procedure A
 Procedure B
Recordkeeping
Policy:
Procedures:
 Procedure A
 Procedure B
Internal Controls
The organization employs several safeguards to ensure that financial transactions are properly
authorized, appropriated, executed and recorded.
Lines of Authority
Policy:
Procedures:
 Procedure A
 Procedure B
Conflict of Interest
SAMPLE Policy: All employees and members of the Board of Directors are expected to use good
judgment, to adhere to high ethical standards, and to act in such a manner as to avoid any
actual or potential conflict of interest. A conflict of interest occurs when the personal,
professional, or business interests of an employee or Board member conflict with the interests
of the organization. Both the fact and the appearance of a conflict of interest should be avoided.
SAMPLE Procedures:
 Upon or before hire, election, or appointment each employee and Board member must
provide a full written disclosure of all direct or indirect financial interests that could
potentially result in a conflict of interest. Examples include employer, business, and other
nonprofit affiliations, and those of family members or a significant other. This written
disclosure will be kept on file and will be updated annually and as needed.
Fiscal Policies & Procedures
Page | 2
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE


Employees and Board members must disclose any interests in a proposed transaction or
decision that may create a conflict of interest. After disclosure, the employee or Board
member will not be permitted to participate in the transaction or decision.
Should there be any dispute as to whether a conflict of interest exists:
o The Executive Director shall determine whether a conflict of interest exists for
an employee, and shall determine the appropriate response.
o The Board of Directors shall determine whether a conflict of interest exists for
the Executive Director or a member of the Board, and shall determine the
appropriate response.
Segregation of Duties
SAMPLE Policy: The organization’s financial duties are distributed among multiple people to
help ensure protection from fraud and error. The distribution of duties aims for maximum
protection of the organization’s assets while also considering efficiency of operations.
Procedures:
 Procedure A
 Procedure B
Physical Security
SAMPLE Policy: The organization maintains physical security of its assets to ensure that only
people who are authorized have physical or indirect access to money, securities, real estate and
other valuable property.
Procedures:
 Procedure A
 Procedure B
Financial Planning & Reporting
The organization’s financial statements are prepared in accordance with Generally Accepted
Accounting Principles (GAAP). The presentation of the Financial Statements shall follow the
recommendation of the Financial Accounting Standards Board (FASB) No. 117, “Financial
Statements of Not-For-Profit Organizations.” Under GAAP, revenues are classified based on the
existence or absence of donor-imposed restrictions. Accordingly, the net assets of the
organization are classified as unrestricted, temporarily restricted and permanently restricted.
Budgeting Process
SAMPLE Policy: The organization’s annual budget is prepared and approved annually for all
departments. The budget is prepared by the Executive Director in conjunction with the Director
of Operations and the Board Finance Committee. The budget is to be approved by the Board of
Directors prior to the start of each fiscal year. The budget is revised during the year only if
approved by the Board of Directors.
Fiscal Policies & Procedures
Page | 3
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE
SAMPLE Procedures:
 The Executive Director will work together with the Director of Operations, Director of
Development, and all program managers to ensure that the annual budget is an accurate
reflection of programmatic and infrastructure goals for the coming year.
 The Director of Operations will ensure that the budget is developed using the organization’s
standard revenue recognition (p. X) and cost allocation (p. X) procedures.
 The Executive Director, Director of Operations, and the Board Treasurer will present a draft
budget to the Finance Committee at least 60 days prior to the end of the fiscal year and at
least 30 days prior to its submission to the full Board of Directors.
 The Finance Committee shall review and approve a recommended fiscal year budget and
submit it for approval to the Board of Directors. The budget shall contain revenues and
expenses forecasted by month. A chart describing monthly cash flow shall be included.
 The Board of Directors will review and approve the budget at its last meeting prior to the
start of the fiscal year.
Internal Financial Reports
SAMPLE Policy: The organization prepares regular financial reports on a monthly basis. All
reports are finalized no later than 30 days after the close of the prior month.
SAMPLE Procedures:
 The Finance Manager is responsible for producing the following year-to-date reports within
30 days of the end of each month: Statement of Financial Position, Statement of Activities,
Budget v. Actual and updated Cash Flow Projection.
 The Executive Director, Director of Operations, and Board Finance Committee review
financial reports each month, and the Finance Committee presents reports to the full Board
of Directors on a quarterly basis.
 On a quarterly basis, the Director of Operations prepares a narrative report that summarizes
the organization’s current financial position and includes explanations for budget variance.
Audit
Policy:
Procedures:
 Procedure A
 Procedure B
Tax Compliance
Exempt Organization Returns
Policy:
Procedures:
 Procedure A
 Procedure B
Fiscal Policies & Procedures
Page | 4
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE
Quarterly/Annual Payroll Reports
Policy:
Procedures:
 Procedure A
 Procedure B
Revenue & Accounts Receivable
Invoice Preparation
SAMPLE Policy: All grants and projects are invoiced each month to capture all billable time and
expenses and ensure a regular healthy cash flow for the organization. All final invoices for the
prior month are completed by the 15th of the following month (ex: June 15th for May).
SAMPLE Procedures:
 The Finance Manager gathers relevant expense documentation, prepares all invoices, and
submits to the Director of Operations for approval by the 10th of each month.
 Following approval, the Finance Manager makes two copies of the invoice. One copy is
mailed to the client/customer no later than the 15th of the month and one copy is filed in
the client folder.
 As part of the monthly close process, the Finance Manager reviews an Accounts Receivable
Aging report and alerts the Director of Operations of invoices more than 60 days overdue.
 The Director of Operations determines appropriate collection efforts for long outstanding
invoices. The Executive Director is also notified of any receivables that are more than XX
days outstanding and/or more than $XX.
Revenue Recognition
SAMPLE Policy: All contributions will be recorded in accordance with GAAP, with specific
attention to standards FASB 116 and 117. Contributions are recorded as pledged or received in
accordance with FASB 116, and must be credited to the appropriate revenue lines as presented
in the annual budget and coded as designated in the organization’s Chart of Accounts.
SAMPLE Procedures:
 The Director of Operations reviews all revenue in excess of $5,000 and indicates on the
letter or copy of the check how the revenue shall be recognized (as earned/contributed,
conditional/unconditional and restricted/unrestricted). If there is a question or uncertainty
about how to recognize a particular contribution, the Director of Operations will ensure that
the donor is contacted to clarify the intent of the contribution.
 The Finance Manager is responsible for posting revenue to the general ledger in accordance
with the determination made by the Director of Operations.
Fiscal Policies & Procedures
Page | 5
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE
Cash Receipts
Policy:
Procedures:
 Procedure A
 Procedure B
Deposits
Policy:
Procedures:
 Procedure A
 Procedure B
Expense & Accounts Payable
Payroll
Policy:
Procedures:
 Procedure A
 Procedure B
Time Sheet Preparation & Approval
SAMPLE Policy: All employees, exempt and non-exempt, are required to record time worked,
holidays, leave taken for payroll, benefits tracking, and cost allocation purposes
SAMPLE Procedures:
 Employees complete time sheets and submit them to their supervisors on the due date,
based on the schedule produced at the beginning of the year.
 Supervisors review, correct if necessary, sign and submit timesheets to the Finance Manager
within three (3) working days from the time sheet due date.
 The Finance Manager is responsible for entering time sheet information into the payroll and
accounting systems as needed. All paid time off balances are maintained within the payroll
system, based on the information provided on approved timesheets.
Payroll Additions, Deletions, and Changes
Policy:
Procedures:
 Procedure A
Fiscal Policies & Procedures
Page | 6
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE
Payroll Preparation & Approval
Policy:
Procedures:
 Procedure A
 Procedure B
Pay Upon Termination
Policy:
Procedures:
 Procedure A
 Procedure B
Purchases & Procurement
SAMPLE Policy: Any expenditure in excess of $XXX for the purchase of a single item should have
bids from three (3) suppliers if possible. These bids will be reviewed by the Director of
Operations and the bid award must be specifically approved in advance by the Executive
Director and Director of Operations.
Procedures:
 Procedure A
 Procedure B
Independent Contractors
Policy:
Procedures:
 Procedure A
 Procedure B
Invoice Approval & Processing
SAMPLE Policy: All invoices must be approved by the manager of the department for which the
expense was incurred. Approved invoices will be paid within 30 days of receipt.
SAMPLE Procedures:
 Invoices and bills will be opened and reviewed by the Office Manger. The Executive Director
or Director of Operations will be notified immediately of any unexpected or unauthorized
expenses.
 Invoices are then routed to the appropriate department manager for authorization prior to
payment being issued. If the expense is greater than $300 and was not authorized through
Fiscal Policies & Procedures
Page | 7
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE

the purchase order system, either the Executive Director or Director of Operations must also
approve the expenditure.
Copies of all invoices paid will be filed in the finance department. After two years these
documents will be archived and they will not be destroyed.
Cash Disbursements
Policy:
Procedures:
 Procedure A
 Procedure B
Petty Cash
SAMPLE Policy: The Project Coordinator and the Office Manager will each keep a petty cash box
not to exceed $100. Petty cash will be used primarily to purchase office supplies, snacks,
delivery tips etc. Petty cash will be kept in a lockbox that is locked in a cabinet. Keys to the cash
box and cabinet should be kept on the custodian’s person.
SAMPLE Procedures:
 The petty cash custodians will be given $100 to be kept in a lock box locked in their desk.
 When cash is used a record must be entered in the individual’s petty cash spreadsheet.
Receipts for all purchases are kept in the lock box.
 When cash is low the custodian will submit a check request form signed by their supervisor
with a print out of the tracking spreadsheet and all receipts attached.
 A check will be cut in the amount to bring petty cash back to $100. It is the custodian’s
responsibility to cash the check and keep track of funds in the box.
Employee Expense Reimbursements
Policy:
Procedures:
 Procedure A
 Procedure B
Travel Expenses
Policy:
Procedures:
 Procedure A
 Procedure B
Fiscal Policies & Procedures
Page | 8
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE
Credit Cards
Policy:
Procedures:
 Procedure A
 Procedure B
Expense Allocations
Policy:
Procedures:
 Procedure A
 Procedure B
Asset Management
Cash Management and Investments
Policy:
Procedures:
 Procedure A
 Procedure B
Capital Equipment
Policy:
Procedures:
 Procedure A
 Procedure B
Employee Retirement Accounts
Policy:
Procedures:
 Procedure A
 Procedure B
Operating Reserve
SAMPLE Policy: The target minimum operating reserve fund for the organization is three (3)
months of average operating costs. The calculation of average monthly operating costs includes
Fiscal Policies & Procedures
Page | 9
SAMPLE NPO FISCAL POLICIES AND PROCEDURES
Approved by the Board of Directors, DATE
all recurring, predictable expenses such as salaries and benefits, occupancy, office, travel,
program, and ongoing professional services.
SAMPLE Procedures:
 The amount of the operating reserve will be calculated each year after approval of the
annual budget, reported to the Finance Committee and Board of Directors, and included
in regular financial reports.
 The operating reserve will be funded with surplus unrestricted operating funds. The
Board of Directors may from time to time direct that a specific source of revenue be set
aside for operating reserves. Examples may include one-time gifts or bequests, special
grants, or special appeals.
 To use the operating reserves, the Executive Director will submit a request to the
Finance Committee of the Board of Directors. The request will include the analysis and
determination of the use of funds and plans for replenishment. The organization’s goal
is to replenish the funds used within twelve (12) months to restore the operating
reserve fund to the target minimum amount.
Fiscal Policies & Procedures
Page | 10
Work health policy template
How to use the policy template
1. Read stage one of the work health planning guide: Management commitment.
2. After your management has endorsed the health and wellbeing program, use this
as a template for your policy or statement.
3. This should outline your organisation’s vision for improving employee health and
wellbeing.
Note: This policy template can be branded, changed or manipulated to cater for the
individual needs of your organisation.
Add business logo and/or
contact details here
Work health and wellbeing policy
1. Policy statement
[Insert company/workplace name] will ensure that all work practices, the work
environment and the workplace culture will value, enhance and protect the health
and wellbeing of all employees.
2. Scope
This workplace health and wellbeing policy outlines how [Insert company/workplace
name] will support the health and wellbeing of all employees. The policy is applicable
to all [Insert company/workplace name] employees and aligns with other relevant
health and safety policies and guidelines.
3. Goals and objectives
This workplace health and wellbeing policy provides the foundation for developing
activities and modifying work environments, policies and practices that support the
health and wellbeing of all employees. Positive benefits are also likely to extend
beyond employees to result in better health for families and the community.
[Insert company/workplace name] will enhance workplace health and wellbeing by:
 establishing and supporting a workplace health and wellbeing committee
 creating and supporting a workplace health and wellbeing program
 consulting with employees to ensure workplace health and wellbeing strategies
meet the needs of the workforce
 supporting employee participation in health and wellbeing activities (including
allowing activities to be held on work premises outside of work hours)
 supporting employees to adopt and maintain healthy behaviours and decrease
unhealthy behaviours.
4. Responsibilities
Executive management team/management team
The [Insert company/workplace name] senior executives will do all they can to
enhance the health and wellbeing of employees by ensuring that the health of
employees is valued, workplace environments and systems are supportive of
employee health and wellbeing and employees have the opportunity to participate in
health and wellbeing activities.
[Insert company/workplace name] senior executives will participate in and encourage
employee participation in the health and wellbeing program and support and
contribute ideas, opinions and expertise to the work of the health and wellbeing
committee.
Human resources department
The [Insert company/workplace name] human resources department will do all it can
to enhance the health and wellbeing of employees by ensuring that the health of
employees is valued, workplace environments and systems are supportive of worker
health and wellbeing, and employees have the opportunity to participate in health
and wellbeing activities.
[Insert company/workplace name] human resources department will review, revise or
develop human resources policies that ensure consistency with this policy and
support for workplace health and wellbeing, in consultation with the health and
wellbeing committee and health and wellbeing coordinator.
Insert your version control information here
Add business logo and/or
contact details here
Workplace health and wellbeing committee
The [Insert company/workplace name] workplace health and wellbeing committee will
enhance workplace health and wellbeing by assessing needs, collaboratively
developing, implementing and evaluating health and wellbeing initiatives, and
facilitating long term cooperation and commitment to workplace health and wellbeing.
Employees
[Insert company/workplace name] employees will work within any procedures and
policies implemented to address workplace health and wellbeing, contribute ideas,
opinions and expertise to the workplace health and wellbeing committee and health
and wellbeing coordinator and participate in relevant initiatives.
5. Health and wellbeing activities
Health and wellbeing activities that contribute to the achievement of this policy’s aims
and objectives will be outlined within the collaboratively developed health and
wellbeing plan. The health and wellbeing plan identifies specific health and wellbeing
initiatives and their management.
6. Policy review
This workplace health and wellbeing policy will be reviewed annually by the health
and wellbeing committee and the health and wellbeing coordinator in conjunction with
the executive management team and human resources department.
*Ensure the review is properly signed off and dated by the relevant committee or
management representative.
Health and wellbeing committee chair signature:
Date:
Director signature:
Date:
CEO signature:
Date:
Acknowledgment
Content reproduced with permission of Queensland Health
Insert your version control information here
MAINTENANCE DEPARTMENT
POLICY AND PROCEDURES
I.
ORGANIZATION
A.
OBJECTIVES
1.
Directandcoordinatetheoperationsandactivitiesofthephysicalplantmaintenance,
includi
ngbutnotl
i
mi
t
edt
o: faci
l
i
t
i
esengineeringadministration,layout,design,and
constructi
on;equi
pmentmai
nt
enance;utilitiesoperationsandmaintenance;buildingandgrounds
maintenance;facilitiesprotectionandsecurity;departmentalsafety;andenvironmental
compliance.
2.
Provideengineeringconsultingservices,surveys,andrecommendationstoall
Department
s;t
oout
si
dearchi
t
ect
/
engineerfirmsperformingservicesforthefaci
lity;andt
o
PublicUtilities.
3.
Ensurecompl
i
ancewi
t
happlicablefederal,state,andlocallaws,regulations,stat
ut
es,and
codes;securingrequiredpermits;andcoordinatingwithappropriatelocalauthorities.
4.
Cont
ractwi
t
handoverseet
heactivitiesofvariouscontractorsandconsultantsfort
he
fulfillmentoffaci
l
i
tyengi
neeri
ngresponsibilities.
6
B.
FUNCTIONS
1.
ManagementResponsibility
1.
1
TheM ai
nt
enanceM anagershoul
dsetgoal
s,pl
an,organi
ze,andcont
rolt
heact
i
vi
t
i
es
underhisjuri
sdi
ct
i
on.
1.
2
Al
lgoal
sshoul
dbespeci
fi
c,welldefined,andquantifiable,withanestimatedtimeof
achi
evementgivenforeachgoal
.
1.
3
Eachgoalshoul
dbecommuni
cat
edfreelyandclearlyt
oal
lt
hosei
nvol
ved.
1.
4
Goal
sshoul
dberevi
ewedregul
arlybyt
heM ai
nt
enanceM anager,M ai
nt
enance
Supervi
sor,andoperat
i
onsrepresent
at
i
ves.
2.
Organi
zati
on
2.
1
PlantM ai
nt
enance,Engineering,OperationsandProductionmustshareresponsi
bi
l
i
tyi
n
acoordinatedeffortt
oopt
i
mi
zefaci
lityperformance.
2.
2
Pl
antmai
nt
enance,asaservi
cefunct
i
on,hasresponsi
bi
l
i
tyforsafe,effici
ent
,and
t
echni
cal
lysoundexecut
i
onofmai
nt
enancework.
2.
3
Engineeri
nghasresponsi
bi
l
i
tyforprovidingtechnicalinformation,guidance,andsupport
t
ooperat
i
onsandmai
nt
enanceaspartoft
heteam effort
.
2.
4
Operat
i
onsandProduct
i
on,asequi
pmentowners,haveaccount
abi
l
i
tyforthei
r
maintenancecosts.
3.
Admini
strati
on
AdministrativeoperationsoftheM aintenanceDepartmentinclude:
3.
1
Program coordi
nat
i
onfort
heDepart
mentandl
i
ai
sonwi
t
hal
lot
herDepart
ment
sfort
he
procurementandmai
nt
enanceofal
lrealproperty,product
i
onequi
pment
,ut
i
l
i
tyservi
ces,and
communicationservices.
3.
2
Preparat
i
onofM ai
nt
enanceDepart
mentbudget
s.Coordi
nat
i
onwi
t
hot
herDepart
ment
s
i
nt
hepreparat
i
onoft
hei
rmai
nt
enancebudget
s.
3.
3
Preparat
i
onofproj
ectcostestimates;proposal,justification,andmanagementofcapi
t
al
proj
ect
sandexpendi
t
ures.
3.
4
M ai
nt
enanceofrecordsofpl
annedandcurrentconst
ruct
i
onandmai
nt
enancecont
ract
s.
7
10.
6
Designi
ng,speci
fying,i
nst
al
l
ing,andmaintainingallfireprotectionandsecuritysyst
ems.
10.
7
Assuri
ngcompl
i
ancewi
thallapplicablelifesafetyandbuildingcodesandregul
at
i
ons.
10.
8 Provi
si
onoffi
rst
-responsecapabi
l
i
tyforal
ll
i
fe-t
hreat
eni
ngandpropertyt
hreat
eni
ng
emergencies.
10.
9 M ai
nt
ai
ni
ngl
i
ai
sonwi
t
hl
ocalcommuni
tyemergency-responseandl
aw-enforcement
organi
zat
i
onsforassi
st
anceasrequi
red.
10.
10 Conduct
i
ngnecessarysecuri
tychecks,inspections,surveys,andinvestigationstoassure
thattherequiredstandardsofphysicalsecurityaremaintained.
11.
Uti
l
i
ti
esOperati
ons& EnergyManagement
UtilitiesoperationsandenergymanagementresponsibilitiesrequiredoftheM aintenance
Depart
menti
ncl
ude:
11.
1. Operat
i
onsandmai
nt
enanceofallutilitysystemsandequipmentinthefacility,
11.
2. Compl
et
i
onofoperat
i
ngl
ogs,report
s,andrecordsrequi
redbyfederal
,st
at
e,l
ocal
agencies,andthecompany,
11.
3. Compl
i
ancewi
t
hal
lappl
i
cablefederal,state,andlocalcodes,statutesand
regulati
ons,
11.
4. Liai
sonwi
t
hPubl
i
cUt
i
l
i
t
i
es,
11.
5. Procurementoffuel
sandenergy,
11.
6. Speci
fyi
ng,operat
i
ng,andmaintainingbackuputilitysystems.
12.
Envi
ronmentalConcerns(SeeProgram inAppendix)
M aintainsetofstateandlocalqualitystandardsandcompanycompliancerequirements.Identify
andrecordequi
pmentmoni
t
oredandbreakdowns;monitoringdevices,reporting,andal
arms;
equi
pmentmai
nt
enance,repai
rs,repl
acementandreport
i
ng;andmoni
t
ori
ngdevicemai
nt
enance,
repai
rs,repl
acement
,andreport
i
ng.M ai
nt
ai
nrecordsoft
est
sandi
nspect
i
onsofdri
nki
ngwat
er
qual
i
tyandst
andards.IfonCi
tyW at
er,haveback-fl
ow prevent
i
onval
vestest
edeachyearand
maintainrecords.
13
D.
OVERTIME
1.
Overtimeshallbegovernedbycompanypolicy.
2.
Overtimemustbeauthorizedbytheemployee’simmediatesupervisor.
E.
VACATION/
TIME OFF
1.
Vacat
i
onandpersonaldaysshal
lbegovernedbythecompanypol
i
cy.
2.
Employeevacationsshallbescheduledsothattheabilitytoservicethecompany’s
requirementsi
snotundul
ydegraded.
3.
A blankvacat
i
onform shal
lbepostedintheshopsoemployeesmayindicatethei
r
desiredvacationtime.Incaseofconflicts,theM aintenanceSupervisorwillattempttomediatea
solutionthatmeetscompanyneedsandsatisfiestheaffectedemployees.
F.
APPRAISALS
1.
M ai
nt
enanceempl
oyeesshal
lbeapprai
sedbyt
heM ai
nt
enanceM anagerordesi
gnated
M ai
nt
enanceSupervi
soronanannualbasi
s.
2.
Eachempl
oyeeshal
lhavearunningevaluationofworkhabits,strengthsandskil
ll
evel
s,
aswel
l.
20
1.2
ShortTerm
Prepareandupdat
eafacil
i
tyandequi
pmentpl
anformai
nt
enance,overhaulsandrepl
acement
st
o
keeppacewithoutputcapabilitiesintothenearfuture.
1.3
LongTerm
Prepareandupdat
eapl
ant
oexpandfaci
l
i
t
i
esandequi
pmentt
omeeti
ncreasedproduct
i
on
requi
rement
s.Prepareapl
ant
ot
ot
al
lyrepl
aceequi
pmentwi
t
hnewerequipmentwhi
l
e
upgradingfacilities.
2.
CapitalProjects
M aintainallrecordsofeachCapitalProjectincludingplans,budgets,authorizations,contracts,
andcompletions,includingprojectsnotapprovedattimeofsubmittal.
2.1
Proposals
TheM ai
nt
enanceDepartmentwi
l
lundert
aket
oprepareCapi
t
alProj
ectProposal
satt
hedi
rect
i
on
ofthePl
antM anager.EachProposalwillbebasedonthedesiredoutcomeoftheScopeofW ork
andtheProj
ectEst
i
mat
eofcost
sforlabor,material,equipment,andsiteacquisitionand
preparat
i
on.
2.2
Estimati
ngcosts& time
CapitalProjectcostestimateswillbepreparedaftertheScopeofW orkhasbeenpreparedand
approvedbyconcerneddepart
mentheadsandt
hePl
antM anager.
2.3
Approval
s
Proj
ectproposalform wil
lbei
ni
t
i
at
edandci
rcul
atedforsignat
ureapprovalaft
ercompl
et
i
onof
t
heScopeofW ork,Est
i
mat
e,andProposalandwi
l
lbeaccompaniedbycopi
esoft
hesei
t
ems.
2.4
Biddi
ng
TheM ai
nt
enanceM anagerwi
l
li
ni
t
i
at
et
hebi
dprocessoncet
heproposalhasbeensi
gnedand
approvedbyal
lsignat
oriesandhasbeenal
l
ocat
edsuffi
ci
entcapi
t
alfundi
ngforproj
ect
compl
etion.
2.5
RequestForQuote
RequestForQuotewillbesenttoaselectedgroupofGeneralContractingCompanieswiththe
appropri
at
edocument
sforbi
ddi
ngont
heproject
.
26
(5)
UseCont
ract
or’sbesteffort
st
odi
sposeof,i
nt
hemanner,att
he
times,totheextent,andatthepriceorprices,directedor
aut
hori
zedbyOwner,anymat
eri
al
st
hathavenotbeen
i
ncorporat
edi
nt
heW ork(provi
dedt
hatt
heproceedsofanysuch
di
spositi
onshallbeappli
edinreductionofContractor’sout
-ofpocketcost
s),and
(6)
TransfertitleanddelivertoOwner,atthetimeandtotheextent
di
rect
edbyOwner,t
hefabri
cat
edorunfabricat
edpart
s,worki
n
progress,completedwork,supplies,andallothermaterials
producedasapartof,orrequi
redi
nt
heperformanceof,t
heW ork
t
ermi
nat
edbyt
henot
i
ceoft
ermi
nat
i
on,aswel
lasal
lcompl
et
ed
andpart
i
al
lycompl
et
edplans,drawi
ngs,i
nformat
ion,andot
her
propertyrelat
i
ngt
ot
heW ork.
b.
Ownermay,withoutcause,directContractor,inwriting,tosuspend,
del
ay,ori
nt
errupttheW orkinwholeorinpartforsuchperiodoft
i
meas
Ownermaydet
ermi
ne.Cont
ract
orshal
lfol
l
ow suchdi
rect
i
on.An
Adj
ust
mentshal
lbemadefori
ncreasesordecreasesi
nt
hecostof
performanceoft
heW orkandCont
ract
or’sot
herobl
i
gat
i
onsundert
he
Cont
ractDocuments(includingprofitonanyincreasedordecreasedcost
ofperformance)di
rect
lyresul
t
i
ngfrom anysuchsuspensi
on,del
ay,or
i
nt
errupt
i
on.Noadj
ust
mentshal
lbemade,however,t
ot
heext
ent
(1)performancei
s,orwas,orwoul
dhavebeen,sosuspended,del
ayed,or
i
nt
errupt
edbyanot
hercauseforwhi
chCont
ract
ori
sresponsi
bl
e,or
(2)Anequi
t
abl
eadj
ust
menti
smadeordeni
edunderanot
herprovi
si
onof
thisAgreement.
17.
eri
nganyareaonOwner’s
Passes;Owner’sRulesandRegulations: Beforeent
premi
seswhereOwner’srul
esandregulat
i
onsrequi
repasses,Cont
ract
orshal
l
obt
ai
nforal
li
t
sworkers(andfort
hoseofanyapprovedsubcont
ract
ors)
appropri
at
epassesfrom Owner.Contractoragreestofamiliarizeitsworkers(and
38
Ent
erPM W orkOrderi
ssuanceschedul
ei
nt
oCM M Swi
t
hcompl
i
ance/
non-compl
i
ancet
racki
ng
& report
i
ngori
ssuebyhandarrangedschedul
e.
PM W orkOrdersmustbeschedul
edandcompl
etedwi
t
ht
hesamepri
ori
tyasot
herworkorders.
Allwork,incl
udi
ngPM work,mustbeenteredintotheequipment’smachineryhistoryfi
l
e.
2.
Predi
cti
veMai
ntenancePlan
Predictivemaintenancetechniquesshallbeutilizedtoreduceequipmentfailureandreduce
maintenanceworkloadthroughtheabilitytoidentifyapproachingproblemsbytestsand
inspections.M ai
nt
enancemanhoursspentonthejobwillbereducedthroughpurchasinghigh
quali
tyequi
pmentwhi
chi
smai
nt
enancerepair/replacementfriendly.Initialequipment
purchasi
ngneedst
omoni
t
orandrevi
ew manyfactorsbeforepurchasi
ngoral
l
owi
ngt
he
contractortopurchaseequipment.Strictinitialspecificationswillcostmorebutsavemany
timesthecostoverthelifeoftheequipment.
Testi
ng& Inspecti
on
2.
1
VibrationLoggingProgram
Largerotatingequipmentandselectedsmallerequipmentwillbeincludedinthevibration
measurementprogram.Eachpi
eceofequipmentwillbecheckedandreadingsrecordedwi
t
h
timeanddate.Atdesignatedintervals,aPM W O (PreventiveM aintenanceW orkOrder)willbe
issuedtotakereadingsagain.Thesuccessivereadingswillshow apatternofwearovertime.
Outofnorm readi
ngswi
llcausearedfl
agandwarni
ngt
obei
ssuedt
ocheckt
heequi
pmenti
n
questi
on.
2.
2
Alignment
Alignmentreadingsonlargerotatingequipmentwillbetakenoninstallationandrecordedinthe
equipment’smachineryhistorynotes.Periodically,thealignmentcanberecheckedandthe
readingsrecordedandlogged.Ifapieceofequipmenthasbeenremovedandreinstalled,the
previousalignmentreadingswillmakethejobgofasterandmoreaccurately.
47
A procedureforrecordi
ngt
heuseofcurrentpartsandmaterialwillensurethatt
hecurrent
inventorywillremainmoreorlessrelevanttilltheinventorycanberelocatedtoastoreroom.
TheProjectM anager(PM )willneedtocheckequipmentmanualstodeterminealistofrequired
andcri
t
i
calsparesandmat
eri
alneededt
okeept
hepl
antrunni
ngeffi
ci
ent
lyonacosteffect
i
ve
basi
s.
Thisli
stcanbecomparedwi
t
hwhatisactuallyintheinventory.Seniormaintenanceand
productionempl
oyeescanbeconsul
tedonthemakeupofthefinallistofrequiredpartsand
mat
eri
al
.ThePM cansetupal
i
stofpreferredsuppl
i
ersandvendorsforthel
i
st
.Asmuchoft
he
mat
eri
alandsparesmaybehel
datt
hesuppl
i
erswarehouseandpurchasedasneeded.Thi
s
requi
resadegreeoft
rustandreci
proci
tybet
weentheCompanyandt
hesuppl
i
er.
TheCompanywi
l
ldevelopt
hel
i
stofpreferredsuppl
i
ersassuppl
i
erswhodel
i
veront
i
me,accept
ret
urns,openi
nt
henightforanemergency,andotherwi
seprovi
deexcel
l
entservi
ce.Inret
urn,
t
heCompanywi
l
lpurchasemostoft
hepart
sfrom t
hesepreferredsuppl
i
ers.Thenumberof
preferredsuppl
i
ersshoul
dbefai
rlysmal
l
,fourorfi
ve,foraCompanyoft
hreehundredt
ofi
ve
hundredempl
oyees.
TheM ai
nt
enanceDepartmentwi
l
lsetupandmai
nt
ai
nt
hel
i
stofpreferredsuppl
i
ersandvendors.
M ai
nt
enancewi
l
lprepareaformatforrat
i
ngt
hesesuppl
i
ersandal
soprepareaform for
i
nvest
i
gat
i
onofadefecti
nasuppl
i
er’sserviceorpart
s/
mat
eri
aldel
i
very.A si
gni
fi
cantdefector
afterseveraldefect
sandconsul
t
at
i
onswiththesupplierwithnoimprovementcouldresul
ti
nt
he
concernedsupplierbeingderatedfrom preferredsuppliertosupplierandreplacedbya
compet
i
t
orsupplyinggoodsi
nt
hesamearea.Thi
ssuppl
i
erwoul
dt
henbecomeoneoft
he
preferredsuppl
i
ers.
ThePM wi
l
ldevel
opal
ayoutfort
hest
orageoftheproposedi
nvent
oryofpart
sandmat
erial
deci
deduponi
nt
heconsul
t
at
i
onswi
t
ht
heconcerneddepart
mentalexpert
s.Thel
ayoutshoul
d
trytogrouppart
ssuchasel
ect
ri
cal
,instrument,electronic,bearings,motors,gears,gearboxes,
et
c.Ampl
eaccommodationsshoul
dbemadefortheaddi
t
i
onofmorepart
si
neachareaand
correspondi
nglymorepartassi
gnednumbersi
nt
hedat
abase.
55
2.
*
Vi
ol
at
i
ons
*
Correct
i
veAct
i
ons
HAZARDOUS MATERIAL & DISPOSAL
Al
lhazardousmat
eri
ali
nusemustbet
rackedfrom pl
antent
ryt
ofi
naldepart
ure.Depart
ure
i
ncl
udest
hroughwast
ewat
ervi
aCl
eani
ngInPl
ace(CIP),wast
eoi
l
,orhazardousmat
eri
al
di
sposal
.Nohazardousmat
eri
ali
st
obedi
scardedi
nt
ot
herecycl
ebi
nsorregul
arwast
eand
garbagebinsorcontai
ners.Nohazardouschemicals,oils,solvents,liquids,acids,causti
csor
cl
eani
ngwast
efrom usagei
st
obefl
ushedi
nt
ot
hepl
antsewersyst
em ort
hefl
oordrai
nwast
e
wat
ersystem ot
hert
hant
hatfrom CIP.Allaccidentalspillsanddischargesofhazardouswast
e
materialmustbereport
edt
ot
heSupervisorofthatareaimmediatelyandcontainment/cl
eanup
begunassoonassafelypossi
bl
e.Al
lcl
eanupwastei
st
obet
reat
edashazardouswast
e.
*
Agency
*
ComplianceRequirements
*
Report
s
*
Letters
*
Vi
ol
at
i
ons
*
Correct
i
veAct
i
ons
2.1.
MSDS ListandPosting
Hazardouschemi
cal
sandmat
eri
al
si
nusei
neachareaanddepart
mentwi
l
lbedi
scussedona
regul
arandcont
i
nui
ngbasi
sduri
ngnew empl
oyeeori
ent
at
i
onandregul
arsafetymeet
i
ngs.
2.2.
Storage
*
Hazardousmat
eri
alst
oragecont
ai
nersmustbeproperlylabel
edaccordi
ngt
oregulat
i
ons.
*
Nohazardousmat
eri
almayberemovedfrom itsoriginalcontainerandstoredor
t
ransport
edi
nanot
hercont
ai
nerunl
esst
hatcont
aineri
sspeci
fi
cal
lyapprovedandi
dent
i
fi
edfor
t
hehazardousmat
eri
al
.
*
Eachhazardousmateri
alst
orageareamustbei
dent
i
fi
edandpost
edforusage.
*
Ot
hermat
erial
sorcont
ainersmustnotbest
oredi
nanunaut
hori
zedarea.
68
4.
Respi
ratoryProtecti
on(SeeAppendixD)
Compliancerequi
rement
s-CAL/OSHA Title8,Division1,Chapter4Subchapter7,Group16,
Sec.5139-5155
ders-Al
l
,Annual
RespiratoryTrai
ni
ng–W el
5.
FirstAi
d
Compli
anceRequi
rements-CAL/OSHA Title8,Division1,Chapter4Subchapter7,Group2,
Sec.3400
5.
1 BasicFirstAid –Supervi
sors,Vol
unt
eers,AnnualRefresher
5.
2 Advanced FirstAid –Supervi
sors,Volunteers,Annual–Supervisors
6.
HotW orkPermi
t(SeeAppendix)
Compl
ianceRequi
rements-CAL/OSHA Title8,Division1,Chapter4Subchapter7,Group9,
Sec.4649-4665andGroup11,Sec.4648-4853
6.
1
lSupervisors,Annual
TrainingIssuer–Al
6.
2
lM ai
nt
enance,Annual
TrainingReceiver–Al
7.
Heari
ngConservati
on(SeeAppendixC)
ComplianceRequi
rements-CAL/OSHA Title8,Division1,Chapter4Subchapter7,Group15,
Sec.5095-5100
7.
1
l
,Annual
Training–Al
7.
2
Ini
ti
alTest
i
ng–Al
l
,W henHired
7.
3
YearlyTest
i
ng–Al
l
,Annual
7.
4
Compl
i
anceSi
gnagePost
i
ng–EntrancePointstohighnoiseareas
8.
Fal
lProtecti
on
Compliancerequi
rement
s-CAL/OSHA Title8,Division1,Chapter4Subchapter7,Group4,
Sec.3207-3239and3270-3280
8.
1
Hazard Training& Identification –All,Annual
79
AppendixA
INDEX
OF
JOB DESCRIPTIONS
1.
BLANK FORM 1
2.
BLANK FORM 2
3.
BOILER OPERATOR
4.
M AINTENANCE CARPENTER
5.
ELECTRICAL TECHNICIAN
6.
GROUNDSKEEPER
7.
INSTRUM ENT TECHNICIAN
8.
JANITOR
9.
M AINTENANCE M ACHINIST
10.
M AINTENANCE ELECTRICIAN
11.
M AINTENANCE M ECHANIC
12.
PLANNER/SCHEDULER
13.
SHEETM ETAL W ORKER
14.
M ATERIAL COORDINATOR
15.
TOOL ROOM ATTENDANT
16.
W ELDER/FABRICATOR
17.
M AINTENANCE PAINTER
90
Sample Shared Governance Policy and
Procedure
Public Law 110-134, Section 642 (d)(B) – The facilitation of meaningful consultation
and collaboration about decisions of the governing body and the policy council.
POLICY STATEMENT
It is the policy of ________________________________________________,
the grantee agency, to fully adhere to and comply with all requirements as outlined in
the Head Start Program Performance Standards and Public Law 110-134 (The Head
Start Act).This document describes how responsibilities are shared among the decision
makers.
The ( Insert Number ) decision makers will implement shared decision
making in a manner that promotes open communication, trust, respect and clear lines of
authority and honors the chain of command. The decision makers outlined are:
1. The Governing Body (Board of Directors, Tribal Council, School Board,
County Government, etc.)
2. The Agency Director (or Superintendent, Executive Director, etc.)
3. The Head Start/Early Head Start Policy Council/Policy Committee
4. The Head Start/Early Head Start Director
(
Insert Name of Agency
), the Grantee is represented by the (
Insert Governing Body Type ); they assume the role of the governing body. The
governing body has legal and fiscal responsibilities which involve funding, personnel
policies and procedures, procedures for overall program policy, establishing,
maintaining and ensuring adherence to internal controls.
The Agency Director is represented by the ( Insert the Title ); this position
reports to the Governing Body and supervises the Head Start Director (specify if this is
different). The role of the Agency Director is further outlined by the Governing Body.
The Head Start/Early Head Start Director is responsible for the day-to-day
management and oversight of the Head Start/Early Head Start Program.
The Policy Council / Policy Committee performs the duties, primarily approval
or disapproval or recommendations, procedures, grant applications, etc., as outlined in
the appropriate regulations.
It is agreed that all decision makers will work in concert to achieve the purpose,
goals and objectives of the Head Start/Early Head Start Program.
GENERAL PROCEDURES
1. Policy Council/Policy Committee Composition and Formation
The Policy Council/Policy Committee will consist of ( Insert a Number )
members, composed as follows:
_____ parents from _______ centers/classrooms
_____ members at large of the community
Total size is _______
2. Election of Parent Members
During the month of _____________, the Parent Committee(s) will elect _______
parent(s) and _______ alternate(s) to serve on the Policy Council/Committee. The
parents will be notified of their upcoming seating/installation at the _________________
meeting.
3. Selection of Members at Large of the Community
The Governing Body will recommend actual nominees ( Actual Names of People
or Organizational Representatives ) to serve on the Policy Council/Committee by (
Insert Date ). The Policy Council/Committee and other management staff will
recommend nominees to serve on the Policy Council/Committee by ( Insert Date ).
The individuals recommended to serve as members at large of the community are
drawn from the local community, businesses, public/private sector, civic and
professional organizations and others familiar with resources and services for low
income families. They may include former Head Start parents. The nominees will be
presented to the parent members of the Policy Council/Committee in person or in
writing at the ( Insert Month ) meeting for approval or disapproval. Upon approval
they will be notified about the first meeting and the seating/installation.
4. Staff Membership on the Policy Council/Policy Committee
No staff member or members of their immediate family will be permitted to serve
on the Policy Council or Policy Committee (Refer to your agency definition of immediate
family)
5. Reciprocal Membership
There will be (1) one current or former parent member from the Policy
Council/Committee that serves on the Governing Body. This is a voting member with all
the rights and responsibilities as any member. The Policy Council/Committee will select
this member during the _____________ meeting. The Policy Council/Committee bylaws
and Governing body by-laws will reflect this membership. (For Governing Bodies that
only have elected positions this section can be omitted or reversed to allow a Governing
Body member to be elected to the Policy Council/Committee as a member at large of
the community )
6. Approval/Disapproval
In most instances the Policy Council/Policy Committee will act on issues
regarding the Head Start/Early Head Start Program prior to those items of business
being presented to the Governing Body. If the policy group does not approve the issue
Head Start management can modify its content so it is acceptable to the Policy
Council/Committee, the item should be revised and resubmitted to the policy group and,
if approved, submitted to the Governing Body. If time is an issue and the meeting of the
Governing Body is scheduled before the Policy Council/Committee will meet, the item
may be presented to the Governing Body for approval before the Policy
Council/Committee acts on that issue. For issues that have broader agency implications
( eg: approval of personnel policies and procedures) those items of business may be
presented to whichever group holds its meeting first.
7. Internal Dispute
When the group with approval/disapproval responsibility reviews an issue and
does not uphold the decision of the other group, it shall be the responsibility of the
chairperson ( or secretary of this second group) to notify the agency director, Head Start
Director and the chairperson of the other decision making group of an impasse. Refer to
approved Internal Dispute Resolution procedures as outlined.
8. Annual Governance Training
The grantee will provide an annual joint training for the Policy Council/Committee
and Governing Body in (Insert Month). For those Governing Body members unable to
attend training materials will be provided with an invitation to contact the Head Start
Director for an individual conference either in person, by telephone or electronically.
Insert business logo/letterhead here
Recovery/return to work procedure (draft)
1. Purpose
Our business is committed to helping workers recovering from a work injury to remain at or return to work. This
procedure describes the process to support our workers and manage recovery/return to work.
2. Related documents
2.1
2.2
2.3
2.4
Return to Work Act 2014 (‘the Act’)
Return to Work Regulations 2015 (‘the Regulations’)
Work Health Safety and Return to Work Policy
Grievance and/or Dispute Resolution Procedure, Equal Opportunity Policy etc.
3. Recovery and return to work
3.1 Reporting of injury
A worker should report the injury to their supervisor as soon as practicable, within 24 hours.
Insert details about how the reporting process occurs.
The supervisor will immediately advise the return to work coordinator (coordinator) of the injury.
3.2 Injury pack
The coordinator will give the worker an injury pack and explain its content:
• Medical authority to exchange information with treating medical practitioners
• Letter to send to the doctor
• Worker’s information, rights and responsibilities under the Act
• Travel and chemist reimbursement forms.
3.3 Medical treatment
First aid will be provided onsite, if appropriate and available.
If immediate offsite treatment is needed the coordinator (or nominated person) will accompany the worker
to the medical clinic/hospital. At the appointment, support, return to work and suitable duties can be
discussed with the doctor if permission is given by the worker.
If the worker is admitted to hospital, SafeWork SA must be informed.
3.4 Claim lodgment
The coordinator (or nominated person) will help the worker lodge a claim via phone to the claims agent on
13 18 55 (Monday – Friday; 8:30am – 5:00pm).
3.5 Identify suitable duties
The coordinator will contact the treating doctor to clarify if capacity for work is unclear.
The coordinator will meet with the worker and supervisor to identify and agree on suitable duties.
Insert details about how this will be done.
The coordinator will document the suitable duties and may prepare a recovery/return to work plan.
3.6 Implementing return to work
The coordinator will:
• Provide clear, accurate and current information on return to work arrangements
• Engage interpreting and translating services, if needed
• Ensure any necessary training is provided before undertaking modified/alternate suitable duties.
3.7 Monitor progress
The coordinator will review progress:
• When a new Work Capacity Certificate is received
• At significant milestones
• When the worker provides new information that impacts on their ability to fulfil their role.
Progress can be reviewed by:
• Visiting and/or meeting the worker and supervisor/team leader in the workplace
• Convening or attending case conferences
• Staying in touch with the case manager, treating doctor and other medical providers.
Duties and/or hours of work will be adjusted if practicable to respond to any change in capacity for work.
3.8 Reports on return to work (refer to section 52 of the Act)
The coordinator will advise the claims agent in writing when a worker in receipt of income support:
• Returns to work after being totally incapacitated
• When there is a change in earnings for a worker who is partially incapacitated
• When there is a change in the type of work being performed.
3.9 Unable to return to pre-injury duties
If it is proposed the worker cannot return to pre-injury duties:
• Every effort will be made to identify and offer suitable duties
• Suitable duties are supplied to aid recovery and promote return to pre-injury work
• Undertaking suitable duties will be monitored/reviewed through the recovery/return to work plan.
If it is evident that the worker cannot return to normal duties in the foreseeable future:
• The recovery/return to work plan goal will change to ‘different employment, pre-injury employer’
• Every effort will be made to identify and offer suitable employment, including:
‒ Considering the worker’s circumstances (work capacity, previous employment, age, education,
skills, work experience and place of residence) and match them to roles that exist in the business
‒ Obtaining additional information if needed to assist, such as a functional capacity evaluation,
worksite assessment and/or vocational assessment services
‒ Providing training and/or modifications to the workplace if required/recommended.
The coordinator will:
• Discuss the need for any such return to work services with the claims agent
• Ensure any necessary training is provided before commencing any new suitable duties or employment.
3.10 Unable to identify suitable employment
If suitable employment cannot be identified the claims agent MUST be notified in writing.
The claims agent will consider the evidence as a result of the above activity, and;
• Decide if any other return to work services/assessments may be required
• Review the recovery/return to work goal together with the worker and employer.
A review may also occur due to section 25(10) of the Act to consider whether new or other employment
options for the worker need to be taken into account to assist a return to suitable employment.
If the worker believes the employer is not complying with the Act requirements for their retention,
employment or re-employment, they may request ReturnToWorkSA to investigate (section 15(2) of the Act).
4. Other matters
4.1 Resolving grievances
Any issue regarded as unfair or against the intent of a successful recovery/return to work can be raised.
In the first instance the issue will be raised with (identify role that deals with workplace issues).
(Identified role) will be responsible for following up and attempting to resolve the grievance.
The worker will be kept informed throughout the process and notified of the outcome in writing.
Issues relating to the provision of a service, or the retention, employment or re-employment of the worker
may be raised directly with ReturnToWorkSA.
The Ombudsman may also consider issues, refer to http://www.ombudsman.sa.gov.au/return-to-work/.
***Note this does not include claim decisions made by the claims agent that have review rights to the South
Australian Employment Tribunal. The rights of appeal section in these letters should be considered.
4.2 Confidentiality
Information obtained during recovery/return to work will be treated with sensitivity and confidentiality.
The worker will be requested to sign a Medical Authority to permit the coordinator to contact the worker’s
treating medical providers.
The employer will ensure that all personal and medical information relating to the worker is protected
against loss and unauthorised access, use, modification or disclosure and against other misuse. Section 185
and 186 of the Act describes these obligations.
4.3 Case notes and records
The coordinator will keep secured, accurate and objective case notes for each worker’s return to work.
Hard copy records will be kept in locked storage, or electronically, to only be accessible by the coordinator.
Insert details of what case notes must contain, storage and archiving of case notes.
4.4 Information and training
All workers and supervisors/managers will be trained in this procedure.
Induction programs for new workers will include recovery and return to work information.
The coordinator’s details will be displayed in the following locations ***where***.
5. Responsibilities
5.1 Employer
• Inform managers/supervisors and workers of their roles in the recovery and return to work process.
•
•
•
•
•
•
•
(Include how you do this. E.g. within induction, a specific training session, team and/or toolbox meetings).
Report a work injury to the claims agent as soon as possible; the agent will advise if a claim form needs to
be completed and if a mobile case manager will be assigned
Participate and cooperate in the development of a recovery/return to work plan
Comply with any obligations set out in a recovery/return to work plan
Arrange suitable duties that can be performed safely whilst recovering from an injury
Provide suitable employment when the worker can return to work but cannot perform pre-injury work
Support the return to work coordinator to perform their functions
Appoint contacts at each worksite to assist the coordinator to perform their functions.
5.2 Worker with a work injury
•
•
•
•
•
•
•
•
Notify the employer of a work injury as soon as possible (within 24 hours if you can)
Make a claim as soon as possible
Actively participate in activities designed to support your recovery and return to work
Participate and cooperate in developing a return to work plan
Comply with any obligations set out in your return to work plan
Provide current Work Capacity Certificates
Return to suitable employment when able to do so.
Insert any other responsibilities.
5.3 Return to work coordinator
The coordinator performs the following functions (section 26(4) of the Act):
• Assist injured workers to remain at work, or return to work as soon as possible, after injury
• Assist prepare and implement recovery/return to work plans
• Liaise with anyone involved in the return to work, or the provision, of medical services to the worker
• Monitor the progress of the worker’s capacity to return to work
• Take steps to prevent the occurrence of re-injury.
Other responsibilities include; (insert any others that are assigned).
5.4 Managers and supervisors
•
•
•
•
•
•
•
Make regular contact with the worker to ensure that there are no issues or concerns
Meet with the worker and coordinator to review the worker’s progress at agreed intervals
Advise the coordinator about any changes, issues or concerns immediately
Assist identify suitable duties to promote recovery and stay at and/or return to work
Ensure the worker does not work outside the capacity identified on the Work Capacity Certificate
Support and offer assistance as required.
Insert any other responsibilities.
5.5 Co-workers
• Insert any other responsibilities.
6. Review of procedure
Click here to insert details of when and how this procedure will be reviewed.
Approved by: Click to enter name
Signature:
Position: Click to enter position details
Date: Click here to enter a date.
***[Delete this note]***
 This document is a template only – it MUST be adapted to your specific workplace and practices
 When adapting, consider; the size of your business; how many locations you have and where they are; how
often you have injuries; who is involved in your practices, ‘who’ does ‘what’, ‘when’
 Communicate and train all staff about what is in the procedure
 Check to make sure the procedure is followed – consider audit and/or scheduled review to ensure ‘who’
does ‘what’ and ‘when’ is happening as written in your procedure
 Use the same structure, language and document control etc. that you have for your other procedures
 Return to work coordinator training and operational guidelines has further information for employers
E-MAIL, PRIVACY, AND THE WORKPLACE
Tami A. Tanoue
CIRSA General Counsel/Claims Manager
September 20, 2002
A. Privacy issues.
1. Unlike private employers, public entities must keep in mind the
Fourth Amendment to the U.S. Constitution , which protects
persons against unreasonable searches and seizures by
governments. This protection applies in both criminal and noncriminal contexts, and thus may be pertinent to employment.
2. To balance an employee’s privacy concerns against an
employer’s interest in maintaining an orderly and efficient
workplace, the following factors are relevant:
a. Did the employee have a subjective expectation of
privacy?
b. Was that expectation reasonable?
c. Did the employer have a legitimate business need that
justified an intrusion of that privacy?
3. Various forms of workplace monitoring or surveillance could
be considered a “search” within the meaning of the Fourth
Amendment.
4. One of the reasons why an electronic communications
monitoring policy is valuable is that it can help defeat a
subjective expectation of privacy by clearly delineating various
work areas and equipment (including computers, telephones,
1
etc.) as non-private, as well as provide some evidence of
consent to monitoring. (A sample policy is attached.)
5. A workplace “search” need not be preceded by a search
warrant, but it must be “reasonable”. Whether a search is
reasonable is evaluated on the following factors:
6. Did the employer have reasonable grounds to believe that an
employee engaged in work-related misconduct, or was a search
necessary for some other work-related purpose?
7. Was the search conducted in a reasonable fashion in relation to
the reason for the search?
8. Of course, a search is also permissible if the employee has
consented to it.
9. Various common law invasion of privacy torts exist under state
law; however, given the protections of the Governmental
Immunity Act, such torts may be largely inapplicable to public
entities.
10. But again, remain mindful of applicability of constitutional
protections where public entities are concerned.
B. Employee monitoring policies: Why?
1. Electronic data is increasingly a major battleground for
discovery in litigation. Information contained in electronic
media could create big surprises in litigation, and can be
extremely burdensome to locate.
2. Real-life problems encountered by employers include:
a. Racially discriminatory or harassing messages
transmitted by e-mail;
b. Use of internet services to access pornographic
materials or the use of e-mail to transmit materials with
sexual content, lending credence to a “hostile work
environment” sexual harassment claim;
2
c. Evidence of leaking confidential information,
transmission of defamatory information, or criminal
conspiracies contained in computer files or e-mail; and
d. Copyright infringement or misuse of copyrighted
materials, such as software.
3. For these reasons, many employers have implemented
monitoring policies for electronic communications, to help
assure that employer facilities are not being used for
inappropriate purposes. A sample policy is attached.
C. Federal/state electronic communications privacy laws.
1. The principal federal law pertaining to monitoring of electronic
communications is the Electronic Communications Privacy Act
of 1986, 18 U.S.C. Section 2510 et seq.
2. The ECPA applies to wire, oral, and electronic
communications, protecting such communications from
intentional interception and disclosure during transmission, and
protecting against unlawful access to stored communications.
3. Certain exceptions exist in the ECPA, such as monitoring by an
employer for legitimate business reasons, monitoring by an
employer who has provided the communications system; and
monitoring with consent; as well as accessing of stored
information by an employer who has provided computer, voice
mail, and email systems.
D. Colorado Open Records Act issues.
1. Under the Open Records Act, C.R.S. Section 24-72-203(3),
digital or electronic records are generally considered public
records open for inspection and copying in much the same way
as records on other media. Generally, three working days is
presumed to be a reasonable time within which to respond to a
records inspection/photocopying request (although a period of
extension not to exceed seven working days is permitted).
2. Under C.R.S. Section 24-72-203(2)(b), where a record is kept
only in miniaturized or digital form (whether on magnetic or
3
optical disks, tapes, microfilm, microfiche, etc.), the custodian
of records must:
a. Adopt a policy concerning the retention, archiving, and
destruction of such records; and
b. Take measures to ensure public access to such records
without unreasonable delay or unreasonable cost.
These measures could include diskette copies of
computer files, or “direct electronic access via on-line
bulletin boards or other means.”
c. C.R.S. Section 24-72-204.5 requires each political
subdivision that operates or maintains an e-mail
communications system to adopt a written policy on
any monitoring that will be done, and the circumstances
under which it will be conducted. The policy must
include a “statement that correspondence of the
employee in the form of electronic mail may be a public
record under the public records law and may be subject
to public inspection under section 24-72-203.”
4
Sample - Electronic Communications Policy
DRAFT September 5, 2002
This policy governs the use of computers, networks, and related services of
the City/Town. Users of these resources are responsible for reading,
understanding, and complying with this policy. Computers and networks can
provide access to resources within and outside the City/Town, as well as the
ability to communicate with other users worldwide. Such access is a
privilege and requires that individual users act responsibly.
Users must respect the rights of others, respect the integrity of the
computers, networks, and related services, and observe all relevant laws,
regulations, contractual obligations, and City/Town policies and procedures.
Misuse of the City/Town Computer System can undermine public
confidence and waste taxpayer resources.
The City/Town Computer System
The City/Town Computer System includes: computers and related
equipment, e-mail, telephones, voice mail, facsimile systems,
communications networks, computer accounts, internet and/or web access,
network access, central computing and telecommunications facilities, and
related services.
Access to and use of the City/Town Computer System is a privilege granted
to City/Town staff. All users of the Computer System must act responsibly
and maintain the integrity of the Computer System. The City/Town reserves
the right to deny, limit, revoke, or extend computing privileges and access to
the Computer System in its discretion.
The City/Town may, in its discretion, limit the use of specified portions of
the Computer System to certain employees, and/or deny the use of specified
portions of the Computer system to certain employees.
The City/Town Computer System may not be used in any manner or for any
purpose which is illegal, dishonest, disruptive, threatening, is damaging to
the reputation of the City/Town, is inconsistent with the mission of the
City/Town, or could subject the City/Town to liability.
5
Any violation of this policy or of other City/Town policies in the course of
using the Computer System may result in an immediate loss of computing
privileges, disciplinary action up to and including termination of
employment, and referral of the matter to the appropriate authorities.
No Expectation of Privacy
City/Town personnel have no expectation of privacy in City/Town property
and equipment. Such property and equipment includes, but is not limited to,
the City/Town Computer System, and all messages, data files and programs
stored in or transmitted via the Computer System ("Electronic
Communications"). The City/Town reserves the right to monitor, access,
use, and disclose all messages, data files and programs sent over or stored in
its Computer System for any purpose. City/Town management reserves the
right to monitor, inspect, and examine any portion of the Computer System
at any time and without notice.
Further, correspondence of an employee in the form of e-mail may be a
public record under the public records law, and may be subject to public
inspection under C.R.S. Section 24-72-203, unless an exception provided by
law applies. The City/Town may monitor or access an employee’s e-mail,
with or without notice, for any business-related purpose, including any
situation in which a supervisor has reason to believe that an employee is
misusing or abusing e-mail privileges, or is violating any other City/Town
policy.
Passwords
Portions of the City/Town Computer System may be accessible by password
only. The purpose of a password is not to provide privacy, but to control
and prevent unauthorized access.
Every password issued for the use of any part of the City/Town Computer
System is the responsibility of the person in whose name it is issued. That
individual must keep the account secure from unauthorized access by
keeping the password secret, by changing the password often, and by
reporting to the City/Town when anyone else is using the password without
permission. Passwords not provided by the City/Town, but generated by the
user, must be provided to the City/Town’s ________ .
Passwords are intended to help prevent unauthorized access and may not be
shared with unauthorized persons. The contents of all password protected
6
data files and programs belong to the City/Town and are subject to access
and disclosure by the City/Town as set forth in this policy.
Improper Use of the Computer System.
Improper use of the Computer System is prohibited. The following are
examples of improper use of the Computer System:

Storage, Transmission, or Printing of Improper Materials:
Storing, transmitting or printing any of the following types of
Electronic Communications on the Computer System is prohibited:
material that infringes upon the rights of another person; material that
is obscene; material that consists of any advertisements for
commercial enterprises; material or behaviors that violate laws,
regulations, contractual obligations, and City/Town policies and
procedures; or material that may injure someone else and/or lead to a
lawsuit or criminal charges.

Harassment: Any electronic communication that violates the
City/Town harassment policy is prohibited. Additionally, any
electronic communication that is annoying, abusive, profane,
threatening, defamatory or offensive is prohibited. Some examples
include: obscene, threatening, or repeated unnecessary messages;
sexually, ethnically, racially, or religiously offensive messages; and
continuing to send messages after a request to stop.

Destruction, Sabotage: Intentionally destroying anything stored on
the Computer System, including anything stored in primary or random
access memory is prohibited. Deliberately performing any act that will
seriously impact the operation of the Computer System. This includes,
but is not limited to, tampering with components of a local area
network (LAN) or the high-speed backbone network, otherwise
blocking communication lines, or interfering with the operational
readiness of a computer or peripheral.

Evasive Techniques: Attempts to avoid detection of improper or
illegal behavior by encrypting or passwording electronic messages
and computer files are prohibited.

Unauthorized Use/Access: Using the Computer System to gain or
attempt to gain unauthorized access to remote computers is prohibited.
7
Other prohibited behaviors include: actions that give simulated sign
off messages, public announcements, or other fraudulent system
responses; possessing or changing system control information (e.g.,
program status, protection codes, and accounting information),
especially when used to defraud others, obtain passwords, gain access
to and/or copy other user's electronic communications, or otherwise
interfere with or destroy the work of other users.

E-Mail Forgery: Forging e-mail, including concealment of the
sender's identity, is prohibited.

Theft/Unauthorized Use of Data: Data created and maintained by
the City/Town, or acquired from outside sources, are vital assets of
the City/Town and must be used only for authorized purposes. Theft
of or unauthorized access to or use of data is prohibited.

Program Theft: Unless specifically authorized, copying computer
program(s) from the Computer System is prohibited.

Viruses, etc: Intentionally running or installing on the Computer
System, or giving to another, a program that could result in damage to
a file or the Computer System, and/or the reproduction or
transmission of itself, is prohibited. This prohibition includes, but is
not limited to, the classes of programs known as computer viruses,
Trojan horses, and worms.

Security: Attempting to circumvent data protection schemes or
uncover security loopholes is prohibited.

Wasting Resources: Performing acts that are wasteful of computing
resources or that unfairly monopolize resources to the exclusion of
others is prohibited. These acts include, but are not limited to: sending
mass mailings or chain letters; creating unnecessary multiple jobs or
processes; generating unnecessary or excessive output or printing; or,
creating unnecessary network traffic.

It is understood that, occasionally, staff members use e-mail or
internet access for non-commercial, personal use. Such occasional
non-commercial uses are permitted if they are not excessive and are
limited to breaks or lunch hours, do not interfere with the performance
of the employee’s duties, do not interfere with the efficient operation
8
of the City/Town, and are not otherwise prohibited by this policy or
any other City/Town policy.

Accessing User Accounts: Unauthorized attempts to access or
monitor another user's electronic communications are prohibited.
Unauthorized accessing, reading, copying, changing, disclosing, or
deleting another user's messages, files or software without permission
of the owner is prohibited.

Backup Copies. All data on the Computer System is subject to
backup at the discretion of the City/Town.

Deleting Electronic Communications. Users of the Computer
System should be aware that Electronic Communications are not
necessarily erased from the Computer System when the user "deletes"
the file or message. Deleting an Electronic Communication causes the
Computer System only to "forget" where the message or file is stored
on the Computer System. In addition, Electronic Communications
may continue to be stored on a backup copy long after it is "deleted"
by the user. As a result, deleted messages often can be retrieved or
recovered after they have been deleted.

Criminal Laws. Under C.R.S. Section 18-5.5-101 et seq., criminal
sanctions are imposed for offenses involving computers, computer
systems, and computer networks. Any person committing an offense
with respect to them may be subject personally to criminal sanctions
and other liability. Federal laws may also apply to some
circumstances.

Copyright Infringement. The Copyright Laws of the United States
prohibit unauthorized copying. Violators may be subject to criminal
prosecution and/or be liable for monetary damages.
In general, you may not copy, download, install or use software on the
Computer System without acquiring a license from the publisher. (For
example, you may not copy it from a friend or other source.)
Furthermore, you may not copy the City/Town’s software, unless such
copying is specifically authorized by the City/Town and permitted by
the license agreement.
The ability to download documents from the Internet, and to attach
files to E-mail messages, increases the opportunity for and risk of
9
copyright infringement. A user can be liable for the unauthorized
copying and distribution of copyrighted material through the use of
download programs and E-mail. Accordingly, you may not copy
and/or distribute any materials of a third party (including software,
database files, documentation, articles, graphics files, audio or video
files) unless you have the written permission of the copyright holder
to do so. Any questions regarding copying or downloading should be
directed to the City/Town’s _______.
10
Incident Management Policy
Incident Management Policy
Draft SEC Subsidiary Document V1.2
1
DEFINITIONS
Term
Black Start
CPNI
Code of
Connection
Crisis
Management
Disaster
Error Handling
Strategy
HMG
Incident Party
Interested Party
Known Error
Live Service
Nominated
Individual
Root Cause
Root Cause
Analysis
Service Alert
Supplier of last
resort
Definition
The recovery process for restoring electricity on the transmission system following either a partial or total
shutdown of the transmission system
Centre for the Protection of National Infrastructure
One of the following Subsidiary Documents: DCC Gateway Connection Code of Connection; DCC User
Interface Code of Connection; Registration Data Interface Code of Connection; Self Service Interface Code of
Connection; SMKI Code of Connection; SMKI Repository Code of Connection; DCCKI Code of Connection;
DCCKI Repository Code of Connection.
The planning and control of an organisation’s response to an event that disrupts the provision of services
An event that causes significant disruption to the provision and use of services, such that the provision and
use of service(s) cannot be sustained without the invocation of exceptional measures to recover infrastructure
and/or resources
The procedures to be followed and actions to be taken where a Service Request or the commands or responses
related to it fail to provide the result expected from that type or category of Service Request as further
described in Section 4
Her Majesty’s Government
A User, Eligible Non Gateway Supplier, Registration Data Provider, DCC Gateway Party, or Authorised
Subscriber that may raise or, in the reasonable opinion of the DCC, may be impacted by an Incident
A Party or Registration Data Provider that is or has the potential to be affected by a Problem or Incident
A fault in a component of the DCC Total System which is used for the provision of Live Services, identified
by the successful diagnosis of an Incident or Problem and for which both Root Cause and a temporary workaround or a permanent solution have been identified
Means
1) any of the Services that the DCC is obliged to provide to a User, an Eligible Non-Gateway Supplier, an
Authorised Subscriber, a DCC Gateway Party (once its connection is capable of operation), but excluding
Testing Services as set out in H14, and
2) the exchange of data pursuant to Section E2.
Means an individual who has been nominated by an Incident Party in accordance with clause 1.4.5 of the
IMP
is the ultimate cause of an Incident or Problem
a class of problem solving methods aimed at identifying the Root Cause of a Problem or Incident
An alert notifying Interested Parties of a current issue which may impact the provision of Services
A Supplier appointed by Ofgem to resume the responsibility for supplying gas and/or electricity to customers
of a failed Supplier
2
Incident Management Policy
Contents
1
2
3
4
Introduction
4
1.1
Purpose
4
1.2
Background
4
1.3
Scope
4
1.34 General Provisions
4
Incident Management
6
2.1
Pre-requisites to Raising an Incident
6
2.2
Raising an Incident
6
2.3
Required Information
7
2.4
Incident Prioritisation & Categorisation
7
2.5
Incident Assignment
9
2.6
Identifying Interested Parties
10
2.7
Communications
10
2.8
Incident Escalation
10
2.9
Escalation Process
11
2.10 DCC Major Incidents and Major Security Incidents
11
2.11 Non-DCC Major Incidents not Assigned to the DCC
13
2.12 Incident Closure
13
2.13 Re-opening Closed Incidents
13
2.14 Re-occurring Incidents
14
Problem Management
15
3.1
Opening a Problem
15
3.2
Prioritisation and Timescale for Closure of Problems
15
3.3
Closing a Problem
15
Business Continuity & Disaster RecoveryError Handling Strategy
4.1
BCDR General Provisions
4.2 BCDR Procedures5Business
17
17
Continuity
&
Disaster
Recovery
18
5.1
BCDR General Provisions
18
3
5.2
Business Continuity and Disaster Recovery Procedures
1918
4
Incident Management Policy
1
Introduction
1.1
Purpose
1.1.1
This document details the Incident Management Policy in
accordance with the requirements of Section H9. It deals with the
management of Incidents, including those related to Registration Data.
1.1.2
[this clause is left intentionally blank]Additionally, sections 4 and 5 cover
the Error Handling Strategy and Business Continuity and Disaster Recovery
respectively.
1.2
Background
1.2.1
The subject matter of this document is closely related to that of the Incident
Management aspects of the Registration Data Interface Specification and the
Non-Gateway Interface Specification. In order to ensure an integrated
solution to managing Incidents and the Incidents governed by thatose
documents, certain common aspects of Incident Management are set out in
this document and cross-referred to in the Registration Data Interface
Specification or the Non-Gateway Interface Specification (as applicable).
1.2.2
The timetable for Registration Data refreshes is set out in the Registration
Data Interface Code of Connection and the Registration Data Incident types
are set out in the Registration Data Interface Specification.
1.2.3
Error conditions and how they should be handled are covered in Section 4,
the Error Handling Strategy.
1.3
Scope
1.3.1
The Incident Management Policy details the full Incident Management
lifecycle including management and declaration of DCC Major Incidents,
Problems and escalations.
1.3.2
[this clause is left intentionally blank]
1.4
General Provisions
1.4.1
Incidents may be raised only by the DCC or an Incident Party and in
accordance with this Incident Management Policy.
1.4.2
Incidents raised and managed under this Incident Management Policy may
relate to any Live Service, other than the Testing Services set out in H14, for
which the Testing Issue Resolution Process set out in H14.37- 45 shall apply.
1.4.3
In the event that an Incident Party considers it necessary to raise an issue
relating to the provision of Services but which it considers outside the scope
of Live Services or Testing Services, it shall contact the DCC directly and
each of that Party and the DCC shall, acting reasonably, agree between
them responsibility for resolution of the issue, which shall be resolved by the
responsible Party as soon as reasonably practicable.
1.4.4
Incidents shall be raised and recorded in the Incident Management Log in
5
accordance with clause 2.
1.4.5
Each Incident Party shall provide the DCC with, and shall subsequently
provide the DCC with any changes to, a list of Nominated Individuals from
their organisation who are authorised to:
a) contact the DCC to raise and record in the Incident Management Log
an Incident and communicate with the DCC regarding the Incident
b) perform the roles identified in the escalation process defined in clause
2.9.
1.4.6
Each Registration Data Provider, when providing the DCC with a list of
Nominated Individuals, shall provide details of both the core operating hours
for the Registration Data Provider and the Registration Data Provider’s outof-hours facility.
1.4.7
Each Incident Party shall ensure that only its Nominated Individuals shall
contact the DCC to raise an Incident.
1.4.8
The DCC shall ensure that only those Nominated Individuals pursuant to
clause 1.4.5(a) shall raise an Incident.
1.4.9
The DCC shall implement an authentication procedure for confirming that a
communication is from an Incident Party’s Nominated Individual, and such
procedure shall be commensurate with the risk to the Services and Data.
Incident Parties shall comply with this procedure.
1.4.10 The DCC and Incident Parties shall each ensure that information regarding
Incidents and Problems is recorded and kept up to date in the Incident
Management Log as follows:
a) for Major Incidents, the Incident Party shall comply with clause 2.2.2
b) the Incident Party shall use the Self Service Interface where it is able
to do so and the DCC shall ensure that information provided in this
way is automatically added to the Incident Management Log
c) where the Incident Party is unable to use the Self Service Interface,
it shall provide information to the Service Desk by email or by phone
and the Service Desk shall ensure that this information is entered
into the Incident Management Log
d) when an Incident is submitted by email and the Incident Party does
not provide the required information as detailed in clause 2.3, the
Service Desk shall return an email to the Incident Party requesting
the missing information and the Incident shall not be recorded in the
Incident Management Log until the required information has been
received by the Service Desk
e) the Service Desk shall enter information that the DCC originates into
the Incident Management Log
f) the resolver shall ensure all actions to resolve the Incident are
recorded in the Incident Management Log
g) In regard to items a) – f) above, the DCC and Incident Parties shall
each ensure that information is as complete as is possible and is
entered into the Incident Management Log as soon as is reasonably
practicable.
6
Incident Management
2
Incident Management
2.1
Pre-requisites tobefore Raising an Incident
DCC
2.1.1
Before raising an Incident the DCC shall use all reasonable endeavours to
ensure an Incident does not already exist for the issue.
2.1.2
Pursuant to Section E2.12(d), prior to the DCC raising an Incident regarding
the provision of Registration Data by a Registration Data Provider, the DCC
shall use all reasonable endeavours to confirm that the issue does not
reside within the DCC System or processes.
I nci dent Parti es other t han Registration Data Providers
2.1.32 For the purposes of this clause 2.1.32 and clause 2.1.43, references to
“Incident Party” do not include Registration Data Providers.
Before raising an Incident with the DCC the Incident Party shall use all
reasonable endeavours to:
a) where appropriate, confirm that the issue does not reside within the
HAN, or the Smart Meter, or other Devices which the Incident Party is
responsible for operating;
b) confirm that the issue does not reside within the Incident Party’s own
systems and processes;
c) follow the guidance set out in the self-help material made available by
the DCC, including checking for known errors and the application of
any workarounds specified; and
d) where the party is a User and to the extent that this is possible, submit
a Service Request to resolve the Incident in accordance with Section
H9.2.
2.1.43 In the event that the activities in clause 2.1.32 have been completed and an
Incident is to be raised with the DCC, where it has access to the Self-Service
Interface, the Incident Party shall check on the Self Service Interface to
establish whether an Incident has already been raised or a Service Alert
issued for this issue and:
a) in the event that the Incident Party can reasonably determine that an
Incident or Service Alert for this Incident exists, the Incident Party shall
notify the Service Desk who shall register the Incident Party as an
Interested Party within the Incident Management Log;
b) in the event that the Incident Party cannot identify an existing Incident
or Service Alert they shall progress to clause 2.2 to raise an Incident.
Registration Data Provider
2.1.54 Pursuant to Section E2.12(d), prior to raising an Incident regarding the
provision of data to and by the DCC, the Registration Data Provider shall use
all reasonable endeavours to confirm that the issue does not reside within
the Registration Data Provider’s systems and processes.
2.2
Raising an Incident
2.2.1
Incidents can be raised at any time as set out in in clause 2.2.3, but only
7
Incident Management
once the steps in clause 2.1 have been followed.
2.2.2
Where an Incident Party believes that an Incident ought to be treated as a
meets the criteria of a Category 1 Incident (see clause 2.4.4), the Incident
Party shall call the Service Desk as soon as reasonably practicable.
2.2.3
An Incident Party shall raise what it considers to be Category 2, 3, 4 and 5
Incidents as set out in clause 1.4.10 and provide information as set out in
clause 2.3.1, subject to Section H8.19(a).
2.3
Required Information
2.3.1
When raising an Incident, the DCC or Incident Party shall provide the
following information:
a) Contact name;
b) Contact Organisation;
c) Contact details;
d) Organisation’s Incident reference number (where available);
e) Date and time of occurrence;
f) MPxN or Device ID (where appropriate);
g) Summary of Incident;
h) Business impact; and
i) Results of initial triage and diagnosis including references to existing
Incidents, where appropriate, and details of investigations performed to
satisfy pre-requisites set out in clause 2.1.
2.4
Incident Prioritisation and Categorisation
2.4.1
The DCC shall assign an Incident Category to an Incident raised by an
Incident Party based on the information available at the time the Incident is
recorded in the Incident Management Log.
2.4.2
The DCC shall categorise an Incident raised by itself the DCC using
information available to the DCC at the time the Incident is recorded in the
Incident Management Log.
2.4.3
The DCC shall progress the resolution of Incidents in priority order. The
DCC shall determine the priority of an Incident by considering the Incident
Category and the time remaining until the Target Resolution Time, as defined
in clause 2.4.4.
Categorisation Matrix
2.4.4
The DCC shall, acting reasonably, assign a Category to an Incident, having
regard to the table below. The table further details the Target Resolution
Time in accordance with Section H9.1(c).
8
Incident Management Policy
Incident
Category
Description
1
A Category 1 Incident ( Major Incident) is an
which, in the reasonable opinion of the DCC:




Incident
Target Initial
Response
Time
Target
Resolution
Time
10 minutes
4 hours
prevents a large group of Incident Parties from
using the Live Services;
has a critical adverse impact on the activities of
the Incident Parties using the Live Services ofr
the DCC;
causes significant financial loss and/or disruption
to the Incident Parties; or
results in any material loss or corruption of DCC
Data
For a Major Security Incident there are additional
considerations:



HMG, through CPNI, have declared a
Major Incident based on their procedures;
a pattern has been seen across the DCC Total
System that in total would have a significant
security impact; or
Data covered by the Data Protection Act has
either been lost or obtained by an unauthorised
party, or is seriously threatened.
2
An Incident which in the reasonable opinion of the DCC:
 has a non-critical adverse impact on the activities
of Incident Parties, but the Live Service is still
working at a reduced capacity; or
 causes financial loss and/or disruption to other
Incident Parties which is more than trivial but
less severe than the significant financial loss
described in the definition of a Category 1
Incident.
20 minutes
24 hours
3
An Incident which, in the reasonable opinion of the DCC:
45 minutes
72 hours
3 hours
5 days
1 day
10 days


