The primary objectives of the Fire Safety Management Plan are to:
1. Understand and apply the latest life safety codes of the National Fire Protection Association and all applicable local, state, and federal regulatory and accreditation standards.
2. Develop corrective action plans for fire safety deficiencies when necessary.
3. Maintain a level of safety (i.e., interim Life Safety) during all levels of renovation or construction.
4. Test and practice staff compliance and knowledge through participation in fire drills.
5. Maintain the Statement of Conditions as a working document.
6. Train staff in the RACE (Rescue, Alarm, Confine, Evacuate or Extinguish) and “PASS” (Pull, Aim, Squeeze, Sweep) protocol for fire extinguisher use.
7. 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
The Fire Safety Management Plan is developed and implemented in order to establish and maintain a fire safe environment of care for Hillcrest students and staff.

This Plan shall be reviewed and evaluated each year for its effectiveness, scope, performance and objectives. A work group typically consisting of the Director of Quality Assurance, the Director of Facilities, and the Chairpersons of 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 shall be implemented each July at the beginning of the new Program Year.

The maintenance and supervision of all grounds and equipment is the ultimate, joint responsibility of the Maintenance Department and the campus Program Director. Others, as noted above, share this responsibility.

Hillcrest Educational Centers:
• Operates 24 hours per day, 365 days per year.
• Has multiple residential and non-residential sites.
• Primarily serves children and adolescents who have severe psychiatric and behavior disorders and who sometimes act in a manner that is dangerous to themselves or others.
• Holds the safety and security of students, clients and staff as our highest priority.

Given these conditions and priorities, it is necessary to have numerous people at the agency and campus levels who are authorized to intervene whenever conditions pose an immediate threat to life or health (such as a chemical spill, gas leak) or threaten damage to buildings or equipment (such as water leaks, electrical power system malfunction). Additionally, the agency clearly communicates by word and deed that there is a preference and an expectation for authorized persons to act proactively, preventively, and decisively in high risk situations.

The following people are authorized and expected to intervene in such cases.
1. Agency level
The Director of Quality Assurance
Any member of the Senior Management Team (i.e., Senior Managers and department heads)
The Director of Facilities
2. Campus level
Program Director
Any campus administrator/department head
Direct care Supervisors (who run all shifts each day)
Any member of the campus Environment of Care Committee.

Finally, as noted above, Hillcrest considers safety management to be an interactive process involving all staff members. 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 and clients.

While all Hillcrest employees are expected to attend to matters of safety and security, and while the Board of Directors and the President/CEO are ultimately responsible for safety at Hillcrest, the following persons and groups are responsible for the implementation and monitoring of the Safety Management Plan.
1. Agency level
At the agency level, safety management is the responsibility of the agency Director of Quality Assurance and the Hillcrest Senior Management Team, which is comprised of Senior Managers, Program Directors and department heads.
2. Campus/program level
At the campus/program level, safety management is the responsibility of the campus Program Director, and their delegates (including other campus administrators and the direct care Supervisors who run shifts each day), and campus Environment of Care Committees. Campus Environment of Care Committees are multi-disciplinary groups that meet at least six times each year with a focus on safety and security in the environment of care. The campus Environment of Care Committee reports to the campus’ IOP Committee, which is comprised of the campus’ multidisciplinary leadership and which is focused on systematically improving care, treatment and general operations, including environment of care. The Environment of Care Committee regularly reports to the IOP Committee, which in turn reports quarterly and annually to the Senior Management and the Board of Directors on performance issues, including safety and security.

Hillcrest Policies and Procedures are available in all departments at all times. However, policies and procedures related to safety are distributed to all departments for purposes of review and revision as needed, and the Safety Management Plan is reviewed annually, and revised as needed, as noted in section XII. below.

New staff are oriented to Safety policies and procedures during New Staff Orientation, and training in procedures related to safety, security and emergency management and response is provided on a quarterly basis.

As noted, HEC conducts an Infection Control Program and has a Continuity of Operations Plan (COOP), as required by the state of Massachusetts.

Each Hillcrest site has one or more Automated External Defibrillator, and staff are trained in proper AED utilization.

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.