Monitoring of safety related performance is conducted on an ongoing basis in different ways.
1. Staff knowledge and skills
The monitoring of staff knowledge and skills associated with safety is conducted through regular observation of performance, including drills, by supervisors, through formal supervision meetings, through annual performance evaluations, and through training conducted each year.

2. Level of staff participation
The monitoring of staff participation is accomplished through means described in section 1. above.

3. Monitoring and inspection activities
Hazard surveillance inspections are conducted on each campus at least quarterly. Hazard surveillance inspection reports, any other safety related reports and any investigation findings are reviewed by campus Environment of Care Committees, as they occur.

HEC also operates an Infection Control Program (see IC Plan).

4. Emergency and incident reporting
All incident reports, including reports related to safety, are reviewed by supervisors, nursing staff, clinical staff, and program administrators. Safety related reports are also reviewed by the campus Environment of Care Committee and by program and agency administration.

Incidents that are not documented require follow up by supervisors, and incident reports that are not completed correctly or according to procedure, are returned for follow up by the supervisor.

5. Inspection, preventive maintenance and testing of equipment
Safety related equipment is tested/inspected and maintained on a schedule recommended by the manufacturer and/or on a schedule consistent with regulation or accreditation standards, whichever is the higher standard.

The agency Director of Quality Assurance and the Director of Facilities jointly manage development, implementation, and monitoring of safety management throughout the agency. He/she primarily works with and through campus Environment of Care Committees, Improving Organizational Performance committees, the Executive Director, the Senior Vice President, Program Directors, and the Director of Facilities.

The campus Environment of Care Committee, which meets at least six times each year, is a multi-disciplinary work group responsible for the monitoring and coordination of safety on the campus. The Environment of Care Committee regularly reports to, and makes recommendations to the IOP (Improving Organizational Performance) Committee, which in turn makes recommendations and reports quarterly and annually to the Senior Management and the Board of Directors on performance issues, including safety and security. The Environment of Care Leadership Committee meets periodically to make decisions about and review progress on EOC related issues and projects.

Hazard surveillance inspections are conducted on each campus at least quarterly. Hazard surveillance inspection reports, any security related reports and any investigation findings are reviewed by campus Environment of Care Committees.

At least three times each year, the Maintenance Dept. conducts a Hazard Surveillance to check all doors equipped with magnetic auto closure mechanisms, to insure that the doors close and latch when the fire alarm goes off and the magnet disengages the door.

These fire door focused Hazard Surveillance activities will be scheduled in, and documented by the SchoolDude Preventative maintenance direct system.

Product safety recalls will typically be sent to Hillcrest’s central administration or directly to the department purchasing and/or using the item. Hillcrest administration and/or the department using the recalled item will immediately stop using the item until complete information about the recall is obtained. If safety questions or concerns continue, use of the item will be discontinued indefinitely, and the item will be replaced if necessary. Under no conditions will Hillcrest continue to use any purchased item about which there are reasonable safety questions or concerns.

All safety-related incidents, including accidents, injuries and property damage, are reported immediately to the direct care supervisor and/or the campus maintenance staff for immediate attention. The supervisor will determine if the event meets the criteria for notification to an administrator after conducting a preliminary investigation and taking whatever immediate action is necessary. The administrator will determine if the event meets the criteria for notification to the on-call Senior Manager.

Depending on the nature and seriousness of the event, nursing (e.g., for injuries) and/or maintenance (e.g., for property damage) may also be notified.

An Incident Report will be completed for any safety-related event and depending on the nature and significance of the event, an investigation may be initiated by the Senior Vice President or the Program Director, in consultation with the Executive Director. The Quality Assurance Director would conduct such an investigation.

In the event that an outside municipality or company (i.e., fire, ambulance, police, hazmat, utility, etc.) is called onto a campus for an incident that disrupts services in some way, the Director of Quality Assurance conducts a thorough review of the incident and debriefs the incident with relevant managers and staff. The debriefing report is also shared with members of the Senior Management Team.
The purpose of this review and debriefing is to learn from the incident and, if possible, to prevent such incidents from occurring in the future.

Hillcrest will periodically evaluate the impact of buildings, grounds, equipment and internal physical systems on Hillcrest students, clients, staff and services and will make improvements, including both minor and major improvements, as indicated and as feasible, for each campus.

Planning for specific and significant demolition, renovation and/or construction projects will include impact assessment procedures for the project. The impact assessment is intended to identify conditions that could potentially compromise student, clients or staff safety and/or care in occupied areas of the buildings or in any part of the campus in which work is being done for, at least the following factors: air quality, infection control, utilities, noise/vibration, and emergency procedures.

Depending on the outcome of the project impact assessment, Hillcrest will select and implement controls and measures to reduce, minimize and/or eliminate any impact upon or risk to Hillcrest students, clients and staff. Additionally, on every such project of significance Hillcrest works closely with the local Fire, Building and Health authorities to insure compliance with local and state codes and standards.

On an ongoing basis, HEC operates a proactive program to identify and reduce adverse events and safety risks.  With regard to routine safety assessments, please refer to section V. Hazard Surveillance.

The primary objectives of the Safety Management Plan are to:
• Establish and maintain a physical environment free of hazards.
• Manage student, client and staff activities to reduce the risk of injuries.
Hillcrest will accomplish these objectives in a manner compliant with regulations promulgated by the Mass. Dept. of Early Education and Care (DEEC), Mass. Department of Elementary and Secondary Education (DESE), standards established by the Joint Commission (JC), and all other applicable laws, regulations and standards.

PURPOSE
Hillcrest Educational Centers is committed to providing a safe environment for students, clients, staff and visitors. Safety management is an interactive process designed to involve all staff members in the continuous monitoring and evaluation of the elements that make up a safe and secure environment of care. Each staff member, regardless of position or role, is trained and expected to be vigilant and proactive with regard to safety and security in order to maximize the therapeutic and protective nature of the Hillcrest environment for students, clients and staff. The Safety Management Plan helps to define and structure this process.

In the event that any Hillcrest campus or site is significantly affected by a disaster or emergency event, one that fundamentally affects operations, at least the following activities will be considered and/or implemented.

A) Structural and building systems inspections.
As needed and as indicated by the nature and extent of the disaster/emergency event, structural and/or building systems inspections will be conducted by both the Hillcrest Maintenance Department, local building inspectors, and by outside consultants (e.g., architects, engineers).

B) Disaster counseling for students and staff.
Disaster recovery counseling (individual, group) could be conducted for students and/or for staff by Hillcrest staff who trained in Emotional First Aid as members of the Berkshire Trauma Response Team; Hillcrest Clinical personnel from other campuses; and/or trained disaster recovery personnel from an outside agency (e.g., American Red Cross). Hillcrest will determine the indicated modality and format contingent upon the nature and extent of the disaster/emergency event.

Hillcrest staff and their families also have access to EAP counseling on a confidential, as needed basis.

This Plan shall be reviewed and evaluated each year for its effectiveness, scope, performance and objectives. A work group minimally consisting of the Director of Quality Assurance, the Director of Facilities, and the Chairpersons from each campus EOC Committee and/or their designee will conduct the review and evaluation between March and May of each year. The results of the review and evaluation, and related recommendations, will be reported sequentially to the campus EOC Committees and the Senior Management Team for their review and approval. Barring unforeseen and unavoidable delays, this revised Plan will be implemented each July at the beginning of the new Program Year.

All new staff, regardless of their position, role or work site, participate in a 9 day Orientation to the agency and designated work site which includes a module on emergency preparedness and response.

On an ongoing basis, program staff participate in Emergency Preparedness and Response training each quarter.