4
5
has an adverse impact on the activities of an
Incident Party but which can be reduced to a
moderate adverse impact due to the availability
of a workaround; or
has a moderate adverse impact on the activities
of an Incident Party.
An Incident which, in the reasonable opinion of the DCC
has a minor adverse impact on the activities of an
Incident Party.
An Incident which, in the reasonable opinion of the DCC
has minimal impact on the activities of Incident Party
Table 1 - This table covers all Incident categories including Security Incidents.
2.4.5
If an Incident Party believes an Incident has been allocated an incorrect
Incident Category by the DCC or has been subsequently updated to an
incorrect Incident Category by the DCC, it may invoke the escalation process
set out in clause 2.9.
9
Incident Management Policy
2.4.6
The DCC may change the Incident Category of an Incident if more
information becomes available. The DCC shall provide to Interested Parties,
by a reasonable mechanism, details of why the Incident Category has been
changed. The DCC shall update the Incident Management Log with the
revised Incident Category.
2.5
Incident Assignment
2.5.1
The Service Desk shall manage Incidents recorded in the Incident
Management Log through the Incident lifecycle.
2.5.2
The DCC shall assess the Incident and assign resolution activities to the
appropriate resolver in accordance with Section H9.2, and the resolver may
be the DCC or an Incident Party.
2.5.3
In the event that Incident resolution activities are assigned to a Registration
Data Provider at a time which falls outside of the Registration Data
Provider’s hours of operation, and where the DCC has classified the Incident
as a Category 1 or 2, the DCC shall contact the Registration Data Provider
via its out-of-hours facility as provided in accordance with the clause 1.4.6.
2.5.4
In the event that Incident resolution activities are assigned to a
Registration Data Provider at a time which falls outside of the Registration
Data Provider’s hours of operation and the DCC has classified the Incident
as a Category 3, 4 or 5, the DCC shall contact the Registration Data
Provider when their business operations commence on the next Working
Day. In such instances the time during which the Registration Data Provider
was not able to be contacted shall be disregarded for the purpose of
calculating the resolution time for the Incident.
2.5.5
Pursuant to H9.8(a), the resolver assigned to an Incident shall perform the
appropriate steps to resolve the Incident in accordance with H9.8, and shall
record information as set out in clause 1.4.10.
2.5.6
When assigning an Incident to an Incident Party where the DCC requires
the Incident Party to diagnose or confirm resolution of an Incident, the DCC
shall:
a) engage with the Incident Party by a reasonable mechanism;
b) set the Incident status to pending; and
c) assign the activity to the Incident Party, and the resolution time shall
not include the period of time for which the activity is so assigned
2.5.7
The Incident Party shall, using a reasonable mechanism, confirm to the
DCC when all activities requested pursuant to clauses 2.5.5 and 2.5.6 are
complete, providing details of steps taken, which the Service Desk shall
ensure are included in the Incident Management Log. The DCC shall then
reassign the Incident or update the status in the Incident Management
Log to resolved, as appropriate, based on the information received.
2.5.8
Where an Incident has been recorded in the Incident Management Log and
investigated but has subsequently been determined not to be an Incident,
the Service Desk shall contact the appropriate Incident Party and provide the
relevant information that the DCC holds to enable the Incident Partyit to raise
and manage the Incident within its own system. The Service Desk shall set
the status in the Incident Management Log to closed.
10
Incident Management
2.5.9
If an Incident Party identifies that an Incident has been assigned to it but it
should not be responsible for resolving it, the Incident Party shall advise the
Service Desk, providing supporting information, and the DCC shall
investigate and re-assign as appropriate.
2.5.10 The DCC shall collate and make available to Network Parties and the Panel
data related to the time taken to resolve Incidents associated with the
exchange of data pursuant to Section E of the Code, where the DCC is
responsible for resolving the Incident but in order to do so, activity must be
undertaken by a Registration Data Provider.
2.6
Identifying Interested Parties
2.6.1
The Service Desk shall use all reasonable endeavours using information
available from the Live Services including Incident data, as appropriate, to
identify Interested Parties for an Incident.
2.6.2
The Interested Parties identified by the DCC will be informed of the Incident
by DCC by reasonable means.
2.7
Communications
2.7.1
Throughout the lifecycle of the Incident, the Service Desk shall
communicate updates to the Incident Party or other identified Interested
Parties. These communications may be via email, phone call and/or via
updates to the Incident Management Log.
2.8
Incident Escalation
2.8.1
The rules and process for the escalation of an Incident are detailed in this
clause and clause 2.9.
2.8.2
The DCC and Incident Party shall adopt the escalation process as defined
in clause 2.9 to ensure that Nominated Individuals with the necessary
authority and the appropriate resources are applied to resolving the
Incident.
2.8.3
The Service Desk shall monitor Incidents throughout their lifecycle and
automatic reminder notifications shall be sent to appropriate resolvers based
on Incident Category, target initial response time and Target Resolution
Time.
2.8.4
Subject to clause 2.8.5, the Incident Party that raised an Incident with the
Service Desk, an Interested Party, or an Incident Party to which the Incident
has been subsequently reassigned by the DCC, may request that the
Incident is escalated.
2.8.5
Incidents may be escalated under the following circumstances:
a) disagreement with categorisation;
b) Target Response Time has not been met;
c) Target Resolution Time about to be exceeded;
d) lack of appropriate response;
e) dissatisfaction with the progress of an assigned activity;
f) dissatisfaction with the progress of an Incident;
g) dissatisfaction with resolution.
11
Incident Management Policy
2.8.6
The Service Desk shall include full details of the escalation in the Incident
Management Log.
2.9
Escalation Process
2.9.1
Escalated Incidents shall be progressed in accordance with the table below.
All escalations shall follow the process and adhere to the sequential order.
Level
DCC
Incident Party
L1 Escalation
Service Desk
Individual nominated to act in the role
of service desk operator in clause 2.8.2
L2 Escalation
Service Desk
Manager
Individual nominated to act in the role
of service desk manager in clause 2.8.2
L3 Escalation
Service Manager
Individual nominated to act in the role
of Service Manager in clause 2.8.2
L4 Escalation
Head of Service
Individual nominated to act in the role
of Head of Service in clause 2.8.2
L5 Escalation
Operations Director
Individual nominated to act in the role
of Operations Director in clause 2.8.2
Table 2 – Escalation Process
2.9.2
If, following a Level 5 escalation, a resolution cannot be satisfactorily agreed
between the DCC and the escalating organisation, the Incident may be
escalated by any Interested Party to the Panel and
a) In regard to circumstances a)–f) in clause 2.8.5, the Panel shall make a
determination that shall be final and binding; and
b) In regard to circumstance g) in clause 2.8.5, the Panel shall provide an
opinion.
2.9.3
The DCC and escalating Incident Party shall provide appropriate evidence to
the Panel that it has been through all earlier escalation levels before
escalating an Incident to the Panel.
2.10
DCC Major Incidents and Major Security Incidents
2.10.1 All Category 1 Incidents shall be treated as Major Incidents. Major Security
Incidents shall also be treated as Category 1 Incidents.
2.10.2 Once an Incident has been recorded in the Incident Management
Logreported to the Service Desk pursuant to clause 2.2.2, the Service Desk
shall perform initial triage on the Incident. The Major Incident management
process and/or the DCC security team shall be engaged to progress and
resolve the Incident where triage confirms that the DCC believes that the
12
Incident Management Policy
Incident should be treated as a Category 1 Incident, unless the
circumstances set out in 2.10.7 apply.
2.10.3 If an Incident is updated to become a Category 1 Incident the provisions of
this section will also apply.
2.10.4 The DCC shall notify Interested Parties of a Major Incident by a reasonable
means in accordance with Section H9.11.
2.10.5 On resolution of the Major Incident, the DCC shall raise a Problem to confirm
the root cause.
2.10.6 The DCC shall make the details from the Problem available to Interested
Parties.
2.10.7 Where a Major Incident has been logged and investigated but then turns out
to be an Incident which the DCC is not responsible for resolution (as set out
in H9.2(b)) then the Service Desk shall:
a) Contact the appropriate Incident Party through a reasonable
mechanism
b) assign the Incident to the Incident Party
c) set the Incident status to pending.
2.10.8 Where a Major Incident has been logged and investigated but turns out not to
be an Incident:
a) the Service Desk shall contact the Incident Party that raised the
Incident through a reasonable mechanism and provide the details to
enable the Incident Party to raise and manage the incident within their
own system
b) the Service Desk shall set the status of the Incident to closed.
2.10.9
Should the Service Desk be inaccessible through the usual mechanisms and
any alternate mechanism provided under H8.20, the DCC will inform Incident
Parties of an alternative method of access through a reasonable mechanism.
Major Security Incidents
2.10.109
Clauses 2.10.110 and 2.10.121 shall apply for a Major Security
Incident.
2.10.110
The Incident Party shall notify the Panel and Security Subcommittee, in
accordance with Section G3, and, pursuant to section H9, the DCC if:
a) it detects a security Incident within its environment of which the DCC
needs to be informed;
b) any potential Security Incident it detects appears to relate to the DCC
Total System.;
2.10.121
The DCC shall notify the Panel and Security Subcommittee, in
accordance with Section G2, and, pursuant to Section H9, inform an Incident
Party by an appropriate mechanism if:
a) any Security Incident occurs that is identified in the SEC as requiring
notification to the Incident Party or the Panel and Security
Subcommittee; or
13
b) a Security Incident indicates a breach of the provisions of a Code of
Connection.
2.11
Major Incidents not Assigned to the DCC
2.11.1 In the event that a Major Incident is assigned to an Incident Party other than
the DCC:
a) the Incident Party may request that the DCC provides reasonable
assistance. When this is requested the DCC shall provide reasonable
assistance to the Incident Party responsible for resolving the Incident in
accordance with Section H9.12(a) and
b) as part of such reasonable assistance, the DCC may disseminate the
information to Incident Parties if requested by the Incident Party, using
the Self Service Interface and other mechanisms as appropriate.
2.12
Incident Closure
2.12.1 The rules for the closure of Incidents are detailed below.
2.12.2 An Incident that the DCC is responsible for resolving shall be resolved by the
DCC in accordance with the Target Resolution Times set out in the
categorisation matrix in clause 2.4.
2.12.3 The Service Desk and the resolver shall each record details of all steps they
have each taken to resolve the Incident in the Incident Management Log, as
set out in clause 1.4.10.
2.12.4 The Service Desk shall notify the Incident Party and/or other Interested
Parties and the resolver via email when the DCC sets the Incident status to
resolved.
2.12.5 If the Incident is resolved through the application of a workaround, the
Service Desk shall either raise a new Problem or the Incident shall be
associated with an existing Problem where one exists.
2.12.6 If it does not consider that the Incident is resolved, the Incident Party,
resolver or an Interested Party shall respond to the Service Desk via email or
phone call within 3 Working Days, unless a longer period has been agreed
by the Service Desk, such agreement to not be unreasonably withheld. In so
doing, the relevant party shall provide supporting information as to why they
consider the Incident not to be resolved. Then,
a) If the Service Desk receives, with supporting information, a response
detailing that the Incident is not resolved, the Service Desk will change
the status from resolved and reassign the Incident for investigation in
accordance with H9; or
b) If a response is not received from the Incident Party within the
aforementioned timeframe the Service Desk shall close the Incident.
2.12.7 In the event that the Incident Party requires subject matter expert advice
before confirming closure and the subject matter expert is unavailable, the
Incident Party may contact the Service Desk via email or phone call to
request that the closure period be extended.
2.12.8 In the event that the Incident is the result of an intermittent issue the Service
14
Desk shall apply what it reasonably deems to be an appropriate closure
period based on the frequency of the occurrences of the issue, and shall
close the Incident after this period has elapsed without any further
occurrences. The Service Desk shall record this in the Incident Management
Log.
2.12.9 After the Incident has been resolved, the Service Desk may raise a Problem
and link it to the Incident.
2.13
Re-opening Closed Incidents
2.13.1 The Incident Party that originally raised an Incident may only re-open it if it
was closed with a workaround and one of the following circumstances
occurs:
a) the workaround fails; or
b) the workaround deteriorates to a point that it affects normal business
operations.
2.13.2 If a Problem associated with an Incident has been closed, it shall not be
possible to re-open the Incident. In this case, the Incident Party shall raise a
new Incident.
2.14
Re-occurring Incidents
2.14.1 If a previous Incident reoccurs after it has been closed in line with the
procedures in this Incident Management Policy, the Incident Party shall raise
a new Incident, in accordance with the provisions set out above.
2.14.2 The DCC may identify re-occurring Incidents by performing trending,
correlation and incident matching. Confirmed re-occurrences may be
progressed through Problem management.
2.14.3 An Incident Party may identify a re-occurring incident and may notify the
DCC. In so doing, the Incident Party shall provide all related Incident
reference numbers to the DCC who may progress the issue through Problem
management, as set out in clause 3.
15
Incident Management Policy
3
Problem Management
3.1
Opening a Problem
3.1.1
The DCC shall open a Problem in the Incident Management Log in the
following circumstances:
a) when a Major Incident has been resolved;
b) when an Incident is closed with a workaround applied; or
c) when the DCC has identified a re-occurring Incident.
3.1.2
3.2
The DCC shall allocate a reasonable initial timescale for carrying out the
Root Cause Analysis to enable the re-classification of the Problem as a
Known Error.
Prioritisation and Timescale for Closure of Problems
3.2.1
The DCC shall periodically issue and make available a report listing open
Problems to Incident Parties and the Panel.
3.2.2
The report shall set out for each open Problem:
a) date opened;
b) Problem classification;
c) Problem status;
d) the target closure date;
e) the anticipated costs (in DCC’s reasonable opinion) for the
investigation and resolution of the Problem, where appropriate;
f) the anticipated timescales for the closure of a Problem;
g) the likely impact on the DCC’s business, and its effects on Incident
Parties of closing a Problem and continuing with a workaround,
highlighting instances where implementing a permanent solution may
not be the recommended approach; and
h) the reason for any target closure date change.
3.2.3
Following the issuing of such a report, the DCC shall discuss with Incident
Parties the prioritisation and preferred timescales for the progression of each
Problem. Following discussion, and taking respondents’ views into account,
the DCC will determine the prioritisation and preferred timescales for the
progression of each Problem.
3.2.4
If a Problem investigation or resolution requires a change to the SEC a
Modification Proposal shall be raised and submitted by the DCC.
3.3
Closing a Problem
3.3.1
The rules for closure of a Problem are detailed below, as required by Section
H9.1(k).
3.3.2
Following the application of a permanent fix, the DCC shall discuss the
outcome with Interested Parties before closing the Problem.
3.3.3
Details of all steps taken to close the Problem shall be recorded, as set out in
clause 1.4.10.
16
3.3.4
The DCC shall only close a Problem once the DCC has discussed with
Interested Parties that one of the following conditions has been met:
a) the permanent fix has been applied;
b) an enhanced and acceptable workaround is in place; or
c) the DCC will not continue investigations.
17
4.
Error Handling Strategy
4.1
The first version of the contents of the Error Handling Strategy will be the
‘Error Handling Strategy – Draft SEC Subsidiary Document’ as submitted to
the Secretary of State on 20th December 2014.
4.2
The DCC shall make the Error Handling Strategy available to Users through
the Self Service Interface.
4.3
The DCC may update the Error Handling Strategy from time to time. The
DCC shall ensure that Parties are consulted prior to making any changes to
the Error Handling Strategy and take into account any relevant views
expressed by Parties in making any changes to it.
18
Incident Management Policy
54
Business Continuity and Disaster Recovery
4.1
5.1 BCDR General Provisions
54.1.1 Users, Other Parties and Registration Data Providers shall ensure that the
contact details provided to the DCC for the purposes of Incident notifications
are up to date.
54.1.2
The DCC shall record and treat any Disaster as a Major Incident.
54.1.3 The DCC shall coordinate recovery actions for any Disaster in order to
minimise the impact on Services.
54.1.4 The DCC shall notify Incident Parties of a Disaster, with details of the Major
Incident and the expected duration of the outage, if any. The DCC shall
further inform Incident Parties when Services are restored.
54.1.5 The DCC shall implement the processes and arrangements outlined in the
tables in section 54.2 in order to meet the requirementsRecovery Time
Objectives (RTOs) as detailed in Section H10.13 and Recovery Point
Objectives (RPOs) associated with the Services.
54.1.6 When requested by the DCC, upon restoration of Services, Incident Parties
shall confirm that Services are fully restored.
54.1.7 Upon restoration of Services, if an Incident Party continues to have loss of
Services they shall follow the incident management process steps outlined in
Section 2.1.
19
Incident Management Policy
4.2
5.2 Business Continuity and Disaster Recovery Procedures
54.2.1 Pursuant to the requirements of Section H10:
a)
b)
c)
the DCC shall implement the measures in the table below under ‘DCC Mitigation’ to reduce the likelihood of the Disaster
occurring and limit the impact in the event that a Disaster has occurred;
in the event of a Disaster, the DCC shall follow the actions in the table below detailed under ‘DCC Recovery Action;
and
Incident Parties may experience the impact set out in the table below under ‘Incident Party Impact’ and shall follow
the actions as detailed under ‘Incident Party Actions on failure, failover or failback’.
Disaster ID
DCC Disaster Impact
DCC Mitigation
D1
The DCC loses the
primary data centre
provided pursuant to the
(data services) contract
referred to in paragraph
1.2(a) of Schedule 1 of
the DCC Licence.
The DCC shall provide primary and
secondary data centres providing data
services for the DCC Live Systems, with a
resilient server configuration in the
primary data centre with an activepassive configuration between data
centres.
DCC Recovery Action
The DCC shall do one of the
following:
a) fail over to the secondary data
centre; or
b) recover Services at the
primary data centre.
All configurations and data are backed up
and backups are stored offsite. There are
resilient network links to the data centres
providing communication services.
Incident Party Impact
Incident Party Actions on
failure, failover or failback
Incident Parties may
experience a loss of all
Services on failover to the
secondary data centre and on
failback to the primary data
centre, with the exception of
some Testing Services which
operate from the secondary
data centre.
1. When requested by the DCC,
Incident Parties shall suspend
submission of Service Requests
and Signed Pre-Commands
until notified that Services have
been restored.
2. Upon restoration of impacted
Services, Incident Parties may
recommence submission of
Service Requests and Signed
Pre-Commands (including
submitting any that have failed).
3. When requested by the DCC,
the Incident Party shall take
each of the actions identified in
column 6, rows D5 to D12
inclusive and row D15 of this
table as relevant when DCC
fails over from or fails back to
the primary data centre.
20
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
Incident Party Impact
Incident Party Actions on
failure, failover or failback
D2
The DCC loses the
secondary data centre
provided pursuant to the
(data services) contract
referred to in paragraph
1.2(a) of Schedule 1 of the
DCC Licence.
The DCC shall provide the ability to
deliver Testing Services from either the
secondary or primary data centres.
The DCC shall do one of
the following:
Incident Parties will
experience a loss of some
Testing Services.
1. When requested by the DCC,
Incident Parties shall suspend
the use of Testing Services until
notified that Services have been
restored.
D3
a)
All configurations & data are backed up
& backups are stored offsite. There are
resilient network links to the data centres
providing communication services.
The DCC loses both the
The DCC shall ensure that all
primary and secondary
configurations & data are backed up &
data centres provided
backups are stored offsite.
pursuant to the (data
services) contract referred
to in paragraph 1.2(a) of
Schedule 1 of the DCC
Licence.
b)
recover Services at the
primary data centre; or
recover Services at the
secondary data centre.
The DCC shall do one or more of
the following:
a)
b)
recover Services at the
primary data centre;
recover Services at the
secondary data centre;
c)
restore Services to new
infrastructure at an
alternative data centre;
d)
set up network links to the
new data centre;
21
Incident Parties may
experience a loss of some
data within Testing Services.
Incident Parties may
experience a loss of all
Services.
Incident Parties may
experience a loss of some
transactions.
Some information related to
billing and Service Levels
may be lost.
On restart the DCC may
impose systems-driven
Restrictions on transaction
volumes/types.
2. Upon Services restoration,
Incident Parties may resubmit
failed test messages.
1. When requested by the DCC,
Incident Parties shall suspend
submission of Service Requests
and Signed Pre-Commands
until notified that Services have
been restored.
2. Upon Services restoration,
Incident Parties may resubmit
failed messages.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
D4
DCC Services are
impacted by a virus or
malware
The DCC shall do one or more of
The DCC constantly monitors its
environments and networks to ensure the the following:
integrity of firewalls and anti-virus
a) halt processing and clear
measures.
the virus or malware;
Incident Party Impact
Incident Party Actions on
failure, failover or failback
Incident Parties may
experience a loss or
interruption to affected
Services.
1. When requested by the DCC,
Incident Parties shall suspend
use of any affected Services.
b)
failover to a secondary data
centre (or primary data
centre) in the case of
Testing Services;
The DCC may impose
systems-driven restrictions on
transaction volumes/types on
restart.
c)
isolate the affected
system and clear the virus
or malware;
Additional impacts are detailed
in column 5 of rows D2, D5 to
D12 and D15 of this table.
d)
cease to process
transactions from Incident
Parties impacted by the
virus or malware until
confirmation is received
that they have applied
necessary measures;
e)
apply any software
patches to its Services; or
f)
recover from backup.
22
2. Prior to re-commencement of
Service provision, the DCC may
request that each Incident Party
confirms that it has cleaned its
User Systems and applied
necessary measures to prevent
the virus or malware
reoccurring.
3. When requested by the DCC,
Incident Parties shall take each
of the actions identified in
column 6, rows D5 to D12
inclusive and row D15 of this
table as relevant when DCC
fails over from or fails back to
the primary data centre.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
D5
The DCC’s experiences a
failure of the part of the
DCC Systems responsible
for delivering Service
Requests, Commands,
Responses & Alerts
The DCC shall provide primary &
The DCC shall do one of
the following:
secondary data centres providing data
services for the DCC Live Systems, with
resilient server configuration in the primary
a) fail over to the secondary
data centre; or
data centre with an active- passive
configuration between data centres.
b) recover Services at the
primary data centre.
All configurations & data are backed up
& backups are stored offsite. There are
resilient network links to the data centres
providing communication services.
D6
The DCC experiences a
failure of the systems
used to support the
provision of service
management.
DCC Recovery Action
The DCC shall do one of
The DCC shall provide primary &
the following:
secondary data centres providing data
services for the DCC Live Systems, with
a) fail over to the secondary
resilient server configuration in the primary
data centre; or
data centre with an active-passive
configuration between data centres.
b) recover Services at the
All configurations & data are backed up &
primary data centre; and
backups are stored offsite. There are
resilient network links to the data centres
c) the DCC Service Desk
providing communication services.
shall capture Incidents
using another method
until it regains access to
the Service
Management System.
23
Incident Party Impact
Incident Party Actions on
failure, failover or failback
Incident Parties may
experience a loss of
Communication, Enrolment
and Local Command
Services.
1. When requested by the DCC,
Incident Parties shall suspend
submission of Service Requests
and Signed Pre-Commands
until notified that Services have
been restored.
Incident Parties may
experience a loss of all
Services, with the exception of
some Testing services which
operate from the secondary
data centre, during failover to
the secondary data centre and
failback to the primary data
centre.
2. Upon restoration of impacted
Services, Incident Parties may
recommence submission of
Service Requests and Signed
Pre-Commands (including
submitting any that have failed).
3. When requested by the DCC,
Incident Parties shall take each
of the actions identified in
column 6, rows D5 to D12
inclusive and row D15 of this
table as relevant when DCC
fails over from or fails back to
the primary data centre.
Incident Parties may be unable 4.
1. When requested by DCC,
to raise incidents or access
Incident Parties may only
incident information via the Self
submit Category 1 Incidents.
Service Interface.
2. Upon Services restoration,
Incident Parties may submit
outstanding Incidents.
Incident Parties may
experience a loss of all
Services, with the exception of
some Testing services which
operate from the secondary
data centre during the failover
to the secondary data centre
and on failback to the primary
data centre.
3. When requested by the DCC,
Incident Parties shall take each
of the actions identified in
column 6, rows D5 to D12
inclusive and row D15 of this
table as relevant when DCC
fails over from or fails back to
the primary data centre.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
D7
The DCC experiences a
failure of the systems
used to support the
provision of data
warehousing and
reporting.
The DCC shall do one of
The DCC shall provide primary &
the following:
secondary data centres providing data
services for the DCC Live Systems, with
resilient server configuration in the primary
a) fail over to the secondary
data centre with an active-passive
data centre; or
configuration between data centres.
All configurations & data are backed up &
backups are stored offsite. There are
resilient network links to the data centres
providing communication services.
DCC Recovery Action
b)
recover Services at the
primary data centre.
24
Incident Party Impact
Incident Party Actions on
failure, failover or failback
Incident Parties may
experience unavailability of
preconfigured reports via the
Self Service Interface.
1. When requested by the DCC,
Incident Parties shall suspend
submission of Service Requests
and Signed Pre-Commands
until notified that Services have
been restored.
Incident Parties may
experience a loss of all
Services, with the exception of
some Testing services which
operate from the secondary
data centre during the failover
to the secondary data centre
and on failback to the primary
data centre.
2. Upon restoration of impacted
Services, Incident Parties may
recommence submission of
Service Requests and Signed
Pre-Commands (including
submitting any that have failed).
3. When requested by the DCC,
Incident Parties shall take each
of the actions identified in
column 6, rows D5 to D12
inclusive and row D15 of this
table as relevant when DCC
fails over from or fails back to
the primary data centre.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
D8
The DCC experiences a
failure of the systems
used to support the
operation of the CoS
Party.
The DCC shall do one of
The DCC shall provide primary &
the following:
secondary data centres providing data
services for the DCC Live Systems, with
resilient server configuration in the primary
a) fail over to the secondary
data centre with an active-passive
data centre; or
configuration between data centres.
All configurations & data are backed up &
backups are stored offsite. There are
resilient network links to the data centres
providing communication services.
DCC Recovery Action
b)
recover Services at the
primary data centre.
Incident Party Impact
Incident Party Actions on
failure, failover or failback
Incident Parties would be
unable to successfully send
CoS Update Security
Credentials Service Requests.
1. When requested by the DCC,
Incident Parties shall suspend
submission of Service Requests
and Signed Pre-Commands
until notified that Services have
been restored.
Incident Parties may
experience a loss of all
Services during the failover to
the secondary data centre.
Incident Parties would also
experience a loss of all
Services on failback to the
primary data centre.
25
2. Upon restoration of impacted
Services, Incident Parties may
recommence submission of
Service Requests and Signed
Pre-Commands (including
submitting any that have failed).
3. When requested by the DCC,
Incident Parties shall take each
of the actions identified in
column 6, rows D5 to D12
inclusive and row D15 of this
table as relevant when DCC
fails over from or fails back to
the primary data centre.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
Incident Party Impact
Incident Party Actions on
failure, failover or failback
D9
The DCC experiences a
loss of connectivity to
one or more Incident
Parties
The DCC shall provide primary &
secondary data centres providing data
services for the DCC Live Systems, with
resilient server configuration in
the
primary data centre with an activepassive configuration between data
centres. There are resilient network links
to the DCC User Gateway Connection
with automatic rerouting between both
data centres.
The DCC shall do one or more of the
following:
Incident Parties will
experience loss of connectivity
to Services via the DCC User
Gateway Connection.
1. In the event of a Services
interruption, when advised by
the DCC, Incident Parties shall
suspend submission of Service
Requests and Signed PreCommands via the DCC User
Gateway Connection until
Services are restored.
a)
recover connection at the
primary data centre;
b)
recover connection at the
secondary data centre;
c)
recover User connection.
2. In the event of a Services
interruption, when requested
by the DCC, Incident Parties
shall only submit Category 1
Incidents.
3. Upon restoration of impacted
Services, Incident Parties may
recommence submission of
Service Requests and Signed
Pre-Commands (including
submitting any that have failed).
26
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
D10
The DCC experiences a
failure of the systems
used to support the SelfService Interface
The DCC shall do one of the
The DCC shall provide primary &
following:
secondary data centres providing data
services for the DCC Live Systems, with
a) fail over to the secondary
resilient server configuration in the primary
data centre; or
data centre with an active-passive
configuration between data centres.
b) recover Services at the
primary data centre.
All configurations & data shall be backed
up & backups are stored offsite. There are
resilient network links to the DCC User
Gateway Connection with automatic
rerouting between both data centres.
Incident Party Impact
Incident Party Actions on
failure, failover or failback
Incident Parties would
experience loss of connectivity
to Services via the Self
Service Interface.
1. When requested by the DCC,
Incident Parties shall suspend
submission of Service Requests
and Signed Pre-Commands
until notified that Services have
been restored.
Incident Parties may
experience a loss of all
Services, with the exception of
some Testing services which
operate from the secondary
data centre during the failover
to the secondary data centre
and on failback to the primary
data centre.
2. Upon restoration of impacted
Services, Incident Parties may
recommence submission of
Service Requests and Signed
Pre-Commands (including
submitting any that have failed).
3. Incident Parties may need to log
in to the Self Service Interface
again.
4. When requested by the DCC,
Incident Parties shall take each
of the actions identified in
column 6, rows D5 to D12
inclusive and row D15 of this
table as relevant when DCC
fails over from or fails back to
the primary data centre.
27
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
Incident Party Impact
Incident Party Actions on
failure, failover or failback
D11
The DCC experiences a
failure of the connection
between the service
providers referred to in
paragraphs 1.2(a) and
1.2(b) of Schedule 1 of the
DCC Licence (DCC WAN
Gateway).
The DCC shall provide primary &
secondary data centres providing data
services for the DCC Live Systems, with
resilient server configuration in the
primary data centre with an activepassive configuration between data
centres.
The DCC shall do one of
the following:
Incident Parties may
experience a delay or failure in
the processing of Service
Requests, Commands,
Responses and Alerts.
1. When requested by the DCC,
Incident Parties shall suspend
submission of Service Requests
and Signed Pre-Commands
until notified that Services have
been restored.
Incident Parties may
experience a loss of all
Services during the failover to
the secondary data centre.
2. Upon restoration of impacted
Services, Incident Parties may
recommence submission of
Service Requests and Signed
Pre-Commands (including
submitting any that have failed).
a)
fail over to the secondary
data centre; or
b)
recover connection at the
primary data centre.
All configurations & data shall be backed
up & backups are stored offsite. There
are resilient network links to the data
centres providing communication
services.
Incident Parties would also
experience a short impact on
all Services on failback to the
primary data centre.
Commands, Responses & Alerts shall be
cached.
D12
Loss of the systems used
to support
Communications Hub
ordering.
The DCC shall provide dual instances of
the order management system in
resilient configuration across primary and
secondary data centres.
All configurations & data are backed up
with backups stored offsite. The DCC
shall provide multiple network links &
diverse routing.
The DCC shall do one or more of the
following:
a) capture orders using
electronic or paper forms;
b)
restore the system from
backups; and
c)
on restoration of the system,
the DCC shall ensure that all
captured orders are entered.
28
Restoration of the CH
Ordering System will not
impact Incident Parties.
3. When requested by the DCC,
Incident Parties shall take each
of the actions identified in
column 6, rows D5 to D12
inclusive and row D15 of this
table as relevant when DCC
fails over from or fails back to
the primary data centre.
1. In the event of a service
interruption, Incident Parties
shall submit orders as
requested by the DCC.
2. No action is required from
Incident Parties on restoration
of the system.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
Incident Party Impact
Incident Party Actions on
failover or failback
D13
The DCC loses its
primary data centre
provided pursuant to
the (SMKI) contract
referred to in Schedule
1 of the DCC Licence.
The DCC shall provide instances of the
SMKI service infrastructure at primary &
secondary SMKI data centres in an
active-passive configuration with full
data replication between sites and
resilient network links to the Data
Service Provider.
The DCC shall do one of
the following:
Incident Parties would be
unable to request new
Organisational or Device
Certificates during failure,
failover or failback to the
primary data centre.
1. When requested by the DCC,
Incident Parties shall suspend
transmission of Certificate
Signing Requests.
Incident Parties may be
unable to request new
Organisational or Device
Certificates.
1. When requested by the DCC,
Incident Parties shall suspend
submission of Certificate
Signing Requests until Services
have been restored.
a)
fail over to the secondary
data centre; or
b)
recover Services at the
primary data centre.
The DCC shall backup all SMKI
configurations & data and shall store
backups offsite.
D14
The DCC loses both
primary & secondary
data centres provided
pursuant to the (SMKI)
contract referred to in
Schedule 1 of the DCC
Licence.
The DCC shall maintain full off-site
configuration & data backups.
The DCC shall:
a)
Restore failed services at
one of the existing
datacentres; or
b)
restore failed Services to
new infrastructure at an
alternative data centre
and shall then redirect
network links to the
alternate data centre.
29
2. Upon restoration of impacted
Services, Incident Parties may
recommence submission of
Certificate Signing Requests
(including submitting any that
have failed).
2. Upon Services restoration,
Incident Parties may resubmit
failed Certificate Signing
Requests.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
Incident Party Impact
Incident Party Actions on
failure, failover or failback
D15
A failure of a connection
or interface between
one or more
Registration Data
Providers (RDP) and
the DCC
There are resilient network links to the
Registration Data Providers from both
primary and secondary data centres.
The DCC shall do one or more of
the following:
There may be a delay in the
update of registration data on
the DCC. This may cause
some Service Requests to fail
registration data checks even
though the Party submitting
them is an Eligible User.
1. Upon service restoration,
Incident Parties may resubmit
failed Service Requests.
There would be no impact on
Incident Parties from
a
single communications service
data centre failure.
1. No action would be required
from Incident Parties to resolve
this Incident.
D16
The DCC loses a data
centre provided pursuant
to the (communications
services) contract
referred to in paragraph
1.2(b) of Schedule 1 of
the DCC Licence.
The DCC shall provide primary &
secondary sites for communication
services data centres in an active-active
configuration. All configurations & data
are backed up and backups are stored
offsite.
In the event of failure of one
communications service data centre,
Services would continue to be provided
from the secondary data centre.
a)
recover connection at the
primary data centre;
b)
recover connection at the
secondary data centre;
c)
recover connection to the
Registration Data
Provider; or
d)
Send and receive
Registration update by
alternative (secure) means.
The DCC shall:
a)
b)
restore the provision of
Impacted Services at the
affected communications
data centre; or
restore the provision of
impacted Services at a new
data centre.
30
Restoration of the existing
data centre will not impact
Incident Parties.
2. When requested by the DCC,
RDPs shall send and receive
updates by alternative (secure)
means.
2. Restoration of the existing data
centre will not require action
from Incident Parties.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
Incident Party Impact
D17
The DCC loses both data
centres provided pursuant
to the (communications
services) contract referred
to in paragraph 1.2(b) of
Schedule 1 of the DCC
Licence.
The DCC shall maintain full off-site
configuration & data backups.
The DCC shall:
Incident Parties may be
1. When requested by the DCC,
unable to send Commands to
Incident Parties shall suspend
Devices or receive Responses
submission of Service Requests
and Device Alerts via the DCC
and Signed Pre-Commands
and will experience loss of
until notified that Services have
some Services.
been restored.
The service provided
pursuant to the contract
referred to in paragraph
1.2(b) of Schedule 1 of the
DCC Licence experiences
multiple access node
failure.( Failure of a single
access node would not be
regarded as a DCC
Disaster).
The DCC has significant, although not
complete, overlap between access
nodes.
D18
The DCC shall ensure that access nodes
are of a resilient design and that it has
sufficient provision of mobile equipment
and components spares to restore
service within acceptable timescales.
a)
restore impacted Services
to new infrastructure at the
affected location(s); or
b)
restore services at an
alternative data centre(s)
The DCC shall:
a) deploy field maintenance
and/or mobile equipment to
restore Services.
31
Incident Party Actions on
failure, failover or failback
2. Incident Parties shall also
comply with all reasonable DCC
requests to assist with
prioritising & phasing back
transmission of Service
Requests.
Incident Parties may
experience the failure of
impacted Services directed to
meters, Communications
Hubs and Gas Proxy
Functions in the affected
area(s).
1. Upon Services restoration,
Incident Parties may resubmit
failed Service Requests.
Incident Management Policy
Disaster ID
DCC Disaster Impact
DCC Mitigation
DCC Recovery Action
Incident Party Impact
Incident Party Actions on
failure, failover or failback
D19
Communications Hub
Product Recall
The DCC has more than one source for
Communications Hubs.
The DCC shall:
This could result in Incident
Parties diverting field staff to
uninstall affected
Communications Hubs,
resulting in delays in
installations. It might also
impact stocks and future
supply.
1. Incident Parties shall
provide reasonable assistance
to the DCC in resolving issues.
a)
determine the nature and
extent of the problem; and
b)
notify all Incident Parties of
the extent of product recall
required and effects on
existing stocks and future
supply.
Buffer stocks are held by the DCC and
Communications Hub manufacturers.
D20
Loss of a site housing a
DCC service function
The DCC shall have arrangements in
place to resume all activity at an alternate
location as part of its business continuity
arrangements.
The DCC shall:
a)
relocate the service function
to the designated recovery
site & shall restore service
from there; or.
b)
Recover at services at
existing site
Incident Parties maybe unable 1. There is no action required from
to contact the affected service
Incident Parties.
function until it has been
recovered at an alternate
location.
Table 3 – Business Continuity and Disaster Recovery Procedures
32
Social Media Policy
This sample policy was ruled lawful by the NLRB in a May 2012 Operations Management Memo
At [Employer], we understand that social media can be a fun and rewarding way to share your
life and opinions with family, friends and co-workers around the world. However, use of social
media also presents certain risks and carries with it certain responsibilities. To assist you in
making responsible decisions about your use of social media, we have established these
guidelines for appropriate use of social media.
This policy applies to all associates who work for [Employer], or one of its subsidiary companies
in the United States ([Employer]).
Managers and supervisors should use the supplemental Social Media Management Guidelines
for additional guidance in administering the policy.
Guidelines
In the rapidly expanding world of electronic communication, social media can mean many
things. Social media includes all means of communicating or posting information or content of
any sort on the Internet, including to your own or someone else’s web log or blog, journal or
diary, personal web site, social networking or affinity web site, web bulletin board or a chat
room, whether or not associated or affiliated with [Employer], as well as any other form of
electronic communication.
The same principles and guidelines found in [Employer] policies and three basic beliefs apply to
your activities online. Ultimately, you are solely responsible for what you post online. Before
creating online content, consider some of the risks and rewards that are involved. Keep in mind
that any of your conduct that adversely affects your job performance, the performance of fellow
associates or otherwise adversely affects members, customers, suppliers, people who work on
behalf of [Employer] or [Employer’s] legitimate business interests may result in disciplinary
action up to and including termination.
Know and follow the rules
Carefully read these guidelines, the [Employer] Statement of Ethics Policy, the [Employer]
Information Policy and the Discrimination & Harassment Prevention Policy, and ensure your
postings are consistent with these policies. Inappropriate postings that may include
discriminatory remarks, harassment, and threats of violence or similar inappropriate or unlawful
conduct will not be tolerated and may subject you to disciplinary action up to and including
termination.
Be respectful
Always be fair and courteous to fellow associates, customers, members, suppliers or people
who work on behalf of [Employer]. Also, keep in mind that you are more likely to resolved workrelated complaints by speaking directly with your co-workers or by utilizing our Open Door
Policy than by posting complaints to a social media outlet. Nevertheless, if you decide to post
complaints or criticism, avoid using statements, photographs, video or audio that reasonably
could be viewed as malicious, obscene, threatening or intimidating, that disparage customers,
members, associates or suppliers, or that might constitute harassment or bullying. Examples of
such conduct might include offensive posts meant to intentionally harm someone’s reputation or
posts that could contribute to a hostile work environment on the basis of race, sex, disability,
religion or any other status protected by law or company policy.
Be honest and accurate
Make sure you are always honest and accurate when posting information or news, and if you
make a mistake, correct it quickly. Be open about any previous posts you have
altered. Remember that the Internet archives almost everything; therefore, even deleted
postings can be searched. Never post any information or rumors that you know to be false
about [Employer], fellow associates, members, customers, suppliers, people working on behalf
of [Employer] or competitors.
Post only appropriate and respectful content

Maintain the confidentiality of [Employer] trade secrets and private or confidential
information. Trades secrets may include information regarding the development of
systems, processes, products, know-how and technology. Do not post internal reports,
policies, procedures or other internal business-related confidential communications.

Respect financial disclosure laws. It is illegal to communicate or give a “tip” on inside
information to others so that they may buy or sell stocks or securities. Such online
conduct may also violate the Insider Trading Policy.

Do not create a link from your blog, website or other social networking site to a
[Employer] website without identifying yourself as a [Employer] associate.

Express only your personal opinions. Never represent yourself as a spokesperson for
[Employer]. If [Employer] is a subject of the content you are creating, be clear and open
about the fact that you are an associate and make it clear that your views do not
represent those of [Employer], fellow associates, members, customers, suppliers or
people working on behalf of [Employer]. If you do publish a blog or post online related to
the work you do or subjects associated with [Employer], make it clear that you are not
speaking on behalf of [Employer]. It is best to include a disclaimer such as “The postings
on this site are my own and do not necessarily reflect the views of [Employer].”
Using social media at work
Refrain from using social media while on work time or on equipment we provide, unless it is
work-related as authorized by your manager or consistent with the Company Equipment
Policy. Do not use [Employer] email addresses to register on social networks, blogs or other
online tools utilized for personal use.
Retaliation is prohibited
[Employer] prohibits taking negative action against any associate for reporting a possible
deviation from this policy or for cooperating in an investigation. Any associate who retaliates
against another associate for reporting a possible deviation from this policy or for cooperating in
an investigation will be subject to disciplinary action, up to and including termination.
Media contacts
Associates should not speak to the media on [Employer’s] behalf without contacting the
Corporate Affairs Department. All media inquiries should be directed to them.
For more information
If you have questions or need further guidance, please contact your HR representative.
Fixed Asset Policy & Procedures
______________________________________________________________________________________
Content
1. Purpose ..........................................................................................3
2. Definitions ......................................................................................3
3. Responsibility ..................................................................................3
4. Tagging and Identifying Inventoriable Assets.......................................4
5. Additions to Fixed Assets ..................................................................4
6. Transfer of Assets ............................................................................5
7. Disposition of Assets ........................................................................6
8. Conducting Physical Inventory ...........................................................6
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Fixed Asset Policy & Procedures
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1. Purpose
The purpose of this manual is to set forth the regulations and procedures governing
the control and reporting of capital and controlled assets. It is intended to assist
personnel in implementing and maintaining an effective property control program.
The implementation of an effective and accurate process for tracking fixed assets is
necessary for several reasons:



Our organization prepares financial information using the Generally
Accepted Accounting Principles (GAAP). Government regulations require
us to track an asset’s cost, depreciation, and the disposal of the asset.
Assets that will be depreciated have been categorized and assigned a
depreciation life. (For example, technology equipment has an expected
book life of five (5) years).
We also utilize asset records for insurance purposes. In the event of a
loss it is necessary to have an accurate record of the asset to ensure
adequate insurance coverage, of the item lost.
The most important reason is accountability. Assets are purchased
using taxpayers’ funds. It is important to have a process in place to
account for the use of taxpayers’ funding.
2. Definitions
For the purpose of these policies and procedures the following definitions apply.
Assets
Refers to both “capital” and “controlled assets” when used without specifically
indicating either.
Capital Assets
Refers to real or tangible personal property having:

A value greater than or equal to the capitalization threshold for the particular
classification of the capital asset;
and

Having an estimated useful life of greater than one year from the time of
acquisition.
Controlled Assets
Refers to those items with a historical cost of less than $1000, but which are
particularly at risk or vulnerable to loss or theft.
3. Responsibility
Asset Management Sponsor
The Asset Management Sponsor shall be responsible for administering the policy
and related regulations and procedures.
Administrator
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Fixed Asset Policy & Procedures
______________________________________________________________________________________
The Administrator is responsible for custody and control of assets assigned to the
applicable department/facility.
Asset Management Coordinator
The Asset Management Coordinator is responsible for coordinating asset audits
and physical inventories with the asset management provider as well as
recording capital asset acquisitions, transfers, and disposals.
4. Tagging and Identifying Inventoriable Assets
Reason to Tag
To identify inventoriable assets as belonging to the organization.
What to Tag
All furniture and equipment with a replacement value above $1,000 must be
tagged, including, but not limited to:




Furniture
Computers and Laptops
Audio Visual Equipment
Other equipment above $1,000 such as kitchen, health and fitness, or office
machines
Controlled Assets
Include assets that are sensitive, portable, or prone to theft.
When to Tag
All items shall be tagged upon receipt.
When Not to Tag
When impractical or impossible. Reasons not to mark are, but are not limited to,
when the item:



Has a unique, permanent serial number usable for identification, security, and
inventory control (such as vehicles);
Would lose significant historical or resale value if marked; and,
Would have its warranty negatively impacted if permanently marked.
Method for Marking
Items shall be marked or tagged with a property tag.
5. Additions to Fixed Assets
In order to maintain accurate asset records, when receiving a new asset into the
organization, the first step is to determine if the asset should receive a property tag.
Any item that the cost exceeds $500 and has a life greater than one year should be
tagged. Additional items to be barcoded regardless of their value include controlled
items such as overhead projectors, printers, televisions, DVD players, video
cameras, digital cameras, fax machine, PCs, monitors, laptop computers, tablets,
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Fixed Asset Policy & Procedures
______________________________________________________________________________________
two-way radios, and any item which may be easily stolen. If you have questions
concerning a specific asset, contact
Once an asset has been labeled, it needs to be recorded. The Fixed Asset
Maintenance Form is used to reporting all adjustments required in the Fixed Asset
Master File. When receiving a new asset, fill out the following columns:







Code: Refer to the bottom of the form for codes. The code “A” is used for new
assets.
Barcode Number: Fill in the number shown on the bottom of the barcode label
that was placed on the asset.
PO Number and/or Cost: Fill in the cost of the asset and/or the number if the
purchase order used to purchase asset. Note: We must have a cost and/or
PO# to add an asset to the system. This enables a value for the asset to be
established and my help to determine the source of funding by account
number.
Room Number: Room number where asset is primarily located.
Asset Description: Brief description of the item.
Make/Model: Use the manufacturer’s name and model number.
Serial #: Use the manufacture’s serial number.
The Fixed Asset Maintenance Form shall be completed in entirety and forwarded
to Business and Finance.
6. Transfer of Assets
In order to maintain accurate asset records, asset transfers shall be recorded
promptly. A permanent transfer is one that has no current plans of return.
The administrator transferring equipment will complete a fixed asset maintenance
form. Information required on the form includes:




Code: Refer to the bottom of the form for codes. The code “T” is used to
transfer and asset.
Barcode Number for Fixed Asset: The building administrator must note the
Fixed Asset number located on the barcode affixed to the asset, or obtain the
number from the Fixed Asset listing that identifies the correct item. Consult
the Fixed Asset listing for the proper asset number.
Complete description of the item, including brand, model, etc. “DVD player”
or “Laptop Computer” is not sufficient to properly identify the property.
Identify the destination of the item. Send a copy of the form to Business and
Finance and the receiving building’s administrator.
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Fixed Asset Policy & Procedures
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7. Disposition of Assets
In order to maintain accurate asset records, asset disposals shall be recorded
promptly. These records shall reflect whether the items have been surplused, traded
in, sold, stolen, or destroyed. When property is beyond repair or is no longer
needed, the equipment item must be returned to the Service Center for appropriate
disposal. IT equipment will be disposed of by IT Department.
The administrator will complete a fixed asset maintenance form. Information
required on the form includes:


Barcode of Fixed Asset Number. The building administrator must note the Fixed
Asset Number located on the barcode affixed to the asset or obtain the number
from the fixed asset listing that identifies the correct item. Consult the Fixed
Asset Listing for the proper asset number.
Complete description of the item, including brand, model, serial number, color,
and size, etc. “Color Monitor or Desk” is not sufficient to properly identify
property.
Send completed form to Business and Finance.
8. Conducting Physical Inventory
A physical inventory will be conducted annually for all inventoriable assets.
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PRODUCT MANAGEMENT FRAMEWORK
Erik Bjernulf, PM Creator
Magnus Billgren, CEO and founder
Tolpagorni Product Management AB
CA 1001 001 08 Tolpagorni Product Management Framework
Abstract
This paper outlines the art and science of product management. It creates a
framework not only for the role product manager and the function but also for the
process.
Product management is a key organizational process for high tech B2B companies
involving more or less all parts of the company.
The Product management arena is defined as four key areas:
-
Insight creation
-
Product strategy
-
Product planning
-
Product marketing (go-to-market)
We look into the organizational boundaries and interfaces seen from the product
management perspective.
A maturity model for product management is introduced. How can we reach high
performing levels?
© TOLPAGORNI product management AB 2016
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Eight Tools for Successful PM
[2]
The Product Management Arena, PMA
Definitions of product management are roughly the same around the globe and in
various industries. In some cases, Product marketing is treated as a separate role –
the degree of responsibility for overall profitability, deliveries and sales forecasts
varies quite a lot. We define PM as four key areas:

Product planning: Making sure that the right product is offered

Product marketing: Enabling the product to reach its potential

Product strategy: The guide for product value delivery over the life cycle

Creating insights: Understanding legacy, ecosystems/markets and driving forces
Inner Loop
Fig. 1 Product management arena, Inner Loop
In the complex environment of today, in particular for B2B technology companies, we cannot
longer use a simple value chain model to describe our business. Often our competitors are
marketing friends and customers at the same time. We need to introduce the concept of an
ecosystem where actors interact in various ways and there are multiple interdependencies.
As product managers we want to identify and leverage market opportunities in our
Ecosystem. As a rule, rather than an exception, we create solutions to solve multi-dimensional
user problems. Sometime we deliver products and services on our own – but more often our
products are integrated and used in combination with other components.
© TOLPAGORNI product management AB 2016
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[3]
So, how do we move forward and plan for new products? How do we get through the Fuzzy
Front End? How do we generate a fantastic launch?
We often see companies developing products they cannot sell. We often see companies
selling things that aren’t developed. High performing Product Management enables
companies to sell what is developed and develop what we can sell.
The Product Strategy connects selling with development. Making sure what we develop can
and will be sold – and that we market what we have in our portfolio (or Roadmap). The
Product strategy shall be aligned with overall corporate directions and goals. In some cases
the corporate strategy can be developed by the Product Strategy. A product manager must
never wait for the corporate strategy. Without Product strategy we cannot do the job of
product management. The Product strategy shall be used in product planning but also in
product marketing.
In order to create a successful strategy, it is essential to have what we call Insights. Obviously
we want to know what will happen to supporting technology, customer segments, and new
disruptive innovations preparing ground for new solutions. We want to have good grip on
market trends – how will our target market evolve over the coming period? Product
Management needs to look into the future and act on it.
Insights is also about our own capabilities and strategies. What is (really) the intention from
corporate management? Is it realistic that our R&D department can produce cutting edge
designs? Do we have the right skill set in our sales force to sell not only products but
complete solutions including an extensive service offering?
© TOLPAGORNI product management AB 2016
www.tolpagorni.com
Eight Tools for Successful PM
[4]
Outer Loop
Fig. 2 Product management arena, Outer loop
In some companies Product Managers are stuck with operational support to ongoing
deliveries and projects. Solving technical and delivery issues which are popping up every now
and then. Product Managers are also sometimes key technical sales support if the sales force
is lacking product know-how on their own. This work will drastically reduce the Product
Manager’s ability to deliver the core of Product Management.
Another dimension is actual business forecasting. The work of product management builds
the basis for scaling up the business. Delivery units, sales units, support units etc need to be
activated. We often see situations were sales forecasts are going down when we start to
approach the launch date. What was a realistic (?) ambition level when creating the business
case is suddenly difficult when we need to commit to actual sales volumes? Reality check is a
crucial part of the role as Product Manager. Product Managers must never be afraid to speak
up and give factual input.
In a growing number of companies, corporate management expects product managers to
empower sales and marketing to reach the business goals for each product. The increased
focus of sales empowerment increases the role of Product Management. Staffing the role will
also require additional skills.
© TOLPAGORNI product management AB 2016
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Eight Tools for Successful PM
[5]
Fig. 3 Three pillars of Product Management
Product management role is built on three pillars:

Product Planning

Product Strategy

Product Marketing
Product planning and Product marketing are clear outputs from Product Management. To be
successful a Product Strategy is needed in aligning the two areas.
Insights – not only the market insights – is the foundation for generating a product strategy
and to tie it all together.
A main challenge for the individual product manager is to juggle with them all in parallel!
But – where do we start? The problem is often to be found in product planning or in product
marketing. But to deliver it we need the strategy and the insights.
© TOLPAGORNI product management AB 2016
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Eight Tools for Successful PM
[6]
Product Management Interfaces, PMI
When drawing a picture of any part of an organization your own part often ends up in the
middle. In the case of product management this is certainly true – very few other functions
interact with the entire company.
Key interfaces for a product manager are: corporate management, development, operations
and sales & marketing.
Fig. 4 Key interfaces of Product Management
Management
PM delivers “product investment proposals” and receive “project budgets” for R&D and
marketing campaigns and activities in return. We talk about the Product Governance process
and involves steering groups and product councils.
© TOLPAGORNI product management AB 2016
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[7]
There should also be a continuous process of aligning corporate strategies vs product
strategies. Often new insights and opportunities, having a profound impact on the future of
the company, are originating from the PM team
Development
Tolpagorni deploys regularly surveys in the PM community. Results show that overall product
managers spend in average 50% of their time handling requirements and product planning.
Efficient and effective collaboration with the R&D teams is critical for product success.
In a typical setup the ratio between developers and product managers are close to 20:1 .
The reality is that product managers will often have to adopt to the R&D ways of working.
The Agile environment sets very different requirements on a PM compared to a traditional
waterfall project organization.
A key responsibility of product management is to define product requirements but also to
convey an understanding of context – the domain know how.
Delivery organization
Sales forecasts are coming from different sales regions and channels. In some companies’
product managers are asked to at least “check out” – sometime even approve consolidated
sales and/or production forecasts. Companies might want a matrix control – per region (for
all products/Sales director) but also per product (for all regions/Product director).
If sales are way above forecasts product managers might be asked to participate or even take
final decisions on allocation.
In critical situations Product management needs to get involved in the delivery work. To
avoid line stops in own production (one component is not available – can we replace it?) – or
at a customer (can they accept a product deviation?) product managers again can be
involved.
In service intensive organizations Product Management should take an active part in the
process design and competence build up. These are fundamentals in scaling up the service
focused business. The process and the competence build up should be treated as a part of
the product.
Sales & Marketing
The Product Brief is your consolidated product presentation to marketing. Defining the key
unique selling point (USPs) and the value you deliver with your product. Who are the target
Personas? What are the target applications? What is your resonating focus?
In return from sales you would expect a lot of market and customer insights.
© TOLPAGORNI product management AB 2016
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[8]
Real customers in the market
Sales departments always filter a lot of useful information. They cannot share all their insights
with you. Sales has a different objective compared with Product Management. Sales will and
shall always focusing in getting the next customer on board. Product management must act
to create a sustainable business over time. Product management can never rely on having
sales as a proxy for market information. There is no substitute from seeing actual existing (or
potential new) customers. In fact – product managers are highly appreciated by customers.
They see product managers as reliable and trustworthy and not as a salesperson. This gives
product mangers a unique opportunity to collect true insights from direct customer contacts.
The Product Management Maturity Model, PMMM
Product management is one of few positions in a company where you can indeed
pursue your career and take giant steps without actually changing formal positions.
“Going from being reactive, giving support to driving the business is a big difference”
Fig. 5 Three levels of Product Management Maturity
At Tolpagorni we have developed a maturity model for product management. This is not only
confined to your skills and competences but also to the product management process. In
order to reach higher level, you would need acceptance and support from (corporate)
management, Sales and R&D.
© TOLPAGORNI product management AB 2016
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[9]
Let us combine the Product Management working arena with the Maturity Model.
Product planning
At a basic level the product manager will just collect requirements from all stakeholders and
hand over the compiled list to development. At the highest level you would inform about the
context (target market and Personas), give direction and enable individual developers to take
their own decisions, eg when composing every single line of code or designing the
mechanics for the casing. You will also drive the requirements. Telling marketing and sales
where you want to go. What kind of projects are we looking for? What kind of requirements
will be approved?
Fig. 6 Acting at maturity levels
Product Marketing
The basic product manager produces the marketing items on the checklist. We probably
provide a good and useful slide deck for the upcoming customer visit. The High Performing
product manager identifies target applications, discovers pains and gains for the customer,
and the journey for solving them. The High Performing Product Managers build a journey for
our customers’ success and a resonating focus for our product.
Product Strategy
There are many schools describing how strategies should be created. After all – it is not that
difficult. What is trickier is to implement strategies in products and in our product
management work. The tools we use are directly connected to the strategy. It can be how we
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Eight Tools for Successful PM
[10]
prioritize requirements. It can be deciding in which customer we do user studies by. It can be
in what order we launch a new product line.
The Tolpagorni Product Management Framework, TPMF
The Tolpagorni Product Management Framework is based on the one from ISPMA.
We have chosen to add some boxes, in particular to address not only software
intensive products – but all kinds of products including HW and services.
Fig. 7 Product management framework
Main areas
Strategic management is an activity within an organization with the content to define, plan,
agree, implement and evaluate the organization’s strategy.
Product strategy is the guide for profitability for one particular product (family), creating
strategic assets.
Product planning is the core responsibility to define the product offering over time.
Development – all technical product aspects including the implementation of changes and
extensions to the product.
Marketing – marketing and deployment of products.
Sales and Distribution includes supply chain, sales and distribution to customers.
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[11]
Service and Support – all services offered and provided to customers. This includes both
product-related services and consulting services that are not product-related. Product-related
services can include education, installation, customization, operations, and user help desk
covering technical and non-technical problems.
Typical responsibility for Product Management
Participation: strategic management (responsibility within corporate management)
Core: insights, product strategies, product positioning, pricing, ecosystem management,
product launches, value analysis
Orchestration: directing other parts of the company – in particular R&D and
marketing
Participation of product management
Corporate Strategy consists of vision, mission, values and goals, corporate positioning,
business model and financial plan, product portfolio and its evolution, resource and
competency evolution, technology trends and innovation strategy, market trends and
competitive strategy, policies and governance.
Portfolio management is the process where the overall offerings in the portfolio is balanced
and investment decisions are taken.
Innovation management is the corporate process to organize for (disruptive) innovation in
general. Including technical and business innovation.
Resource management is the organizational, strategic and budgeting process to plan and
secure resources for development, sales etc.
Core responsibility of product management
Market analysis includes quantitative and qualitative reporting on segments, customer values
and market trends.
Product analysis is the financial and quality reporting and analysis of the entire portfolio of
products.
Insights are based not only on market and product analysis but also a deeper understanding
of legacy, ecosystem, capabilities and driving forces.
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[12]
Positioning and definition includes: functional and quality scope, intended use and users, UX
and the complete set of components determining the offering. Value definition (from a
customer perspective), focus with regard to target market and segments, company product
portfolio and product life cycle phase (e.g. revitalization), channel options and required
partnerships and alliances.
Delivery model & Service strategy about how to deliver the offering, standards vs
customization, packaging – included services.
Sourcing includes the buy or make decision as well as strategies for suppliers
Business case and costing is about cost estimates and ROI calculations for investments.
Pricing includes building a price pyramid including values, structure, policy and price levels.
Ecosystem management includes collaboration regarding requirements, development,
marketing, sales, distribution, and services
Legal and IPR management is everything from supplier/customer contracts to protecting
intellectual property.
Performance and Risk management is about continuous tracking and analysis of selected
relevant measures; timely action taking if needed. Risk management is continuous tracking
and analysis of risks; timely action taking if needed
Product life cycle management is taking the right actions from a marketing and technical
perspective in order to increase profitability over life time of the product.
Roadmapping is the strategic process where a roadmap is created. The roadmap contains
both market, business and technical development over time. A roadmap is a powerful
strategy communications tool.
Release planning is the process where new and/or improved functionality/values are planned
in time for a particular release or product version. Market needs and own capabilities have to
be considered.
Product requirements engineering is the process to gather, structure and prioritize
requirements for a particular product or offering.
Product architecture is the strategic process where the overall offering is structured into
modules and platforms with identified interfaces. Platforms is not only technical but also eg
ways-of-working.
Product launches mean the introduction of a new product, version or release to the market.
Value analysis means defining the values offered to the customer and create a corresponding
product story – e.g. using the Value Tree model.
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Eight Tools for Successful PM
[13]
Orchestration by product management
Engineering management includes (technical) system architecture, development processes
and tools, configuration management, knowledge management, resource and skills
management, Development sourcing and estimations.
Project management is about execution of development activities. Depending on
methodology (agile/V-model etc) this is handled in different ways.
Project requirements engineering is the process of defining the content of a particular
development effort. Sometimes one project covers several products. In agile this is about
defining the Backlog.
User experience design addresses every aspect of the buyer’s/users’ interactions with a
product or component with the purpose of shaping behaviors, attitudes, and emotions about
that product or component
Quality Management in this context includes all technical quality aspects – including testing.
Marketing planning addresses the development and negotiation of plans for all marketingrelated activities during a given timeframe, often a year, including respective budgets.
Customer analysis means the frequent analysis of existing or potential customers or groups
of customers with regard to additional business opportunities and retention.
Opportunity management means the continuous pursuance of identified business
opportunities with the objective to turn these opportunities into concrete product success.
Marketing mix optimization means the selection, implementation and management of
channels appropriate for a product and the management of marketing partners within the
product ecosystem.
Operational marketing means the execution of the marketing plan, tracking of the relevant
measurements and taking corrective actions when measurements deviate from plan.
Sales planning addresses the development and negotiation of plans for all sales-related
activities during a given timeframe, often a year, including target values and incentives.
Channel preparation means that the selected channels are enabled in time to sell a new
product, version or release.
CRM or customer relations management means the systematic management of a company’s
interactions with customers, clients, and sales prospects.
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[14]
Operational Sales includes the execution of the Sales Plan, tracking of the relevant
measurements and taking corrective actions when measurements deviate from plan.
Operational Distribution means ensuring smooth order and distribution processes, stable and
easy order and distribution and smooth and correct billing/payment.
Supply Chain Management means all aspects of monitoring and taking actions to improve
overall supply chain performance.
Service and Support – all services offered and provided to customers. This includes both
product-related services and consulting services that are not product-related. Product-related
services can include education, installation, customization, operations, and user help desk
covering technical and non-technical problems.
Service Planning and Preparation address the development and negotiation of plans for all
product service-related activities during a given timeframe, often a year, including target
values and incentives.
Service provisioning is the execution of the service plan, tracking of the relevant
measurements and taking corrective actions when measurements deviate from plan.
Technical support means the fulfillment of maintenance contracts.
Marketing support means providing help to Marketing. It may include the production and
distribution of marketing material, organization and execution of marketing events
(conferences, user groups etc.) and documentation and tracking of marketing activities and
their results
Sales support means providing help to sales representatives and channels
© TOLPAGORNI product management AB 2016
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Eight Tools for Successful PM
[15]
References
EXPERIENCE
The paper is written based on experience working with great companies like: Ericsson, ABB, Wurth,
Tetra Pak, Scania, Volvo, Hexagon, IBM, Atlas Copco and others.
Scientific foundations are found in research project participation at Blekinge Institute of Technology,
Swedish Institute of computer science, Uppsala University and other fine institutions.
Results have been discussed and tested in co-operation with thought leaders such as: Rich Mironov,
Steve Johnson, Michael McGrath, Hans-Berndt Kittlaus, Adrienne Tan and others.
SOURCES of INSPIRATION and DISCUSSIONS
International Software Product Management Association, ISPMA
www.ispma.org
The Art of product management, Rich Mironov www.mironov.com
Under10 Consulting,
Steve Johnson
www.under10consulting.com
Professor Dr Tony Gorschek www.gorschek .com
McGrath ME (2001) Product Strategy for high technology companies, second edition
The conference Product Leadership Day (2009-2016) with 50-100 Product Managers
Ten Product Management Networks, hundreds of training sessions with product managers
The Business Model Canvas. Osterwald
Inspired – Creating product your customer love, Marty Cagan
About Tolpagorni
Research and Knowledge are the key foundations of Tolpagorni. We take the lead in testing new
strategies and in developing a framework of methods, tools and techniques for effective product
management. We work closely with research organizations and we continuously build our skills
framework through our ongoing projects. We also take an active part in building the Book of
Knowledge (BoK) for the world’s leading organization for Software Product Management (ISPMA).
However, the most important thing for us is to make sure we deliver results to our customers. We
understand that theory on its own will not deliver usable outcomes. We strive to apply our knowledge
in a practical, hands-on approach so that our customers have tools and methods to use in their
everyday work practice. This approach also develops the role of the Product Manager so that they add
value to their business.
All of us who work at Tolpagorni know product management from the inside, because we have done it
ourselves. We believe that the combination of theoretical research and “on-the-floor” pragmatism is
what makes us excel in what we do.
If you want to learn more about Tolpagorni go to www.tolpagorni.com.
© TOLPAGORNI product management AB 2016
www.tolpagorni.com
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[16]
UCL Academic Manual
Chapter 1: Student Recruitment and Admissions Framework
Annex 1.1.1
Market Research Policies and Procedures
Contact: Lydia Harwood, Data and Research Manager
Access to Data and Data Protection
1. The Data and Research Team receives UCL data from Portico Services or the
Student Data Services team. Any data received is stored on the shared UCL drive
and not removed or kept on personal drives. Furthermore, data is kept separately
from analytical tools where possible and names of individual students are removed.
2. Data purchased by Student Recruitment Marketing (SRM) will remain the
responsibility and property of SRM, and often does not have permission to be shared
in its raw state outside the team.
3. Any external purchased data will be dealt with according to contractual obligations
and this will be upheld by the Data and Research Team. Any queries on appropriate
use of purchased data must be directed to the Data and Research Manager.
Market Insight
4. The Data and Research Team will produce annual benchmarking analyses into the
performance of UCL in recruitment, predominantly though the lens of country of
domicile, with additional ad hoc analyses completed where appropriate and beneficial
to the institution.
5. These analyses are not designed to identify individual students, but to understand
trends and performance, and areas for improvement. No data analysed is used for
identifying current or prospective students, but is for informing direction and
understanding performance during the cycle of recruitment.
6. The Data and Research Team also produces regular scorecards informing the wider
internal UCL community of the student recruitment activity throughout the year.
These are distributed to senior management and other stakeholders, although can be
shared more widely within the internal UCL community.
Publications and Media Research
7. Publications research sits within SRM’s redesign processes, as set out in annexes
1.1.3, 1.1.4 and 1.1.5.
8. These research projects will be agreed prior to the beginning of an academic year,
and ideally six months in advance of the research deadline.
9. Publications and media research will be conducted according to the requirements of
the team, but generally is used to identify the enquirer, offer holder, and/or student
needs and wants in publications, alongside other, predominantly external,
stakeholders, including school counsellors and university representatives.
Faculty Research
10. In order for departments to request market research, the Request for Proposed
Programme Market Analysis document (available on the internal CAM website) must
be completed and submitted at least one month prior to any deadlines for the
submission. Good practice is to submit at least six weeks in advance of deadlines.
11. In order for research to be comprehensive, all elements of the request must be
completed to a suitable level of detail, including module proposals and identified
competitors.
12. SRM is only able to conduct secondary research into programme markets. It is
generally advised that departments undertake additional, primary research,
particularly when proposing innovative and unique programmes with few identified
competitors.
13. The majority of the analysis will be completed using HESA and other purchased data.
Due to contractual obligations data must be presented in rounded numbers and the
original datasets cannot be shared outside SRM.
14. The Data and Research Team are able to provide advice and recommendations into
the good practice and techniques to employ primary research where required.
SAMPLE CUSTOMER SERVICE POLICY AND VALUES
STATEMENT
The Gymnastics Center strives for excellence and professionalism in providing customer service,
both inside and outside the organization, within the limits of available, well-managed resources.
To accomplish this mission, we agree upon these values:
q
q
q
q
q
q
q
Anticipating the needs of our customers and planning accordingly
Greeting our customers promptly, cheerfully and respectfully
Listening carefully and giving full consideration to the requests and concerns of our
customers
Communicating honestly, courteously and knowledgeably
Providing follow-through for our customers promptly, responsibly and efficiently
Serving with pride, commitment, and with high ethical standards
Respecting the individual and encouraging participation
Policy Statement
It is the Gymnastics Center’s policy and responsibility to provide excellent service to the public.
Customer feedback helps us measure whether our services are meeting public needs and
expectations. It also helps us identify problems that need to be solved. High quality customer
service depends on customer feedback. While praise is always welcome, constructive criticism is
truly helpful in the long run.
The purpose of this policy is to establish uniform standards and procedures for responding to
customer feedback, thus making sure those responses are timely and that issues do not “fall
through the cracks.” The policy strives to treat every interaction with the public as an opportunity
to produce a satisfied customer, or at least one who feels that he or she was listened to and
taken seriously, even if it was not possible to meet his or her request.
Customer feedback comes to the Gymnastics Center in many ways. This policy outlines a
procedure for responding to complaints, requests for service and questions that come to the
Gymnastics Center Office through a customer visit, call, letter or email. Departments are
expected to use similar standards and procedures for the complaints, requests and questions that
come directly to the department and not through the Gymnastics Center Office.
The policy is not intended to cover:
•
•
Complaints about the performance of specific employees, which are handled by the
department manager in conjunction with the gym owner.
Claims for damages, which are to be filed with the Gymnastics Center Insurance carrier.
Response Standards
When possible, complaints, questions and requests for service should be resolved in “real time”
on the same day they arrive. However, in many instances, referral and follow-up are necessary
in order to fully understand and resolve the issue. In such instances, the following standards for
acknowledgement and resolution should be followed.
gym.net – gymnastics risk management and consultation
Acknowledgement
• All complaints, questions and requests for service should be acknowledged within one
business day.
• This acknowledgement should note the person to whom the issue has been referred and
when the customer can expect a response.
• If the customer feedback is delivered by phone or in person, this acknowledgement should be
given verbally during the call or visit.
• If the customer feedback is delivered by e-mail, the acknowledgement should be given by email.
• If the customer feedback is delivered by postal mail the acknowledgement should be sent via
telephone, postal mail or e-mail, whichever is appropriate.
• For written acknowledgements, templates with standard language should be used to
minimize staff processing time.
Resolution
• A substantive response should be provided within seven business days.
• This response should include the Gymnastics Center’s analysis of the issue and the
proposed resolution. Clear reasons should be given if it is not possible for the Gymnastics
Center to accommodate the customer’s request.
• If a resolution is not possible within seven business days, the customer should be notified
and given the date by which they can expect a response.
• The resolution can be communicated to the customer verbally, by e-mail or by postal mail,
depending on the communication method most appropriate to the situation.
Response Procedure
Calls / Visits to the Gymnastics Center Office
• When a customer calls or visits the Gymnastics Center Office with a complaint, question, or
request for service, the issue should be resolved immediately, if possible, by the Gymnastics
Center Office or by referral to the appropriate department.
• If immediate resolution is not possible, the Gymnastics Center Office will take down the
necessary information and let the customer know when and from whom he or she can expect
a response.
• The department receiving the referral is responsible for resolving the issue per the above
standards.
E-mails or Postal Letters to the Gymnastics Center Office
• When customers send e-mail (or postal mail) to the Gymnastics Center Office with
complaints, questions, and requests for service, the Gymnastics Center Office will send an
acknowledgment e-mail (or postcard) within one business day.
• Of course, if the Gymnastics Center Office is able to answer the question or resolve the issue
right away without referral, it will do so and let the customer know. In such instances, a
separate acknowledgement email (or postcard) is not necessary.
• Also within the first business day, the Gymnastics Center Office will forward the item to the
appropriate department for response, noting the expected resolution date.
• The department receiving the referral is responsible for resolving the issue per the above
standards.
Additional Comments
Since customers do not always know to whom to direct their concerns, any staff member at a
public counter or answering the phone is called upon to be a customer service agent. When
transferring a caller, staff should always take the caller’s number so that they can call back if
need be.
gym.net – gymnastics risk management and consultation
Information Classification Level: PUBLIC
April 2017
___________________________________________________________________________
Document title: Survey Policy and Procedures – 2014
Approval date: April, 2014
Approval of reviewed policy date: April, 2017
Purpose of document: DAIR, as part of its support for assessment of learning and institutional
effectiveness, has developed a survey policy and procedures to help coordinate and support
the development, administration and analysis of surveys at AUC.
Office/department responsible: The Office of Data Analytics and Institutional Research
(DAIR)
Approved by: Sherif Kamel, VP for Information Management
Document classification level: PUBLIC (AUC Community)
Document accessible: http://www.aucegypt.edu/about/university-policies
Document includes: Policy, and related forms
___________________________________________________________________________
Survey Policy and Procedures
Policy Statement
All institutional surveys following the scope below must be coordinated and administered
through DAIR. This is to ensure quality and timing of surveys, maximize benefit from survey
results, and ensure objectivity in analyzing and reporting the results.
SURVEYS COVERED BY THIS POLICY
This policy applies to any broad sampling or census of a population at AUC (including
applicants, former students, and alumni) addressing the internal operations of AUC or topic
directly related to the internal operations of AUC. A survey may be addressed to any part of
the AUC community. Examples of surveys covered by this policy are (but not limited to):
• Surveys that address all faculty, staff, and/or students within the university
• Surveys that are aimed at a broad subset of the population (e.g. first-year student
population)
• Surveys covering a variety of topics (e.g. use and satisfaction with various university
services)
Reason for Policy/Purpose
This policy has been developed in an effort to:
• ensure the use of efficient survey methodology and design
• prevent survey fatigue by limiting the number and timing of surveys
• avoid duplication of data
• maximize response rates
AUC Policy Template • Page 1 of 6
Information Classification Level: PUBLIC
April 2017
•
•
•
•
encourage sharing of results
make sure information provided by respondents remains confidential
ensure the projects in which students, faculty and staff participate are consistent with
the university’s mission and priorities
ensure that projects are conducted in a manner that is consistent with regulatory
requirements such as Family Educational Rights and Privacy Act (FERPA)1
Who Approved This Policy
Ted Purinton, Dean, Graduate School of Education
Ahmed Tolba, Associate Provost for Strategic Enrollment Management
Sherif Kamel, VP for Information Technology
Who Needs to Know This Policy
The entire AUC community.
1
Non-­‐public student data can be used without the student’s consent by college employees for “legitimate educational” purposes provided the data are not reported in such a way that individual students can be identified. All other users must receive written consent from the students to access non-­‐public student data. AUC Policy Template • Page 2 of 6
Information Classification Level: PUBLIC
April 2017
Web Address for this Policy
http://www.aucegypt.edu/about/university-policies
Contacts
Responsible University Official: Heba Fathelbab, Director of Assessment and Accreditation
Responsible University Office: The Office of Data Analytics and Institutional Research
(DAIR)
If you have any questions on the policy or procedure for [ Survey Policy and Procedures ]
, you may:
1. Call Heba Fathelbab at 02 2615 2233
2. Send an e-mail to heba.f@aucegypt.edu
Policy/Procedures
SCOPE
If there is any uncertainty as to whether a survey falls under this policy, DAIR should be contacted
for guidance.
Surveys covered by this policy
This policy applies to any broad sampling or census of a population at AUC (including applicants,
former students, and alumni) addressing the internal operations of AUC or topic directly related to
the internal operations of AUC. A survey may be addressed to any part of the AUC community.
Examples of surveys covered by this policy are (but not limited to):
• Surveys that address all faculty, staff, and/or students within the university
• Surveys that are aimed at a broad subset of the population (e.g. first-year student population)
• Surveys covering a variety of topics (e.g. use and satisfaction with various university
services)
Surveys not covered by this policy
Surveys of a small scale and/or focused intent are not covered by this policy. Such surveys may
include:
• Part of assigned coursework or degree requirements
• Focus groups
• Evaluation of a specific program or service by the faculty or unit offering the program or
service for the purpose of quality assurance review
• Teaching evaluation forms
Note: DAIR is not responsible for surveys that are not covered by this policy.
AUC Policy Template • Page 3 of 6
Information Classification Level: PUBLIC
April 2017
SURVEY COMPLIANCE
•
•
•
DAIR cannot supersede the policies and procedures of the AUC Institutional
Review Board (IRB)2. Researchers are still responsible for obtaining required IRB
exemptions or permissions before implementing any survey particularly if it pertains
to asking questions of a “sensitive nature”3.
All surveys must comply with the requirements of the Family Educational Rights
and Privacy Act (FERPA).
Respondents must be informed that their responses will be confidential and their
participation is voluntary. Confidentiality indicates that the presented information
will not be associated with a specific individual. If email addresses, login credentials
or other personal identifiable information is captured as part of the survey
completion process, confidentiality of the data must be assured.
DATA SECURITY
Departments or offices conducting the survey are responsible for managing obtained survey data.
Released data will not contain any identifiable respondent data. When presenting survey results,
survey administrators are responsible for ensuring the confidentiality of respondents. Departments or
offices conducting surveys must understand and acknowledge that they will have an obligation to
use data compiled responsibly, ensuring that data is not redistributed to parties inside or outside the
AUC community, unless clearly detailed when requesting survey approval.
SURVEY REQUEST PROCESS
Departments and offices wishing to conduct survey research must submit a Survey Request Form
electronically through the DAIR website. The online Survey Request Form will ask for information
regarding the purpose of the survey, intended population, timing of administration, and the survey
questions.
1. Requests requiring samples of more than 200 students or any subset (freshmen, sophomores,
etc.) of all students, faculty or staff should be submitted at least 3 months prior to the
proposed administration date.
2. DAIR will review the survey proposal and will typically respond within one week of the date
it is received.
3. DAIR will work closely with the individuals or offices directly associated with the particular
survey request to gather more information, ensure a team-based approach to decisionmaking, and ensure that efforts are well thought out and coordinated.
4. DAIR will take into consideration certain criteria and questions when reviewing survey
requests and making recommendations. Following are examples of the criteria and questions
that will be requested:
•
Purpose of survey (Why is the survey being conducted?)
•
Importance and Impact (Does the survey provide useful information for academic
or institutional planning? Does the survey overburden respondents?)
•
Overlap with other surveys (Do data already exist that will meet the needs of those
interested in surveying a group? Are there ongoing efforts to collect similar data?)
2
Detailed information about the AUC IRB policy is available on the AUC website: http://www.aucegypt.edu/research/ReviewBoard/Documents/IRBpolicy.pdf 3
“Sensitive information,” according to the National Institutes of Health, includes (but is not limited to): information related to sexual attitudes/preferences/practices; information relating to the use of alcohol, drugs or other addictive products; information pertaining to illegal conduct; information that, if released, might be damaging to an individual’s financial standing, employability, or reputation within the community or might lead to social stigmatization or discrimination; information pertaining to an individual’s psychological well-­‐being or mental health. AUC Policy Template • Page 4 of 6
Information Classification Level: PUBLIC
April 2017
•
Intended use of the data (Who will have access to the information? Are plans in
place to
review the data and use it for programmatic improvement? Do you plan to
disseminate
findings publically and/or publish findings?)
•
Content and design of the survey questionnaire (Is the survey well-designed? Is it
of reasonable and appropriate length? Are the questions easily understood and
interpreted?)
•
Population of interest (Who is the target population? Will the entire population be
surveyed, or a sample? If the former, is a sample an option that should be considered
to lessen the burden on faculty, staff, or students? Does the survey overburden the
target population?)
•
Timing (When will the survey be administered? Does it overlap with other surveys
of the same population? Is it conducted at a time during the academic year when
survey recipients are likely to respond?)
•
Resources (What resources will be needed to conduct the survey? Will data other
than contact information be required?)
•
IRB Approval or Exemption (Is IRB approval or exemption necessary?)
5. Based on the previous criteria, DAIR will then recommend that a survey:
• be administered as is (i.e., no revisions necessary).
• be reconsidered or revised accordingly to ensure it meets the above criteria.
• have its timeline changed to prevent conflicts with other surveys that may be underway.
• not be administered (with good reason provided).
ROLES AND RESPONSIBILITIES RELATED TO SURVEY ADMINISTRATION AND REPORTING
General Responsibilities of DAIR as it relates to Surveys Conducted at AUC
• Update the survey policy and procedures, as needed.
•
Establish and maintain an institution survey calendar on the DAIR website.
•
Maintain a spreadsheet of information regarding each survey, including the purpose of the
survey, its use in quality improvement, and actions taken in response to survey data.
•
Ensure that the institution has in place a plan for continuous quality improvement around
survey data.
•
Produce an annual report summarizing survey activity and use of data for quality
improvement
The following table outlines the roles and responsibilities of DAIR and the survey requester(s)
related to:
1) survey set-up and administration
2) data review, interpretation, and planning.
AUC Policy Template • Page 5 of 6
Information Classification Level: PUBLIC
April 2017
Table 1. Survey Set-up and Administration
Office of Data Analytics and Institutional Research
Survey Requester
(DAIR)
1. Evaluate all survey requests and respond in a
1. Consult with DAIR to inquire about
timely manner.
existing data.
2. Work closely with survey requester during
2. Develop the survey instrument and
survey development process.
submit to DAIR.
3. Serve as a reviewer of the survey instrument.
3. Review Institution Survey Calendar
4. Create surveys or host a survey version designed
on the DAIR website.
by the survey requestor on DAIR's Survey
4. Submit online Survey Request Form.
Monkey account.
5. Work closely with DAIR during the
5. Populate Survey Monkey account with the
survey development process.
names and email addresses for all individuals to
6. Submit to DAIR a list of names and
whom the survey is to be sent or send link to
email addresses for all individuals to
survey requester to send out to respondents.
whom the survey is to be sent.
6. Distribute/launch all surveys and generate
regular reminders for non-responders.
Table 2. Review of Survey Results, Interpretation of Data, and Planning
Office of Data Analytics and Institutional Research
Survey Requester
(DAIR)
• Maintain confidentiality of the data.
• Interpret survey results and identify
areas warranting further discussion
• Compile survey results (raw data, automated
and action.
analyses, and reports).
•
Propose and implement a plan to
• Distribute survey results to survey requester.
address areas warranting further
• Request completed action plans (Survey Result
discussion and action.
Action Plan Form) on an annual basis to
• Document the actions taken in
facilitate completion of DAIR report on surveys.
response to survey data.
• Produce an annual report summarizing survey
• Complete Survey Results Action Plan
activity and use of data for improvement.
Form (available on the DAIR
• Provide a copy of the annual report to the AUC
website).
Planning and Assessment Committee, and post
as a resource on the AUC website.
Forms/Instructions
•
•
•
Survey Request Application Form
Survey Results and Action Plan Form
Helpful Tips for Conducting a Survey at AUC
These forms can be found at: http://www.aucegypt.edu/about/data-analytics-andinstitutional-research/institutional-surveys
Related Information
N/A
Appendices (optional)
N/A
History/Revision Dates
Origination Date: April, 2014
Last Amended Date: Nov, 2016
Next Review Date: April, 2017
AUC Policy Template • Page 6 of 6
New Product Development
Risky Business
95% of new businesses fail in the first 5 years
Failure rates for new consumer packaged goods:
1961
1971
1981
1991
45.6%
53.4%
64.5%
80.0%
Why Introduce New Products?
Large Firms
• If you do not attack your own brands someone else will
(Barco)
• Approximately 30% of corporate profits come from new
products (5 years old or less)
• Innovation by large firms tends to be more incremental
despite:
– additional resources
– greater risk of cannibalization
– lower risk aversion
Why Introduce New Products?
Start-Ups
Not aware of the risks
• Never hear about the failures
• Over-estimate own abilities
Positive expected return despite the risks
• Large upside
• Can manage downside (jumping into a cold pool)
Test Before You Leap
Stage
Idea Screening
Concept Test
Product Development
Test Marketing
National Launch
Ideas
Success
Ratio
64
16
8
4
2
1:4
1:2
1:2
1:2
1:2
Cost /
Idea
Total
Cost
$1,000
$20,000
$200,000
$500,000
$5,000,000
$64,000
$320,000
$1,600,000
$2,000,000
$10,000,000
Stages in the Process
1. Idea generation
2. Screening
3. Concept testing
4. Product development
5. Market testing
6. Launch
Business plan
Idea Generation: Examples
Channel suggestions: aspirin prevents heart attacks
Foreign markets :
Muesli breakfast cereal
Consumers:
Lite beer
Basic research:
nylon
Competitors:
diet colas
Employees:
baking soda is a deodorizer
Existing products:
personal computers
Idea Screening
Conservatively screen impractical, infeasible or unmarketable ideas
Set Criteria:
product can be introduced within 5 years
market potential of at least $50 million
market has at least a 15% growth rate
product will yield at least 30% return on sales
product will yield at least 40% return on investment
product will achieve technical or market leadership
Allow trade-offs between criteria
Separate tasks of sponsoring and evaluating the idea:
start ups need a mentor
banks are not a good screen (SBA distortion)
Concept Testing
Product Concept:
• target market
• needs
Powder to add to milk to increase its nutritional value and taste
•
An instant breakfast drink for adults who want a quick
nutritious breakfast with little preparation
•
A tasty snack drink for children as a midday refreshment
•
A health supplement for older adults to drink before retiring
Concept Testing
A powdered product that is added to milk to make an instant breakfast
providing all of the required nutrition in a convenient, tasty drink. The
product would be offered in chocolate, vanilla and strawberry flavors
and would be packaged individually and sold in packs of 6 for 79 cents.
1.
2.
3.
4.
5.
Does this product satisfy a need for you?
Do other products currently satisfy this need?
Is the price reasonable in relation to value?
Would you purchase this product?
How frequently would you use this product?
Concept Testing
Begin informally (CD exchange service)
If advertising is important, advertise before the product is
available
Do not ignore the results: “just using the wrong copy”
Business Plan
1.
2.
3.
4.
5.
Strategic plan
Tactics
Financial predictions
Timetable
Hurdles
Business Plan: Financial Predictions
Estimate costs:
additive
Estimate demand:
multiplicative
do sensitivity analysis
Estimating demand is even harder when:
–
–
–
–
–
customers have multiple needs
customers’ needs vary (segments)
needs are measured on non-monetary scales
the product is very new/different
the benefits are hard to evaluate (need to predict credibility)
Product Development
Extensive topic of ongoing research
Examples:
1.
Involve suppliers:
–
–
2.
increase surplus (coordination)
share surplus (horizontal competition)
Resolve language problems:
–
House of Quality
Market Testing
Generally optimistic because attention is focussed
Consumer Products:
– Simulated Test
– Controlled Test
– Test Market
Industrial products
– Alpha Test
– Beta Test
– Test Market
Under-test: perceived risk of competitive entry
Launch
Few firms use a national or global launch
Phased roll-out is an extension of market testing
Which markets?
Example
Large industrial equipment manufacturer: EngTech
Idea Generation: Bain & Co.
Idea Screening: Phase 1 research
Concept Testing: Phase 2 research
Product Development: go/no go
Phase 1 Research
Screen out training services that customers do not need
Process: telephone interviews with 20 customers
–
–
–
–
do you need?
what do you currently do?
how much do you spend?
is EngTech appropriate?
Willingness to Pay
NEED
Operator Training
Technician Training
Engineer Training
Management Training
Segment
1
Segment
2
Segment
3
Segment
4
Segment
5
Number of Customers
PROFIT POTENTIAL
Segment
1
Segment
2
Segment
3
Segment
4
Segment
5
Operator Training
Technician Training
Engineer Training
Management Training
Factors: Willingness to Pay
Number of Customers
Cost of Delivery
Overall Attractiveness of Training Options
Operator Training
Technician Training
Engineer Training
Management Training
Phase 2 Research
Objectives:
– identify whether to proceed with Product Development
– identify customer response to different product features
Process:
–
–
–
–
e-mail interview with 20 customers
asked to choose between different product alternatives
varied delivery format, price and length of consulting services
focussed on concepts that survived the Phase 1 research
Phase 2 Results
• Many prefer these alternatives over their current solution.
• Strongly prefer on-site over interactive
• Price insensitive
• More depth is preferable to less depth
• Wide variance in number of operators from each plant who
would be sent for training.
Generic Shipping Policy template
Shipping Policy
Thank you for visiting and shopping at M
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conditions that constitute our Shipping Policy.
Domestic Shipping Policy
Shipment processing time
All orders are processed within 2-3 business days. Orders are not shipped or delivered on
weekends or holidays.
If we are experiencing a high volume of orders, shipments may be delayed by a few days. Please
allow additional days in transit for delivery. If there will be a significant delay in shipment of your
order, we will contact you via email or telephone.
Update this section if your processing time exceeds 2-3 business days.
Shipping rates & delivery estimates
Shipping charges for your order will be calculated and displayed at checkout.
Shipment method
Estimated delivery time
Shipment cost
FedEx Standard
3-5 business days
Free
FedEx Two Days
2 business days
$12.95
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1-2 business days
$19.95
* Overnight delivery is only available for orders with delivery addresses within the continental United
States.
Delivery delays can occasionally occur.
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Shipment confirmation & Order tracking
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Customs, Duties and Taxes
My Website (change this)​ is not responsible for any customs and taxes applied to your order. All
fees imposed during or after shipping are the responsibility of the customer (tariffs, taxes, etc.).
Damages
My Website (change this)​ is not liable for any products damaged or lost during shipping. If you
received your order damaged, please contact the shipment carrier to file a claim.
Please save all packaging materials and damaged goods before filing a claim.
International Shipping Policy
We currently do not ship outside the U.S.
Update this section if ship to countries outside your home country.
Returns Policy
Our ​Return & Refund Policy​ provides detailed information about options and procedures for
returning your order.
Create your own Return/Refund Policy
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Disclaimer: Legal information is not legal advice. ​Read the disclaimer​.
Sample Child Protection Policy
and Procedure Template
Please note this is a guide to a policy and procedure. It is not meant to be directly copied
and it is highly recommended that all members develop documents specific to their service
and needs. This is not an exhaustive list and there may be other essentials required.
Sample Policy Statement
NAME OF SERVICE is committed to safeguarding the well-being of all the children and young
people with whom our staff come into contact. Our policy on child protection is in accordance
with “Children First – National Guidance for the Protection and Welfare of Children” (Department
of Children and Youth Affairs, 2011) and Our Duty to Care. The principles of good practice for the
protection for children and young people”.1 We are committed to promoting the rights of the child
to be protected, be listened to and have their own views taken into consideration.
1
The Legislation for these documents are set out in appendix 6.
Principle:
This policy is underpinned by the Childcare (Preschool Services) Regulations 2006 and Children
First: National Guidance for the Protection and Welfare of Children.
Purpose
This policy applies to all employees and volunteers who have contact with children and young
people on childcare service premises or through their work on behalf of the childcare service.
It is of high importance to ensure all employees/ volunteers have an ability to recognise abuse as it
can be defined in many ways. Please see the appendices for the Definitions of Abuse.
Dealing with Child Protection and Welfare Concerns
All employees, and volunteers of Named Service, will be made aware of and be familiar with the
childcare services child protection policy through an in-house induction, on-going training and
they will sign up to the overall child protection policy of the childcare service.
All staff and volunteers will sign up to the overall child protection policy of the childcare service.
The Designated Liaison Person acts as a liaison with outside agencies and a resource person to any
staff member or volunteer who has child protection concerns. The Designated Liaison Person is
responsible for reporting allegations or suspicions the Child and Family Agency Tusla or An Garda
Siochana. (See Children First 3.3)
Named service has put in place a standard reporting procedure for dealing with disclosures,
concerns or allegations of child abuse. The childcare service has appointed a Designated Liaison
Person who will be …………………………………………..
once they communicate ‘reasonably and in good faith’ (see Paragraph 3.10.1 of Children First
National Guidance for the Protection and Welfare of Children).
Reporting procedure for dealing with disclosures, concerns or allegations of child abuse
In making a report on suspected or actual child abuse, the Designated Liaison Person must ensure
that the first priority is always for the safety and welfare of the child/ young person and that no
child/ young person is ever left in a situation that could place a child/young person in immediate
danger.
1. The employee or volunteer who has received a disclosure of child abuse or who has concerns
about a child should bring them to the attention of the Designated Liaison Person immediately.
2. Under no circumstances should a child be left in a situation that exposes him or her to harm
or of risk to harm pending Tusla intervention. In the event of an emergency where you think a
child is in immediate danger and you cannot get in contact with Tusla, you should contact the
Gardaí. This may be done through any Garda station.
How to Make a Report
3. Where the Designated Liaison Person considers that a child protection or welfare concern
meets the reasonable grounds for concern criteria outlined below, then the Designated Liaison
Person can refer to Tusla.
Guiding principles to reporting child abuse:
• The safety and well-being of the child or young person must take priority;
• Reports should be made without delay to the Child and Family Agency Tusla, Local Health
Office area where child resides.
• A suspicion, which is not supported by an objective indication of abuse or neglect, would not
constitute a reasonable suspicion or reasonable grounds for concern.
Examples of reasonable grounds for concern are:
• specific indication from the child that he/she was abused;
• an account by the person who saw the child being abused;
• evidence, such as an injury or behaviour which is consistent with abuse and unlikely to be
caused in another way;
• an injury or behaviour which is consistent with abuse and with an innocent explanation but
where there are corroborative indicators supporting the concern that it may be a case of
abuse. An example of this would be a pattern of injuries, an implausible explanation, other
indications of abuse, dysfunctional behaviour;
• Consistent indication over a period of time that a child is suffering from emotional or physical
neglect. See Appendix 1 or also visit: FAQ on
www.tusla.ie/services/child-protection-welfare/children-first/
4. Where the Designated Liaison Person remains uncertain he/she should contact the Child
and Family Agency Tusla for informal advice relating to the allegation, concern or disclosure.
5. The Designated Liaison Person will ensure that the parents/ carers are informed that a report/
referral had been made to Tusla. The Designated Liaison Person will make an appointment
with parents to inform them that the report has been made to Tusla unless to do so would be
likely to endanger the child.
6. After consultation with the Duty Social Worker the Designated Liaison Person will then take
one of two options:
a. Report the allegation, concern or disclosure to the relevant authority (e.g. Tusla, An Garda
Síochána, etc.) using the standard reporting form from Children First and in the case of out of
hours or immediate danger contact An Garda Siochana.
b. b.
In those cases where a childcare service decides not to report concerns to Tusla or
An Garda Siochana, the individual employee or volunteer who raised the concern should be
given a clear written statement of the reasons why the childcare service is not taking such
action. The employee or volunteer should be advised that if they remain concerned about
the situation, they are free as individuals to consult with, or report to, the Tusla or An Garda
Siochana. The provisions of the Protections for Persons Reporting Child Abuse Act 1998 apply
If the report is in relation to the safety and welfare of children / young people, the report should be
made to the Designated Liaison Person (in the childcare Service name)
However, these suspicions should be recorded or noted internally by the Designated Liaison Person
as future suspicions may lead to the decision to make a report and earlier suspicions may provide
important information for the statutory child protection agency or An Garda Siochana.
Who can make a report to (Name of Childcare service?)
Reports can be made by:
• Children / young people;
• Parents / guardians;
• Employees, volunteers of Insert Service Name here;
• Other advocates on behalf of children / young people.
How to Handle a Report of Abuse by a Child / Young Person
In the event of a child / young person disclosing an incident of abuse it is essential that this is dealt
with sensitively and professionally by the employee / volunteer involved. In such circumstances,
the employee / volunteer should:
•
•
•
•
•
•
•
•
•
•
•
React calmly;
Listen carefully and attentively; take the young person seriously;
Reassure the young person that they have taken the right action in talking to you;
Do NOT promise to keep anything secret;
Ask questions for clarification only. Do not ask leading questions, this is not an interview, but
rather receiving a disclosure from a child;
Check back with the child/young person that what you have heard is correct and understood;
Do not express any opinions about the alleged abuser;
Record the conversation as soon as possible, in as much detail as possible. Sign and date the
record;
Ensure that the child/young person understands the procedures which will follow;
Pass the information to the Designated Liaison Person do not attempt to deal with the
problem alone;
Treat the information confidentially.
Retrospective Disclosures by Adults
Role of the Designated Liaison Person
Parents and staff who are working with children and young adults or who attend child protection
training may disclose abuse which took place during their childhood. A disclosure of abuse by an
adult which took place during their childhood must be noted or recorded.
The Designated Liaison Person in Insert Service Name here has the ultimate responsibility for
ensuring that the child protection and welfare policy is promoted and implemented.
In these cases it is essential that consideration is given to the current risk to any child who may be
in contact. If any risk is deemed to exist to any child who may be in contact with the alleged abuser,
a report of the allegation should be made to the Child and Family Agency Tusla without delay.
Investigation of disclosures by adult victims of past abuse frequently uncovers current incidents of
abuse and is therefore an effective means of stopping the cycle of abuse.
An increasing number of adults are disclosing abuse that took place during their childhoods. Such
disclosures often come to light when adults attend counselling. It is essential to establish whether
there is any current risk to any child who may be in contact with the alleged abuser revealed is
such disclosures.
If any risk is deemed to exist to a child who may be in contact with an alleged abuser, the Designated
Liaison Person should report the allegation to the Child and Family Agency Tusla without delay.
The National Counselling Service is in place to listen to, value and understand those who have
been abused in childhood. The service is a professional, confidential counselling and psychotherapy
service and is available free of charge in all regions of the country (see http://www.hse.ie/eng/
services/list/4/Mental_Health_Services/National_Counselling_Service/). The service can be accessed
either through healthcare professionals or by way of self-referral.
Protections for Persons Reporting Child Abuse Act, 1998*
Named service wish to draw the attention of the staff and volunteers to this Act Protection for
Persons Reporting Child Abuse Act, 1998 provides immunity from civil liability to persons who
report child abuse “reasonably and in good faith” to the HSE or An Garda Síochána. Section 3(1) of
the Act states:
“A person who, apart from this section, would be so liable shall not be liable in damages in respect
of the communication, whether in writing or otherwise, by him or her to an appropriate person of
his or her opinion that—
• a child has been or is being assaulted, ill-treated, neglected or sexually abused, or
• a child’s health, development or welfare has been or is being avoidably impaired or neglected,
unless it is proved that he or she has not acted reasonably and in good faith in forming that
opinion and communicating it to the appropriate person”.
This protection applies to childcare services and to individuals.
Designiated Liason Person
Identity of Designated Liaison Person
The childcare service’s nominated Designated Liaison Person is …………………, and the Insert Service
Name here Deputy Designated Liaison Persons will be ……………………………………… Name & Address
of the service & telephone No.
The role of the Designated Liaison Person involves the following duties:
•
•
•
•
•
•
•
•
•
To be familiar with “Children First”, National Guidance for the Protection and Welfare of Children
and “Our Duty to Care”, the principles of good practice for the protection of children & young
people and to have responsibility for the implementation and monitoring of the child protection
and welfare policy;
The Insert Service Name here Designated Liaison Person provides support to staff members
who are dealing with/have dealt with a child protection concern or disclosure.
To receive reports of alleged / suspected or actual child abuse and act on these in accordance
with the guidelines;
To ensure that training is provided for all new and existing staff in Insert Service Name here
on the child protection policy;
To build a working relationship with the Child and family Agency Tusla, An Garda Síochána and
other agencies, as appropriate;
To ensure that supports are put in place for the young person, employees or volunteers in
cases of allegations being made;
To keep up to date and undertake relevant training on child protection policy and practice, in
order to ensure the relevance and appropriateness of Insert Service Name here policy and
procedures in this area;
To review the Insert Service Name here policy and procedures on child protection on an
annual basis and amend as appropriate;
To ensure that systems are in place for recording and retaining all relevant documentation in
relation to child protection issues.
Confidentiality
In matters of child abuse, an employee / volunteer should never promise to keep secret any
information which is divulged. It should be explained to the child/young person that this information
cannot be kept secret but only those who need to know in order to safeguard the child, will be told.
It is essential in reporting any case of alleged / suspected abuse that the principle of confidentiality
applies. The information should only be shared on a ‘need to know’ basis which means sharing
information with persons who have a need to know in order to safeguard a child/young person
and is not a breach of confidentiality and the number of people that need to be informed should
be kept to a minimum.
If an employee has any doubt as to whether a report should be made, he / she should consult with
the childcare service’s Designated Liaison Person.
Record Keeping
Under the Data Protection Act every person has a right to establish the existence of personal data,
to have access to any such data relating to him and to have inaccurate data rectified or erased.
The Named Service Data Controller will ensure that data that is collected fairly, is accurate and upto-date, is kept for lawful purposes and is not used or disclosed in any manner incompatible with
those purposes. All data in relation to child protection records collected must be stored in a safe
and confidential manner in a secure locked cabinet.
This will be kept in the office of the Designated Liaison Person. Only the Designated Liaison Person
and the Deputy Designated Liaison Person will have access to this information.
Recruitment and Child Protection
All advertisements, screening and recruitment for vacant posts within the childcare service will
reflect the childcare service’s commitment to equality. We will ensure that interviewers conduct
interviews in a non-discriminatory way. Interviews will be undertaken by a minimum of two
representatives of the childcare service using an agreed set of questions. All assessments and
workplace tests, including psychometric testing for job applicants and performance assessments for
employees, will be conducted in a fair and non-discriminatory way, bearing in mind the principles
of equality of opportunity. Advertisements will be posted on the Insert Service Name here website,
recruitment websites and newspapers where applicable (national or local). All applicants will be
provided with:
Details of the childcare service
A Job Description and Person Specification
An Application Form.
A minimum of two references (one from the most recent employer) will be taken up followed by a
telephone reference check using the Named Service Telephone Reference Check for same.
Named Service Child Protection Policy will be rolled out to existing staff through an in-house
training programme. On-going training will be provided following annual review or statutory/
guideline changes.
Allegations Against an Employee/Volunteer
Upon receipt of an allegation, the Designated Liaison Person will notify the Manager/Owner/
Committee Chairperson. If the allegation relates to the manager/Owner/Committee Chairperson,
the Designated Liaison Person will notify the Board of Management of the allegation. If the allegation
relates to the Designated Liaison Person then the Deputy Designated Liaison Person will notify the
Manager/Owner/Committee Chairperson.
If an allegation is made against an employee, the Designated Liaison Person or the Deputy
Designated Liaison Person in these situations there are two parts to the process, i.e. dealing with
the allegation of abuse and dealing with the employee/volunteer. Where possible these two pieces
should be dealt with by two different people.
There are two different procedures that are followed:
1
The reporting procedure in respect of the child
a) The safety of the child is the first priority of Named Service and all necessary measures
will be taken to ensure that the child and other children/young people are safe.
b) The Designated Liaison Person will deal with the procedure involving the child/young
person and the reporting to the Child and Family, Tusla.
2
The procedure for dealing with the worker
References should be in writing and no references from family or relatives will be accepted.
Successful candidates will be offered a Contract of Employment in accordance with Employment
legislation requirements and each contract will include a probationary period. All employees’
contracts will include signing up to the Named Service Child Protection Policy.
These guidelines will apply both to the recruitment of new employees and to the selection of
internal candidates for promotion or job change.
Named Service will not employ, contract or involve as a volunteer, any person to work with children
or young adults who has a criminal conviction for violent crime, sexual crime, drugs related offences,
or any other offences deemed inappropriate in relation to work with children.
All workers employed, contracted to work, or volunteering to work with children through Named
Service will be required to sign a declaration form outlining any previous criminal convictions
and granting permission for vetting from An Garda Síochána to be sought. Garda Vetting will be
undertaken for all Named Service Board and staff.
Guidelines for Management of Staff
Named Service staff provides monthly work reports to Line Managers. Formal Support & Supervision
meetings take place monthly or more frequently if the workload requires it. Informal Support &
supervision is available to staff members as requested or as required. Full Team Meetings take place
a minimum of twice per year. Individual teams meet fortnightly as work demands require.
In accordance with the Named Service Staff handbook all staff undergoes an induction process
including the Child Protection Policy and will confirm in writing that the induction process has
taken place.
a) The Designated Liaison Person and the Manager/Owner/Committee Chairperson will
work in close co-operation with each other and with the HSE and An Garda Siochana.
b) If a formal report is being made, the Manager/Owner/Committee Chairperson), will
notify the employee that an allegation has been made and what the nature of the allegation
is. The employee has a right to respond to this and this response should be documented
and retained. Furthermore, Named Service will ensure that the principle of ‘natural justice’
will apply whereby a person is considered innocent until proven otherwise.
c) The Manager/Owner/Committee Chairperson), will suspend the employee / volunteer
with pay (where appropriate). In the case where the worker is not suspended the level of
supervision of the worker will be increased.
d) The Manager/Owner/Committee Chairperson), will liaise closely with the HSE Children
and Family Services/An Garda Siochana to ensure that the actions taken by the childcare
service will not undermine or frustrate any investigations.
e) The protective measures which can be taken to ensure the safety of children and
young people can include the following:
• suspension of duties of the person accused,
• re-assignment of duties where the accused will not have contact with children / young
people,
• working under increased supervision during the period of the investigation
• or other measures as deemed appropriate.
Code of Behaviour
•
•
•
•
•
•
•
•
All employees and volunteers of Named Service must make themselves aware of the childcare
service’s good practice guidelines and must be familiar with the overall child protection policy
of the childcare service and sign up to it;
Parents of children involved with our work must be informed of our policy and procedures;
Named Service has appointed a Designated Liaison Person to deal with any complaints or
issues arising which concern the safety or welfare of any child / young person (see above for
identity of the Designated Liaison Person of the childcare service). This person is appropriately
trained and familiar with the procedures to be followed in the event of an allegation, concern
or disclosure of child abuse;
Named Service has put in place an anti-bullying policy. Named Service will not tolerate
any bullying behaviour by children/young people or adults and will deal with any incidents
immediately in accordance with the DCYA anti-bullying policy when working with children and
young people. Where bullying amounts to any form of abuse it will be treated as such and be
recorded and reported as appropriate; (see appendix 3).
Insert Service Name here Staff show respect and understanding for the rights, safety and
welfare of the children and young people;
Named Service has put in place a complaints procedure, (See Appendix 4)
Employees and volunteers should avoid working in isolation with children and favouritism.
Named Service respects and promotes the principles of equality and diversity and works with
all children in a culturally sensitive way within the context of the Irish Constitution and law and
the UN Convention on the Rights of the Child i.e. staff should never physically punish or be
in anyway verbally abusive to a child, nor should they ever tell jokes of a sexual nature in the
presence of children.
Named Service will review their Child Protection Policy on an annual basis. The next review will take
place in…………………………….. Notification of our policy and any changes devised will be displayed on
the Insert Service Name here on the Staff and Parents Noticeboard/ website.
Date: _____________________________________
Signed by: _________________________________ on behalf of Management
This Policy will be reviewed on (insert date here) ______________in collaboration with staff
Duty Social Worker Number:
Garda Station contact details:
Appendices:
Definition of Child Abuse
Child abuse is complicated and can take different forms, but usually consists of one or more of the
following signs and symptoms:
Neglect can be defined in terms of an omission where the child suffers significant harm or
impairment of development by being deprived of food, clothing, warmth, hygiene, intellectual
stimulation, supervision and safety, attachment to and affection from adults, and or medical care.
“The threshold of significant harm is reached when the child’s needs are neglected to
the extent that his or her well-being and/or development are severely affected”. “Neglect
generally becomes apparent in different ways over a period of time rather than at one
specific point. For example, a child who suffers a series of minor injuries may not be having
his or her needs met in terms of necessary supervision and safety. A child whose height
or weight is significantly below average may be being deprived of adequate nutrition. A
child who consistently misses school may be being deprived of intellectual stimulation”.
Emotional abuse is normally to be found in the relationship between a care-giver and a child rather
than in a specific event or pattern of events. It occurs when a child’s need for affection, approval,
consistency and security are not met. Emotional abuse can be manifested in terms of the child’s
behavioural, cognitive, affective or physical functioning e.g. ‘anxious’ attachment, non-organic
failure to thrive, unhappiness, low self-esteem, educational and developmental underachievement,
and oppositional behaviour.
Examples may include:
• the imposition of negative attributes on a child, expressed by persistent criticism , sarcasm,
hostility or blaming;
• conditional parenting in which the level of care shown to a child is made contingent on his or
her behaviours or actions;
• emotional unavailability of the Childs parent/carer;
• unresponsiveness of the parent/carer and/or inconsistent or inappropriate expectations of the
child;
• unrealistic or inappropriate expectations of the child’s capacity to understand something or to
behave and control himself or herself in a certain way;
• under- or over-protection of the child;
• failure to show interest in, or provide age-appropriate opportunities for, the child’s cognitive and
emotional development;
• use of unreasonable or over-harsh disciplinary measures;
• exposure to domestic violence;
• exposure to inappropriate or abusive material through new technology.
Physical abuse of a child is that which results in actual or potential physical harm from an interaction,
or lack of interaction, which is reasonably within the control of the parent or person in a position
of responsibility, power or trust. There may be single or repeated incidents.
Physical abuse can involve:
• severe physical punishment;
• beating, slapping, hitting or kicking;
• pushing, shaking or throwing;
• pinching, biting, choking or hair pulling
• terrorising with threats;
• observing violence;
• use of excessive force in handling;
• deliberate poisoning;
• suffocation;
• fabricated/induced illness;
• allowing or creating a substantial risk of significant harm to a child.
Sexual abuse occurs when “a child is used by another person for his or her gratification or sexual
arousal or for that of others”.
Examples of child sexual abuse include:
•
•
•
•
•
•
exposure of the sexual organs or any sexual act intentionally performed in the presence of the
child;
intentional touching or molesting of the body of a child whether by a person or object for the
purpose of the sexual arousal or gratification;
masturbation in the presence of the child in an act of masturbation;
sexual intercourse with the child, whether oral, vaginal or anal,
sexual exploitation of a child, which includes inciting, encouraging, propositioning, requiring
or permitting a child to solicit for, or to engage in, prostitution or other sexual acts. Sexual
exploitation also occurs when a child is involved in the exhibition, modelling or posing for the
purpose of sexual arousal, gratification or sexual act, including its recording (on film, video tape
or other media) or the manipulation, for those purposes, of the image by computer or other
means. It may also include showing sexually explicit material to children, which is often a
feature of the ‘grooming’ process by perpetrators of abuse;
Consensual sexual activity involving an adult and an underage person. In relation to child sexual
abuse. It should be noted that, for the purposes of the criminal law, the age of consent to sexual
intercourse is 17 years for both boys and girls. An Garda Siochana will deal with the criminal
aspects of the case under the relevant legislation.
Reckless Endangerment is when a person having authority or control over a child or an abuser,
who intentionally or recklessly endangers a child by:
(a) Causing or permitting any child to be placed or left in a situation which creates a substantial
risk to the child of being a victim of serious harm or sexual abuse, or
(b) Failing to take reasonable steps to protect a child from such a risk while knowing that the
child is in such a situation, is guilty of an offence’.
The above are some of the examples of abuse for more information see section 2 of Children First.
Please follow the links below:
Anti-bullying Policy- (Sample Document) Our Duty to Care Factsheet
Child Protection & Welfare Practice Handbook
Children First: National Guidance for the Protection and Welfare of Children
Our Duty to Care
N.B. Your Service Complaints Policy should be attached to this Child Protection Policy
Sample Infection Control Policy
1. Purpose and Scope
The purpose of this policy is to minimise as far as possible risks of harm to [insert
organisation name] Board members, staff, consumers, volunteers, students and
visitors which may arise through passing infections between each other.
2. Definitions
Infection requires three main elements — a source of the infectious agent, a mode of
transmission and a susceptible host.
Infection control is preventing the transmission of infectious organisms and
managing infections if they occur.
Infectious agents are biological agents that cause disease or illness to their hosts.
Contact transmission usually involves transmission of an infectious agent by hand or
via contact with blood or body substances. Contact may be direct or indirect.
Direct contact transmission occurs when infectious agents are transferred from one
person to another, for example, a consumer’s blood entering a healthcare worker’s
body through an unprotected cut in the skin.
Indirect contact transmission involves the transfer of an infectious agent through a
contaminated intermediate object or person, for example, an employee touches an
infected body site on one consumer and does not perform hand hygiene before
touching another consumer.
Standard precautions are work practices which require everyone to assume that all
blood and body substances are potential sources of infection, independent of
perceived risk.
3. Principles
Effective infection control is central to providing high quality support for consumers
and a safe working environment for [insert organisation name] employees, Board
members, students, and visitors.
Mental Health Coordinating Council www.mhcc.org.au
Psychological Injury Management Guide 2012
Staff and consumers are most likely sources of infectious agents and are also the
most common susceptible hosts. Other people visiting the premises may be at risk of
both infection and transmission.
The main modes for transmission of infectious agents are contact (including blood
borne), droplet and airborne. Transmission of infection may also occur through
sources such as contaminated food, water, medications, devices or equipment.
Infection control is integral to consumer support, not an additional set of practices.
Consumers’ rights are respected at all times; they are involved in decision-making
about their support, and they are sufficiently informed to be able to participate in
reducing the risk of transmission of infectious agents.
4. Outcomes
Infections and infection transmission is prevented and managed as far as possible
through the application of standard precaution practices.
5. Functions and Delegations
As for Work Health and Safety
6. Risk Management
Risks of infection are regularly assessed, identified and managed.
Employees are trained in infection control practice, including relevant application of
precautions to minimise the risk of infection.
[if applicable - employees are offered vaccinations against Influenza,
Diphtheria, Tetanus, Hepatitis A & B, and other relevant contagious
conditions].
Mechanisms are in place for monitoring compliance with infection control
procedures.
7. Policy Implementation
The organisation ensures effective implementation of infection control.
All staff have access to policies and procedures relating to infection control.
Tailored training is provided to persons with specific tasks where infection
transmission is a risk.
Mental Health Coordinating Council www.mhcc.org.au
Psychological Injury Management Guide 2012
Records of infection control activities are maintained, including infection control
training undertaken, information provided to consumers and the use of personal
protective equipment (PPE).
There are mechanisms for monitoring compliance with infection control.
8. Policy Detail
8.1
Infection Control Risk Management Plan
Once infection risks are identified, the organisation’s risk management program
includes:
o eliminating the risk factors
o modifying or changing procedures, protocols and work practices
o monitoring consumer and employee compliance with infection control
procedures
o providing information/education and training to consumers and employees.
8.2
Infection Risk Assessment
[insert organisation name] identifies and assesses infection control risks by taking
into consideration the likelihood of infection from a particular hazard, and the
consequences if a person is infected. Factors such as frequency of exposure, levels
of training and knowledge, existing controls, environmental factors and the
experience of employees are considered.
The risk assessment matrix (see Risk Management Policy) prioritises identified risks
for action.
[insert organisation name] develops and prioritises actions for managing identified
risks.
8.3
Education and Information
Education regarding infection prevention core principles is provided to all new staff
and to existing staff annually.
Advice and information is provided to staff regarding new and emerging infectious
disease threats and trends. Advice and education related to infection prevention is
routinely provided to consumers.
Mental Health Coordinating Council www.mhcc.org.au
Psychological Injury Management Guide 2012
8.4
Standard Precautions
Standard precautions are applied in all situations in which staff may have contact
with blood / body fluids.
8.4.1 Hand Washing and Hand Care
Hand washing and hand care are considered the most important measures in
infection control. Skin is a natural defence against infection. Cuts and abrasions on
exposed skin should be covered with a water resistant dressing changed as often as
necessary.
Hands must be washed and dried before and after any direct consumer contact
and/or the removal of gloves. Hands should be washed with a soap or cleaning
agent covering all surfaces. Protective gloves must be worn when handling blood
and body substances.
8.4.2 Protective Barriers
Protective barriers (eye shields, gloves, gowns and masks) are to be used whenever
there is a potential for exposure to blood and body substances.
General purpose utility gloves should be worn for housekeeping tasks including:
cleaning clinical instrument and handling chemical disinfectants.
Utility gloves are to be discarded if they are peeled, torn or punctured or have other
evidence of deterioration.
8.4.3 Needles and Sharps
Special care must be taken to prevent injuries during procedures when cleaning
sharp instruments, and use or disposal of sharps (needles). Sharps must not be
passed from one worker to another unless specifically required for the proper
conduct of the procedure.
Needles must not be removed from disposable syringes for disposal nor resheathed
before disposal. Where special circumstance require resheathing, it is preferable to
use forceps or a protective guard.
Sharps containers should be placed as close as practical to the consumer care area,
not easily accessible to visitors and out of the reach of children. Containers should
be clearly labelled with the biohazard symbol and never overfilled.
Mental Health Coordinating Council www.mhcc.org.au
Psychological Injury Management Guide 2012
8.4.4 Quarantining
Staff, Board members, students, volunteers and consumers experiencing infectious
conditions will be requested to refrain from [insert organisation name] premises
and activities during the infectious period of the condition.
8.5
Response to Possible Infection
When potentially infected body fluids come into contact with an employee, Board
member, student, volunteer or consumer, steps are taken to decrease the impact of
such contact, including first aid and assessment at a medical service.
A supervisor must be notified of such incidents as soon as possible and an incident
report form completed.
8.6
Notifiable Diseases
[insert organisation name] notifies the Public Health Unit in the event of an
outbreak of any of the following: food borne illness in two or more related cases or
gastroenteritis among people of any age in an institution.
9.
References + Resources
9.1
Internal
Work Health and Safety Policy
Risk Management Policy
Incident Report Form
Vaccination Risk Assessment
Mental Health Coordinating Council www.mhcc.org.au
Psychological Injury Management Guide 2012
9.2
External
Legislation
Work Health and Safety Act 2011 (Commonwealth)
Model Work Health and Safety Regulations 2011 (Cth)
Resources
National Health and Medical Research Council (NHMRC) 2010, Australian
Guidelines for the Prevention and Control of Infection in Healthcare, Commonwealth
of Australia.
NSW Health Department 2007, Infection Control Policy. NSW Health, Sydney.
This policy is taken from the NADA Infection Control Policy.
http://www.nada.org.au/index.php?option=com_content&task=view&id=236&Itemid=
44
Mental Health Coordinating Council www.mhcc.org.au
Psychological Injury Management Guide 2012
PARENT ISSUES AND CONCERNS POLICY
Purpose
The purpose of this policy is to provide a transparent process for Matthew-John Early Learning Centre (“MJELC”)
to use when parents/guardians bring forward issues or concerns relating to their children enrolled at MJELC.
This policy complies with the requirements of the Child Care and Early Years Act, 2014, S.O. 2014, c. 11, Sched. 1
(the “Act”) and its regulations.
Policy
A. Overview
Parents/guardians are encouraged to take an active role in MJELC programs and regularly discuss what their
child(ren) are experiencing with our program. As reflected in our program statement, we support positive and
responsive interactions among the children, parents/guardians, educators and support staff, and foster the
engagement of and ongoing communication with parents/guardians about the program and their children. Our
staff are available to engage parents/guardians in conversations and support a positive experience during every
interaction.
All issues and concerns raised by parents/guardians are taken seriously by MJELC and every effort will be made
to address and resolve these issues and concerns to the satisfaction of all parties and as quickly as possible. An
initial response will be provided to parents/guardians within two (3) business days.
Concerns may be brought forward verbally or in writing. Responses and outcomes will be provided verbally, or
upon request, in writing. The person who raised the issue/concern will be kept informed throughout the
resolution process. Investigations of issues and concerns will be fair, impartial and respectful to all parties
involved.
B. Confidentiality
Every issue and concern will be treated confidentially and every effort will be made to protect the privacy of
parents/guardians, children, staff, students and volunteers, except when information must be disclosed for legal
reasons (e.g. to the Ministry of Education, College of Early Childhood Educators, law enforcement authorities or
a Children’s Aid Society).
August 2017
When communicating with parents in relation to responses, progress reports or final resolutions, the level of
detail provided will respect and maintain the confidentiality of all parties involved.
C. Conduct
MJELC programs maintain a high quality for positive interaction, communication and role modeling for children.
Harassment and discrimination will therefore not be tolerated from any party. If at any point a parent/guardian,
provider or staff feels uncomfortable, threatened, abused or belittled during an interaction, they may
immediately end the interaction and report the situation to the MJELC Supervisor.
D. Concerns about the Suspected Abuse or Neglect of a child
General Obligation
Everyone, including members of the public and professionals who work closely with children, is required by law
to report suspected cases of child abuse or neglect. If a parent/guardian expresses concerns that a child is being
abused or neglected, they will be advised to contact the local Children’s Aid Society (CAS) directly in accordance
with the “Duty to Report” requirement under The Child and Family Services Act, R.S.O. 1990, c. C.11.
For more information, visit
http://www.children.gov.on.ca/htdocs/English/childrensaid/reportingabuse/index.aspx
Procedures
If the issue or concern is:
1. Program Room Related, for example, schedule, sleep arrangements, toilet training, indoor/outdoor program
activities, feeding arrangements, etc., the parent/guardian can raise the issue or concern to the classroom staff
directly or to the MJELC Supervisor;
2. General, Centre or Operations-Related, for example, child care fees, hours of operation, staffing, waiting lists,
menus, etc., the issue should be raised to the MJELC Supervisor;
3. Staff-Related, the parent/guardian can raise the issue or concern to the individual directly and/or to the
MJELC Supervisor. All issues or concerns about the conduct of staff that puts a child’s health, safety and wellbeing at risk should be reported to the MJELC Supervisor as soon as parents/guardians become aware of the
situation; and
4. Student / Volunteer Related, the issue or concern should be raised to the staff responsible for supervising the
volunteer or student or to the MJELC Supervisor. All issues or concerns about the conduct of students and/or
volunteers that puts a child’s health, safety and well-being at risk should be reported to the MJELC Supervisor as
soon as parents/guardians become aware of the situation.
The Steps for Staff and/or Supervisor in responding to issue/concern
Staff must:
August 2017
1. Address the issue/concern at the time it is raised or arrange for a meeting with the parent/guardian within
five (5) business days.
2. Document the issues/concerns in detail. Documentation should include: (i) the date and time the
issue/concern was received; (ii) the name of the person who received the issue/concern, (iii) the name of
the person reporting the issue/concern, (iv) the details of the issue/concern, and (v) any steps taken to
resolve the issue/concern and/or information given to the parent/guardian regarding next steps or referral.
3. Provide contact information for the appropriate person if the person being notified is unable to address the
matter.
4. Ensure the investigation of the issue/concern is initiated by the appropriate party within three (3) business
days or as soon as reasonably possible thereafter and document reasons for delays in writing.
5. Provide a resolution or outcome to the parent(s)/guardian(s) who raised the issue/concern.
Escalation of Issues or Concerns
Where parents/guardians are not satisfied with the response or outcome of an issue or concern, they may
escalate the issue or concern verbally or in writing to the MJELC Supervisor and/or the MJELC Board of Directors.
Issues/concerns related to compliance with requirements set out in the Act and Ontario Regulation 137/15
should be reported to the Ministry of Education’s Child Care Quality Assurance and Licensing Branch.
Issues/concerns may also be reported to other relevant regulatory bodies (e.g. local public health department,
police department, Ministry of Environment, Ministry of Labour, fire department, College of Early Childhood
Educators, Ontario College of Teachers, College of Social Workers etc.) where appropriate.
E. REVIEW
This policy will be provided to all MJELC employees at the commencement of their employment and will be
made available to them at all times thereafter. The contents of this policy and the procedures set out herein will
be reviewed at least annually and at any time that changes are required by law. A record will be kept showing
the date of each review conducted, and each record will be signed by each person who conducted or
participated in the review.
August 2017
Home Care Policy Manual
September 2015
PURPOSE OF THE SASKATCHEWAN MINISTRY OF HEALTH HOME CARE
POLICY MANUAL
As the Home Care Program is administered and delivered by the Regional Health
Authorities and funded by the Saskatchewan Ministry of Health, this manual is designed
to ensure consistency of home care services and home care standards throughout the
province.
The program expectations in the delivery of home care are addressed in this
Saskatchewan Ministry of Health Home Care Policy Manual.
This manual provides direction and guidance to regional health authorities. The policies
represent a statement of required course of action. Guidelines, on the other hand, are
provided as recommendations to assist in meeting the expectations of policies.
Adherence to the policies is one of the conditions under which funding is provided to the
Regional Health Authorities by the Minister of Health.
It should be noted that this manual does not address in any detail, requirements which
home care programs must meet as established by other legislation.
Home Care is an integral part of the continuum of care that includes both community and
institutional services necessary to ensure the best possible quality of life for people with
varying degrees of short and long-term illness or disability and support needs. An
effective continuum of care requires strong community and institutional support sectors
so that appropriate services can be accessed when and where they are needed.
The Board of each Regional Health Authority is vested with full legal authority and
responsibility for the home care program. Though not limited to the following, the board
is responsible for the observance of, and compliance with, The Regional Health Services
Act and Regulations and provincial policy pertaining to the delivery of home care. The
exception to this is the Athabasca Health Authority, which is responsible for the
observance of, and compliance with, the Service Agreement between the Athabasca
Health Authority and the Minister of Health and any policies pertaining to the delivery of
home care.
The Regional Health Authority is accountable:
a)
through the Minister of Health to the Legislature for the proper
expenditure of public funds to provide home care services;
b)
for planning, administrating and delivering home care services in the
region; and
c)
for adhering to program policies established by the Community Care
Branch of the Saskatchewan Ministry of Health.
The Saskatchewan Ministry of Health provides global funding to the Regional Health
Authorities for the day-to-day delivery of health programs and services, including home
care services.
The regions have the flexibility to use the global funds to provide a full range of home
care services to help people remain healthy and independent. The regions strive to ensure
that appropriate care is provided to clients in their regions. However, when considering
the delivery of health care services, the Regional Health Authority must take into
consideration the needs of the entire region, within available resources.
The Saskatchewan Ministry of Health would like to acknowledge the contribution to the
manual by the staff of the Regional Health Authorities.
September 2006
(Updated October 2007)
(Updated September 2009)
(Updated November 2010)
(Updated November 2012)
(Updated March 2013)
(Updated September 2013)
(Updated December 2015)
Home Care Policy Manual
1.
INTRODUCTION
1.1
Purpose of Home Care
1.2
Objectives
1.3
Philosophy
1.4
Board Responsibilities
2.
CONTINUUM OF CARE
2.1
Maintaining Continuity of Service
3.
CLIENT ACCESS TO SERVICE
3.1
Coordinated Access
3.2
Eligibility Criteria
3.3
Acceptance Criteria
3.4
Restrictions on Acceptance to the Home Care Program
3.5
Priorities
3.6
Accessing Service for Unpredicted Needs after Hours
3.7
Referrals to Other Agencies if Unable to Meet Needs
3.8
Non-Acceptance
4.
CONSENTS
4.1
Consents
5.
CLIENT RIGHTS AND RESPONSIBILITIES
5.1
Client Rights
5.2
Client Abuse
5.3
Client Responsibilities
6.
ASSESSMENT PROCESS
6.1
Assessment Tool
6.2
Assessment Requirements
6.3
Clients’ Rights Regarding Assessments
6.4
Assessment and Approval Process
6.5
Clients’ Right to Appeal
6.6
Appeal Process
7.
CASE COORDINATION/MANAGEMENT
7.1
Case Coordination/Management
8.
CARE PLAN
8.1
Development of Care Plans
8.2
Care Plan Participants
8.3
Implementation of Service
8.4
Reassessment/Revision of Care Plans
8.5
Authority and Requirements for Discharge
8.6
Re-admission
September 2015
Page 1 of 4
Home Care Policy Manual
9.
CLIENT RECORDS
9.1
Client Records
9.2
Documentation Requirements
9.3
Incident Reports and Investigation
9.4
Reportable Critical Incident Review
9.5
Retention of Client Records
10.
TYPES OF CARE
10.1 Types of Care
10.2 Acute Care
10.3 Long Term Supportive Care
10.4 Rehabilitation
10.5 Maintenance
10.6 Palliative Care/End of Life
10.7 References
11.
HOME CARE SERVICES
11.1 Home Care Services
11.2 Primary Home Care Services
11.2.1
Assessment
11.2.2
Case Management and Care Coordination
11.2.3
Nursing Services
11.2.4
Homemaking Services
11.2.5
Meal Service
11.3 Additional Home Care Services
11.3.1
Home Maintenance Services
11.3.2
Volunteer Service
11.3.3
Therapy Services
12.
SERVICE PROVIDERS
12.1 Assessor/Case Manager/Care Coordinator
12.2 Nursing Service Providers
12.3 Home Care Aide/Continuing Care Assistant Service Providers
12.4 Meal Service/Restaurant and Institutional Providers
12.4.1
Private Meal Service Providers
12.5 Home Maintenance Service Providers
12.6 Volunteers
12.7 Occupational Therapy and Physiotherapy Providers
12.8 Family Care Providers
13.
SPECIAL PROGRAMS
13.1 Individualized Funding
13.1.1
Collective Funding
13.2 Children with Highly Complex Care Needs
September 2015
Page 2 of 4
Home Care Policy Manual
September 2015
14.
NURSING PRACTICE
14.1 Nursing Practice
14.2 Nursing Procedures by Transfer of Medical Functions
14.3 Special Nursing Procedures
14.4 Licensure of Nurses
14.5 Delegation of Nursing Procedures
14.6 Evidence-Based Practices and Outcomes
15.
HOME CARE CLIENT FEES AND CHARGES
15.1 Basic Home Care Client Fee Policy
15.1.1 Short-term Acute Home Care
15.2 Calculation of Client Fees for Regional Health Authorities
15.3 Charges to Temporary Residents
15.4 Third Party Payers
15.5 Home Care Nursing Supplies
15.6 Home Parenteral Medication Program Coverage
15.7 Programs Covering Drug and Supply Costs
15.8 Palliative Care Supplies and Charges
15.9 Benefits/Payment Policy for Saskatchewan Residents Out of Province (OOP)
16.
QUALITY MONITORING AND IMPROVEMENT
16.0 Quality Monitoring and Improvement
16.1 Assessment and Care Coordination Standards
16.1.1
Assessment and Care Coordination: Structure Standards
16.1.2
Assessment and Care Coordination: Process Standards
16.1.3
Assessment and Care Coordination: Outcome Standards
16.2 Nursing Service Standards
16.2.1
Nursing Service: Structure Standards
16.2.2
Nursing Service: Process Standards
16.2.3
Nursing Service: Outcome Standards
16.3 Homemaking Service Standards
16.3.1
Home Care Aide/Continuing Care Assistant: Structure Standards
16.3.2
Home Care Aide/Continuing Care Assistant: Process Standards
16.3.3
Home Care Aide/Continuing Care Assistant: Outcome Standards
16.4 Meal Service Standards
16.4.1
Meal Service: Structure Standards
16.4.2
Meal Service: Process Standards
16.4.3
Meal Service: Outcome Standards
16.5 Home Maintenance Service Standards
16.5.1
Home Maintenance Service: Structure Standards
16.5.2
Home Maintenance Service: Process Standards
16.5.3
Home Maintenance Service: Outcome Standards
Page 3 of 4
Home Care Policy Manual
16.6
16.7
September 2015
Volunteer Service Standards
16.6.1
Volunteer Service Standards: Structure Standards
16.6.2
Volunteer Service Standards: Process Standards
16.6.3
Volunteer Service Standards: Outcome Standards
Home Care Standards
16.7.1
Home Care Outcome Standards
17.
REPORTING REQUIREMENTS
17.1 Reporting Requirements for Regional Health Authorities
18.
OCCUPATIONAL HEALTH and SAFETY
18.0 Occupational Health and Safety
18.1 Safety Hazards
18.2 Infection Control
18.3 Lifting and Moving
18.4 Client Transportation
Page 4 of 4
Community Care
Home Care Policy
Section:
Index Ref: 1.1
Introduction
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Purpose of Home Care
1.1
PURPOSE OF HOME CARE
Home care helps people who need acute, end-of-life, rehabilitation, maintenance and long-term
care to remain independent at home. Home care encourages and supports assistance provided by
the family and/or community.
Community Care
Home Care Policy
Section:
Index Ref: 1.2
Introduction
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Objectives
1.2
OBJECTIVES
1.
To help people maintain independence and well being at home by:
a)
determining needs and abilities, developing and coordinating plans of care;
b)
teaching self-care and coping skills;
c)
improving, maintaining or delaying loss of functional abilities;
d)
promoting and supporting family and community responsibility for care; and,
e)
supporting acute, end-of-life, rehabilitation, maintenance and long-term care
provided by family, friends and neighbours.
2.
To facilitate appropriate use of health and community services by:
a)
preventing or delaying the need for admission to long-term care facilities and
assisting on discharge;
b)
supporting people waiting for long-term care admission;
c)
preventing the need for hospital admission, making earlier discharge from
hospital possible, and reducing the frequency of re-admission;
d)
helping individuals and families access needed services;
e)
promoting volunteer participation;
f)
educating the public about home care; and,
g)
participating in local service planning and coordination.
3.
To make the best use of home care resources by:
a)
serving people with the greatest need first; and,
b)
operating economically and efficiently.
4.
To meet client needs and optimize client independence within available home care
financial resources while working cooperatively with other community agencies,
organizations and individuals.
Community Care
Home Care Policy
Section:
Index Ref: 1.3
Introduction
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Philosophy
1.3
PHILOSOPHY
Home care is guided by the following principles:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
People can usually retain greater independence and control over their lives in their own
homes;
Most people prefer to remain at home and receive required services at home;
Support provided by families and friends should be encouraged and preserved and, if
necessary, supplemented;
Service should assist individuals and families to retain maximum independence and avoid
unnecessary dependencies;
Home care should assist people to access needed health and community services;
Home care should preserve and promote volunteer involvement;
Service decisions in home care should be based on assessed client need and the risk to the
client if service is not provided;
Individuals and their supporters should help identify their needs, establish goals, and
develop plans to meet goals;
People with the greatest need for home care should receive priority for service;
Individuals have the right to be treated with kindness, dignity and respect;
A person’s right to live at risk to one’s self and to accept or refuse services is respected;
Home care services should be provided respecting the client’s cultural values and,
whenever possible, by staff who are of the client’s language and culture;
Regional Health Authorities should have significant responsibility for planning and
delivering home care services;
Home care involves the planning and coordinating of local health and community
services; and,
Home care does not usually provide services to allow caregivers to work at a long-term
job. Home care is not normally provided to relieve parents from routine childcare.
Community Care
Home Care Policy
Section:
Index Ref: 1.4
Introduction
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Board Responsibilities
1.4
BOARD RESPONSIBILITIES
1.
The Regional Health Authority is the governing body of the health region, which includes
the home care program. The board is vested with full legal authority and responsibility
for the home care program. Though not limited to the following, the board is responsible
for the observance of, and compliance with, The Regional Health Services Act and
Regulations and provincial policy pertaining to the delivery of home care 1.
2.
The Regional Health Authority is accountable:
a)
through the Minister of Health to the Legislature for the proper expenditure of
public funds to provide home care services;
b)
for planning, administrating and delivering home care services in the region; and,
c)
for adhering to program policies established by the Community Care Branch of
the Saskatchewan Ministry of Health.
1
The exception to this is the Athabasca Health Authority, which is responsible for the observance of, and
compliance with, the Service Agreement between the Athabasca Health Authority and the Minister of Health
and any policies pertaining to the delivery of home care.
Community Care
Section:
Index Ref: 2.1
Page 1
Date of Issue
Home Care Policy
Continuum of Care
September 2006
Revised September 2015
Subject:
Maintaining Continuity of Service
2.1
MAINTAINING CONTINUITY OF SERVICE
GUIDELINES
Maintaining continuity of service includes:
a)
b)
c)
d)
e)
f)
g)
h)
i)
providing the same home care service providers to clients where feasible;
educating organizations and providers about home care services;
identifying major referral sources and establishing communication links;
liaising with other organizations or Regional Health Authority services involved with
clients (e.g. adult day program);
developing an awareness of and integrating complementary services provided by other
organizations and agencies;
working collaboratively with other organizations providing service;
referring appropriately to other organizations;
ensuring relevant information is communicated in a timely manner; and,
working with families/supporters to achieve continuity of service.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.1
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Coordinated Access
3.1
COORDINATED ACCESS
POLICY
Regional Health Authorities, as a minimum, will provide coordinated access to long-term care,
respite, adult day programs and home care. Other services may be included, as appropriate.
GUIDELINES
1.
Coordinated access to long-term care, home care, adult day programs and respite services
ensures that clients are prioritized based on greatest need.
2.
Coordinated access enables the Regional Health Authority to identify gaps in
programming and the need for new initiatives, and to effectively use resources within the
region.
3.
Coordinated access includes a case management approach, avoids duplication of service
and ensures that appropriate service is provided.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.2
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Eligibility Criteria
3.2
ELIGIBILITY CRITERIA
POLICY
1.
Applicants for home care must meet one of the following eligibility criteria in order to
have their applications considered:
a)
hold a valid Saskatchewan Health Services card;
b)
be in the process of establishing permanent residence in Saskatchewan and have
applied for a Saskatchewan Health Services card; or,
c)
be a resident of Manitoba or Alberta in a border area where contractual
arrangements have been approved by the Saskatchewan Ministry of Health.
2.
Regional Health Authorities must consider applications for home care from any
Saskatchewan resident. Indian Bands may enter into contractual service agreements with
Regional Health Authorities to request services for Registered Status Indians living on
reserve.
3.
Non-residents must apply for a Saskatchewan Health Services card in order to receive
subsidized home care services beyond three months. This three-month period
corresponds with the waiting period for coverage under Saskatchewan hospital, medical,
and other health plans.
Non-residents who are not required to apply for a Saskatchewan Health Services card in
order to access home care services include:
a)
students (who are in the province for less than 12 consecutive months);
b)
individuals who have employment contracts for a maximum of 12 months;
c)
interim refugees who are covered by Health Canada;
d)
refugees intending to remain in Saskatchewan who receive coverage upon
application for a Saskatchewan Health Services card;
e)
RCMP who are covered under Health Canada; and,
f)
individuals of Military and Corrections Canada.
4.
Saskatchewan residents who are out of province and are eligible for home care services
may receive services in another province. The Saskatchewan Ministry of Health will pay
for this service based on the fee structure established by the Ministry. Prior approval
from the Saskatchewan Ministry of Health is required.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.2
Page 2
Date of Issue:
September 2006
Revised September 2015
Subject:
Eligibility Criteria
GUIDELINES
1.
Saskatchewan home care programs may accept applications from non-Saskatchewan
residents staying temporarily in the province. Non-residents are liable for the full costs
of all services provided, including assessment and coordination costs, but not
administration costs.
2.
In exceptional circumstances, where the charge for services provided imposes a serious
financial hardship for the non-resident client, the Regional Health Authority may charge
less than the full cost of service defined above. The Regional Health Authority should
not charge less than the amount a Saskatchewan resident with the same income would be
charged for the same service if she/he applied for an income-tested subsidy.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.3
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Acceptance Criteria
3.3
ACCEPTANCE CRITERIA
POLICY
1.
The Regional Health Authority shall set acceptance priorities based on assessed need and
level of risk.
2.
Individuals requiring a single service shall be assessed to determine need and risk if the
service is not provided.
3.
The provision of a single service shall not be linked to the requirement of an additional
service (e.g. Regional Health Authorities are not to link homemaking to another service).
4.
When an applicant is accepted to the program and there are serious reservations about
safety, either for the individual requiring care or the home care provider, home care must:
a)
set any conditions it believes are necessary to make service arrangements
workable;
b)
ensure that any conditions for admission are clearly explained to the applicant and
to involved family members and supporters;
c)
ensure ongoing documentation of client needs and circumstances, factors
affecting service arrangements, and all discussions and agreements with clients
and supporters regarding service arrangements; and,
d)
ensure that the service arrangements are reviewed at least once a month.
GUIDELINES
1.
Home care services may be provided to any person based on assessed need where:
a)
the person requires care and support while living in the community; and,
b)
the services to be provided do not replace the assistance usually provided by the
family or community, unless necessary.
2.
Home care services may be provided to:
a)
determine a person’s needs and develop appropriate plans for care;
b)
improve a person’s ability to function independently by teaching self-care;
c)
prevent or delay the functional deterioration of a person;
d)
provide needed assistance and relief to the family and others who are providing
care to a person;
e)
assist a person with a disability to function as independently as possible;
f)
eliminate or delay the need for a person’s admission to a special-care home,
hospital or other care-giving institution;
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.3
Page 2
Date of Issue:
September 2006
Revised September 2015
Subject:
Acceptance Criteria
g)
h)
i)
3.
maintain a person in the community pending placement in a special-care home or
other care-giving institution;
allow a terminally ill person to remain at home as long as possible; and,
permit earlier discharge of a person from hospital or reducing the frequency of
re-admissions.
The provision of home care may be reconsidered if:
a)
staff have serious reservations about the safety and/or benefits of providing
services to the applicant;
b)
the required help is available from others who are willing and able to provide the
applicant’s care;
c)
the applicant is unwilling to accept the assessment process or care plan, or to
cooperate with plans for delivering services;
d)
the applicant’s safety between service visits cannot reasonably be assured because
of inadequate home support;
e)
a life-threatening situation exists and the program cannot guarantee delivery of
the required services;
f)
the services required cannot be safely provided because of the applicant’s home
situation; or,
g)
the program has inadequate resources (personnel or financial) to serve the needs
of the applicant.
When serious reservations about the applicant’s safety are involved, consideration must
be given to whether or not the applicant will be better off with or without the service
being offered. The right of the individual to knowingly take risks must be considered. A
written agreement with the applicant should be considered.
4.
Accepting Clients with Difficult Behaviours
Procedures should be developed for accepting clients when there are serious reservations
about safety for the client or home care provider. Procedures must include:
a)
A definition of what home care is willing to provide and the conditions under
which it will do so. These must be fully explained to the applicant, family
members and supporters who are involved. What home care will do and what the
individual and informal supporters will be responsible for should be clearly
identified;
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.3
Page 3
Date of Issue:
September 2006
Revised September 2015
Subject:
Acceptance Criteria
b)
c)
Documenting the agreement and all relevant aspects of the case on an ongoing
basis. Documentation for decisions, actions and their rationales is the best
evidence that the provider acted in good faith and in accordance with acceptable
standards; and,
Close monitoring of the situation. If the Regional Health Authority finds it
necessary to impose additional requirements to those in the initial agreement, they
must be documented and communicated to the client. If the client chooses not to
accept these requirements, it may be necessary to discontinue services. The
Regional Health Authority has the obligation to find service alternatives for the
client and must not leave the client in an unsafe situation.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.4
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Restrictions on Acceptance to the Home Care Program
3.4
RESTRICTIONS ON ADMISSION TO THE HOME CARE PROGRAM
POLICY
1.
No applicant shall be accepted to the home care program if:
a)
required services are the legal responsibility of the operator of the applicant’s
place of residence; or,
b)
required services are not services the home care program is authorized to provide.
2.
Professional Home care services (nursing, therapies, assessment and case
management/coordination) may be provided to residents of personal care homes, group
homes or special-care homes which provide supervision, programming and/or personal
care and treatment to the residents. Some examples of homes, which fall into this
category, are:
a)
personal care homes licensed under The Personal Care Home Act where residents
pay a fee to the operator in exchange for care. The care may range from minimal
supervision to intensive personal care and nursing;
b)
group homes under The Residential Services Act;
c)
residential alcohol and drug treatment homes under The Housing and Special-care
Homes Act;
d)
special care homes under The Housing and Special-care Homes Act, (intravenous
therapy in a special-care home may be administered by a home care nurse); or,
e)
approved homes with a certificate issued under The Mental Health Services Act
for the accommodation of patients who are discharged from an in-patient facility
or who require the accommodation and supervision that may be provided in the
home.
In such situations, there may be questions about the responsibilities of the operator and
those of the home care program which need clarification.
3.
Home care should not provide any service which is understood to be part of the care
provided to the residents by the operator. There may be a written contract specifying the
operator’s responsibilities. If the contract is verbal, the home care program will have to
attempt to determine what care has been promised in exchange for the fee charged.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.4
Page 2
Date of Issue:
September 2006
Revised September 2015
Subject:
Restrictions on Acceptance to the Home Care Program
4.
Under no circumstances should home care assume responsibility for providing home
maintenance, meals, or homemaking to a resident of one of these care homes.
Assessment, case management, therapies and nursing care may be provided if the home
care program has reason to believe that the operator does not have responsibility for
providing such care. Any potential clients in the home would be subject to all home care
assessment, admission, review and discharge procedures.
GUIDELINE
When it is not clear whether or not the service required is the responsibility of the operator, the
Regional Health Authority should proceed carefully before reaching a decision about providing
care. The problem should be discussed with the operator and other parties concerned, including
the client and the client’s family. The Regional Health Authority should not unilaterally
withdraw services that have been previously provided without consulting the parties concerned.
Community Care
Home Care Policy
Section:
Index Ref: 3.5
Client Access to Service
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Priorities
3.5
PRIORITIES
POLICY
1.
The Regional Health Authority must give priority to admitting and serving people with
the greatest need for home care service.
2.
The Regional Health Authority shall determine need through an assessment process,
which provides a comprehensive multi-dimensional account of the individual’s situation,
including the person’s functional abilities and home environment.
3.
The Regional Health Authority will explore alternative ways of meeting the individual’s
needs as part of its assessment and care coordination process.
4.
The Regional Health Authority must consider and balance the following criteria to
determine the degree of need:
a)
the more serious and immediate the consequences to the individual if service is
not provided, the higher the priority; and,
b)
if more appropriate alternatives are available to the individual, the lower the
priority.
5.
The Regional Health Authority shall consider the relative cost effectiveness of other
appropriate alternatives available to the individual.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.6
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Accessing Services for Unpredicted Needs After Hours
3.6
ACCESSING SERVICE FOR UNPREDICTED NEEDS AFTER HOURS
DEFINITION
Accessing service after hours for unpredicted needs means, at a minimum, telephone contact
with a person knowledgeable about the home care program. Appropriate action may include:
a)
coordinating arrangements to meet the client’s needs; and,
b)
referring to a home care staff member, if required.
POLICY
1.
Planned and predictable service based on an assessed need is available at any time
(i.e. weekends, evenings, and nights).
2.
Regional Health Authorities shall make 24-hour access to home care available to address
unpredictable and variable client needs for existing clients.
3.
Policies and procedures must address the following expectations:
a)
clients must be able to access the Regional Health Authority home care program
at any time of the day or night; and,
b)
clients must be able to speak to a person at any time. Telephone contact allows
the person taking the call to assess the service response required.
GUIDELINES
1.
Access to home care “after hours” may not be with the home care program itself, but
rather the request may be received through staff at the health centre, special-care home or
hospital. The staff must be sufficiently familiar with the home care program to be able to
respond in a knowledgeable way and to be able to assess the client’s situation
appropriately.
2.
Some individuals may be able to wait until morning for service. Some situations may
require a home visit to address the need, while others may require an alternative service
response such as calling an ambulance.
3.
HealthLine, a free, confidential 24-hour health advice telephone line staffed by registered
nurses, may be able to assist some individuals. HealthLine can provide individuals with
immediate, professional health advice or information, and direct the individual to the
most appropriate care. This can include issues regarding mental health and addictions.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.7
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Referrals to Other Agencies if Unable to Meet Needs
3.7
REFERRALS TO OTHER AGENCIES IF UNABLE TO MEET NEEDS
POLICY
1.
Regional Health Authorities must have a process in place to refer applicants to another
more appropriate organization or another Regional Health Authority service when home
care is unable to meet an applicant’s needs.
Community Care
Home Care Policy
Section:
Client Access to Service
Index Ref: 3.8
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Non-Acceptance
3.8
NON-ACCEPTANCE
POLICY
1.
Regional Health Authorities must have a process in place to monitor all referrals and
non-acceptance situations. The process must communicate the reason(s) for the referral
and/or non-acceptance of the client.
2.
All referrals and non-acceptance situations must be documented.
Community Care
Home Care Policy
Section:
Index Ref: 4.1
Consents
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Consents
4.1
CONSENTS
POLICY
1.
All information concerning an individual client is confidential.
2.
Home care staff, regional assessment staff and Saskatchewan Ministry of Health staff
have access to confidential information for program purposes only (i.e. on a “need to
know” basis).
3.
The Regional Health Authority must obtain and document informed verbal or informed
written consent from the client as follows:
a)
to assess the client;
b)
to release the client’s personal health information to anyone other than regional
staff and Saskatchewan Ministry of Health personnel; and,
c)
to provide service to the client.
4.
The Regional Health Authority must obtain and document informed verbal consent. To
obtain informed verbal consent, the Regional Health Authority must ensure that the client
has full knowledge of the specific actions for which the consent has been requested.
5.
To obtain informed written consent, the Regional Health Authority must ensure that the
client has full knowledge of the specific actions for which the consent has been
requested, and that those actions are specified in the consent document signed by the
client. A witness must certify the client’s signature.
6.
When applicable, the Regional Health Authority shall discuss Health Care Directives and
communicate this to appropriate team members.
7.
The Regional Health Authority must have a policy regarding disclosure of health
information with consent or as otherwise specifically authorized in The Health
Information Protection Act 1.
1
Government of Saskatchewan. (2004). The Health Information Protection Act. Regina, SK:
http://www.qp.gov.sk.ca/documents/english/Statutes/Statutes/H0-021.pdf
Community Care
Section:
Home Care Policy
Index Ref: 5.1
Client Rights and
Responsibilities
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Client Rights
5.1
CLIENT RIGHTS
POLICY
1.
The Regional Health Authority must establish written policies and procedures regarding
the rights of home care clients. This includes the promotion and protection of each
client’s right to receive necessary information, to be given reasonable choices and to be
treated with dignity.
2.
The Regional Health Authority will ensure that processes are in place to:
a)
ensure that clients understand their rights;
b)
help clients exercise their rights; and,
c)
investigate and resolve claims regarding a violation of client’s rights.
3.
Clients have the right to refuse service.
4.
Clients have the right to live at risk.
5.
Clients have the right to fully participate in the assessment process.
6.
Clients have the right to participate in the service delivery and make personal choices
within the parameters of services available.
7.
Clients have the right to appeal service plan decisions.
8.
Clients have the right to receive safe, appropriate and timely service.
9.
Clients have the right to be referred to other appropriate services.
10.
Clients have the right to participate in team conferences. Clients must be treated with
consideration, respect and full recognition of their dignity and individuality.
11.
Clients have the right to freedom from abuse, neglect or exploitation from home care
staff.
12.
Clients have the right to be assured of confidential treatment of their care records and
personal information.
13.
Clients, or the persons authorized to make health care decisions on behalf of the clients,
have the right to have their concerns heard, reviewed and where possible, resolved.
Community Care
Home Care Policy
Section:
Index Ref: 5.1
Client Rights and
Responsibilities
Page 2
Date of Issue:
September 2006
Revised September 2015
Subject:
Client Rights
GUIDELINES
Advising Clients of Possible Consequences when Exercising their Rights
1.
In some cases, exercising a right may affect the ability to serve a client’s needs.
2.
The assessor is always responsible for ensuring that the client, or advocate, understands
the possible effects of exercising a particular right and for documenting the discussion
with the client/family/supporter.
3.
For example, if a person refuses to undergo any part of an assessment interview, it would
be very difficult for the assessment process to reach rational decisions about needs and
services.
4.
Similarly, refusal to allow the assessor to seek the views of a third party, such as a
physician, might also affect the assessor’s ability to make the best possible decision about
needs and services.
5.
If a client with impaired judgement makes decisions that could seriously compromise
health/safety, the assessor must communicate this to appropriate others
(e.g. family/supporter, physician and those involved with the assessment process).
Community Care
Section:
Home Care Policy
Index Ref: 5.2
Client Rights and
Responsibilities
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Client Abuse
5.2
CLIENT ABUSE
DEFINITION
Abuse is considered any activity that causes physical, mental, financial or emotional injury to a
client.
Abuse is a violation of a client’s civil and human rights.
POLICY
1.
Regional Health Authorities have a duty to protect clients from abuse. A zero-tolerance
approach to client abuse must be enforced without exception.
2.
The Regional Health Authority shall develop appropriate policies and procedures to
ensure a zero-tolerance approach to client abuse.
3.
Regional Health Authority policies and procedures related to client abuse must be clearly
communicated to all management, staff and union representatives.
4.
Client abuse is a reportable serious incident. Failure to report an incident or suspicion of
abuse shall be cause for disciplinary action. Anyone who mistreats a client may be
prosecuted under the law.
GUIDELINES
Client abuse may be defined as:
1.
Physical Abuse:
• use of physical force that may result in bodily injury, physical pain, or impairment
including, but not limited to, slapping, pinching, pushing, striking, shoving, shaking,
choking, kicking, burning and other rough handling;
• force-feeding;
• inappropriate use of medication; and,
• forced confinement.
Community Care
Home Care Policy
Section:
Index Ref: 5.2
Client Rights and
Responsibilities
Page 2
Date of Issue:
September 2006
Revised September 2015
Subject:
Client Abuse
2.
Emotional/Psychological Abuse:
• the infliction of anguish, pain or distress through verbal or non-verbal acts;
• verbal assaults including, but not limited to, yelling, swearing, threats, derogatory
comments, humiliation, intimidation;
• denial of rights including, but not limited to, denying client participation with respect
to his/her life; and,
• social isolation including, but not limited to, giving the “silent treatment,” treating
like a child/infant, isolating from family/friends/regular activities.
3.
Financial Abuse:
• misuse of client’s funds, property or assets including, but not limited to:
– forcing a client to sell his/her personal belongings or property;
– stealing a client’s money, pension cheques, or possessions; and
– withholding a client’s money that is needed for daily living; and,
• fraud, forgery, extortion.
4.
Sexual Abuse:
• molestation;
• sexual assault; and,
• sexual harassment.
5.
Neglect:
• abandonment of the client by the caregiver; and,
• failure or refusal to provide with life necessities including, but not limited to,
withholding of food/water, personal care or health care services, etc.
The Regional Health Authority’s solicitor should be consulted as needed when developing
regional policies and procedures.
Community Care
Home Care Policy
Section:
Client Rights and
Responsibilities
Index Ref: 5.3
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Client Responsibilities
5.3
CLIENT RESPONSIBILITIES
POLICY
1.
The Regional Health Authority will ensure that clients understand their responsibility to:
a)
participate in developing and carrying out the service plan;
b)
be available at a given time for service, as agreed;
c)
notify the organization of any changes that may affect the provision of service;
d)
respect the human rights of the service provider (e.g. freedom from abuse,
exploitation, and racism);
e)
maintain a safe working environment for the service provider;
f)
use equipment, which is necessary for staff/client safety, in a safe and proper
manner;
g)
agree to using equipment as determined through the assessment process to ensure
client/home care worker safety; and,
h)
ensure client/worker safety for equipment they have obtained privately by
meeting the safety requirements of the manufacturer, maintaining the equipment
and documenting preventive maintenance as required.
2.
In situations where clients do not carry out their responsibilities, the Regional Health
Authority will:
a)
communicate client responsibilities (as indicated in 1. above) to clients and staff;
b)
eliminate or minimize factors that contribute to inappropriate behaviour;
c)
teach positive or desirable behaviour;
d)
use restrictive actions only when all positive processes have failed;
e)
integrate these actions into the plan of service as necessary; and,
f)
document the situation and actions taken.
Community Care
Home Care Policy
Section:
Assessment Process
Index Ref: 6.1
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Assessment Tool
6.1
ASSESSMENT TOOL
POLICY
1.
All assessments must be conducted using standard assessment tools, which have been
approved by the Saskatchewan Ministry of Health.
The standard provincial assessment tool is MDS-Home Care*. Additional tools
from the suite of interRAI instruments may also be used**.
* with the exception of the Athabasca Health Authority.
** Future implementation of additional screening tools may be introduced, e.g.
Emergency Department screening tool.
2.
All assessment and care coordination staff must complete assessment training.
Community Care
Home Care Policy
Section:
Assessment Process
Index Ref: 6.2
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Assessment Requirements
6.2
ASSESSMENT REQUIREMENTS
POLICY
1.
The Regional Health Authority must ensure that all applicants are assessed prior to the
provision of home care services.
2.
Risk factors will determine the urgency of service provision or the decision that service is
not required.
GUIDELINES
1.
A comprehensive assessment should be completed for applicants who:
a)
require one or more services;
b)
require palliative care;
c)
require case management;
d)
have a progressive illness;
e)
are high risk; or,
f)
receive services from another agency.
2.
When an eligible applicant requires immediate assistance, the Regional Health Authority
may arrange services before an assessment is completed. The Regional Health Authority
must establish procedures for initiating services in these circumstances. A full standard
assessment must be completed as soon as possible.
3.
The comprehensive assessment may be waived when:
a)
only a nursing service is required (e.g. if the person only requires foot care). A
nursing assessment must be completed in lieu of a full standard assessment; or,
b)
only a single therapy service is required (e.g. if physiotherapy is required for a
short period). A physiotherapy assessment must be completed in lieu of a full
standard assessment.
4.
The comprehensive assessment may be waived but a shortened assessment is used for:
a)
meals on wheels for short term;
b)
volunteer services; or,
c)
home management or home maintenance for short term.
Section:
Community Care
Home Care Policy
Assessment Process
Index Ref: 6.3
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Clients’ Rights Regarding Assessments
6.3
CLIENTS’ RIGHTS REGARDING ASSESSMENTS
POLICY
Clients are major participants in the assessment process, not simply the subjects of
assessment.
1.
Assessors must ensure that the client, or the persons authorized to make health care
decisions on behalf of the client (i.e. the advocate), are informed of their rights prior to
the assessment interview.
2.
Assessors are responsible for advising clients or their advocates of any foreseeable
consequences of their decisions.
3.
Assessors must inform the client or their advocates of their rights regarding their personal
health information including:
a)
when a trustee is collecting personal health information from the client, the trustee
must take reasonable steps to inform the client of the anticipated use and
disclosure of the information by the trustee; and,
b)
a trustee must establish policies and procedures to promote knowledge and
awareness of the rights extended to individuals by The Health Information
Protection Act, including the right to request access to their personal health
information and to request amendment of that personal health information.
GUIDELINES
1.
In some cases, the exercise of a right might affect the ability of the program to serve
client’s needs (e.g. if a person refuses to undergo any part of an assessment interview, it
would be very difficult to reach rational decisions about needs and services). Similarly,
refusal to allow the management of the Regional Health Authority to seek the views of a
third party, such as a physician, might also affect ability to make the best possible
decision about needs and services. The assessor is always responsible for ensuring that
the applicant, or advocate, understands the possible effects of exercising a particular
right.
2.
No applicant should be automatically refused admission to the program because he or she
is unwilling to cooperate fully in the assessment process. A decision should be made on
each case based on available information.
Section:
Community Care
Home Care Policy
Assessment Process
Index Ref: 6.3
Page 2
Date of Issue:
September 2006
Revised September 2015
Subject:
Clients’ Rights Regarding Assessments
3.
During the assessment process all clients have the right to:
a)
b)
c)
d)
e)
f)
g)
h)
have their views and desires recorded during the assessment interview;
choose whether a family member/supporter is present during the assessment
interview;
be present if an advocate or translator is required for the assessment interview;
refuse to answer any question or refuse to participate in any or all of the
assessment;
view the assessment record on request and request amendments to the record
(The Health Information Protection Act);
be consulted before the views of third parties are sought, and to approve, restrict
or deny such access;
be fully informed of the program’s service decisions and participate in care
planning; and,
give their consent for any collection, use and disclosure of their personal health
information, and the right to restrict release to third parties for the use of
information.
Community Care
Home Care Policy
Section:
Assessment Process
Index Ref: 6.4
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Assessment and Approval Process
6.4
ASSESSMENT AND APPROVAL PROCESS
POLICY
1.
The Regional Health Authority must ensure that an assessment and approval process is in
place to make decisions regarding care.
2.
The Regional Health Authority must guarantee consistency in the determination of
client’s need for service.
3.
The process must ensure the following critical elements:
a)
the coordinated entry to home care and long-term care services and placement;
b)
an equitable and consistent service across the Regional Health Authority;
c)
a mechanism to monitor the assessment process; and,
d)
the use of a consistent assessment tool.
4.
The assessment process must:
a)
ensure that the assessment tool and related manuals approved by Saskatchewan
Health are used to conduct assessments;
b)
review all assessment data to determine if an applicant meets all the eligibility and
acceptance criteria;
c)
evaluate the need for services and match the need with available resources as
much as possible;
d)
explore alternatives to meet identified needs, including referrals to other agencies
and/or other Regional Health Authority services;
e)
develop a care plan and a service delivery schedule;
f)
name a person to coordinate the care plan and establish reporting relationships
with service providers;
g)
review the progress of clients at regular intervals to ensure that the services are
still required and that they meet the needs of clients and their families;
h)
ensure that appropriate plans are established for the care of clients upon
discharge; and,
i)
ensure that decisions are communicated to the relevant parties.
5.
Clients must be major participants in the assessment process, not simply the subjects of
the assessment.
6.
A nurse must be included in the decision making process when nursing issues are being
discussed.
Community Care
Home Care Policy
Section:
Assessment Process
Index Ref: 6.4
Date of Issue:
September 2006
Revised September 2015
Subject:
Assessment and Approval Process
GUIDELINES
Those attending the assessment and approval process meetings may include:
•
•
•
•
•
•
Page 2
client and/or advocate;
other regional staff;
supervisors of contracting agencies;
medical consultants;
therapists, social workers or other available professionals in the community; and,
any other available person with knowledge or expertise that could benefit the decision
making process.
Community Care
Home Care Policy
Section:
Assessment Process
Index Ref: 6.5
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Client’s Right to Appeal
6.5
CLIENTS’ RIGHT TO APPEAL
POLICY
1.
Clients have the right to appeal decisions made by Regional Health Authority staff.
2.
Assessors must ensure that the client, or the person authorized to make health care
decisions on behalf of the client, is informed of their right and the process to appeal when
dissatisfied with:
• the care being provided; or,
• decisions about acceptance, service schedule or discharge.
Community Care
Section:
Home Care Policy
Index Ref: 6.6
Assessment Process
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Appeal Process
6.6
APPEAL PROCESS
POLICY
1.
The Regional Health Authority must develop a policy that clearly outlines the appeal
process.
2.
The Regional Health Authority must have two levels of appeal:
a)
the first level of appeal is to the respective program manager in the Regional
Health Authority who is responsible for appeal assessment. The appeal assessor
must not have been involved with the initial assessment; and,
b)
the second level of appeal is through a Regional Appeals Committee as
determined by the Regional Health Authority.
Clients and/or families may request the Quality of Care Coordinator to assist them
through the stages of appeal.
3.
The appeal assessor must reassess the client whenever significant assessment information
is in question.
4.
A thorough review of the case must be conducted within two weeks of receiving an
appeal.
5.
The appeal assessor must provide a written statement and explanation of his/her decision
to the client and/or advocate. If this decision is appealed, the appeal assessor must then
provide a copy of the written statement and explanation to the Regional Appeals
Committee.
6.
The Regional Appeals Committee must hear an appeal within two weeks of receiving an
appeal.
7.
The Regional Appeals Committee must hear from representatives of the regional
assessment personnel and from the client and/or advocate, and may invite opinions from
others as appropriate.
8.
The Regional Appeals Committee must provide a copy of the appeal decision, including
the rationale for the decision, to the regional assessment personnel and to the client
and/or advocate.
9.
The decision of the Regional Appeals Committee is final.
Community Care
Home Care Policy
Section:
Case Management
Index Ref: 7.1
Page 1
Date of Issue:
September 2006
Revised September 2015
Subject:
Case Coordination/Management
7.1
CASE COORDINATION/MANAGEMENT
DEFINITION
1.
Case coordination/management includes assessment, planning, coordinating,
implementing, monitoring and evaluating health-related services.
2.
It is a collaborative, client-centred process that is continuous across provider and agency
lines.
3.
Case coordination/management promotes quality care and cost effective outcomes while
addressing the health and well being of clients.
POLICY
1.
The Regional Health Authority must have a structure in place for case
coordination/management.
2.
Case coordination/management must be implemented in the following circumstances:
a)
high risk clients;
b)
complex home care clients;
c)
palliative care;
d)
home care clients receiving services from other agencies; or,
e)
client receiving more than one home care service.
GUIDELINES
1.
Case Manager’s Role:
• In collaboration with clients/families, the case manager facilitates and coordinates
services by linking clients with service providers and community resources.
• The case manager works with families, friends, other caregivers and communities
associated with the client.
• The case manager is familiar with the client’s goals and is continually involved in
monitoring and ongoing reassessment.
• The role and skills of the case manager are essential to an effective assessment.
• The assessment tool provides direction to the case manager about the type and
amount of information that should be collected from individuals.
• The assessment tool also provides a place to document information.
Community Care
Home Care Policy
Section:
Case Management
Index Ref: 7.1
Page 2
Date of Issue:
September 2006
Revised September 2015
Subject:
Case Coordination/Management
2.
Purpose of Case Management is to develop an approach that improves access to
coordinated and integrated health services that are client-centred, community-based and
meet the client’s health needs.
3.
Principles of Case Management:
a)
respects clients’ dignity, responsibility and self-determination;
b)
recognizes and responds to clients’ and caregivers’ needs and expectations;
c)
ensures clients are informed, are provided with options, and participate in making
decisions;
d)
respects the role of families, other caregivers and community resources in
planning and implementing care for clients;
e)
promotes easy access to timely and appropriate services (not only traditional
health services);
f)
respects the importance of confidentiality (Sharing of information should be
client-directed on a need-to-know basis);
g)
protects the rights of others as well as clients;
h)
promotes coordination of services through a multi-disciplinary team approach;
i)
fosters good communication, cooperation and collaboration among service
providers, clients and communities;
j)
promotes early interaction aimed at identifying people at risk;
k)
emphasizes the support of independence and community-based living;
l)
promotes and provides opportunities for education;
m)
supports staff strengths and skills to deal with complex human issues;
n)
promotes efficient, effective and equitable use of resources, focused on achieving
positive health outcomes; and,
o)
provides opportunity and information to collaboratively plan the health system
and for the clients.
Section:
Community Care
Index Ref: 7.1
Case Management
Home Care Policy
Page 3
Date of Issue:
September 2006
Revised September 2015
Subject:
Case Coordination/Management
Diagram: Integrated Case Management Process and Components 1
Beginning the Case
Management Process
Exit
Identifying a Lead
Case Manager
Assessment
Gather and Pool
Information
Identify Strengths,
Needs and Supports
Planning
Documentation
occurs
throughout the
process.
Plan
Interventions
Develop Goals
Coordination/
Implementation of
Care Plan
Assistance
may be
required of
non-team
members at
any point
Monitoring
and Evaluation
Transfer or
Discharge
1
Government of Saskatchewan (1998) Saskatchewan Human Services: Integrated Case Management.
Regina, SK.
Community Care
Section:
Index Ref: 8.1
Page 1
Date of Issue:
Home Care Policy
Care Plan
September 2006
Revised September 2015
Subject:
Development of Care Plans
8.1
DEVELOPMENT OF CARE PLANS
POLICY
1.
The care plan must specify:
a)
the type and frequency of service the client needs and will receive;
b)
the client-centered goals of the service with a target date;
c)
goals that should be individualized, measurable and achievable;
d)
the date that service will commence;
e)
referrals to be made;
f)
the role of the client in self-care;
g)
services to be carried out by:
–
informal caregivers support network;
–
other organizations or agencies; and
–
the home care program; and,
h)
service review date.
2.
The plan should include:
a)
health promotion;
b)
illness prevention;
c)
emotional support and counseling;
d)
education to promote self care and independence; and,
e)
transition/discharge.
3.
The care plan must be updated on an ongoing basis to reflect changing needs, met or
changed goals, altered service or support.
Community Care
Section:
Index Ref: 8.2
Page 1
Date of Issue:
Home Care Policy
Care Plan
September 2006
Revised September 2015
Subject:
Care Plan Participants
8.2
CARE PLAN PARTICIPANTS
POLICY
1.
Clients and/or persons authorized to make health care decisions on behalf of clients, are
participants in the development of the care plan.
GUIDELINES
1.
Appropriate team members, clients and/or supporters collaborate in the development of
care plans.
2.
Care plans should be communicated to appropriate persons.
Community Care
Section:
Index Ref: 8.3
Page 1
Date of Issue:
Home Care Policy
Care Plan
September 2006
Revised September 2015
Subject:
Implementation of Service
8.3
IMPLEMENTATION OF SERVICE
POLICY
1.
Appropriate team members must implement care plans in a timely manner and document
the service.
2.
Services must be implemented according to accepted standards of practice and the
Regional Health Authority’s policies.
GUIDELINES
1.
Continuity of implementing service is promoted by:
a)
assigning the same individual(s) to provide service over time when feasible;
b)
orientating replacement staff and volunteers to their assigned responsibilities and
to the individual needs of clients;
c)
having regular team discussions of clients’ progress; and,
d)
communicating appropriately with other agencies or other Regional Health
Authority services involved in care.
Section:
Community Care
Index Ref: 8.4
Page 1
Date of Issue:
Home Care Policy
Care Plan
September 2006
Revised September 2015
Subject:
Reassessment/Revision of Care Plans
8.4
REASSESSMENT/REVISION OF CARE PLANS
POLICY
1.
The Regional Health Authority must have established procedures for changing care plans.
2.
There must be a process for the case manager to approve all major changes to care plans.
3.
A thorough review or reassessment of every client within ninety (90) days of the client’s
admission, and at least once annually thereafter, must be conducted to ensure the
changing needs of the client are continuously met.
4.
Additional case reviews or reassessments as warranted by the condition or situation of
clients must be conducted.
5.
All relevant information must be considered in conducting a review.
6.
Reassessment must be conducted using an assessment tool approved by Saskatchewan
Health.
7.
Consents must be reviewed and documented with each reassessment.
8.
Prior to making any major changes to clients’ care arrangements, Regional Health
Authority staff must notify clients and explain the basis for the proposed changes.
Section:
Community Care
Index Ref: 8.5
Page 1
Date of Issue:
Home Care Policy
Care Plan
September 2006
Revised September 2015
Subject:
Authority and Requirements for Discharge
8.5
AUTHORITY AND REQUIREMENTS FOR DISCHARGE
POLICY
1.
Clients must be discharged from the program at any time when home care services are no
longer appropriate or required.
2.
Clients who have not received a home care service for twelve (12) consecutive months
must be discharged from the program unless they are living in a Personal Care Home.
3.
Clients shall participate in planning for discharge from the program.
4.
Appropriate and necessary contacts or referrals must be made.
5.
Discharge plans, referrals, and discharge data must be documented on clients’ care plans.
GUIDELINES
1.
The Regional Health Authority will ensure that support is available for clients, informal
caregivers, their support network, staff and volunteers following discharge, transfer or
death of a client.
2.
The support offered by the Regional Heath Authority in the event of death may include:
a)
individual or group counseling;
b)
pastoral visits;
c)
referral to other groups;
d)
memorial services; or,
e)
debriefing.
Community Care
Section:
Index Ref: 8.6
Page 1
Date of Issue:
Home Care Policy
Care Plan
September 2006
Revised September 2015
Subject:
Re-admission
8.6
RE-ADMISSION
POLICY
1.
When a previously discharged client is re-admitted into the home care program for
service, the decision for re-admission is based on one or more of the following:
a)
progress summary notes; or,
b)
completion of the standard assessment tool approved by the Saskatchewan
Ministry of Health.
2.
The updated client care plan must reflect new or revised goals and interventions and must
indicate a timeline for evaluation/follow-up.
Community Care
Section:
Index Ref: 9.1
Page 1
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Client Records
9.1
CLIENT RECORDS
POLICY
1.
The Regional Health Authority must maintain complete records on all clients
receiving home care services.
2.
Client records are to be kept confidential.
3.
All records must be securely stored.
4.
RHAs must have policies to ensure security and integrity of client records at all times.
GUIDELINES
1.
There should be written policies and procedures indicating how the various forms are to
be completed and used. Documentation should:
a)
provide pertinent information on the condition of clients;
b)
provide client care plans with specific goals and time frames;
c)
outline various interventions by physicians, nurses and other persons who are
involved in the care of clients;
d)
communicate the response of clients to various interventions; and,
e)
record actual care provided to clients.
2.
All home care providers should be familiar with standard charting requirements.
3.
Home care providers who are inexperienced in documenting client care records should be
given the preparation necessary to perform the recording functions.
4.
Client care records should:
a)
contain sufficient information to:
–
identify clients clearly;
–
justify the reasons for admission;
–
identify problems including, where applicable, diagnosis of disease and
subsequent treatment; and,
–
document the results of treatment.
b)
document the care provided (the client’s physical condition, problems,
psychological status and goals, and client progress (or lack of progress) should be
evident).
Community Care
Section:
Index Ref: 9.1
Page 2
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Client Records
5.
All records should contain at least the following:
a)
identifying data (i.e. surname, given names, birth date, Saskatchewan Health
Services card number, address, etc);
b)
assessment form;
c)
care plan, including goals and time frames;
d)
social histories and, if indicated, a nursing history;
e)
records of medications, therapeutic treatments and care provided;
f)
the reason for any decision made and documented (i.e. signed on behalf of a client
by any person other than the client);
g)
physician’s orders;
h)
progress notes, flow sheets;
i)
any record of action taken to arrange alternate care if the client is discharged; and,
j)
a discharge summary, indicating the date and time of discharge, reason for
discharge or cause of death, circumstances of discharge and person notified.
6.
All data listed above should be maintained in a single client record.
Community Care
Section:
Index Ref: 9.2
Page 1
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Documentation Requirements
9.2
DOCUMENTATION REQUIREMENTS
POLICY
1.
Proper charting is an essential component of ensuring the provision of quality client care.
In evaluating the quality of that care, it is not possible to effectively determine what has
been done for a client, how well it has been done, or what should be done in the future
unless adequate documentation has been completed. It is important then, that:
a)
anyone who is involved in the care of the client has access to the client care
record; and,
b)
irrespective of who provides care to a client, that person shall record the service
provided and as necessary, the client’s response to the service (i.e. charting by
exception) 1.
2.
Client care records are a legal document; therefore, care providers shall be familiar with
charting requirements.
3.
Client care records shall contain:
a)
sufficient information to:
–
clearly identify the client;
–
justify the reasons for admission;
–
identify problems including, where applicable, the diagnosis of disease
and subsequent treatment(s); and,
–
document results of treatment.
b)
documentation of the care rendered and an indication of the clients’ physical
condition, problems, psychological status and goals, and client progress (or lack
of progress) shall be evident.
GUIDELINES
Home care providers may use the following charting requirements when recording and
documenting in client care records.
1
‘charting by exception’ infers that all standards for care have been met and the client responded as expected.
Longhand charting is required when there is a change in client response, significant findings and/or when unusual
events occur.
Community Care
Section:
Index Ref: 9.2
Page 2
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Documentation Requirements
1.
Identification of Client – The name of the client, the current date and page number should
be recorded on each sheet of the client care record.
2.
Permanency of Record – Client care records are permanent documents. Therefore, every
precaution should be taken to ensure permanency. All entries must be made either in ink
or another permanent medium.
3.
Correction of Entry
a)
Written Copy – The writer should then indicate that it is an “incorrect entry” and
initial beside the incorrect entry.
The newly documented page may be labeled as “corrected copy” and placed in
front of the original page.
b)
Electronic Documentation – Follows similar rules as paper based documentation.
Electronic document should have accessible audit trail which captures date, time,
person for every entry.
When there is correction, the original should be available with a time stamp and the new
correct entry saved in the appropriate location and/or chart.
This is done in various methods:
• Electronic software can mimic this correction by showing a correction by putting a
line through the previous entry and having correct entry as a new update or could
overwrite with the corrected entry; however, the original is still available.
• Some software allows a deletion of the entry (cut and paste functions) but does
maintain the legal record of changes in the audit trail functions in case the clinician
has made a decision based on the previous documentation.
• Some software provides an alert function for corrections to the primary provider of
the patient/client record (this is usually for lab result corrections).
• Flow sheet changes can also be charted and accepted with a corrected notation.
Either process is acceptable for electronic charting.
4.
Timeliness – It is recommended that home care staff chart on a daily basis and
immediately after a particular event(s) rather than waiting for an established charting
time.
Community Care
Section:
Index Ref: 9.2
Page 3
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Documentation Requirements
5.
Individual Recording – The home care provider should only document the specific care
provided to a client. Only the care provider who observed or performed the action being
recorded should complete the recording.
6.
Chronological Order – Information should be recorded in chronological order. This
means events should be recorded in the order or sequence in which they occurred. If an
entry is made out of chronological sequence, a notation should be made to that effect
(i.e. in the nursing/progress notes, the writer should record the current date and time of
documentation and then record the date and time of when the event/actions had originally
occurred; an arrow may be placed indicating where the entry should be placed within the
sequence). All notations should be dated and signed by the writer.
7.
Abbreviations and Codes – Abbreviations in client care records should be kept to a
minimum. Only those abbreviations recognized by all members of the home care staff
should be used in the client care records.
8.
Accuracy – The client care record must be accurate in all aspects. All home care
providers must accurately record what is observed or heard and any relevant statements
made by the client.
Accurate charting of medication administration and treatment given is as important as the
administration itself.
9.
Conciseness – The wording in the client care record should be short and concise in order
to avoid misinterpretation. Forms should be designed in a fashion so as to eliminate
unnecessary searches throughout the entire record and to save time in recording.
If flow sheets are used, there is no need to record on the progress notes unless something
unusual has happened, or a change in the client’s health status has occurred.
10.
Legibility – All entries must be legible.
11.
Uniformity – The system of recording information should be uniform throughout the
home care program. No individual should, on his or her own initiative, add or omit
items, which are not in accordance with home care policies or practices.
Routine events should always be recorded on the form. An event that is routine to one
client, might not be routine to another.
Community Care
Section:
Index Ref: 9.2
Page 4
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Documentation Requirements
12.
Date, Signature and Initials – All entries must include the date, time, and signature of the
care provider. When signing entries, home care staff should always identify themselves
with their first initial and full last name, followed by their professional designation
(e.g. RN, LPN, HCA, RD, OT/PT and RSW).
Unless the policy of the Regional Health Authority home care program states differently,
initials may also be used. It must, however, be immediately apparent who initialed the
entry.
13.
Master Signature List – The master signature list should contain the names of all home
care providers. The list should display the full name (printed), signature, initials and
professional designation of each care provider. A copy of the master signature list may
be kept on file in the client care records. All entries to the client care records must be
signed in a clearly identifiable manner.
Community Care
Section:
Index Ref: 9.3
Page 1
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Incident Reports and Investigation
9.3
INCIDENT REPORTS AND INVESTIGATION
POLICY
1.
The Regional Health Authority shall have a system to report and record incidents that
have the potential to injure or result in actual injury to clients, staff or volunteers. This
system shall also include the investigation of incidents and the development of
recommendations to prevent future incidents of a similar nature.
2.
A report shall be completed at the time of the event, or as soon as possible thereafter, of
any unusual occurrence involving clients, staff or volunteers.
3.
When an incident meets the threshold for a critical incident as per the Saskatchewan
Critical Incident Reporting Guideline 2004, please refer to Policy 9.4.
GUIDELINES
1.
Incidents should be reported on an Incident Report form.
2.
Situations requiring the completion of an Incident Report form include:
a)
accidents involving clients, staff, or volunteers;
b)
unusual incidents where care staff are involved (e.g. adverse drug reactions,
incorrect performance of procedures by staff affecting the care given to clients);
c)
loss of, or damage to, personal belongings of clients, staff or volunteers;
d)
damage to equipment or furniture as a result of an unusual circumstance; and,
e)
medication errors (errors in the actual administration of the drug or errors of
judgment).
3.
Where there has been an accident involving a client, staff, or volunteer in the client’s
home, an Incident Report should be initiated at the time of the incident by the witness or
staff member with primary involvement. Information contained in the Incident Report
should:
a)
be objective, clearly written and concise. The witness should report what she/he
actually experienced (saw or heard) not what others have experienced (e.g. rather
than report “client fell out of bed” report “client found on floor” unless client was
actually observed falling out of bed;
b)
give the reader a clear picture of the event. Use precise and descriptive language
in recording observations (e.g. if the client fell out of bed, the witness should
record such items as the location and position of the client on discovery, the
location, size and color of any wound or bruise);
Community Care
Section:
Index Ref: 9.3
Page 2
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Incident Reports and Investigation
c)
d)
e)
include observations of the client (e.g. colour, vital signs, level of consciousness,
emotional state);
record any nursing actions taken at the time of the incident, the name of the
physician notified and time, the physician’s response to the notification, and time
of his/her response; and,
relevant details of any action by the individual involved in the accident.
4.
Where there has been a medication error:
a)
an Incident Report should be initiated as soon as the error is recognized;
b)
information in the report should be factual. Documentation should include
identification of the actual error as it occurred and as well as the action taken by
the care provider once the error was recognized;
c)
additional information that should be recorded in the incident report may include:
the name of the physician notified, the time the physician was notified and the
response of the physician notified; and,
d)
the care provider involved in the incident should provide an explanation and a
rationale as to why the incident occurred.
5.
The filing of an Incident Report does not lessen the care provider’s responsibility for
recording the event on the nursing report and on the client care record.
6.
The nursing notes should contain relevant clinical information so that those involved with
the client’s care will be aware of the incident, the medical and nursing action taken and
the client’s response to both the incident and the intervention.
7.
The Regional Health Authority should ensure that there is a policy concerning the filing
of Incident Reports.
8.
Regular reviews and evaluations should be done to determine whether particular
occurrences were preventable. The Incident Report should be thought of as one method
of assessing the quality of care that is provided. Recommendations and follow-up action
should be documented. All incidents should be investigated with the aim of developing
recommendations to prevent the recurrence of similar incidents.
Community Care
Section:
Index Ref: 9.4
Page 1
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Reportable Critical Incident Review
9.4
REPORTABLE CRITICAL INCIDENT REVIEW
POLICY
1.
The Director of Community Services/Home Care Manager shall notify the Saskatchewan
Ministry of Health as soon as possible of any critical incident that has affected clients,
staff or volunteers. Verbal notification should be followed by a written report.
2.
Refer to section 58 of The Regional Health Services Act for guidance regarding the steps
to be taken when investigating and reporting a critical incident.
GUIDELINES
1.
The intent of the policy is to inform the Saskatchewan Ministry of Health of the
circumstances surrounding a critical incident.
2.
Events or circumstances that should be considered reportable include:
a)
any serious problem affecting clients;
b)
an outbreak of infectious disease reportable to the local Medical Health Officer as
per Communicable Disease Control Guidelines;
c)
any client death which results in a coroner’s inquest;
d)
any serious incident, accident or injury to clients that are potentially disabling or
life threatening;
e)
any harm or suspected harm suffered by clients as a result of unlawful conduct,
improper treatment or care, harassment or neglect (i.e. any incident of client
abuse);
f)
any incident which has been reported to law enforcement officers; and,
g)
other incidents or events as determined by the management of home care.
Community Care
Section:
Index Ref: 9.5
Page 1
Date of Issue:
Home Care Policy
Client Records
September 2006
Revised September 2015
Subject:
Retention of Client Records
9.5
RETENTION OF CLIENT RECORDS
POLICY
1.
Records for an adult client must be kept for a minimum of six (6) years after the date that
service is last provided.
2.
Records for a child must be kept until the child reaches 18 years of age, plus two (2)
years.
GUIDELINES
1.
The suggested retention periods are minimums and intended only to be general
guidelines.
2.
In any particular case where litigation seems to be a possibility, all records relevant to the
case should be maintained until it is clear that the difficulties have been resolved.
3.
When in doubt about whether a particular document or record should be destroyed, the
Regional Health Authority’s solicitor should be consulted.
4.
For further information, refer to The Health Information Protection Act:
http://www.qp.gov.sk.ca/documents/english/Statutes/Statutes/H0-021.pdf
Community Care
Section:
Index Ref: 10.1
Page 1
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
Types of Care
10.1
TYPES OF CARE
POLICY
1.
All home care programs within the Regional Health Authorities must provide acute care,
end-of-life, rehabilitation, maintenance and long-term care to remain independent at
home.
Community Care
Section:
Index Ref: 10.2
Page 1
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
Acute Care
10.2
ACUTE CARE
POLICY
1.
A client who needs immediate or urgent time limited (up to three (3) months or less)
intervention to improve or stabilize a medical or post-surgical condition.
2.
This category is designed to identify situations (other than palliative care) in which the
home care program provides a service that might otherwise be provided in a hospital or
health centre.
In many cases, the services will be provided to a person recently discharged from
hospital. This may include persons with mental illness or mental health disorders.
3.
Clients who are discharged early from hospital or who are receiving services to
avoid/prevent re-admission and to avoid/prevent imminent admission (Policy 15.1.1 short
term acute) will not be charged fees for personal care services (up to 14 days).
(Policy 15.1)
GUIDELINES
1.
A person in the acute care category will usually receive nursing/therapy services but may
also receive support services (e.g. meals, home management).
2.
The client’s care plan will usually indicate a definite time frame of acute care.
3.
Once the client has been stabilized and indefinite home care involvement is indicated, the
category should be changed to a more appropriate type.
4.
This category also includes situations in which the family is providing all or some of the
nursing/personal care that might otherwise have to be provided in hospital, and where
home care is providing other services (e.g. meals, home management, some
nursing/personal care) to help the family cope during an acute episode.
Community Care
Section:
Index Ref: 10.3
Page 1
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
Long-Term Supportive Care
10.3
LONG-TERM SUPPORTIVE CARE
POLICY
1.
A client is at significant risk of institutionalization due to unstable, chronic health
conditions, and/or living condition(s) and/or personal resources.
2.
This is a category which applies when neither acute, rehabilitation, maintenance or
palliative care apply. Clients may be considered to be “long term supportive care” when:
a)
home care services are provided on an indefinite basis for the primary purpose of
assisting clients to remain in the community (and/or to avoid admission to
long-term care facilities);
b)
home care services are providing respite to the clients’ supporters; or,
c)
any other situation in which the type of care does not fall into either the acute,
rehabilitation, maintenance or palliative care categories.
Community Care
Section:
Index Ref: 10.4
Page 1
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
Rehabilitation
10.4
REHABILITATION
POLICY
1.
This category applies to a client with a stable health condition that is expected to improve
with a time-limited focus on goal-oriented, function rehabilitation. The rehabilitation
plan specifies goals and expected duration of therapy.
Community Care
Section:
Index Ref: 10.5
Page 1
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
Maintenance
10.5
MAINTENANCE
POLICY
1.
This category applies to a client with stable, chronic health conditions, stable living
conditions and person resources, who needs ongoing support in order to remain living at
home.
Community Care
Section:
Index Ref: 10.6
Page 1
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
Palliative Care/End of Life
10.6
PALLIATIVE CARE/END OF LIFE
In one’s best clinical judgment, a client with any end-stage disease who is expected to live less
than six months. Judgment should be substantiated by well-documented disease diagnosis and
deteriorating clinical course.
DEFINITION
Palliative care refers to interdisciplinary services that provide active compassionate care to the
client who is terminally ill at home, in hospital or in another care facility. It is a service made
available to terminally ill persons and their supporters who have determined that treatment for
cure or prolongation of life is no longer the primary goal.
POLICY
1.
This category applies to clients who are dying and who have chosen to spend as much
time as possible in their own homes. Clients may be considered “palliative” when:
a)
their condition has been diagnosed by a physician as terminal with life expectancy
of weeks or months;
b)
active treatment to prolong life is no longer the goal of care; or,
c)
the case management process in the Regional Health Authority has determined
through assessment that the individual requires palliative care.
GUIDELINES
1.
Key Elements of the Palliative Care Process include:
a)
the individual’s disease is not curable and the individual and/or family have been
informed of this. This is a period when goals must be redefined and when it is
appropriate to discontinue certain treatments. New symptoms may arise or
existing symptoms worsen, necessitating modification of management or the
initiation of new measures to ensure the comfort of the person;
b)
the individual and/or family may have determined that palliative care will
improve the quality of remaining life and that cure and prolongation of life may
no longer be appropriate; and,
c)
there are three (3) stages in the palliative process:
–
early;
–
intermediate; and,
–
end stage or dying stage.
Community Care
Section:
Index Ref: 10.6
Page 2
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
Palliative Care/End Of Life
2.
“Early” and “Intermediate” Stage Palliative Care – Individuals in the early and
intermediate stage of the palliative process normally would be considered “stable”, where
deterioration is proceeding at a slower pace, and minimal or occasional assistance is
required due to terminal illness.
3.
“End Stage” Palliative Care – The following parameters may be used to help determine
whether terminally ill individuals are in the end stage of the palliative process and are
dealing with end of life (dying) issues:
a)
the time frame for the end stage may be measured in terms of days or weeks of
dying. Time frames are difficult to determine, however, and in some cases, this
end stage may be longer than a few weeks or as short as one (1) or two (2) days;
b)
there are typically day-to-day changes with deterioration proceeding at a dramatic
pace. There may also be a sudden drop in the Palliative Performance Rating
according to the Palliative Performance Scale developed by the Victoria Hospice
Society and the Capital Region Home Nursing Care in British Columbia;
c)
end stage may be characterized by:
–
increasing intensity of need;
–
increasing assistance required for physical and psychological need and
family exhaustion; and/or,
–
a requirement for social work, pastoral care, and therapies (e.g. pet and
music).
d)
there is documented clinical progression of disease, which may include a
combination of the following symptoms:
–
dyspnea;
–
increased pain (crescendo pain);
–
increased nausea;
–
profound weakness;
–
being essentially bed bound;
–
drowsy for extended periods;
–
disorientation as to time;
–
severely limited attention span;
–
increasing disinterest in food and fluid;
–
difficulty swallowing medication;
–
dependence in activities of daily living (bathing, dressing, feeding,
transfers, continence of urine and stool, ability to ambulate independently
to bathroom);
–
social withdrawal;
–
restlessness;
–
ascites;
–
lymphedema; and,
–
anxiety.
Community Care
Section:
Index Ref: 10.6
Page 3
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
Palliative Care/End of Life
e)
the end stage terminally ill individual is assessed and given a Palliative Performance
Rating of 30% or lower according to the Palliative Performance Scale developed by the
Victoria Hospice Society and the Capital Region Home Nursing Care in British
Columbia. 1
Community Care
Section:
Index Ref: 10.7
Page 1
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
References
10.7
REFERENCES
Saskatchewan Health. (1994). Guidelines for developing an integrated palliative care service.
Regina, Saskatchewan.
Canadian Hospice Palliative Care Association (2002). A model to guide hospice palliative care:
Based on national principles and norms of practice. Ottawa, Ontario.
Palliative Performance Scale (PPSv2)
version 2
PPS
Level
100%
Ambulation
90%
Full
80%
Full
70%
Reduced
60%
Reduced
50%
Mainly Sit/Lie
40%
Mainly in Bed
30%
Totally Bed
Bound
Totally Bed
Bound
Totally Bed
Bound
Death
20%
10%
0%
Full
Activity & Evidence of
Disease
Normal activity & work
No evidence of disease
Normal activity & work
Some evidence of disease
Normal activity with Effort
Some evidence of disease
Unable Normal Job/Work
Significant disease
Unable hobby/house work
Significant disease
Unable to do any work
Extensive disease
Unable to do most activity
Extensive disease
Unable to do any activity
Extensive disease
Unable to do any activity
Extensive disease
Unable to do any activity
Extensive disease
-
Self-Care
Intake
Conscious Level
Full
Normal
Full
Full
Normal
Full
Full
Normal or
reduced
Normal or
reduced
Normal or
reduced
Normal or
reduced
Normal or
reduced
Normal or
reduced
Minimal to
sips
Mouth care
only
-
Full
Full
Occasional assistance
necessary
Considerable assistance
required
Mainly assistance
Total Care
Total Care
Total Care
-
Full
Full
or Confusion
Full
or Confusion
Full or Drowsy
+/- Confusion
Full or Drowsy
+/- Confusion
Full or Drowsy
+/- Confusion
Drowsy or Coma
+/- Confusion
-
Community Care
Section:
Index Ref: 10.7
Page 2
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
References
Instructions for Use of PPS (see also definition of terms)
1.
PPS scores are determined by reading horizontally at each level to find a ‘best fit’ for the patient
which is then assigned as the PPS% score.
2.
Begin at the left column and read downwards until the appropriate ambulation level is reached,
then read across to the next column and downwards again until the activity/evidence of disease is
located. These steps are repeated until all five columns are covered before assigning the actual
PPS for that patient. In this way, ‘leftward’ columns (columns to the left of any specific column)
are ‘stronger’ determinants and generally take precedence over others.
Example 1: A patient who spends the majority of the day sitting or lying down due to fatigue from
advanced disease and requires considerable assistance to walk even for short distances but who is
otherwise fully conscious level with good intake would be scored at PPS 50%.
Example 2: A patient who has become paralyzed and quadriplegic requiring total care would be PPS
30%. Although this patient may be placed in a wheelchair (and perhaps seem initially to be at 50%),
the score is 30% because he or she would be otherwise totally bed bound due to the disease or
complication if it were not for caregivers providing total care including lift/transfer. The patient may
have normal intake and full conscious level.
Example 3: However, if the patient in example 2 was paraplegic and bed bound but still able to do
some self-care such as feed themselves, then the PPS would be higher at 40 or 50% since he or she
is not ‘total care.’
3.
PPS scores are in 10% increments only. Sometimes, there are several columns easily placed at
one level but one or two which seem better at a higher or lower level. One then needs to make a
‘best fit’ decision. Choosing a ‘half-fit’ value of PPS 45%, for example, is not correct. The
combination of clinical judgment and ‘leftward precedence’ is used to determine whether 40% or
50% is the more accurate score for that patient.
4. PPS may be used for several purposes. First, it is an excellent communication tool for quickly
describing a patient’s current functional level. Second, it may have value in criteria for workload
assessment or other measurements and comparisons. Finally, it appears to have prognostic
value.
Copyright © 2001 Victoria Hospice Society
Community Care
Section:
Index Ref: 10.7
Page 2
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
References
Definition of Terms for PPS
As noted below, some of the terms have similar meanings with the differences being more readily
apparent as one reads horizontally across each row to find an overall ‘best fit’ using all five columns.
1. Ambulation
The items ‘mainly sit/lie,’ ‘mainly in bed,’ and ‘totally bed bound’ are clearly similar. The subtle
differences are related to items in the self-care column. For example, ‘totally bed ‘bound’ at PPS 30% is
due to either profound weakness or paralysis such that the patient not only can’t get out of bed but is also
unable to do any self-care. The difference between ‘sit/lie’ and ‘bed’ is proportionate to the amount of time
the patient is able to sit up vs need to lie down.
‘Reduced ambulation’ is located at the PPS 70% and PPS 60% level. By using the adjacent column, the
reduction of ambulation is tied to inability to carry out their normal job, work occupation or some hobbies
or housework activities. The person is still able to walk and transfer on their own but at PPS 60% needs
occasional assistance.
2. Activity and Extent of Disease
‘Some,’ ‘significant,’ and ‘extensive’ disease refer to physical and investigative evidence which shows
degrees of progression. For example in breast cancer, a local recurrence would imply ‘some’ disease,
one or two metastases in the lung or bone would imply ‘significant’ disease, whereas multiple metastases
in lung, bone, liver, brain, hypercalcemia or other major complications would be ‘extensive’ disease. The
extent may also refer to progression of disease despite active treatments. Using PPS in AIDS, ‘some’
may mean the shift from HIV to AIDS, ‘significant’ implies progression in physical decline, new or difficult
symptoms and laboratory findings with low counts. ‘Extensive’ refers to one or more serious complications
with or without continuation of active antiretrovirals, antibiotics, etc.
The above extent of disease is also judged in context with the ability to maintain one’s work and hobbies
or activities. Decline in activity may mean the person still plays golf but reduces from playing 18 holes to 9
holes, or just a par 3, or to backyard putting. People who enjoy walking will gradually reduce the distance
covered, although they may continue trying, sometimes even close to death (eg. trying to walk the halls).
3. Self-Care
‘Occasional assistance’ means that most of the time patients are able to transfer out of bed, walk, wash,
toilet and eat by their own means, but that on occasion (perhaps once daily or a few times weekly) they
require minor assistance.
‘Considerable assistance’ means that regularly every day the patient needs help, usually by one
person, to do some of the activities noted above. For example, the person needs help to get to the
bathroom but is then able to brush his or her teeth or wash at least hands and face. Food will often need
to be cut into edible sizes but the patient is then able to eat of his or her own accord.
‘Mainly assistance’ is a further extension of ‘considerable.’ Using the above example, the patient now
needs help getting up but also needs assistance washing his face and shaving, but can usually eat with
minimal or no help. This may fluctuate according to fatigue during the day.
Community Care
Section:
Index Ref: 10.7
Page 4
Date of Issue:
Home Care Policy
Types of Care
September 2006
Revised September 2015
Subject:
References
‘Total care’ means that the patient is completely unable to eat without help, toilet or do any self-care.
Depending on the clinical situation, the patient may or may not be able to chew and swallow food once
prepared and fed to him or her.
4. Intake
Changes in intake are quite obvious with ‘normal intake’ referring to the person’s usual eating habits
while healthy. ‘Reduced’ means any reduction from that and is highly variable according to the unique
individual circumstances. ‘Minimal’ refers to very small amounts, usually pureed or liquid, which are well
below nutritional sustenance.
5. Conscious Level
‘Full consciousness’ implies full alertness and orientation with good cognitive abilities in various
domains of thinking, memory, etc. ‘Confusion’ is used to denote presence of either delirium or dementia
and is a reduced level of consciousness. It may be mild, moderate or severe with multiple possible
etiologies. ‘Drowsiness’ implies either fatigue, drug side effects, delirium or closeness to death and is
sometimes included in the term stupor. ‘Coma’ in this context is the absence of response to verbal or
physical stimuli; some reflexes may or may not remain. The depth of coma may fluctuate throughout a 24
hour period.
© Copyright Notice.
The Palliative Performance Scale version 2 (PPSv2) tool is copyright to Victoria Hospice Society and replaces the
first PPS published in 1996 [J Pall Care 9(4): 26-32]. It cannot be altered or used in any way other than as intended
and described here. Programs may use PPSv2 with appropriate recognition. Available in electronic Word format by
email request to edu.hospice@viha.ca
Correspondence should be sent to Medical Director, Victoria Hospice Society, 1952 Bay Street, Victoria, BC, V8R
1J8, Canada
Community Care
Section:
Index Ref: 11.1
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Home Care Services
11.1
HOME CARE SERVICES
POLICY
1.
All home care services must be provided in accordance with relevant home care policies,
procedures and standards included in the Saskatchewan Ministry of Health Home Care
Policy Manual.
Community Care
Section:
Index Ref: 11.2
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Primary Home Care Services
11.2
PRIMARY HOME CARE SERVICES
DEFINITION
Primary home care services are services for which funding is authorized by the Saskatchewan
Ministry of Health.
POLICY
1.
Every Regional Health Authority must offer the primary home care services.
2.
Primary home care services include:
a)
assessment;
b)
case management and care coordination;
c)
nursing;
d)
homemaking that includes personal care, respite and home management; and,
e)
meal service.
3.
Primary home care services are provided through paid personnel.
Community Care
Section:
Index Ref: 11.2.1
Page 1
Date of Issue:
Home Care Policy
Home Care Services
Subject:
Assessment
11.2.1
ASSESSMENT
See Section 6.
September 2006
Revised September 2015
Section:
Community Care
Index Ref: 11.2.2
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Case Management and Care Coordination
11.2.2
CASE MANAGEMENT AND CARE COORDINATION
See Section 7.
Community Care
Section:
Index Ref: 11.2.3
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Nursing Services
11.2.3
NURSING SERVICES
POLICY
1.
Home Care nursing services includes:
a)
teaching and supervising self-care to clients receiving personal care or nursing
services;
b)
teaching personal care and nursing procedures to family members and other
supporters;
c)
performing nursing assessments;
d)
performing nursing treatments and procedures as outlined in a home care nursing
textbook approved by Community Care Branch;
e)
providing personal care when the assessment process specifies that it is warranted
by the condition of the client;
f)
teaching and supervising home care aides/continuing care assistants providing
personal care and performing delegated nursing tasks; and,
g)
initiating referrals to other health professionals and agencies.
GUIDELINES
1.
Home Care nursing services are performed using evidence-based best practice. 1
1 – “Evidence Informed/Evidence-Based Practice” – Practice which is based on successful strategies that improve
client outcomes and are derived from a combination of various sources of evidence, including client perspective,
research, national guidelines, policies, consensus statements, expert opinion and quality improvement data (CHSRF,
2005). Saskatchewan Registered Nurses Association, Standards and Foundations Competencies for the Practice of
Registered Nurses March 1, 2007, http://www.srna.org.
Community Care
Section:
Index Ref: 11.2.4
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Homemaking Services
11.2.4
HOMEMAKING SERVICES
POLICY
1.
Homemaking Services have three components:
a)
personal care;
b)
respite; and,
c)
home management.
2.
Homemaking services are provided by Home Care Aides/Continuing Care Assistants.
Policy for the Delegation, Supervision and Evaluation of Tasks to Home Care Aides:
1.
A practicing member of the Saskatchewan Registered Nurses Association, the Registered
Psychiatric Nurses Association of Saskatchewan, or the Saskatchewan Association of
Licensed Practical Nurses must teach, evaluate and supervise the performance of Home
Care Aides when tasks are delegated in providing:
a)
personal care;
b)
activities of daily living for persons who cannot safely be left on their own due to
confusion, frailty or some other functional disability;
c)
specific assistance to a client when the informal care provider is present. In order
to evaluate this situation the informal care provider must be prepared to assist the
person as necessary; and,
d)
activities of daily living when the home care aide/continuing care assistant is
providing respite for family members or other primary caregivers.
GUIDELINES
Personal Care Component
1.
Personal care component may include:
a)
assisting with/or supervising activities of daily living, such as bathing, grooming,
dressing, medication assists, feeding, toileting and transferring;
Community Care
Section:
Index Ref: 11.2.4
Page 2
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Homemaking Services
Respite Component
1.
Respite is any combination of services provided specifically for the purpose of giving
relief to the family or other caregivers of a dependent person who lives at home.
2.
Objectives of respite care are to:
a)
relieve primary caregivers from the constant responsibility of providing care;
b)
give primary caregivers the security of knowing that temporary relief is available
if a personal crisis arises, and provide that relief if necessary;
c)
support and strengthen families or other support systems to enable dependent
persons to remain at home; and,
d)
delay or prevent placement of dependent persons in long-term care facilities.
3.
In home care, respite may mean providing relief for time periods ranging from a few
hours to a few days. Time periods will depend on the needs of families and other
caregivers in addition to regional resources and other options available for respite.
4.
Respite may be provided occasionally, or periodically on a regular basis, to allow
primary caregivers time to perform everyday tasks. Respite does not usually include
home care services provided to allow caregivers to work at a long-term job. Respite is
not normally provided to relieve parents from routine childcare; however, the region may
make exceptions for complex care children when no other resources are available to the
family.
5.
Home care may provide crisis relief to allow the primary caregivers, and their families,
the opportunity to deal with stressful events such as an illness, hospitalization or a death
in the family.
6.
An assessment determines if respite is needed to relieve caregivers, and a care plan is
developed to meet that objective. The content of the respite care plan will depend on the
needs of the dependent person and their supporters. At a minimum, the care plan will
include supervision of activities of daily living, but may also include other aspects of
personal care, a meal or home management. The care provider in a respite situation is
temporarily taking the place of the primary caregiver and must provide whatever
assistance the dependent person needs.
Community Care
Section:
Index Ref: 11.2.4
Page 3
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Homemaking Services
Home Management Component
1.
Home management may include:
a)
general household cleaning;
b)
menu planning;
c)
meal preparation;
d)
laundry;
e)
changing linen;
f)
teaching self care; and,
g)
other aspects of operating a household as determined by the assessment process.
2.
Additional home management components for Mamawetan Churchill River and
Keewatin Yatthé Regional Health Authorities, and the Athabasca Health Authority may
include:
a)
providing transportation;
b)
escorting clients for medical appointments, grocery shopping, etc.;
c)
interpreting for clients and other health staff;
d)
assisting clients in attending community events scheduled by the home care
program, (i.e. friendship days, elders lunch, etc.); and/or,
e)
home maintenance tasks specific to northern residents.
Community Care
Section:
Index Ref: 11.2.5
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
11.2.5
MEAL SERVICE – Meals-on-Wheels and Wheels-to-Meals
POLICY
1.
Meal service is provided to improve and/or maintain the nutritional status and general
health of clients.
2.
Every effort must be made to assist clients to become as self-reliant as possible in meal
preparation.
3.
The home care meal service includes:
a)
meals-on-wheels, in which meals are delivered from an institution, restaurant or
private meal provider to clients at home; and/or,
b)
wheels-to-meals, in which meals are prepared and provided to clients at a central
location where a meal is served. (e.g., Senior Citizens’ Activity Centre). The
local Public Health Inspector should be informed.
4.
Volunteers should deliver meals whenever possible.
GUIDELINES
1.
Guiding Principles for the Provision of Meal Services:
a)
meal service should be provided to maintain the client’s health and independence;
b)
meal service should support self-reliance in meal preparation and good nutrition;
c)
meals should be provided until the clients’ strengths, abilities and/or motivation
enable them to become self-reliant;
d)
meals may be part of a respite component when the primary caregiver is not
available; and,
e)
clients or their supporter should be taught to prepare meals independently.
2.
Source of Meals:
The Regional Health Authority may contract the preparation of home care meals to:
a)
an affiliate as defined in The Regional Health Authority Act;
b)
any public eating establishment licensed by the Regional Health Authority,
pursuant to the Technical Guideline #154 administered by the Regional Health
Authority; and,
c)
a private meal provider when no other option is available.
Canada’s Food Guide to Healthy Eating should be followed.
Community Care
Section:
Index Ref: 11.2.5
Page 2
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
Meals-on-wheels is not required to include a serving from the Grain Products group or
the Milk Products group. It is anticipated that the client will be able to supply these items
to complete the meal.
Wheels-to-meals; however, must provide servings from each of the four (4) food groups
(Meat & Alternates, Vegetables & Fruit, Grain Products, and Milk Products).
3.
Content of the Meal:
The meal should provide the following to ensure it is acceptable to the client:
a)
variety in food selection and preparation;
b)
variety in taste and appearance;
c)
consideration of the client’s special needs, such as therapeutic diets, dental soft
foods, foods in bite size pieces, food allergies and food intolerances;
d)
consideration of the client’s background, including ethnic food preferences,
religious, and cultural food preferences; and,
e)
consideration of foods suitable for the client; for example pizza, although
nutritious, may not be an appropriate choice for some elderly people.
4.
Menu Planning:
The Regional Health Authority dietitian should provide advice about menu planning.
5.
Therapeutic Diets:
Therapeutic diets must be provided as directed by the client’s physician in consultation
with a dietitian (Physician’s Instruction Form H31-7010).
The decision to determine whether a specific meal provider has the capacity to prepare
therapeutic diets rests with the consulting dietitian. If the meal provider lacks the
capacity to prepare a particular therapeutic diet other options to allow for the provision of
meals to this client must be explored.
The following therapeutic diet meals, prepared in accordance with the most recent
Manual of Clinical Dietetics, may be provided without the supervision of a dietitian on
site:
a)
diabetic;
b)
modified in sodium (salt) content;
c)
modified in fat content;
d)
bland;
e)
weight reducing; and,
f)
modified in fiber content.
Community Care
Section:
Index Ref: 11.2.5
Page 3
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
A dietitian or physician must provide written diet instructions to the meal provider for all
therapeutic diets.
It is advisable that clients on therapeutic diets be given diet counseling and written
information by a dietitian, nutritionist or physician prior to acceptance to the meal service
program.
If the client does not understand the diet, the case manager should refer the client to the
home care nurse or community dietitian for appropriate instruction.
6.
Packaging of Food Items for Each Meal:
Only disposable containers appropriate for hot foods should be used to package hot food
items. The following materials are recommended:
a)
disposable aluminum plates covered with aluminum foil or foil-backed cardboard
lids;
b)
disposable Styrofoam cups, plates and/or bowls covered with plastic or Styrofoam
lids; and/or,
c)
disposable plastic cups and/or bowls covered with plastic lids.
Only disposable containers appropriate for cold foods shall be used to package cold food
items. The following materials are recommended:
a)
disposable Styrofoam plates, bowls, or cups covered with Styrofoam or plastic
lids;
b)
disposable plastic plates, bowls or cups covered with plastic lids;
c)
disposable plastic-coated paper plates, cups or bowls covered with aluminum foil;
and,
d)
plastic wrap or paper envelopes (for breadstuffs, if served).
DISPOSABLE MATERIALS SHALL BE USED ONLY ONCE
Hot and cold foods must be kept separate.
Food shall be served into the disposable containers just prior to meal delivery unless the
containers can be promptly refrigerated and/or heated until delivery.
Prepared foods must be held at a temperature less than 4°C (40°F) or greater than 60°C
(140°F) in order to limit the risk of bacterial growth that can lead to food poisoning.
Community Care
Section:
Index Ref: 11.2.5
Page 4
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
7.
Packaging the Meals for Delivery:
Meals must be packed in insulated carrying cases which adequately retain the
temperature of the food.
8.
Transportation of the Meal:
Meals should be transported by a volunteer whenever it is practical to do so.
Transportation time must be kept to a minimum in order to limit the growth of bacteria
that can occur if food is held at temperatures between 4°C (40°F) – 60°C (140°F).
9.
Private Meal Service Provider:
a)
2
Safe Food Service
Since individual meal service providers are not formally regulated to the same
extent as institutions and restaurants, the following will provide guidance for the
preparation of safe food by individual meal service providers:
•
all food and drink used in the preparation of meals shall be clean, safe, and
free from spoilage and prepared for safe human consumption;
•
all precautions shall be taken to ensure food remains free from
contamination and spoilage during its preparation, storage and delivery;
•
milk products served or used in food preparation must have been
processed in an approved pasteurization plant;
•
shell eggs must be clean and free from cracks and odors;
•
all food and drink must be obtained from sources approved by a Medical
Health Officer or Public Health Inspector;
•
the use of home-canned food is prohibited because of the possible risk of
botulism food poisoning from consumption of inadequately or improperly
canned food; and
•
No wild game shall be served. 2
Exception to be made to the Northern Home Care Services. The reason for an amendment is based
upon the cultural backgrounds of the people; the consideration of financial costs associated with the
transportation of goods into the isolated regions and that wild game is a staple diet for many of the
inhabitants in Mamawetan Churchill River and Keewatin Yatthé Region, and Athabasca Health Authority.
Wild game is to be processed in accordance with the guidelines set out by the Saskatchewan Ministry of
Health and the Federal Government food safety regulations.
Community Care
Section:
Index Ref: 11.2.5
Page 5
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
Water safe for human consumption shall be used in the preparation of food or
drink:
•
water softened by the sodium ion exchange process shall not be used in
the preparation of food or drink for clients requiring restricted sodium
diets;
•
water from sources not subject to routine bacteriological examination must
be tested as required by the Medical Health Officer or Public Health
Inspector or as often as necessary to ensure safety and be of a quality
compatible with provincial standards 3;
•
the meal provider must have a new or temporary water supply tested and
approved before it is used; and,
•
containers or receptacles in which water is stored must be clean and
covered. A person shall draw the water from the container by means of a
tap or other approved dispensing service.
b)
3
Environment
•
floors, walls, and ceilings of all rooms in which food or drink is stored or
prepared, or in which utensils are washed, must be clean and in good
repair.
•
floors must not be swept when food or drink is exposed.
•
the premises must be free of any animal or insect detrimental to the
operation of a food service. This includes rats, mice, cockroaches, flies
and other vermin.
•
the local Public Health Inspector must approve all material and equipment
used for vermin control.
•
pets or birds must not be kept or permitted in food storage or preparation
areas unless approved by the Medical Health Officer or Public Health
Inspector.
•
all garbage must be placed in a covered, nonabsorbent, leak proof
container and be disposed of as necessary. Garbage must not remain in a
food preparation or storage area in excess of twenty-four (24) hours.
Samples for bacteriological examination are to be placed in containers available from the local regional
health office. The Saskatchewan Ministry of Health Provincial Laboratories will provide the required
bacteriological examination.
Community Care
Section:
Index Ref: 11.2.5
Page 6
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
c)
Cleaning Supplies
Toxic and poisonous substances, including cleaning supplies, must be:
•
kept in an area separate from food, food equipment, and food contact
surfaces;
•
kept in containers that bear a label on which the contents of the container
are clearly identified; and,
•
used only in such conditions that the substances do not contaminate food
or endanger the health of any person.
d)
Equipment
The equipment necessary to prepare and store all food must be available
(e.g. freezer, refrigerator, stove, accurate thermometers, etc.)
All equipment, utensils, and food contact surfaces which may come in contact
with food or drink during storage, preparation or delivery (serving) must be:
•
clean;
•
kept in good repair;
•
corrosion resistant;
•
washed and sanitized as required if of a reusable type; and,
•
constructed of an approved material.
All equipment and utensils, including single service utensils for meal delivery,
must be handled and stored so that surfaces coming in contact with the food or the
user’s mouth have not been contaminated.
Cups, glasses or dishes that are chipped or cracked must not be used in the
preparation, service or storage of food.
e)
Storage
All food must be protected by means of enclosed cases or cabinets or other
enclosure and must be stored in such a manner that odors and flavors are not
transferred from one type of food to another.
Food must not be stored on the floor. Food shall be stored in an appropriate
container and placed on a pallet or shelf.
Community Care
Section:
Index Ref: 11.2.5
Page 7
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
f)
Food Handling
Potentially hazardous food that is being stored prior to preparation or held prior to
delivery for human consumption, must be kept at either:
•
4oC (40oF) or less; or,
•
60oC (140oF) or greater, which ever is appropriate depending on the food.
Potentially hazardous food means any raw or prepared food that consists, in
whole or in part, of milk or milk products, eggs, meat, poultry, fish, shellfish, or
edible crustacea, in a form capable of supporting rapid and progressive growth of
infectious or toxigenic microorganisms.
When it is necessary for potentially hazardous food to remain at temperatures
between 4oC and 60oC (40oF and 140oF) it must be for as short a time as possible
but never longer than two hours after preparation.
Food should be tasted for acceptability before it is served. Sampling of food with
fingers is not permitted. Using the same spoon more than once for tasting is not
permitted because of the potential danger of food contamination.
A sanitized thermometer should be used frequently to indicate temperature of
food prior to service. Temperature of food should be checked periodically by the
Regional Health Authority at delivery.
Potentially hazardous foods shall be cooked to the appropriate minimum internal
temperature described in the following chart:
Hazardous Food
Poultry
Ground Beef
Beef, lamb, pork, and veal
Boiled Eggs (Boil for 9 minutes
minimum)
Fish (flesh is opaque, flakes easily)
Alternatives for cooking Fish
Internal Temperature
°C
°F
74
165
71
160
71
160
80
178
71
70
65
80
160
158 - at least 2 minutes
150 - 10 minutes
176 - a few seconds
Community Care
Section:
Index Ref: 11.2.5
Page 8
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
g)
Cleaning and Sanitizing
Both a detergent and a sanitizer must be used to accomplish a thorough cleaning
of utensils, equipment, and work areas. A detergent is a chemical substance used
to facilitate cleaning through removal of all visible, physical debris. A sanitizer is
a heat or chemical method used to destroy all disease-causing bacteria.
In summary, detergents first help remove physical debris, then sanitizers kill the
remaining micro-organisms.
All utensils, equipment and work areas are to be thoroughly cleaned and sanitized
after each use. An ample supply of hot and cold water for washing and sanitizing
utensils, equipment and tableware must be available.
All utensils and equipment used for food preparation must be cleansed by the
three-step method: 4
•
Washed with an effective detergent where the wash water temperature is
not lower than 44oC (111oF);
•
Rinsed in clean water at a temperature not lower than 44oC (111oF);
•
Sanitized using one of the following bactericidal treatments:
–
use of the “saniwash” or “sanitize” feature on a household
dishwasher as approved by the Regional Health Authority;
–
immersion for at least two minutes in clean water at a temperature
of at least 82oC (180oF) (a suitable thermometer must be provided);
–
immersion for at least two minutes in a lukewarm chlorine solution
of not less than one hundred parts per million available chlorine
when freshly prepared and not less than fifty parts per million at
any time; 5 or,
–
immersion for at least two minutes in a lukewarm solution
containing a quaternary ammonium compound having a strength of
at least two hundred parts per million.
•
Air dried to prevent recontamination through use of drying towels. 6
Cutting boards, chopping blocks, table grinders, slicers and other utensils must be
thoroughly cleaned and sanitized after each use.
4
The three-step method consists of wash, rinse and sanitize and requires a three compartment sink (a dishpan may
be utilized as the third sink in some situations)
5
Facilities (test kit) for determining the concentration of the sanitizing solution shall be available.
6
Cloths and towels used for washing, drying, polishing utensils, equipment, tables or counters must be clean and
used for one purpose only.
Community Care
Section:
Index Ref: 11.2.5
Page 9
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Meal Service
h)
Personnel
Every individual meal provider shall practice good personal hygiene.
Every person who handles or comes in contact with food or any utensil used in
the preparation or service of food must:
•
be clean;
•
wear clean garments;
•
keep hair confined; and,
•
wash hands before commencing work, after use of toilet facilities, after
smoking or any other time hands are soiled or contaminated.
Meal providers must not smoke while preparing food.
A meal provider with a communicable disease shall not prepare food when the
meal provider’s condition may jeopardize the safety of the food being prepared.
A meal provider shall not prepare or serve food when experiencing any of the
following symptoms:
•
diarrhea;
•
vomiting;
•
fever; or,
•
severe abdominal discomfort.
A meal provider must wear disposable gloves when preparing food if she/he has a
cut or opening on the hand. If the cut is infected, the meal provider must not be
involved in food preparation.
The home care program does not require meal providers to have a medical
examination as a condition of employment. However, the Medical Health Officer
or management may, at any time, order a medical examination if circumstances
warrant.
Meals from a meal-providing household must be discontinued if there is a risk of
spreading an illness in the household to meal recipients.
Whenever a meal provider is aware of a situation where a communicable disease
may be transmitted to a meal recipient, the meal provider shall notify the Medical
Health Officer or a Public Health Inspector.
Community Care
Section:
Index Ref: 11.3
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Additional Home Care Services
11.3
ADDITIONAL HOME CARE SERVICES
POLICY
Additional home care services may include:
1.
2.
3.
4.
home maintenance;
volunteer programs;
therapies when available i.e. physiotherapy and occupational therapy; and,
any other service that the Regional Health Authority deems appropriate.
GUIDELINES
1.
Procedure for approval of additional home care services.
A regional home care program wishing to provide services in addition to those indicated
in 11.2, should seek specific approval from the Regional Health Authority senior
management. The approval for proposed services beyond the primary services will be
reviewed on an individual basis considering traditional service patterns, assessed need
and availability of resources and cost.
Community Care
Section:
Index Ref: 11.3.1
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Home Maintenance Services
11.3.1
HOME MAINTENANCE SERVICE
POLICY
1.
Home maintenance services are provided only when the safety of the individual is at risk,
the individual’s physical abilities are less than optimal and no reasonable alternative is
available.
2.
Home care does not provide home maintenance services when the same or similar
services are available from another source.
3.
Home care is not responsible for the costs of any materials or supplies needed to perform
a home maintenance service.
4.
Home maintenance may be provided by a volunteer program service if volunteers are
available.
5.
If Regional Health Authorities do not provide home maintenance services, care managers
should attempt to refer the client to an agency that can provide the services.
GUIDELINES
1.
Home maintenance service may include:
a)
performing minor outdoor tasks essential for the safety of clients;
b)
performing minor home maintenance repairs essential for the safety of client;
c)
installing and maintaining equipment aids for independent living; and,
d)
installing handrails and non-skid surfaces.
2.
Home Maintenance services in the North 7 may also include:
a)
splitting and hauling wood into the client’s home;
b)
hauling water into the client’s home, as required;
c)
transporting clients’ for appointments, grocery shopping, berry picking, monthly
home care events; and/or,
d)
deliveries related to the home care program.
7
Mamawetan Churchill River, Keewatin Yatthé Regions and Athabasca Health Authority.
Community Care
Section:
Index Ref: 11.3.2
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Volunteer Service
11.3.2
VOLUNTEER SERVICE
POLICY
1.
The Regional Health Authority promotes the participation of volunteers.
2.
The Regional Health Authority must ensure that policies are in place to address
responsibility for coordination of volunteer activities, their orientation, training and
supervision.
GUIDELINES
1.
A Regional Health Authority may organize and provide any volunteer service consistent
with the home care philosophy and objectives provided that:
a)
the Regional Health Authority’s role is limited to administrative support; and,
b)
the administration of volunteer services does not detract from the management of
the primary services.
2.
Every Regional Health Authority should define clearly what services are to be provided
by volunteers.
3.
Volunteer services provided by Regional Health Authorities to home care clients may
include:
a)
surveillance;
b)
delivering meals;
c)
friendly visiting;
d)
attendant service;
e)
errands and shopping;
f)
transportation; and,
g)
home maintenance services.
4.
Services classed as volunteer service may be provided by paid personnel if volunteers are
unavailable and:
a)
provision of a primary service is dependent upon the volunteer service (e.g.
delivery of meals);
b)
the volunteer service is judged to be essential for the client’s wellbeing on the
basis of the assessment process (e.g. supervising a client who cannot be left
alone); or,
c)
when the provision of the service by paid personnel does not result in an
incremental cost to the program (e.g. surveillance by salaried staff).
Community Care
Section:
Index Ref: 11.3.2
Page 2
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Volunteer Service
5.
Regional Health Authorities may provide a stipend for volunteers or provide volunteers
with a charitable tax receipt to offset transportation costs.
6.
Surveillance by Volunteers
a)
Every Regional Health Authority should ensure that surveillance services are
available to residents of the region, though it may not be necessary for the
Regional Health Authority to organize and provide surveillance directly.
b)
Regional Health Authorities should attempt to preserve existing informal
surveillance arrangements and volunteer services whenever possible.
c)
A Regional Health Authority may provide surveillance to any person, regardless
of whether or not that person is receiving other home care services.
d)
Surveillance should be delivered in combination with other services received by
the client whenever possible (e.g. meal deliverers can also perform a surveillance
function).
Community Care
Section:
Index Ref: 11.3.3
Page 1
Date of Issue:
Home Care Policy
Home Care Services
September 2006
Revised September 2015
Subject:
Therapy Services
11.3.3
THERAPY SERVICES
POLICY
1.
Therapy services support the overall goal of home care services by assisting individuals
to achieve or maintain maximum independence in their home in the community.
2.
Therapy services are consistent with current effective practice guidelines.
GUIDELINES
1.
Therapy services include occupational therapy, physical therapy, respiratory therapy,
dietetics and speech language pathology services and may be provided by home care
directly or provided through other programs in the Regional Health Authority.
2.
Therapy services may include initial and ongoing client assessment, intervention,
consultation, recommendation of equipment/adaptive aids, acquisition and training of
these aids, health promotion, and education.
3.
Therapists may delegate appropriate duties to support personnel and other members of
the team; however, therapists retain responsibility for assessment, treatment planning and
review, and discontinuation of therapy services.
4.
Client records shall be maintained as per home care standards.
Section:
Community Care
Index Ref: 12.1
Page 1
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Assessor/Case Manager/Care Coordinator
12.1
ASSESSOR/CASE MANAGER/CARE COORDINATOR
POLICY
1.
The Regional Health Authority shall ensure that appropriate management staff is in place
who are responsible for selecting and arranging appropriate supervision of assessors, case
managers and care coordinators.
2.
The minimum qualifications for assessment and care coordination staff hired after
September 1, 1988 are:
a)
a degree or diploma in health services, social services, education or a related area;
or,
b)
several years experience in assessment and care coordination in a home care
program, with significant training in assessment and interviewing techniques.
GUIDELINES
1.
The Regional Health Authority may hire a person with less than the minimum
qualifications for assessments if it is unable to find an appropriate person with those
qualifications. In this case, the Regional Health Authority must assess the individual’s
knowledge and skills, and specify any in-service training required prior to providing
service.
Community Care
Section:
Index Ref: 12.2
Page 1
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Nursing Service Providers
12.2
NURSING SERVICE PROVIDERS
POLICY
1.
Home care (Professional) nursing services shall be provided by:
a)
RNs registered as practicing members of the Saskatchewan Registered Nurses’
Association (SRNA);
b)
RPNs registered as practicing members of the Registered Psychiatric Nurses
Association of Saskatchewan (RPNAS); or,
c)
LPNs registered as practicing members with the Saskatchewan Association of
Licensed Practical Nurses (SALPN).
GUIDELINES 1
1.
RNs, RPNs and LPNs provide care directed first and foremost toward the health and well
being of the client. Nurses work collaboratively and cooperatively with clients, families,
each other, and other care providers in order to provide safe, quality care that maximizes
benefits to the client.
2.
RNs, RPNs and LPNs act in a manner consistent with their professional responsibilities,
ethical and legal guidelines and standards of practice.
3.
The regulatory bodies (SRNA, RPNAS and SALPN) have the legislated responsibility to
articulate scopes of practice for their respective members, to establish practice and ethical
standards and to review respective members who do not meet the standards.
4.
RNs, RPNs and LPNs, practice within their own individual level of competence. They
may seek additional information and/or the guidance of an experienced nurse when
aspects of the care required are beyond their current skill level or competence.
5.
RNs, RPNs and LPNs must recognize that within the nursing team there are areas of
shared competencies and overlapping roles, and that scopes of practice evolve over time
in response to changing health care needs. In some care situations, several team members
may possess the necessary knowledge, skills and judgment to provide specific nursing
care. In other situations the knowledge, skills and judgment required may be unique to
one team member.
1
Guiding principles from the Registered Psychiatric Nurses Association, Saskatchewan Association of Licensed
Practical Nurses, Saskatchewan Registered Nurses’ Association. (2000). Nursing in collaborative environments.
Regina, SK: Authors.
Community Care
Section:
Index Ref: 12.2
Page 2
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Nursing Service Providers
6.
Employers have a responsibility to ensure that job descriptions, policies and procedures
for all employees providing nursing care are developed in keeping with relevant
legislation and competencies, professional standards and scopes of practice for the
nurses. Employer documents should identify the roles and responsibilities of RNs, RPNs,
and LPNs within the various practice settings and address how collaborative practice is
carried out.
Section:
Community Care
Index Ref: 12.3
Page 1
Date of Issue:
Service Providers
Home Care Policy
September 2006
Revised September 2015
Subject:
Homemaking Service Providers
12.3
HOMEMAKING SERVICE PROVIDERS
Personal Care and Respite
POLICY
1.
Personal care and respite is provided by home care aides/continuing care assistants who
have successfully completed the personal care course, and have completed or are in the
process of completing the other courses of a training program approved by the
Saskatchewan Ministry of Health.
2.
All home care aides/continuing care assistants must complete a training program
approved by the Saskatchewan Ministry of Health within two years of initial
employment.
3.
Employers must ensure that home care aides/continuing care assistants who have not
completed the training have the skills to perform the tasks.
4.
Persons who have successfully completed a program as a registered nurse, a registered
psychiatric nurse or a licensed practical nurse may be hired as a home care aide/
continuing care assistant without the need to complete the approved training program,
unless the employer deems it appropriate.
5.
The Regional Health Authority is responsible for ensuring all staff have the training and
skills to do the work, and work within the parameters of the continuing care assistant
scope of practice and job description.
Home Management
POLICY
1.
Home management services are provided by home care aides/continuing care assistants
who have completed, or are in the process of completing a training program approved by
the Saskatchewan Ministry of Health.
2.
All home care aides/continuing care assistants must complete a training program
approved by the Saskatchewan Ministry of Health within two years of initial
employment.
Community Care
Section:
Index Ref: 12.3
Page 2
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Homemaking Service Providers
GUIDELINES
1.
Exceptions to Formal Training for Personal Care and Home Management
Persons who believe they have the required knowledge and skills or have previous formal
equivalent training may request to challenge one or more courses of a training program
approved by the Saskatchewan Ministry of Health. The person will not be required to
complete those sections that have been successfully challenged.
Community Care
Section:
Index Ref: 12.4
Page 1
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Meal Service/Restaurant and Institutional Providers
12.4
MEAL SERVICE/RESTAURANT AND INSTITUTIONAL PROVIDERS
POLICY
1.
Restaurants and institutional providers must prepare meals in accordance with
Policy 11.2.5 Meal Service guidelines and Policy 16.4 Meal Service standards of the
Saskatchewan Ministry of Health Home Care Policy Manual.
GUIDELINES
1.
2
The Regional Health Authority may contract the preparation of home care meals to:
a)
an affiliate as defined in The Regional Health Authority Act; or,
b)
any public eating establishment licensed by the Regional Health Authority,
pursuant to the Technical Guideline #154 administered by the Regional Health
Authority. 2
May be obtained from local Regional Health Authority administration office and/or Regional Health Authority’s
Public Health Inspector.
Community Care
Section:
Index Ref: 12.4.1
Page 1
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Private Meal Service Providers
12.4.1
PRIVATE MEAL SERVICE PROVIDERS
POLICY
1.
If the Regional Health Authority contracts with individuals, the Regional Health
Authority must ensure the individual meal provider has:
a)
completed, or agree to complete by the earliest possible date as determined by the
board, the food safe course of a continuing care assistant training program
approved by the Saskatchewan Ministry of Health; or,
b)
successfully completed the public health Sanitation Training Program for Food
Handlers or the Food Safe food handler’s course.
2.
Individual meal providers must prepare meals in accordance with Meal Service Policy
and Guidelines 11.2.5 and Policy 16.4 Meal Service standards of the Saskatchewan
Ministry of Health Home Care Policy Manual.
GUIDELINES
1.
Individual meal providers who believe they have the required knowledge and skills or
have previous formal training may challenge the food safe and/or nutrition course(s) of
an approved continuing care assistant training program. The Individual meal providers
will not be required to complete the course(s) that have been successfully challenged.
2.
A contract with an individual meal provider should contain the same basic elements as a
contract with an agency. However, a contract with an individual meal provider involves
only one service provider and a relatively small amount of service. This difference in
scale has some implications:
a)
some specific contract requirements, such as the requirement for an annual
audited financial statement, do not apply to contracts with individual meal
providers;
b)
verbal contracts are acceptable with existing individual meal providers. All new
individual meal providers should sign a written contract (a written contract is
preferred because it confirms the agreement and helps to prevent
misunderstandings); and,
c)
a written contract may be in the form of a letter, if signed and returned by the
individual meal provider.
Section:
Community Care
Index Ref: 12.5
Page 1
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Home Maintenance Service Providers
12.5
HOME MAINTENANCE SERVICE PROVIDERS
POLICY
1.
The Regional Health Authority must require staff providing home maintenance services
to have or take training appropriate for the home maintenance tasks performed.
Community Care
Section:
Index Ref: 12.6
Page 1
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Volunteers
12.6
VOLUNTEERS
POLICY
1.
Volunteers may perform the volunteer services designated by the Regional Health
Authority under the “Definition of Volunteer Services” (Policy 11.3.2).
2.
The Regional Health Authority must ensure that adequate supervision is provided for
volunteers (Policy 11.3.2).
GUIDELINES
1.
Regional Health Authorities may require volunteers to take specific instructions or
on-the-job training which, in the judgment of the senior staff member responsible for
volunteer services, is appropriate.
2.
Volunteers may perform administrative or other tasks as deemed appropriate.
Community Care
Section:
Index Ref: 12.7
Page 1
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Therapies
12.7
THERAPIES
POLICY
1.
Home care occupational therapy, physiotherapy, social work, respiratory therapy and
dietetics shall be provided by therapists licensed as practicing members of the
Saskatchewan College of Occupational Therapists, Saskatchewan College of Respiratory
Therapists, Saskatchewan Dietetic Association, the Saskatchewan College of Physical
Therapists and Saskatchewan Association of Social Workers.
GUIDELINES
1.
Therapists may delegate appropriate tasks and functions to trained (formally or
on-the-job) support personnel, other members of the team, and client family members.
Community Care
Section:
Index Ref: 12.8
Page 1
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Family Care Providers
12.8
FAMILY CARE PROVIDERS
POLICY
1.
Regional Health Authorities may not compensate a family care provider for assisting a
member of his/her family unless both of the following circumstances apply:
a)
no practical alternative exists (e.g. a remote rural area with no resident home care
providers in reasonable proximity); and,
b)
the care provider holds the qualifications and training required of a home care
provider.
GUIDELINES
1.
The general intent of the policy on payment to family members is that family members
should not be compensated by home care for caring for a family member. However, the
policy allows Regional Health Authorities some discretion to enable them to cope with
exceptional situations.
2.
Regional Health Authorities may choose to define guidelines that reflect the
characteristics of the region and types of problems faced by the Regional Health
Authority staff. These guidelines should assist staff to come to practical decisions when
assessing particular cases. For example, a Regional Health Authority might specify that
no exceptions will be made if:
a)
the care provider is a member of the nuclear family (the client’s parents, children
and siblings);
b)
the care provider lives with the client;
c)
the care provider has given care in the past without receiving payment; or,
d)
the care provider is not willing to serve other home care clients in addition to their
family member.
Community Care
Section:
Index Ref: 12.8
Page 2
Date of Issue:
Home Care Policy
Service Providers
September 2006
Revised September 2015
Subject:
Family Care Providers
12.9
VOLUNTEERS
POLICY
1.
The Regional Health Authorities will determine how a volunteer program achieves the
purpose and mission of the regional health authority.
RESOURCES
Resources for the Regional Health Authorities may include “The Canadian Code for Volunteer
Involvement, Volunteer Canada 2006.”
Community Care
Section:
Index Ref: 13.1
Page 1
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Individualized Funding
13.1
INDIVIDUALIZED FUNDING
POLICY
1.
Regional Health Authorities shall offer Individualized Funding (IF) as an option of the
home care program.
Individualized Funding allows the consumer, or their guardian, to accept responsibility to
manage and direct supportive service.
The Regional Health Authority is authorized to provide funding to an individual to
arrange and manage his/her own supportive care services. The level of funding is based
on assessed need and used for approved services only. These services may include
personal care, home management and other supportive services.
The Regional Health Authority shall inform the Saskatchewan Ministry of Health of new
clients and discontinuance of clients to the IF program (See Appendix A and B).
2.
To be Eligible for Individualized Funding, the Consumer:
a)
meets the eligibility requirements to receive home care supportive services;
b)
requires long term supportive services for at least 6 – 12 months;
c)
has relatively stable supportive service needs;
d)
has indicated the desire and ability to manage the required care and the
willingness to assume the responsibilities and risks associated with Individualized
Funding, or has a guardian who will do so;
e)
has no other party (e.g. SGI, WCB, other agency, etc.) which may be responsible
for the cost of the required services; and,
f)
is accepted as an employer eligible for coverage under The Workers’
Compensation Act. Where a guardian is entering an Individualized Funding
Agreement, the guardian must be eligible for coverage under The Workers’
Compensation Act.
3.
Needs Assessment and Review:
a)
A needs assessment will be done jointly by the Regional Health Authority staff
and the consumer to determine the need for supportive care services, and the level
and type of services that are required;
b)
An individualized plan will be developed;
c)
Professional services such as registered nursing or therapies are excluded from
Individualized Funding and will continue to be available as required through the
regional home care program;
Community Care
Section:
Index Ref: 13.1
Page 2
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Individualized Funding
d)
e)
f)
A needs review will be done annually or more frequently if required;
The Regional Health Authority will remain in contact with the consumer as
required for the duration of the Agreement; and,
The consumer will not be eligible to receive home care supportive services
directly from the home care program, if those services have been funded for and
defined in the Individualized Funding Agreement.
4.
Funding Level:
a)
The funding level for supportive services will be based on assessed need and
calculated at a per unit of service rate as determined by the Saskatchewan
Ministry of Health. One unit of service equals one hour (See Schedule A Services
and Payment Schedule, and Amendment to Schedule A);
b)
A monthly administrative allowance is provided in addition to the calculated
funding level. The administrative allowance can be used for payroll services or
other costs of managing the agreement. (See Schedule D);
c)
The annual insurance premium for WCB coverage is included in the calculated
funding level;
d)
The total maximum monthly client care cost to the home care program will not
exceed the amount paid by the Saskatchewan Ministry of Health for long term
care funding for the same period. (See Schedule D). This will be reviewed by the
Saskatchewan Ministry of Health and updated for implementation on October 1st
yearly;
e)
The maximum monthly level is based on the provincial average publicly funded
contribution to the cost of institutional long-term care per resident using the most
recent data available. This maximum will be reviewed annually;
f)
Consumers will continue to be subject to applicable home care fees. Charges for
home care fees will be calculated based on the number of actual hours of service
that the consumer employs staff (but not greater than the assessed hours); and,
g)
Home care fees will be invoiced to the consumer. However, in exceptional
circumstances, as requested by the consumer, the fee may be deducted from the
payment made to the consumer from the Regional Health Authority.
5.
Use of Individualized Funding:
a)
Funding will be used by the consumer/guardian to hire workers to provide those
supportive services described in the individualized plan;
b)
Funds may not be used to hire family members such as the consumer’s spouse,
parent, child, sibling, grandparent, or grandchild, related directly or through
marriage or common law;
Community Care
Section:
Index Ref: 13.1
Page 3
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Individualized Funding
c)
d)
e)
f)
g)
h)
6.
Regional Health Authority conflict of interest guidelines may prohibit Regional
Health Authority employees from also being employed under an Individualized
Funding agreement;
Funds may not be used to hire workers on a contract basis who would be
considered self employed (i.e. service providers are to be considered employees
who receive benefits, etc.) except as a short term emergency backup. (The client
must be made aware that their purchasing power is reduced);
Funds may not be used to purchase services from a person or organization when
that person or organization owns, leases, rents, or otherwise manages or provides
care in the residence in which the consumer lives (e.g. personal care home,
licensed group home);
Funds may not be used by the consumer/guardian to pay for services provided in
any hospital or long-term care facility, or for services related to any other health
program funded by the Regional Health Authority;
Funds may not be used for any product or service not usually provided by home
care (e.g. food allowances for service providers), or for any other item not
identified in the care plan or Agreement; and,
A consumer/guardian who wishes to use funds to pay for needed services outside
of Saskatchewan must obtain written approval from the Regional Health
Authority in advance.
•
Approval may be granted at the discretion of the case manager to a
maximum of 30 cumulative days during any calendar year.
•
The Regional Health Authority may consider requests for approval of
periods beyond 30 cumulative days per year, if supported by the home
care manager.
The Consumer/Guardian is Responsible for:
a)
recruiting, hiring, training, scheduling, paying, managing the performance of, and
terminating their workers;
b)
negotiating reasonable and fair salary and benefits for their workers;
c)
making deductions at source such as Income Tax, Canada Pension Plan,
Employment Insurance and any other benefits (the consumer/guardian may use
funding to purchase payroll and accounting services);
d)
applying for coverage under Section 12 of The Workers’ Compensation Act. If
WCB coverage is not available, individualized funding will not be an option;
e)
complying with all applicable legislation such as The Labour Standards Act, The
Occupational Health and Safety Act, The Income Tax Act, The Employment
Insurance Act, etc.;
f)
establishing an emergency back up plan for supportive services that does not rely
on the home care program, in the event their scheduled care provider is absent;
Community Care
Section:
Index Ref: 13.1
Page 4
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Individualized Funding
g)
h)
submitting a copy of their employee time sheets to the Regional Health Authority
on a monthly basis as determined by the Regional Health Authority (See
Employee Time Sheet, Schedule B.); and,
Upon the death of the client funding for the workers may continue for two (2)
weeks.
7.
Agreement:
a)
The consumer or their guardian will enter into an Individualized Funding
Agreement with the Regional Health Authority;
b)
The consumer/guardian is legally responsible for compliance with the Agreement
and will be responsible for all specified duties;
c)
The Agreement will describe the types of services that funding can be used for,
the amount of funding, the duration of the Agreement, and other terms;
d)
The Agreement expiry date shall be no later than one year from the date of
signing; and,
e)
A needs review will be completed thirty (30) days prior to the expiry of the
Agreement and a revised Agreement negotiated if the consumer continues to meet
the program criteria.
8.
Financial Management:
a)
The consumer/guardian will open a bank account specifically for Individualized
Funding that provides monthly statements and cancelled cheques, and allows for
direct deposit;
b)
A quarterly financial report will be submitted to the Regional Health Authority,
including monthly banking statements (see Quarterly Financial Statement,
Schedule C); and,
c)
Any funding surplus accumulated by the consumer/guardian in excess of one
month’s payment will be returned quarterly to the Regional Health Authority.
9.
Financial Accountability:
a)
The Regional Health Authority will undertake a financial review with all
consumers/guardians in the first year of an Individualized Funding Agreement;
and,
b)
The Regional Health Authority may undertake a random financial review as part
of the accountability process (see Financial Audit).
Community Care
Section:
Index Ref: 13.1
Page 5
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Individualized Funding
10.
Temporary Stoppage of Payment:
a)
The consumer/guardian will notify the case manager of any circumstances in
which funds are not required for a period of two (2) weeks or more;
b)
Recovery of overpayments will made on quarterly basis; and,
c)
The case manager will notify the appropriate Regional Health Authority personnel
of the temporary stoppage of payment, and also the date that payment will be
resumed.
11.
Termination of the Agreement:
a)
The term of the Agreement will be for a maximum period of one year. It will be
reviewed and renewed annually if the consumer continues to meet the eligibility
criteria;
b)
The Regional Health Authority or the consumer/guardian may terminate the
Agreement for any reason with 30 days notice;
c)
The Regional Health Authority may terminate the Agreement immediately if the
consumer/guardian is:
•
not managing the funds appropriately;
•
no longer eligible for Individualized Funding; or,
•
in breach of the Agreement.
d)
Following termination of the Agreement, the consumer may be eligible to receive
direct home care services;
e)
The Regional Health Authority may undertake a review within 30 days of
termination of the Agreement, regardless of the reason for termination.
12.
Review Process:
a)
The consumer/guardian may use the Regional Health Authority client
representative to review decisions.
FINANCIAL AUDIT
1.
The Regional Health Authority will audit each consumer or guardian’s financial records
relating to the Individualized Funding Agreement once within the first year of
participating in the Individualized Funding option of the home care program. Thereafter,
the frequency will be at the discretion of the Regional Health Authority.
2.
The Regional Health Authority will contact the consumer to set up a mutually agreeable
time to meet.
Community Care
Section:
Index Ref: 13.1
Page 6
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Individualized Funding
3.
The purpose of the audit is to:
a)
review the financial records for accuracy and compliance with the requirements of
the Individualized Funding Agreement;
b)
verify the financial positions as reported on each Quarterly Financial Report; and,
c)
confirm that funds are being spent in accordance with the terms of the
Individualized Funding Agreement.
4.
For the audit, the consumer or guardian is expected to have the following records
available:
a)
Cheque Register;
b)
Receipts Journal;
c)
Payroll Register;
d)
Employee Time Sheets;
e)
All bank statements;
f)
All cancelled cheques;
g)
All receipts/invoices substantiating the use of the funds; and,
h)
All copies of remittances to Canada Customs and Revenue Agency.
5.
This audit is strictly a review of financial records. It is independent of care needs reviews
conducted by the Regional Health Authority.
Community Care
Section:
Index Ref: 13.1.1
Page 1
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Collective Funding
13.1.1
COLLECTIVE FUNDING
POLICY
Collective funding is intended to simplify the managing, funding and accounting process for
groups of people living together that are eligible for individualized funding through the home
care program. This group of individuals is referred to as the collective group.
This policy is an addendum to the Saskatchewan Ministry of Health Home Care Policy 13.1,
titled Individualized Funding.
1.
Collective funding is an option of the Regional Health Authority’s home care program.
2.
The principles and intent of the Individualized Funding Policy apply to the Collective
Funding Policy.
3.
Collective funding may not be used to purchase services from a person or organization
when that person or organization owns, leases, rents or otherwise manages the residence
and provides care in which the individual lives (e.g. personal care home, licensed group
home, etc).
4.
The representative of the collective group, acting in the best interest of the individuals,
accepts the responsibility of arranging and managing the support services for the
individuals, and reporting to the Regional Health Authority.
5.
The needs of each eligible individual will be assessed using the current needs assessment
process. The assessment will identify unmet needs of the individual for supportive care
services. These services will be consistent with services normally provided by the home
care program.
6.
Efficiencies in the care plan for the collective group may be gained when the congregate
setting of the individuals is considered.
7.
The monthly funding level will be calculated by multiplying the hours of care required by
the collective group per month, by a per hour rate as determined by the Saskatchewan
Ministry of Health (See Schedule D).
8.
The home care fee of the collective group will be calculated based on individual assessed
need and adjusted monthly income of the individual. The invoice for the home care fee
will be sent to the representative of the collective group, who will be responsible for
payment.
Community Care
Section:
Index Ref: 13.1.1
Page 2
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Collective Funding
9.
The Regional Health Authority will determine the need for the administrative allowance
and Workers’ Compensation Board premium.
10.
The group representative will be responsible for accounting for the monthly funding
level, plus funding provided for the Workers’ Compensation Board premium and
administrative allowance, if applicable.
11.
An agreement is entered into between the Regional Health Authority and the
representative of the collective group, and includes (but is not limited to):
a)
names of the individuals receiving support services;
b)
support service amount for each individual;
c)
monthly funding level;
d)
home care fee;
e)
reporting requirements, which may include utilization, change in service need,
change in individual status, audited financial statement, etc.;
f)
duration of the agreement;
g)
renewal notice; and,
h)
termination notice.
12.
The Regional Health Authority shall inform the Saskatchewan Ministry of Health of
Collective Funding agreements and provide information regarding clients served through
this funding arrangement, upon commencement of the agreement and then every
February 15th and September 15th (See Appendix C).
FINANCIAL AUDIT
1.
The Regional Health Authority will audit each consumer or guardian’s financial records
relating to the Collective Funding Agreement once within the first year of participating in
the Collective Funding option of the home care program. Thereafter, the frequency will
be at the discretion of the Regional Health Authority.
2.
The Regional Health Authority will contact the consumer to set up a mutually agreeable
time to meet.
3.
The purpose of the audit is to:
a)
review the financial records for accuracy and compliance with the requirements of
the Collective Funding Agreement;
b)
verify the financial positions as reported on each Quarterly Financial Report; and,
c)
confirm that funds are being spent in accordance with the terms of the Collective
Funding Agreement.
Community Care
Section:
Index Ref: 13.1.1
Page 3
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Collective Funding
4.
For the audit, the group representative is expected to have the following records
available:
a)
Cheque Register;
b)
Receipts Journal;
c)
Payroll Register;
d)
Employee Time Sheets;
e)
All bank statements;
f)
All cancelled cheques;
g)
All receipts/invoices substantiating the use of the funds; and,
h)
All copies of remittances to Canada Customs and Revenue Agency.
5.
This audit is strictly a review of financial records. It is independent of care needs reviews
conducted by the Regional Health Authority.
Community Care
Section:
Index Ref: 13.1.1
Page 4
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Collective Funding
FORMS
Note: While the forms have been primarily designed for “Individualized Funding” they can be
used for “Collective Funding” as well.
See the following pages for:
•
Appendix A, Individualized Funding Utilization New Client
•
Appendix B, Individualized Funding Utilization Discontinued Clients
•
Appendix C, Collective Funding Utilization
•
Schedule A (Consumer Version), Services and Payment Schedule
•
Schedule A (Guardian Version), Services and Payment Schedule
•
Amendment to Schedule A (Consumer Version)
•
Amendment to Schedule A (Guardian Version)
•
Schedule B, Time Sheet
•
Schedule C, Quarterly Financial Report
•
Schedule D, Funding Levels
Appendix A
Individualized Funding Utilization
New Client
The Saskatchewan Ministry of Health is interested in knowing about
Individualized Funding Utilization.
For any individualized funding (IF) agreements signed after January 1, 2003,
please fill out this form and mail or fax to:
Home Care Consultant
Community Care Branch
Saskatchewan Ministry of Health
1st Floor, 3475 Albert Street
REGINA SK S4S 6X6
Fax: (306) 787-7095
Thank you.
1.
Health Region:
2.
Client Saskatchewan Health number:
3.
Client date of birth: (d/m/y)
4.
Date IF agreement started: (d/m/y)
5.
Reason for choosing IF:
6.
Home care client immediately prior to IF? Yes
7.
Total assessed hours of support service needed by client per month:
No
8.
Funding level per month:
9.
Are other home care services (eg. Nursing) being provided?
Yes
No
If yes, what kind?
10.
Agreement signed by consumer or guardian?
11.
Relationship of guardian to consumer (if applicable):
12.
Estimated case management time spent prior to signing agreement:
Information provided by
Phone
Revised September 2015
Date
Appendix B
Individualized Funding Utilization
Discontinued Clients
The Saskatchewan Ministry of Health is interested in knowing about
Individualized Funding utilization.
For any Individualized Funding clients, whose agreements have been discontinued
or not renewed, please fill out this form and mail or fax to:
Home Care Consultant
Community Care Branch
Saskatchewan Ministry of Health
1st Floor, 3475 Albert Street
Regina SK S4S 6X6
Fax: (306) 787-7095
Thank you.
1.
Health Region:
2.
Client Saskatchewan Health Number:
3.
Date IF agreement discontinued: (d/m/y)
4.
Reason for discontinuing IF:
Information provided by
Phone
Date
APPENDIX C
COLLECTIVE FUNDING UTILIZATION
1. Regional Health Authority
2. Date Collective Funding Agreement started (d/m/y)
3. Funding level per month
4. Agreement signed by
5. Estimated case management time spent prior to signing agreement
6. Information provided by
Phone __________________ Date
The Saskatchewan Ministry of Health is interested in knowing about collective
funding utilization.
For any Collective Funding Agreements signed please fill out this form and mail or
fax to:
Saskatchewan Ministry of Health
Community Care Branch
Director of Program Support (Continuing Care and Rehabilitation)
1st Floor, 3475 Albert Street
REGINA SK S4S 6X6
Fax (306) 787-7095
Thank-you
CLIENTS SERVED THROUGH COLLECTIVE FUNDING
Number
Client ID#
Date of
Birth
Home Care
Client Prior
(d/m/y)
Yes
Other
Home Care
Services Used
No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Total
Total Hours
Needed Per
Week
Schedule A
(Consumer Version)
Services and Payment Schedule
Note: Provide a copy of Schedule A (and any Amendments) to the Consumer.
Section A: Consumer Information
Name: _________________________________________________________________
Address:________________________________________________________________
Telephone: (H)____________________________ (W) __________________________
Section B: Purpose (check one only)
__ Initial establishment of Individualized Funding payment
__ Renewal of Agreement
__ Adjustment of regular monthly payment
Section C: Calculation of Monthly Payment (round to nearest dollar)
Approved Services:
Personal care services _______________ hours per month
Home management services ______________ hours per month
Total hours per month _____________ × $25.23
(includes benefits)
$___________
PLUS Monthly Administrative Allowance
+ $43.34
Total Monthly Payable
$___________
Section D: Calculation of Worker’s Compensation Premium
The annual premium is based on the current WCB rate per $100.00 of gross payroll (Industry
code G22-04).
Section E: Bank Account
A void cheque (for automatic deposit) must be provided for the first Agreement and whenever
the bank account is changed.
Name of Bank: ____________________________ Account Number: _______________
Bank Address: ___________________________________________________________
Section F: Declaration of Consumer
I understand that this Schedule is issued pursuant to the Individualized Funding Agreement and
that:
The assessment of services as shown above in Section C provides the basis for my monthly
payment;
The payment includes consideration of employee benefit costs, administrative costs, and
Workers’ Compensation premiums;
The amount indicated as Total Payable Each Month shall be the amount paid to me every
month; and
This schedule is effective as of ____________________ and replaces any previous schedule on
that date.
________________________________
Consumer
__________________________________
Signature
Section G: Regional Health Authority Approval
Case Manager: ___________________________ Signature: ______________________
Home Care Manager: ______________________ Signature: ______________________
Date: _______________________
Schedule A
(Guardian Version)
Services and Payment Schedule
Note: Provide a copy of Schedule A (and any Amendments) to the Guardian.
Section A: Guardian Information
Name: _________________________________________________________________
Address:________________________________________________________________
Telephone: (H)____________________________ (W) __________________________
Section B: Purpose (check one only)
__ Initial establishment of Individualized Funding payment
__ Renewal of Agreement
__ Adjustment of regular monthly payment
Section C: Calculation of Monthly Payment (round to nearest dollar)
Approved Services:
Personal care services _______________ hours per month
Home management services ______________ hours per month
Total hours per month _____________ × $25.23
(includes benefits)
$___________
PLUS Monthly Administrative Allowance
+ $43.34
Total Monthly Payable
$___________
Section D: Calculation of Worker’s Compensation Premium
The annual premium is based on the current WCB rate per $100.00 of gross payroll (Industry
code G22-04).
Section E: Bank Account
A void cheque (for automatic deposit) must be provided for the first Agreement and whenever
the bank account is changed.
Name of Bank: ____________________________ Account Number: _______________
Bank Address: ___________________________________________________________
Section F: Declaration of Guardian
I understand that this Schedule is issued pursuant to the Individualized Funding Agreement and
that:
The assessment of services as shown above in Section C provides the basis for my monthly
payment;
The payment includes consideration of employee benefit costs, administrative costs, and
Workers’ Compensation premiums;
The amount indicated as Total Payable Each Month shall be the amount paid to me every
month; and
This schedule is effective as of ____________________ and replaces any previous schedule on
that date.
________________________________ __________________________________
Guardian
Signature
Section G: Regional Health Authority Approval
Case Manager: ___________________________ Signature: ______________________
Home Care Manager: ______________________ Signature: ______________________
Date: _______________________
Amendment to Schedule A
(Consumer Version)
Date forwarded by Case Manager: ____________________
Note: Complete applicable sections. Provide a copy to the consumer.
Section A: Consumer Information
Name: _________________________________________________________________
Address:________________________________________________________________
Telephone: (H)____________________________ (W) __________________________
Section B: Stop Payment Advice
Stop payment as of:
(month/day/ year)
Comments
Consumer will move/has moved out of
district
Consumer is deceased
Consumer will move/has moved into an
alternate care facility
Consumer is in hospital
Date of admission ________________
Initiated by case manger for other
reasons
Please specify:
Termination of agreement
Case manager signature __________________________________
Date: _______________
Section C: Resume Payment Advice
Comments
Resume payment as of ________________________
Case manager signature _________________________________
Date: _________________
Section D: Special Payment
Amount: $ _____________________
Required for month of _________________, 20_ __
Reason: _________________________________________________________________
________________________________________________________________________
Section E: Regional Health Authority Approval
Case Manager: ___________________________ Signature: ______________________
Home Care Manager: ______________________ Signature: ______________________
Date: _______________________
Amendment to Schedule A
(Guardian version)
Date forwarded by Case Manager: ____________________
Note: Complete applicable sections. Provide a copy to the guardian.
Section A: Guardian Information
Name: _________________________________________________________________
Address:________________________________________________________________
Telephone: (H)____________________________ (W) __________________________
Name of consumer: ______________________________________________________
Section B: Stop Payment Advice
Stop payment as of:
(month/day/ year)
Comments
Consumer will move/has moved out of
district
Consumer is deceased
Consumer will move/has moved into an
alternate care facility
Consumer is in hospital
Date of admission ________________
Initiated by case manger for other
reasons
Please specify:
Termination of agreement
Case manager signature __________________________________
Date: _______________
Section C: Resume Payment Advice
Comments
Resume payment as of ________________________
Case manager signature _________________________________
Date: _________________
Section D: Special Payment
Amount: $ _____________________
Required for month of _________________, 20_ __
Reason: _________________________________________________________________
________________________________________________________________________
Section E: Regional Health Authority Approval
Case Manager: ___________________________ Signature: ______________________
Home Care Manager: ______________________ Signature: ______________________
Date: _______________________
Schedule B
Time Sheet
Employee __________________________________________
Employer
__________________________________________
Month of
_______________________ Year ______________
Day
Start
Time
End
Time
Hours
Day
1
16
2
17
3
18
4
19
5
20
6
21
7
22
8
23
9
24
10
25
11
26
12
27
13
28
14
29
15
30
31
Total Hours _______________
I certify that the above hours are correct.
Employee ________________________________
Employer ________________________________
Start Time
End
Time
Hours
Schedule C
Quarterly Financial Report
Please complete and return this Quarterly Report to the Regional Health Authority within 15
days of the indicated reporting period.
This Quarterly Report is for the period ending (check one):
____ January 31
____ April 30
____ July 31
____ October 31
____ Termination
Consumer/guardian name: _________________________________________________
Address: ______________________________________________________________
Telephone: (H) ________________________ (W)_____________________________
Please enclose a copy of your bank statement.
Bank statement balance for the last month of the reporting period.
(e.g. send a statement with an April date for the April 30 report)
$_____________ A
MINUS: Cheques written on the account to the end of the
reporting period that have not yet cleared the bank.
$_____________ B
MINUS: Vacation pay held in trust for employee(s) if not paid out
on every cheque.
$_____________ C
EQUALS: Unused funds. (A minus B minus C)
$_____________ D
MINUS: One month’s payment from the regional health authority.
$_____________ E
EQUALS: Money to be returned to the Regional Health Authority. $_____________ F
(D minus E). If negative, enter 0.
Please make cheque or money order payable to the _____________Regional Health Authority
and remit the amount shown on line F along with this form to:
Name
Address
I, ________________________________________, Consumer/guardian under this
Individualized Funding Agreement, certify that I have:
1.
Retained all funds received pursuant to the Individualized Funding Agreement in a
separate chequing account, and
2.
In my possession all records, cancelled cheques, bank statements, receipts and invoices
establishing all expenses, wages, deductions and remittances and any other information
regarding the supportive services provided for under the Individualized Funding
Agreement.
_______________________________________
Consumer/guardian(signature)
______________________
Date
Schedule D
INDIVIDUALIZED FUNDING LEVELS: EFFECTIVE OCTOBER 1, 2015.
A. Maximum Monthly Amount:
Maximum monthly amount for 2015-16 is $6,445.00, based on March 31, 2014,
average provincial costs for institutional supportive care.
B. Monthly Administration Allowance:
Allowance for 2015-16 is $43.34.
C. Home Care Aide/ Continuing Care Assistant Rates:
Rates for 2015-16 are $25.23, which includes 15% for benefits.
(Workers Compensation, Employment Insurance, Canada Pension Plan)
Section:
Community Care
Index Ref: 13.2
Page 1
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Children with Highly Complex Care Needs
13.2
CHILDREN WITH HIGHLY COMPLEX CARE NEEDS
POLICY
1.
Children with complex, life-threatening conditions benefit from living with their family
in their own community. Regional Health Authorities shall provide support to family
caregivers to allow these children to live safely at home. The Saskatchewan Ministry of
Health will assist the Regional Health Authorities in funding the direct care costs of
children with very exceptional home care needs both in terms of complexity and
intensity, and where the alternative would be the child living in specialized institutional
care. This funding does not cover the costs of equipment or supplies.
2.
To be eligible for the program the following conditions must be met:
a)
the child’s needs can be safely met at home;
b)
the family accepts the role as primary care giver;
c)
the cost of the child’s assessed direct care needs exceeds the average provincial
monthly amount paid by the Saskatchewan Ministry of Health for Institutional
Supportive Care (See Schedule D, Individualized Funding Level Section);
d)
the child requires ongoing care for a period of time greater than three (3) months;
and,
e)
the child is younger than 22 years of age.
3.
Access to the program will typically be achieved through the following steps:
a)
the Regional Health Authority staff identify a child with complex care needs as
being potentially suitable for care at home. The Saskatchewan Ministry of Health
is advised of the situation;
b)
the assessment process is completed jointly by the discharging Regional Health
Authority and the family in consultation with the receiving Regional Health
Authority; the results of the needs assessment are used to jointly develop a care
plan by the discharging Regional Health Authority, the receiving Regional Health
Authority, and the family;
c)
a funding request form is submitted to:
Director of Program Support (Continuing Care and Rehabilitation)
Community Care Branch
Saskatchewan Ministry of Health
1st Floor, 3475 Albert Street
REGINA SK S4S 6X6
Section:
Community Care
Index Ref: 13.2
Page 2
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Children with Highly Complex Care Needs
d)
e)
f)
the funding request will be forwarded to the Executive Director, Community Care
Branch for final approval.
following approval from the Saskatchewan Ministry of Health and subject to the
availability of funds, funding will be allocated for that fiscal year and provided on
a bi-weekly basis to the RHAs; and,
if the funding need continues into the next fiscal year, the Regional Health
Authority must submit a subsequent funding request.
4.
Care needs will be reviewed as follows:
a)
the child’s and family’s care needs, including assessment of the appropriateness
of the level of care that has been provided and the level of training of the care
provider, will be reviewed and re-assessed as necessary, at least every six (6)
months;
b)
these re-assessed needs will be used to determine the level of care that will
subsequently be provided;
c)
a summary of all re-assessments, including changes in care needs and budget
implications, will be submitted to the Saskatchewan Ministry of Health; and,
d)
a service summary will be submitted from the Regional Health Authority to the
Saskatchewan Ministry of Health on February 15th, and September 15th of each
year (See Appendix 3).
5.
The child’s care needs will be funded as follows:
a)
the Regional Health Authority providing the care will assume responsibility for
the equivalent average provincial amount paid per month by the Saskatchewan
Ministry of Health for Institutional Supportive Care funding (See Schedule D,
Individualized Funding Levels).
b)
the family will be responsible for home care fees as per the provincial fee
schedule;
c)
when possible, third party settlements will be accessed prior to additional funding
from the Saskatchewan Ministry of Health;
d)
the Saskatchewan Ministry of Health will assume responsibility for the balance of
the direct care costs, provided provincial funds are available;
e)
funding will be based on average hourly rates for staff as established by the
Saskatchewan Ministry of Health; and,
f)
quarterly reports of service provided and costs associated with the care of the
client will be provided to the Saskatchewan Ministry of Health.
Section:
Community Care
Index Ref: 13.2
Page 3
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Children with Highly Complex Care Needs
6.
Since this program is only available for individuals younger than 22 years of age, the
Regional Health Authority will initiate transition planning with the client and the client’s
family well in advance of the individual’s 22nd birthday. Options for the individual, and
the family and the Regional Health Authority to consider may include regular home care
services, Individualized Funding or alternate living arrangements such as special-care
homes.
GUIDELINES
1.
Client Selection
a)
The family is willing to care for their child at home as an alternative to facility
based care.
b)
The family accepts the role of primary care provider for their child.
c)
The home care program can safely meet the child’s needs without undue risk to
the child, family or care provider (i.e. the child is medically stable).
2.
Assessment and Care Plan Development
a)
An interdisciplinary team, including the client and family, home care coordinator,
nurses, physicians, social workers, therapists (occupational, physical, respiratory,
speech-language therapists), educators and others, should be involved in the
assessment and care plan development.
b)
A case manager should be identified.
c)
The assessment and care plan should consider the short-term and long-term
physical, emotional, psychosocial, spiritual and educational needs of the child and
family.
d)
The family should be integrally involved in the development and direction of the
care plan.
e)
The care plan should promote the greatest level of independence possible for the
child and family.
f)
The most appropriate care provider should be used depending on the child’s
needs. For example, a registered nurse may develop a care plan that is delegated
to a home care aide/continuing care assistant to implement.
g)
Recognized standards of care should be used.
3.
Discharge Planning from Hospital
a)
The family and other care providers must receive training in the provision of
necessary care and the operation of any equipment in the home. Outreach training
may be required if the child is transferring to another Regional Health Authority.
b)
The family should provide as much of the child’s care as possible prior to
discharge.
Section:
Community Care
Index Ref: 13.2
Page 4
Date of Issue:
Home Care Policy
Special Programs
September 2006
Revised September 2015
Subject:
Children with Highly Complex Care Needs
c)
d)
e)
f)
g)
The necessary equipment and supplies (e.g. ventilators, feeding pumps, wheel
chairs, tracheostomy supplies, etc.) will be obtained from the appropriate source
(e.g. SAIL, Regional Health Authority, private supplier, etc).
The home will be modified to accommodate the child’s needs. The Regional
Health Authority staff will assist the family to determine how to make the
modifications.
“Step down” units, day trips, and weekend passes may be used to ease the
transition from facility to home.
An emergency plan will be established to guide the response to potential
catastrophic events. Care providers will be aware of this plan.
Arrangements for schooling should be made where appropriate.
4.
Needs Review
a)
The child’s care needs will be reviewed at least every six (6) months.
b)
The review should include input from the child and family, the care providers and
other agencies involved.
c)
The review will acknowledge the child’s changing needs and the family’s ability
to provide for those needs.
5.
The rates will be reviewed by the Saskatchewan Ministry of Health on a regular basis. In
the case of Home Health Aides, rates are taken from the most representative and current
collective agreement. The rates include 15% for benefits (See Appendix 1).
Appendix 1
HOURLY RATES
(Effective October 1, 2015)
The following rates will be used to calculate the care costs on the Funding Request Form. The
rates will be reviewed by the Saskatchewan Ministry of Health on a regular basis.
Job Classification
Registered Nurse
Hourly Rate
2015-16
$52.29
(effective October 1/15)
Licensed
Practical Nurse
Home Care
Aide/Continuing
Care Assistant
$39.39
(effective October 1/15)
$25.23
(effective October 1/15)
Appendix 2
Funding Request Form for Children with Complex Care Needs
WInitial request
W Subsequent request
Child’s name
Date of birth _________________________
Child’s address
Saskatchewan Health Number
Other funding agency_______________________________________________________
Diagnosis ________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Care needs per week. (See Hourly Staffing Rates)
Direct Care (per week)
Job Classification
Hours
Rate
Cost
Registered Nurse
(RN)
Licensed Practical
Nurse (LPN)
Home Care Aide
(HCA) or
equivalent
Sub-total
TOTAL COST
(direct + respite)
Respite Care (per week)
Hours
Rate
Cost
8. Funding Request per month:
= [(Total cost per week × 52) ÷ 12 ] − $6,445
= [ ($
× 52) ÷12 ] − $6,445
=$
=$
− $6,445
Number of months this funding will be required:
6 months
12 months
Other _____________________
Start date if known: _________________________
Care provided by the family (please describe):
_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________
Comments from Pediatric Advisory Team (if applicable):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________
Comments: ___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date of next care needs review: ___________________________________________
Submitted by: ____________________________ Title: _______________________
Telephone Number: _______________________ Date: _______________________
Please forward this form and a copy of the assessment to:
Saskatchewan Ministry of Health
Community Care Branch
Director of Program Support (Continuing Care and Rehabilitation)
1st Floor, 3475 Albert Street
REGINA SK S4S 6X6
Phone: (306) 787-4587
Fax. (306) 787-7095
Client Name:
Service
Provider
HHA
LPN
RN
Total
Minus $5,543.
Average YTD
Service
Provider
HHA
LPN
RN
Total
Minus $5,543.
Average YTD
May
June
July
Cost
Units
Cost
Units
Cost
Units
Cost
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
-$6,445.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
April
Units
October
November
December
January
Units
Cost
Units
Cost
Units
Cost
Units
Cost
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
$6,445.00
Comments:
Note: As per the Children with Highly Complex Care Needs policy, hourly staff rates are:
Registered Nurse
Licensed Practical
Home Care Aide
Job
Nurse
Classification
October 1, 2015 $52.29 October 1, 2015 $39.39
October 1, 2015 $25.23
2015-16
August
September
Units
Cost
Units
$0.00
$0.00
$0.00
$0.00
$6,445.00
$6,445.00
February
Units
Cost
$0.00
$0.00
$0.00
$0.00
$6,445.00
$6,445.00
Units
Community Care
Section:
Index Ref: 14.1
Page 1
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Nursing Practice
14.1
NURSING PRACTICE
POLICY
1.
The professional nurse has the legal and ethical responsibility for assessing the nursing
needs of clients and for planning and giving nursing care. While selected activities or
tasks may be delegated to others (employees), the (RN, RPN, LPN) retains responsibility
for the quality of care given.
2.
The parts of a client care plan that involve nursing treatments should be carried out by a
qualified nurse only after receipt of orders from the client’s physician or registered nurse
(nurse practitioner) [RN(NP)]. A signed physician’s or RN(NP)’s order should be kept in
the client’s file.
GUIDELINES
1.
In providing client care, nurses carry out a variety of interventions in many different
settings. Client safety demands that nurses perform only those procedures for which they
have had appropriate educational preparation.
2.
Nurses should not perform any procedure for which they do not feel competent.
3.
Before developing a nursing care plan, the professional nurse should be fully cognizant of
the findings of the assessment process. Using this information and any additional
information as deemed necessary, i.e. collated in collaboration with the client and other
professionals concerned with the client’s care (e.g. physician, community health nurse,
physical therapist, social worker), the nurse will identify the client’s care needs and
determine appropriate nursing intervention.
4.
Nursing assessments and nursing services may be initiated without a physician’s referral
or orders if a client care plan is defined during the assessment process as personal care
only.
5.
The measures and methods of nursing interventions are based on the knowledge and
skills required to implement the preventive, supportive, restorative, and rehabilitative
functions.
Community Care
Section:
Index Ref: 14.2
Page 1
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Nursing Procedures by Transfer of Medical Functions
14.2
NURSING PROCEDURES BY TRANSFER OF MEDICAL FUNCTIONS
DEFINITION
Nursing procedures by transfer of medical functions are those medical functions performed
primarily by physicians that are outside the usual scope of nursing practice, but which may be
transferred to specific nurses in the interests of client care.
POLICY
1.
The Regional Health Authority must establish written policies and procedures in
accordance with the criteria and standards developed by the Saskatchewan Registered
Nurses’ Association (SRNA), Registered Psychiatric Nurses Association of
Saskatchewan (RPNAS) and Saskatchewan Association of Licensed Practical Nurses
(SALPN).
2.
The Regional Health Authority must identify nursing procedures by transfer of medical
function and ensure the procedures are reasonable, appropriate and consistent with
nursing practice in Saskatchewan (as defined by the SRNA, RPNAS and SALPN).
3.
The Regional Health Authority’s nursing administration and medical authorities, as well
as individual physicians, will exercise judgment in developing policies transferring the
performance of specific medical functions to nurses.
GUIDELINES
1.
The Regional Health Authority must consider the appropriateness of the region’s ability
to provide resources for instruction, supervision, in-service, and continuing certification
for the nurse accepting the transfer of medical function.
2.
The Regional Health Authority must consider the accessibility of a physician, range of
support services and client population when determining the need to transfer a medical
function to nursing.
3.
The Regional Health Authority should contact the College of Physicians and Surgeons of
Saskatchewan, Saskatchewan Registered Nurses Association, Registered Psychiatric
Nurses Association of Saskatchewan or Saskatchewan Association of Licensed Practical
Nurses for assistance when determining the appropriateness of the transfer of medical
function.
Community Care
Section:
Index Ref: 14.2
Page 2
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Nursing Procedures by Transfer of Medical Functions
4.
The nurse is responsible and accountable for competent performance. The nurse should
not perform any procedure in which she/he does not feel competent.
5.
Regional Health Authority policies and procedures must be based upon the criteria for
safe client care as outlined in the SRNA document, “The registered nurse scope of
practice: Special nursing procedures and nursing procedures by transfer of medical
functions (1993)”.
6.
The Regional Health Authority may access and refer to the following position statements:
Further information is available on the following websites:
http://www.srna.org/
http://www.rpnas.com/
http://www.salpn.com/
Community Care
Section:
Index Ref: 14.3
Page 1
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Special Nursing Procedures
14.3
SPECIAL NURSING PROCEDURES
DEFINITION
Special nursing procedures are those procedures in the practice of nursing for which the basic
nursing education programs provide neither specific theory nor clinical practice. These
procedures are not taught in basic nursing education programs, either because many clients do
not need them or because they are required only in specialty areas of practice.
POLICY
1.
The Regional Health Authority must establish written policies and procedures in
accordance with the criteria and standards developed by the Saskatchewan Registered
Nurses’ Association (SRNA), Registered Psychiatric Nurses Association of
Saskatchewan (RPNAS) and Saskatchewan Association of Licensed Practical Nurses
(SALPN).
2.
The Regional Health Authority is responsible for providing the nurse with the education
and the experience needed to perform special nursing procedures.
3.
Special nursing procedures are to be performed only by a nurse with practicing
membership under the SRNA, RPNAS and SALPN. Each specific nurse must be
certified for each specific special nursing procedure.
4.
The Regional Health Authority must identify the special nursing procedure and its
implementation ensuring it is reasonable, appropriate and consistent with the nursing
practice in Saskatchewan (as defined by SRNA, RPNAS and SALPN).
GUIDELINES
1.
Regional Health Authority policies and procedures must be based upon the criteria for
safe client care as outlined in the SRNA, RPNAS and SALPN documents, The registered
nurse scope of practice: Special nursing procedures and nursing procedures by transfer
of medical functions (1993).
2.
A nurse should only perform special nursing procedures after the successful completion
of an educational program of specific theory and practice.
3.
The nurse should not perform any procedures in which s/he does not feel competent.
Community Care
Section:
Index Ref: 14.3
Page 2
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Special Nursing Procedures
4.
The Regional Health Authority may access and refer to the following position statements:
Further information is available on the following websites:
http://www.srna.org/
http://www.rpnas.com/
http://www.salpn.com/
Community Care
Section:
Index Ref: 14.4
Page 1
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Licensure of Nurses
14.4
LICENSURE OF NURSES
POLICY
1.
Employers are responsible for complying with relevant nursing legislation with respect to
licensing and registration and for reporting professional misconduct or incompetence
resulting in termination.
2.
All nurses are responsible for maintaining current practicing membership with their
respective regulatory professional bodies such as the Saskatchewan Registered Nurses’
Association, the Registered Psychiatric Nurses Association of Saskatchewan, and the
Saskatchewan Association of Licensed Practical Nurses.
GUIDELINES
1.
Employers should retain on file a current copy of the employees’ “License to Practice” as
verified by annual documentation issued by the employee’s respective regulatory
professional body (i.e. SRNA, RPNAS, SALPN).
Community Care
Section:
Index Ref: 14.5
Page 1
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Delegation of Nursing Procedures
14.5
DELEGATION OF NURSING PROCEDURES
POLICY
1.
All decisions related to delegation of nursing activities must be based upon the
fundamental principle of public protection.
2.
Registered Nurses, Registered Psychiatric Nurses and Licensed Practical Nurses have
ultimate accountability for the management and provision of nursing care, including all
delegation decisions.
GUIDELINES
1.
Each RN, RPN and LPN is accountable for his/her own practice 1. However, the
provision of safe client care is a shared responsibility. All organizations and health care
providers involved in the delivery of nursing services have a responsibility to provide
safe care.
2.
The RN, RPN, LPN who assigns a task or procedure to an unregulated health care
provider is responsible for ensuring appropriate support is provided1. The nurse must
consider the client’s status and requirements for care, the competence of the care provider
and the practice environment.
3.
The Regional Health Authority must take into consideration that a single nurse is seldom
accountable for all aspects of the decision-making process for delegation, its
implementation, supervision and evaluation1.
4.
RN, RPN and LPN may delegate a task only, not the decision making tool1.
5.
The Regional Health Authority must have formal processes in place to support the
delegator and delegatee.
1
Registered Psychiatric Nurses Association, Saskatchewan Association of Licensed Practical Nurses, Saskatchewan
Registered Nurses’ Association. (2000). Nursing in collaborative environments. Regina, SK: Authors.
Community Care
Section:
Index Ref: 14.5
Page 2
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Delegation of Nursing Procedures
6.
The Regional Health Authority may consider accessing and referring to the following
additional resources in clarifying specific issues of delegation:
a)
b)
c)
d)
e)
f)
The Practice of Nursing: RN Assignment and Delegation (2004);
The Registered Psychiatric Nurses Association, Saskatchewan Association of
Licensed Practical Nurses, Saskatchewan Registered Nurses’ Association. (2000).
Nursing in Collaborative Environments;
Registered Psychiatric Nurses’ Association of Saskatchewan (RPNAS),
www.rpnas.com;
Saskatchewan Association of Licensed Practical Nurses (SALPN),
www.salpn.com; or,
Canadian Practical Nurses Association (CPNA), www.cpna.ca.
Saskatchewan Registered Nurses Association (SRNA), http://www.srna.org/
Section:
Community Care
Index Ref: 14.6
Page 1
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Evidence-Based Practices and Outcomes
14.6
EVIDENCE-BASED PRACTICES AND OUTCOMES
DEFINITION
Evidence-based practice is a process of using current evidence to guide nursing practice and
decision-making through the application of consistent, scientific research that demonstrate
interventions which improve client care, outcomes and quality of life.
POLICY
1.
The Regional Health Authority shall have available written nursing policies and
procedures based on current best practice guidelines and other recent evidence-based
practice and outcomes.
GUIDELINES
1.
The Regional Health Authority nursing policies and procedures should be based upon
existing and emerging statements of recommended best practice guidelines.
2.
The design and development of regional policies and procedures should provide guidance
to and act as a resource for home care staff.
3.
Best practice guidelines will:
a)
improve client care;
b)
improve client satisfaction;
c)
provide accessible and available services;
d)
reduce variation in care;
e)
transfer research evidence into practice;
f)
promote nursing knowledge base;
g)
assist with clinical decision making;
h)
identify gaps in research;
i)
stop interventions that have little effect or cause harm; and,
j)
reduce cost.
4.
Best practice guidelines should facilitate and support evidence-based practice.
5.
Regional Health Authority home care nursing staff should use the most recent scientific
evidence in their practice.
Section:
Community Care
Index Ref: 14.6
Page 2
Date of Issue:
Home Care Policy
Nursing Practice
September 2006
Revised September 2015
Subject:
Evidence-Based Practices and Outcomes
6.
Regional Health Authorities have the responsibility to create practice environments that
foster critical thinking, allow questioning of current practice and have systems to support
and encourage home care nursing staff to access and/or implement research evidence in
the delivery of care.
7.
Examples of nursing treatments requiring established nursing policy and procedures
include: wound management; home IV therapy; negative pressure wound therapy
(Vac Therapy), etc.
Community Care
Section:
Index Ref: 15.0
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Home Care Client Fees and Charges
15.0
HOME CARE CLIENT FEES AND CHARGES
POLICY
1.
Regional Health Authorities shall charge fees as outlined in the Saskatchewan Ministry of
Health Home Care Policy Manual and any subsequent policies established by the
Saskatchewan Ministry of Health.
Community Care
Section:
Index Ref: 15.1
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Basic Home Care Client Fee Policy
15.1
BASIC HOME CARE CLIENT FEE POLICY
POLICY
1.
Regional Health Authorities shall charge fees for homemaking (including personal care
and respite provided by an aide), home maintenance and meal service, except for services
provided to end stage palliative clients, a palliative client requiring acute care
management of palliative symptoms, and except for personal care services (up to
14 days) provided to short–term acute clients.
2.
Regional Health Authorities may not charge Saskatchewan residents for assessment and
care coordination, nursing services provided by a nurse (including personal care and
respite provided by a nurse) or for therapy provided by an occupational or physical
therapist.
3.
Home care clients must be informed on admission about the right to apply at any time for
an income-tested subsidy to reduce charges for homemaking, home maintenance and
meal services.
4.
Clients receiving an income-tested subsidy must re-apply annually.
Community Care
Section:
Index Ref: 15.1.1 Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Short-term Acute Home Care
15.1.1
SHORT-TERM ACUTE HOME CARE
POLICY
1.
Regional Health Authorities shall support the acute care system by providing the capacity
for early hospital discharge to avoid/prevent re-admission and to avoid/prevent imminent
admission.
Short-term acute home care includes case management, nursing, personal care and home
IV without fees for up to 14 days.
Community Care
Section:
Index Ref: 15.2
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Calculation of Client Fees for Regional Health Authorities
15.2
CALCULATION OF CLIENT FEES FOR REGIONAL HEALTH
AUTHORITIES
POLICY
1.
The billing period for home care services is one calendar month.
2.
A unit of chargeable service is a meal, an hour of homemaking or an hour of home
maintenance calculated rounded either up or down to ¼ hour increments (See exceptions
in 4 and 5 below).
3.
There are no fees for services provided by a case manager, nurse, physical therapist, or
occupational therapist.
4.
There are no fees for services provided to palliative clients who are assessed as
“end stage” or as requiring acute care management of palliative symptoms, regardless of
the palliative stage.
5.
For short-term acute home care clients in addition to the services normally provided
without charge (e.g. case management, nursing, home IV), there is no fee for personal
care for up to 14 days in order to aid in early discharge from hospital and to avoid or
prevent re-admission to hospital, as well as to avoid or prevent imminent admission to
hospital. Acute home care clients include clients with mental health issues.
6.
All clients are charged a flat rate per unit for the first 10 units of chargeable service in the
month. The unit charge will be determined annually and become effective October 1st.
(See Appendix A1 for the current rate). 1
7.
The following clients will only be charged for the first 10 chargeable units of service that
they access within the month:
a)
clients receiving Saskatchewan Assistance Plan (SAP) or Saskatchewan
Employment Supplement (SES);
b)
clients receiving Saskatchewan Income Plan (SIP) and not receiving a War
Veteran’s Allowance; or,
c)
clients with an adjusted monthly income equal to or less than the cost of 10 home
care units.
Community Care
Section:
Index Ref: 15.2
Page 2
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Calculation of Client Fees for Regional Health Authorities
8.
For other clients who access more than 10 chargeable units per month, home care charges
will be based on the current fee schedule (See Appendix A2):
a)
clients who do not apply for an income-tested subsidy, or who apply but do not
qualify, are charged the highest rate on the fee schedule; and,
b)
clients who apply and qualify for an income-tested subsidy are charged a rate
from the following fee schedule based on their Adjusted Monthly Income (AMI)
as determined by the “Calculation of Income Tested Subsidy” that follows the fee
schedule (See Appendix B1).
9.
The Saskatchewan Ministry of Health will annually adjust the cost per unit of home care
to reflect the percentage increases to Old Age Security (OAS)/Guaranteed Income
Supplement (GIS) benefit rates.
10.
The Saskatchewan Ministry of Health will annually adjust the basic exemption levels
used to determine the adjusted monthly income of home care clients.
POLICY
Instructions for Calculation of Income Tested Subsidy (See Appendix B1).
Home Care Subsidy Application (See Appendix B2).
Community Care
Section:
Index Ref: 15.3
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Charges to Temporary Residents
15.3
CHARGES TO TEMPORARY RESIDENTS
GUIDELINES
1.
For Canadian Citizens who are not Saskatchewan Residents:
a)
Regional Health Authorities should charge non-Saskatchewan residents staying
temporarily in the province for all services, including assessment and care
coordination, nursing and therapies;
b)
Regional Health Authorities should charge non-Saskatchewan residents staying
temporarily in the province the direct cost of providing a unit of service, including
all service costs, but not administration costs; and,
c)
In exceptional circumstances, where the charge for services provided imposes a
serious financial hardship for the non-resident client, Regional Health Authorities
may charge less than the full cost of service. A Regional Health Authority,
however, should not charge less than the amount a Saskatchewan resident with
the same income would be charged for the same service if she/he applied for an
income-tested subsidy.
2.
For Non-Canadian Citizens:
a)
Out-of-country residents staying temporarily in the province should be charged
full cost of service including administrative costs.
Community Care
Section:
Index Ref: 15.4
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Third Party Payers
15.4
THIRD PARTY PAYERS
GUIDELINES
1.
A third party payer is an agency or program that is responsible for paying the costs of
services provided to a client. The major third party payers in Saskatchewan are:
a)
Saskatchewan Government Insurance (SGI);
b)
Workers Compensation Board (WCB); and,
c)
Veterans Affairs Canada (VAC);
2.
These guidelines outline the key factors for determining eligibility and the benefits that
may be provided for each of the major third party payers. The program descriptions are
simplified to highlight aspects of interest to home care programs and are not
comprehensive.
3.
The guidelines also recommend basic procedures for Regional Health Authorities to
follow when dealing with each of the major third party agencies and provide contact
information for other agencies.
Saskatchewan Government Insurance (SGI)
Eligibility
Benefits
Based on the insurance policy and, in liability cases, the judgment of a court.
SGI will pay the Regional Health Authority the client fee portion of
providing the home care service.
Recommendations When a home care client has established a valid claim with SGI, the
Regional Health Authority should bill SGI directly for the client fee portion
of providing the following home care service:
• Home Management
• Meals on Wheels; and,
• Home Maintenance.
Notes
The Regional Health Authority will continue to be the key agent in
collecting SGI payment for the provision of home care services to a client.
Section:
Community Care
Index Ref: 15.4
Page 2
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Third Party Payers
Workers’ Compensation Board (WCB)
Eligibility
Benefits
Workers injured on the job excluding teachers, domestics, out-workers,
employees of farmers and ranchers, and workers exempted by regulations.
Some of the above may be covered through voluntary action of their
employer.
The WCB pays costs incurred as a direct result of a compensable injury.
Each case is assessed by the WCB on its own merits, and a range of benefits
may be available. Some types of benefits relevant to home care include:
• costs of personal care services (for current payment rates contact WCB);
• nursing services prescribed by a doctor; and,
• other services, such as home modification, are sometimes approved.
The level of benefits provided is based on individual circumstances.
Normally payment is made directly to the care provider or care-providing
agency. Prior approval of services is required.
Recommendations In the case of a service that is directly related to an injury incurred on the
job, the Regional Health Authority should:
• seek immediate approval from WCB;
• begin providing the service; and,
• charge unit costs, including administration and assessment and
coordination costs, to the WCB if and when the service is approved.
Notes
Regional Health Authorities may have to subsidize the cost of services
provided before approval is received.
Contact
Workers’ Compensation Board
1881 Scarth Street
REGINA SK S4P 4L1
Telephone:
306-787-4370
Toll Free:
1-800-667-7590
Section:
Community Care
Index Ref: 15.4
Page 3
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Third Party Payers
Veterans Affairs Canada (VAC)
Veterans Affairs Canada has three programs that may be of significance to Regional Health
Authorities:
War Veterans Allowance
Recommendations Veterans Affairs covers costs to the client only (e.g. client fees). The
Regional Health Authority should advise the client to contact the nearest
Veterans Affairs district office (Regina or Saskatoon) directly.
Canadian Pension Commission
Recommendations This program does not generally cover home care services. The Regional
Health Authority should advise the qualified individual requiring benefits to
contact the nearest Veterans Affairs district office (Saskatoon or Regina)
directly.
Veterans Independence Program
Recommendations Veterans Affairs covers costs to the client only (e.g. client fees). The
Regional Health Authority should advise the client to contact the nearest
Veterans Affairs district office (Saskatoon or Regina) directly.
In a case where an eligible client needs more services than the Regional
Health Authority can provide, or services not offered by home care, the
client may be able to obtain financial assistance from the Veterans
Independence Program. When a Regional Health Authority identifies such
needs, it may be able to facilitate the coverage for the client by contacting
the nearest Veterans Affairs district office directly.
Veterans Affairs may request home care assessment information to support
the client’s application. Regional Health Authorities may provide this
assessment information with the consent of the client.
Section:
Community Care
Index Ref: 15.4
Page 4
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Third Party Payers
Veterans Affairs may also ask the Regional Health Authority to conduct an
additional nursing assessment of the client using its own form. The Regional
Health Authority may agree to do the requested nursing assessments but
should charge for it. Veterans Affairs Canada has agreed to pay
“the customary professional fee” for nursing assessments conducted on its
behalf. Note that occasionally Veterans Affairs Canada may ask a Regional
Health Authority to perform a nursing assessment (using its form) of a
person who is not a home care client. Again, the Regional Health Authority
may agree to perform the assessment, but should charge costs to Veterans
Affairs Canada.
Contacts
Veterans Affairs Canada
1783 Hamilton St. Suite 108
REGINA SK
Telephone: 1 800 522 2122 (toll free)
Section:
Community Care
Index Ref: 15.4
Page 5
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Third Party Payers
Others Agencies
Indian and Northern Affairs Canada (INAC)
The INAC-Saskatchewan Region comprises of a regional office in Regina, a district office in
Prince Albert (North Central District), and budget centers in Regina (North West Budget Centre)
and Fort Qu’Appelle (South Budget Centre). These offices provide a variety of services to
approximately 120,000 Registered First Nations people in Saskatchewan.
Contacts
Regional Office
1821 Albert St.
REGINA SK S4P 2S9
Telephone:
306-780-5392
Fax:
306-780-5733
North Central District office
110-3601 – 5th Avenue East
PRINCE ALBERT SK S6W 0A2
Telephone:
306-953-8522
Fax:
306-953-8648
South Budget Centre
PO Box 760
2nd Floor, Room 210
Treaty Four Governance Centre, Sioux Avenue
FORT QU’APPELLE SK S0G 1S0
Telephone:
306-332-8500
Fax:
306-332-6019
INAC Website: http://ainc-inac.gc.ca/eng/1100100020587
Section:
Community Care
Index Ref: 15.4
Page 6
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Third Party Payers
First Nations and Inuit Health Branch (FNIHB) - Health Canada
Contacts
Regional Director
First Nations and Inuit Health Branch
Health Canada
18th Floor - 1920 Broad Street
REGINA SK S4P 3V2
Telephone:
306-780-5413
Fax:
(306) 780-7733
Email:
Regional Home Care Coordinator
Saskatchewan Region
First Nations and Inuit Health Branch
18th Floor - 1920 Broad Street
REGINA SK S4P 3V2
Telephone:
306-780-6559
Fax:
306-780-6026
Email:
IHB Website: http://www.hc-sc.gc.ca/fniah-spnia/index-eng.php
Community Care
Section:
Index Ref: 15.5
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Home Care Nursing Supplies
15.5
HOME CARE NURSING SUPPLIES
POLICY
1.
Regional Health Authorities shall provide the following nursing supplies to home care
clients, if required (nursing supplies are available at no charge to the client):
a)
Wound Care Supplies:
i.
Standard gauze (2x2, 4x4), klingwrap, abdominal pads;
ii.
bandages (e.g. conform);
iii.
medical tape (e.g. standard tape, mefix, hypafix);
iv.
absorbent under pads;
v.
saline and antimicrobial solutions (e.g. salvodil);
vi.
gloves, sterile dressing trays, suture removal sets, staple removal sets,
sterile cotton tipped applicators; and,
vii.
dressings and substances that facilitate wound healing, and reduce the
number and frequency of dressing changes.
b)
Urinary Supplies:
i.
Catheters;
ii.
catheter trays;
iii.
irrigation trays;
iv.
urinary drainage bags (bedside bags &/or leg bags);
v.
gloves; and,
vi.
water-soluble lubricant (supply list does not include adult incontinent
products e.g. Attends).
c)
Bowel supplies:
i.
enema bags;
ii.
rectal tubes;
iii.
gloves; and,
iv.
water-soluble lubricant (supply list does not include Fleet enemas).
2.
These supplies are in addition to any other supplies that home care clients would be
eligible for, without charge (Policies 15.6 and 15.8 of the Saskatchewan Ministry of
Health Home Care Policy Manual).
Community Care
Section:
Index Ref: 15.6
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Home Parenteral Medication Program Coverage
15.6
HOME PARENTERAL MEDICATION PROGRAM COVERAGE
POLICY
1.
Regional Health Authorities will cover home/nursing home administration of approved
parenteral medications when they are prescribed as an acute care replacement measure.
The Saskatchewan Drug Plan will cover approved parenteral medications administered
for maintenance therapy of life long or chronic conditions except when the patient is a
registered inpatient in an acute care facility. Drugs administered parenterally include
sub-cutaneous or intramuscular injections as well as intravenous medications.
2.
The Regional Health Authorities will cover supply costs for medications listed below in
both the acute and chronic therapy categories. These are purchased through hospital
contracts and would have significant cost implications if purchased outside of these
contracts. The supplies to be provided to the client without charge include but are not
limited to, intravenous solutions, tubing, cathlons, heparin locks and caps, pump
cassettes, syringes and needles.
3.
Eligibility of drugs for coverage will be subject to the Hospital Benefit Drug List,
Saskatchewan Formulary, and/or Regional Health Authority protocols.
4.
These policies apply to residents of special care homes as well as community residents.
GUIDELINES
1.
Acute Care Replacement medications are parenteral medications that enable early
discharge from the acute care site, or that prevent admission to the acute care site:
a)
Medications are to be provided by the Regional Health Authority without charge
to the individual;
b)
Eligible drugs are listed in the Hospital Benefit Drug List (Supplementary
Information Section) of the Saskatchewan Health Drug Plan Formulary;
c)
Changes to the Hospital Benefit Drug List are through recommendations of the
Saskatchewan drug review process and the Advisory Committee on Institutional
Pharmacy Practice;
d)
Regional Health Authorities shall establish appropriate guidelines for home
parenteral therapy and an appropriate screening mechanism for the services; and,
Community Care
Section:
Index Ref: 15.6
Page 2
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Home Parenteral Medication Program Coverage
e)
2.
Considerations when determining if parenteral therapy at home or in a
special-care home is appropriate for a particular individual shall include the:
i.
ability to coordinate and plan the care with the physician, home care
program/special-care home program, hospital/health centre and
pharmacist;
ii.
practicality and safety of administering the drug at home or in a
special-care home;
iii.
ability and motivation of the individual and/or the availability of family
support, when therapy is delivered at home;
iv.
availability of more appropriate oral alternatives; and,
v.
cost-effectiveness of providing the drug at home or in a special-care home.
Chronic Condition Medications are injectable drugs used in the treatment of chronic
conditions administered in the community or in hospitals to hospital outpatients where
the only purpose in entering a hospital is to receive the drug. Cost of these injectable
drugs will be covered under the Saskatchewan Drug Plan and subject to a co-payment
and deductible where applicable:
a)
eligible drugs are listed in the Saskatchewan Health Drug Plan Formulary;
b)
maintenance of the Formulary is through the formulary approval process via the
Saskatchewan drug review process;
c)
where applicable, these medications are subject to Exception Drug Status
approval, co-pay, and family deductible;
d)
drugs that have not been approved by the Saskatchewan review process will not
be considered benefit drugs under the Drug Plan;
e)
certain drugs require Exception Drug Status (EDS) approval (see Appendix A of
the Saskatchewan Health Drug Plan Formulary for EDS Program information, as
well as a complete list of EDS drugs); and,
f)
benefits provided prior to this policy will be grandfathered (e.g. pulse therapy, IV
iron, Eprex).
Section:
Community Care
Index Ref: 15.7
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Programs Covering Drug and Supply Costs
15.7
PROGRAMS COVERING DRUG AND SUPPLY COSTS
POLICY
1.
All patients receive coverage of most drug and medical supply costs while they are in the
hospital. People who are not in hospital may have their costs covered by a variety of
programs, depending on factors such as the nature of their condition, the type of drug or
supply needed and their own financial need.
2.
This section outlines some of the major programs that may cover the costs of drugs
and/or supplies for persons outside hospitals. Regional Health Authorities should inform
clients about relevant programs and encourage them to pursue the options available to
them.
3.
All references in regards to the provision of nursing supplies to clients are described
under Policies 15.5, 15.6, and 15.8 of the Saskatchewan Ministry of Health Home Care
Policy Manual.
GUIDELINES
1.
Hospital Services
a)
The Saskatchewan Ministry of Health funds Regional Health Authorities to pay
for most services provided by hospitals to inpatients;
b)
For outpatient beneficiaries, coverage extends only to those services administered
on hospital premises; and,
c)
In practice, some hospitals do provide a two or three-day supply of approved
medications or required supplies to patients leaving the hospital if the patient does
not have immediate access to those medications or supplies (this procedure of
emergency dispensing is intended to assist the patient only until he or she can
have a prescription filled or purchase supplies through a retail pharmacy).
2.
Saskatchewan Prescription Drug Plan
a)
Coverage of Drugs Listed in the Formulary:
i.
the Drug Plan provides benefits to eligible beneficiaries to assist with the
acquisition of drugs, which are listed in the Saskatchewan Formulary and
prescribed by a licensed physician, registered nurse(nurse practitioner),
dentist or duly qualified Optometrist;
ii.
insulin and urine testing agents, which may be obtained without a
prescription, are also covered;
Section:
Community Care
Index Ref: 15.7
Page 2
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Programs Covering Drug and Supply Costs
iii.
iv.
v.
the range of drugs listed in the formulary enables physicians to select
appropriate courses of therapy for most patients;
the Plan does not cover drugs that are covered by other government
agencies (e.g. drugs administered in hospitals, anti-tuberculosis drugs,
antineoplastic agents, blood derivatives, vaccines and sera); and,
the Plan also does not normally cover over-the-counter preparations that
are available without a prescription at reasonable cost.
b)
Standard Beneficiaries (See Appendix C for Current Rates);
c)
Income Supplement Beneficiaries (See Appendix C for Current Rates);
d)
Non-Standard Beneficiaries
i.
Certain categories of beneficiaries are entitled to Prescription Drug Plan
benefits that entail the payment of a minimal prescription charge, or are
exempted from the charge when they receive certain drugs:
•
Saskatchewan Social Assistance Plan recipients are entitled to
receive the following prescribed drugs without charge:
(a)
insulin preparations;
(b)
oral hypoglycemics;
(c)
injectable Vitamin B12;
(d)
oral contraceptives;
(e)
allergenic extracts; and,
(f)
products used in megavitamin therapy.
•
Saskatchewan Social Assistance Plan recipients are entitled to
receive other formulary drugs at a reduced prescription charge
(a maximum of $2.00);
•
Saskatchewan Social Assistance Plan recipients, who are granted
additional coverage on the basis of drug need, and persons 18 years
of age or under who are dependants of Saskatchewan Social
Assistance Plan beneficiaries, are entitled to obtain all formulary
drugs without charge; and,
•
Cystic fibrosis patients, paraplegics and chronic renal disease
patients are entitled to receive all prescribed formulary drugs at no
cost (Saskatchewan Aids to Independent Living also covers the
cost of certain non-formulary disease-related drugs prescribed for
these beneficiaries).
•
Palliative Care clients receive formulary drugs at no cost.
Section:
Community Care
Index Ref: 15.7
Page 3
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Programs Covering Drug and Supply Costs
e)
Exception Drug Status (EDS)
i.
these drugs are listed in the formulary as exception drug status Exception
Drug Status (EDS) drugs (refer to Appendix A of the Formulary); and,
ii.
the prescribing physician, registered nurse(nurse practitioner), dentist, or
pharmacist must make requests for exception drug status to the
Saskatchewan Prescription Drug Plan;
•
Regional Health Authorities may call the Saskatchewan
Prescription Drug Plan inquiry line at 1-800-667-7578 (press 1)
when in doubt about what to advise a client regarding coverage of
drugs.
f)
Saskatchewan Aids to Independent Living (SAIL)
i.
One of the SAIL programs may provide the following types of equipment,
appliances and supplies to persons with physical disabilities in the
community:
•
prosthetic and orthotic appliances (no charge);
•
mobility aids, such as conventional, manual and electric power
wheelchairs, positioning devices and specialized walking aids,
walkers (free loan);
•
environmental adaptations, such as commodes, hydraulic patient
lifts, hospital beds and accessories (free loan);
•
oxygen funding when prescribed by a physician and oximetry or
blood gas criteria are met; and,
•
respirators and suction machines for oral and tracheal suctioning
when prescribed by a physician.
ii.
SAIL provides some other special appliances, equipment and/or medical
supplies through the Parapelgia Program, Compression Garment Program,
Hemophlia Program and Ostomy program (50% coverage for Ostomy
supplies) for paraplegics, disabled children, hemophiliacs, persons who
need special telephone appliances and persons requiring ostomy supplies
(50% cost coverage for ostomy supplies) as special benefits;
iii.
SAIL also covers the costs of non-formulary disease-related drugs,
including prescription fees, for patients with cystic fibrosis, paraplegia and
chronic renal disease;
iv.
Physicians, registered nurse (nurse practitioners), physical and
occupational therapists, public health nurses and approved home care
nursing coordinators each have authority to requisition some types of
SAIL equipment; and,
Section:
Community Care
Index Ref: 15.7
Page 4
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Programs Covering Drug and Supply Costs
v.
g)
The Special Needs Equipment Program provides repair services for loaned
equipment. For more information contact:
Saskatchewan Aids to Independent Living
3475 Albert Street
REGINA SK S4S 6X6
Telephone (306) 787-7121
http://www.health.gov.sk.ca/aids-services-benefits
Supplemental Health Program
i.
Persons who are nominated through Social Services including
beneficiaries of the Saskatchewan Social Assistance Plan, Family Health
Benefits or Saskatchewan Income Plan may be eligible for Supplementary
Health Program benefits; and,
ii.
The Supplementary Health benefits include the costs of most medical
supplies and appliances that are prescribed by the appropriate health care
professional and loans low cost aids such as environmental aids such as:
•
bath seats and benches;
•
wall bars;
•
tub clamps and toilet arm rests; and,
•
ambulatory aids such as crutches and canes.
See the section above on the Saskatchewan Prescription Drug Plan
(Non-standard beneficiaries) for information on coverage of drugs
for Social Assistance Plan recipients.
3.
Saskatchewan Cancer Agency
Cancer treatment drugs included on the Saskatchewan Cancer Agency’s formulary, or
approved for coverage through its exception drug status program, are provided to cancer
patients at no charge. In addition to the two tertiary cancer centres, chemotherapy is also
provided for cancer patients in community oncology centres across the province.
Section:
Community Care
Index Ref: 15.7
Page 5
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Programs Covering Drug and Supply Costs
4.
Local Resources
a)
Regional Health Authorities should investigate resources that are available
locally;
b)
Many organizations, such as the Canadian Cancer Society and the Multiple
Sclerosis Society of Canada, have local chapters that may be able to provide
information on sources of supplies for their client groups; and,
Local service clubs may be willing to donate money for medical supplies, as some have
done in the past.
Community Care
Section:
Index Ref: 15.8
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Palliative Care Supplies and Charges
15.8
PALLIATIVE CARE SUPPLIES AND CHARGES
POLICY
1.
Individuals who have been designated as “end stage” palliative, or assessed as requiring
management of acute palliative symptoms, through the Regional Health Authority’s
assessment and case management process, are exempt of:
a)
home care fees for home care services;
b)
resident charges when in the hospital;
c)
resident charges when admitted specifically for “end stage” palliative purposes in
special-care (nursing) homes and health centres; and,
d)
resident charges when admitted specifically for management of acute palliative
symptoms in hospital, in special-care (nursing) homes and health centres
(i.e. are exempted from charges regardless of the care setting).
2.
Individuals assessed as stable and requiring long term care or respite services by the
Regional Health Authority’s assessment and case management process are responsible
for:
a)
home care fees when receiving home care; and,
b)
resident charges when in hospital, special-care (nursing) homes and health centres
(i.e. are assessed charges regardless of the care setting).
3.
Dietary Supplements and Basic Supplies
a)
Individuals (who may be receiving care in their own homes, in hospitals, in
special-care homes or in health centres) who have been designated as
palliative (regardless of stage) by the Regional Health Authority’s assessment
and case management process are provided without charge:
i.
required dietary supplements/meals replacements and all accompanying
supplies;
ii.
dressing supplies, in addition to those currently available without charge
to cancer patients;
iii.
ambulatory infusion pumps and equipment, including cassettes, solutions,
tubing and supplies and other approved pain control delivery technologies;
iv.
intravenous (IV) and hypodermoclysis equipment, including minibag IV
solutions, tubing, cathlons, heparin/saline locks and caps, syringes and
needles;
v.
urinary catheter equipment, including catheter bags, connectors and
catheter trays; and,
Community Care
Section:
Index Ref: 15.8
Page 2
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Palliative Care Supplies and Charges
vi.
incontinence briefs and pads with the exception that in special care homes
and health centers, incontinent briefs and pads are provided without
charge only to individuals who are admitted specifically to those facilities
for end stage palliative purposes or specifically for management of acute
palliative symptoms.
4.
Oxygen Coverage 1
a)
The full cost of approved oxygen and corresponding equipment prescribed by a
physician and required at home, in special-care homes, or in health centres is
covered by Saskatchewan Aids to Independent Living (individuals must be
designated as “end stage” palliative through the Regional Health Authority’s
assessment and case management process); and,
b)
Blood gas and oximetry criteria are waived for those clients designated “end
stage” palliative and considered eligible for additional benefits through the
Regional Health Authority’s assessment and case management process.
5.
Drug Coverage
a)
Physicians have the authority to designate individuals as palliative and therefore
eligible for drug plan coverage for regular formulary and exception drug status
drugs; and
b)
Individuals in the later stages of their illness, for whom care consists primarily of
managing symptoms such as pain, nausea and stress, may be eligible for full
coverage of benefit drugs under the Saskatchewan Prescription Drug Plan. 2
1
Required oxygen in a hospital setting is supplied by the Regional Health Authority.
Drug Plan coverage does not depend on the Regional Health Authority’s designation of the individual as
“palliative,” but rather on the physician’s designation. As well, drug coverage is not restricted to the end stage of the
palliative process.
2
Community Care
Section:
Index Ref: 15.9
Page 1
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Benefits/Payment Policy for Saskatchewan Residents
Out Of Province within Canada
15.9
BENEFITS/PAYMENT POLICY FOR SASKATCHEWAN RESIDENTS OUT
OF PROVINCE WITHIN CANADA
POLICY
1.
The Saskatchewan Ministry of Health will provide out-of-province (OOP) home care
benefits for eligible Saskatchewan residents in other provinces within Canada, as follows:
a)
Home-based services and supplies, and intravenous drugs and supplies, required
for:
i.
acute-care discharge;
ii.
palliative home care for a maximum of three months, until the individual
is eligible for health benefits in their new home province; and,
iii.
short-term OOP vacations (maximum of 30 days/year) accompanied by a
family member, or to visit family members who will provide the client
with support while the client is OOP (services provided during the OOP
vacations may include respite care for the primary caregivers, including
day programs if appropriate).
GUIDELINES
1.
Approval Process
a)
the client or his/her advocate (which may include an OOP or Regional Health
Authority case manager) will request, and receive approval from the
Saskatchewan Ministry of Health before OOP services commences; and,
b)
a case-specific written agreement will be negotiated between the Saskatchewan
Ministry of Health and the OOP agency providing the services prior to the
provision of services, including the following terms and conditions:
i.
identification of the parties of the agreement (i.e., the OOP service agency
and the Saskatchewan Ministry of Health) and the name, permanent
address, sex, birth date and Saskatchewan personal health number of the
client;
ii.
term of the agreement;
iii.
type of services, equipment, supplies, and drugs required by the client as
assessed by the Saskatchewan Ministry of Health and/or the OOP agency,
and the cost of each;
iv.
specific services, equipment, supplies, and drugs that will be covered by
the Saskatchewan Ministry of Health; and,
v.
charges for which the OOP agency will bill the client, if any.
Community Care
Section:
Index Ref: 15.9
Page 2
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Benefits/Payment Policy for Saskatchewan Residents
Out Of Province within Canada
2.
Limitations
a)
Available benefits are subject to the following limitations:
i.
approval for OOP benefits must be applied for and received prior to the
commencement of services (in exceptional cases, and at the Saskatchewan
Ministry of Health’s discretion, retroactive approval may be given);
ii.
daily costs for the OOP home-based “acute care substitution” services
cannot exceed the per diem rate paid in the out-of-province hospital;
iii.
costs for other services covered by this policy must be less than or
comparable to costs for those services in Saskatchewan; and,
b)
fees paid by the client for OOP home-based services and supplies and intravenous
drugs and supplies will be consistent with Saskatchewan provincial policy
regarding fees and supplies (the client will be charged fees by the out-of-province
agency as if the client were receiving services in Saskatchewan).
3.
Administration of the Policy
a)
Requests for OOP services for Saskatchewan residents will be received, reviewed
and negotiated by the Community Care Branch, in consultation with Drug Plan
and Extended Benefits Branch when appropriate. Requests will be approved or
denied based on the preceding policy criteria.
b)
During negotiations, arrangements will be made to link the OOP agency and
client to a case manager in the Saskatchewan Regional Health Authority where
the client normally resides (if a case manager is not already involved), in order to
facilitate the client’s return to Saskatchewan and resumption of services in
Saskatchewan if required.
c)
For exceptional cases, a letter will be provided to the client/or family and to the
client’s Regional Health Authority explaining decisions regarding the approval or
denial of coverage.
4.
Definitions
a)
Home Care Services – services covered by this policy include case
management/assessment, nursing, personal care, respite and related supplies.
Home management (e.g., housework), meals, and home maintenance are not
included.
b)
Acute Care Substitution – acute care substitution services are those services
which home care is providing that might otherwise have to be provided in
hospital, to a person recently discharged from hospital; or services provided by
home care which eliminate the need for hospital care. The client’s care plan will
usually indicate a definite term of acute care.
Community Care
Section:
Index Ref: 15.9
Page 3
Date of Issue:
Home Care Policy
Home Care Client Fees and Charges
September 2006
Revised September
2015
Subject:
Benefits/Payment Policy for Saskatchewan Residents
Out Of Province within Canada
c)
Palliative Care – a client is considered to be requiring palliative care when:
i.
the client has a condition which has been diagnosed by a physician as
terminal with life expectancy of weeks or months (usually not longer than
six (6) months); and,
ii.
active treatment to prolong life is no longer the goal of the treatment and
care of the client.
Appendix A1
Rate for First 10 Units of Service
All clients are charged a flat rate per unit for the first 10 units of chargeable service in the
month. As of October 1, 2015, the unit charge is $7.96 for each unit for the first 10 units.
For Mamawetan Churchill River and Keewatin Yatthé Regional Health Authorities and
Athabasca Health Authority, the client fee is $2.50 per unit of service to a maximum of
$75.00 (or 30 units) per month per client for chargeable services.
Appendix A2
CLIENT FEE INSTRUCTION
Calculation of Client Charges (effective October 1, 2015)
1. There is no fee for services provided by a nurse, physical therapist, or
occupational therapist. There is no fee for services provided to palliative clients
who are assessed as end stage or as requiring acute care management of palliative
symptoms regardless of palliative stage. In addition, there is no fee for personal care
services for up to 14 calendar days for short-term acute clients, including clients with
mental health issues, in order to aid in early discharge from hospital and to avoid or
prevent readmission to hospital, as well as to avoid or prevent imminent admission to
hospital.
2. For chargeable services, all clients pay $7.96 for each unit for the first 10 units in a
month. After 10 units in a month, the client will be charged a unit rate corresponding
to the client's adjusted monthly income. A unit is an hour or a meal.
3. The maximum monthly charge is $79.60 for:
• clients receiving S.A.P. or S.E.S.;
• clients receiving S.I.P. and not receiving a War Veteran's Allowance; and,
• any other client with an adjusted monthly income of $79.60 or less.
4. For all other clients, the maximum charge is the lesser of:
The rate indicated below corresponding to the client’s adjusted monthly income,
or $480 per month.
Appendix A2
Rate after 10 Units of Service
HOME CARE FEE SCHEDULE (Effective October 1, 2015)
Adjusted Monthly
Unit Charge
Maximum
Income*
After 10 Units
Monthly Charge
$0 - $79.60
$0.00
$79.60
$79.61- $99
$1.88
$79.61 - $99
$100 - $149
$2.40
$100 - $149
$150 - $199
$3.08
$150 - $199
$200 - $249
$3.52
$200 - $249
$250 - $299
$4.36
$250 - $299
$300 - $349
$4.84
$300 - $349
$350 - $399
$5.65
$350 - $399
$400 - $449
$6.12
$400 - $449
$450 - $499
$6.92
$450 - $470
$500 - $549
$7.44
$480
$550 - $599
$7.96
$480
$600 + or no subsidy
$8.60
Maximum
Monthly Charge:
$480
*Adjusted monthly income equals total monthly income less total monthly
deductions and exemptions.
Appendix B1
POLICY
Instructions for Calculation of Income Tested Subsidy
GENERAL
The subsidy application is usually administered to the applicant in person by an employee of the
Regional Health Authority’s home care program or the region’s assessment and case
management unit. Only the income of the applicant and spouse (if residing with the applicant)
should be included. In some circumstances, the client may choose to forward the completed
subsidy application to the regional home care program office. If the client is under 18 years of
age, the income of the parents or guardians should be used for the subsidy application.
I.
Annual Income
Net Annual Income - Enter the amount from line 236 of the Canada Revenue Agency
Notice of Assessment for both the applicant and spouse.
II.
Deductions
Total Payable – Enter the amount from line 435 of the Canada Revenue Agency
Notice of Assessment for both the applicant and spouse.
III.
Exemptions
Basic Exemption levels are established periodically for the applicant, spouse, and
dependent children. Effective October 1, 2015, the monthly rates are: (a) $1,529 for
the applicant; (b) $980 for the spouse; (c) $436 for each dependent under 18 years of
age; and (d) $980 for the first dependent child under 18 years of age in a single parent
family. Note that if a single parent claims a spousal exemption for one child, that
child cannot also receive a dependent exemption.
IV.
Calculation of Adjusted Monthly Income
The applicant’s adjusted monthly income is calculated by subtracting the total annual
deductions from total annual income, and dividing the remainder by 12 months to
arrive at the Total Monthly Income. Monthly exemption amounts are then subtracted
from the Total Monthly Income to arrive at the Adjusted Monthly Income.
V.
Declaration
Regional Health Authorities have the authority to require evidence that the applicant's
income declaration is accurate. Be sure that the applicant and spouse read and
understand the declaration before signing.
Appendix B2
Saskatchewan
Home Care Subsidy Application
Calculation of the Income Tested Subsidy
Applicant’s name _________________________ Spouse’s Name_________________________
Date of Birth: Day___ Month___ Year ___
HSN___________
SAP/SES/SIP? Yes____ (full subsidy) No____ If yes, move to Section V
(Enter “0” in AMI and transfer to Procura so full subsidy is captured)
I.
II.
III.
Annual Income:
Annual Income (Line 236)
Spousal Annual Income (Line 236)
Deductions:
Total Payable (Line 435)
Spousal Total Payable (Line 435)
_____________
_____________
1. Total Annual Income_____________
_____________
_____________
2. Total Annual Deductions_____________
Exemptions:
Basic Monthly Exemption
Spousal Monthly Exemption
_____________
_____________
Dependent Monthly Exemptions
_____________
3. Total monthly deductions _____________
Calculation of adjusted monthly income:
Annual Income (enter amount from line 1)
_____________
Less: Total Deductions (enter amount from line 2)
_____________
Equals: Applicable Annual Income
_____________
Applicable Annual Income
divide by 12 months = Total Monthly Income
Less: Total Monthly Exemptions (enter amount from line 3)
_____________
Equals: Adjusted monthly income (AMI)
_____________
(single parent can claim spousal deduction for one child)
IV.
V.
Declaration: I hereby declare that, to the best of my knowledge, the information given
in this application is true and complete. I understand that I may be required to provide
records to verify the contents of this application.
_________________________
Signature of applicant
_________________________
Signature of spouse
_________________________
Signature of regional employee
completing the application
Date______/____________/_______
Day
Month
Year
Appendix C - Special Support Program
Effective July 1st, 2002, the $850 semi-annual deductible was eliminated. Families who
previously relied on the $850 deductible may apply to the Drug Plan Special Support
Program for assistance with the cost of their prescriptions. The Special Support program
is designed to assist those with benefit drug costs that are high in relation to their income;
This program establishes a threshold (deductible) and/or copayment percentage based on
adjusted total family income and total actual family drug costs.
Adjusted total family income is based on 3.4% of total income (Line 150) less $3500 for
each dependent under 18 years of age.
Deductible periods are semi-annual (January – June; July – December)
The Special Support Program does not include individuals/families who are covered
under federal government programs, such as the federal Non-Insured Health Benefits
Program or Veteran Affairs Canada.
Prescription drugs listed on the Saskatchewan Formulary and approved under Exception
Drug Status.
Application forms are available:
•
•
•
online on the Government website
at your pharmacy
by contacting the Drug Plan and Extended Benefits Branch toll free at 1800-667-7581 or in Regina at 787-3317
Side A – CRA Application/Consent One-Time Application Form
To apply for the Special Support Program, complete and sign an application and consent
form. By using Side A the applicant authorizes the release of income information from
Canada Revenue Agency to the Drug Plan and Extended Benefits Branch to determine
eligibility and reassess coverage each year.
Side B – Annual Application
To apply for Special Support Program, this form can be completed and submitted with
income information each year.
Appendix D – Seniors Drug Plan
Effective July 1, 2008, an income test component was introduced to the Seniors’ Drug
Plan.
Individuals are eligible if:
•
They are a Saskatchewan resident 65 years of age and older;
•
They have a reported net income (Line 236) that is less than the provincial age
credit.
Individuals must submit a complete application (Form A). The program ensures that
eligible Saskatchewan seniors pay $20* per prescription for drugs listed in the
Saskatchewan Formulary or approved under Exception Drug Status.
The Seniors’ Drug Plan does not include seniors who are covered under federal
government programs, such as the federal Non-Insured Health Benefits Program or
Veteran Affairs Canada.
Seniors with Guaranteed Income Supplement (G.I.S.) or Seniors’ Income Plan (S.I.P.)
have a $200 or $100 semi-annual deductible. Individual prescriptions under these two
programs are $20.
Seniors with Special Support coverage will pay the lesser of the Special Support
co-payment or the $20 per prescription.
Clients with the following coverage WILL NOT be affected and will continue to be
covered in the same manner as in the past:
•
•
•
Saskatchewan Aids to Independent Living (SAIL)
Palliative Care
Seniors receiving S.I.P. and residing in a long term facility
Which prescriptions are covered?
Prescription drugs listed on the Saskatchewan Formulary and approved under Exception
Drug Status.
How does someone apply?
Application forms are available:
•
online at www.health.gov.sk.ca/seniors-prescription-drug-plan
•
at your pharmacy
•
by contacting the Drug Plan and Extended Benefits Branch toll free at 1-800-6677581 or in Regina at 787-3317
Form A – CRA Application/Consent One-Time Application Form
To apply for the Seniors’ Drug Plan program, each eligible senior must complete and
sign an application and consent form. By using Form A, the applicant authorizes the
release of income information from Canada Revenue Agency to the Drug Plan and
Extended Benefits Branch to determine eligibility and reassess coverage each year.
Form B – Annual Application
To apply for the Seniors Drug Plan, this form can be completed and submitted with
income information each year.
Appendix E
Income Assistance Programs: eligibility to the income assistance programs are
determined by the Ministry of Social Services.
Saskatchewan Assistance Plan covers benefit prescription drug costs: (SAP) (Plan 1,2,3)
•
•
$2.00 for prescriptions for Plan 1
$0.00 for prescriptions for Plan II, Plan III and children under 18 years of age.
Family Health Benefits covers benefit prescription drug costs:
Adults have a $100 semi-annual deductible; once deductible is reached, the copayment is
reduced to 35% of the actual cost;
Children under 18 years of age pay $0.00 for their prescriptions.
Saskatchewan Assured Income Disability (SAID) has similar coverage as SAP.
Seniors receiving the federal Guaranteed Income Supplement (GIS).
$100 (if in a nursing home) and $200 semi-annual deductible; once the deductible is
reached, the copayment is reduced to 35% of the actual cost;
Seniors receiving the provincial Saskatchewan Income Plan (SIP)
$100 semi-annual deductible; once the deductible is reached, the copayment is reduced to
35% of the actual cost.
Appendix F
Drug Plan programs: must meet medical criteria to be eligible.
•
Saskatchewan Aids to Independent Living (Chronic Renal Disease, Cystic Fibrosis,
Paraplegics)
•
Palliative Care
Community Care Section: 1
Index Ref: 16.0
Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Quality Improvement Program
16.0
QUALITY IMPROVEMENT PROGRAM
POLICY
1.
The Regional Health Authority shall deliver optimal client care that is goal-directed,
within the resources available. This may be done through the development and
implementation of a quality improvement program.
2.
Each Regional Health Authority shall develop and implement an effective mechanism for
evaluating the home care program.
3.
This guide was developed to:
a)
improve each Regional Health Authority’s home care program; and,
b)
ensure that the objectives of the Saskatchewan Home Care Program are being
met.
GUIDELINES
1.
The development of a quality improvement program should be done through the Quality
Improvement Coordinator of the Regional Health Authority. The Regional Health
Authority board, on advice from its management, professional and other staff, may
determine the overall plan for the quality improvement program. The goals of each home
care service’s quality improvement program should be consistent with the overall goals
of the program.
2.
Within the quality improvement program there should be a:
a)
system to evaluate human and financial resources;
b)
system to identify actual and potential problems;
c)
mechanism for assessment and investigation of problems;
d)
process to monitor activities to ensure that the desired results have been achieved
and are sustained;
e)
system for documenting the effectiveness of the plan in improving client care;
and,
f)
process to measure outcomes of the home care service as they relate to the
philosophy, mission and goals of the Regional Health Authority.
Community Care Section: 1
Index Ref: 16.0
Page 2
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Quality Improvement Program
3.
Quality improvement activities should:
a)
manage human resources;
b)
manage risk and incident reporting;
c)
review program utilization;
d)
review processes; and,
e)
educate staff and volunteers in quality improvement.
4.
The effectiveness of the home care quality improvement program should be reviewed on
an annual basis. The review should identify components of the program that should be
expanded, altered or deleted.
5.
The quality improvement program evaluation should ensure that it is ongoing,
comprehensive and effective in improving client care as well as being cost-effective and
program-efficient.
Community Care Section: 2
Index Ref: 16.1
Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Standards
16.1
ASSESSMENT AND CARE COORDINATION STANDARDS
16.1.1
Assessment and Care Coordination Structure Standards are determined in the
following areas:
General Structure of the System
Structures for Initial Screening, Providing Information and Referring
Approving Assessment Tool
Assessment/Care Planning
Confidentiality Procedures
Appeal Mechanisms
Safe Working Conditions
Performance Reviews
1.
2.
3.
4.
5.
6.
7.
8.
16.1.2
Assessment and Care Coordination Process Standards are determined in the following
areas:
1.
Client Centred Process
2.
Screening, Information Provision and Referral
3.
Assessment Requirements
4.
Assessment Rights
5.
Assessment Approach
6.
Assessment Interview
7.
Assessment Summary
8.
Consultations
9.
Admissions
10.
Care Planning
11.
Ongoing Care Planning and Coordination
12.
Re-assessment / Revision of Care Plan
13.
Discharge
14.
Re-admission
15.
Appeal Process
16.
Consents
16.1.3
Assessment and Care Coordination Outcome Standards are determined in the
following areas:
1.
Screening and Referral Outcomes
2.
Outcomes of the Assessment and Care Coordination Process
3.
Appeal Outcomes
Community Care Section: 3
Index Ref: 16.1.1 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Structure Standards
16.1.1
ASSESSMENT AND CARE COORDINATION: STRUCTURE STANDARDS
Standard
Measure/Indicator
1. General Structure of the System
The assessment and care coordination system is Factors reflected in
organized to balance:
rationale for system
• home care program objectives and priorities; design.
• the unique needs of the Regional Health
Authority;
• the quality of assessment and care
coordination; and,
• the cost of assessment and care coordination.
Regional Health Authorities re-evaluate their
Evidence of periodic
assessment and care coordination system
re-evaluation.
periodically to ensure that the structures in place
continue to be appropriate.
2. Structures for Initial Screening, Providing Information and Referring
Regional Health Authorities have a defined
Existence of written
screening process to ensure appropriate
criteria, policies and
responses and response time to inquiries, and to procedures.
prevent unnecessary assessments.
Employees handling
inquiries can define
The screening process includes:
criteria, policies and
• criteria for identifying whether inquiries
screening procedures.
should lead to provision of information,
referral or assessment;
• criteria for identifying urgent situations;
• a policy on when and how to document
inquiries;
• procedures for handling inquiries; and,
• response time for handling inquiries.
Regional Health Authorities assign
Responsibility for
responsibilities for screening to staff.
screening is included in job
description for staff.
Regional Health Authorities train staff for
Screening is included in
screening and referral responsibilities.
Regional Health Authority
training for staff.
Methods
Review of system
organization.
Review of system
organization.
Interview staff.
Examine documents.
Interview staff.
Examine job
descriptions.
Interview staff.
Community Care Section: 3
Index Ref: 16.1.1.Page 3
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Structure Standards
Standard
Measure/Indicator
The Regional Health Authority home care
Existence of written
program has procedures for providing immediate procedures.
service in urgent situations.
Staff are aware of
procedures.
3. Approving Assessment Tool
The Regional Health Authority ensures the use
of the assessment tool as approved by the
Saskatchewan Ministry of Health.
4. Assessment/Care Planning
The Regional Health Authority home care
program has procedures to ensure that decisions
are appropriate to the home care client’s needs.
The Regional Health Authority home care
program has procedures for changing care plans.
5. Confidentiality Procedures
Regional Health Authorities have procedures to
ensure that all information concerning clients is
kept confidential.
Regional Health Authorities have procedures to
ensure that all client files in the office and in the
homes of assessment and care coordination staff
are kept secure.
6. Appeal Mechanisms
The Regional Health Authority home care
program has procedures in place to ensure that
clients may appeal decisions.
7. Safe Working Conditions
Methods
Examine Regional
Health Authority
procedures.
Interview staff.
Evidence of approval.
Review documentation.
Existence of procedures.
Interview staff
members.
Review procedures.
Interview staff.
Existence of procedures.
Evidence of policies and
procedures in compliance
with Heath Information
Protection Act.
Evidence of policies and
procedures in compliance
with Health Information
Protection Act.
Interview staff.
Evidence of an appeal
procedure.
Review procedure.
Interview staff.
Community Care Section: 3
Index Ref: 16.1.1.Page 3
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Structure Standards
Standard
Regional Health Authorities must have policies
and procedures to ensure working conditions are
as safe as possible in the office and in the field.
8. Performance Review
Regional Health Authorities must ensure that
assessment and care coordination personnel
receive annual performance reviews.
Performance reviews should determine whether
staff are able to; meet responsibilities as defined
in their job descriptions; and set realistic goals
and achieve them.
Measure/Indicator
Existence of written
policies and procedures.
Methods
Review policies and
procedures
Evidence that performance Interview Staff.
appraisals have been done.
Community Care Section: 4
Index Ref: 16.1.2 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
16.1.2
ASSESSMENT AND CARE COORDINATION: PROCESS STANDARDS
Standard
Measure/Indicator
1. Client Centred Process
Clients are encouraged to participate in all
Evidence of client input.
phases of the assessment and care coordination
process, including defining needs, setting goals,
developing and revising the care plan.
2. Screening, Information Provision and Referral
Regional Health Authorities screen all applicants Evidence of screening
prior to assessing them.
procedures.
The screening process includes information on:
• types of problem(s);
• relevance of home care; and,
• urgency of need.
The screening process includes providing
information or arranging service from another
agency or program when a request is not
appropriate to home care.
3. Assessment Requirements
Regional Health Authorities assess all applicants
prior to providing any primary service other than
assessment and care coordination to them (the
only exceptions are urgent situations and
situations identified in Policy 6.2).
Each Regional Health Authority develops
policies and procedures to provide an assessment
in urgent situations.
(Policy 6.2)
Methods
Review of client
records.
Observe process.
Evidence in screening
records.
Review assessments
resulting in no service.
Review of screening
procedures.
Review of screening
and referral records.
Evidence in screening and
referral records.
Review of screening
and referral records.
Evidence of assessments
conducted when required
by policy.
Review of client
records.
Evidence that the
Review of client
Regional Health Authority records.
has policy and procedures
in place.
Records indicate that
assessments are conducted
within a reasonable time.
Community Care Section: 4
Index Ref: 16.1.2 Page 2
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
Measure/Indicator
Regional Health Authorities conduct a shortened Evidence of shortened
assessment only when appropriate (Policy 6.2).
assessment when
appropriate.
4. Assessment Rights
Assessors inform all applicants or their
advocates of the following rights prior to the
assessment interview. (Policy 6.3)
The right to:
• have their views and desires recorded during
the assessment interview;
• choose whether a third party is present
during the assessment interview;
• be present if an advocate or translator is
required for the assessment interview;
• refuse to answer any question;
• refuse to undergo any or all of the
assessment;
• view the assessment record on request;
• be consulted before the views of third parties
are sought, and to approve, restrict, or deny
such access; and,
• be fully informed of the program’s service
decisions and to participate in care planning.
Assessor ensures that the applicant or advocate
understands the possible effects of exercising the
right to not participate fully in the assessment
and care coordination process.
5. Assessment Approach
The assessor conducts the assessment in a
manner that is meaningful, relevant and
acceptable to the client.
Methods
Review of client
records.
Evidence that assessors
inform clients.
Evidence that clients are
aware of their rights.
Observation of
assessment.
Client interviews or
questionnaires.
Supervisor interviews
or questionnaires.
Evidence that assessors
inform clients.
Evidence that applicants
who refuse to participate
are aware of the
implications.
Observation of
assessment.
Client interview or
questionnaire.
Client feedback about the
quality and relevance of
the assessment.
Interview clients.
Community Care Section: 4
Index Ref: 16.1.2 Page 3
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
The assessor is objective when interviewing the
client.
6. Assessment Interview
The assessor uses SCIP or MDS-Home Care
assessment tool.
The assessor conducts the assessment in the
applicant’s home, if possible.
The assessor obtains and records all details about
the following factors that may be relevant to
preparing a care plan:
• the client’s physical health;
• the client’s mental health;
• the client’s home environment;
• the client’s support system;
• the client’s functional needs; and,
• any other factors that have a bearing on
unmet needs for service.
The assessor obtains and records the client’s
views of his or her needs and what the goals for
service should be.
The assessor obtains and records the views of
other persons consulted.
Measure/Indicator
Evidence questions are
asked in a neutral manner.
Evidence client’s
responses are accurately
recorded.
Evidence of inappropriate
or unnecessary subjective
comments on the
assessment record.
Methods
Observation of
assessment process,
and/or interview clients.
Review of client
records.
Assessments are recorded
on appropriate forms.
Rationale for assessments
done elsewhere.
Completeness of
assessment records in each
of these areas.
Review of client
records.
Review of client
records.
Review of client
records.
Evidence in assessment
records.
Review of client
records.
Evidence in assessment
records.
Review of client
records.
Community Care Section: 4
Index Ref: 16.1.2 Page 4
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
7. Assessment Summary
The assessor records his/her own summary of the
client’s situation, including:
• the needs and strengths of the client, the
potential for self care, learning and
motivation;
• the needs and strengths of the family and
informal support system, and their current
and potential role in teaching, motivating
and caring for the client; and,
• the need for assistance from home care
and/or other agencies.
The assessor’s summary is based on objective
evidence from the interview, observation of the
home situation, and when appropriate from other
sources (e.g. physician’s referral).
The assessor records his/her own
recommendation of what the short term and long
term goals for service should be. Goals should
be as specific as possible and stated in
measurable terms.
8. Consultations
Regional Health Authority staff obtains the
client’s specific consent to consult with other
persons concerning the client’s needs.
Regional Health Authority staff consults with the
main supporter whenever his/her support is or
could be an important factor in the client’s care.
Measure/Indicator
Methods
Evidence in assessment
records.
Review of client
records.
Evidence in assessment
records.
Review of client
records.
Evidence in assessment
records.
Review of client
records.
Consent is noted on the
assessment and other client
records.
Supporter interview
sections are complete on
the assessment tool.
Other consultations with
supporter are noted.
Evidence that decisions are
based on knowledge of
support.
Review of client
records.
Review of client
records.
Community Care Section: 4
Index Ref: 16.1.2 Page 5
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
Regional Health Authority staff may consult
with other care providers when their support is
an important factor in the client’s care.
Regional Health Authority staff may consult
with the client’s physician whenever the
physician’s input may help to define the client’s
needs.
9. Admissions
All admission, discharge and re-admission
decisions, except in urgent situations where an
immediate decision must be made, are made by
an assessment and care coordination staff
member and approved by the process established
by the Regional Health Authority.
If the assessor has serious reservations about the
safety and/or benefits of providing services to a
client, the assessor considers as part of the
decision making process:
• whether the applicant will be better off with
or without the service that can be offered;
and,
• the right of the individual to knowingly
accept risks.
Measure/Indicator
Supporter interview
sections are complete on
the assessment tool.
Other consultations with
supporter are noted.
Evidence that decisions are
based on knowledge of
support.
Consultations noted on
assessment and other client
records.
Methods
Review of client
records.
Evidence assessment and
care coordination staff
makes the decisions except
in urgent situations, and
approvals occur.
Review of client
records.
Interview assessment
and care coordination
staff.
Evidence that difficult
situations are assessed and
considered rather than
screened out.
Evidence of factors
considered in difficult
cases.
Review of client
records.
Interview assessment
staff.
Review of client
records.
Community Care Section: 4
Index Ref: 16.1.2 Page 6
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
When an applicant is admitted to the program
despite serious reservations about the person’s
safety between service visits, the assessment
process must:
• set the conditions for the admission;
• ensure that the conditions for the admission
are clearly explained to the applicant and to
involved family members and supporters;
• consider entering into a written agreement
with the applicant; and,
• ensure ongoing documentation of client
needs and circumstances, factors affecting
service arrangements, and all discussions and
agreements with the client and his/her
supporters regarding service arrangements.
No applicant is automatically refused admission
to the program because he or she is unwilling to
cooperate fully in the assessment process. The
assessor decides each case based on available
information.
10. Care Planning
Except in urgent situations, service begins after
the development of the care plan.
The assessor reviews all assessment information
and seeks other information if required to
develop the care plan.
During the care planning process consultation
occurs as required.
Measure/Indicator
Evidence that conditions
are established and agreed
to when needed.
Evidence of complete
documentation.
Evidence of monthly case
reviews.
Methods
Review of records.
Evidence that efforts were
made to accommodate
clients who refused to
cooperate.
Review of client
records.
Evidence service is not
normally started until a
care plan is developed.
Evidence of review.
Evidence that the care plan
is based on adequate
information.
Evidence of consultation
as needed.
Interview assessor,
client and/or supporters.
Review of records.
Observation of
assessment process.
Review of records.
Interview assessors.
Community Care Section: 4
Index Ref: 16.1.2 Page 7
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
All alternatives to meet identified needs are
explored:
• teaching and self care;
• mobilizing family and friends;
• volunteer services;
• home care services;
• referrals to other agencies; and,
• providing support and assistance to families
or friends providing care.
The goals of service are defined and specified in
the care plan. The goals should be as specific as
possible so that their accomplishment can be
assessed.
The type and frequency of service to be provided
are defined and specified in the care plan.
All major changes to the care plan are approved
by the case manager and dated.
The client is fully informed of and has the
opportunity to help formulate and comment on
all goals and service decisions.
Measure/Indicator
Methods
Evidence of consideration. Observation of process.
Evidence of appropriate
Review records.
use of resources.
Goals are defined in the
plan.
Goals are as specific as
possible.
Type and frequency of
service are recorded in the
care plan.
Evidence that changes are
approved.
Evidence that information
is provided.
Evidence that clients are
knowledgeable.
Evidence that coordination
has been assigned.
A person is assigned to coordinate the care plan
and establish reporting relationships with care
providers.
11. Ongoing Care Planning and Coordination
There is ongoing communication between the
Notation in client records.
home care program and the client, family, and
supporters regarding the client’s needs and
whether the services provided are meeting those
needs and fulfilling the goals specified in the
care plan.
Individuals and agencies involved in assisting
Notation in client records.
the client are consulted when changes to the
client’s needs or services occur that may affect
the role of the individuals or agencies.
Review records.
Review records.
Review client records.
Client interview or
questionnaire.
Review client records.
Review client records.
Review client records.
Community Care Section: 4
Index Ref: 16.1.2 Page 8
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
Case conferences with family, care providers and
involved staff are held whenever significant
changes to the client’s needs or services occur.
Case conferences may include staff from other
agencies (who are providing care to the client),
particularly when the role of the agency is
affected by a change in the client’s needs or
service.
12. Re-assessment/Revision of Care Plan
A thorough case review or a re-assessment of
every case is conducted within 90 days of the
client’s admission and at least once annually
thereafter (Policy 8.4).
Additional case reviews or re-assessments are
conducted as warranted by the condition or
situation of the client.
A thorough case review includes compiling and
examining all relevant information from the
client’s file and people involved in providing
care to the client.
A thorough case review evaluates identified
changes to the client’s needs and/or support in
relation to the goals of the care plan and the
services provided to meet those goals.
Before conducting a reassessment, the assessor
reviews the relevant information selected from
the client’s file.
The assessor uses an approved assessment tool
and follows the relevant re-assessment
instructions.
Measure/Indicator
Notation of case
conferences in client
records.
Notation in client records.
Methods
Review client records.
Existence of reviews.
Review client records.
Evidence of additional
reviews in difficult
situations.
Evidence client’s files are
thoroughly reviewed.
Review client records.
Evidence goals and
services are adjusted in
response to change.
Review case review
records.
Evidence that these items
are reviewed.
Review client records.
Review case review
records.
Review client records.
Interview with
assessors. Observation
of process.
Reassessments are
Review client records.
recorded on appropriate
Interview assessor or
forms.
supervisors.
Evidence assessors follow Observe
re-assessment instructions. re-assessments.
Community Care Section: 4
Index Ref: 16.1.2 Page 9
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
13. Discharge
Clients are discharged when service is no longer
necessary or appropriate.
The determination that service is no longer
necessary or appropriate is based on a case
review or a re-assessment.
Any client who has not received service for 24
consecutive months is discharged from the
program (Policy 8.5) unless residing in a
personal care home. (12 months)
Measure/Indicator
Evidence that inactive
clients no longer have an
ongoing need for home
care.
Evidence of basis for
discharge decisions.
Methods
Review client records.
Review client records.
Clients who have not
Review client records.
received service in
previous 12 months and
are not living in a personal
care home.
The home care program is responsible for taking Evidence the home care
Review client records.
reasonable measures to ensure that appropriate
program knows clients
plans and referrals are established for the care of with substantial needs will
clients who have substantial need for assistance be cared for upon
when they are discharged.
discharge.
14. Re-admission
The decision to re-admit a discharged client is
Evidence of basis for
Review client records.
based on:
re-admission decisions.
• a progress summary or completion of the
standard assessment tool (Policy 8.6).
15. Appeal Process
The Regional Health Authority has a policy that Evidence procedures are
Review any records of
outlines the appeal process (Policy 6.6):
followed when appeals
appeals.
arise.
Interview staff.
• the client’s first level of appeal is to the
respective Program Manager; and,
• the client’s second level of appeal is through
a Regional Appeals Committee as
determined by the Regional Health
Authority.
The client and/or the family may request the
Evidence that the QCC
Review appeal records.
Quality of Care Coordinator (QCC) to assist
assisted the client and/or
Interview client and/or
them through the stages of appeal.
the family as required.
family.
Community Care Section: 4
Index Ref: 16.1.2Page 10
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Process Standards
Standard
16. Consents
The Regional Health Authority obtains and
documents informed written or verbal consent
from the client before releasing information to
anyone other than Regional Health Authority
staff and Saskatchewan Health personnel (Policy
4.1).
Informed verbal consent requires that the client
has full knowledge of the specific actions for
which the consent has been requested.
Informed written consent requires:
• client to have full knowledge of the specific
action;
• the specific actions are identified in the
consent document; and,
• the consent document is signed by the client
and certified by a witness.
Measure/Indicator
Methods
Assessor documentation or Review client records.
written consent for any
release of confidential
information.
Evidence client has been
given full knowledge.
Evidence client has been
given full knowledge.
Consent document
complete.
Observation of consent
process.
Review of consent
documents.
Observation of consent
process.
Review consent
documents.
Community Care Section: 5
Index Ref: 16.1.3 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Outcome Standards
16.1.3
ASSESSMENT AND CARE COORDINATION: OUTCOME STANDARDS
Standard
Measure/Indicator
Methods
1. Screening and Referral Outcomes
Applicants are always assessed and considered
Evidence that difficult
Review screening
for admission when a need for home care service cases are not screened out. procedures.
is indicated.
Review assessment
records.
Review client records.
Interview staff.
Applicants and clients who need services other
Evidence that both persons Review screening
than home care services are given appropriate
who inquire and existing
procedures.
advice and/or assistance to obtain them.
clients receive appropriate Review client records.
advice or referrals.
Interview staff.
Interview clients and
supporters (obtain client
consent).
2. Outcomes of the Assessment and Care Coordination Process
All persons admitted to the program meet the
Evidence in assessment
Review client records.
criteria for provision of services specified as
record.
follows:
• the person requires care and support while
living in the community; and,
• the services to be provided do not necessarily
replace the assistance provided by the family
or community.
Community Care Section: 5
Index Ref: 16.1.3 Page 2
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Outcome Standards
Standard
All persons admitted to the program require
services for the purpose of:
• determining a person’s needs and developing
appropriate plans for care;
• improving a person’s ability to function
independently by teaching self care;
• delaying or preventing the functional
deterioration of a person;
• providing needed assistance and relief to the
family and others who are providing care to a
person;
• assisting a person with a disability to
function as independently as possible;
• delaying or eliminating the need for a
person’s admission to a special-care home or
other care-giving institution;
• maintaining a person in the community
pending placement in a special-care home or
other care-giving institution;
• allowing a terminally ill person to remain at
home as long as possible; or,
• permitting earlier discharge of a person from
hospital or reducing the frequency of
re-admissions.
All requests for home care services are handled
without undue delay according to the urgency
rating and response time policy.
Measure/Indicator
Evidence in assessment
record and care plan.
Methods
Review client records.
Time from initial contact
to initiation of service is
minimal given available
resources. Urgent
situations are handled
immediately.
Review client records.
Community Care Section: 5
Index Ref: 16.1.3 Page 3
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Assessment and Care Coordination Outcome Standards
Standard
All care plans are appropriate to the needs of the
individual client and maximize the independence
and autonomy of the client in accordance with
the purpose, philosophy and objectives of the
home care program.
Clients and their families/supporters feel they
have adequate influence on care decisions that
affect their lives.
3. Appeal Outcomes
Clients appealing decisions believe that appeals
are conducted as fairly as possible.
Measure/Indicator
Evidence that care plans
meet current needs.
Evidence that the care
provided promotes
independence, and does
not unnecessarily replace
informal support.
Evidence that informal
support is mobilized and
supported.
Evidence of client
satisfaction.
Methods
Review client records.
Interview clients and
supporters.
No evidence of justifiable Review of client
client complaints about the complaints about appeal
appeal process.
process.
Community Care Section: 6
Index Ref: 16.2
Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Nursing Service Standards
16.2
NURSING SERVICE STANDARDS
16.2.1
Nursing Service Structure Standards are determined in the following areas:
Philosophy, Goals and Objectives
Organization of the Nursing Service
Scope of Nursing Service
Qualifications of Nurses
Special Nursing Procedures and Nursing Procedures by Transfer of Medical
Functions
Nursing Supplies and Equipment
Resource Material
Safe Working Conditions
1.
2.
3.
4.
5.
6.
7.
8.
16.2.2
Nursing Service Process Standards are determined in the following areas:
1.
Service Guidelines
2.
Nursing Process
3.
Records
4.
Confidentiality
5.
Nursing Decisions
6.
Supervision of Nursing Staff
7.
Personal Care
8.
Orientation
9.
Staff Development
10.
Performance Appraisals
11.
Safe Working Conditions
16.2.3
Nursing Service Outcome Standards are determined in the following areas:
1.
Client Care
Community Care Section: 7
Index Ref: 16.2.1 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Nursing Service Structure Standards
16.2.1
NURSING SERVICE: STRUCTURE STANDARDS
Standard
1. Philosophy, Goals and Objectives
The Regional Health Authority should have
clearly stated philosophy, goals and objectives
for the provision of nursing services that are
consistent with those outlined in the
Saskatchewan Ministry of Health Home Care
Policy Manual (Policy 1.1, 1.1.1. & 1.1.2).
2. Organization of the Nursing Service
The nursing service should be organized to
balance the following considerations:
• home care program objectives and priorities;
• home care nursing needs of the Regional
Health Authority;
• service provided by other health agencies in
the Regional Health Authority;
• quality of nursing care;
• cost of nursing service;
• appropriate use of nursing staff to ensure
competency; and,
• need to ensure and promote team effort.
Authorities should evaluate the organization of
the nursing service annually to ensure that the
structures in place continue to be appropriate.
3. Scope of Nursing Service
Regional Health Authorities should provide
policies and procedures to nursing personnel with
clear direction about the scope and limitations of
their functions and responsibilities for client care
(Policy 12.2).
Measure/Indicator
Written philosophy, goals
and objectives are clear
and consistent with those
included in the
Saskatchewan Ministry of
Health Home Care Policy
Manual.
Method
Review document.
Interview staff.
Factors are reflected in the Review the
rationale for system
organization of the
design.
system.
Interview staff.
Evidence of annual
evaluation.
Review system
organization.
Interview staff.
Existence of written
policies and procedures
that reflect the Regional
Health Authority’s
practice.
Review policies and
procedures.
Interview staff.
Community Care Section: 7
Index Ref: 16.2.1 Page 2
Date of Issue:
Home Care Policy
Quality Monitoring and Improvement
September 2006
Updated September
2009
Subject:
Nursing Service Standards
Standard
Measure/Indicator
Method
4. Qualifications of Nurses
Each nurse employed/contracted in the home care Evidence of current
Review documentation.
program must possess current practicing
practicing registration for
registration with the Saskatchewan Registered
each nurse.
Nurses Association, Registered Psychiatric
Nurses Association of Saskatchewan or
Saskatchewan Association of Licensed Practical
Nurses
(Policy 14.4).
5. Special Nursing Procedures and Nursing Procedures by Transfer of Medical Functions
Regional Health Authorities must have specific
Existence of specific
Review specific
policies and procedures for Special Nursing
written policies and
policies and procedures.
Procedures and Nursing Procedures by Transfer procedures for Special
of Medical Functions prior to their
Nursing Procedures and
implementation (Policy 14.2 and 14.3).
Nursing Procedures by
Transfer of Medical
Functions.
6. Nursing Supplies and Equipment
Regional Health Authorities should provide
Inventory of available
Review inventory.
nursing personnel with supplies and equipment
supplies and equipment
Interview staff.
necessary to perform nursing duties.
and their distribution.
Equipment provided to nursing personnel must
Existence of a system for Review system.
be properly maintained, clean and safe for use.
cleaning, repairing and
maintaining equipment.
The Regional Health Authority will provide
Existence of written
Review policies and
without charge to home care clients, the nursing policies and procedures
procedures.
supplies outlined in Policy 15.5.
that reflect the Regional
Health Authority’s
practice.
7. Resource Material
Nursing personnel have access to resource
Existence of resource
Review resource
material appropriate to the scope of nursing
material.
material.
service.
Interview staff.
8. Safe Working Conditions
Regional Health Authorities must have policies
Existence of written
Review policies and
and procedures to ensure working conditions are policies and procedures.
procedures.
as safe as possible in the office and in the field.
Community Care Section: 7
Index Ref: 16.2.1 Page 3
Date of Issue:
Home Care Policy
Quality Monitoring and Improvement
Subject:
Nursing Service Standards
September 2006
Updated September
2009
Community Care Section: 8
Index Ref: 16.2.2 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Nursing Service Process Standards
16.2.2
NURSING SERVICE: PROCESS STANDARDS
Standard
1. Service Guidelines
Nursing service must be provided in accordance
with the purpose, philosophy and objectives of
the home care program.
2. Nursing Process
Home care nurses must follow established
nursing practice.
3. Records
Home care nurses must initiate, maintain and
update nursing records for all clients receiving
nursing care.
4. Confidentiality
Information in a client’s nursing record must be
kept confidential. Nursing records that are
maintained outside of the office are kept in a
manner that ensures confidentiality.
5. Nursing Decisions
The staff member responsible for the nursing
service must have input for all decisions that
directly or indirectly affect the nursing service.
Measure/Indicator
Evidence that service
provided relates to
purpose, philosophy and
objectives.
Method
Review of client record.
Evidence of data about the Review of client record.
client’s health status is on
record.
Existence of a care plan
with nursing diagnoses,
care goals and
interventions.
Evidence that nursing
actions have been based on
the plan.
Evidence of systematic
re-evaluation.
Evidence of records on all
nursing clients.
Review of client record.
Evidence of policies and
Review procedures.
procedures in compliance
with Health Information
Protection Act.
Evidence confidentiality is
maintained.
Evidence of appropriate
involvement.
Interview senior staff.
Community Care Section: 8
Index Ref: 16.2.2 Page 2
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Nursing Service Process Standards
Standard
6. Supervision of Nursing Staff
Regional Health Authorities must ensure that
there is supervision for all nursing staff.
7. Personal Care
Regional Health Authorities must ensure that
Home Care Aides/Continuing Care Assistants
providing personal care are effectively
supervised by a Registered Nurse, Registered
Psychiatric Nurse or a Licensed Practical Nurse.
(Policy 11.2.4)
8. Orientation
Regional Health Authorities should provide
orientation for nursing personnel.
9. Staff Development
Measure/Indicator
Method
Evidence of direct
supervision and indirect
supervision on an ongoing
basis.
Interview staff.
Review supervision
arrangement.
Evidence assigned tasks
are appropriate.
Evidence that supervision
is provided by the
appropriate person.
Interview staff.
Review work
assignments.
Review policies on
supervision.
Review documentation.
Evidence of appropriate
orientation is provided.
Evidence of the content of
the orientation.
Interview staff.
Review orientation
procedure and
documentation.
Community Care Section: 8
Index Ref: 16.2.2 Page 3
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Nursing Service Process Standards
Standard
Regional Health Authorities should provide
ongoing staff development for all nursing
personnel. Staff development should respond to
the needs of the staff.
10. Performance Reviews
Regional Health Authorities must ensure that
nursing personnel receive annual performance
reviews. Performance reviews should determine
whether staff are able to:
practice nursing in accordance with the
Saskatchewan Registered Nurses’ Association,
the Registered Psychiatric Nurses’ Association
of Saskatchewan or the Saskatchewan
Association of Licensed Practical Nurses nursing
standards and competencies, and scope of
practice;
meet responsibilities as defined in their job
descriptions; and set realistic goals and achieve
them.
11. Safe Working Conditions
The staff member responsible for the nursing
services must ensure that nursing personnel
adhere to the policies and procedures for safe
working conditions.
Measure/Indicator
Evidence staff
development is provided.
Evidence staff
development is appropriate
to staff needs.
Method
Interview Staff.
Review orientation
procedure and
documentation.
Evidence that performance Interview staff.
appraisals have been done.
Evidence that staff adhere Interview staff.
to policies and procedures.
Community Care Section: 8
Index Ref: 16.2.2 Page 4
Date of Issue:
Home Care Policy
Quality Improvement Program
Subject:
Nursing Service Process Standards
September 2006
Revised September
2015
Community Care Section: 9
Index Ref: 16.2.3 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Nursing Service Outcome Standards
16.2.3
NURSING SERVICE: OUTCOME STANDARDS
Standard
1. Client Care
The nursing assessment and care planning
process ensures that nursing care provided is
appropriate to the needs of the individual and/or
family.
The nursing services provided to each client
contribute to accomplishing the mutually agreed
upon goals established in the care plan.
Clients and their families/supporters are full
participants in the nursing assessment and care
planning process.
Measure/Indicator
Method
Evidence that the care plan Review client record.
is appropriate to the needs Client questionnaire or
of the client.
interview.
Evidence that nursing
services contribute to the
identified goals.
Evidence of
client/supporter input.
Review client record.
Review goals and care
plan.
Review client record.
Interview client.
Community Care Section: 10
Index Ref: 16.3
Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Homemaking Service Standards
16.3
HOMEMAKING SERVICE STANDARDS
16.3.1
1.
2.
3.
4.
5.
6.
7.
8.
Homemaking Service Structure Standards are determined in the following areas:
Goals and Objectives
Organization of the Service
2.1
Organization of Care Providers
2.2
Service to Family Members
Scope and Limitations of Service
Job Descriptions
Training
5.1
Training Policy
5.2
Exemptions From Training
Supervision
Confidentiality
Safe Working Conditions
3.
4.
Homemaking Process Standards are determined in the following areas:
Orientation, Training and Staff Development
1.1
Orientation
1.2
Training
1.3
Staff Development
Care Planning and Coordination
2.1
Assignment of Home Care Aides
2.2
The Home Care Aides/Continuing Care Assistants Role as a Team
Member
Safe Environment
Supervision of Home Care Aides
1.
2.
Homemaking Service Outcome Standards are determined in the following areas:
Contribution of Homemaking Services
Achievement of Goals
16.3.2
1.
2.
16.3.3
Community Care Section: 11
Index Ref: 16.3.1 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Homemaking Service Structure Standards
16.3.1
HOMEMAKING SERVICE: STRUCTURE STANDARDS
Standard
1. Goals and Objectives
The Regional Health Authority has goals and
objectives for the provision of homemaking
services that are consistent with the purpose,
philosophy and objectives as stated in the
Saskatchewan Ministry of Health Home Care
Policy Manual (Policy 1.1, 1.1.1 and 1.1.2).
2. Organization of the Service
2.1. Organization of Homemaking
The Homemaking service is organized to
facilitate efficient and effective use of Home
Care Aides, taking into consideration the:
• need for service and its distribution in the
region;
• need to maintain Home Care Aides skills;
• cost of providing service; and,
• quality of service provided.
2.2. Service to Family Members
Home Care Aides are not employed to
provide service to their own families unless
all of the criteria of Policy 12.8 apply.
Measure/Indicators
Written goals and objectives
are clear and consistent with
the purpose and philosophy
in the Saskatchewan
Ministry of Health Home
Care Policy Manual.
Method
Determine if written
statements exist and
examine them for
consistency.
These factors are reflected in Review organization.
the organization of the
service.
No Home Care Aides is
Review staff
assigned to work for a
assignments.
family member unless all the Interview staff.
criteria of Policy
12.8 apply.
3. Scope and Limitations of Service
Regional Health Authority policies provide
The Regional Health
Review Regional Health
clear direction on the scope and limitations of Authority’s policy manual
Authority policy manual.
the homemaking service.
outlines the scope and
limitations of functions.
4. Job Descriptions
The Regional Health Authority has a written Evidence of job descriptions Review job descriptions.
job description for Home Care Aides.
for Home Care Aides.
Community Care Section: 11
Index Ref: 16.3.1 Page 2
Date of Issue:
Home Care Policy
Quality Monitoring and Improvement
September 2006
Updated September
2009
Subject:
Homemaking Service Standards
Standard
5. Training
5.1. Training Policy
The Regional Health Authority policies
provide Home Care Aide personnel with clear
direction about the requirements of a training
program approved by Saskatchewan Health.
5.2. Exemptions from Training
The Regional Health Authority has policies
and procedures to provide direction regarding
exemptions from the requirements for training
of Home Care Aides/continuing care
assistants (Policy 12.3).
6. Supervision
The Regional Health Authority has policies
and procedures to provide Home Care Aide
personnel with clear directions about the role
and frequency of supervision.
7. Confidentiality
The Regional Health Authority has policies
and procedures to ensure that information is
kept confidential by Home Care Aides.
Measure/Indicators
Method
Evidence that Home Care
Aides have the training as
required.
Review documentation
of training.
Documentation of the
exemptions from the
requirements for training of
Home Care Aides.
Review documentation.
Existence of specific written Review Regional Health
policies and procedures.
Authority policy and
procedures.
Home Care Aides/evidence Review Regional
of policies and procedures in Health Authority policies
compliance with The Health and procedures.
Information Protection Act.
8. Safe Working Conditions
The Regional Health Authority must have
Evidence of written policies
policies and procedures to ensure working
and procedures.
conditions are as safe as possible in the office
and in the field.
Review Regional
Health Authority policies
and procedures.
Community Care Section: 12
Index Ref: 16.3.2 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Homemaking Service Process Standards
16.3.2
HOMEMAKING SERVICE: PROCESS STANDARDS
Standard
Measure/Indicators
Method
1. Orientation, Training and Staff Development
1.1. Orientation
The Regional Health Authority provides
Evidence that orientation is Interview staff.
orientation for new employees.
given to new employees.
Review orientation
procedures and
documentation.
1.2. Training
The Regional Health Authority ensures that
Evidence that Home Care Review documentation.
persons who have completed, or are in the
Aides have the training
Interview staff.
process of completing, a training program
required.
approved by the Saskatchewan Ministry of
Health provide home management services.
1.3. Staff Development
The Regional Health Authority provides staff
Evidence that all Home
Review documentation.
development opportunities for all Home Care
Care Aides have an
Interview staff.
Aide personnel.
opportunity for staff
development.
2. Care Planning and Coordination
2.1. Assignment of Home Care Aides/Continuing Care Assistants
The Regional Health Authority considers the
Evidence that these factors Interview staff.
following factors when assigning Home Care
are considered.
Interview client.
Aides to a client:
• needs of the client;
• knowledge and skills of the Home Care
Aides; and,
• compatibility of Home Care Aides and
client.
Community Care Section: 12
Index Ref: 16.3.2 Page 2
Date of Issue:
Home Care Policy
Quality Monitoring and Improvement
September 2006
Updated September
2009
Subject:
Homemaking Service Standards
Standard
Measure/Indicators
Method
2.2. The Home Care Aide’s Role as a Team Member
The Home Care Aide as a team member, is:
Evidence that the Home
Interview staff.
• given the opportunity to have direct input in Care Aide participates as a Review documentation.
member of the team.
the development of care plans and goals;
• kept informed of any significant changes to
the client, situation and the care plan;
• involved in care planning/case conferences;
and,
• given the responsibility to keep his/her
supervisor informed of changes in the client
situation.
3. Safe Environment
The Regional Health Authority ensures that the
Home Care Aides promote
Home Care Aide performs work in a manner that and maintain a safe
promotes a safe working and living environment. working and living
environment as indicated
in:
• incident reports; and,
• low incidence of
Worker Compensation
claims.
4. Supervision of Home Care Aides
The Regional Health Authority ensures that
Documentation of
Home Care Aides providing service are
supervision.
supervised directly and indirectly as required.
Evidence that supervision
is provided.
5. Performance Review
Regional Health Authorities must ensure that
Evidence that performance
Home Care Aides receive annual performance
appraisals have been done.
reviews. Performance reviews should determine
whether staff are able to: meet responsibilities as
defined in their job descriptions; and set realistic
goals and achieve them.
Interview staff and
clients.
Review incident reports
and worker injury
reports.
Review documentation.
Interview Staff.
Community Care Section: 13
Index Ref: 16.3.3 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Homemaking Service Outcome Standards
16.3.3
HOMEMAKING SERVICE: OUTCOME STANDARDS
Standard
1. Contribution of Homemaking Services
Homemaking services that are provided
contribute to the autonomy, independence and
well being of the client.
Measure/Indicators
Method
Evidence in progress
summaries and
re-assessments.
Review progress
summaries and
re-assessments.
Interview client.
2. Achievement of Goals
Homemaking services that are provided
contribute to the achievement of the goals
specified in the care plan.
Evidence in progress
summaries and
re-assessments.
Review progress
summaries and
re-assessments.
Interview client.
Community Care Section: 14
Index Ref: 16.4
Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Meal Service Standards
16.4
16.4.1
MEAL SERVICE STANDARDS
Meal Service Structure Standards are determined in the following areas:
Goals and Objectives
Organization of the Service
2.1
Meal Service
2.2
Volunteer Delivery
2.3
Review of Organization
3.
Contractor/provider Requirements
3.1
Meal Service Providers
3.2
Written Contract
1.
2.
16.4.2
1.
2.
3.
4.
5.
16.4.3
Meal Service Process Standards are determined in the following areas:
Training
1.1
Sanitation Training Program
Preparation of Food (for Private Meal Providers)
Diets
3.1
Canada’s Food Guide to Healthy Eating
3.2
Physicians’ Instructions for Therapeutic Diets
3.3
References for Therapeutic Diets
3.4
Therapeutic Diets Not Requiring Professional Supervision
3.5
Diet Instructions to Meal Providers
3.6
Diet Instructions to Client
Packaging of Foods
4.1
Hot Food Containers
4.2
Cold Food Containers
4.3
Packaging
Delivery of Meals
5.1
Maintenance of Proper Food Temperatures
5.2
Client Care of Meals
5.3
Volunteers
Meal Service Outcome Standards are determined in the following areas:
1.
Meal Preparations and Delivery
2.
Contribution of Meal Service
3.
Achievement of Goals
Community Care Section: 15
Index Ref: 16.4.1 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Meal Service Structure Standards
16.4.1
MEAL SERVICE STRUCTURE STANDARDS
Standard
1. Goals and Objectives
The Regional Health Authority has clearly stated
goals and objectives for provision of meal
services consistent with the purpose, philosophy
and objectives as stated in the Saskatchewan
Ministry of Health Home Care Policy Manual
(Policy 1.1, 1.1.1 and 1.1.2).
2. Organization of the Service
2.1. Meal Service
The meal service is organized to balance the
following considerations:
• provincial and regional program objectives,
priorities and policies;
• the need for meals and service distribution in
the region;
• the availability of meal providers and
deliverers, and their distribution in the
region;
• the quality and safety of meals provided to
clients; and,
• the cost of providing meals.
2.2. Volunteer Delivery
The delivery of meals is organized to make use
of volunteers whenever practical to do so, taking
into consideration:
• the number and distribution of meal
providers and clients receiving meals in the
region;
• the need to ensure that meals are delivered
quickly and safely; and,
• the availability and distribution of volunteers
and volunteer time in the region.
Measures/Indicators
The Regional Health
Authority policy manual
has written goals and
objectives.
Method
Review Regional
Health Authority policy
manual.
Evidence that these factors Review organization.
are reflected in the
organization of the service.
These factors are reflected
in the organization of the
service.
Review organization.
Community Care Section: 15
Index Ref: 16.4.1 Page 2
Date of Issue:
Home Care Policy
Quality Monitoring and Improvement
September 2006
Updated September
2009
Subject:
Meal Service Standards
Standard
2.3. Review of Organization
The organization of the meal service, including
delivery, is reviewed at least annually to ensure
that the structures in place continue to be
appropriate.
3. Contractor/Provider Requirements
3.1. Meal Service Providers
The Regional Health Authority may contract the
preparation of home care meals to:
a) an affiliate as defined in The Regional
Health Authority Act; or,
b) any public eating establishment licensed by
the Regional Health Authority, pursuant to
the Technical Guideline #154 administered
by the Regional Health Authority.
Restaurants and institutional providers must
prepare meals in accordance with Policies 11.2.5
and 16.4 . of the Saskatchewan Ministry of
Health Home Care Policy Manual.
3.2. Written Contract
The contract(s) between the Regional Health
Authority and each restaurant, institution, agency
or individual that serve as meal providers,
conform to Policies 12.4 and 12.4.1, if
applicable.
Measures/Indicators
Method
Evidence that the service is Review organization.
reviewed every year.
Interview staff.
Evidence that the service is Review contract.
reviewed every year.
A signed, dated current
contract is on file.
Review file.
Interview staff.
Community Care Section: 16
Index Ref: 16.4.2 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
Subject:
Meal Service Process Standards
16.4.2
MEAL SERVICE PROCESS STANDARDS
September 2006
Revised September
2015
Community Care Section: 17
Index Ref: 16.4.3 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Meal Service Outcome Standards
16.4.3
MEAL SERVICE: OUTCOME STANDARDS
Standard
1. Meal Preparation and Delivery
The meal preparation and delivery process
ensures that the meal provided is appropriate to
the needs of the client and is in accordance with
the standards and guidelines for meal service as
set out in the Saskatchewan Ministry of Health
Home Care Policy Manual.
2. Contribution of Meal Service
Meal services provided contribute to the
autonomy, independence and well being of the
client.
3. Achievement of Goals
Meal services provided contribute to the
achievement of the goals specified in the care
plan.
Measures/Indicators
Method
Evidence that the meal is
appropriate to the client’s
needs and is in accordance
with the standards and
guidelines.
Review client records.
Review meal
preparation and
delivery process.
Evidence in progress
summaries and
re-assessments.
Review progress
summaries and
re-assessments.
Interview clients.
Evidence in progress
summaries and
re-assessments.
Review progress
summaries and
re-assessments.
Interview client.
Community Care Section: 18
Index Ref: 16.5
Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Maintenance Service Standards
16.5
HOME MAINTENANCE SERVICE STANDARDS
16.5.1
1.
2.
3.
4.
5.
Home Maintenance Service Structure Standards are determined in the following
areas:
Goals and Objectives
Education Requirements
Scope and Limitations of Service
Safe Working Conditions
Confidentiality
1.
2.
3.
4.
Home Maintenance Service Process Standards are determined in the following areas:
Care Planning
Service Provision
Staff Supervision
Reporting
16.5.2
16.5.3
Home Maintenance Service Outcome Standards are determined in the following
areas:
1.
Appropriateness of Service
2.
Achievement of Goals
Community Care Section: 19
Index Ref: 16.5.1 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Maintenance Service Structure Standards
16.5.1
HOME MAINTENANCE SERVICE STRUCTURE STANDARDS
Standard
1. Goals and Objectives
The Regional Health Authority has clearly stated
goals and objectives for the provision of home
maintenance services that are consistent with the
purpose, philosophy and objectives as stated in
the Saskatchewan Ministry of Health Home Care
Policy Manual (Policy 1.1, 1.1.1, and 1.1.2).
2. Education Requirements
Regional Health Authority staff who install SAIL
equipment, non-skid surfaces and handrails are
appropriately trained.
3. Scope and Limitations of Service
Regional Health Authority policies provide clear
direction on the scope and limitations of the
home maintenance service.
4. Safe Working Conditions
The Regional Health Authority must have
policies and procedures to ensure working
conditions are as safe as possible in the office
and in the field.
5. Confidentiality
The Regional Health Authority has policies and
procedures to ensure that information is kept
confidential by Home Maintenance staff.
Measures/Indicators
The Regional Health
Authority policy manual
has written goals and
objectives.
Method
Review Regional
Health Authority policy
manual.
The training program is
Review training
outlined and implemented. program.
The Regional Health
Authority’s policy manual
outlines the scope and
limitations of functions.
Review Regional
Health Authority policy
manual.
Evidence of written
policies and procedures.
Review Regional
Health Authority
policies and procedures.
The Regional Health
Authority policy manual
defines the parameters of
confidentiality for home
maintenance staff.
Evidence policies and
procedures are in
compliance with Health
Information Protection
Act.
Review Regional
Health Authority
polices and procedures.
Community Care Section: 20
Index Ref: 16.5.2 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Maintenance Service Process Standards
16.5.2
HOME MAINTENANCE SERVICE: PROCESS STANDARDS
Standard
1. Care Planning
Home maintenance workers are given clear
direction in performing assigned tasks taking into
consideration:
• the goals and objectives of the care plan;
• the client situation;
• the nature and extent of the work to be done;
and,
• the work schedule.
2. Service Provision
Home maintenance workers ensure that work is
done in a manner that promotes and maintains a
safe working environment.
3. Staff Supervision
Home maintenance workers are supervised
directly and indirectly during the probationary
period and on an ongoing basis.
The supervisor is responsible for ensuring that
the work is done:
• properly;
• in accordance with the care plan; and,
• safely.
4. Reporting
Home maintenance workers should indicate that
work was done in accordance with the care plan.
Measures/Indicators
Method
Evidence that instruction is Interview staff, clients
given to home
and supervisors.
maintenance workers
before they begin assigned
tasks.
Low number of incident
reports. Low report of
worker injury.
Review documentation
and reports.
Documentation of
supervision.
Review documentation.
Service reports indicate
that work was done
according to care plan.
Review care plan and
service reports.
Community Care Section: 21
Index Ref: 16.5.3 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Maintenance Service Outcome Standards
16.5.3
HOME MAINTENANCE SERVICE: OUTCOME STANDARDS
Standard
1. Appropriateness of Service
Home maintenance services are provided only
when the safety of the individual is at risk and no
reasonable alternative can be found.
2. Achievement of Goals
Home maintenance services contribute to the
achievement of the goals specified in the care
plan.
Measures/Indicators
Method
Evidence in care planning
and coordination.
Review assessments
and care plans.
Interview staff.
Evidence in progress
summaries and
re-assessments.
Review progress
summaries and
re-assessments.
Interview client.
Community Care Section: 24
Index Ref: 16.6
Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Volunteer Service Process Standards
16.6
Volunteer Service Standards
16.6.1
1.
2.
3.
4.
5.
Volunteer Service Standards are determined in the following areas:
Goals and Objectives
Organization of the Service
Scope and Limitations
Safe Working Conditions
Confidentiality
1.
2.
3.
4.
5.
Volunteer Service Process Standards are determined in the following areas:
Orientation
Care Planning
Service Provision
Staff Supervision
Preparation of Food (for Private Meal Providers)
1.
Volunteer Service Outcome Standards are determined in the following areas:
Achievement of Goals
16.6.2
16.6.3
Community Care Section:
Index Ref: 16.6.2.Page 1
Date of Issue:
Home Care Policy
Quality Monitoring and Improvement
September 2006
Updated September
2015
Subject:
Volunteer Service Standards: Process Standards
16.6.1 Volunteers Service: Structure Standards
Standard
1. Goals and Objectives
The Regional Health Authority has goals and
objectives for the provision of volunteer services
that are consistent with the purpose , philosophy
and objectives as stated in the Saskatchewan
Health Home Care Policy Manual (Policy 1.1,
1.1.1 and 1.1.2)
2. Organization of the Service
The Volunteer service should be organized to
balance the following considerations:
• home care program objectives and
priorities;
• home care volunteer needs of the
Regional Health Authority;
• quality of volunteer service; and,
• appropriate use of volunteers.
3. Scope and Limitations
Regional Health Authorities should provide
policies and procedures to volunteers with clear
direction about the scope and limitations of their
functions and responsibilities.
4. Safe Working Conditions
Regional Health Authorities must have policies
and procedures to ensure conditions are as safe
as possible in the office and in the field.
5. Confidentiality
The Regional Health Authorities has policies and
procedures to ensure that information is kept
confidential by Volunteers.
Measures/Indicators
Written goals and
objectives are clear and
consistent with the purpose
and philosophy in the
Saskatchewan Ministry of
Health Home Care
Manual.
Method
Determine if written
statements exist and
examine them for
consistency.
Factors are reflected in the Review the
rationale for system
organization of the
design.
system.
Existence of written
policies and procedures
that reflect the Regional
Health Authority’s
practice.
Review policies and
procedures. Interview
staff.
Existence of written
policies and procedures.
Review policies and
procedures.
The Regional Health
Authority policy manual
defines the parameters of
confidentiality for
volunteers. Evidence
policies are in compliance
with Health Information
Protection Act.
Review Regional
Health Authority
policies and procedures.
Community Care Section:
Index Ref: 16.6.2.Page 1
Date of Issue:
Home Care Policy
Quality Monitoring and Improvement
September 2006
Updated September
2015
Subject:
Volunteer Service Standards: Process Standards
16.6.2 Volunteer Service Process Standards
Standard
1. Orientation
The Regional Health Authority should provide
orientation for nursing personnel.
2. Care Planning
The Regional Health Authority considers the
following factors when assigning Volunteers to a
client:
• needs of the client;
• knowledge and skills of the Volunteer;
and,
• compatibility of the volunteer and client.
3. Supervision
Regional Health Authority ensures that
Volunteers providing services are supervised
directly and indirectly as required.
Measures/Indicators
Evidence of appropriate
orientation is provided.
Evidence of the content of
the orientation.
Method
Interview staff.
Review orientation
procedure and
documentation.
Evidence that these factors Interview staff.
are considered.
Interview client.
Documentation of
supervision.
Evidence that supervision
is provided.
Review documentation.
Community Care Section:
Index Ref: 16.6.2.Page 1
Date of Issue:
Home Care Policy
Quality Monitoring and Improvement
September 2006
Updated September
2015
Subject:
Volunteer Service Standards: Process Standards
Community Care Section: 25
Index Ref: 16.6.3 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Volunteer Service Standards: Outcome Standards
16.6.3 Volunteer Service: Outcome Standards
Standard
Measures/Indicators
1. Achievement of Goals
Volunteer services that are provided contribute to Evidence in progress
the achievement of the goals specified in the care summaries and
plan.
re-assessments.
The Regional Health
Authority’s policy manual
outlines the scope and
limitations of functions.
Method
Review progress
summaries and
re-assessments.
Interview client.
Review the Regional
Health Authority policy
manual.
Community Care Section: 26
Index Ref: 16.7
Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Care Standards
16.7
HOME CARE STANDARDS
16.7.1
Home Care Outcome Standards are determined in the following areas:
Maintaining Independence and Well Being
1.1
Assessing Clients and Coordinating Care
1.2
Teaching Self-Care and Coping Skills
1.3
Maintaining, Improving or Delaying Loss of Functional Abilities
1.4
Promoting and Supporting Family and Community Responsible for Care
1.5
Provide Acute, Palliative and Supportive Care that Family, Friends and
Neighbors Cannot Provide
Facilitating Appropriate Use of Health and Social Services
2.1
Delaying or Preventing Long Term Care Admission and Facilitating
Discharge
2.2
Supporting People Waiting for Long Term Care Admission
2.3
Preventing Unnecessary Hospital Admissions and Facilitating Earlier
Discharge
2.4
Helping Access Service
2.5
Promoting Volunteers
2.6
Educating the Public
2.7
Participating in Service Planning Coordination
Prioritizing
3.1
Operating Economically and Efficiently
Using Resources to Meet Client Needs
1.
2.
3.
4.
Community Care Section: 27
Index Ref: 16.7.1 Page 1
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Care Outcome Standards
16.7.1
HOME CARE OUTCOME STANDARDS
Standard
Measures/Indicators
1. Maintaining Independence and Well Being
Individuals are
Functional abilities and strengths, needs and
assisted to maintain
limitations are assessed and used in planning
independence and
care.
well being at home.
Clients are encouraged and supported to do
what they can for themselves.
Clients’ rights to accept risks and refuse
services are respected.
Clients are involved in defining needs, setting
goals, developing and revising care plans.
Goals that are set with clients contribute to
well being and independence, and are
achievable.
Clients’ rights to maintain dignity and control
of their own lives are respected.
Clients believe home care:
• helps maintain their independence and well
being;
• helps them and their supporters to manage;
• helps them maintain control over their
lives;
• informs and involves them in assessment
and care planning;
• allows them to influence service decisions;
and,
• respects their privacy and treats them
appropriately.
Method
Review screening records and
client records.
Interview:
• staff;
• clients;
• supporters; and,
• other health and social
service providers.
Observe service delivery.
Community Care Section: 27
Index Ref: 16.7.1 Page 2
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Care Outcome Standards
Standard
Measures/Indicators
1.1. Assessing Clients and Coordinating Care
Needs and abilities
People who might need home care are not
are determined and
screened out prior to assessment.
plans for care are
developed and
Client and supporter abilities and unmet needs
coordinated.
are consistently defined.
Goals incorporate abilities of client and
supporters and address unmet needs.
All options (e.g. teaching, informal support,
volunteers, services referral, support to family)
are explored in developing care plans.
All support is coordinated to achieve goals.
All cases are reviewed when situations change
and goals are amended as required.
1.2. Teaching Self-Care and Coping Skills
Teaching self-care
Client potential to learn self-care and coping
and coping skills are skills is always thoroughly explored in
facilitated.
assessments.
Whenever learning potential is identified,
responsibilities and goals are defined in the
care plan.
1.3. Maintain, Improve or Delay Loss of Functional Abilities
Clients maintain,
Potential to maintain, improve, or delay loss of
improve, or delay
functional abilities is consistently and
loss of functional
thoroughly explored in assessments.
abilities.
Goals and responsibilities are defined in care
plans.
1.4. Promoting and Supporting Family and Community Responsible for Care
Family and
Family and/or community assistance to clients
community
is encouraged and supported.
responsible for care
are promoted and
Family and supporters’ strengths and needs are
Method
Community Care Section: 27
Index Ref: 16.7.1 Page 3
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Care Outcome Standards
Standard
supported.
Measures/Indicators
consistently and thoroughly explored in
assessments and responsibilities are defined in
care plans.
When family or other support is provided, or
has the potential to be provided, the supporter
is interviewed and the interview is
documented.
Method
Goals are established to promote and support
the role of family and other supporters.
No activities are performed for clients that
supporters are willing and able to perform.
Families/supporters are:
• responsible and involved in the client’s
care;
• able to manage care giving without undue
stress; and,
• accepting of care provided.
1.5. Providing Acute, Palliative and Supportive Care that Family, Friends and Neighbours
Cannot Provide
Direct care is
Home care does not replace help usually
provided only when provided by families and communities or
needed to supplement provide care that clients can manage
informal support.
independently.
The Regional Health Authority provides the
following types of service when needed:
• night and weekend service;
• respite appropriate to the supporter’s
needs; and,
• special nursing procedures and nursing
procedures by transfer of medical
functions when appropriately transferred to
a home care nurse.
All direct care contributes to achievement of
goals.
Cases are reviewed and clients discharged
Community Care Section: 27
Index Ref: 16.7.1 Page 4
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Care Outcome Standards
Standard
Measures/Indicators
when services are no longer needed.
Method
2. Facilitating Appropriate Use of Health and Social Services
Appropriate use of
People who need home care are not screened
health and social
out, refused admission, offered unduly
services is facilitated. restricted service levels or discharged.
Review screening and client
records.
Interview:
• staff;
The Regional Health Authority refers or
• clients;
involves other agencies and health and social
• families, supporters and
service providers when appropriate.
consumer representatives;
• people who have been
screened out; and,
• other health and social
service providers.
2.1. Delaying or Preventing Long Term Care Admission and Facilitating Discharge
Admission to
Regional Health Authorities inform clients,
Interview:
institutional longfamilies and other agencies about the full
• staff;
term care is delayed extent of the program’s ability to provide
• health and social service
or prevented and
support at home as their needs increase.
providers;
assistance on
• consumer representatives;
discharge is provided. Home care provides care to delay or prevent
and,
admission to long term institutional care
• clients and supporters.
whenever the opportunity arises.
Review records of clients who
are discharged to institutional
Home care does not refuse admission or refer care, screened out or refused
clients for institutional care when needs can be admission.
met in the community.
Home care facilitates discharges from long
term care institutions whenever there is an
opportunity.
2.2. Supporting People Waiting for Long Term Care Admission
Support to people
Support is provided to people awaiting
waiting for admission placement whenever this is the most
to long-term care
appropriate option available.
facilities is provided.
Interview:
• staff;
• other health and social
service providers; and,
Community Care Section: 27
Index Ref: 16.7.1 Page 5
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Care Outcome Standards
Standard
Measures/Indicators
Method
•
people recently placed on
waiting list.
2.3. Preventing Unnecessary Hospital Admissions and Facilitating Earlier Discharge
Unnecessary
Home care provides care to prevent hospital
Interview staff.
admissions to
admissions and facilitate earlier discharges
Review records:
hospitals are
whenever appropriate.
• screening;
prevented and earlier
• refusals of admission; and,
discharges are
The Regional Health Authority receives and
• discharges.
possible.
responds to referrals for:
• special nursing procedures; and,
Interview:
• nursing procedures by transfer of medical • physicians;
functions. Medical functions transferable • clients; and,
to nursing personnel when needed to
• hospital representatives.
prevent hospital admission or to facilitate
discharge.
2.4. Helping Access Service
Individuals and
Applicants, clients, families and supporters are Review client records.
families are assisted assisted to access other services when
Interview:
in accessing services. appropriate and desired.
staff;
clients;
family and supporters; and,
The Regional Health Authority receives
other health and social service
referrals consistent with program objectives
providers.
and acts according to priority of need.
The Regional Health Authority coordinates its
services with others.
2.5. Promoting Volunteers
The participation of
The volunteer option is explored and used
volunteers is
whenever volunteer services could contribute
promoted.
to the achievement of care plan goals.
Examine assessments and care
plans.
Review volunteer
programming.
Interview:
• volunteers;
• staff;
• clients; and,
• other health and social
Community Care Section: 27
Index Ref: 16.7.1 Page 6
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Care Outcome Standards
Standard
Measures/Indicators
2.6. Educating the Public
The public is
The general public, interest groups and
educated about home agencies understand the program well enough
care.
to make appropriate referrals and contacts with
home care.
2.7. Participating in Service Planning Coordination
Home care
Home care encourages and contributes in
contributes to the
planning services.
planning and
coordination of
services in the
Regional Health
Authority.
3. Prioritizing
The Regional Health Cases with high priority needs are not screened
Authority makes the out, refused admission, offered unduly
best use of home care restricted service levels or discharged.
resources by serving
people with the
greatest need first.
3.1. Operating Economically and Efficiently
Home Care operates The Regional Health Authority uses the least
economically and
costly staff (e.g. RN, RPN, LPN) that is
efficiently.
qualified and competent to address the needs
of the clients.
Method
service providers.
Review educational materials.
Interview:
• staff;
• Regional Health Authority
board;
• other health and social
service providers;
• consumer groups;
• agencies; and,
• supporters.
Interview:
• staff; and,
• other health and social
service providers.
Review complaints.
Review discharges and
non-admissions.
Interview:
• staff;
• consumer groups; and,
• health and social service
providers.
Check for absence of restrictive
policies that may deter people
with greatest need.
Interview:
• staff;
• clients;
• supporters; and,
Community Care Section: 27
Index Ref: 16.7.1 Page 7
Date of Issue:
Home Care Policy
Quality Improvement Program
September 2006
Revised September
2015
Subject:
Home Care Outcome Standards
Standard
Measures/Indicators
Method
•
The Regional Health Authority provides only
the kind, quality and frequency of service
necessary to meet client needs.
4. Using Resources to Meet Client Needs
The Regional Health The Regional Health Authority identifies and
Authority is able to
admits people who need home care services.
meet client needs and
optimize client
The Regional Health Authority defines needs
independence within and goals to address those needs with each
available financial
client.
resources while
working
Client goals contribute to optimizing
cooperatively with
independence.
other community
agencies,
Client goals are realistic and achievable.
organizations, and
individuals.
Service is provided which encourages and
supports clients to do what they can for
themselves.
Regional Health Authority staff considers
priorities and resources when developing care
plans.
The Regional Health Authority provides only
the kind, quality and frequency of services
necessary to achieve client goals.
The Regional Health Authority refers, receives
referrals and involves other health and social
service providers when appropriate.
The Regional Health Authority participates
cooperatively in care coordination and health
planning groups.
other health and social
providers.
Review client records.
Interview:
• staff;
• clients;
• supporters; and,
• other health and social
service providers.
Review client records.
Community Care
Home Care Policy
Section:
Index Ref: 17.1
Reporting Requirements
Page 1
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
17.1
REPORTING REQUIREMENTS FOR REGIONAL HEALTH AUTHORITIES
POLICY
1.
Regional Health Authorities shall submit all required home care data to Saskatchewan
Health, including:
a)
Admission/Discharge information;
b)
Service Summary information;
c)
Management Information System Provincial Chart of Accounts information; and
d)
RHA Accountability Indicator information.
GUIDELINES
1. Admission Information
Region
PHN
Out of province code
Birth Date
Sex
Date Referred to Home Care
Regional Health Authority providing service
Client’s health services number
Province of residence if not Sask. resident
1. Male
2. Female
1. The date the client becomes known to home care or
is referred for home care services and it is
determined a home care service may be required.
Community Care
Section:
Home Care Policy
Index Ref: 17.1
Reporting Requirements
Page 2
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
Reason For Referral
Type of admission
Reason for
Assessment/Reassessment
Hospital discharge information
1. Post Hospital Care – Referral to assess any
necessary care requirements following a stay of any
length – in hospital or clinic.
2. Community Chronic Care – Referral to assess the
specific needs for rehabilitative, restorative, or long
term care in a community setting. The initial need
for community care has already been established.
The referral is to determine exactly what the needs
are.
3. Home Placement Screen – Referral to assess proper
placement of the client in any institutional LTC
facility.
4. Eligibility for Home Care – Referral to assess the
client’s appropriateness for home care. This is
different than Community Chronic Care in that the
need for any home care has not been established.
5. Daycare – Referral to assess the client’s
appropriateness for an Adult Day Care setting.
6. Other: All 3rd party requests such as DVA, WCB,
SGI, competency assessments.
1. Regular – all clients admitted to the home care
program and receiving a comprehensive assessment.
2. Short-term nursing – clients admitted to home care
and most likely will not receive case management.
1. Initial Assessment.
2. Follow-up Assessment.
3. Routine Assessment at fixed intervals.
4. Review within 30-day period prior to discharge from
the program.
5. Review at return from hospital.
6. Change in status.
7. Other – (Quality assurance, clinical research,
confirmation of current care plan – appeal,
development of acuity scale, community needs
assessment, inter – rater reliability).
1. Yes – directly to home care.
2. Yes – within previous 30 days.
3. No.
Community Care
Home Care Policy
Section:
Index Ref: 17.1
Reporting Requirements
Page 3
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
Marital status
Living arrangements
Where Lived at Time of Referral
Place of residence
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
1.
2.
3.
1.
2.
3.
4.
Never married.
Married (includes common law).
Widowed.
Separated.
Divorced.
Lives alone.
With spouse only.
With spouse and others.
With other family members.
With others.
Private home/apartment with no home care services.
Private home/apartment with home care services.
Board and care/assisted living/group home.
3.1.Personal Care Home.
3.2.Assisted Living.
3.3.Group Home – A non institutional community
residential setting-shared living environment
with varying degrees of supportive services.
3.4.Residential Care facility (LTC).
3.5.Hospital.
3.6.Other (Homeless, hotel etc).
Farm / rural.
Village / hamlet.
Town.
City.
Community Care
Home Care Policy
Section:
Index Ref: 17.1
Reporting Requirements
Page 4
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
Type of Care
Level of Care
Income category
Number living on income
Subsidy requested
Income plans
TMI
1. Acute – A client who needs immediate or urgent
time limited (up to three months or less) intervention
to improve or stabilize a medical or post surgical
condition.
2. Long Term Supportive Care – A client who is at
significant risk of institutionalization due to
unstable, chronic health conditions, and/or living
condition(s) and/or personal resources.
3. Rehabilitation – A client with a stable health
condition that is expected to improve with a timelimited focus on goal oriented, functional
rehabilitation. The rehabilitation plan specifies goals
and expected duration therapy.
4. Maintenance – A client with stable, chronic health
conditions, stable living conditions, and personal
resources, who needs ongoing support in order to
remain living at home.
5. Palliative/End of Life – In one’s best clinical
judgment, a client with any end-stage disease who is
expected to live less than six months. Judgment
should be substantiated by well documented disease
diagnosis and deteriorating clinical course.
1. Level 1
2. Level 2
3. Level 3
4. Level 4
I__I
I__I
1. Yes
2. No
1. Sask. Assistance Plan (SAP).
2. Saskatchewan Employment Supplement.
3. Sask. Income Plan (SIP).
4. DVA Pension.
5. None.
6. Unknown.
Total monthly income.
Community Care
Home Care Policy
Section:
Index Ref: 17.1
Reporting Requirements
Page 5
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
AMI
Admission date
2. Discharge Information
Discharge
Discharge date
Reason for discharge
Adjusted monthly income.
The date the client becomes known to home care and it
is determined that a home care service may be required.
The administrative process by which a health region
records the cessation of all home care services being
delivered to the client.
All home care clients to be discharged if they have not
received home care services within a 12 month period
unless they are living in a personal care home where
regular assessments will be completed every 24 months.
Date of discharge is the day following the actual date of
last service. (Date there is no longer a need to keep the
client file open).
1. Client no longer requires service.
2. Client referred to other health services:
2.1.Hospital.
2.2.LTC Facility.
2.3.Hospital based ambulatory care.
2.4.Assisted Living setting (includes group home,
supportive housing, congregate living setting).
2.5.Community-based health service/program.
3. Client no longer eligible for service (funding).
4. Client withdrew/ended services.
5. Client moved out of area.
6. Deceased.
7. Agency unable to contact/reach client.
8. Physical environment unsuitable for service
delivery.
9. Services ended due to Occupational Health and
Safety reasons.
Community Care
Home Care Policy
Section:
Index Ref: 17.1
Reporting Requirements
Page 6
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
Alternative arrangements
1. Acute care hospital stay.
2. Special care home or level 4 in hospital.
2.1.Special Care Home.
2.2.Level 4 in Hospital.
3. Other care home (approved, private, group, etc.).
4. Self / family care.
5. Other.
Blank if deceased or not discharged.
3. Service Summary Information
Region #
Region name
Regional Health Authority providing service.
HSN
Client’s health services number.
Name
Last, First.
Service date
Month and year service(s) received.
Units of Service:
Personal care - nursing
Hours of service received in the month.
Other - nursing
Hours of service received in the month.
Physiotherapy
Hours of service received in the month.
Meals
Number of meals received in the month.
Home Maintenance
Hours of service received in the month.
Personal care – homemaking
Hours of service received in the month.
Home management –
Hours of service received in the month.
homemaking
Services Fee
Total amount billed in the month.
Supplies Fees
Total cost provided in the month.
4. Data Definitions
Type of Care
Acute
A client who needs immediate or urgent limited (up to three months or less)
intervention to improve or stabilize a medical or post surgical condition.
Long Term
Services provided to clients for the purpose of living independently in the
Supportive
community; respite services provided to client’s supporters; or services
Care
provided to clients that don’t fit into the other two categories.
Community Care
Home Care Policy
Section:
Reporting Requirements
Index Ref: 17.1
Page 7
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
Rehabilitation
A client with a stable health condition that is expected to improve with a time
limited focus on goal oriented, functional rehabilitation. The rehabilitation
plan specifies goals and expected duration of therapy.
Maintenance
A client with stable, chronic health conditions, stable living conditions and
personal resources, who needs ongoing support in order to remain living at
home.
Palliative/End In ones best clinical judgment, a client with any end-stage disease who is
of Life
expected to live less than 6 months. Judgment should be substantiated by
well-documented disease diagnosis and deteriorating clinical course.
Level of Care (applies to condition of client, not services received or services provided)
Level 1
Supervisory Care
• needs no or minimal assistance with personal care
• needs assistance with heavier tasks, may need meal preparation
• frail or minor physical limitations
• independent mobility or uses aid
• occasional forgetfulness
• no behavior problems
Level 2
• Limited Personal Care
• needs supervision or assistance with personal care
• help needed with heavier tasks and some lighter tasks
• limitations due to chronic ailments or advanced age
• independently mobile or uses aid or wheel chair
• mildly confused
• minor behavior problems
Level 3
Intensive Care
• significant help with personal care, incontinence
• needs assistance with all household tasks
• significant disabilities due to disease and/or aging
• significant restrictions on mobility; may be bed fast
• moderately confused, some behavior problems that can be managed
Level 4
Extended Care
• severe disability
• needs continuous supervision and high level of assistance
• usually bed fast
• significant behavior problems
Community Care
Home Care Policy
Section:
Reporting Requirements
Index Ref: 17.1
Page 8
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
Type of Service
Nursing
Assessments, treatments, and procedures; teaching and promoting self-care to
clients and others; personal care; collaboration with other care providers and
agencies.
Case
Pertains to services provided to support and make effective and efficient se and
Management management of available Home Care/community resources in order to meet the
client’s service goals and expected outcomes. Key elements of case
management include:
• Assessment to determine client needs, wants and service goals
• Care and service planning and coordination of services. This includes
the location, establishment and maintenance of services and the
maintenance of communication and liaison across services
• Care implementation
• Monitoring, coordinating and evaluating client outcomes
• Reassessment and subsequent revisions of care plans
• Service completion and discharge
Assessment
Assessment refers to a formal, comprehensive process for the purpose of
evaluating the need for services, assessing an individual’s physical,
psychosocial, emotional and cognitive health status, identification of service
recipient goals and expected outcome, identification of diagnosis and
consequences of health conditions and the extent of services required.
Assessment
1. Home Care (includes Assisted Living)
Type
2. Individualized Funding/Collective Funding
3. LTC Placement
4. Discharge Planning (Acute/LTC) Case coordination/management activities
which facilitate the discharge from institutional acute care or LTC to home
care services/LTC service or Personal Care Home.
5. PCH
6. Quick Response
7. Institutional Respite
8. Day Program
9. Convalescent/Transition Care
Homemaking Personal care, such as assistance with bathing and grooming, care of bed-bound
clients, activation, and routine foot and nail care; home management services,
such as household cleaning, meal preparation, laundry, and other aspects of
operating a household; attendant care in order to provide respite for the primary
caregiver. Direct client services are reported under personal homemaking;
indirect client services, under other homemaking.
Community Care
Home Care Policy
Section:
Reporting Requirements
Index Ref: 17.1
Page 9
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
Meals
Home
Maintenance
Direct
Service
Indirect
Service
Face to Face
Visit
Telephone
Visit
Meals-on-wheels and wheels-to-meals.
Installing Saskatchewan Aids to Independent Living Program equipment,
handrails, and non-skid surfaces; some outdoor tasks essential to the safety of
the client.
Units/hours provided in the delivery of home care services to or on behalf of
the home care client. Includes client assessments, provision of services aimed at
health promotion, improving/maintaining health status or minimizing the
impact of deterioration on function, quality of life, consultation/communication
with other service providers regarding the status and/or needs of the specific
client, client/caregiver education and clinical documentation related to services
provided.
Hours/units spent in activities not directly related to client care which includes:
• Travel time to and from a client’s home
• Attendance at educational sessions or in-services
• Case conferences to discuss a number of clients
• Non clinical documentation
• Compiling statistical data
Occasions during which home care services were provided face to face to a
client for longer than 5 minutes, and where the service was documented by the
service provider. These include visits for client assessment and the provision of
home health support services.
The number of occasions, captured retrospectively, during which home care
services were provided over the telephone to a home care client in lieu of a face
to face visit. These services are documented by the service provider and are
provided longer than five minutes. Includes client assessment and the provision
of home health and home support services. (Any electronic visits including
email, telemonitoring or Skype)
Community Care
Home Care Policy
Section:
Reporting Requirements
Index Ref: 17.1
Page 10
Date of Issue:
September 2006
September 2015
Subject:
Reporting Requirements for Regional Health Authorities
5. Home Care Information in the Management Information System Provincial Chart of
Accounts Information
Summary of Revenues:
Patient Fees:
Home Care Fees
Summary of Expenditures by Functional Centre:
Home Based Services - Supportive Care:
Nursing
Homemaking / Other
Meals
Case Management
Facilities / Administration
Individualized Care
Home Based Services - Community (Acute Care Substitution
& Palliative Care):
Nursing
Homemaking / Other
Meals
Case Management
Facilities / Administration
Community Care Section:
Index Ref: 18.0
Page 1
Date of Issue:
Home Care Policy
Occupational Health and Safety
September 2006
Revised September
2015
Subject:
Occupational Health and Safety
18.0
OCCUPATIONAL HEALTH AND SAFETY
POLICY
1.
The Regional Health Authority shall have policies in place to ensure the provision of a
safe work environment for home care employees.
2.
Copies of the most recent Occupational Health and Safety Act and the associated
Regulations of Saskatchewan Labour must be readily available to home care employees.
GUIDELINES
1.
The prevention of accidents and provision of a safe work environment is the
responsibility of every individual who works in home care.
2.
The Occupational Health and Safety Committee will oversee the identification of existing
and potential risks to the health or safety of workers and the measures that must be taken
to reduce, eliminate or control those risks.
3.
All accidents should be reported to the home care supervisor and recorded on an incident
form.
4.
The cause of every accident should be determined so preventative action can be taken.
Reference: Saskatchewan Association of Health Organizations. (1998). Occupational health and
safety guidelines for home care/community services. Regina, SK: Author.
Community Care Section:
Index Ref: 18.1
Page 1
Date of Issue:
Home Care Policy
Occupational Health and Safety
September 2006
Revised September
2015
Subject:
Safety Hazards
18.1
SAFETY HAZARDS
POLICY
1.
The Regional Health Authority shall have policies in place to reduce the risk of injury to
home care employees as a result of exposure to safety hazards that commonly occur in
the work environment. Common safety hazards may include not being able to
communicate with the home care office, faulty electrical equipment, poorly maintained
equipment, lack of fire protection devices, and exposure to cleaning products.
GUIDELINES
1.
Mechanisms to ensure that home care workers have contact with the home care office at
all times are required.
2.
The Regional Health Authority should ensure that all equipment used by the home care
staff is in safe working condition. Even if the client maintains the equipment the
employer has a responsibility to ensure its safety.
3.
Home care staff should be aware of the fire safety plan and the availability of fire
protection devices for each home where service is provided.
4.
Any chemical product used in the home by staff must come from clearly marked
manufacturer’s containers. The home care office shall maintain material safety data
sheets (MSDS) on each product used by home care staff.
Reference: Saskatchewan Association of Health Organizations. (1996). Home Care MSDS
Information. Regina, SK.
Community Care Section:
Index Ref: 18.2
Page 1
Date of Issue:
Home Care Policy
Occupational Health and Safety
September 2006
Revised September
2015
Subject:
Infection Control
18.2
INFECTION CONTROL
POLICY
1.
The Regional Health Authority shall have an Infection Control Policy and Program in
place to prevent, control and monitor the spread of infectious organisms between clients,
home care staff and home care equipment that is in accordance with the Saskatchewan
Health Communicable Disease Control Regulations and the Public Health Act.
GUIDELINES
1.
The Regional Health Authority should develop and implement policies and procedures
related to standard precautions and transmission-based precautions to guard against the
spread of pathogens through airborne, droplet, and contact means.
2.
The Regional Health Authority should provide regular updated information to home care
staff on infection control (i.e. continuing education workshops, in-services, newsletters
and other media).
3.
All home care staff should be familiar with the policies and procedures specific to their
role in infection control.
4.
All home care staff should be advised to be immunized against commonly communicable
diseases that may occur in the client group they are serving. Immunizations may include
Hepatitis A, Hepatitis B, Influenza, Measles, Mumps, Pneumococcal, Polio, Rubella,
Diphtheria and Tetanus 1.
5.
Home Care staff should have provisions in place for personal protective clothing and/or
equipment relevant to the health and safety of their workplace 2.
6.
All reusable home care equipment should be disinfected through an approved method
between uses on the same or different clients. Depending on the type of equipment, this
may be accomplished by submerging the instrument in boiling water for 10 to 20 minutes
or by submerging the instrument in a chemical disinfectant for the time period
1
2
MMR immunization is limited, i.e., if health care worker is born before 1970, they do not require immunization.
Safety glasses/shields, masks, latex/latex-free gloves, disposable moisture-proof pads/aprons, mouth-to-mouth
ventilation devices, alcohol based waterless agent, etc.
Community Care Section:
Index Ref: 18.2
Page 2
Date of Issue:
Home Care Policy
Occupational Health and Safety
September 2006
Revised September
2015
Subject:
Infection Control
recommended by the manufacturer. Home microwaves cannot be used to safely disinfect
equipment.
7.
The Regional Health Authority should have a policy and procedure to deal with exposure
to infectious materials/organisms that includes:
a)
the identification of workers who may be exposed;
b)
a description of ways infectious materials or organisms can enter the body of a
worker;
c)
a description of signs and symptoms of disease that may arise from exposure;
d)
appropriate first aid treatment to the exposure site;
e)
indications for prompt medical evaluation, counseling, and prophylactic
treatment;
f)
appropriate work restrictions for specific infections;
g)
infection control measures including the limitations of such measures;
h)
the reporting of cases of communicable diseases as mandated by the
Saskatchewan Health Communicable Disease Control Regulations and the Public
Health Act; and,
i)
annual infection control education and evaluation.
8.
Biomedical waste should be disposed of in accordance with the Saskatchewan
Biomedical Waste Management Guidelines.
References:
Chinnes, L.F., Dillon, A.M., & Fauerbach, L.L. (2002). Home care handbook of infection
control. Washington, DC: Association for Professionals in Infection Control and Epidemiology.
Health Canada. (2002). Canadian immunization guidelines. (6th ed.). Ottawa, ON: National
Advisory Committee on Immunization.
Health Canada. (2004). Population and public health and branch guidelines. Retrieved June 14,
2004 from www.hc-sc.gc.ca/pphb-dgspsp/dpg_e.html#infection
Saskatchewan Health. (1990). Communicable disease control manual. Regina, SK: Author.
Saskatchewan Health. (1998). Saskatchewan biomedical waste management guidelines. Regina,
SK: Author.
Community Care Section:
Index Ref: 18.3
Page 1
Date of Issue:
Home Care Policy
Occupational Health and Safety
September 2006
Revised September
2015
Subject:
Lifting and Moving
18.3
LIFTING AND MOVING
POLICY
1.
The Regional Health Authority shall have a policy and procedure in place concerning any
lifting or moving that a home care worker must do in the course of their work. The
policy and procedure should aim to reduce the incidence and the potential risks of
musculoskeletal injuries among home care staff.
2.
The Regional Health Authority will have in place policies and procedures which are
compliant with The Occupational Health and Safety Act and regulations regarding lifting
and moving.
GUIDELINES
1.
The Regional Health Authority should provide the home care workers with instruction
and information on:
a)
assessment of load;
b)
equipment available to assist workers in their tasks; and,
c)
procedures to obtain mechanical equipment or assistance by another person.
2.
When risk is identified, workers must be informed regarding the risk and common
symptoms of musculoskeletal injuries, and be protected from the risk by:
a)
providing equipment designed to reduce the effects of the activity,
i.e., mechanical lifts; and,
b)
implementing appropriate work practices and procedures to reduce harmful
effects of an activity (e.g. always wash floors with a mop and pail, rather than
washing floors on hands and knees).
Community Care Section:
Index Ref: 18.4
Page 1
Date of Issue:
Home Care Policy
Occupational Health and Safety
September 2006
Revised September
2015
Subject:
Client Transportation
18.4
CLIENT TRANSPORTATION
POLICY
1.
The Regional Health Authority shall have a policy in place concerning the transportation
of clients in home care staff vehicles.
2.
Given that the provision of such transportation is a legal issue that involves the
consideration of liability concerns, Regional Health Authorities should seek legal
consultation when developing their policy.
3.
The following guidelines are only suggestions if the Regional Health Authority allows
staff to provide transportation to clients.
GUIDELINES
1.
Home Care Staff must possess a valid Saskatchewan Driver’s licence.
2.
The Regional Health Authority should consult with SGI regarding proper insurance and
registration procedures.
3.
Assistance to transfer a client in and out of a vehicle should be provided according to the
care plan.
4.
Clients with a history of violent or harassing behaviour should not be transported in a
staff vehicle.
Injection Safety Policies and Procedures
(Template)
This sample document should be modified to make it unique to your facility’s injection safety program
needs.
Purpose:
To prevent the spread of blood borne pathogens and bacterial infections through the use of
safe injection practices and ongoing standardized competency training.
Policy:
All members of the healthcare team will follow best practices guidance from the U.S. Centers
for Disease Control and Prevention (CDC) and Association for Professionals in Infection Control
(APIC) regarding the safe use of needles, syringes, medications, cannulas and intravenous
delivery systems.
Procedures:
The following procedures apply to the use of all needles, syringes, medication vials, intravenous
delivery systems and sharps containers.
1. Follow hand hygiene guidelines at all times;
a. Before patient contact
b. Before carrying out a clean/aseptic procedure such as handling an invasive device,
preparing injections
c. Immediately after contact with body fluids, mucous membranes or wound dressings
d. After touching patient surroundings, all inanimate surfaces in the patient care area and
upon leaving the patient room
2. Injections are prepared using aseptic technique in a clean area free from contamination or
contact with blood, body fluids, or contaminated equipment.
3. Needles and syringes are used for only one patient (this includes manufactured prefilled
syringes and cartridge devices such as insulin pens).
4. The rubber septum on a medication vial is disinfected with alcohol prior to piercing.
POLICY TEMPLATE
5. Medication vials are entered with a new needle and a new syringe, even when obtaining
additional doses for the same patient.
6. Single-dose or single-use medication vials, ampules, and bags or bottles of intravenous
solution are used for only one patient.
7. Medication administration tubing and connectors are used for only one patient.
8. Multi-dose vials are dated by healthcare worker when they are first opened and discarded
within 28 days unless the manufacturer specifies a different (shorter or longer) date for that
opened vial. Note: This is different from the expiration date printed on the vial.
9. Multi-dose vials are dedicated to individual patients whenever possible.
10. Multi-dose vials to be used for more than one patient are kept in a centralized medication
area and do not enter the immediate patient treatment area (e.g., operating room, patient
room/cubicle). Note: If multi-dose vials enter the immediate patient treatment area, they should be
dedicated for single-patient use and discarded immediately after use.
▪
Approved by (signature): _____________________________________________
▪
Date: _______________ Annual review date: _______________
Minnesota Department of Health
Infectious Disease Epidemiology, Prevention and Control
PO Box 64975, St. Paul, MN 55164
651-201-5414
www.health.state.mn.us
To obtain this information in a different format, call: 651-201-5414.
03/2018
2
OVERDOSE PREVENTION, RESPONSE, & POSTVENTION:
Promising Policies and Practices for
Organizations
2019
Health Resources in Action, Inc. (HRiA) is a nonprofit public health and medical research
funding organization based in Boston, Massachusetts whose mission is to help people live
healthier lives and build healthier communities through prevention, health promotion, policy, and
research.
Through the Opioid Overdose Prevention Training Project (OOPTP), HRiA provides training and
technical assistance in opioid overdose prevention, recognition, and response to staff and
service providers in community corrections centers, homeless shelters, family shelters, public
libraries, public housing, and other venues. The goal is to help staff prevent, prepare for, and be
able to respond to opioid overdose emergencies. The OOPTP is funded by the Massachusetts
Department of Public Health’s Bureau of Substance Addiction Services, whose funding comes
from a larger federal grant through the Substance Abuse Mental Health Services Administration
(SAMHSA).
The recommendations below aim to reduce fatal opioid overdoses in a variety of settings. This
includes but is not limited to community corrections centers, family and individual shelters, and
substance use treatment facilities. While these recommendations are focused on addressing
opioid overdose, implementing these recommendations may also be helpful in relation to other
medical emergencies or traumatic events.
This document provides guidance for the development, implementation, and updating of policies
and procedures within your organization. The needs and resources of every organization are
different. Many of these recommendations can be implemented on their own or combined with
existing policies. Please take these recommendations as a menu of suggestions to implement
and integrate into existing organizational policies.
Overdose Prevention, Response, & Postvention: Promising Policies and Practices for Organizations 2019 is funded by a grant from the Substance
Abuse and Mental Health Services Administration to the Massachusetts Department of Public Health, Bureau of Substance Addiction Services.
Table of Contents
Addressing Risks and Concerns ........................................................................................ 3
GOOD SAMARITAN LAW ......................................................................................................................... 3
FENTANYL EXPOSURE ........................................................................................................................... 3
Overdose Prevention .......................................................................................................... 4
BATHROOM SAFETY ............................................................................................................................... 4
MESSAGES TO PROMOTE SAFETY....................................................................................................... 6
Overdose Response ........................................................................................................... 7
TRAINING .................................................................................................................................................. 7
NALOXONE (NARCAN)........................................................................................................................... 7
PURCHASING NALOXONE (NARCAN) ................................................................................................. 8
IN THE EVENT OF AN OVERDOSE ......................................................................................................... 8
Overdose Postvention ........................................................................................................ 9
OFFER SUPPORT AND AN OPPORTUNITY TO DEBRIEF WITH STAFF ............................................. 9
REFRESH STAFF EDUCATION ............................................................................................................... 9
REPLENISH OVERDOSE KITS .............................................................................................................. 10
CREATE SAFETY PLANS WITH CLIENTS AND PARTICIPANTS AT HIGH RISK FOR OVERDOSE 10
Appendix A ....................................................................................................................... 12
RESOURCES FOR CLIENTS ................................................................................................................. 12
Appendix B ....................................................................................................................... 13
FAQs ........................................................................................................................................................ 13
Appendix C Sample Organizational Policy ...................................................................... 17
POLICY AND PURPOSE ......................................................................................................................... 17
GENERAL ................................................................................................................................................ 17
TRAINING ................................................................................................................................................ 17
PROCEDURE (REVIEWED IN YEARLY TRAINING) ............................................................................. 18
LEGAL/LIABILITY .................................................................................................................................... 18
2
Addressing Risks and Concerns
Your staff may be concerned about intervening during an overdose for fear of their own
safety or of being held liable should an overdose victim die after a staff member
intervenes. Below is information on legal protections and maintaining personal safety for
individuals responding to opioid overdose.
GOOD S AM ARIT AN LAW
40 states and the District of Columbia have enacted some form of a Good Samaritan or 911 Drug
Immunity Law to encourage people to seek out medical attention for an overdose or for follow-up care
after naloxone has been administered. These laws generally protect people when calling 911 or
intervening during a medical emergency. Specifically, they typically grant immunity from arrest, charge, or
prosecution for controlled substance possession and paraphernalia offenses when a person overdoses or
a person attempts to rescue another person overdosing by seeking help. Some states provide immunity
from violations of pretrial, probation, or parole conditions and violations of protection or restraining orders
in these circumstances. Bystanders are protected from liability when acting in good faith to respond to a
medical emergency such as an opioid-related overdose. The Commonwealth of Massachusetts has a
Good Samaritan Law which explicitly provides immunity from criminal prosecution to anyone who seeks
medical assistance for themselves or another person who is experiencing a drug-related overdose.
Limitations of the Massachusetts Good Samaritan Law
•
The Good Samaritan Law does have limitations. You can be arrested for possessing the
following, also known as the “3 Ws”:
—
Weapons
—
Warrants (out for someone’s arrest)
—
Weights (large quantities of drugs)
FENTANY L EXPOSURE:
Staff may be concerned about their personal safety when responding to an overdose due to exposure to
fentanyl. Fentanyl, like other opioids, can cause overdose when it is injected, sniffed, or taken by mouth.
Fentanyl powder does not cause overdose by touching it alone. If any suspicious powder is present, it is
prudent to wear gloves. Further information and recommendations on fentanyl and safety are available
here:
•
White House recommendations on fentanyl can be found here: http://bit.ly/whfentanylsafety.
•
The American College of Medical Toxicology also has a statement on fentanyl exposure, which
can be found on their website at http://bit.ly/acmtfentanyl.
•
Other questions around fentanyl can be found in Appendix B of this document.
3
Overdose Prevention
The recommendations below are intended to prevent fatal opioid overdoses before
they occur.
BATHROOM S AFETY:
All public restrooms are places where people may use drugs. The tools below are recommended to make
bathrooms safer:
Ensure adequate bathroom monitoring while continuing to respect individuals’ dignity and
privacy. Options include:
•
Assign a staff member to monitor bathrooms with a door knock every 3-5 minutes.
•
Lock bathroom doors, requiring people to ask for a key or pass code so staff are aware of when
the bathroom is occupied and how long it has been occupied. Implemented with a timer policy,
this ensures that if someone is in there for longer than 3-5 minutes they will be checked on.
•
Install an intercom (call button) to communicate with someone using the bathroom without having
to knock or open the door to ensure someone’s safety. Many intercom systems also have call
buttons that allow the person in the bathroom to call for help on their own, if they are able.
Intercom systems are best used to complement the use of timers or time limit policies.
•
Install a reverse motion detector.
•
________________________________________
—
A reverse motion detector is a
bathroom monitoring system
that will sound an alarm if
someone who has entered a
bathroom does not move for a
set amount of time (usually two
minutes).
—
Reverse motion detectors can
either complement or be an alternative to timers or time limit policies.
________________________________________
Assigning staff to monitor the bathrooms with a
________________________________________
knock every 3-5 minutes can prevent a fatal
overdose from occurring in a bathroom setting.
Assigning staff to monitor the bathrooms with a
________________________________________
knock every 3-5 minutes can prevent a fatal ov
In single stall or full-door bathrooms, remove the bottom 6 inches from the bathroom door to
make it easier to see if a patron is on the ground in distress/overdosing.
Post bathroom policies on or outside the door.
•
Indicate the set time that people can use the bathroom before someone checks on them. Clearly
communicate to all staff and those using the bathroom how often and in what manner the policies
are enforced.
•
Indicate access instructions clearly outside the door, in cases when a key or pass code is
required for access.
4
Ensure that staff can easily unlock and access the bathroom if someone were to require
emergency assistance inside. This may include:
•
Providing the bathroom key/code to multiple staff members to ensure someone on site always
has a key available.
•
Having a designated place for staff to access a bathroom key in case of emergency.
•
Ensuring that bathroom doors open out.
—
When doors open in, a person may not be able to push the door open if there is a body or
something else blocking the way.
—
Having doors that open out from the bathroom will allow someone to get to an overdose
victim or other unresponsive individual quickly and easily.
Install Secure Sharps Boxes in all bathrooms.
•
Sharps boxes can allow for proper and safe disposal of used needles. This has benefits for the
broader community as well because it makes it less likely that people will dispose of used
needles in trashcans, toilets, or public areas.
•
Sharps boxes should be placed in each bathroom, and some sites may choose to include contact
information for the nearest syringe services program (SSP) on the box. A list of SSPs in
Massachusetts can be found at http://bit.ly/massplocations.
—
•
Engaging with SSPs can help people who use drugs learn harm reduction strategies and
reduce their risk of fatal overdose and other negative outcomes. Including this information
in the bathroom can increase access for participants.
Some SSPs offer sharps pick-up. Contact your local SSP for more information.
Easy access to naloxone (Narcan )
________________________________________
•
Equip your organization’s bathrooms with
Easy accessibility to naloxone is crucial to ensure
a naloxone rescue kit. Ensure that each
an adequate response to an overdose.
bathroom has a naloxone rescue kit that is
________________________________________
easily accessible to anyone who may
need it (i.e. not in a locked drawer or
desk). Naloxone should be accompanied by other rescue and protective equipment including
pocket masks, gloves, bag-valve mask, etc., as well as brief steps for responding to an overdose.
•
If it is not feasible to have a rescue kit in or directly outside each bathroom, post clear signage
that indicates where naloxone is in case of emergency.
•
See Appendix A for additional information on where and how to obtain naloxone.
5
M ESSAGES TO PROM OTE S AFETY
•
Post signs suggesting ways to keep oneself safer if using drugs.
—
For example, signs can promote proper syringe disposal or explain risk factors for an
overdose (such as using alone) and ways to mitigate those risks.
•
Share pamphlets promoting resources including treatment options, harm reduction programs, and
where to obtain naloxone.
•
Educate staff on overdoses and how to administer naloxone.
—
Seek opportunities or formalize a process discussing overdose prevention with clients,
participants, tenants, and residents whenever possible, such as: at intake, when looking
at waitlists, during trauma screening or individual/group counseling, at discharge, and
after an overdose.
_______________________________________________________________________________
Overdose prevention and other materials can be ordered free through
the Massachusetts Health Promotion Clearinghouse:
https://massclearinghouse.ehs.state.ma.us/category/BSASOVD.html
_______________________________________________________________________________
6
Overdose Response
The recommendations below offer guidance on responding to an opioid overdose. This
includes steps we recommend taking in advance, as well as the steps for performing a
rescue in the event of an opioid overdose.
TRAINING
•
Offer staff trainings annually and as part of new employee orientation. Ensure all staff (on all
shifts) are trained in overdose response, including security guards, program managers, cleaning
and maintenance staff, and all others. Training may be accessed through Health Resources in
Action by emailing grolfe@hria.org or through local Overdose Education and Naloxone
Distribution (OEND) Sites. Find OEND sites here: http://bit.ly/dph_oend.
•
Boston Public Health Commission has created short videos in English (http://bit.ly/2VDIEyP) and
Spanish (http://bit.ly/2JJJv9N) that can be used to supplement in-person overdose prevention and
response training.
•
Practice overdose response drills on a regular basis so staff are prepared in the case of an
emergency.
NALOXONE (N ARC AN  )
•
•
Place naloxone rescue kits in easily accessible places. Naloxone should be accompanied by
other rescue and protective equipment such as pocket masks, gloves, and bag-valve mask, as
well as brief steps for responding to an overdose. Try to standardize naloxone placement in
multiple rooms/floors throughout your building, similar to how Automated External Defibrillators
(AEDs) and first aid kits may be accessible.
—
Do not lock up naloxone rescue kits.
—
Place clear and prominent signage indicating where kits are located.
Track the expiration date and availability of the naloxone and replace as necessary.
—
This can be done in a variety of ways depending on organizational and individual needs
and preferences. For example, when placing kits, you can set calendar reminders before
they expire or check the expiration of kits along with other routine tasks (such as after
completing a monthly assignment, weekly timesheet, etc.).
—
If you have placed naloxone rescue kits in busy or public areas of your site, check
routinely to ensure they are still there. Replenish as necessary.
•
Hang educational posters throughout your site. The posters can alert staff and clients about the
use of naloxone as part of an overdose response protocol, where naloxone can be obtained,
and/or where training is offered.
•
Develop organizational policies that document all of the above decisions about training frequency,
naloxone placement, and rescue kit storage, maintenance, and replacement.
—
A sample of the San Francisco Public Library Opioid Overdose Response Procedure can
be found in Appendix C.
7
PURCHASING N ALOXONE (N ARC AN  )
•
Each municipality and non-municipal agency needs a single Massachusetts Controlled
Substances Registration (MCSR) for their public employees to administer naloxone or other
approved opioid antagonists. More information on MCSRs can be found here:
http://bit.ly/mamcsr.
IN THE EVENT OF AN OVERDOSE
•
•
Develop an on-site overdose prevention and response plan.
—
This should describe how staff will monitor clients/participants/tenants who appear
sedated, and how they will recognize and respond to an overdose emergency.
—
An example of an Opioid Overdose Response Procedure, used by the San Francisco
Public Library, can be found in Appendix C.
Designate Roles/Steps
—
With any type of emergency, it is vital that staff and workers have designated roles and
responsibilities. It is possible for one person to effectively respond to an overdose, but we
recommend the following roles as examples:
1. One person who gets the naloxone kit(s).
2. One person who administers the naloxone and provides rescue breathing.
3. Multiple people may be able to give rescue breaths by taking turns or rotating
roles.
4. One person who calls 911.
5. One person who stands outside and directs EMTs to where the overdose has
occurred.
6. One or more people to keep track of how much time has passed, how long the
victim has been unconscious, how many doses of naloxone have been given,
etc.
7. One or more people to usher other tenants, clients, or participants away from the
emergency if they are not actively helping.
8. Post-overdose: a manager should check in with staff and lead a debriefing and
make sure that staff take a break if needed (see more in next section).
—
In the event a single person is responding to an overdose, the recommended response
steps are:
1. Recognize overdose.
2. Call 911.
3. Administer naloxone as soon as available.
4. Begin rescue breathing (1 big breath every 5 seconds).
5. Stay with the person until help arrives.
• Place them in recovery position (http://bit.ly/2JGXWvr) if you need to leave
for any length of time.
8
Overdose Postvention
The recommendations below are intended for actions to take after an overdose occurs.
OFFER SUPPORT AND AN OPPORTUNITY TO DEBRIEF WITH STAFF
Take some time to debrief with staff who were present during the overdose. Discuss what happened, how
the team responded, how they are feeling, any additional support they may need, and how the team
might have responded differently at another time. Check in together again later in the day and, if needed,
in the days or weeks that follow, and connect staff to support resources.
•
This debriefing will look different depending on your organization and circumstances.
The following are some recommendations regarding how to approach a post-overdose
conversation:
—
Be prepared to hold a debrief that could last anywhere from 5 minutes to an hour.
1. A manager, human resources staff, or an external counselor can lead these
debriefs.
—
If possible, allow for the site to close for a short period to give staff time to take a walk,
get a coffee, or do another self-care activity.
1. If this is not possible, try to allow staff a quiet space and/or some time away from
the site. This may occur in shifts/on rotation depending on the circumstances.
•
—
Include discussion of overdose prevention and response in team lunches or half/full day
retreats for healing and team-building.
—
If individual staff need extra support, have a plan in place for individual clinical
supervision in addition to group clinical supervision.
—
If clinical supervision is not currently in place, set up a regular group clinical supervision
for the staff.
—
Allow staff to schedule counseling sessions, attend support groups, or participate in
another self-care activity during the work day as needed and when possible.
Revise policies/procedures as needed, based on what was learned from this experience
and staff feedback.
REFRESH STAFF EDUCATION
•
Ensure that staff know how to assess overdose risk among those who may have been using with
the individual who overdosed.
•
Confirm staff feel confident about talking with clients about overdose prevention and/or safer use.
•
Discuss ways to share information about who the staff consider are at high risk to experience an
overdose (i.e. do you have clients who have overdosed in the past? Do you have clients who
have had brief or sustained periods of abstinence? Do you have clients who tend to use alone?).
9
•
•
Ensure staff have updated lists of ongoing
support groups, naloxone trainings, and
other relevant resources to share. The
Massachusetts Substance Use Helpline
(https://helplinema.org) can be a resource
for anyone seeking substance use
treatment or harm reduction services.
Once staff feel ready, run a skill-building
practice session where people go over the
steps of responding to an overdose
through hands-on role playing.
________________________________________
Ensure staff have updated lists of ongoing support
________________________________________
groups, naloxone trainings, and other relevant
________________________________________
resources to share. The Massachusetts
Substance Use Helpline can be a resource for
anyone seeking substance use treatment or harm
reduction services.
________________________________________
REPLENISH OVERDOSE KITS
•
Add new naloxone and other needed supplies like face masks or gloves to rescue kits, even if
just one naloxone dose was used.
CREATE S AFETY PLANS WITH CLIENTS AND P ARTICIP ANTS AT HIGH
RISK FOR OVERDOSE
•
Both people engaged in treatment and those not engaged are at risk for overdose, so anyone
who has used opioids should have an overdose prevention safety plan.
•
Staff can work with clients at high risk of overdose to develop a safety plan, which can minimize
the risk of overdose and other negative health outcomes.
—
Questions to consider when helping someone plan for safety:
1. What does the person’s overdose prevention plan look like, if they have one?
•
What is the person’s plan to avoid using alone?
•
Where will the individual keep their naloxone?
•
What type of setting do they typically use in?
•
How does the person feel about calling 911 if they were to witness an
overdose?
2. Where can the person access clean and sterile injecting equipment?
3. Are they aware of the risk factors of overdose and fatal overdose (i.e. using
alone, periods of abstinence, etc.)?
•
Additional information for public health workers on postvention efforts can be found in Franklin
Cook’s Coping with Overdose Fatalities (http://bit.ly/cwodf) document.
10
11
Appendix A
RESOURCES FOR CLIENTS
OEND Sites
•
Contact Overdose Education and Naloxone Distribution (OEND) Sites (http://bit.ly/dph_oend) to
obtain naloxone and trainings.
•
Consumers can obtain free naloxone from all OEND sites in Massachusetts.
Syringe services programs (SSPs)
•
Visit SSPs (http://bit.ly/massplocations) to get sterile (new) needles and syringes free of cost,
dispose of used needles and syringes, and get connected to other services such as testing for
hepatitis C, HIV and other sexually transmitted infections, overdose education, and naloxone.
•
Many SSPs and OEND sites offer both services.
Boston Public Health Commission - Overdose Prevention and Bystander Training
•
Free online course that provides information about the opioid epidemic and how to recognize and
respond to an opioid overdose
•
Includes practical, step-by-step guidance for performing rescue breathing and administering
naloxone
•
Can receive Certificate of Training once course is completed
•
Visit this website for more information: http://bit.ly/dvlcbphc.
Massachusetts Substance Use Helpline
•
Free and anonymous resource to find substance use treatment, recovery, and harm reduction
resources anywhere in Massachusetts
•
Toll-free phone: 800-327-5050
•
Website: HelplineMA.org
12
Appendix B
FAQs
Where has carfentanil appeared in the US? If not in Massachusetts, what states have been
seeing it?
Carfentanil is a fentanyl analog, as is furanylfentanyl, and acetylfentanyl. Unlike carfentanil, which is
about 10,000 times more potent than morphine, furanylfentanyl, and acetylfentanyl is estimated to be less
potent than fentanyl (these estimates vary).
•
From July-December 2016, the CDC looked at data from 10 states that are part of the State
Unintentional Drug Overdose Reporting System (SUDORS). In this time, there were 5,152 opioid
overdose deaths across these states. 720 (14%) had a fentanyl analog present. Carfentanil was
present in 389 (7.6%) of the total deaths. Find the report here: http://bit.ly/2w44IDr.
Number and percentage of opioid overdose decedents testing positive for fentanyl analogs and U-47700 —
10 states, July–December 2016. For full table: https://www.cdc.gov/mmwr/volumes/66/wr/mm6643e1.htm
STATE
TOTAL OPIOID
OVERDOSE
DEATHS
ANY FENT ANALOG PRESENT, NO. (%)
CARFENTANIL,
NO. (%)
Total
5,152
720 (14.0)
389 (7.6)
Maine
154
44 (28.6)
0
Massachusetts
1,071
17 (1.6) (reported analogs were furanylfentanyl
(10) and acetylfentanyl (est. 5)
0
NH
131
16 (12.2)
0
New Mexico
166
11 (6.6)
0
Ohio
2,043
531 (26.0)
354 (17.3)
West Virginia
393
79 (20.1)
35 (8.9)
Wisconsin
413
14 (3.4)
0
MO (22 counties),
OK & RI
781
8(1.0)
0
13
•
CDC data from 10 states (SUDORS) between July-December 2016 shows carfentanil deaths in
Ohio and West Virginia, with Ohio leading as 17.3% of their total opioid overdose deaths involved
carfentanil. In all of 2016, Florida reported over 500 carfentanil deaths.
•
Ohio is a state to watch. CDC data from SUDORS states is showing a pattern where soon after
carfentanil deaths in Ohio peak, other states observe a spike. CDC information from July 2016June 2017 shows that when rates of carfentanil related deaths decreased, the number of deaths
with any fentanyl analog increased — mainly furanylfentanyl, and acetylfentanyl. 1
Have we been seeing carfentanil in Massachusetts?
•
While CDC data has not captured any carfentanil related deaths in MA, two deaths involving
carfentanil were reported in local news in July of 2017. 2
•
Carfentanil has been identified in a lab analysis of samples from MA State Police. Local news
reported on three samples containing carfentanil in June of 2017. By September 2017, the lab
had identified a dozen samples of carfentanil. 3
What happens physiologically when someone experiences “wooden chest” during a fentanyl
overdose? Given that opioids are depressants, what happens in the body that gives way to this
seizing of the muscles in the upper body?
•
Chest wall rigidity, or “wooden chest,” is observed with fentanyl and other lipophilic synthetic
opioids and causes the muscles in the chest and abdominal muscles to become rigid. Chest
wall rigidity makes it difficult to provide assisted ventilation, or rescue breathing. When wooden
chest is present, it is important to perform rescue breathing through the nose in addition to
through the mouth. 45
•
Chest wall rigidity is not completely understood, but there are case studies with patients in
hospital settings who have adverse reactions to fentanyl when administered for surgery.
Researchers do not believe it is related to the depression of the respiratory drive that is typically
seen with opioid overdoses.
1
O’Donnell J, Gladden RM, Mattson CL, Kariisa M. Notes from the Field: Overdose Deaths with Carfentanil and
Other Fentanyl Analogs Detected — 10 States, July 2016–June 2017. MMWR Morb Mortal Wkly Rep 2018;67:767–
768. https://www.cdc.gov/mmwr/volumes/67/wr/mm6727a4.htm
2 Croteau, S. (2017, July 17). 2 people dead, 1 person hospitalized in suspected drug overdoses in Lawrence.
MassLive. Retrieved from
https://www.masslive.com/news/index.ssf/2017/07/2_people_dead_1_person_hospita.html
3 AP. (2017, Sept 26). Mass State Police: Opioid carfentanil found in a dozen samples this year. Boston News.
Retrieved from https://www.boston.com/news/local-news/2017/09/26/mass-state-police-opioid-carfentanilfound-in-dozen-samples-this-year
4 Çoruh,B., Tonelli, M.R., & Park, D.R. (2013). Fentanyl-induced chest wall rigidity. Chest, 143(4).
https://www.ncbi.nlm.nih.gov/pubmed/23546488
5 Phua, C.K., Wee, A., Lim, A., Abisheganaden, J., & Verma, A. (2017). Fentanyl-induced chest wall rigidity syndrome
in a routine bronchoscopy. Respiratory Medicine Case Resports, 20, 205-207.
https://www.ncbi.nlm.nih.gov/pubmed/28337407
14
Chest wall rigidity risk factors:
1. Dose and rapidity of injection of opioids
2. Extremes of age (newborns and elderly)
3. Critical illness with neurologic or metabolic diseases
4. Use of medications that modify dopamine levels
Helping someone experiencing wooden chest:
•
In hospital settings, naloxone has worked to alleviate chest wall rigidity. As this involves a
seizing of the muscles, administering a short-acting neuromuscular blockade has been
effective in some cases. Additionally, one can continue providing ventilator support and
rescue breathing both through the nose and mouth.
Some organizations that are licensed through MA DPH (but not through BSAS) view that having
naloxone on site is a liability; these Bureaus within DPH will not allow these organizations to have
naloxone on the premises.
Should there be an adverse event, and those involved acted in good faith, responsibility would not fall on
those individuals or the site.
•
Title IV Chapter 258C Section 13: ''Good Samaritans;” liability6
—
•
Title XVI Chapter 112 Section 12FF: Immunity of person administering naloxone or another opioid
antagonist to person experiencing opiate-related overdose7
—
•
“No person who, in good faith, provides or obtains, or attempts to provide or obtain,
assistance for a victim of a crime as defined in section one, shall be liable in a civil suit for
damages as a result of any acts or omissions in providing or obtaining, or attempting to
provide or obtain, such assistance unless such acts or omissions constitute willful,
wanton or reckless conduct.”
“Any person who, in good faith, attempts to render emergency care by administering
naloxone or any other opioid antagonist, as defined in section 19B of chapter 94C, to a
person reasonably believed to be experiencing an opiate-related overdose, shall not be
liable for acts or omissions resulting from the attempt to render this emergency care;
provided, however, that this section shall not apply to acts of gross negligence or willful or
wanton misconduct.”
Title XV Chapter 94C Section 19: Prescription; restrictions on issuance8
—
“…The responsibility for the proper prescribing and dispensing of controlled substances
shall be upon the prescribing practitioner, but a corresponding responsibility shall rest
with the pharmacist who fills the prescription…
6
https://malegislature.gov/Laws/GeneralLaws/PartIII/TitleIV/Chapter258c/Section13
https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXV/Chapter94C/Section34A
8 https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXV/Chapter94C/Section19
7
15
—
(d) Naloxone or other opioid antagonist may lawfully be prescribed and dispensed to a
person at risk of experiencing an opiate-related overdose or a family member, friend or
other person in a position to assist a person at risk of experiencing an opiate-related
overdose. For purposes of this chapter and chapter 112, any such prescription shall be
regarded as being issued for a legitimate medical purpose in the usual course of
professional practice.”
What is the possibility of experiencing an overdose from fentanyl becoming “airborne?” Is there a
possibility of experiencing an overdose simply from touching fentanyl?
1. The Safety Recommendations for First Responders published by the White House states that
while the inhalation of airborne fentanyl powder would likely have harmful effects, it is less likely
to occur than skin contact, which is already unlikely. Skin contact with fentanyl does not have any
expected harmful effects.9
•
Additionally, the American College of Medical Toxicology and American Academy of Clinical
Toxicology released a position statement on Preventing Occupational Fentanyl and Fentanyl
Analog Exposure to Emergency Responders in July of 2017. In the case of airborne fentanyl, they
state that the risk of experiencing an overdose due to fentanyl inhalation is minute. It takes about
200 minutes of exposure to airborne fentanyl to reach a dose of 100 micrograms. Additionally, the
vapor pressure of fentanyl is very low, so it is unlikely that it would evaporate into a gaseous
phase.10,11
•
Inhalation is only a concern if the drug particles are suspended in the air. An unlikely event that
may involve lethal doses of fentanyl or fentanyl analogs is one involving a weaponized aerosol
containing the drug.
•
Should one be concerned about significant exposure to airborne fentanyl, a properly fitted
respirator or mask should provide sufficient protection.
9
https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final STANDARD size of Fentanyl Safety
Recommendations for First Respond....pdf
10 ACMT site; information on fentanyl exposure precautions
https://www.acmt.net/cgi/page.cgi/_zine.html/The_ACMT_Connection/ACMT_Statement_on_Fentanyl_Exposure
11 ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to
Emergency Responders. https://www.acmt.net/_Library/Positions/Fentanyl_PPE_Emergency_Responders_.pdf
16
Appendix C
Sample Organizational Policy
San Francisco Public Library
OPIOID OVERDOSE RESPONSE PROC EDURE
APPROVED BY: Office of the City Librarian
Date: August 22, 2017
Staff Responsible for Training Coordination:
SUBJECT: Opioid Overdose Prevention and Response Protocol
POLICY AND PURPOSE:
To prevent fatal opioid overdose and to intervene rapidly and effectively in the event of an opioid
overdose to ensure the best possible health outcomes for all library patrons.
GENERAL:
The community served by the San Francisco Public Library (SFPL) includes opioid users who may be at
risk for a potential overdose. Whenever a library patron is suspected of overdosing, City emergency
services are called. However, there are many interventions to assist during a potential opioid OD that staff
can do while waiting for emergency services to arrive.
TRAINING:
SFPL will provide a voluntary overdose response training for all security and library staff once per year
and ensure that all new staff members are offered the option of training in overdose prevention and
response protocol as part of their orientation.
Training is provided by the Drug Overdose Prevention and Education (DOPE) Project. The DOPE Project
is contracted and registered with the San Francisco Department of Public Health to provide overdose
response training and naloxone to San Francisco service providers free of charge pursuant to Section
1714.22 of the Civil Code.
17
PROCEDURE (REVIEWED IN Y EARLY TRAINING):
1. If a library patron is unresponsive and/or unconscious and SFPL staff suspects the patron may be
suffering from an opioid overdose, staff should try to wake the patron. If staff is unable to wake
the patron, staff should check breathing. If the patron is not breathing the staff member should
immediately alert another staff member and engage Emergency Medical Services (EMS) by
calling 911. Communicate to EMS dispatch: “person is unresponsive and not breathing, possible
overdose, please have naloxone/Narcan.”
2. Only staff members who have received the training offered by SFPL/DOPE under this policy in
overdose recognition, response, and naloxone administration may determine whether the
patron’s condition requires naloxone and, if so, may administer naloxone to the patron consistent
with that training. Naloxone is stored in the First AID kits at the location’s information desk(s) on
each floor. Staff will administer one dose of naloxone to the patron (naloxone may be
administered nasally, which is the type of naloxone available at library locations).
3. If staff is trained in CPR, they may begin standard CPR after the first dose of naloxone has been
administered, including rescue breathing (OD is a respiratory emergency, not necessarily a
cardiac emergency, please perform rescue breathing in addition to chest compressions if
comfortable). If available, an Ambu Bag (artificial breathing) can be used instead.
4. If there is no response to the naloxone from the patient after 2-3 minutes, staff shall administer a
second dose of naloxone and continue with CPR/rescue breathing while awaiting EMS.
5. EMS will assess patient and either transport to the hospital or patient will refuse transport.
Patients refusing transport will be asked to leave library property for the remainder of the day.
LEGAL/LIABILITY:
Under California law, a prescriber may issue a standing order authorizing the administration of naloxone
by any trained layperson to someone who may be experiencing an opioid overdose. If the program does
not have an authorized prescriber (anyone who has prescribing privileges in the state of California), then
they may work with a program that provides training and naloxone distribution to come provide training
to staff.
Pursuant to Section 1714.22 of the California Civil Code:
For purposes of this section, the following definitions shall apply:
1.
“Opioid antagonist” means naloxone hydrochloride that is approved by the federal Food and
Drug Administration for the treatment of an opioid overdose.
2.
“Opioid overdose prevention and treatment training program” means any program operated by a
local health jurisdiction or that is registered by a local health jurisdiction to train individuals to
prevent, recognize, and respond to an opiate overdose, and that provides, at a minimum, training
in all of the following:
A. The causes of an opiate overdose.
B. Mouth to mouth resuscitation.
C. How to contact appropriate emergency medical services.
D. How to administer an opioid antagonist.
18
3. A licensed health care provider who is authorized by law to prescribe an opioid antagonist may
issue standing orders for the administration of an opioid antagonist to a person at risk of an
opioid-related overdose by a family member, friend, or other person in a position to assist a
person experiencing or reasonably suspected of experiencing an opioid overdose.
E. A person who is prescribed or possesses an opioid antagonist pursuant to a standing
order shall receive the training provided by an opioid overdose prevention and treatment
training program.
F. Notwithstanding any other law, a person who possesses or distributes an opioid
antagonist pursuant to a prescription or standing order shall not be subject to
professional review, be liable in a civil action, or be subject to criminal prosecution for this
possession or distribution. Notwithstanding any other law, a person not otherwise
licensed to administer an opioid antagonist, but trained as required under paragraph (1)
of subdivision (d), who acts with reasonable care in administering an opioid antagonist, in
good faith and not for compensation, to a person who is experiencing or is suspected of
experiencing an overdose shall not be subject to professional review, be liable in a civil
action, or be subject to criminal prosecution for this administration.
Director:
Date:
19
MDPH Vaccine Management
Unit Phone # 617-983-6828
Vaccine Management Standard Operating Procedure (SOP) Template
Purpose: To ensure the vaccine cold-chain is maintained for optimum potency.
Instructions:
- Review and update document annually, when vaccine management policies change, and when staff
with designated vaccine management responsibilities change.
- Post on or near vaccine storage unit(s).
- All staff handling vaccines including only in emergency settings must read, sign, and adhere to the
protocols described in this document.
Office/Practice Name
Pin Number
Vaccine Coordinators
Primary Vaccine Coordinator
Back-Up (Alternate) Vaccine Coordinator
Name
Phone Number
Email Address
Date of VFC
Date:
Date:
Compliance and
 in-person  webinar  conference
 in-person  webinar  conference
Vaccine S&H Training
*Notify the Vaccine Management Unit within 10 days if a new Primary Vaccine Coordinator or Backup is
identified.
Emergency Vaccine Storage Location
Location Name
Location Address
Contact Name:
Contact phone #
Does the vaccine storage location have a pharmaceutical grade refrigerator for storage?
Date of confirmation that location is still available for use as a back-up location:
Additional Contact Information (ex. Nurse Coordinator, pharmacist, maintenance, etc.)
Vaccine Management SOP- MDPH
1
Jan 2021
MDPH Vaccine Management
Unit Phone # 617-983-6828
Vaccine Storage & Handling
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Refrigerators/freezers designated for vaccine storage are required to maintain the proper temperature.
Pharmaceutical-grade refrigerators are required for refrigerated vaccine storage for all facilities that
administer at least some vaccines to those <19 years of age, excluding sites that only administer flu vaccine.
This requirement applies to all state-supplied vaccine storage units.
The use of any household combination refrigerator/freezer unit for storage of any vaccines including
temporary storage is strictly prohibited.
Refrigerated vaccines should be stored within the temperature range of 2° C to 8° C in a pharmaceutical-grade
refrigerator designated for vaccine storage only.
Varicella and MMRV vaccine must be stored in a stand-alone freezer that maintains a temperature
between -50° C and -15° C. Store MMR vaccine in the freezer to reduce the likelihood of a vaccine loss due
to a refrigeration issue.
Do not store anything on top of the storage unit which could prevent the door from completely closing.
Rotate stock ensuring that short-dated vaccine is used first.
Mark or identify inventory to differentiate state-supplied and privately purchased vaccine.
Place the digital data logger probe in a central area of the refrigerator and freezer unit affixing it to the shelf,
adjacent to the vaccine.
Do not store food or beverages in vaccine storage units.
Store vaccines centrally in the refrigerator or freezer, and away from walls to allow for proper air circulation.
There should be sufficient space between rows of vaccine boxes or bins and shelving units to allow proper air
circulation. Do not over crowd refrigerators, especially during flu season.
Store cold/gel packs in the refrigerator as part of your emergency preparedness, in case the need arises to
transport vaccine during an emergency.
Stabilize freezer temperatures by placing freezer packs where there is empty space.
Post a “DO NOT UNPLUG” sign next to the electrical outlet for all vaccine storage units and post a “DO NOT
DISCONNECT” sign next to the circuit for any vaccine storage units on the circuit breaker.
Plug all vaccine storage units directly into a wall outlet. Check with electrician to see if a ‘dedicated line’ is
needed for your refrigerator(s).
Never plug storage units into power strips, surge protectors or use extension cords. Never plug storage units
into Ground Fault Circuit Interrupter outlets (GFC).
Temperature Monitoring
• All vaccine storage units holding state-supplied vaccines must be monitored by a digital data logger. The
digital data logger must have a calibrated glycol-encased probe and be certified by an appropriate agency (e.g.
National Institute of Standards and Technology).
• Monitor refrigerator/freezer daily minimum and maximum temperatures and acknowledge twice daily by
pressing the read button on the Fridge Tag 2L data logger. The read button must be pushed 4 times in the
AM and two times in the PM to fully review and acknowledge all temperatures. Other monitoring systems
Vaccine Management SOP- MDPH
2
Jan 2021
MDPH Vaccine Management
Unit Phone # 617-983-6828
•
must have this capability and will need prior authorization to be used by the MDPH Vaccine Management
Unit. A certificate of calibration must be kept on file.
If your state-supplied data logger is broken, call the Vaccine Management Unit for immediate replacement.
Vaccine Receiving
• Staff receiving shipments (front office, loading dock, reception, etc.) must notify the vaccine coordinators as
soon as a vaccine shipment arrives.
• Open shipping container immediately upon arrival. Check the two transit temperature monitors for those
shipments sent from McKesson. If temperature monitors indicate a possible temperature deviation, contact
McKesson Specialty at (877) 822-7746 and the Vaccine Management Unit by the end of the day.
• For direct ship vaccines from Merck, check the shipment date located on the packing list. Varicella shipments
can be sent in a 2-day or 4-day box. MMRV shipments are always shipped in a 24-hour box. Contact Merck
Order Management Center by the end of the day of receipt (800-637-8579) and the Vaccine Management
Unit if date received is greater than the shipper insert indicates.
• Count vaccines in shipment and compare with packing list and original order to make sure the order and
delivery is correct. Check to ensure that expiration dates and lot numbers match. Make sure diluent is also
accounted for.
• Ensure that all containers noted on the packing list have been delivered. Retain packing lists for 3 years.
• Place vaccine in the refrigerator/freezer designated for vaccine storage immediately after an inventory of the
shipment is completed.
• Contact the Vaccine Management Unit immediately for guidance if there are any concerns or inaccuracies
with the vaccine order.
Vaccine Transportation Procedures
• Contact the Vaccine Management Unit whenever you are considering transporting state-supplied vaccines
outside of your facility to ensure you have the most relevant guidance and advice for your specific situation.
• Obtain and store an adequate number/amount of appropriate packing containers and materials (e.g., frozen
and refrigerated gel packs, bubble wrap) needed to pack vaccines for safe transport.
• If a site is transferring all of their vaccine due to a power outage or refrigerator malfunction, they must ensure
that the primary data logger is always kept with state-supplied vaccine.
• In cases where you are transporting a smaller amount of vaccine because you are transferring
doses to another site, call the Vaccine Management Unit for more guidance.
• Use separate packing containers for refrigerator stored vaccines and freezer stored vaccines. Label outside of
packing container ‘Must Store in Refrigerator’ or ‘Must Store in Freezer’.
• Refrigerated gel packs should be placed in the container used to transport refrigerated vaccines. Separate
the vaccine from the cold packs with cardboard and /or bubble wrap. Never place frozen gel packs or ice
packs with refrigerated vaccines.
• Frozen gel packs should be placed in the container to transport frozen vaccines. (Dry ice is not
recommended for the transport of frozen vaccines. It is too cold.)
• Place a digital data logger in each packing container near the vaccine to monitor the temperatures.
• Record the time and temperature when vaccine was removed from the storage units and placed in the
containers at the beginning and end of the transport on the Temperature Troubleshooting log.
• Transport of vaccines is considered a temperature excursion
• Do not administer the vaccine
• Upload the temperature log into the MIIS
• Contact the Vaccine Management Unit with the amount of time that vaccine was out of a refrigerator or
freezer and the warmest and coldest temperatures recorded.
• Do not discard vaccine without contacting the Vaccine Management Unit for guidance.
Vaccine Management SOP- MDPH
3
Jan 2021
MDPH Vaccine Management
Unit Phone # 617-983-6828
Vaccine Ordering and Inventory Control
• Place vaccine orders through the MIIS Vaccine Management Module and upload the most recent temperature
logs for all vaccine storage units within one day of submitting order.
• Upload all temperature logs monthly even if not placing monthly vaccine orders. Data loggers only hold
56 days of temperatures.
• Complete a physical inventory of all vaccines in the refrigerator(s) and freezer(s), checking expiration dates at
least monthly and before placing an order.
• Order when vaccine inventories reach about a 4 week supply.
• Establish a routine to order no more than once per month.
• Contact the Vaccine Management Unit to update any changes in shipping address. Changes to shipping hours
or shipping contact can be updated directly in the MIIS. Vaccines will be based on shipping information in the
MIIS.
• Transfer short-dated vaccines to another pediatric provider 2-3 months prior to expiration. Document all
vaccine transfers in the MIIS Transfer Vaccine Module.
Vaccine Returns
• Only the Vaccine Management Unit can determine loss of efficacy due to exposure to out of range
temperatures.
• Document all vaccines that cannot be used due to expiration, exposure to unsafe temperatures or vaccines
that are wasted/damaged in the New Order Module or the Storage/Handling Problem Module. Refer to the
Quick Start Guide for instructions.
• Pack vaccine in a box with the return form. A return label will either be e-mailed or UPS will provide a label at
time of pick up.
• Do not return broken vials or syringes, opened multi-dose vials or vaccine drawn up into a syringe. Make sure
these doses are documented in the MIIS.
Temperatures Out of Range
If there are out of range temperatures, suspend vaccine administration, quarantine vaccine, upload
temperature logs and immediately contact the Vaccine Management Unit for guidance.
• Suspend vaccine administration of state-supplied vaccines in the unit that is experiencing the out of range
temperature.
• Quarantine vaccines by keeping the vaccines in the proper temperatures and marking them as ‘Do Not Use’.
• Upload temperature logs into the MIIS and select ‘Urgent Temperature Log Issue’
• Immediately call the Vaccine Management Unit and report that your out of range temperature. Vaccine
Management Unit staff will determine if vaccines are viable by contacting vaccine manufacturers.
• Use Troubleshooting log to document out of range temperatures, contact with the Vaccine Management Unit,
and actions taken.
• Remove any vaccine determined by the Vaccine Management Unit to be damaged from the storage unit.
Power Failure/Refrigerator Failure
• Pack vaccines according to the Vaccine Transportation Procedures on page 2 and transport to Emergency
Storage location.
• Notify the Vaccine Management Unit as soon as possible. Consult the Vaccine Management Unit before
transporting Varicella and MMRV vaccine, if possible.
• Review and update the provider emergency plan on an annual basis.
Documentation
• Enroll annually in the MDPH Immunization Program/Vaccines for Children (VFC) program by completing online
enrollment in the MIIS Provider Enrollment Module.
• Review and update the SOP annually and when any changes occur.
Vaccine Management SOP- MDPH
4
Jan 2021
MDPH Vaccine Management
Unit Phone # 617-983-6828
•
•
•
•
Retain a record of vaccines received or transferred, including type of vaccine, manufacturer, lot number,
expiration date and number of doses, for a minimum of 3 years. Keep packing slip received in shipments from
both McKesson and Merck.
Maintain temperature logs for a minimum of 3 years. Temperature logs uploaded to the MIIS do not need to
be maintained on site. There is no need to retain paper copies if every temperature log for all vaccine storage
units is uploaded into the MIIS monthly.
Offer the appropriate Vaccine Information Statement (VIS) with each dose of vaccine administered.
Subscribe to the CDC’s e-mail update for VIS at: www.cdc.gov/vaccines/hcp/vis/index.html.
Record vaccine administration information in the patient’s chart including: administration date, type of
vaccine, manufacturer, lot number, expiration date, VIS publication date, date VIS is given, name and
credentials of person administering the vaccine.
Report all state-supplied doses administered in the MIIS Vaccine Management Module with each vaccine
order. Most EHRs are connected so that the dose will decrement from inventory and appear in your usage
report as immunizations given.
Staff Training/Provider Education Requirements
• The primary and back-up Vaccine Coordinators must participate in one of the following activities each year.
Certificates of completion must be kept on file.
o VFC compliance site visit with training component (conducted every other year, must be present at site
visit and request complete training to receive certificate).
o In-person presentation (VFC breakout session at MIAP, MDPH Immunization Update Conference, or onsite training by MDPH staff). Certificates will be given after each activity.
o MDPH on-line webinar trainings.
Go to the training page of the MIIS Resource Center, www.contactmiis.info, to view training materials,
Quick Reference Guides and Webinars about the MIIS.
This SOP was created and completed by:
Name
Title
Date of Completion
Signature
Date
Employee Name
Vaccine Management SOP- MDPH
Employee Signature
5
Jan 2021
Handling a Temperature Excursion in Your Vaccine Storage Unit
Any temperature reading outside recommended ranges is considered a temperature excursion. Identify temperature excursions quickly and take immediate
action to correct them. This can prevent vaccine waste and the potential need to revaccinate patients.
➢ Notify the primary/back-up
vaccine coordinator immediately
or report the problem to a
supervisor.
➢ Notify staff by labeling exposed
vaccines, ‘DO NOT USE’, and
quarantine them. Do not discard
these vaccines and move them
into a unit that is operating
within the recommended
temperature range.
➢ Upload the temperature log into
the MIIS. Choose ‘Urgent
Temperature Issue’ as the reason
code.
➢ Document details of the
temperature excursions in the
notes section when uploading
the log. Include:
• Date and time
• Description of the event
• Length of time vaccine may
have been affected
• Vaccines affected
➢ Document details in the
‘Temperature Troubleshooting
Guide’.
➢ Call the Vaccine Management
Unit at 617-983-6824 to discuss
the temperature excursion.
➢ Be prepared to answer questions
about what caused the incident
and review the temperature log.
➢ If you are unable to log into the
MIIS, contact the MIIS Helpdesk
at 617-983-4335.
➢ If the data logger alarms
repeatedly, do not dismiss the
alarm until you have determined
and addressed the cause.
➢ Check the basics, including:
• Power supply
• Unit door(s)
• Thermostat setting
• Ice build-up in freezers
➢ If you believe the storage unit
has failed, inform the Vaccine
Management Unit and
implement your emergency
vaccine SOP.
➢ Never allow vaccines to remain
in a nonfunctioning unit.
Massachusetts Department of Public Health
Immunization Division | Vaccine Management Unit
P: 617-983-6828 | F: 617-983-6924 | E: dph-vaccine-management@massmail.state.ma.us
September 2019
Emergency Response
Procedures
Kalgoorlie Health Campus
WACHS Goldfields
Healthier country communities through partnership and innovation
Draft date: 29/05/2020
Version:
Effective:
< Insert1.02
Date >
Effective:
XXX
Emergency Response Procedures
Approval
These emergency response procedures assign responsibilities, actions and procedures
that are implemented at Kalgoorlie Health Campus following the occurrence of an
emergency.
These procedures have been formally endorsed by the Goldfield’s Emergency
Management Committee as the Standard Operating Procedure to be followed during an
emergency response at Kalgoorlie Health Campus.
Recommended
Jason Grimes
Emergency Services Coordinator
4 February 2020
Dated
Endorsed
David Bowdidge
Operations Manager
26 February 2020
Dated
Approved
Peter Tredinnick
Regional Director
10 June 2020
Dated
Printed or saved electronic copies of this policy document are considered uncontrolled.
Always source the current version from WACHS HealthPoint Policies.
Date of Last Review: May 2020
Page 1 of 160
Date Next Review: May 2025
Emergency Response Procedures – Kalgoorlie Health Campus
Table of contents
1.
Introduction ........................................................................................................8
1.1
Emergency response ........................................................................8
1.2
Classifying emergencies ...................................................................9
1.2.1
Code Blue and Code Brown .............................................................9
1.2.2
Continuous improvement ..................................................................9
1.3
Business Continuity Plan ................................................................10
2.
Emergency Control Organisation...................................................................10
2.1
First responder................................................................................10
2.2
Emergency Response Coordinator.................................................10
2.3
Area Warden...................................................................................10
2.4
Emergency Response Team ..........................................................11
2.5
Communications Officer .................................................................11
2.6
Medical Emergency Response Team .............................................11
2.7
Scene-specific ECO structure.........................................................12
2.8
Site-wide ECO structure .................................................................12
3.
Documentation and equipment ......................................................................13
3.1
3.2
3.3
3.4
3.5
4.
3.5.1
Emergency Control point ................................................................13
Area Warden Points........................................................................13
Action cards ....................................................................................13
Kalgoorlie Health Campus Communications Log ...........................14
Equipment.......................................................................................14
Identification ...................................................................................14
3.5.2
Equipment checking and maintenance...........................................14
Communication................................................................................................14
4.1
Emergency Warning and Information System ................................14
5.
Notification .......................................................................................................16
5.2.1
Paging system ................................................................................17
6.
Post incident activities ....................................................................................17
7.
Code Red – Fire / Smoke.................................................................................20
7.1.
7.2.
7.3.
7.4.
7.5.
7.6.
7.7.
7.2.1.
Introduction .....................................................................................20
Activation ........................................................................................20
Manual triggering ............................................................................20
7.2.2.
Automatic triggering........................................................................20
7.2.3.
Automatic fire safety measures ......................................................21
7.5.1.
Staff, patient and visitor safety........................................................21
First responders ..............................................................................21
Fighting the fire ...............................................................................22
Firefighting equipment ....................................................................22
Fire Strategy ...................................................................................23
Fire Warning System ......................................................................23
Printed or saved electronic copies of this policy document are considered uncontrolled.
Always source the current version from WACHS HealthPoint Policies.
Date of Last Review: May 2020
Page 2 of 160
Date Next Review: May 2025
Emergency Response Procedures – Kalgoorlie Health Campus
7.7.1.
Warden Intercommunications Point phone.....................................24
7.8.
Evacuation ......................................................................................24
7.9.
Post incident activities ....................................................................24
7.10.
False Fire Alarms............................................................................24
7.11.
Code Red Action Cards ..................................................................25
Action Card 1 First Responder ........................................................................26
Action Card 2 Emergency Response Coordinator ...........................................27
Action Card 3 Area Warden .............................................................................32
Action Card 5 Emergency Response Team.....................................................33
Action Card 6 Communications Officer............................................................35
8.
Code Purple Bomb threat / suspicious substance ......................................36
8.1
Introduction .....................................................................................37
8.2
Types of threats ..............................................................................37
8.3
Telephone threats ...........................................................................37
8.4
Malicious Call Trace .......................................................................38
Telephone Bomb Threat Checklist .........................................................................39
8.5
Written threat ..................................................................................40
8.6
Identifying an object as suspicious .................................................40
8.6.1.
Actions on finding a suspicious object ............................................40
8.7
8.8
8.9
8.8.1.
Suspicious substance .....................................................................40
Evaluation .......................................................................................41
Evaluating potential risks ................................................................41
8.9.1.
Searching........................................................................................41
Search order ...................................................................................42
8.9.2.
Search procedure ...........................................................................42
8.10
8.11
8.11.1.
Evacuation ......................................................................................42
On detonation of a device ...............................................................43
Detonation after evacuation............................................................43
8.11.2.
Detonation in occupied area ...........................................................43
8.12
National Terrorism Threat Level .....................................................43
8.13
Code purple action cards ................................................................43
Action Card 7 First Responder ........................................................................44
Action Card 8 Emergency Response Coordinator ...........................................46
Action Card 9 Area Warden .............................................................................52
Action Card 11 Emergency Response Team Member ....................................56
Action Card 12 Communications Officer..........................................................59
61
9.
Code Black – Personal threat .........................................................................61
9.1
9.2
9.3
Introduction .....................................................................................61
General ...........................................................................................61
Self-harm ........................................................................................62
Printed or saved electronic copies of this policy document are considered uncontrolled.
Always source the current version from WACHS HealthPoint Policies.
Date of Last Review: May 2020
Page 3 of 160
Date Next Review: May 2025
Emergency Response Procedures – Kalgoorlie Health Campus
9.4.1
Responding to the Aggressive Person............................................62
Activation and notification ...............................................................62
9.4.2
De-escalation..................................................................................62
9.4.3
Withdrawal ......................................................................................63
9.4.4
Evasion ...........................................................................................64
9.5.1
Management Strategies for the Aggressive Patient........................64
Patient Care Plan............................................................................64
9.5.2
Environmental Management Plan...................................................64
9.5.3
Discharge/Release .........................................................................64
9.5.4
Restraint .........................................................................................65
9.4
9.5
9.6
9.7
Description of Offender Form..........................................................66
Code Black Action Cards ................................................................67
Action Card 13 First Responder ......................................................................68
Action Card 14 Emergency Response Coordinator .........................................71
Action Card 15 Area Warden ...........................................................................73
Action Card 17 Emergency Response Team Member ....................................75
Action Card 18 Communications Officer..........................................................76
78
10. Code Black Alpha - Infant / Child Abduction.................................................78
10.1
Introduction .....................................................................................78
10.2
Removal of child by an unauthorised person..................................78
10.3
Response strategy ..........................................................................78
10.4
Description of Abducted Infant / Child Form ...................................79
10.5
Code Black Alpha Action cards.......................................................80
Action Card 19 First Responder ......................................................................81
Action Card 20 Emergency Response Coordinator .........................................83
Action Card 21 Area Warden ...........................................................................86
Action Card 23 Emergency Response Team Member ....................................89
Action Card 24 Communications Officer..........................................................90
11. Code Black Bravo - Active Shooter................................................................92
92
11.1
Introduction .....................................................................................92
11.2
Threat context .................................................................................92
11.3
Response strategy to an active shooter..........................................92
11.4
Staff response.................................................................................92
11.5
Protective measures .......................................................................93
11.6
Crime scene and evidentiary recovery............................................93
11.7
Code Black Bravo Action Cards......................................................93
Action Card 25 First Responder ......................................................................94
Action Card 26 Emergency Response Coordinator .........................................96
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Action Card 27 Area Warden ...........................................................................99
Action Card 29 Emergency Response Team Member ..................................101
Action Card 30 Communications Officer........................................................102
12. Code Yellow – Infrastructure and other internal emergencies..................104
104
12.1.
12.2.
12.3.
12.4.
12.4.1.
Introduction ...................................................................................104
Sub-plans......................................................................................104
Infrastructure damage...................................................................104
Essential service disruptions ........................................................104
Facility system status report .........................................................105
12.5.
12.6.
12.6.1.
ICT downtime procedures.............................................................106
Hazardous materials .....................................................................106
Hospital Response to a Code Yellow Hazardous Spill .................106
12.7.
Earthquake ...................................................................................106
12.8.
Missing Inpatient ...........................................................................107
12.9.
Code Yellow - facility system status report template ....................108
12.10.
Code Yellow workarounds ............................................................114
12.11.
Action Cards .................................................................................115
Action Card 31 First Responder ....................................................................116
Action Card 32 Emergency Response Coordinator .......................................117
Action Card 33 Area Warden .........................................................................121
Action Card 36 Communications Officer........................................................125
127
13. Code Orange – Evacuation ...........................................................................127
13.1
13.2
13.3
13.4
13.5
13.6
13.7
13.8

Introduction ...................................................................................127
Decision making ...........................................................................127
Authority to evacuate ....................................................................127
Preferred order of emergency evacuation ....................................127
Stages in evacuation.....................................................................127
Evacuation Routes........................................................................128
Designated Safe Points and Assembly Areas ..............................128
Other considerations.....................................................................129
Mobility impaired staff ...................................................................130

Records relevant to immediate patient care .................................130

Evacuation equipment ..................................................................130

Head counts..................................................................................130

Communications ...........................................................................130

Pharmacy......................................................................................130
13.9
13.10
Patient care during and after an evacuation .................................130
Re-population of area or facility ....................................................130
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13.11
Decanting and relocating inpatients..............................................131
13.12
Planned relocations and sheltering in place .................................131
13.13
Action cards ..................................................................................131
Action Card 37 First Responder ....................................................................132
Action Card 38 Emergency Response Coordinator .......................................134
Action Card 39 Area Warden .........................................................................138
Action Card 41 Emergency Response Team Member ..................................141
Action Card 42 Communications Officer........................................................142
14. Appendices.....................................................................................................144
14.1
14.2
14.3
14.4
14.5
14.6
14.7
14.8
14.9
14.10
14.11
14.12
Appendix A – Communications Log...............................................144
Appendix B – EWIS Operating Instructions ...................................145
Appendix C - Warden Intercommunication Point phones .............147
Appendix D - Personal Emergency Evacuation Plan....................148
Appendix E - Evacuation checklist................................................150
Appendix F - Patient Transfer / Discharge Log .............................151
Appendix G – Emergency Code Activation Log.............................152
Appendix H - Code Black Team....................................................153
Appendix I – Duress Devices.........................................................154
Appendix J – External Muster Points .............................................156
Appendix K – Control of Hospital Exits ..........................................157
Appendix L – Emergency Contacts................................................158
This document can be made available in alternative formats
on request for a person with a disability
Contact: Program Manager - Disaster and Emergency Management (T. Spicer)
Directorate: Operations
EDRMS Record # ED-CO-20-19520
Version: 1.02
Date Published: 25 June 2020
Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from
any fair dealing for the purposes of private study, research, criticism or review, as permitted under the
provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever
without written permission of the State of Western Australia.
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1. Introduction
These Emergency Response Procedures (ERP) outline the assigned responsibilities,
actions and procedures to be undertaken at Kalgoorlie Health Campus to respond to
and manage a potential or actual emergency affecting the facility.
The ERP forms the initial part of the emergency management suite of documents. It
covers the roles, responsibilities, actions, equipment and procedures required during
the emergency response phase, in line with the WACHS Emergency (Disaster)
Management Arrangements Policy.
1.1 Emergency response
The emergency response is the initial phase following the occurrence of an
emergency. The ERP is the document that addresses the actions to be undertaken
in the emergency response phase.
This ERP is facility-specific and covers:
 immediate actions to be taken by the first responder; and
 Follow-on actions (action cards) to be taken by members of the facility’s
Emergency Control Organisation (ECO).
Following the implementation of the ERP, the emergency may abate and resolve, or
transition into the incident management and/or business continuity phases.
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1.2 Classifying emergencies
Emergencies in hospitals are categorised into colour codes, as set out in Australian
Standard (AS) 4083:2010 – Planning for emergencies – Health care facilities, and
AS 3745:2010 – Planning for emergencies in facilities.
Code Red
Fire / smoke
Code Blue
Medical emergency
Code Purple
Bomb threat / substance
Code Yellow
Infrastructure and other internal emergencies
Code Black
Personal threat
Code Brown
External emergency
Code Orange
Evacuation
Additionally, there are two subcategories of code black:
 Code Black Alpha – infant/child abduction.
 Code Black Bravo – active shooter.
Some hospitals may have separate emergency management sub-plans for specific
hazards in their community, such as cyclones, bushfires, storm surge, and
hazardous materials.
As a minimum, one printed copy of these procedures should be available on site,
located at the Emergency Control Point (see section 3.1). Additional copies of these
procedures may be printed and stored on site where required.
1.2.1
Code Blue and Code Brown
Code Blue action cards are not included as part of these ERPs. Resources,
information and templates pertaining to Code Blue Medical Emergency Response
processes, please refer to the Clinical Escalation of Acute Physiological Deterioration
including Medical Emergency Response Policy.
Code Brown action cards are not included as part of these ERPs. Please refer to the
site’s Code Brown Emergency Response Procedure.
1.2.2
Continuous improvement
The ERP should be regularly reviewed, tested and updated based on lessons
learned from actual emergencies or drills and exercises.
As per Clause 2.2 (d) of AS 3745:2010, the ERP is to be reviewed at least every five
years.
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1.3 Business Continuity Plan
This site’s Business Continuity Plan (BCP) documents the procedures and strategies
to be enacted when critical business activities and/or services are disrupted. The
BCP aims to restore disrupted services within acceptable pre-identified timeframes
as part of the business continuity response phase to an emergency.
Business Continuity is not to be confused with contingency arrangements that are
documented in the Code Yellow procedures. Code Yellow procedures deal with the
initial emergency response to an infrastructure failure or other internal emergency,
and the actions required to protect people and assets.
2. Emergency Control Organisation
The ECO is a person or a group of trained persons that are responsible for directing
and controlling the implementation of the site’s ERPs.
The primary role of the ECO is to ensure the safety of the facility’s occupants and
protection of assets. Occupant safety always takes precedence over asset
protection.
2.1 First responder
Although not part of the ECO, the first responder is any staff member who first
notices and initiates the response to an emergency. The first responder’s main
responsibilities are to maintain safety of the building occupants, and to notify the
ECO of the occurrence of an emergency.
2.2 Emergency Response Coordinator
The Emergency Response Coordinator (ERC) leads the ECO for the entire site. The
ERC has responsibility for commanding and coordinating the site’s emergency
response in order to control the emergency. An ERC is rostered for all hours of
Kalgoorlie Health Campus’s operation.
In the event of an emergency, the ERC has principal accountability of all patients,
staff and visitors within the facility, regardless of their organisational position or
tenancy arrangements. In complex emergencies or incidents that requiring ongoing
incident or business continuity management, the ERC escalates the management of
the emergency to the Hospital Incident Commander (HIC).
2.3 Area Warden
In each ward, department or area, an Area Warden is to be appointed during all
times of operation. In the event of an emergency, the Area Warden has immediate
responsibility of all staff within the designated area, regardless of their organisational
position or tenancy arrangements
The Area Warden is normally the ward’s Clinical Nurse Manager, shift coordinator,
nominated delegate, or otherwise senior person designated by the Site Service
Manager or senior lead for the site.
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2.4 Emergency Response Team
The Emergency Response Team (ERT) may be mobilised to respond to an
emergency. The ERT carries out front line actions for all emergencies except for
Code Blue, at the direction of the ERC.
The role of the ERT is to:
 Attend the scene of a reported emergency within the facility grounds.
 Provide expert assistance where required.
 Prevent unauthorised people from entering the scene area.
 Liaise with emergency services personnel when they arrive.
 Assist staff to evacuate the area if the situation requires it.
2.5 Communications Officer
The Communications Officer may form part of the ECO to assist with clerical support
and record maintenance during an emergency response.
The Communications Officer is the single point of contact for any event affecting a
facility. In the event of an actual or potential incident, the Communications Officer is
responsible for:
a) Receiving the initial notification of an actual or potential incident.
b) Notifying the ECO and hospital staff of any actual or potential incident via
paging and PA announcements.
c) Contacting emergency services under the direction of the ECO or senior staff.
2.6 Medical Emergency Response Team
The Medical Emergency Response (MER) Team is a defined team of staff that
respond to a medical emergency response, as defined by this site’s on site
escalation procedure. The size and composition of the MER Team is to be
dependent on the facility’s staffing profile and rostering.
Resources, information and templates pertaining to Code Blue Medical Emergency
Response processes, please refer to the Clinical Escalation of Acute Physiological
Deterioration including Medical Emergency Response Policy.
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2.7 Scene-specific ECO structure
The following diagram outlines the ECO governance structure for a scene-specific
emergency response.
2.8 Site-wide ECO structure
The following structure outlines the ECO governance structure for a site-wide
emergency response.
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3. Documentation and equipment
3.1 Emergency Control point
The Emergency Control Point is located at the main fire panel near the Emergency
Department entrance. The Emergency Control Point serves as the staging area for
the ERC, Communications Officer and the Emergency Response Team. The
Emergency Control Point should contain:








Ring bound, laminated action cards for the ERC.
Vests for the ERC and Communications Officer. Vests should be consistent
with requirements in section 3.5.1.
Contact list for the wards/departments, DECT numbers, WIP phone numbers,
PSTN emergency phone numbers.
Map detailing the fire compartments throughout the facility.
A laminated table of each ward/department, their primary and secondary stage
two and three assembly areas.
Chinagraph pencils or other suitable writing instrument.
Contact details for emergency services.
A hard copy of these Emergency Response Procedures.
3.2 Area Warden Points
Each area is to have an Area Warden Point. The point should be situated near a
Warden Intercommunication Point (WIP) phone and have an Area Warden Pack
contained with a box or document holder, ideally mounted and made of Perspex.
The Area Warden Pack should contain:
 Ring bound, laminated action cards for the Area Warden and First Responder.
 Yellow Area Warden Vest with Area Warden clearly labelled front and back.
 Search map – a schematic of the respective area/fire compartment showing all
rooms, doors, and exits. This is used to conduct a search of an area during
some emergencies (eg: fire, bomb threat, evacuation).
 Chinagraph pencils or other suitable writing instrument.
 The primary and secondary evacuation routes and assembly areas.
 Instructions on operating the Warden Intercommunication Point (WIP) phone.
 An “area evacuated” sign.
 Description of Offender form.
3.3 Action cards
Action cards have been developed for first responders and each member of the
ECO. When an emergency occurs, ECO members are to complete their respective
action cards.
Following the emergency, the ERC is responsible for collating the action cards and
reviewing them. The ERC is also responsible for ensuring new action cards are
printed and replaced in warden kits and muster points as soon as possible. The ERC
may delegate a staff member to re-stock warden kits.
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3.4 Kalgoorlie Health Campus Communications Log
The Emergency Response Coordinator is to allocate a staff member to commence
a communications log. The log should capture key decisions, communication details
between key stakeholders, and any other relevant communications as part of the
emergency response.
Once the emergency response is stood down, the ERC is to review the
communications log for accuracy before sending to the Operations Manager. Once
reviewed, the HSM is to attach the log to action card documentation for that event
and electronically save the record. A communication log template is available in
Appendix A.
3.5 Equipment
ECO members are issued with pieces of equipment to assist them in responding to
an emergency.
3.5.1
Identification
ECO members are required by clause 5.8 of AS 3745 to identify themselves to allow
for easy recognition. This site uses vests and hard hats.
The ECO positions should be identifiable by the following colours, with the position
clearly labelled front and back.
Position
Emergency Response Coordinator
Emergency Response Team
Area Warden
Colour of vest
White
Orange
Yellow
3.5.2
Equipment checking and maintenance
ECO members are responsible for checking their emergency equipment at the start
of each shift to ensure it is in working order.
Following the occurrence of an emergency, ECO members are responsible for
refurbishing their equipment in warden kits and muster points.
4. Communication
A series of communication systems may be used during an emergency to
communicate with key stakeholders. This includes, but is not limited to:
4.1 Emergency Warning and Information System
The Emergency Warning and Information System (EWIS) can notify building
occupants of emergencies through the use of a series of audible tones. This includes
an alert tone (BEEP… BEEP…) and an evacuation tone (WHOOP… WHOOP…). A
Public Address (PA) system can also be used to allow the ERC or the emergency
services to communicate to the entire facility or selected areas. The EWIS can be
operated from the Fire Indicator Panel, located at:

Main Fire Panel located in the Emergency Department Entrance.
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Area Specific Fire Sub-Panels (no access to WIP phones):











Engineering
Laundry
Kitchen
Children’s Ward
Theatre
S.S.Q.
Brick Quarters
Maternity
Conference Room
Antenatal Clinic
HCR & CCR rooms (Gas Suppression Systems)
The EWIS is only be operated by DFES or the ERC who has been trained in its
operation.
Instructions on how to use the EWIS system are listed in Appendix B.
4.2 Warden Intercommunication Point phones
WIP phones are linked to the EWIS and allow the ERC or emergency services to
directly communicate with Area Wardens for respective areas. Each department /
ward should have one or more WIP phones located within their vicinity.
Instructions on how to use the WIP phones is listed in Appendix C.
4.3 Digital Enhanced Cordless Telecommunications
This facility used Digital Enhanced Cordless Telecommunications (DECT) as part of
its internal communication system. A number of paging groups have been set up to
provide notification messages to predetermined handsets.
4.4 Two-way Radios
This facility used Ultra High Frequency (UHF) two-way radios to communicate
between key emergency responders during an emergency. Radios are to be set to
channel 15 when in use.
These radios are checked by the Emergency Department, Emergency and Disaster
Preparedness Portfolio Holder (reportable to the ED CNM) on a minimum monthly
basis. Radios and spare batteries are located in the ‘Disaster Store 2’ in the ED
ambulance entry airlock.
4.5 Mobile telephones
Mobile telephones are a critical communication platform, and may be used to notify
stakeholders on or off site.
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4.6 Satellite telephones
Satellite telephones (sat phones) may serve as a primary notification method in some
remote sites or as redundancy when other communication platforms are unavailable.
4.7 Runners
Runners are staff members who may be co-opted to relay key pieces of information
or instructions. Runners may be used when conventional communication platforms
become overwhelmed or unavailable.
4.8 Situation reports
A situation report (SITREP) is a short verbal summary of the current situation that
can be used to inform decision making and actions required. A SITREP may be
simply “all ok” or more detailed about the nature of the emergency and its current or
anticipated impact. A SITREP should contain the below fields:




Current situation (what has happened, where it occurred, what time).
What actions have been undertaken (what has been done)?
What actions still need to be completed (what needs to be done)?
Any other issues (anything of interest or noteworthy).
Situation report procedure can be found here
5. Notification
There are a number of automatic and manual notification processes used by this
facility. More detail on notification is provided in the specific emergency code
sections.
5.1 Automatic notification
This facility has a fire detection system installed to automatically detect smoke or fire.
This includes smoke and thermal detectors, and sprinkler systems. These systems
are linked to the Fire Indicator Panel.
This system will automatically notify the Department of Fire and Emergency Services
(DFES) through the Direct Brigade Alarm (DBA). It will also automatically send out a
page via the Spok paging system to all staff assigned to the Code Red paging group.
5.2 Manual notification
A first responder can manually notify about the occurrence of any emergency by a
number of methods, including:
 A 55 emergency call.
 Manual call points (break glass alarms).
 Duress Alarms.
When notifying of an emergency via 55, the first responder should provide the
switchboard operator with information to develop the first report. This information
should include:


Type of emergency (e.g. Code Red).
Exact location of emergency.
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

Brief description of the incident.
Name and title of caller.
NOTE: A Manual call point (break glass alarm) should always be activated prior to a
55 call for a code red.
5.2.1
Paging system
This facility uses SPOK to send paging messages to notify the ECO of an
emergency.
Pager groups are:







Code Black
Code Blue
Code Red
Code Purple
Code Orange
Code Yellow
Code Brown
6. Post incident activities
Following the abatement or resolution of the emergency, the ERC is responsible for
ensuring appropriate post-incident activities are implemented.
6.1 Reporting
All emergencies, regardless of whether they are false alarms or actual events, are to
be reported on. There are three main avenues of reporting:
1. Emergency Code Reporting Tool. This online data collection tool is used to
capture the occurrence of a code red false alarm, code yellow, code orange
code purple, code black alpha, code black bravo, and code brown
emergencies.
All reports submitted through this tool will require Tier 4 manager review and
approval.
2. Safety Risk Report Form. This form is to be completed for all code red (real
event) and code black incidents.
3. Code Blue emergencies – Medical emergencies are to be reported as per the
Clinical Escalation of Acute Physiological Deterioration including Medical
Emergency Response Policy.
4. Datix CIMS (Clinical Incident Management System) – to be completed for a
Code Black where a restraint occurred and has resulted, or may have
resulted, in harm to the patient. If restraint occurs in an Authorised Hospital
reporting to Chief Psychiatrist and appropriate use of Mental Health Act 2014
is essential.
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Code Red – Fire / Smoke
False Alarms only
Code Purple – Bomb Threat
Code Yellow – Infrastructure
and other internal emergencies
Code Orange - Evacuation
Emergency
Emergency Code
Code Reporting
Reporting Tool
Tool
Code Brown – External
Emergency
Code Black Alpha – Infant /
Child Abduction
Code Black Bravo – Active
Shooter
Code Red – Fire Smoke
Confirmed fires only
Safety
Safety Risk
Risk Report
Report Form
Form
Code Black – Personal Threat
Code Blue – Medical
Emergency
Datix
Datix // CIMS
CIMS
Further information is available from the Reporting of Emergencies Procedure.
6.2 Debriefing
Following the occurrence of an incident, the ERC should determine whether a debrief
is warranted. There are two forms of debriefing:
a) Hot Debrief - A hot debrief is a quick and informal debrief. The main objectives
of a hot debrief are to determine:
 How the emergency or near miss occurred.
 If any staff members, patients, and other building occupants have been
affected by the emergency, and any follow up actions that are required.
This may include referrals to Employee Assistance Programs.
 If there are any ongoing potential hazard/s or risk/s to personnel.
 Any urgent actions to mitigate risk/s.
 Appropriate reporting and notification requirements.
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b) Formal Debrief – a formal debrief may be convened a number of days
following the occurrence of the emergency. A formal debrief involves a more
detailed analysis of the emergency to determine:
 What was the cause of the emergency?
 What was the impact(s) of the emergency?
 Contributing factors that affected the outcome of the emergency.
 Any risks or issues that that have been identified as a result of the
emergency.
 Recognition of staff members involved in the emergency.
 Opportunities for continuous improvement with respect to training,
emergency response procedures or equipment.
 Any follow-up recommendations required to prevent a reoccurrence, or
mitigate the impacts, of the emergency.
The formal debrief may involve an investigation, and a formal report should
be drafted and tabled at the Goldfield’s Emergency Management Committee.
The committee should track progress on the implementation of any
recommendations.
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7.
Code Red – Fire / Smoke
7.1. Introduction
A code red emergency may be called in response to an actual, or suspected, fire or
smoke emergency within the facility grounds.
7.2. Activation
A code red emergency may be automatically or manually triggered.
7.2.1. Manual triggering
Any staff member on discovering fire or smoke is to declare a code red emergency
by triggering the manual call point (break glass alarm) and following it up by dialling
55.
Upon phoning 55, the staff member is to state:
 “Code Red”
 Brief description of incident
 Exact location of incident
 Name and title
The Admissions Communications Officer (ACO) is to activate the code red paging
group and work under the direction of the ERC.
7.2.2. Automatic triggering
This facility is fitted with a fire detection system that includes thermal detectors,
smoke detectors and sprinkler systems. Upon detection of smoke or fire, the alarm
will be sent directly to Fire Indicator Panel (FIP) which will trigger an automatic
notification to DFES.
The system will automatically send a message through to the Code Red paging
group.
The Main Fire Indicator Panel is located in the Emergency Department entrance
and is also the Emergency Control Point.
The Fire Indicator Sub-Panels (no WIP phone access) are located at:
 Engineering
 Laundry
 Kitchen
 Children’s Ward
 Theatre
 SSQ
 Brick Quarters
 Maternity
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


Conference Room
Antenatal Clinic
HCR and CCR rooms (Gas Suppression Systems)
The FIP displays the location of the alarm activation and also allows the isolation of
zones.
7.2.3. Automatic fire safety measures
Upon triggering of the fire detection system, a number of fire safety measures are
implemented to stop the spread of smoke and fire. These measures include:
 Closure of fire safety doors / smoke doors
 Automatic shutdown of the air handling units and extraction systems in any
fire compartment that is in fire mode. Non affected compartments will remain
operational.
7.3. Staff, patient and visitor safety
 Close doors and windows. This is to help prevent the spread of smoke and
fire.
 Turn off electrical equipment (except lights).
 Keep low in a smoke filled room / area. Smoke is responsible for the
majority of fatalities in structural fires. In a room full of smoke, the cleanest
air is between 30cm and one metre from the floor. Cover your mouth with a
cloth and breathe slowly.
 Never go back into a fire or smoke filled area for any reason. Do not
attempt to retrieve objects or look for missing persons. DFES Officers are
trained and have the appropriate Personal Protective Equipment (PPE) to
conduct any searches.
 Avoid flashover. A fire consumes oxygen and where a door is closed to
contain the fire; it will use the available oxygen and begin to diminish. If this
has occurred and the door is then opened, fresh oxygen is introduced that
can result in immediate explosive burning, known as ‘flashover’.
7.4. First responders
In the event of a fire or visible smoke, first responders should follow the R.A.C.E
mnemonic
R
Remove
Remove all people from immediate danger - if safe to do so.
Remove any flammable material or equipment – if safe to do so.
A
Alert
Activate the nearest manual call point (break glass alarm)
Dial 55 and state:
 “Code Red”
 Exact location of the incident
 Brief description of the incident.
 Your name and title
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C
Contain
Close doors and windows
Turn off any electrical equipment, except lights
E
Extinguish / evacuate
Extinguish the fire if safe to do so and trained to use an extinguisher. Where
firefighting poses an unacceptable risk (fire is greater than the size of a
waste paper basket), responders are to withdraw.
Evacuate the immediate area. Await further instructions from the Area
Warden.
7.5. Fighting the fire
Kalgoorlie Health Campus uses a variety of firefighting equipment. Where firefighting
becomes an unacceptable risk (that is greater than the size of a waste bin),
responders are to withdraw from the situation.
7.5.1.
Firefighting equipment
Carbon Dioxide (CO2) Extinguishers
Used for
Electrical and oil fires, small paper fires. Not suitable for outdoor use.
Appearance
Red cylinder with black band and large nozzle.
Use
P – Pull out the pin
A – Aim at the base of the flame
S – Squeeze the handle
S – Sweeping action
Time
Lasts for approximately 10 – 15 seconds
Range
Approximately 1.5 metres. Activate at 2 metres and move in to 1.5 metres
Dry chemical powder extinguisher
Used for
Electrical equipment, flammable liquids, paper, wood
Appearance
Red cylinder with white band
Use
P – Pull out the pin
A – Aim at the base of the flame
S – Squeeze the handle
S – Sweeping action
Time
Lasts for approximately 20 – 25 seconds
Range
Approximately 3 metres.
Water extinguisher
Used for
Paper, textiles, wood.
Dangerous if used on flammable liquid, electrical equipment and cooking oils/fat
fires
Appearance
Red cylinder
Use
P – Pull out the pin
A – Aim at the base of the flame
S – Squeeze the handle
S – Sweeping action
Time
Lasts for approximately 1 minute
Range
Approximately 6 metres.
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Hose Reel (water)
Used for
Paper, textiles, wood. Dangerous if used on flammable liquid, electrical equipment and
cooking oils/fat fires
Appearance
Red drum with retractable hose.
Use
Turn on water at the hand wheel (this will release the nozzle). Direct water stream at
base of the fire and sweep
Time
Unlimited
Range
Approximately 8 metres. The hose should extend to a maximum 36 metres.
Fire blanket
Used for
Small localised fires (eg: saucepan of oil) and to smother burning clothes of a person on
fire
Appearance
Usually in a pouch mounted on a hook. Usually in kitchen areas.
Use
Hold blanker between you and the fire. Grasp the blanket at the corners folding it back
behind your hands. Walk carefully towards the fire holding the bottom edge of the blanket
clear of the ground (10cm) and place blanket over fire ensuring the fire is fully covered.
Time
Do not lift blanket to see if fire is extinguished. Leave it in place.
Range
N/A
Insert picture
7.6. Fire Strategy
If a fire/smoke is detected in Kalgoorlie Health Campus the fire detection system
should automatically trigger the following mechanisms:
 The fire doors located in this specific compartment and the adjacent
compartment(s) will close.
 The access control doors located in this specific compartment and the
adjacent compartment(s) will unlock.
 The DBA (Direct Brigade Alarm) will notify the DFES.
 An automatic paging alert will be sent to the Code Red paging group.
 An alert tone will start in the main hospital facility.
 An evacuation tone and a voice message will state ‘evacuate as directed’.
Note: The evacuation voice message automatically advises occupants of the
facility to evacuate when the Emergency Response Coordinator (ERC) has NOT
over ridden the Emergency Warning Intercommunications System (EWIS) after
two minutes. Where the EWIS system has been overridden by the ERC, all
occupants are to act as directed by the ERC.
7.7. Fire Warning System
An Emergency Warning Intercommunication System (EWIS) is located at:
 Entrance to the Emergency Department
The EWIS comprises of two sub-systems:

Emergency Warning System (EWS) - Transmits via speakers in evacuation
zones, alert and evacuation signals, and allows the Emergency Response
Coordinator to publicly address the facility. The EWS can automatically
initiate an evacuation or be manually operated.
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
Emergency Intercommunication System (EIS) - A totally independent
intercommunication system provided to communicate on a one to one basis
from the Master Emergency Control Panel to the individual Warden
Intercommunications Point (WIP) phone within the evacuation zones.
Note: The EWS and EIS are collectively referred to as the EWIS.
7.7.1. Warden Intercommunications Point phone
All communications between the Emergency Control Organisation during a Code
Red are to be through the WIP phones located throughout the facility. Pick up the red
handset to either receive or make calls. When making a call, a confidence tone will
be heard until the ERC answers.
7.8. Evacuation
The Code Red ‘immediate actions’ for first responders, prescribes the removal of
people from the immediate area (Stage 1 evacuation) when there is a fire or a
suspicion of one (e.g. the smell of smoke). Additionally, the Code Orange
evacuation procedures outline the specific actions to be undertaken in an
emergency evacuation.
7.9. Post incident activities
Following the occurrence of a fire, the ERC should convene a hot debrief to check on
staff and patient welfare, and determine any residual risks or issues that warrant
urgent attention.
The Nurse Coordinator or area manager is responsible for arranging a formal debrief
within one week of the incident. This should involve any staff members involved in
the incident, the Regional Occupational Safety and Health Coordinator, Program
Manager Disaster and Emergency Management, Regional Manager of Infrastructure
and Support Services, and any Department of Fire and Emergency Services
representatives. The debrief report is to be tabled at the WACHS Goldfields Disaster
Preparedness & Emergency Management Committee for subsequent follow up.
All confirmed fires are to be fully investigated. Following the occurrence of a fire, the
ERC is responsible for completing a Safety Risk Report Form (SRRF).
7.10. False Fire Alarms
False fire alarms can and do occur across WACHS for a variety of reasons. This can
include malicious activation, cooking, system malfunction or accidental triggering.
False fire alarms create an unnecessary burden on already limited resources and as
of 2019, attract a fine of $920 per false fire alarm event.
All staff members should be cognisant and attempt to minimise the occurrence of
false fire alarms.
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7.11. Code Red Action Cards
Action cards have been developed for the following positions





Code Red Action Card 1 – First responder
Code Red Action Card 2 – Emergency Response Coordinator
Code Red Action Card 3 – Area Warden
Code Red Action Card 5 – Emergency Response Team Member
Code Red Action Card 6 – Communications Officer
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Code Red
Fire / Smoke
Action Card 1
Action Card
First Responder
1
Reports to: Area Warden
Responsibilities
 Ensure the immediate safety of anyone within the vicinity of the fire/smoke.
 Take measures to ensure that the Department of Fire and Emergency Services
are notified.
 Take measures to ensure that the Emergency Response Coordinator is notified.
A staff member who discovers a fire or smells smoke,
or who is alerted to a fire and/or smoke, is to carry out the
following immediate actions.
1.
Remove all people from the immediate danger.
2.
Alert the Department of Fire and Emergency Services by
triggering the nearest manual call point (break glass alarm).
3.
Contain the fire by closing doors and windows.
4.
Extinguish the fire with the correct firefighting equipment if
safe to do so (e.g. fires smaller than a waste basket) and if
trained in the equipment use.
a) Fire extinguishers
b) Fire hose
c) Fire Blankets
5.
6.
Time
Sign
Establish contact with the Admissions Communications
Officer by dialling 55 and give the first report. If this is not
possible establish contact with the Emergency Response
Coordinator by dialling 0427 087 147 or Directory 364
First Report:
a) Code red
b) Exact location of the incident
c) Caller's name and role
Move to your safest muster point and wait for instructions
from the Area Warden.
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Action Card 2
Emergency Response
Coordinator
Code Red
Fire / Smoke
Action Card
2
Position: CNM Patient Flow or A/H nurse Mngr
Reports to: Hospital Incident Commander (Operations Manager) - 0428 949 930
Responsibilities
 Control the internal emergency response of an emergency within the facility.
 Ensure the health and safety of patients (including permanent care residents), staff
and visitors when faced with an emergency.
ALERT
Time
1.
Proceed immediately to the Emergency Control Point at the
main Fire Indicator Panel (FIP) located at the Emergency
Department entrance.
2.
Collect vest, action card and radio (if required)
a) Don vest.
b) Keep action card on hand.
c) Turn radio on and radio check functionality.
Sign
Ensure the Department of Fire And Emergency Services
(DFES) have been notified on 000.
3.
If a fire alarm has been manually notified, confirm that the fire
alarm detection system has triggered. If not, trigger the nearest
Manual Call Point (Break Glass Alarm) to ensure the spread of
smoke is inhibited.
Change the Emergency Warning Intercommunications System
(EWIS) panel from automatic to manual.
4.
a) Open the EWIS panel door, turn the key from automatic to
manual
b) press button “buzzer mute/ACK” and then “master reset” (to
silence alarm)
Open the door to the fire panel Ascertain the point of alarm
(DFES request we don’t acknowledge the alarm)
5.
Activate the P.A system for the entire facility and make the fire
alert announcement. (if not already completed by the ACO)
6.
“Attention all areas, attention all areas, this is the
Emergency Response Coordinator. Possible Code Red –
<say location>. Remain calm and wait for further
instructions.
(Say twice.)
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Action Card 2
Code Red
Fire / Smoke
Emergency Response
Coordinator
Action Card
2
Position: CNM Patient Flow or A/H nurse Mngr
ALERT (continued)
Time
Sign
Establish contact with the Area Warden at the point of alarm by
making a call to the WIP phone and request a SITREP.
7.
Note:
 Where the Area Warden does not answer the WIP phone,
use the PA system to ask the Area Warden to attend to the
WIP or deploy a runner to investigate.
 Where the alarm is from an area that is out of hours,
arrange security or staff with a suitable escort to proceed to
area and report back.
Ensure the main entrance is clear and public access to the
facility is restricted.
8.
Note: Where a fire alarm is activated, entry to the facility is
only permitted by Emergency Services.
Establish contact with Area wardens adjacent to the point of
alarm using the WIP phone and provide SITREP.

9.
10.
Current situation (what has happened, where did it
occur, what time)
 What actions have been undertaken (what has been
done)
 What actions still need to be completed (what needs to
be done)
 Any other issues (anything of interest or noteworthy).
Brief Department of Fire and Emergency Services (DFES)
personnel upon arrival on the type, scope and location of the
emergency.
11.
Provide DFES personnel with an escort to the source.
12.
Where a fire is confirmed, carry out confirmed code red
actions.
13.
Where the DFES Officer in Charge or the Engineering Officer
Emergency Services confirms that there is no fire/smoke, carry
out stand down actions.
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Action Card 2
Code Red
Fire / Smoke
Emergency Response
Coordinator
Action Card
2
Position: CNM Patient Flow or A/H nurse Mngr
CONFIRMED FIRE / SMOKE
1.
2.
3.
4.
Time
Instruct the Admissions Communications Officer to send a
code red confirmed page to the paging group (if not already
done), and dial 000 to confirm fire alarm activation is genuine.
Activate the P.A System for the entire facility and make the
code red confirmed announcement.
“Attention all areas, this is the Emergency Response
Coordinator. Code Red Confirmed <state location>, . Area
Wardens, please stand by your WIP phones and await
further instructions”
(Say twice.)
Cancel the P.A system and re-activate the alert tone in the
affected area.
Re-establish contact with Area Warden at the point of alarm
and request another SITREP. Determine:
 Whether Code Orange Evacuation Procedures need
to be activated
 Level of evacuation (stage II – horizontal or stage III
entire building)
 Assistance or resources required in the affected areas.
5.
Deploy staff to provide assistance as required.
6.
Establish contact with Hospital Incident Commander
(Operations Manager) and provide a SITREP. Request
activation of Business Continuity Plan.
7.
Respond to the directions of DFES Officer in Charge (OIC).
8.
Re-establish contact with Area Wardens of adjacent areas to
point of alarm using the WIP telephones and provide verbal
SITREP.
9.
Where the DFES or the Engineering Officer render the area
safe, carry out the stand down actions.
10.
Sign
Maintain communications with all key stakeholders.
Periodically update on progress.
Note: if unable to establish contact with the DFES Incident
Controller, call triple zero (000) and ask to be put through to
the Incident Controller responding to your incident.
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Action Card 2
Emergency Response
Coordinator
Code Red
Fire / Smoke
Action Card
2
Position: CNM Patient Flow or A/H nurse Mngr
CONFIRMED FIRE / SMOKE
(continued)
Time
Sign
Time
Sign
Complete an impact assessment to determine:
11.
12.


Services impacted by fire
Likely duration of impact
When DFES or the On Call Engineering Officer render the area
safe, carry out the stand down actions.
STAND DOWN / FALSE ALARM
2.
Cancel all alert tone and evacuation tones.
Once the area is rendered safe for re-occupation by DFES or
the On Call Engineering Officer, activate the PA system and
make the Code Red stand down announcement (or direct the
ACO to initiate a Stand Down).
3.
“Attention all areas, attention all areas, this is the
Emergency Response Coordinator, Code Red <state
location> stand down.
(Say twice.)
4.
Provide SITREP to Hospital Incident Commander
5.
Oversee the safe re-occupation of the building.
6.
Ensure all preventative / protective measures are reinstated
and returned to a point of readiness:
 Fire safety doors
 Fire escape routes
 Firefighting equipment (fire hydrants, boosters, fire hose
reels, sprinklers, portable fire extinguishers, fire
blankets).
 Smoke detectors and Manual Call Points (Break Glass
Alarm).
 Lifts
 Fire Indicator Panel is reset.
 Emergency lighting, exit signs.
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Action Card 2
Code Red
Fire / Smoke
Emergency Response
Coordinator
Action Card
2
Position: CNM Patient Flow or A/H nurse Mngr
STAND DOWN / FALSE ALARM
Time
(continued)
7.
Configure the EWIS from manual to automatic.
8.
Refurbish vest and action cards at the Emergency Control
Point.
9.
Arrange for a hot debrief to be conducted with key staff, DFES
and any other relevant stakeholders to capture key lessons
and names of people involved in the incident.
Sign
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Action Card 3
Fire / Smoke
Action Card
Area Warden
. Code Red
3
Position: CNM / Shift Coordinator
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
 Control the initial response to the emergency in the area.
 Maintains communication with the Emergency Response Coordinator.
ALERT
Time
Sign
Time
Sign
Proceed to the Area Warden Point, collect Area Warden Pack.
1.
Don vest and keep action cards on hand.
2.
3.
4.
Proceed to the most central Warden Intercommunication Point
(WIP) telephone.
Instruct staff to check the area in pairs (where practicable) for
signs of fire or smoke and provide SITREP back to you when
complete.
Ensure fire and smoke doors are properly closed.
Provide a SITREP to the Emergency Response Coordinator.
If there are no signs of fire of smoke, report “Nil reported
smoke or fire”
If smoke or fire detected, provide SITREP to ERC
5.
SITREP
 Current situation (what has happened, where did it occur,
what time)
 What actions have been undertaken (what has been
done)
 What actions still need to be completed (what needs to
be done)
 Any other issues (anything of interest or noteworthy).
Advise if there is a need to evacuate.
6.
Remain within the immediate vicinity of the local area warden
point and WIP phone; maintain communications with the ERC
and take control of emergency response activities in the area.
7.
Respond to the directions of the ERC.
CONFIRMED FIRE
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Action Card 3
Fire / Smoke
1.
2.
Action Card
Area Warden
. Code Red
3
Position: CNM / Shift Coordinator
Liaise with the Emergency Response Coordinator and/or any
emergency services on site. Advise of any particular hazards
and special areas for consideration.
Respond to the directions of the Emergency Services.
Provide updated SITREP to the ERC. If there are no signs of fire
of smoke, report “Nil reported smoke or fire”
If smoke or fire detected, provide updated SITREP to ERC.
3.
3.
4.
5.
SITREP
 Current situation (what has happened, where did it occur,
what time)
 What actions have been undertaken (what has been
done)
 What actions still need to be completed (what needs to
be done)
 Any other issues (anything of interest or noteworthy).
Advise ERC if there is a need to evacuate.
Carry out Code Orange evacuation procedures were instructed
to do so, on activation of the evacuation tone (WHOOP,
WHOOP), or when the situation warrants this.
Maintain communications with all key stakeholders.
Where the stand down message is heard, carry out the stand
down actions.
STAND DOWN / FALSE ALARM
1.
2.
3.
4.
5.
Time
Sign
Where patients have been evacuated, coordinate their return to
their wards or relocation as appropriate.
Coordinate the reinstatement of fire prevention/protection
measures.
Refurbish vest and action cards in the Area Warden Pack and
return to the Area Warden Point.
Participate in the debriefing process.
Act as directed by the Emergency Response Coordinator to
compile a report.
Action Card 5
Code Red
Fire / Smoke
Emergency Response
Team
Action Card
5
Position: Fire Wardens / Delegated Staff
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Action Card 3
Fire / Smoke
Action Card
Area Warden
. Code Red
3
Position: CNM / Shift Coordinator
Reports to: Area Warden
Responsibilities:
 Assists the Area Warden in maintaining safety of staff, patients and visitors
ALERT
1.
Proceed to the Area Warden Point.
a) Don vest where available
b) Keep action cards on hand.
2.
Report to the Area Warden.
3.
5.
1.
Proceed to the affected area as a team.
2.
Respond to the directions of the Area Warden.
3.
Maintain communications with the Area Warden.
Carry out Code Orange evacuation procedures were instructed
to do so, on activation of the evacuation tone (WHOOP,
WHOOP), or when the situation warrants this.
STAND DOWN / FALSE ALARM
1.
2.
Sign
Time
Sign
Time
Sign
Where the Area Warden is absent, assume the responsibilities
of the Area Warden until they arrive.
Respond to the directions of the Emergency Response
Coordinator.
CONFIRMED FIRE /SMOKE
4.
Time
Respond as directed by the Area Warden to reinstate fire
controls.
Assist in the reinstatement of fire controls and refurbishment of
firefighting equipment.
 Re-opening fire and smoke doors
 Clear fire escape exits
 Replacing extinguishers, hose reels, fire blankets
3.
Refurbish vest and action cards at the Area Warden Point.
4.
Participate in the debriefing process.
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Action Card 6
Code Red
Communications Officer
Fire / Smoke
Action Card
6
Position: Admissions Communications Officer
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities: To facilitate communications via P.A. and paging systems
ALERT
1.
2.
4.
Respond to the directions of the Emergency Response
Coordinator.
Sign
Time
Sign
If directed by Emergency Response Coordinator, establish
contact with the Department of Fire and Emergency
Services (DFES) by dialling triple zero (000) and confirm
they have received notification of the alarm.
CONFIRMED FIRE / SMOKE
2.
Time
Initiate code call:
a) Send page to Code Red group
b) Make PA announcement (if not done by ERC):
“Code Red, <area>. Repeat Code Red <area>”
Update the Emergency Code Activation Log
1.
Sign
When receiving a 55 Emergency Call, collect the following
information:
a) Type of emergency
b) Exact location of emergency
c) Quick description of the emergency
d) Name and position of caller
3.
5.
Time
Continue logging events and incoming calls.
If DFES has not arrived, confer with Emergency Response
Coordinator and if instructed, dial triple zero (000) to
confirm with DFES that emergency is legitimate.
Respond to the directions of the ERC
3.
STAND DOWN / FALSE ALARM
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Action Card 6
Code Red
Fire / Smoke
1.
2.
3.
Communications Officer
Position: Admissions Communications Officer
Action Card
6
When informed of a Stand Down, make P.A.
announcement:
“Stand Down, Code Red <area>, Repeat, Stand Down,
Code Red <area>”
Provide a copy of the Emergency Code Activation Log to
the Emergency Response Coordinator if requested to do
so.
Participate in the debriefing process.
8. Code
Purple
Bomb threat / suspicious substance
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8.1 Introduction
A code purple emergency may be called in response to an actual, or suspected,
bomb threat or suspicious substance.
8.2 Types of threats
Bomb and substance threats or actual events could be made by a person or people:
 As a prank or practical joke.
 Intentionally wishing to instil a state of fear, confusion and anxiety (terrorist
act).
 With a grievance against the facility or health service.
 Wanting to disrupt the operating of the facility.
Threats may be
 Written – including letters, emails, or facsimiles.
 Verbal – including threats over the telephone, from a patient, staff member or
visitor, or relayed message.
 Suspicious items – items found at the facility by patients, staff or visitors and
present as a possible threat by virtue of its characteristics.
Threats may also be specific or non-specific:
 A specific threat may describe the location and type of device and the reason
it has been placed.
 A non-specific threat may be a simple, vague, or ambiguous statement about
a bomb or substance with little or no information about the type of bomb, its
location and the reasons why it has been placed.
All bomb threats are to be treated as real events until proven otherwise.
8.3 Telephone threats
On receipt of a telephone threat, attempt to keep the caller on the telephone for as
long as possible. The recipient should aim to gain the attention of another staff
member to raise the emergency by dialling 55 and declaring Code Purple.
The recipient of the bomb threat should attempt to obtain as much information as
possible using the telephone bomb threat checklist.
When fielding the call, keep calm. Do not disconnect the call even once the caller
finishes the call. By keeping the line open, it increases the chance of tracing the call
back to its origin.
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8.4 Malicious Call Trace
Staff at Kalgoorlie Health Campus can initiate a "Customer Originated Trace (COT)"
from any 'handset" on the last incoming answered or unanswered (abandoned during
ring) call received, by:





If the incoming call was answered, you must go on-hook to end the call (hang
up) or
if the “Unwelcome call” was unanswered Then go off-hook (before a
subsequent call ‘ring’ is received).
Hear dial tone, enter 01156 Feature Activation Code.
Hear a recorded message such as “a trace has been performed on the last
incoming call, thank you’.
Manually record the date, time and duration of the call.
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Telephone Bomb Threat Checklist
Remember to keep calm
Do not hang up after call
Call details
Date of call:
Time received:
Duration of call:
Number called:
Caller ID:
Call taken by:
Important questions to ask
When is the bomb going to explode?
What will make the bomb explode?
Where did you put it?
Did you place the bomb?
When did you put it there?
What is your name?
What does the bomb look like?
Where are you?
What kind of bomb is it?
What is your address?
Remember to keep calm
Do not hang up after call
Exact wording of
threat
Threat Language
Well spoken
Background noises
Street noises
Incoherent
House noises
Irrational
Aircraft
Taped
Voices
Message read by caller
Local or STD call
Abusive
Machinery
Other
Other
Callers voice
Accent (specify)
Other
Speech (eg: slow/fast)
Any impediment (specify)
Diction (clear, muffled)
Voice (loud/soft)
Manner (Calm, emotional)
Did you recognise the voice?
Was the caller familiar with the area?
If so, who do you think it was?
Sex of caller
Estimated age
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8.5 Written threat
On receipt of a written threat, ensure the following actions are undertaken:







Contact 55 and declare Code Purple.
Note the date, time, and location of the threat.
Note the identity of the person making the threat (if known).
Refrain from touching the written threat and the envelope it came in as much
as possible. Use a tissue, paper towel or folded piece of paper and place
items in a clip seal bag, manila folder or another envelope and retained for
evidentiary.
Note the email address the written threat came from. Do not delete the email.
source any available CCTV footage of any persons hand delivering the threat.
Note any other relevant information.
8.6 Identifying an object as suspicious
When determining whether an item should be considered suspect, the HOT-UP
mnemonic should be used:
Is the item:
H
Hidden or concealed in any way?
O
Obviously a bomb?
T
Typical for its environment?
U
Unauthorised access to the area?
P
Perimeter breach?
Has there been:
8.6.1. Actions on finding a suspicious object
Upon identification of a suspicious object, the following actions are to be undertaken:
 Do not touch or attempt to move the suspect object.
 Cordon off the immediate area.
 Dial 55 and declare “Code Purple”.
 Clear people away from the immediate vicinity.
 Ensure radio emitting devices (mobile phones, radios, DECT phones, wireless
technology) is kept at least 25 metres from the suspicious object.
8.7 Suspicious substance
Any unexplained presence of a suspicious substance, such as white powder, is to be
treated as a threat until a threat assessment has been completed. Upon discovery of
a suspicious substance the room should be isolated to attempt the dispersion of the
substance.
Staff exposed to the substance should ensure they:
 Do not move, touch or disturb the substance any further.
 Keep hands away from face to avoid contaminating eyes, nose or mouth.
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



Wash hands if able to without leaving the room.
Place an object, such as an empty bin over the substance without disturbing it.
Turning off fans and air-conditioning, where possible.
Preventing others from entering the room without the proper PPE.
Note: accidental chemical spills are managed as a code yellow emergency.
8.8 Evaluation
Following analysis of the information received, the Emergency Response
Coordinator, in consultation with relevant external agencies such as Western
Australia Police, may be able to determine whether the threat is specific or nonspecific.
One of the following four actions may be determined:
1. Take no further action.
2. Search without evacuation.
3. Search and evacuate.
4. Evacuate without search.
Each one of these four options has its advantages and disadvantages related to
safety, speed, thoroughness, productivity and morale and must be assessed against
the potential risk.
8.8.1. Evaluating potential risks
The Emergency Response Coordinator should consider the following factors:
1. Risk of injury – evacuating the building poses additional risk of injury to
staff, patients and visitors. Additionally, keeping staff, patients and visitors
within the facility to a credible threat risks injury and possible death if device
detonated.
2. Response limitation – evacuating staff from the building will limit the ability
to conduct a search.
3. Panic - A sudden bomb threat evacuation may lead to a state of panic and
unpredictable behaviour.
4. Patient dependency – Some patients within the facility may be dependent
on care provided within the building, and may deteriorate or die if evacuated.
5. Reduction in patient care – the level of care provided to patients in an
assembly area is diminished and could compromise patient safety.
8.9 Searching
The most appropriate personnel to carry out a search in any given area are the staff
working in that particular area. This is because the staff have knowledge of “what
belongs” and “what does not belong” to the area.
The aim of the search is to identify any object:




Not normally found in an area or location.
For which an owner is not readily identifiable or becomes suspect.
That is suspiciously labelled.
That matches the description in the threat.
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8.9.1. Search order
Where the search has been initiated by the Emergency Response Coordinator, the
search is to be sequenced in the following order:
 The location described in the threat.
 Outside areas, including evacuation assembly areas.
 Building entrances and exits, and specifically, evacuations routes using be
staff during an emergency.
 Public areas within buildings, such as waiting rooms, wards, cafes.
 Other areas.
One a room has been searched, mark distinctively (on area warden search map or
directly onto door) to avoid duplication of effort.
8.9.2. Search procedure
Staff selected to conduct the search are to ensure the following:
 Proceed with the utmost caution.
 Commence at the outside of the room and work towards the inside.
 Scan from the floor level, moving up to waist height, then scan from waist
height to the ceiling.
Note:
 More than one device may be planted.
 Ensure searchers have no radio emitting devices. Use fixed phones (eg WIPs)
or runners to communicate.
 It should not be assumed that staff, when asked, are to carry out a search. If
staff are unwilling to undertake a search, wait for the Police to arrive.
8.10 Evacuation
The decision to evacuate should not be taken lightly. The evacuation of the facility
may pose additional risks to staff, patients and visitors. Although a stage three
(complete evacuation of building) may seem the most appropriate, a stage two
(partial evacuation) may reduce the risk of injury.
Prior to evacuating, the Area Warden / Emergency Response Team need to ensure
that all relevant evacuation corridors are safe and secured.
If safe to do so, leave all doors open to assist in venting any explosion.
The following points need to be considered when designating a local point of safety:
 Out of the “line of sight” of the device.
 Away from any glass structure.
 In a position with adequate overhead and frontal protection.
Where a location of the bomb and a detonation time has been specified, the device
has not been found and the threat is deemed credible, all persons are to be
evacuated from the area at least 30 minutes prior to the specified detonation time.
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Where the specified detonation time has passed without a detonation, persons must
not re-enter the area until the Emergency Response Coordinator has given
authorisation.
8.11 On detonation of a device
8.11.1. Detonation after evacuation
It is likely the area in which the device detonated may be damaged, and will be
closed for forensic investigation. This will require activation of the site’s Business
Continuity Plan to ensure essential services are restored as quickly as possible.
8.11.2. Detonation in occupied area
Should a device be detonated with staff, patients and visitors in the area, the
immediate priorities are to:


maintain the safety of patients, visitors and employees (remember, there may
be a secondary device)
preservation of life.
The Department of Fire and Emergency Services may need to conduct Urban Search
and Rescue (USAR) operations to rescue casualties from the affected area.
Any deceased persons must be left untouched and uncovered in order to assist with
any criminal investigations.
The Emergency Response Coordinator is to contact the Hospital Incident
Commander and request activation of the site’s Business Continuity Plan.
8.12 National Terrorism Threat Level
Check the latest National Terrorism Threat level at www.nationalsecurity.gov.au.
8.13 Code purple action cards
Code Purple action cards have been developed for the following positions:
Action card 7
Action card 8
Action card 9
Action card 11
Action card 12
First responder
Emergency Response Coordinator
Area Warden
Emergency Response Team member
Communications Officer
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Code Purple
Action Card
Action Card 7
Bomb threat /
suspicious
substance
First Responder
7
Reports to: Area Warden
Responsibilities:
- Take measures to record relevant information.
- Take measures to ensure that the person responsible for the emergency response is
notified.
ALERT - ON RECIEPT OF A TELEPHONE THREAT
Time
Sign
Time
Sign
Keep calm. Attempt to keep the caller on the telephone for as long as
possible.
1.
2.
3.
4.
5.
Do not hang up. Leave the phone line open, even if the caller
disconnects the call.
If possible, gain the attention of another staff member to raise the
emergency by dialling 55 and declaring Code Purple.
Use the telephone bomb threat checklist to glean as much detail about
the telephone threat.
Provide the Telephone Bomb Threat Checklist to the Emergency
Response Coordinator and/or WA Police.
Await the instructions of the Area Warden.
ALERT - ON RECIEPT OF A WRITTEN BOMB THREAT
1.
2.
3.
4.
5.
6.
Refrain from touching the written threat and the envelope it came in as
much as possible. Use a tissue, paper towel or folded piece of paper
and place items in a clip seal bag, manila folder or another envelope
and retained for evidentiary. Do not photocopy the threat document.
Note the date, time, and location of the threat, and the identity of the
person making the threat (if known)
Restrict access to the document. The document is considered physical
evidence, and may be taken away for forensic testing. Minimalising
handling of the document will avoid contaminating evidence.
If receiving the threat through electronic means (e.g.: email, SMS), take
steps to secure the information (e.g.: screen shots, saving, printing).
Contact 55 and provide Switchboard operator with the following
information.
a. Code Purple
b. Location of the incident
c. Brief description
d. Name and positon of caller.
Await instructions from the Area Warden.
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Code Purple
Action Card
Action Card 7
Bomb threat /
suspicious
substance
First Responder
7
ALERT - ON FINDING A SUSPICIOUS OBJECT
1.
Do not touch or attempt to move the suspicious object
2.
Remove all non-essential persons and equipment from the immediate
area. A distance of 25 metres is recommended.
Time
Sign
Time
Sign
Dial 55 and declare a code purple. If this is not possible, establish
contact with the Emergency Response Coordinator – 0427 087 147 or
Directory 364.
3.
4.
State:
a)
b)
c)
d)
Code Purple
Location of the incident
Brief description
Name and positon of caller.
Await instructions from Area Warden.
ALERT - ON FINDNG A SUSPICIOUS SUBSTANCE
1.
Do not touch or attempt to move the suspicious substance.
Attempt to isolate the area to prevent dispersal of the suspicious
substance.
2.
Turn of fans / air-conditioning if possible.
Prevent other people from entering the area.
Dial 55 and declare a code purple. If this is not possible, establish
contact with the Emergency Response Coordinator – 0427 087 147 or
Directory 364.
3.
4.
State:
a)
b)
c)
d)
Code Purple
Location of the incident
Brief description
Name and positon of caller.
Follow the instructions of the Area Warden.
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Code Purple
Bomb threat /
suspicious
substance
Action Card 8
Emergency Response
Coordinator
Action Card
8
Position: CNM Patient Flow or A/H nurse Mngr
Reports to: Hospital Incident Commander – (Operations Manager) - 0428 949 930
Responsibilities:
- Control the response of an internal emergency within the facility
- Ensure the health and safety of staff, patients and visitors.
- Site-wide leadership.
ALERT
1.
2.
Time
Sign
Proceed immediately to the Emergency Control Point at the main Fire
Indicator Panel (FIP) located at the Emergency Department entrance.
Collect vest, action card
a) Don vest.
b) Keep action card on hand.
Important: Do not use radio-emitting devices to communicate with the
Emergency Response Team or Area Wardens.
3.
Use alternative communication methods including Warden
Intercommunication Point (WIP) phones, PA system, or runners.
4.
5.
6.
Receive the report of the threat from the communications officer.
Determine whether to contact WA Police. If WA Police are needed,
instruct the Communications Officer to dial triple zero (000).
Ascertain the nature and location of the threat or suspicious object.
Establish contact with the Area Warden of affected area(s) (by runner
or WIP phone) and provide/receive SITREP.
If required, use PA system to establish contact with Area Warden, and
then revert to WIP phone.
If required, deploy Emergency Response Team to investigate and
report back.
Establish contact with Area Wardens of adjacent areas and
provide/receive SITREP.
7
8.
Evaluate the threat. Determine if threat is specific (detailed
information), non-specific (simple statement) or whether an identified
item has been as flagged as suspicious.
9
Brief Emergency Services on their arrival on type, location and nature
of threat, and arrange for an escort to the affected area(s).
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Code Purple
Bomb threat /
suspicious
substance
Action Card 8
Emergency Response
Coordinator
Action Card
8
Position: CNM Patient Flow or A/H nurse Mngr
ALERT (continued)
Time
Sign
Time
Sign
In conjunction with relevant stakeholders (WA Police, DFES) assess
the risk and determine course of action.
10.
Risks to consider include:
1. Risk of injury – evacuating the building poses additional risk of
injury to staff, patients and visitors. Additionally, keeping staff,
patients and visitors within the facility to a credible threat risks
injury if device detonated.
2. Response limitation – evacuating staff from the building will
limit the ability to conduct a search.
3. Panic - A sudden bomb threat evacuation may lead to a state of
panic and unpredictable behaviour.
4. Patient dependency – Some patients within the facility may be
dependent on care provided within the building, and may
deteriorate or die if evacuated.
5. Reduction in patient care – the level of care provided to
patients in an assembly area is diminished and could compromise
patient safety.
6. Is the threat credible?
Courses of action include:
1.
2.
3.
4.
Take no further action (stand down)
Search without evacuation. – low risk
Search and evacuate. – medium/high risk
Evacuate without search - high risk – refer to Code Orange
Procedures
If decision is made to evacuate, consider:


Partial evacuation from affected area
Complete evacuation of facility.
RESPONSE - SEARCH WITHOUT EVACUATION
(The risk is assessed as low)
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Code Purple
Bomb threat /
suspicious
substance
Action Card 8
Emergency Response
Coordinator
Action Card
8
Position: CNM Patient Flow or A/H nurse Mngr
Establish contact with the Hospital Incident Commander (HIC) and
request approval to search without evacuation.
1.
Note: Searching without evacuation should only be done for low risk
threats.
2.
Instruct the Area Warden for the affected are to initiate a search of the
given area in the following order:
1. The area/department where the threat has been made.
2. The assembly areas and evacuation routes used by people to
evacuate
3. The ward/department’s entrances and exits
4. Public areas within the ward/department (e.g. waiting rooms,
public toilets)
5. Other areas.
Maintain communication with all key stakeholders, including the HIC,
Area Wardens, Emergency Response Team, WA Police and other
external agencies.
3.
Note: Ensure radio emitting devices (mobile phones, radios, DECT
phones, wireless technology) is kept at least 25 metres from the
suspicious object.
If necessary, use runners, WIP phone, landlines to communicate.
Where an item is identified, categorise the item as either suspect of
non-suspect using the HOT-UP mnemonic.
4.
H - Is the item Hidden?
O - Is the item Obviously a bomb
T – Is the item Typical for its environment?
U – Has there been Unauthorized access to the area?
P – Has there been a breach of the facility’s Perimeter or security?
5.
Where an item is confirmed as suspect, carry out the confirmed
suspect item actions.
6.
Where a suspicious item is not found, confer with Police and determine
if a stand-down (no further action) can be issued.
RESPONSE – EVACUATE, THEN SEARCH
(Medium / High Risk)
Sign
Sign
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Code Purple
Bomb threat /
suspicious
substance
Action Card 8
Emergency Response
Coordinator
Action Card
8
Position: CNM Patient Flow or A/H nurse Mngr
Activate the P.A system for the entire facility and make the possible
code purple announcement (if not already done by ACO).
1.
“Attention all areas, attention all areas, this is the Emergency
Response Coordinator. Possible Code Purple. Remain calm and
wait for further instructions”.
(Say twice.)
2.
3.
4.
5.
Ensure the main entrance of the area is kept clear and public access
restricted.
Note: Entry to the area should only be permitted to essential staff and
emergency services (WA Police / DFES).
Ensure the departments muster point and assembly area including any
routes that people may use to evacuate have been searched for
suspect items. Where a suspect item is identified, carry out the suspect
item procedure.
Carry out the Code Orange evacuation procedures to evacuate the
immediate area.
Provide a Situational Report to the Emergency Service(s) Officer(s)
and assign task(s) that require urgent action.
Establish contact with the Hospital Incident Commander, provide
SITREP and request approval to search after evacuation.
6.
7.
8.
Note: Approval to search an area after an evacuation should be based
on the assessed level of risk. Where risk levels are intolerable
(e.g. assessed as high or greater), approval to search should not
be given.
Where the evacuation is complete and a search has been approved by
the Hospital Incident Commander ,instruct the Area Warden of the
affected area to initiate a search of the given area in the following
order:
a) The area/department in which the threat has been made
b) The area/departments entrances and exits.
c) Public areas within the area/department (Waiting rooms, public
toilets).
d) Other areas.
Maintain communications with all key stakeholders (i.e. police, Area
Wardens, and Hospital Incident Commander).
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Code Purple
Bomb threat /
suspicious
substance
Action Card 8
Emergency Response
Coordinator
Action Card
8
Position: CNM Patient Flow or A/H nurse Mngr
Where an item is identified, categorise the item as either suspect or not
suspect:
9.
a)
b)
c)
d)
e)
f)
Is the item unidentified/unaccounted for?
Is the item unusual for the area?
Is the item obviously a bomb?
Is the item hidden or concealed in any way?
Has there been unauthorised access to the area?
Has there been a breach of the areas physical security?
Note: The above questions provide guidance for assessing an item.
10.
Where an item is confirmed as suspect, carry out the confirmed
suspect item actions.
11.
Where a suspect item is not identified, carry out the Code Purple
stand down actions.
RESPONSE
(CONFIRMED SUSPICIOUS ITEM / SUBSTANCE)
1.
Convene all stakeholders and reanalyse the risk.
2.
Ensure the main entrance is clear and public access is restricted.
Time
Sign
Time
Sign
Carry out Code Orange Procedures.
3.
Note: this may involve a stage two (partial) or stage three (complete)
evacuation, depending upon the risk assessment.
Provide SITREP to Hospital Incident Commander, and if necessary,
activate the site’s Business Continuity Plan.
4.
RESPONSE
(CONFIRMED SUSPICIOUS ITEM / SUBSTANCE)
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Code Purple
Bomb threat /
suspicious
substance
6.
Action Card 8
Emergency Response
Coordinator
Action Card
8
Position: CNM Patient Flow or A/H nurse Mngr
Be guided by the advice of Police, DFES and the Hospital Incident
Commander and respond to directions as appropriate.
Provide advice to Police and DFES about any foreseen patient risks.
7.
Maintain communication with all stakeholders.
8.
Where the area is rendered safe by the police, carry out the stand
down actions.
9.
If the suspicious device detonates:
1. Ensure the safety of staff, patients and visitors.
2. Undertake efforts to preserve life and treat injured.
10.
Consider establishing a Casualty Clearing Post in a safe area nearby
to undertake triage and treatment.
11.
In consultation with the Hospital Incident Commander, activate the
site’s Business Continuity Plan and, if necessary, the Code Brown
Procedures.
STAND DOWN (NO FURTHER ACTION REQUIRED)
1.
Once satisfied the situation has been appropriately dealt with, and on
the advice of Police, issue the stand down.
2.
Cancel any alert and evacuation tones on the EWIS system.
3.
Request the ACO to stand down via the paging system “Stand down
Code Purple”
4.
Refurbish vest and action cards in the Emergency Control Point.
5.
Commence hot debriefing process with all available staff members.
Identify staff, patients and visitors affected by the incident.
6.
Compile an urgent report on the incident and submit on the Emergency
Code Reporting Tool.
Time
Sign
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Code Purple
Bomb threat /
suspicious
substance
Action Card 9
Area Warden
Action Card
9
Position: CNM / Shift Coordinator
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
- Controls the initial response to the emergency in for their nominated area.
- Maintains communication with the Emergency Response Coordinator.
- Undertakes search of local area and coordinates any subsequent evacuation.
ALERT
1.
2.
3.
4.
5.
Time
Sign
Time
Sign
On alert from Emergency Response Coordinator, proceed to the Area
Warden Point, collect vest and Area Warden Pack.
Don vest and keep Area Warden Pack on hand.
Obtain SITREP from Emergency Response Coordinator.
Determine the type, form and location of the threat.
If alerted to local threat, dial 55 and declare Code Purple.
State:
 Code Purple
 Location of the incident
 Brief description
 Name and positon of caller.
If a telephone threat, ask the recipient to complete the telephone
bomb threat checklist and to keep caller on line, even if they cancel
the call.
If written threat received, instruct staff to prevent handling of the
written material.
RESPONSE (SEARCH WITHOUT EVACUATION)
(The risk is assessed as low)
If directed by Emergency Response Coordinator, quietly commence
local search for suspicious objects within area of responsibility.
1.
In order, search:
1. Any publically accessible areas within your area of
responsibility.
2. The evacuation routes.
3. The ward/department’s entrances and exits
4. Public areas within the ward/department (eg: waiting rooms,
public toilets)
5. Other areas (eg: staff tea room, store room).
Use Area Warden Pack search map and chinagraph pencil to mark off
areas searched to prevent duplication of effort.
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Code Purple
Bomb threat /
suspicious
substance
Action Card 9
Area Warden
Action Card
9
Position: CNM / Shift Coordinator
RESPONSE (SEARCH WITHOUT EVACUATION)
(continued)
If a suspect item is found, use the HOT-UP mnemonic to determine if
any identified objects are suspect:
2.
Time
Sign
Time
Sign
H - Is the item Hidden?
O - Is the item Obviously a bomb
T – Is the item Typical for its environment?
U – Has there been Unauthorized access to the area?
P – Has there been a breach of the facility’s Perimeter or security?
Maintain communications with the Emergency Response Coordinator,
Emergency Response Team and staff. Provide regular SITREPs to
Emergency Response Coordinator on search progress.
3.
SITREP
 Current situation (what has happened, where did it occur, what
time)
 What actions have been undertaken (what has been done)
 What actions still need to be completed (what needs to be
done)
 Any other issues (anything of interest or noteworthy).
Note: Do not use radio emitting devices such as mobile phones, radios
or DECT phones. Use landline phones, runners or the WIP phone.
4.
5.
Where an item is confirmed as suspect, carry out the confirmed
suspect item actions.
Where a suspicious item is not found, confer with Police and determine
if a stand-down (no further action) can be issued.
RESPONSE (EVACUATE, THEN SEARCH)
Where the bomb threat is verbal or written and the risk has been assessed as
medium or greater.
1.
2.
3.
Ensure the evacuation point including the routes that people will use to
evacuate is clear.
Carry out an evacuation of the affected area. Ensure that all personal
belongings, e.g. handbags, briefcases etc. are removed by the
occupants when evacuating.
Establish contact with the Emergency Response Coordinator and
request approval to search the area.
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Code Purple
Action Card 9
Area Warden
Action Card
Bomb threat /
suspicious
Position: CNM / Shift Coordinator
substance
Where a search has been approved, initiate a search of the given area
by local staff (in pairs) and in the preferred order:
a) The area that is threatened.
b) The departments entrances and exits;
c) Public areas within the department (waiting rooms, public toilets)
d) Other areas.
4.
9
Use Area Warden Pack search map and chinagraph pencil to mark off
areas searched to prevent duplication of effort.
Note: Where an item is located, staff should not touch, cover or move
the item.
RESPONSE (EVACUATE, THEN SEARCH)
(Continued)
5.
Maintain communications with the Emergency Response Coordinator.
6.
Respond to the directions of the Emergency Response Coordinator.
7.
Allocate staff to assist where necessary.
RESPONSE (CONFIRMED SUSPICIOUS ITEM)
1.
Provide SITREP to Emergency Response Coordinator and any onscene emergency services.
 Current situation (what has happened, where did it occur, what
time)
 What actions have been undertaken (what has been done)
 What actions still need to be completed (what needs to be
done)
 Any other issues (anything of interest or noteworthy).
2.
If a suspicious substance is found, close off room and isolate any
exposed persons are isolated until appropriate assistance can arrive.
Advise staff to wash hands with soap and water if they can so without
leaving room, and turn off any fans or air conditioning where possible.
3.
If a suspicious object is found, cordon off the immediate vicinity;
prevent staff, patients and visitors from entering the area. Do not
attempt to touch or move the object. Open any doors or windows.
Time
Sign
Time
Sign
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Code Purple
Bomb threat /
suspicious
substance
Action Card 9
Area Warden
Action Card
9
Position: CNM / Shift Coordinator
4.
Do not use radio emitting devices such as mobile phones, radios or
DECT phones. Use landline phones, runners or the WIP phone.
5.
If directed, or on triggering of evacuation tones (WHOOP, WHOOP)
undertake any stage II or stage III evacuation, as per Code Orange
Evacuation procedures.
6.
Where the area is rendered safe, carry out the Code Purple Stand
Down procedures.
7.
If the suspicious device detonates:
 Ensure the safety of staff, patients and visitors.
 Where able and safe to, evacuate all patients, staff and visitors
from the affected area.
 Be mindful of secondary devices.
STAND DOWN
Time
(NO FURTHER ACTION REQUIRED)
1.
Once satisfied the situation has been appropriately dealt with, and on
the advice of Police, issue the stand down.
2.
Where patients, staff and visitors have been evacuated, coordinate
their return to their wards, or relocate as appropriate.
3.
Instruct staff to reinstate the area to its original status (close doors and
windows, etc.)
4.
Refurbish vest and Area Warden Pack, and return to the Area Warden
Point.
5.
Collate all action cards (complete and incomplete) and any incidentrelated documentation.
Sign
Participate in any hot debriefing processes with all available staff
members.
6.
Identify staff, patients and visitors affected by the incident and refer
onto the Emergency Response Coordinator or line manager.
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Code Purple
Bomb threat /
suspicious
substance
Action Card 11
Emergency Response Team
Member
Action Card
11
Position: Fire Wardens / Delegated Staff
Reports to: Area Warden
Responsibilities:
- Undertakes activities as directed by the Area Warden
ALERT
1.
Time
Sign
Time
Sign
On alert from Emergency Response Coordinator, proceed to the Area
Warden Point, collect vest and Area Warden Pack.
Don vest and keep Area Warden Pack on hand.
2.
Respond to the directions of the Area Warden
RESPONSE (SEARCH WITHOUT EVACUATION)
(The risk is assessed as low)
1.
2.
Proceed as a team to the affected area(s).
Respond to the directions of the Area Warden
Maintain communication with the Area Warden
3.
4.
Note: Turn off radio-emitting devices such as mobile telephones,
radios and DECT phones. Use runners, WIP or landlines to
communicate.
As directed by the Area Warden, undertake a discrete search of the
area. The order of search should be:
1. Any publically accessible areas within your area of
responsibility.
2. The evacuation routes.
3. The ward/department’s entrances and exits
4. Public areas within the ward/department (e.g. waiting rooms,
public toilets)
5. Other areas (e.g. staff tea room, store room).
Ensure searched areas are marked to prevent duplication of effort.
If a suspect item is found, use the HOT-UP mnemonic to determine if
any identified objects are suspect:
5.
H - Is the item Hidden?
O - Is the item Obviously a bomb
T – Is the item Typical for its environment?
U – Has there been Unauthorized access to the area?
P – Has there been a breach of the facility’s Perimeter or security?
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Code Purple
Bomb threat /
suspicious
substance
Action Card 11
Emergency Response Team
Member
7.
11
Position: Fire Wardens / Delegated Staff
RESPONSE (SEARCH WITHOUT EVACUATION)
(The risk is assessed as low)
(Continued)
6.
Action Card
Time
Sign
Time
Sign
Time
Sign
Time
Sign
Where an item is confirmed as suspect, inform the Area Warden and
carry out the confirmed suspect item actions.
Where a suspicious item is not found, inform the Area Warden.
Carry out the stand-down (no further action) actions if directed by
Emergency Scene Coordinator.
RESPONSE – EVACUATE – THEN SEARCH
Enacted when the bomb threat is verbal or written and the
risk has been assessed as medium or greater.
1.
Proceed to the Area Warden Point
2.
Respond to the directions of the Area Warden.
3.
Where the evacuation tone/message is heard, commence the Code
Orange evacuation procedure.
4.
Maintain communications with the Area Warden.
RESPONSE
(CONFIRMED SUSPICIOUS ITEM / SUBSTANCE)
1.
Provide SITREP to Area Warden and any on scene emergency
services.
 Current situation (what has happened, where did it occur, what
time)
 What actions have been undertaken (what has been done)
 What actions still need to be completed (what needs to be
done)
 Any other issues (anything of interest or noteworthy).
2.
If a suspicious substance is found, close off room and isolate any
exposed persons are isolated until appropriate assistance can arrive.
Advise staff to wash hands with soap and water if they can so without
leaving room, and turn off any fans or air conditioning where possible.
3.
If a suspicious object is found, coordinate the cordoning off the
immediate vicinity; prevent staff, patients and visitors from entering the
area. Do not touch or attempt to move the package. Open any doors or
windows,
RESPONSE
(CONFIRMED SUSPICIOUS ITEM / SUBSTANCE)
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Code Purple
Bomb threat /
suspicious
substance
Action Card 11
Emergency Response Team
Member
Action Card
11
Position: Fire Wardens / Delegated Staff
(continued)
4.
Do not use radio emitting devices such as mobile phones, radios or
DECT phones. Use landline phones, runners or the WIP phone.
5.
Respond to the directions of police and the Area Warden.
6.
Where evacuation tones are heard (WHOOP, WHOOP), carry out the
Code Orange Evacuation Procedures.
7.
Where the area is rendered safe, carry out the Code Purple Stand
Down procedures.
8.
If the suspicious device detonates:
 Ensure the safety of staff, patients and visitors.
 Follow the directions of the Area Warden.
 Where able and safe to, evacuate all patients, staff and visitors
from the affected area.
 Be mindful of secondary devices.
STAND DOWN
Time
(No further action required)
1.
Respond to the directions of the Area Warden.
2.
Where patients, staff and visitors have been evacuated, coordinate
their return to their wards, or relocate as appropriate.
3.
Assist staff to reinstate the area to its original status (close doors and
windows, etc.)
4.
Refurbish vest and action card in the Area Warden Point.
5.
Participate in any hot debriefing processes with all available staff
members.
Sign
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Code Purple
Bomb threat /
suspicious
substance
Action Card 12
Communications Officer
Action Card
12
Position: Admissions Communications Officer
Reports to: Emergency Response Coordinator: 0427 087 147 or Directory 364
Responsibilities:
- To facilitate communications via P.A. and paging systems
ALERT
1.
2.
3.
Time
Sign
Time
Sign
When receiving a 55 emergency call, record the following information:
 Callers name
 Exact location of the incident
 Brief description of the threat
o Specific or non-specific
o Written, verbal or suspicious object / substance.
Initiate code call:
a) Make PA announcement:
“Code purple, <area>. Repeat Code purple <area>”
b) Send page to the code purple page group
Update the Emergency Code Activation Log
4.
Respond to the directions of the Emergency Response Coordinator.
5.
If requested by the Emergency Response Coordinator, establish
contact with WA Police by dialling triple zero (000) and provide them
with first report.
ON RECIEPT OF A TELEPHONE THREAT
Keep calm. Attempt to keep the caller on the telephone for as long as
possible.
1.
Do not hang up. Leave the phone line open, even if the caller
disconnects the call.
2.
If possible, gain the attention of another staff member to raise the
emergency by contacting the Emergency Response Coordinator and
declaring Code Purple.
3.
Use the telephone bomb threat checklist to glean as much detail
about the telephone threat.
4.
Provide the Telephone Bomb Threat Checklist to the Emergency
Response Coordinator and/or WA Police.
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Code Purple
Bomb threat /
suspicious
substance
Action Card 12
Communications Officer
12
Position: Admissions Communications Officer
RESPONSE (SEARCH WITHOUT EVACUATION)
(The risk is assessed as low)
1.
Continue logging events and incoming calls.
2.
Maintain communications with the Emergency Response Coordinator.
3.
Respond to the directions of the Emergency Response Coordinator.
RESPONSE (CONFIRMED SUSPECT ITEM)
1.
Continue logging events and incoming calls.
2.
Maintain communications with the Emergency Response Coordinator.
3.
Respond to the directions of the Emergency Response Coordinator.
STAND DOWN
(No further action required)
1.
2.
3.
Action Card
Time
Sign
Time
Sign
Time
Sign
On notification of a Stand Down
a) Send page to the Code Purple page group
b) make P.A. announcement:
“Stand Down, Code Purple <area>, Repeat, Stand Down, Code
Purple <area>”
c) Record Stand Down time in Emergency Code Activation Log
Provide a copy of the Emergency Code Activation Log to the
Emergency Response Coordinator if requested to do so.
Participate in debriefing process.
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9.
Code Black – Personal threat
9.1 Introduction
A code black emergency may be called in response to a personal threat to others or
themselves. The personal threat may range from:
 Armed threat
 Unarmed threat
 Self-harm
 Illegal occupancy
Note: In addition to Code Black personal threat emergencies, the following codes
are used to facilitate the identification and communication of additional risks. For
these emergencies specific sub plans have been established.


Code Black Alpha – Infant or Child Abduction.
Code Black Bravo – Active Shooter.
Kalgoorlie Health Campus has a Code Black Team that is trained in the management
of Code Black Emergency Response and operates under the direction of the Area
Warden or Emergency Response Coordinator. (Appendix H)
9.2 General
A personal threat is an incident where staff, patients and/or visitors are verbally,
physically abused, threatened or assaulted. Personal threats are categorised as
unarmed or armed.
Unarmed confrontations may occur when there is a threat to staff, patients and/or
visitors by an unarmed person confronting them in a violent or threatening manner.
This includes but is not limited to:




Verbal aggression – threatening or abusive language involving excessive
swearing or offensive remarks.
Threatening behaviour.
Physical aggression.
Wilful damage to hospital property.
Armed confrontations may occur when there is a threat to staff, patients and/or
visitors by a person confronting them armed with a weapon. A weapon is defined as
any article used to cause injury.
Some personal threats may be de-escalated quickly and easily addressed at a local
level however some may require a coordinated effort from the hospital’s Emergency
Control Organisation to resolve.
A Code Black refers to a personal threat, actual or perceived that requires a
coordinated effort from the hospital’s Emergency Control Organisation to resolve.
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A Code Black call can be made by any staff member who feels the situation is an
emergency and requires assistance.
9.3 Self-harm
A code black may be called for patients actively attempting to commit suicide or
engaging in self-harm.
When a person is actively engaging in self-harm, remember
 Maintain a safe distance (at least 3 metres).
 Summon assistance (activate duress alarm or call ‘55’ Code Black).
 Communicate calmly with the person from a safe distance (usually a minimum
of 3 metres) if you feel comfortable doing so, whilst waiting for the Emergency
Response Team (ERT) to arrive.
 Remove people not involved from the area.
9.4 Responding to the Aggressive Person
If an incident occurs or escalates, staff must respond to the situation in accordance
with the immediate actions. The immediate actions prescribe the initial notification
and response actions for first responders to a Code Black emergency.
9.4.1 Activation and notification
Any employee can activate a Code Black for a threat to themselves or to others. A
code black can be activated by the following mechanisms:
 Mobile duress alarm e.g. pendant or DECT phone.
 Fixed duress alarm.
 Dialling 55 and starting:
o Code Black.
o Brief description of the incident.
o Exact location of incident.
o Name and title of the caller.
9.4.1.1 Duress alarms
This site uses fixed and mobile duress devices listed in (Appendix I)
Wall mounted duress buttons or strips and DECT phones will alert the Admissions
Communications Officer who is to send a page to the appropriate Emergency group
and then make a P.A. announcement.
Pendants will send a page directly to the Code Black page group; the Admissions
Communications Officer is to make the P.A. announcement, and then call the
pendant directly to verify the location and requirement for a call to WAPOL with the
staff member carrying the pendant.
9.4.2 De-escalation
De-escalation is the process of recognising the early signs of distress, anger or
frustration and intervening to reduce the level or the intensity of those feelings before
the behaviour becomes assaultive or destructive.
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Where confronted with an aggressive situation, staff should first attempt to deescalate the situation by using the LASSIE technique. All de-escalation interventions
should be documented in the patient’s records with an evaluation of the effectiveness
of the technique.
Acronym
L
Listen to what
the person is
saying.





A
Acknowledge
their feelings.


S
Separate the
person form
others
S
Sit the person
down
I
Indicate options
E
Encourage






Intervention
Use open ended questions
Ascertain the trigger (e.g. Fear, frustration,
manipulation, intimidation)
Paraphrase to reinforce you have heard and
clarify your understanding.
Reaffirm your understanding
Begin to set boundaries such as appropriate/
inappropriate behaviour.
Setting limits- is not about telling someone what to
do; it is acknowledging the consumer may not be
able to see the consequences of their behaviour
and assisting them to find an appropriate way of
behaving.
Remove the person from distracting/hectic
environment if appropriate.
Inform colleagues of your location and
approximate time you may need- Do NOT isolate
yourself. Be aware of dual access and egress.
Eye level
Expand on what you have heard in the listening
phase
Options must be realistic and achievable.
Encourage the person to choose from one of the
options available
Commit yourself to the chosen option
See: WACHS Disturbed Behaviour Management- Clinical Practice Standard
9.4.3 Withdrawal
Where a situation cannot be de-escalated, staff should withdraw to a safe area/room
and call a Code Black. The decision to withdraw should be assessed with
consideration to the following:
 the consequences to staff safety should a withdrawal not be carried out
 the proximity of the aggressor to other patients and visitors
 the clinical risks associated with withdrawing staff from clinical areas.
A withdrawal is to be via a person’s most direct and safe route to their nearest safe
area/room.
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9.4.4 Evasion
Evasion is a technique that helps staff safely remove themselves from a violent
situation when a withdrawal route is blocked, when under the threat of attack or when
being attacked.
Where withdrawal to a safe area is not practicable, staff should:
 Call loudly for help.
 Remain as calm and confident as possible.
 Communicate with the aggressor by using their name.
 Stay out of striking range – use barriers (staff stations, desks etc.) if you can.
 Remain alert for cues (clenched fists, picking up a weapon etc.).
 Make an escape plan – where is the door, where is the safe room?
 Defend themselves where necessary – escape from holds, deflect punches
and kicks.
9.5 Management Strategies for the Aggressive Patient
If an incident occurs or escalates, the Emergency Response Coordinator in
consultation with other Emergency Management Team members (Code Black
Responders) and key stakeholders should initiate a management strategy
appropriate to the situation and the training of staff. After an initial evaluation of the
situation, the following management strategies may be initiated to manage an
aggressive person.
NOTE: A safe approach to managing the care of persons who exhibit agitation,
responsive or aggressive behaviour is one that focusses on prevention strategies
and positive changes and implements evidence-based strategies for the prevention,
early recognition and response to challenging behaviours.
9.5.1 Patient Care Plan
 Behavioural assessment: an assessment that aims to define the
aggressive/violent behaviour.
 Investigations; actions taken to investigate the physiological cause of the
aggressive/violent behaviour.
 Interventions/Treatments; medical and or nursing actions taken to manage
aggressive/violent behaviour.
9.5.2 Environmental Management Plan
 Reduce environment stimuli: actions taken to reduce the level of stimulation in
the physical environment.
 Reduce patient confusion: actions taken to maintain clear and concise lines of
communication.
 Protect the person from harming self or others: actions taken to utilise
engineered solutions to protect the patient, staff and others from harm.
 Tolerate restlessness: defining actions that may be made by the person which
are tolerable for staff.
9.5.3 Discharge/Release
 Discharge/release: the actions taken to discharge the patient or allow them to
be released.
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9.5.4 Restraint
WACHS is committed to eliminating restrictive practice - restraint is only to be used
as a last resort, with the least amount of physical force required and for the shortest
period of time, when all other less restrictive interventions have been exhausted.
Any episodes of restraint are to be reviewed to try to minimise further use.
 Physical Restraint: is the application of bodily force to the person’s body to
restrict the person’s movement.
See: WACHS Restraint Minimisation Policy
WACHS Mental Health Restraint Policy
Considerations
Use of de-escalation strategies must be implemented wherever possible prior to
restraint. These include: Respect personal space, establish verbal contact, avoid
prolonged eye contact, use simple language, offer support, listen carefully, set clear
limits, offer choices and as far as reasonable meet the desires of the patient..
Key to a decision to use any form of restraint is finding the balance between:
 A person’s right to self-determination
 Protection from self-harm
 The possibility of harm to others
During and after restraint:
 Minimum of 3 trained staff members required
 Prone restraint should be avoided where possible, if necessary then should
not exceed 3 minutes due to an increased risk of hypoxia
 Continued monitoring of person’s behaviours and mood with a view to ceasing
the intervention as soon as possible
 Continued monitoring of physical health observations
 Medical Assessment
 Supervision- Medical Practitioner/most Senior Registered Nurse in location
 Reporting, including SRRF
 Notification to Office of Chief Psychiatrist (via Datix CIMS) under WA Mental
Health Act 2014 requirements
 Documentation
 Staff Debrief
 Senior Management Review via SRRF
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9.6 Description of Offender Form
Note: To be compiled immediately after incident. A separate form is required for each
person/offender. Place a tick as applicable. If answer is unknown, write ‘Unknown’ against
the heading. Do not consult others during compilation.
STAFF MEMBER COMPLETING FORM
Surname
First name
Position title
Area / ward
Phone No
DESCRIPTION OF THE OFFENDER
Name or Nickname
Approximate Age
Height (approx.)
Gender (tick)
Male  Female  Unknown 
Race / ethnicity
Build
Thin 
Hair
Colour
(tick)
Solid

Soft

Medium

Long
Other (specify):

Medium
Short
Wavy
Curly



Eyes (colour)
Ears (shape/size)
Nose (shape /size)
Lips (size / shape)
Teeth
Good  Bad  Uneven 
Spaced 
Voice
Clear  Loud  Thick 
Slangy 
Spectacles
No 
Yes  
(Colour/shape)
Beard / Moustache
No 
Yes   description
Hands
(description eg: size, shape, nails)
Jewellery description
Scars / Marks (description)
Clothing (description, colour)
Weapon type
Vehicle Make
Colour
Any other relevant information
Obese

Straight
Thin
Bald
Protruding 
Accent:




Missing 
Model
Registration
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9.7 Code Black Action Cards
Code Black action cards have been developed for the following positions:
Action card 13
Action card 14
Action card 15
Action card 17
Action card 18
First responder
Emergency Response Coordinator
Area Warden
Emergency Response Team member
Communications Officer
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Code Black
Action Card
Action Card 13
First Responder
Personal
Threat
13
Reports to: Area Warden
Responsibilities:
- Ensure the safety of yourself and anyone within the immediate vicinity of the aggressor.
- Take measures to ensure that the Emergency Response Coordinator is notified.
UNARMED CONFRONTATION
1.
Remain calm. Avoid showing signs of fear or panic.
2.
Attempt to de-escalate the situation by using the LASSIE technique.
Where the situation can be deescalated, notify the Area Warden and if
applicable commence risk reporting processes.
3.
Where the situation cannot be de-escalated.
4.
5.
6.
7.
Time
Sign
Time
Sign
Time
Sign
Activate duress and withdraw to your nearest safe room/area.
Note: Where a duress alarm cannot be activated, a call for assistance
should be made by whatever means available (I.e. staff assist, attract
the attention of other staff).
Establish contact with the Switchboard operator by dialling 55. If this is
not possible, contact the Emergency Response Coordinator directly
and give the first report.
First Report:
a) Caller's Name and position
b) Exact location of Incident
c) Type of incident (unarmed confrontation).
Record all information on the offender description form using the
Description of Offender Form. Use one form for each offender.
Wait for instructions from the Area Warden (includes directions on
reporting risk).
Where you cannot withdraw to your nearest safe room/area.
8.
Call loudly for assistance.
9.
Remove possible weapons or at least be aware of these.
10
Stay out of striking range – use barriers.
11.
Avoid acting aggressively except when needing to defend yourself escape from holds, deflect punches and kicks.
12.
Make you withdrawal plan, position yourself so you can withdraw –
withdraw when you can.
13.
When escaped, move to your nearest safe room/area and carry out
steps 4 – 6.
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Code Black
Action Card
Action Card 13
First Responder
Personal
Threat
13
ARMED CONFRONTATION
1.
Remain calm and in control – avoid showing signs of fear and panic.
2.
Obey the offender’s instructions (this includes surrendering property),
but do only what you are told and nothing more. Do not volunteer
any information.
3.
Carefully observe any vehicle used by the offender, taking particular
note of its registration number, type and colour and number of
occupants and their description.
4.
Carefully observe the offenders speech, mannerisms, clothing and
distinguishable features such as tattoos.
5.
If able to do so without danger, activate duress.
Note: Where a duress alarm cannot be activated, a discrete call for
assistance should be made by whatever means available.
Where the danger has passed.
6.
Establish contact with the Switchboard operator by dialling 55. If this is
not possible, contact the Emergency Response Coordinator directly by
dialling on 0427 087 147 or Directory 364 and give the first report.
a) Caller's Name and position
b) Exact location of Incident
c) Type of incident (unarmed confrontation).
7.
Record all information on the offender description form.
8.
Wait for instructions from the Area Warden (includes directions on
reporting risk).
SELF HARM
1.
2.
3.
Time
Sign
Time
Sign
Time
Sign
Establish contact with the Admissions Communications Officer by
dialling 55 and give the first report.
a) Caller's name and position
b) Exact location of emergency
c) Type of incident (e.g. self-harm, verbal aggression)
If a discreet alert is required, use Duress Alarm where available.
Calmly clear the area of any unnecessary persons.
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Emergency Response Procedures – Kalgoorlie Health Campus
Code Black
Personal
Threat
Action Card
Action Card 13
First Responder
13
SELF HARM
Time
(Continued)
4.
In a professional, calming and non-confrontational manner and from a
safe distance, identify yourself, state your role and state you are getting
help.
5.
Observe and verbally assist the person from a safe distance. Ensure
you have a safe withdrawal route.
6.
Wait for instructions from the Area Warden.
Sign
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Action Card 14
Code Black
Personal
Threat
Emergency Response
Coordinator
Action Card
14
Position: CNM Patient Flow or A/H nurse Mngr
Reports to: Hospital Incident Commander – (Operations Manager) - 0428 949 930
Responsibilities:
- Control the internal emergency response of an emergency within the facility.
- Ensure the health and safety of patients (including permanent care residents), staff and
visitors when faced with an emergency.
ALERT
1.
Proceed immediately to the area
2.
When able, collect action card and vest.
a) Keep action card on hand.
3.
Ensure the Police have been notified on 000.
4.
Ascertain the point of alarm and the nature of the incident.
5.
Establish contact with the Area Warden at the point of alarm, request a
SITREP and develop a management strategy.
6.
Brief the Emergency Response Team on the management strategy,
assign tasks to the team.
7.
Establish contact with Area Wardens adjacent to the point of alarm and
provide SITREP as required.
8.
9.
10.
11.
3.
Liaise with the Area Warden of the affected area and initiate
appropriate management strategy.
Establish contact with the Hospital Incident Commander and provide a
SITREP if required.
Monitor the progress of management strategy.
4.
Maintain communications with all key stakeholders.
2.
Sign
Time
Sign
Evaluate the situation and determine the need for further assistance
(e.g. clinical, police etc.). Ensure additional resources are sourced
where required.
Where applicable, brief additional clinical staff and/or police upon
arrival on type, scope and location of the emergency.
Where an unarmed/armed confrontation is confirmed, carry out
confirmed code black actions.
Where the Police or the most senior person in the affected area
confirms that there is no confrontation, carry out stand down actions.
CONFIRMED - CODE BLACK RESPONSE
1.
Time
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Action Card 14
Code Black
Personal
Threat
5.
Emergency Response
Coordinator
14
Position: CNM Patient Flow or A/H nurse Mngr
Where the Police or the most senior person in the affected area
confirms that there is no confrontation, carry out stand down actions.
CONFIRMED - SELF HARM RESPONSE
1.
Action Card
Time
Sign
Time
Sign
Liaise with the Area Warden of the affected area or the person in the
area with the most expertise in the subject and initiate verbal
negotiations with the person threatening self-harm until police arrive.
Establish contact with the Area Warden and instruct them to
coordinate:
2.
a)
b)
c)
d)
Clearing of the immediate area of unnecessary persons
Clearing the area beneath the person. (where necessary)
The control of vehicle movement (where necessary)
Discretely acquiring a cover sheet.
3.
If necessary, consider activation of Code Blue Medical Emergency
Response procedures if medical assistance is required.
4.
Respond to the directions of the police.
5.
Monitor the progress of negotiations.
6.
Maintain communications with all key stakeholders.
7
Where police and/or the most senior person in the affected area
renders the area is safe, carry out the Code Black All Clear actions.
STAND DOWN
1.
Ensure the Admissions Communications Officer is advised of the
stand-down.
2.
Ensure physical protective measures are reinstated and third parties
(I.e. monitoring company, Police who are in bound etc.). Are stood
down.
3.
Refurbish action cards at the Emergency Control Point.
4.
Commence debriefing processes with all senior staff and key
stakeholders.
5.
Compile a Safety Risk Report Form and submit to Tier 4 Manager for
Occupational Safety and Health follow up and investigation.
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Action Card 15
Code Black
Personal
Threat
Area Warden
Action Card
15
Position: CNM / Shift Coordinator
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
- Control the initial response to the emergency in the area.
ALERT
1.
Time
Sign
Time
Sign
Proceed immediately and with caution to the point of alarm and liaise
with staff.
When able, collect yellow vest and Area Warden Pack.
2.
a) Don vest
b) Keep action cards on hand.
3.
Direct staff to check the area/floor for any abnormal situations.
4.
Supervise the locking up of offices, securing records, files, cash and
other valuable property if the situation in the area warrants this.
5.
Withdraw staff to a safe area if the situation in the area warrants this.
6.
Provide a SITREP to the Emergency Response Coordinator and any
actions taken.
 Current situation (what has happened, where did it occur, what
time)
 What actions have been undertaken (what has been done)
 What actions still need to be completed (what needs to be
done)
 Any other issues (anything of interest or noteworthy).
Remain within the immediate vicinity of the local Area Warden point
and maintain communications with the Emergency Response
Coordinator.
7.
8.
Note: Where remaining in the vicinity of the local Area Warden point
increases the risk, withdraw to a safer area and maintain
communications with the Emergency Response Coordinator by
whatever means available.
Liaise with and provide SITREP to the Emergency Response Team,
additional clinical staff and/or police upon arrival.
CONFIRMED CODE BLACK RESPONSE
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Action Card 15
Code Black
Personal
Threat
1.
2.
3.
4.
Area Warden
Action Card
15
Position: CNM / Shift Coordinator
Convene all key stakeholders (i.e. clinical staff, Emergency Response
Team, Police), evaluate the situation and develop an appropriate
management strategy.
Communicate management strategy with the Emergency Response
Coordinator
Act on the directions of the Emergency Response Coordinator to
initiate management strategy.
Maintain communications with the Emergency Response Coordinator.
CONFIRMED - SELF HARM RESPONSE
1.
Convene all key stakeholders (i.e. clinical staff who know the person,
Emergency Response Team, Police), evaluate the situation and
develop an appropriate negotiation plan. Communicate negotiation
plan with the Emergency Response Coordinator.
2.
Remove people not involved from the areas.
3.
Act on the directions of the Emergency Response Coordinator to
initiate negotiation plan.
4.
Maintain communications with the Emergency Response Coordinator.
STAND DOWN
1.
Coordinate the return of the area to operational state (I.e. unlocking
offices, records, files, cash and other valuable property etc.).
2.
Coordinate the reinstatement of physical protection.
3.
Refurbish vest and Area Warden Pack at the Area Warden Point.
4.
Participate in the debriefing process.
5.
Respond as directed by the Emergency Response Coordinator to
compile a report.
Time
Sign
Time
Sign
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Action Card 17
Code Black
Personal
Threat
Emergency Response
Team Member
Action Card
17
Position: Code Black Team
Reports to: Area Warden
Responsibilities:
- Carries out emergency response actions at the direction of the Emergency Response
Team Leader.
ALERT
1.
Proceed immediately and with caution to the point of alarm and
liaise with the Area Warden.
2.
Where the Area Warden is absent, assume the responsibilities of
the Area Warden until they arrive.
3.
Respond to the directions of the Emergency Response Team
Leader.
CONFIRMED CODE BLACK RESPONSE
1.
Respond to the directions of the Area Warden.
2.
Maintain communications with the Area Warden.
CONFIRMED SELF HARM RESPONSE
1.
Respond to the directions of the Area Warden.
2.
Maintain communications with the Area Warden
STAND DOWN
1.
Respond as directed by the Area Warden to reinstate fire controls.
2.
Refurbish any specialised equipment as necessary.
3.
Participate in the debriefing process.
Time
Sign
Time
Sign
Time
Sign
Time
Sign
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Code Black
Personal
Threat
Action Card 18
Communications Officer
Action Card
18
Position: Admissions Communications Officer
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
- To facilitate communications via P.A. and paging systems
ALERT
1.
2.
3.
Time
Sign
Time
Sign
When receiving a 55 Emergency Call, record the following
information on the Emergency Code Activation Log:
a) Type of emergency
b) Exact location of emergency
c) Quick description of the emergency
d) Name and position of caller
If notification comes via a pendant, call the pendant to confirm
location and need to call WAPOL.
Initiate the code call:
a) Make P.A. announcement:
“Code Black, <area>, Repeat, Code Black <area>”.
b) Send page to Code Black paging group.
If instructed to by the Emergency Response Coordinator, establish
contact with Police by dialling 000 and give the first report.
4.
5.
6.
7.
a) Caller's Name
b) Exact location of the incident
c) Type of incident (unarmed / armed / self-harmer / abduction).
Record events and incoming calls on the Emergency Code
Activation Log.
Respond to the directions of the Emergency Response
Coordinator.
Maintain communications with the Emergency Response
Coordinator.
CONFIRMED CODE BLACK RESPONSE
1.
Respond to the directions of the Emergency Response
Coordinator.
2.
Continue logging events and incoming calls in the Emergency
Code Activation Log
CONFIRMED SELF HARM RESPONSE
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Code Black
Personal
Threat
Action Card 18
Communications Officer
Respond to the directions of the Emergency Response
Coordinator.
2.
Continue logging events and incoming calls.
STAND DOWN
2.
3.
4.
18
Position: Admissions Communications Officer
1.
1.
Action Card
Time
Sign
Respond to the directions of the Emergency Response
Coordinator.
On notification of a Stand Down,
a) Send page to the Code Black page grop
b) Make P.A. announcement
“Stand Down, Code Black, <area>, Repeat, Stand
Down, Code Black <area>”
c) Record Stand Down time on Emergency Code Activation
Log
Provide a copy of the Emergency Code Activation Log to the
Emergency Response Coordinator if requested to do so.
Participate in the debriefing process.
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Emergency Response Procedures – Kalgoorlie Health Campus
10. Code Black Alpha - Infant / Child
Abduction
10.1 Introduction
A code black alpha emergency may be called in response to an infant or child
abduction.
When an infant or child is abducted, one of the best methods of recovery is to make
an immediate notification so that employees can begin searching the buildings.
10.2 Removal of child by an unauthorised person
The Hospital must be attentive to the legal issues in relation to parents wanting to
remove their child from the ward i.e. Family Court Orders or Department of
Communities – Child Protection and Family Support (CPFS) intervention.
The Hospital is not responsible for enforcing restraining orders, however when a
potential risk to a child is identified it must be reported appropriately and all
information accurately communicated in the patient’s notes.
If the child is the subject of a guardianship or residency order by the Family Court,
the person named on that order is the only person who can remove that child. A copy
of the order must be kept in the child’s medical notes.
The admitting nurse must clearly document on the Paediatric / Neonate Assessment
Form the name of the person to whom the child can be discharged.
10.3 Response strategy
If any unauthorised persons visit, staff should activate a Code Black if required, or
deploy a duress alarm.
If the offending person visits or attempts to remove the child, they should be
approached with caution in an attempt to defuse the situation, whilst activating a
duress alarm to initiate a Code Black Alpha.
If the unauthorised person removes a child from a clinical area or hospital premises:
 Dial 55 immediately to activate a Code Black Alpha emergency response.
 Provide the patient’s details e.g. child’s name, description, situation etc.
 The Emergency Response Coordinator is to then contact the Police.
 Shift Coordinator or Nurse Unit Manager (NUM) is to inform custodial parent or
Department of Communities / Crisis Care if the patient is a child in the care of
the CEO of the Department of Communities – Child Protection and Family
Support (formerly known as ‘ward of the state’).
 Accurately document events in the patient’s notes.
 Control all exits as per roster Appendix K.
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10.4 Description of Abducted Infant / Child Form
PERSON COMPLETING THIS FORM
Surname
First name
Position title
Area / ward
Phone No
Date and time child last seen
Date
Time
DESCRIPTION OF THE CHILD
Surname
First name
Date of Birth
Date of Admission
URMN
Gender
Male
Female
Race
Height
Weight
Build
thin
Hair
Colour
Solid
Soft
Medium
Long
Other
Eyes
Medium
Short
Wavy
Curly
Obese
Straight
Thin
Bald
Colour
Medical Conditions
Ability to vocalise
Other distinguishing features (Describe in full)
Scars of birthmarks
Clothing worn at time of abduction
Last meal / drink / feed
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10.5 Code Black Alpha Action cards
Code Black Alpha action cards have been developed for the following positions:
Action card 19
Action card 20
Action card 21
Action card 23
Action card 24
First responder
Emergency Response Coordinator
Area Warden
Emergency Response Team member
Communications Officer
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Code Black
Alpha
Infant / Child
Abduction
Action Card 19
Action Card
First Responder
19
Reports to: Area Warden
Responsibilities:
- Take measures to ensure that the Emergency Response Coordinator is notified.
IF ANY UNAUTHORISED PERSONS VISITS
1.
2.
3.
2.
3.
4.
5.
2.
Time
Sign
Time
Sign
If the person refuses to leave a Code Black should be initiated.
Alert other staff in immediate vicinity of clinical area.
Contact the Admissions Communications Officer and state ‘Code
Black Alpha’ and request a Hospital Lockdown
Notify the Area Warden and follow their instructions.
If safe to do so, approach the offending person with caution and
attempt to de-escalate the situation the situation by using the
LASSIE technique, whilst maintaining a safe distance.
If offending person attempts to confront you, refer to Code Black
Procedures.
IF THE OFFENDING PERSON HAS REMOVED THE
CHILD OR IF THE CHILD IS MISSING.
1.
Sign
If any unauthorised person visits, staff should speak to the person
to identify their reason for being in the area.
If the person does not have a reason to be in the area they should
be asked to leave and the Area Warden should be notified
IF THE OFFENDING PERSON ATTEMPTS TO
REMOVE A CHILD WITHOUT AUTHORISATION
1.
Time
Remain with the authorised parent and complete the “Description
of Abducted Infant / Child Form” and the Description of
Offender form (section 8.5) with their assistance.
Follow the instructions of the Area Warden.
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Code Black
Alpha
Infant / Child
Abduction
Action Card 19
Action Card
First Responder
19
IF THE OFFENDING PERSON HAS REMOVED THE
CHILD OR IF THE CHILD IS MISSING.
Time
Sign
(Continued)
3.
Cordon the area off and preserve for evidence collection.
4.
Assist the Police with their inquiries as required.
5.
Document occurrence in medical notes.
6.
Following the stand down, participate in any debrief.
7.
If affected by the incident, discuss employee assistance options
with line manager.
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Action Card 20
Emergency Response
Coordinator
Code Black Alpha
Infant / Child
Abduction
Action Card
20
Position: CNM Patient Flow or A/H nurse Mngr
Reports to: Hospital Incident Commander - (Operations Manager) - 0428 949 930
Responsibilities:
- Control the internal emergency response of an emergency within the facility.
- Ensure the health and safety of patients, staff and visitors when faced with an
emergency.
ALERT
1.
Ensure ACO has initiated Code Black Alpha page & P.A.
announcement and Hospital Lockdown.
2.
Proceed to the Area
3.
5.
7.
8.
Time
Sign
Time
Sign
When able, collect vest and action card.
a) Don vest
b) Keep action card on hand
Instruct Area Warden to:
secure the unit and have dedicated staff posted at exits;
a) Initiate a search of the unit including a head count and
identity match of all mothers and infants.
b) Direct all visitors to exit through one point and ensure
bags are checked if suspect.
Establish contact with Area Wardens adjacent to the point of
alarm as appropriate and provide SITREP.
Access CCTV footage to gain information, if available.
9.
Evaluate the situation and determine the need for Police
presence.
10.
Where required, instruct Admissions Communications
Officer to contact Police and confirm that they are needed.
ALERT
(continued)
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Action Card 20
Emergency Response
Coordinator
Code Black Alpha
Infant / Child
Abduction
Action Card
20
Position: CNM Patient Flow or A/H nurse Mngr
11.
Where abduction is confirmed, carry out the confirmed code
black alpha response actions.
12.
Where the infant / child is located, carry out the stand down
actions.
CONFIRMED CODE BLACK ALPHA RESPONSE
1.
Ensure ACO has initiated Code Black Alpha page, P.A.
announcement and Hospital Lockdown.
2.
Establish contact with the Hospital Incident Commander and
provide SITREP.
3.
Ensure all information on the abductor and the infant / child
is cleared for release to the police and other key
stakeholders by the Hospital Incident Commander. Release
information as required.
4.
Liaise with the Area Wardens and Security Officer (if
available) and initiate a comprehensive (internal and
external) search of the facility.
Time
Sign
Instruct Area Wardens adjacent to the affected area and
other key areas/departments to:
5.
a) Secure units/departments and have dedicated staff
posted at exits.
b) Initiate a search of the unit/department.
c) Direct all visitors to exit through one point and ensure
bags are checked if suspect.
7.
Monitor the progress of the search(s).
8.
Maintain communications with all key stakeholders
9.
Where Police and/or the most senior person in the affected
area confirms the location of the infant / child carry out the
Code Black Alpha stand down actions.
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Action Card 20
Emergency Response
Coordinator
Code Black Alpha
Infant / Child
Abduction
Action Card
20
Position: CNM Patient Flow or A/H nurse Mngr
STAND DOWN
1.
2.
Time
Sign
Ensure the police have collected all required evidence and
have finished with the scene.
Contact Admissions Communications Officer and request a
Stand Down and release Hospital Lockdown.
3.
Ensure security measures are reinstated and third parties
are stood down.
4.
Refurbish vest and action cards at the Emergency Control
Point.
Commence debriefing processes with all senior staff and
key stakeholders.
5.
Note: Be sensitive to staff who may experience post
incident stress.
6.
Commence clinical incident reporting requirements, and
document log of event in Emergency Code Reporting Tool.
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Code Black
Alpha
Infant / Child
Abduction
Action Card 21
Area Warden
Action Card
21
Position: CNM / Shift Coordinator
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
- Control the initial response to the emergency for designated area of responsibility.
ALERT
1.
Time
Sign
Time
Sign
Proceed to the Area Warden Point.
Collect vest and Area Warden Pack:
2.
a) Don vest
b) Keep action cards on hand.
3.
Direct staff to check the area/floor for any abnormal situations.
4.
Supervise the manning of egress points, the direction of all visitors
through one access/egress point and the checking of bags (where
suspect).
5.
Lock down the area if the situation in the area warrants this.
6.
Ensure a staff member is with the parents (where applicable) and
an offender description form is being compiled. Hand this over to
the Emergency Response Coordinator when complete.
7.
Obtain a colour photograph and a full written description of the
child from the newborn’s medical records. Hand this over to the
Emergency Response Coordinator when obtained.
Provide a SITREP to the Emergency Response Coordinator and
any actions taken.

8.



9.
Current situation (what has happened, where did it occur,
what time)
What actions have been undertaken (what has been done)
What actions still need to be completed (what needs to be
done)
Any other issues (anything of interest or noteworthy).
Respond to the directions of the Emergency Response
Coordinator.
ALERT
(continued)
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Code Black
Alpha
Infant / Child
Abduction
11.
Action Card 21
Area Warden
Action Card
21
Position: CNM / Shift Coordinator
Liaise with and provide SITREP to the Emergency Response
Team and/or police upon arrival.
CONFIRMED CODE BLACK ALPHA RESPONSE
1.
1.
Time
Sign
Convene all key stakeholders (i.e. on-call Doctor, clinical staff who
know the child/infant, Emergency Response Team, security,
police), evaluate the situation and develop an appropriate search
plan. Communicate search plan with the Emergency Response
Coordinator.
Note: Search the entire interior and exterior of the facility starting
with the unit. This should include a head count of all
mothers and children. Use the Area Warden Search map if
necessary to mark off areas searched to prevent
duplication of effort.
Act on the directions of the Emergency Response Coordinate to
initiate search plan.
3.
Move the parent(s) to a quite area and assign a staff member to
be with them at all times to ensure their privacy and monitor their
condition.
4.
Ensure the scene is secured in order to preserve any evidence
that may be collected or required by the police.
5.
Request staff to remain on duty until excused by the police.
6.
Maintain communications with the Emergency Response
Coordinator and other key stakeholders (including unit staff).
Reassure anxious parents.
STAND DOWN
1.
Sign
Ensure Admissions Communications Officer has been contacted
to initiate Code Black Alpha and Hospital Lockdown.
2.
7.
Time
Ensure Admissions Communications Officer has advised of Stand
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Code Black
Alpha
Action Card 21
Area Warden
Action Card
Infant / Child
Position: CNM / Shift Coordinator
Abduction
Down and request that Hospital Lockdown is ceased.
21
2.
Coordinate the return of the area to operational state.
3.
Coordinate the reinstatement of security measures.
4.
Refurbish vest, search map and action cards into the Area
Warden Pack at the Area Warden Point.
5.
Participate in the debriefing process.
6.
Act as directed by the Emergency Response Coordinator to
compile a report.
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Emergency Response Procedures – Kalgoorlie Health Campus
Action Card 23
Code Black
Alpha
Infant / Child
Abduction
Emergency Response
Team Member
Action Card
23
Position: Fire Wardens / Delegated Staff
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
- Carries out emergency response actions at the direction of the Emergency Response
Coordinator.
ALERT
1.
Proceed immediately to allocated exits.
(If not allocated an exit, proceed to the point of alarm and liaise
with the Emergency Response Coordinator).
2.
Refuse to allow any child under the age 16 to leave the hospital.
Contact the Emergency Response Coordinator to verify the
identification of any child or infant before allowing them to exit.
3.
Where the Emergency Response Coordinator is not present,
report to the Area Warden for instructions.
CONFIRMED CODE BLACK ALPHA RESPONSE
1.
Respond to the directions of the Emergency Response
Coordinator
2.
Maintain communications with the Emergency Response
Coordinator
STAND DOWN
1.
Respond to the directions of the Emergency Response
Coordinator
2.
Refurbish any specialised equipment as necessary.
3.
Participate in the debriefing process.
Time
Sign
Time
Sign
Time
Sign
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Code Black
Alpha
Infant / Child
Abduction
Action Card 24
Communications Officer
Action Card
24
Position: Admissions Communications Officer
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
- To facilitate communications via P.A. and paging systems
ALERT
1.
2.
3.
Sign
Time
Sign
On receiving a request for Code Black Alpha:
a) Immediately initiate Hospital Lockdown
b) Make P.A. announcement:
“Attention all staff…attention all staff… Code Black
Alpha…the hospital is now in lockdown until further notice”
c) Send page to Code Black page group
Collect the following information and update the Emergency Code
Activation Log:
a) Type of emergency
b) Exact location of emergency
c) Quick description of the emergency
Name and position of caller
If directed to by the Emergency Response Coordinator, establish
contact with Police by dialling 000 and give the first report.
a) Caller's Name
b) Exact location of the incident
c) Type of incident (unarmed/armed/self-harmer/abduction).
4.
Record events and incoming calls on the Emergency Code
Activation Log
5.
Respond to the directions of the Emergency Response
Coordinator.
CONFIRMED CODE BLACK ALPHA RESPONSE
1.
Time
On receiving a request for Code Black Alpha:
a)
Immediately initiate Hospital Lockdown
b)
Make P.A. announcement:
“Attention all staff…attention all staff… Code Black
Alpha…the hospital is now in lockdown until further notice”
c)
Send page to Code Black page group
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Code Black
Alpha
Action Card 24
Communications Officer
Action Card
Infant / Child
Position: Admissions Communications Officer
Abduction
Collect the following information and update the Emergency Code
Activation Log:
a)
Type of emergency
2.
b)
Exact location of emergency
c)
Quick description of the emergency
Name and position of caller
If directed to by the Emergency Response Coordinator, establish
contact with Police by dialling 000 and give the first report.
3.
a)
b)
c)
Caller's Name
Exact location of the incident
Type of incident (e.g. abduction)
4.
Record events and incoming calls on the Emergency Code
Activation Log
5.
Respond to the directions of the Emergency Response
Coordinator.
STAND DOWN
1.
24
Time
Sign
When informed of Stand Down
a) Release Hospital Lockdown
b) Send page to Code Black page group
c) Make P.A. announcement:
“Stand Down Code Black Alpha <area>, Repeat, Stand
Down Code Black Alpha <area>”.
d) Record Stand Down time on Emergency Code
Activation Log
2.
Provide a copy of the Emergency Code Activation Log to the
Emergency Response Coordinator if requested to do so.
3.
Participate in the debriefing process.
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Emergency Response Procedures – Kalgoorlie Health Campus
11.Code Black Bravo - Active Shooter
11.1 Introduction
A code black bravo emergency may be called in response to any person armed with
a firearm or any other weapon, who is actively engaged in attempting to kill or cause
serious harm to multiple people in, around or in the vicinity of Kalgoorlie Health
Campus.
11.2 Threat context
While a Code Black Bravo event is extremely rare in the regional Australian context,
threat analyses from the WA Police Protective Security Unit and Australian
intelligence agencies suggest that hospitals (which are classified as places of mass
gathering) are potential targets, and as such, should undertake necessary
preparations. Firearms, while well regulated, are accessible particularly in some
regional areas.
11.3 Response strategy to an active shooter
The typical Active Shooter will attempt to kill as many people as possible within a
short period of time. This is why active shooters generally target places where they
can achieve the greatest impact, such as crowded public places. An Active Shooter
incident does not generally include a hostage situation, but can potentially transition
into one, particularly during the resolution phase.
The aim and objective of all planning and response activities in relation to an Active
Shooter event is to minimise the offender’s access to potential victims. Increased
casualties and deaths from Active Shooter events are caused by delays in police
response and the offender having freedom of movement through a facility. The
equation for this is presented in the box below.
TIME + FREEDOM OF MOVEMENT = INCREASED CASUALTIES
This can be achieved by:
 Prompt recognition of an active shooter event.
 Preservation of life.
 Restriction of offender movement.
 Facilitation of rapid police response.
11.4 Staff response
Staff are advised to follow the Run, Hide, Tell methodology.

Run - and escape if you can do so safely moving away from the intruder until
you are safe. Once far enough away or in a safe location, contact the police
on 000 and advise them of the situation.

Hide - if you cannot escape safely, barricade yourself in a room, turn off lights
and turn your phone on silent. If you have barricaded yourself in a room,
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Emergency Response Procedures – Kalgoorlie Health Campus
remain there. Do not come out until you hear the stand down given by the
Police or Security as they do a sweep of the building post incident.

Tell – if safe to do so, contact the police on 000 and advise them of your
location and follow their instructions.
11.5 Protective measures
The Admissions Communications Officer at Kalgoorlie Health Campus has the ability
to initiate a Hospital Lockdown. Once a Hospital Lockdown has been activated, all
external exits are to be locked and only staff with swipe cards will have access.
Kalgoorlie Health Campus has multiple CCTV cameras located on site and in the
surrounding grounds. Footage from these cameras can be used to identify the
actions of people in public areas in and around the Hospital and can be provided on
request to certain agencies for example WAPOL.
11.6 Crime scene and evidentiary recovery
Following the occurrence of a code black bravo – active shooter incident, parts of, or
the entire facility will likely become a crime scene.
Deceased persons should be left in situ for evidentiary collection, and staff should
avoid unnecessarily contaminating any evidence.
As parts of the facility may become inaccessible, it is likely such an event will
precipitate activation of the site’s Business Continuity Plan. This event is also likely
to trigger activation of the site’s Code Brown – External Emergency Plan.
11.7 Code Black Bravo Action Cards
Code Black Bravo action cards have been developed for the following positions:
Action card 25
Action card 26
Action card 27
Action card 29
Action card 30
First responder
Emergency Response Coordinator
Area Warden
Emergency Response Team member
Communications Officer
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Action Card 25
Code Black
Bravo
First Responder
Active Shooter
All Threatened Staff
Action Card
25
Reports to: Area Warden
Responsibilities:
- Escape to safety.
- Run, Tell, Hide.
RUN
1.
2.
3.
4.
5.
6.
(escape)
If under immediate danger and there is a safe exit route attempt to
leave the area as soon as possible. Take as many people with you
as possible but don’t let them slow you down.
Time
Sign
Time
Sign
Time
Sign
If gunfire is nearby, leave the area immediately moving away from
the gunfire if this can be achieved safely.
Leave your belongings behind.
Do not congregate at evacuation points/muster points.
Try to maintain cover (keep objects between yourself and the
gunman where possible).
If you are escaping, keep your hands visible and follow the
instructions of WA Police.
HIDE
(if you cannot escape)
1.
Personnel not able to immediately move to an area of safety
should shelter in place and find cover and hide behind large
objects e.g. cabinets, desks.
2.
Lock yourself in a room or jam doors shut if possible. Remain quiet,
turn lights off and move away from the door.
3.
Turn off any source of noise including turning phones / pagers to
silent.
4.
If discovered by the intruder, recognise that negotiation sometimes
helps. As a last resort, you may wish to fight the intruder.
TELL
(Once you are safe)
1.
If you can and it is safe to do so, dial 55 and state ‘Code Black
Bravo’ and give as much information as possible on the intruder
and where they are.
2.
NEVER risk your own safety or that of others to gain information. If
you are out of danger, stay there and do not re-enter the area until
the “Stand Down” is given.
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Action Card 25
Code Black
Bravo
First Responder
Active Shooter
All Threatened Staff
Action Card
25
TELL
(Continued)
3.
Time
Sign
Time
Sign
If it is safe to do so, obtain the following information:
 Exact location of the incident.
 Whether the intruder is stationary or moving in any particular
direction.
 Details of weapons being used or possessed and what else
are they carrying.
 Their motives or intent (if known or apparent).
 Number of people in the area.
 Number of casualties
STAND DOWN
1.
Do not touch or move anything - fingerprints and other evidence
may be required from the scene.
2.
Do not make any comment to the media
3.
Participate in the debriefing of the event.
4.
Liaise with your line manager about utilising the Employee
Assistance Program if necessary.
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Action Card 26
Emergency Response
Coordinator
Code Black
Bravo
Active Shooter
Action Card
26
Position: CNM Patient Flow or A/H nurse Mngr
Reports to: Hospital Incident Commander - (Operations Manager) - 0428 949 930
Responsibilities:
- Control the internal emergency response of an emergency within the facility.
- Ensure the health and safety of patients (including permanent care residents), staff
and visitors when faced with an emergency.
IF INTRUDER POSES AN IMMEDIATE RISK
1.
Sign
Time
Sign
Time
Sign
If offender is nearby or poses an immediate threat, follow the First
Responder Action Card (Action Card 1) – Run, Hide, and Tell.
ALERT
1.
Time
Exercise extreme caution. Only if safe to do so and not in the
pathway of the intruder, proceed immediately to the Emergency
Control Point located at the Emergency Department entrance.
Collect vest and action card.
2.
3.
a) Don vest.
b) Keep action card on hand.
Collect information from the Admissions Communications Officer
and Area Warden/s and ascertain the nature and the location of
the emergency. Confirm the Police have been notified by 000.
Activate the P.A system for the entire facility and make the Code
Black Bravo announcement (if not already done by the ACO).
4.
Attention all areas, attention all areas, this is the Emergency
Response Coordinator. Possible Code Black Bravo <say
location>. Remain vigilant and wait for further instructions.
(Say twice.)
5.
If able to, determine the location of the intruder.
6.
Attempt to contact Area Wardens by WIP, DECT phone or other
communication device, if able to. Attempt to understand the
situation.
ALERT
(Continued)
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Action Card 26
Emergency Response
Coordinator
Code Black
Bravo
Active Shooter
Action Card
26
Position: CNM Patient Flow or A/H nurse Mngr
7.
Direct the Emergency Response Team to prevent people from
entering the facility.
8.
Brief police upon arrival on type, scope and location of the
emergency.
COMFIRMED CODE BLACK BRAVO RESPONSE
Time
Sign
Time
Sign
Activate the P.A system for the entire facility and make the
confirmed Code Black Bravo announcement.
1.
Attention all areas, attention all areas, this is the Emergency
Response Coordinator. Possible Code Black Bravo <say
location>. Run and escape if you are able to and if it is safe.
Hide and switch phones to silent if it is not safe. If you have
escaped, dial 000 and provide any information to police.
(Say twice.)
2.
Commence lockdown procedures to prevent the intruder
movement if not already initiated by the ACO.
3.
Notify the Hospital Incident Commander of the incident.
4.
Wait for WA Police to arrive. On arrival of WA Police, provide a
summary of the current situation and assist as necessary. If
lockdown processes have been implemented, provide WA Police
with lockdown override access cards.
5.
If able to, maintain communication with WA Police, Area Wardens
and the Emergency Response Team.
6.
Warn the Emergency Department of possible casualties.
7.
If offender is nearby or poses an immediate threat, follow the First
Responder Action Card (Action Card 1) – Run (escape), Hide,
and Tell.
STAND DOWN
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Action Card 26
Code Black
Bravo
Active Shooter
Emergency Response
Coordinator
Action Card
26
Position: CNM Patient Flow or A/H nurse Mngr
Activate the P.A system for the entire facility and make the
confirmed Code Black Bravo announcement.
1.
Attention all areas, attention all areas, this is the Emergency
Response Coordinator. Stand Down - Code Black Bravo.
(Say twice.)
Deploy the Emergency Response Team to deploy with a Police
escort and commence a search for survivors.
2.
Deceased victims are to be left in situ to preserve evidentiary
collection as part of a crime scene.
In collaboration with the Hospital Incident Commander, determine
the need for the activation of the site’s Business Continuity Plan
or Code Brown – External Emergency Plan.
3.
Note: The entire, or parts of the, hospital may be inaccessible
for a prolonged period as a crime scene is established. Affected
services may require relocation, transfer or suspension as per
the site’s BCP.
4.
Request all witnesses to remain at the scene until the police
authorise them to leave.
5.
Assist the Police in their investigation and provide CCTV footage
when requested.
6.
Refurbish vest and action cards in the Emergency Control Point.
Commence debriefing processes with all senior staff and key
stakeholders.
7.
Contact HR for assistance with EAP and Staff support
requirements.
Note: Be sensitive to staff who may experience post incident
stress.
8.
Do not make any comments to the media.
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Action Card 27
Code Black
Bravo
Active Shooter
Area Warden
Action Card
27
Position: CNM / Shift Coordinator
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
- Control the initial response to the emergency in the area.
ALERT
(when alerted to a possible Code Black Bravo – Active Shooter Incident)
1.
Time
Sign
Time
Sign
Only if safe to do so, proceed to the Area Warden Point.
Exercise Extreme Caution.
Collect action cards from Area Warden Pack.
2
3.
4.
5.
a) Do not don vest as this may make you more of a target.
b) Keep action card on hand.
Keep all staff, patients and visitors calm and aware, and instruct
them to turn noise emitting devices off or to silent.
Provide a SITREP to the Emergency Response Coordinator if
requested.
 Current situation (what has happened, where did it occur,
what time)
 What actions have been undertaken (what has been done)
 What actions still need to be completed (what needs to be
done)
 Any other issues (anything of interest or noteworthy).
Ensure all doors into your department are closed if safe to do so.
RESPONSE
1.
If offender is nearby or poses an immediate threat, follow the First
Responder Action Card (Action Card 1) – Run, Hide, and Tell.
2.
If safe to do so, dial 55 and report the incident.
3.
Keep all staff, patients and visitors calm and aware, and instruct
them to turn noise emitting devices off or to silent.
4.
Ensure all doors into your department are closed if safe to do so.
5.
Try not to collect large numbers of people in one area – encourage
people to hide in various locations, securing themselves behind
heavy furniture / doors in rooms that can be locked if possible, and
advising them to follow instructions for the First Responder
Action Card (Action Card 1) Run, Hide, and Tell.
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Action Card 27
Code Black
Bravo
Active Shooter
Area Warden
Action Card
27
Position: CNM / Shift Coordinator
RESPONSE
(continued)
6.
Direct ambulant persons to evacuate only if safe to do so or if
advised to do so by the Emergency Response Commander and
WA Police.
7.
Continue to assess opportunities to evacuate as safe to do so.
8.
If required and as safe to do so, initiate first aid to any casualties.
9.
Liaise with the Emergency Response Commander and WA Police
when they arrive and as safe to do so.
10.
Remain in area, or a safe alternate location, until Stand Down
notification is received.
STAND DOWN
1.
Perform a head count on all surviving staff, patients and visitors.
2.
Initiate first aid as required.
3.
Instruct staff not attempt to move any deceased persons or to
touch potential evidence. The area will be a crime scene.
4.
Await instructions from WA Police and/or the Emergency
Response Coordinator.
Time
Sign
Time
Sign
Provide staff appropriate assurance and support as required.
5.
Note: Be sensitive to staff who may experience post incident
stress.
6.
Assist WA Police with their enquiries.
7.
Participate in the debriefing process.
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Action Card 29
Code Black
Bravo
Active Shooter
Emergency Response Team
Member
Action Card
29
Position: Code Black Team
Reports to: Area Warden
Responsibilities:
- Carries out emergency response actions at the direction of the Area Warden.
ALERT
(when alerted to a possible Code Black Bravo – Active Shooter Incident)
Exercise extreme caution. Only if safe to do so and not in the
1.
pathway of the intruder, proceed immediately to the Emergency
Control Point located at the Emergency Department entrance.
Respond to the directions of the Emergency Response
2.
Coordinator.
3.
Sign
Time
Sign
Time
Sign
Time
Sign
Prevent people from entering the facility.
CONFIRMED CODE BLACK BRAVO RESPONSE
1.
Respond to the directions of the Emergency Response
Coordinator.
2.
Maintain communications with the Emergency Response
Coordinator.
IF INTRUDER POSES AN IMMEDIATE RISK
1.
Time
If offender is nearby or poses an immediate threat, follow the First
Responder Action Card (Action Card 1) – Run, Hide, and Tell.
STAND DOWN
1.
Respond to the directions of the Emergency Response
Coordinator.
2.
Refurbish any specialised equipment as necessary.
3.
Participate in the debriefing process.
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Code Black
Bravo
Active Shooter
Action Card 30
Communications Officer
Action Card
30
Position: Admissions Communications Officer
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
- To facilitate communications via P.A. and paging systems
ALERT
(when alerted to a possible Code Black Bravo – Active Shooter
Incident)
1.
On receiving a request for Code Black Bravo:
a) Immediately initiate Hospital Lockdown
b) Make P.A. announcement:
“Attention all staff…attention all staff… Code Black
Bravo…the hospital is now in lockdown until further
notice, Repeat Code Black Bravo”
c) Send page to Code Black page group
3.
Establish contact with Police by dialling 000 and give the first
report.
a) Exact location of the incident
b) Type of incident (active shooter).
c) Any other pertinent details.
5.
Provide the Emergency Response Coordinator with any
information you have available:
a) Caller's Name
b) Exact location of the incident
c) Type of incident (i.e. active shooter).
6.
Return to the switchboard and commence a running log of
events and incoming calls.
RESPONSE
1.
Respond to the directions of the Emergency Response
Coordinator.
2.
Record events and incoming calls on the Emergency Code
Activation Log
IF INTRUDER POSES AN IMMEDIATE RISK
Time
Sign
Time
Sign
Time
Sign
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Code Black
Bravo
Active Shooter
1.
Action Card 30
Communications Officer
Action Card
30
Position: Admissions Communications Officer
If offender is nearby or poses an immediate threat, follow the
First Responder Action Card (Action Card 1) – Run, Hide,
and Tell.
STAND DOWN
Time
1.
Respond to the directions of the Emergency Response
Coordinator.
3.
Be prepared to provide WA Police with copies of any records
for evidentiary and investigative requirements.
5.
Participate in the debriefing process.
Sign
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12.Code Yellow – Infrastructure and other
internal emergencies
12.
12.1. Introduction
A code yellow emergency refers to emergencies that impact the facility and may be
caused by infrastructure damage or other internal events that may adversely impact
service delivery and/or the safety of staff, patients and visitors.
A code yellow emergency also covers emergencies that may originate external to a
facility which may also impact on service delivery. Examples include failure or
disruption to electricity, medical gases, water supply, information and communication
technology and incidents involving hazardous materials.
12.2. Sub-plans
The following sub-plans have been established for Kalgoorlie Health Campus, based
on the facility’s risk profile:

Cyclone
12.3. Infrastructure damage
The Kalgoorlie Health Campus is made up of a number of structures where critical
business functions are carried out. Damage to certain infrastructure may affect the
effective functioning of units and may threaten the safety of patients, staff and
visitors.
These Code Yellow (infrastructure damage) emergency response procedures
address infrastructure damage through the implementation of emergency actions.
Where emergency actions have failed and infrastructure damage disrupts critical
business functions for periods greater than the tolerable period or threatens the
safety of people, the Business Continuity Plan and code orange emergency response
procedures are to apply.
12.4. Essential service disruptions
The Kalgoorlie Health Campus is dependent on the integrity of a number of essential
services. Numerous planned and unplanned incidents can disrupt the critical
business functions of the Kalgoorlie Health Campus which may have adverse
impacts on the safety of patients, staff and visitors.
Although the Kalgoorlie Health Campus has a number of contingencies in place to
minimise the risk of essential service loss, these contingencies may also fail at a
critical stage. These Code Yellow emergency response procedures address
contingency failure through the implementation of manual workarounds. Where
contingencies have failed and manual workarounds have become unsustainable,
causing disruption to critical business functions beyond tolerable periods, the
Business Continuity Plan is to apply.
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Refer to the Kalgoorlie Health Campus Business Continuity Plan to determine
essential service contingencies and unit/area dependency levels on essential
services.
The Business Continuity Plan contains contingency arrangements for the loss of key
services which are listed below.
This includes:
 Electricity supply disruption.
 Water supply disruption.
 Medical oxygen.
 Natural Gas supply.
 Air-conditioning system.
 Fuel supply disruption (petrol and diesel.
 Sewerage / waste water.
 Voice telephone system (PABX).
 ICT network.
 3G/4G network.
 Wide Area Network Disruption.
 Paging system.
12.4.1. Facility system status report
The Facility system status report is used to record the status of various critical facility
systems and infrastructure. The form provides an overview of current and potential
system failures or limitations that may affect incident response and recovery.
Should the facility’s infrastructure be damaged or impacted by a disruption or
external hazard, an impact assessment should be undertaken to determine the status
of particular systems throughout the hospital.
The report assesses seven key systems:
 Communications.
 Power.
 Lighting.
 Water.
 Sewerage / toilets.
 Nurse call system.
 Medical gases / oxygen.
When determining the status of systems, the status uses the following definitions:
 Fully functional:
100% operable with no limitations
 Partially functional: Operable or somewhat operable with limitations
 Non-functional:
Out of commission
 N/A:
Not applicable, do not have
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12.5. ICT downtime procedures
A number of applications have formalised downtime procedures in place to deal with
a disruption to ICT applications in systems. Other systems have no formalised
downtime processes in place.
If loss of an ICT application or system results in wards or departments not being able
to deliver their services, refer to the site’s Business Continuity Plan.
12.6. Hazardous materials
Numerous hazardous materials (HAZMAT) such as gases (medical and nonmedical), flammable liquids, poisons, corrosive substances, radioactive materials and
infectious materials are handled and stored within health service facilities.
Additionally, HAZMAT may be transported along the main arterials near the health
facility. HAZMAT incidents are most likely to be accidental, however may also be
caused deliberately.
Although Kalgoorlie Health Campus has a number of engineered control measures in
place to minimise the risk of HAZMAT incidents, these control measures may also fail
at a critical stage. These emergency response procedures address control measure
failure through the implementation of emergency actions.
For further information, refer to the WACHS Managing Risks of Hazardous
Chemicals and Dangerous Goods Procedure.
12.6.1. Hospital Response to a Code Yellow Hazardous Spill
A ‘Code Yellow - Hazardous Spill’ may be declared should the spill of a hazardous
substance impact on the normal operations of the hospital.
If the spill cannot be contained with a local response or it is having a significant
impact on hospital functions, the Department of Fire and Emergency Services
(DFES) should be contacted (via triple zero telephone call) for further advice and
assistance. Appropriate Subject Matter Expertise should also be sought.
12.7. Earthquake
Western Australia is a seismically active state, and has experienced many large
magnitude earthquakes in its history.
When an earthquake occurs:
 DROP, COVER AND HOLD.
 Do not leave the building as you may be in danger from falling debris.
 Stay where you are. Do not attempt to reach another area or floor within the
building until instructed to do so.
 Where possible ensure all persons are under beds, tables, benches or
doorframes to protect them from falling debris.
 If no cover is available, move into a corner or away from the centre of the
room and away from glass, walls/windows.
 Await instructions from the Area Warden or Emergency Services and evacuate
only on orders from them or the Emergency Response Coordinator or Area
Warden.
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Emergency Response Procedures – Kalgoorlie Health Campus

Do not light matches or cigarette lighters, as there may be danger of explosion
caused by ruptured gas lines. Use torches if there is no lighting.
For occupants outside buildings during an earthquake:
 Keep away from buildings, high walls and power lines.
 If you are caught next to a building, seek refuge under archways and
doorways.
 If you are driving, pull off the road and stop.
 After the shaking has stopped, do not enter damaged buildings.
Senior Person in the Area – actions to be taken:
 When the shaking has stopped, check staff and patients / visitors for injuries
and arrange appropriate first aid.
 Survey your area for structural damage, particularly stairwells. Check for fire
and fire hazards such as ruptured gas lines.
 If applicable, determine if medical gas supplies are functional by checking
the gas warning lights in the area. If there is interruption to the main supply it
will be necessary to ensure that bottled gas (oxygen, air) is available for
dependant patients.
 Unless there is immediate danger, do not evacuate until instructed by the
Area Warden, Emergency Response Coordinator, or Fire and Rescue
Officers.
 Ensure no one smokes inside the building or where a fire/explosion hazard
exists.
 Ensure all staff are accounted for and remain in the area until instructed to
evacuate.
 Assist emergency response team and Fire and Rescue officers. Participate
in checking evacuation routes and, once in the assembly area, conduct a roll
call to account for everyone.
Evacuation
Do not evacuate the building during an earthquake. It is safer to remain within the
building taking cover under tables, desks, doorframes and stairwells, to reduce the
risk of injury from falling debris.
It may be necessary to check the evacuation routes before evacuation to ensure the
area is safe. Stairwells may have collapsed. Do not use lifts.
12.8. Missing Inpatient
The procedure for responding to a missing or suspected missing inpatients are
managed under the WACHS missing or suspected missing inpatient procedure.
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12.9.
Code Yellow - facility system status report template
2. Operational Period (#
1. Incident Name
)
DATE:
FROM: ______________________________ TO: _____________________________
TIME:
FROM: ______________________________ TO: _____________________________
3. Name of Facility / Building Reporting Status Below
4. System
5. Status
6. Comments If not fully functional, give location, reason, and estimated
time/resources for necessary repair. Identify who reported or inspected.
Communications
Fax
 Fully functional
 Partially functional
 Non-functional
 N/A
Information Technology
System
Network, applications
 Fully functional
 Partially functional
 Non-functional
 N/A
Nurse Call System
 Fully functional
 Partially functional
 Non-functional
 N/A
Overhead Paging
 Fully functional
 Partially functional
 Non-functional
 N/A
Paging System
 Fully functional
Code teams, standard paging
 Partially functional
 Non-functional
 N/A
Radio Equipment
 Fully functional
Facility handheld, 2-way radios,
antennas
 Partially functional
 Non-functional
 N/A
Radio Equipment
 Fully functional
EMS, local health department,
other external partner
 Partially functional
 Non-functional
 N/A
Radio Equipment
 Fully functional
Amateur radio
 Partially functional
 Non-functional
 N/A
Satellite Phones
 Fully functional
 Partially functional
 Non-functional
 N/A
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Telephone System
 Fully functional
Primary
 Partially functional
 Non-functional
 N/A
Telephone System
 Fully functional
Proprietary
 Partially functional
 Non-functional
 N/A
Telephone System
 Fully functional
Back-up
 Partially functional
 Non-functional
 N/A
Internet
 Fully functional
 Partially functional
 Non-functional
 N/A
Video-Television
 Fully functional
Cable
 Partially functional
 Non-functional
 N/A
Infrastructure
Campus Access
 Fully functional
Roadways, sidewalks, bridge
 Partially functional
 Non-functional
 N/A
Fire Detection System
 Fully functional
 Partially functional
 Non-functional
 N/A
Fire Suppression System
 Fully functional
 Partially functional
 Non-functional
 N/A
Food Preparation
Equipment
 Fully functional
 Partially functional
 Non-functional
 N/A
Ice Machines
 Fully functional
 Partially functional
 Non-functional
 N/A
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Laundry / Linen Service
Equipment
 Fully functional
 Partially functional
 Non-functional
 N/A
Structural Components
 Fully functional
Building integrity
 Partially functional
(Note cracked walls, loose masonry, hanging light fixtures, broken windows)
 Non-functional
 N/A
Patient care
Decontamination
Systems
Including containment
 Fully functional
 Partially functional
 Non-functional
 N/A
Digital Radiography
System, Routine
Diagnostics
PACS, CT, MRI, other
Steam / Chemical
Sterilisers
 Fully functional
 Partially functional
 Non-functional
 N/A
 Fully functional
 Partially functional
 Non-functional
 N/A
Isolation Rooms
 Fully functional
Positive/negative air
 Partially functional
 Non-functional
 N/A
Security
Facility Lockdown Systems
 Fully functional
Door/key card access
 Partially functional
 Non-functional
 N/A
Campus Security
 Fully functional
External panic alarms
 Partially functional
 Non-functional
 N/A
Campus Security
 Fully functional
Surveillance cameras
 Partially functional
 Nonfunctional
 N/A
Campus Security
 Fully functional
Traffic controls
 Partially functional
 Non-functional
 N/A
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Campus Security
 Fully functional
Lighting
 Partially functional
 Non-functional
 N/A
Duress Alarms
 Fully functional
Internal and other reporting
devices
 Partially functional
 Non-functional
 N/A
Utilities
Electrical Power
 Fully functional
Mains feed
 Partially functional
 Non-functional
 N/A
Electrical Power
 Fully functional
Backup generator
 Partially functional
 Non-functional
 N/A
Fuel Storage
 Fully functional
(Note amount on hand)
 Partially functional
 Non-functional
 N/A
Sanitation Systems
 Fully functional
 Partially functional
 Nonfunctional
 N/A
Water
 Fully functional
 Partially functional
 Non-functional
 N/A
Natural Gas/Propane
 Fully functional
 Partially functional
 Non-functional
 N/A
Air Compressor
 Fully functional
 Partially functional
 Non-functional
 N/A
Elevators/Escalators
 Fully functional
 Partially functional
 Non-functional
 N/A
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Hazardous Waste
Containment System
 Fully functional
 Partially functional
 Non-functional
 N/A
Heating, Ventilation, and
Air Conditioning (HVAC)
 Fully functional
 Partially functional
 Non-functional
 N/A
Oxygen
 Fully functional
(Note bulk, H tanks, E tanks, Reserve supply status)
 Partially functional
 Non-functional
 N/A
Medical Gases, Other
 Fully functional
(Note reserve supply status)
 Partially functional
 Non-functional
 N/A
Pneumatic Tube
 Fully functional
 Partially functional
 Non-functional
 N/A
Steam Boiler
 Fully functional
 Partially functional
 Non-functional
 N/A
Sump Pump
 Fully functional
 Partially functional
 Non-functional
 N/A
Water Treatment System
 Fully functional
 Partially functional
 Non-functional
 N/A
Vacuum (for patient use)
 Fully functional
 Partially functional
 Non-functional
 N/A
Water Heater and
Circulators
 Fully functional
 Partially functional
 Non-functional
 N/A
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External Lighting
 Fully functional
 Partially functional
 Non-functional
 N/A
External Storage
Equipment
 Fully functional
 Partially functional
 Non-functional
 N/A
External Storage
Vehicles
 Fully functional
 Partially functional
 Non-functional
 N/A
Parking Structures, Lots
 Fully functional
(Power, panic alarms, access, egress, lighting)
 Partially functional
 Non-functional
 N/A
Landing Zone
 Fully functional
Pads, lighting, fuel source
 Partially functional
 Non-functional
 N/A
7. Remarks (Cracked walls, broken glass, falling light fixtures, etc.)
8. Prepared by
PRINT NAME: ____________________________________________________________
DATE/TIME: ______________________________________________________________
SIGNATURE:
__________________________________________________________
FACILITY:
______________________________________________________________
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12.10. Code Yellow workarounds
Disruption /
Incident Type
Workarounds
Medical Gas

Portable bottles at various locations
Suction


Venturi twin o vac units at point of use
Portable electric units
Water

Bulk supply of bottled water located in the water plant room
Data Network (PC
disruptions)

Department specific







Dedicated emergency mobile phones located in the Primary
Emergency Operations Centre (code brown cupboard)
Runners
Last resort phones
Satellite phones
Landlines
Runners
Last resort phones



SMS to mobile phones
Runners
PA System










Unified devices
Mobile phones
Runners
Patient phones
Hand bells
Increased staff surveillance/rounding
Blankets
Natural ventilation
Manual cool down methods (ice packs, moist towels,
showers etc.)
Portable fans
Ventilation

Natural Ventilation methods
Natural Gas

Liquid Petroleum Gas
Landline
Communications
Mobile
Communications
Paging system
Nurse call bells
Air Conditioning
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12.11. Action Cards
Code Yellow action cards have been developed for the following positions:
Action card 31
Action card 32
Action card 33
Action card 36
First responder
Emergency Response Coordinator
Area Warden
Communications Officer
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Code Yellow
Action Card 31
Action Card
First Responder
Infrastructure
and other internal
emergencies
31
Reports to: Area Warden
Responsibilities:
 Ensure the immediate safety of anyone within the vicinity of the hazard.
 Take measures to ensure that the person responsible for the emergency response
is notified.
1.
On Identifying a Disruption to an Essential Service, Significant
Infrastructure Damage or Hazmat Incident.
Remove all people from immediate danger.
Time
Sign
Time
Sign
Establish contact with the Admissions Communications Officer by
dialling 55 and give the first report. If this is not possible, establish
contact with the Emergency Response Coordinator by dialling 0427
087 147 or Directory 364.
2.
First Report:
a) Caller's Name and position
b) Exact location of the incident
c) Brief description of the incident / type disruption (essential
service/infrastructure)
3.
Wait for directions from the Area Warden.
EARTHQUAKE
1.
2.
During an earthquake: DROP, COVER and HOLD
 Stay inside the building during the earthquake as you will be in
danger from falling debris.
 Where possible, move all persons are under beds, tables,
benches or doorframes to protect them from falling debris.
 Stay where you are. Do not attempt to reach another area or
floor within the building until you are instructed to by the Area
Warden.
 If no cover is available, move into a corner or away from the
centre of the room and away from glass, walls and windows.
After an earthquake:
 Wait for the directions of your area warden.
 Do not light matches or cigarette lighters as there may be a
danger of explosion caused by ruptured gas lines.
 Use torches if there is no lighting.
 Do not use lifts; be cautious using stairs, they may be unsafe.
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Action Card 32
Code Yellow
Infrastructure and
other internal
emergencies
Emergency Response
Coordinator
Action Card
32
Position: CNM Patient Flow or A/H nurse Mngr
Reports to: Hospital Incident Commander - (Operations Manager) - 0428 949 930
Responsibilities:
 Control the internal emergency response of an emergency within the facility.
 Ensure the health and safety of patients (including permanent care residents), staff
and visitors when faced with an emergency.
ALERT
1.
Time
Sign
Time
Sign
Proceed immediately to the Emergency Control Point located at the
Emergency Department entrance.
Collect vest, action card and radio as appropriate.
2.
3.
a) Don vest.
b) Keep action card on hand.
Collect information from the Admissions Communications Officer,
Area Warden and other sources as required.
Notify:
5.
a)
b)
c)
d)
Hospital Incident Commander
Engineering Officer
Emergency services (where applicable)
Service provider (where applicable and following discussion
with the Engineering Officer).
Establish estimated time of arrival/restoration time.
Note: Refer to contact list in the Business Continuity Plan
Activate the PA system for the entire facility and notify the site.
6.
“Attention all areas, attention all areas, this is the Emergency
Response Coordinator. Possible Code Yellow <say incident
category and location>. Remain calm and wait for further
directions.”
(Say twice).
ALERT
(Continued)
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Action Card 32
Code Yellow
Infrastructure and
other internal
emergencies
Emergency Response
Coordinator
Action Card
32
Position: CNM Patient Flow or A/H nurse Mngr
Establish contact with the Area Warden of the affected area(s) via
the Warden Intercommunications Point (WIP) phone and request a
SITREP.
7.
a) Critical business functions disrupted
b) Manual workarounds in place.
Note: Where the Area Warden does not answer the WIP phone,
use the PA system to ask the Area Warden/ Warden to
attend to the WIP or deploy staff in pairs to investigate.
8.
9.
10.
Establish contact with Area wardens adjacent to the affected
area(s) and provide SITREP.
 Current situation (what has happened, where did it occur,
what time)
 What actions have been undertaken (what has been done)
 What actions still need to be completed (what needs to be
done)
 Any other issues (anything of interest or noteworthy).
Direct the Engineering Officer to complete an impact assessment
using the Facility System Status Report template (Section 12.9)
and determine:
a) Systems /infrastructure that are affected by emergency
b) Services / wards and departments that are impacted or
disrupted.
c) Likely duration of impact / disruption.
Refer to the site’s Business Continuity Plan.
Use the Consolidated Dependency Profiles – Infrastructure and
Utilities, Equipment, ICT hardware and telecommunications, and
ICT systems and applications, to determine:
 Wards/departments/services that are highly dependent
(dependency rating 4 or 5) on impacted resource / utility /
system.

Brief the Engineering Officer and emergency service personnel
(where applicable) upon arrival on type of emergency, scope and
location.
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Action Card 32
Code Yellow
Infrastructure and
other internal
emergencies
Emergency Response
Coordinator
Action Card
32
Position: CNM Patient Flow or A/H nurse Mngr
RESPONSE
Infrastructure Damage / Disruption / Earthquake
Time
Sign
Time
Sign
Activate the PA system for the entire facility and notify the site.
1.
“Attention all areas, attention all areas, this is the Emergency
Response Coordinator. Confirmed Code Yellow - <say
category and say location>. Remain calm and wait for further
directions.”
(Say twice.)
2.
Establish contact with Area Wardens of affected areas and initiate
appropriate workarounds. Refer to manual workarounds.
3.
Ensure additional resources are sourced to support operations.
Establish contact with the Hospital Incident Commander
(Operations Manager) - 0428 949 930, and provide SITREP:
4.
a)
b)
c)
d)
e)
Disruption type
Workarounds in place
Critical business functions affected
Restoration times
Maximum Tolerable Periods of Disruptions for affected
activities.
Determine the need to activate relevant Business Continuity Plans.
5.
If Hospital Incident Commander takes control of the incident,
respond to the directions of the Hospital Incident Commander.
6.
Where necessary, activate Business Continuity Plan.
7.
Maintain communications with key stakeholders.
HAZARDOUS MATERIALS
1.
Attempt to ascertain the substance involved in chemical spill and
the areas affected.
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Action Card 32
Code Yellow
Infrastructure and
other internal
emergencies
2.
3.
4.
5.
6.
Emergency Response
Coordinator
32
Position: CNM Patient Flow or A/H nurse Mngr
If agent is known, source the appropriate Safety Data Sheet from
ChemAlert and determine most appropriate action.
Only if safe to do so, direct the cleaning up of spill as per Safety
Data Sheet instructions and in accordance with the Managing
Risks of Hazardous Chemicals and Dangerous Goods Procedure.
Source appropriate PPE and spill kits.
If unsure of agent or spill cleaning requirements, seek appropriate
subject matter expertise, including advice from the Department of
Fire and Emergency Services.
If substance is dangerous and volatile and presents a risk to staff,
or if substance is affecting staff, patient and visitors, consider
activating code orange evacuation procedures.
If further assistance or advice is required, direct the
Communications Officer contact the Department of Fire and
Emergency Services via a Triple Zero (000) call.
STAND DOWN
1.
Action Card
Time
Sign
Advise the Area Warden to wait for the arrival of Emergency
Services or the Engineering Officer.
Once the area is rendered safe and operational by Emergency
Services Officer in Charge or the Engineering Officer, activate the
PA system and notify the site.
2.
“Attention all areas, attention all areas, this is the Emergency
Response Coordinator. Code Yellow <say category type> –
Stand down.”
(Say twice.)
3.
Refurbish vest, action cards and radio in the Emergency Control
Point.
4.
Commence debriefing processes with all senior staff and key
stakeholders.
5.
Compile an emergency response report, as per reporting
processes
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Code Yellow
Infrastructure and
other internal
emergencies
Action Card 33
Area Warden
Action Card
33
Position: CNM / Shift Coordinator
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
 Control the initial response to the emergency in the area
ALERT
1.
Time
Sign
Time
Sign
Proceed to the Area Warden Point.
Collect vest and Area Warden Pack:
2.
a) Don vest.
b) Keep action cards on hand.
3.
Direct staff to check the area/floor for any abnormal situations.
4.
Commence code orange evacuation procedures if the situation
in the area warrants this.
Provide a SITREP to the Emergency Response Coordinator and
any actions taken.

5.



6.
Current situation (what has happened, where did it occur,
what time)
What actions have been undertaken (what has been done)
What actions still need to be completed (what needs to be
done)
Any other issues (anything of interest or noteworthy).
Remain within the immediate vicinity of the WIP Phone and
maintain communications with the Emergency Response
Coordinator.
RESPONSE - INFRASTRUCTURE DAMAGE /
DISRUPTION
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Code Yellow
Infrastructure and
other internal
emergencies
Action Card 33
Area Warden
Action Card
33
Position: CNM / Shift Coordinator
1.
Respond to the directions of the Emergency Response Coordinator
to implement workarounds
2.
Liaise with Engineering Officer/ Emergency Services and advise
them of any particular hazards and areas for special consideration.
RESPONSE - INFRASTRUCTURE DAMAGE /
DISRUPTION
Time
Sign
Time
Sign
(Continued)
Review resource requirements for business continuity. Report
deficiencies to the Emergency Response Coordinator.
3.
a)
b)
c)
d)
e)
f)
g)
ICT systems and applications
Specialised equipment
Office and Telecommunications Equipment
Workforce
Essential services (power, water etc.)
Physical Premises
Transport requirements.
4.
Maintain communications with the Emergency Response
Coordinator.
5.
If Business Continuity Plan is activated, refer to the area’s
Business Continuity Action Plan.
RESPONSE - HAZARDOUS MATERIALS
1.
Do not touch substance. Remove any personnel from the
contaminated area.
2.
Only if safe to do so, attempt to ascertain the substance involved in
chemical spill and share this information with the Emergency
Response Coordinator. If not safe, treat the substance as
unknown.
3.
Seek advice from the Emergency Response Coordinator as to
whether the substance poses a risk to staff, patients and visitors.
4.
Commence code orange evacuation procedures if the situation
in the area warrants this.
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Code Yellow
Action Card 33
Infrastructure and
other internal
emergencies
Area Warden
Action Card
33
Position: CNM / Shift Coordinator
5.
Maintain communications with the Emergency Response
Coordinator.
6.
Follow the instructions of the Emergency Response Coordinator
and Emergency Services.
EARTHQUAKE RESPONSE
1.
Follow the First Responder Actions for earthquakes (Action Card 1)
2.
When the shaking has stopped, check staff and patients / visitors
for injuries and arrange appropriate first aid.
3.
Survey your area for structural damage, particularly stairwells.
Check for fire and fire hazards such as ruptured gas lines.
4.
If applicable, determine if medical gas supplies are functional by
checking the gas warning lights in the area. If there is interruption
to the main supply it will be necessary to ensure that bottled gas
(oxygen, air) is available for dependant patients.
5.
Attempt to establish contact with the Hospital Emergency
Coordinator. Provide SITREP.
 Current situation (what has happened, where did it occur,
what time)
 What actions have been undertaken (what has been done)
 What actions still need to be completed (what needs to be
done)
 Any other issues (anything of interest or noteworthy).
6.
Unless there is immediate danger, do not evacuate the area unless
instructed to.
7.
8.
9.
Sign
Time
Sign
Ensure all staff are accounted for and await instructions from the
Emergency Response Coordinator and/or Emergency Services
personnel.
If instructed to evacuate, follow the Code Orange Evacuation
Procedures.
Ensure there are no ignition sources, including cigarette lighters
and matches, should there be gas leaks nearby.
STAND DOWN
1.
Time
Where patients have been evacuated, coordinate their return to
their wards or relocation as appropriate.
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Code Yellow
Infrastructure and
other internal
emergencies
Action Card 33
Area Warden
Action Card
33
Position: CNM / Shift Coordinator
2.
Instruct staff to reinstate the area to original operational status.
3.
Refurbish vest and Area Warden Pack at the Area Warden Point.
4.
Act as directed by the Emergency Response Coordinator to
compile a report of the actions taken during the emergency for the
debrief.
5.
Participate in the debriefing process.
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Code Yellow
Infrastructure and
other internal
emergencies
Action Card 36
Communications Officer
Action Card
36
Position: Admissions Communications Officer
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
 To facilitate communications via P.A. and paging systems
ALERT
4.
5.
7.
Respond to the directions of the Emergency Response
Coordinator.
8.
Maintain communications with the Emergency Response
Coordinator.
CONFIRMED CODE YELLOW – RESPONSE
4.
Time
Sign
Time
Sign
Initiate code call:
a) Send page to Code Red group
b) Make PA announcement (if not done by ERC):
“Code Yellow, <area>. Repeat Code Yellow <area>”
Update the Emergency Code Activation Log
3.
Sign
When receiving a 55 Emergency Call, collect the following
information:
a) Type of emergency
b) Exact location of emergency
c) Quick description of the emergency
d) Name and position of caller
6.
2.
Time
Continue logging events and incoming calls.
Maintain communications with the Emergency Response
Coordinator and other key stakeholders.
Respond to the directions of the Emergency Response
Coordinator.
STAND DOWN
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Code Yellow
Infrastructure and
other internal
emergencies
Action Card 36
Communications Officer
Position: Admissions Communications Officer
1.
When informed of a Stand Down,
a) Send page to the Code Red page group
b) Make P.A. announcement:
“Stand Down, Code Yellow <area>, Repeat, Stand Down, Code
Yellow <area>”
c) Record Stand Down time on Emergency Code Activation
Log
2.
Provide a copy of the Emergency Code Activation Log to the
Emergency Response Coordinator if requested to do so.
4.
Participate in the debriefing process.
Action Card
36
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13. Code Orange – Evacuation
13.1 Introduction
A code orange emergency evacuation involves the movement of patients, staff and
visitors within or from the facility in as rapid and safe manner as possible when lives
are threatened.
Emergency evacuations will often occur with little or no lead time. In most
circumstances, an emergency evacuation is preceded by a primary, precipitating
emergency or hazard. As such, many emergency response mechanisms have
already been activated, and code orange action cards are referred to midemergency.
13.2 Decision making
The decision to evacuate should be assessed with consideration to the following:
 The consequences to patient, staff and visitor safety, should an evacuation not
be carried out.
 The distance between the hazard and patients, staff and visitors or lead time
from a hazard impact.
 The clinical risks associated with an evacuation of patients in the involved area.
13.3 Authority to evacuate
The authority to order the removal of people from the immediate area (Stage 1) rests
with any staff member.
The authority to order the removal of people to a safe area (Stage 2) rests with the
Area Warden or the Emergency Response Coordinator.
The authority to order the removal of all people from the facility (Stage 3) rests with
the Emergency Response Coordinator.
13.4 Preferred order of emergency evacuation
1.
Those in immediate danger.
2.
Ambulant people.
3.
Ambulant people requiring assistance.
4.
Non – ambulant people.
13.5 Stages in evacuation
Evacuation should be conducted in distinct stages according to the severity of the
emergency.
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Stage 1 Evacuation
A Stage 1 evacuation is the removal of people from the immediate area. This may
include but is not limited to the removal of people from a room that is on fire or has
an aggressive person in it.
Stage 2 Evacuation
A Stage 2 evacuation is the removal of people to a safer area. This may include but
is not limited to the removal of people from their compartment/zone, through
fire/smoke doors to an adjacent compartment/zone or lower level.
Stage 3 Evacuation
A Stage 3 evacuation is the removal of all persons from inside the building and to
an external assembly point, such as a car park, park or nearby site.
Stage 3 evacuations are only undertaken to preserve life as a result of a
catastrophic site-wide emergency which poses an imminent safety risk to all
building occupants. A stage 3 evacuation will most likely precipitate an urgent
response from emergency services, requiring significant coordination to support the
needs of the evacuees.
13.6 Evacuation Routes
The location of the hazard may determine the choice of evacuation route.
In any case, an evacuation is to be via a person’s most direct and safe route to
either:
 their nearest muster point for stage 1 evacuations
 their nearest safe area for stage 2 evacuations; or
 Their nearest safe assembly area for stage 3 evacuations.
Evacuation diagrams provide evacuation information such as evacuation routes in
pictorial format of the floor. Evacuation diagrams are strategically located throughout
the facility.
Note: Lifts are not to be used to evacuate in a Code Red or following an
earthquake unless authorised by the Department of Fire and
Emergency Services (DFES) Officer in Charge (OIC). This is because
lift shafts may act at chimneys during multi-story fires.
Kalgoorlie Health Campus Muster Points Map – (Appendix J)
13.7 Designated Safe Points and Assembly Areas
There are a number of internal designated safe areas where patients, visitors and
staff may be taken/assemble in the event of an evacuation.
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Department / ward
Block One Lower
Level West – OPC
Block One Lower
Level East Administration
Block One Upper
Level – Allied Health
Block One Upper
Level - Med Records
Block Two –
MIT/ED/HDU
Block Four –
Workshop
Block Five – Laundry
& Stores
Block Six – Kitchen
& Pharmacy
Block Nine – A Ward
& Dialysis
Block Ten – Medical
Ward & Pall Care
Block 11 – Surgical
Ward
Block 12 – Maternity
Ward
Block 13 – Day &
Children’s Ward
Block 14 – Theatre &
TSSU
Block 16 – Brick
Quarters
Block 17 – SSQ
Block 18
Safe Area
(Stage two evacuation)
Main Waiting Room
Assembly Area
(stage three evacuation)
MP 2 - Staff Car Park
Corridor 10
MP 1 - CDC Verge
Corridor 5
MP 1 - CDC Verge
Corridor 5
MP 1 - CDC Verge
Main Waiting Room
Foyer Entrance
MP 5 – Corner Charlotte &
Piccadilly Streets
MP 5 – Corner Charlotte &
Piccadilly Streets
MP 5 – Corner Charlotte &
Piccadilly Streets
MP 5 – Corner Charlotte &
Piccadilly Streets
MP 4 - Rear Car Park
Foyer Entrance
MP 4 - Rear Car Park
Foyer Entrance
MP 4 - Rear Car Park
Foyer Entrance
MP 4 - Rear Car Park
Nurses Station
MP 4 - Rear Car Park
CNM Office
MP 3 - SSQ Car Park
Reception
MP 2 - Staff Car Park
Verandas
MP 3 - SSQ Car Park
Training Room
Staff Car Park
Verandas
MP 2 - Staff Car Park
Entrance
Between Laundry and
Stores
Rear Kitchen Entry
Block 19 – Brownhill
House
Block 20 –
Waiting Room
Outpatients
Block 21 – Antenatal
Reception
Unit
Visiting Specialists
Reception
Centre
13.8 Other considerations
MP 3 - SSQ Car Park
MP 2 - Staff Car Park
MP 3 - SSQ Car Park
MP 1 - CDC Verge
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
Mobility impaired staff
Line Managers should establish appropriate Personal Emergency Evacuation Plans
(PEEP) for mobility impaired staff members under their direct supervision. Plans
should be established and maintained in consultation with the staff member to
ensure the appropriateness of the plan and be readily available to the relevant Area
Warden. Refer to Appendix D – Personal Emergency Evacuation Plan Template.

Records relevant to immediate patient care
Saving patient care records that are relevant to the immediate care of a patient is
important however this should not be done at the expense of evacuating people.

Evacuation equipment
There is generally limited equipment that can be used to evacuate people. In most
cases, equipment such as wheelchairs, ski sheets, mats, sled type devices etc. may
need to be turned around quickly to ensure evacuation of non-ambulant patients.

Head counts
At the completion of an evacuation, the Area Warden is to ensure a headcount of all
patients, staff and visitors is conducted to ensure the evacuation is complete.

Communications
Good communication is essential during the evacuation process with rapidly
changing patient and staff locations.

Pharmacy
Pharmacists are to coordinate the review of and access to medications for patients
in the event of an emergency evacuation.
13.9 Patient care during and after an evacuation
Consider vulnerable or at risk patient groups, including but not limited to those aged
over 65 years (or Aboriginal patients over 45), intellectually disabled, significantly
physically disabled, paediatrics, people of cultural or linguistically different
backgrounds and patients diagnosed with mental illness. Patients who may be at
increased risk of harm when evacuated from a health site will require increased
supervision where possible. Refer to WACHS Missing Person or Suspected Missing
Person Procedure if any patient admitted for mental health care is identified as
missing following evacuation.
Patient care can be expected to require an extraordinary effort by staff until such time
as the patients can be returned to their ward, or alternative accommodation can be
found.
13.10 Re-population of area or facility
Following an evacuation of an area or facility, it may be necessary to engage
appropriate specialists to undertake an assessment of the affected areas to deem
whether the area(s) or facility can be safely re-inhabited. This may require input from
engineers, building assessment experts, occupational hygienists, and other
appropriate subject matter experts. Further, some hazards may require a formal
investigation to be undertaken to determine the cause, which may delay the
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resumption of services. This may warrant activation of the site’s Business Continuity
Plan.
Engineering staff may choose to use the Code Yellow - facility system status report
template (section 12.9) to facilitate the any facility assessments.
13.11 Decanting and relocating inpatients
Should the facility be unsuitable for safe re-occupation, patients may require
relocation to another site.
Where patients are required to be relocated to another site as a result of an
emergency, the Hospital Incident Commander is to ensure the Regional Disaster
Health Coordinator is notified of the need to transfer.
The Emergency Response Coordinator should record the transfer of patients in a
patient transfer log. Refer to Appendix F. – patient transfer/discharge log.
13.12 Planned relocations and sheltering in place
Planned relocations and sheltering in place are options that may be considered when
there is no immediate emergency or catastrophic safety risk to staff, patients and
visitors.
Sheltering in place involves the building occupants staying in situ at the facility. A
planned relocation is the controlled and planned movement of patients, staff and
visitors from an affected site to a suitable and safe alternative location, and is
generally associated with an extended lead time before a hazard impact.
Sheltering in place is always the most preferred option when the risk of moving is
seen as greater than the risk of sheltering in place. Key decision considerations
include the timeliness of the hazard impact / loss of facility, and the resources
needed to safely move the facility occupants.
Decision making for planned relocations and sheltering in place should be
undertaken by the Hospital Incident Commander in consultation with the Regional
Health Disaster Coordinator and other relevant stakeholders.
13.13 Action cards
Code Orange action cards have been developed for the following positions:
Action card 37
Action card 38
Action card 39
Action card 41
Action card 42
First responder
Emergency Response Coordinator
Area Warden
Emergency Response Team member
Communications Officer
These action cards have been designed to be enacted mid-response when a primary
emergency precipitates the need to evacuate.
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Code Orange
Action Card
Action Card 37
First Responder
Evacuation
37
Reports to: Area Warden
Responsibilities:
 Take measures to move patients, staff and visitors within or from within the facility.
STAGE ONE EVACUATION
(Following an emergency warranting a local evacuation from area of
danger)
1.
Time
Sign
Time
Sign
Remove persons from immediate danger if safe to do so.
Establish contact with the Admissions Communications Officer by
dialling 55 and give the first report. If this is not possible, establish
contact with the Emergency Response Coordinator by dialling 0427
087 147 or Directory 364.
2.
First Report:
a) Caller's Name and position
b) Exact location of the incident
c) Code Orange
d) Brief description of the incident / type disruption (essential
service/infrastructure) and need to evacuate.
3.
Wait for instructions from the Area Warden.
STAGE TWO EVACUATION
(Following an emergency where an evacuation of an area(s) into another
fire compartment is warranted).
1.
Where practicable, identify a ‘buddy’ to work with. Prepare patients
and visitors for evacuation and prioritise their order of movement.
2.
Move patients and visitors to the nearest safe area via the nearest
safe exit in the preferred order.
5.
Where it is safe to do so for each room:
a) Turn the gas valves off.
b) Leave the lights on.
c) Close doors (do not lock) for fire/smoke, leave doors open for
bomb threats
d) Mark the door with a tape in the form of an X to indicate that it
has been cleared.
Move to the nearest safe area via the nearest safe exit when all
occupants, patients and visitors are evacuated or when the area
becomes unsafe.
Check off your name with the Area Warden.
6.
Wait for instructions from the Area Warden.
3.
4.
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Code Orange
Action Card
Action Card 37
First Responder
Evacuation
37
STAGE THREE EVACUATION
(Following a sudden, catastrophic site-wide emergency which poses an
imminent safety risk to all building occupants and where an evacuation of
the entire facility is warranted).
1.
Where practicable, identify a ‘buddy’ to work with. Prepare patients
and visitors for evacuation and prioritise their order of movement.
2.
Move patients and visitors to the nearest safe area via the nearest
safe exit in the preferred order.
3.
Time
Sign
Time
Sign
Where it is safe to do so for each room:
a) Turn the gas valves off.
b) Leave the lights on.
c) Close doors (do not lock) for fire/smoke, leave doors open for
bomb threats
d) Mark the door with a tape in the form of an X to indicate that it
has been cleared.
4.
Begin evacuation of patients, visitors and employees when directed
by the Area Warden or Emergency Services.
5.
Attend the designated assembly area, and await further
instructions, until stand down notification is received.
STAND DOWN
1.
Assist with returning patients to the area once advised it is safe to
do so, or to an alternate location if advised.
2.
Assess any patients for sign of injury, distress or clinical
deterioration, and initiate appropriate clinical escalation and referral
processes where necessary.
3.
Where advised by the Area Warden, resume normal duties.
4.
Participate in the debriefing process.
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Action Card 38
Code Orange
Evacuation
Emergency Response
Coordinator
Action Card
38
Position: CNM Patient Flow or A/H nurse Mngr
Reports to: Hospital Incident Commander - (Operations Manager) - 0428 949 930
Responsibilities:
 Coordinates the evacuation within and from the facility.
 Ensure the health and safety of patients (including permanent care residents), staff
and visitors when evacuated within or from the facility.
STAGE TWO EVACUATION
(Following an emergency where an evacuation of an area(s) into another
fire compartment is warranted).
Establish contact with the Area Warden of area affected by
1.
whatever means available. Instruct Area Warden to prepare for an
evacuation.
Change the Emergency Warning Intercommunications System
(EWIS) panel from automatic to manual.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Time
Sign
Activate evacuation tones for affected area(s).
Deploy the Emergency Response Team to the scene of emergency
and assist in evacuation.
Activate the PA system for the entire facility and make the
evacuation announcement.
‘Attention all areas, this is the Emergency Response
Coordinator. An emergency has occurred within the building.
<say area(s)/department(s) evacuate <from the area> now.”
(Say twice.)
Establish contact with the Area Warden of area adjacent to the
affected by whatever means available. Instruct Area Warden to
prepare for an evacuation.
Repeat steps 4 - 5 until all areas have been cleared or the
emergency has abated.
Wait for Area Wardens to report back; on the progress of the
evacuation. Record evacuation information on an evacuation
checklist.
Where patients are evacuated, ensure the Senior Emergency
Department Doctor is contacted and provided with an escort to the
designated assembly area(s).
Inform Hospital Incident Commander of evacuation.
Where the evacuation is complete provide the Responsible Person
with the evacuation checklist.
Where the emergency has abated, carry out stand down actions for
the applicable code.
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Action Card 38
Code Orange
Evacuation
Emergency Response
Coordinator
Action Card
38
Position: CNM Patient Flow or A/H nurse Mngr
STAGE THREE EVACUATION
(Following a sudden, catastrophic site-wide emergency which poses an
imminent safety risk to all building occupants, and where an evacuation of
the entire facility is warranted).
Change the Emergency Warning Intercommunications System
(EWIS) panel from automatic to manual.
1.
Time
Sign
Activate evacuation tones for entire building.
Activate the PA system for the entire facility and make the
evacuation announcement.
2.
3.
‘Attention all areas, this is the Emergency Response
Coordinator. An emergency has occurred and the entire
building requires evacuation. Evacuate now to your external
assembly areas. Please follow the directions of your Area
Warden.”
(Say twice.)
Establish contact with all Area Wardens by whatever means
available. Instruct Area Wardens to prepare for stage 3 evacuation.
Allocate staff to conduct a sweep of the hospital and assist with the
evacuation.
4.
5.
6.
7.
8.
Utilse WIP phones or radios for ongoing communications as
appropriate.
If Emergency Services are not already on site, instruct the
Admissions Communications Officer to dial 000 and request
assistance of all available emergency services (Fire Brigade,
Police, and Ambulance).
Once emergency services arrive, identify self and provide SITREP
on:
 Nature of emergency precipitating evacuation
 Current status of evacuation, including areas that have not
been cleared or searched.
 Areas requiring assistance to evacuate
 Any known dangers
Deploy the Senior Emergency Department Doctor and nursing staff
members to the external assembly areas to provide medical
assistance where required.
Wait for Area Wardens to report back on the progress of the
evacuation. This may be through various WIP phones on the
evacuation route.
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Action Card 38
Code Orange
Evacuation
Emergency Response
Coordinator
Action Card
38
Position: CNM Patient Flow or A/H nurse Mngr
9.
Record evacuation information on an evacuation checklist
STAGE THREE EVACUATION
(Following a sudden, catastrophic site-wide emergency which poses an
imminent safety risk to all building occupants and where an evacuation of
the entire facility is warranted).
9.
10.
11.
12.
Time
Sign
Time
Sign
(Continued)
Notify Hospital Incident Commander of evacuation and request
they attend facility.
Deploy Emergency Response Team to the Assembly Area(s).
Request SITREP on:
 Number of external assembly areas
 Total head count (staff, patients, visitors)
 Total number of unaccounted for staff, patients or visitors
 Any medical assistance required.
When the evacuation is complete provide the Hospital Incident
Commander with the evacuation checklist.
Where the emergency has abated, liaise with engineering staff or
emergency services to determine if the building is safe for reoccupation (smoke residue or infrastructure damage).
If building is deemed safe, carry out the stand down actions. If
building is not deemed safe, inform the hospital incident
commander and refer to the site’s Business Continuity Plan.
STAND DOWN
1.
Inform all evacuees of the stand down.
2.
Oversee the return of staff and patients to their wards, or relocation
point.
3.
Refurbish vest, action cards and radio at the Emergency Control
Point.
4.
Commence debriefing processes with all senior staff and key
stakeholders.
5.
Compile an emergency response report for the Hospital Incident
Commander.
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Action Card 39
Area Warden
Code Orange
Evacuation
Action Card
39
Position: CNM / Shift Coordinator
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
 Coordinate the initial response to the emergency in the area.
STAGE TWO EVACUATION
(Following an emergency where an evacuation of an area(s) into another
fire compartment is warranted).
Identify the nearest safe stage 2 assembly area that will provide
1.
the greatest isolation time from the hazard for patients, staff and
visitors.
Provide SITREP to the Emergency Response Coordinator.
2
a) Exact location of evacuation point.
b) Number and type of evacuees.
Ensure the following are carried out:
3.
4.
5.
6.
7.
9.
8.
Time
Sign
a)
b)
c)
d)
Patient lists and staff rosters are collated
the route to the safe area is cleared
the Area Warden of the adjacent area is liaised with
Evacuees are checked off the applicable list as they arrive in
the safe area
e) triage is performed when evacuees arrive.
Establish the priority order for evacuation and brief the evacuation
order to the area staff.
a) Those in immediate danger.
b) Ambulant people.
c) Ambulant people requiring assistance.
d) Non – ambulant people.
Maintain communications with the Emergency Response
Coordinator and other key stakeholders using WIP phones along
the evacuation route and at the stage 2 assembly area.
Control the evacuation of the area.
Consider the collation of specialist medical equipment and medical
records.
Where safe to, conduct a search of area and mark evacuated
areas on Area Warden Search Map. Note any areas that have not
been searched. Hand this information over to the Emergency
Response Coordinator or Emergency Services.
Move to identified stage 2 assembly area when instructed to do so
by the Emergency Response Coordinator or the Emergency
Services or when the area is cleared. Place the “Area Evacuated”
sign on the entrance as you leave.
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Action Card 39
Area Warden
Code Orange
Evacuation
Action Card
39
Position: CNM / Shift Coordinator
STAGE THREE EVACUATION
(Following a sudden, catastrophic site-wide emergency which poses an
imminent safety risk to all building occupants and where an evacuation of
the entire facility is warranted).
1.
2.
3.
4.
5.
Attempt to establish contact with the Emergency Response
Coordinator using WIP phone. Determine nature and location of
emergency and safest external assembly area to evacuate to.
Provide SITREP to the Emergency Response Coordinator.
a) Exact location of evacuation point.
b) Number and type of evacuees.
Ensure the following are carried out:
a)
b)
c)
d)
Patient lists and staff rosters are collated
the route to the safe area is cleared
the Area Warden of the adjacent area is liaised with
Evacuees are checked off the applicable list as they arrive in
the safe area
e) triage is performed when evacuees arrive.
Establish the priority order for evacuation and brief the evacuation
order to the area staff.
a)
b)
c)
d)
Those in immediate danger.
Ambulant people.
Ambulant people requiring assistance.
Non – ambulant people.
Maintain communications with the Emergency Response
Coordinator and other key stakeholders.
7.
Control the evacuation of the area.
8.
Consider the collation of specialist medical equipment and medical
records.
10.
11.
Sign
Proceed to the local Area Warden Point.
6.
9.
Time
Where safe to, conduct a search of area and mark evacuated
areas on Area Warden search map. Note any areas that have not
been searched.
Move to designated external assembly area when instructed to do
so by the Emergency Response Coordinator or the Emergency
Services or when the area is cleared.
Where the emergency has abated carry all clear actions for the
applicable code (i.e. Code Red Stand down procedure).
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Date of Last Review: May 2020
Page 139 of 160
Date Next Review: May 2025
Emergency Response Procedures – Kalgoorlie Health Campus
Action Card 39
Area Warden
Code Orange
Evacuation
Action Card
39
Position: CNM / Shift Coordinator
STAND DOWN
Time
1.
Coordinate the return of staff and patients to their wards, or
relocation point.
2.
Inform Emergency Response Coordinator when re-population of
ward is complete.
3.
Refurbish vest, search map and action cards in the Area Warden
Pack at the Area Warden Point.
4.
Assess whether any staff, patients and visitors are adversely
affected or require medical attention, and escalate as necessary.
5.
Participate in debriefing process.
6.
Compile an emergency response report for the Hospital Incident
Commander.
Sign
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Always source the current version from WACHS HealthPoint Policies.
Date of Last Review: May 2020
Page 140 of 160
Date Next Review: May 2025
Emergency Response Procedures – Kalgoorlie Health Campus
Action Card 41
Code Orange
Evacuation
Emergency Response Team
Member
Action Card
41
Position: Fire Wardens / Delegated Staff
Reports to: Area Warden
Responsibilities:
 Carry out emergency response activities.
FOR ALL STAGE TWO AND THREE EVACUATIONS
1.
Muster immediately on the Area Warden.
2.
Respond to the directions of the Area Warden.
STAND DOWN
1.
Assist with the return of staff and patients to their wards, or
relocation point.
2.
Respond to the directions of the Area Warden.
3.
Refurbish vest and action cards at Emergency Control Point.
4.
Participate in the debriefing process.
Time
Sign
Time
Sign
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Date of Last Review: May 2020
Page 141 of 160
Date Next Review: May 2025
Emergency Response Procedures – Kalgoorlie Health Campus
Action Card 42
Code Orange
Evacuation
Communications Officer
Action Card
42
Position: Admissions Communications Officer
Reports to: Emergency Response Coordinator – 0427 087 147 or Directory 364
Responsibilities:
 To facilitate communications via P.A. and paging systems during an evacuation.
FOR ALL STAGE TWO AND THREE EVACUATIONS
1.
2.
3.
Sign
Time
Sign
When receiving a 55 Emergency Call, collect the following
information:
a)
Type of emergency
b)
Exact location of emergency
c)
Quick description of the emergency
d)
Name and position of caller
Initiate code call:
a) Send page to Code Orange group
b) Make PA announcement (if not done by ERC):
“Code Orange, <area>. Repeat, Code Orange <area>”
If requested by the Emergency Response Coordinator, notify the
applicable Emergency Services that an evacuation has been
ordered.
4.
Update the Emergency Code Activation Log and continue to
update with events that occur during the evacuation.
5.
Receive and transmit instructions, information and enquiries as
required.
6.
Maintain communications with the Emergency Response
Coordinator.
7.
Respond to the directions of the Emergency Response
Coordinator.
STAND DOWN
1.
Time
When informed of a Stand Down,
a) Send page to Code Orange page group
b) make P.A. announcement:
“Stand Down, Code Orange <area>, Repeat, Stand Down, Code
Orange <area>”
c) Record Stand Down time on Emergency Code Activation
Log
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Date of Last Review: May 2020
Page 142 of 160
Date Next Review: May 2025
Emergency Response Procedures – Kalgoorlie Health Campus
Action Card 42
Code Orange
Evacuation
Communications Officer
Position: Admissions Communications Officer
2.
Provide a copy of the Emergency Code Activation Log to the
Emergency Response Coordinator if requested to do so.
3.
Participate in the debriefing process.
Action Card
42
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Date of Last Review: May 2020
Page 143 of 160
Date Next Review: May 2025
Emergency Response Procedures – Kalgoorlie Health Campus
14.
Appendices
14.1 Appendix A – Communications Log
Date of incident: ____ / _____ / ______
Time of notification: ______ :_______
Type of incident: ____________________
Location: ______________________
Name of Emergency Response Coordinator: ________________________________
Name of Communications Officer: _________________________________________
Note: This form serves as a record of all communications, activities and decisions made during
the occurrence of an emergency. On resolution of the emergency, this form is to be electronically
saved for review purposes.
Time
Participants
Decision / communication / activity
Printed or saved electronic copies of this policy document are considered uncontrolled.
Always source the current version from WACHS HealthPoint Policies.
Date of Last Review: May 2020