Risk Prevention and Management Plan

Plan revised December 9, 2011 Approved by Board of Directors: January 25, 2012

Table of Contents
(Click on underlined section title to go to that section.)

INTRODUCTION AND OVERVIEW Foundation for Risk Prevention and Management Activities Authorizing Policy RISK PREVENTION AND MANAGEMENT GOAL ROLES IN RISK PREVENTION AND MANAGEMENT REVIEW AND OVERSIGHT OF AREAS OF POTENTIAL RISK CONFIDENTIALITY, RECORDS AND IMMUNITY ASSOCIATED RPM POLICIES AND PROCEDURES 3 3 3 3 4 10 11

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Introduction and Overview

Foundation for Risk Prevention and Management Activities

Risk prevention and management activities are directly related to Catholic Charities Fort Worths core values of stewardship and excellence, and our key value driver of being a forward driven organization. As stewards of the resources which have been entrusted to us, Catholic Charities Fort Worth (CCFW) recognizes that viability and sustainability depend on the identification, assessment, prioritization, and appropriate response to identified risks. Risk prevention and management practices provide an opportunity to strengthen the organization, and are therefore integrated into the agencys performance and quality improvement system.

Authorizing Policy

Authorization and support for the development and implementation of this Risk Prevention and Plan is found in the Risk Prevention and Management Plan policy initially approved by the CCFW Board of Directors in June, 2007, and revised in December, 2011, with Board approval of the revision anticipated in January, 2012.

Risk Prevention and Management Goal

The goal of the risk prevention and management program is to reduce the frequency and severity of adverse events through risk identification, evaluation, and control, thus minimizing loss and contributing to quality care and safety for CCFWs stakeholders. Risk prevention and management activities are integrated into organizational performance and quality improvement activities; consequently, outcome measures are reflected in the PQI metrics and program/work group annual work plans. (See Catholic Charities Performance and Quality Improvement Plan.)

Roles in Risk Prevention and Management

Catholic Charities Board of Directors: Catholic Charities Board of Directors will provide resources and support for risk prevention and management functions designed to reduce and

control risk related to the organization's human, physical, and financial resources. A designated committee of the Board will review the findings of staff committees responsible for risk reviews and will prepare and present a report to the full Board at least annually. Administrative/Managerial Staff: Administrative staff and department/program managers 1) encourage and provide support for the active and appropriate involvement of staff at all levels in risk prevention and management activities; 2) establish and maintain operational linkages between risk prevention and management functions and PQI functions related to client service and safety; and 3) ensure that information relative to identified areas of risk is readily accessible for support of all risk prevention and management functions. Employees/Volunteers/Other Stakeholders: All personnel and other stakeholders are encouraged to actively participate, as appropriate, in risk prevention and management activities. These may include, but are not limited to: 1. identification of areas of potential risk, including the submission of incident/accident reports or other documentation related to potential risks; 2. participating in planning groups or task forces to design programs to reduce risk; 3. participating in the development of action plans to correct problems as required through the PQI process; 4. serving on agency committees with responsibility for review and monitoring of areas of risk. Departments/Programs/Work Groups: As part of ongoing planning and staff meetings, department or program/work groups should systematically evaluate service delivery, from both administrative and client-focused perspectives, to identify: barriers to quality services; barriers to utilization of services; new or potential areas of risk; and opportunities for improvement in processes to resolve identified problems and ultimately improve client services. While reported through the PQI system, programs/work groups should also review and develop appropriate responses to accidents, injuries, and other safety issues at the unit level. PQI Committees: PQI standing subcommittees (Administration, Client Services, and Safety) have specific responsibilities for review and oversight of areas of potential risk. These are defined in the section which follows. The subcommittees review identified risks quarterly as part of the regular meeting agendas and prepare quarterly reports with recommendations for the agency PQI Committee. The PQI Committee reviews the quarterly reports and acts on the recommendations. See the PQI Plan for further information on recommendations, action plans, and task forces. At least two members of the senior management team sit on the agency PQI Committee to ensure findings are communicated to the senior management.

Review and Oversight of Areas of Potential Risk

Responsibility for monitoring, evaluating, responding to and reducing the causes of potential risk, as well as review and reporting structures and time frames, are outlined in the table that follows.

For further information, see PQI Committee descriptions and responsibilities in Appendix A of the CCFW Performance and Quality Improvement Plan.

Area of Potential Risk

Committee review/oversight assigned to: Oversight shared between VP/Director of Quality Assurance, agency HIPAA Compliance Officer, and agency Custodian of Records PQI Committee

Committee review and reporting requirements Reported to Audit Committee and Board as part of annual report if/when issues arise

Frequency of reports

Additional Notes

Case Records: Access to Case Records

[COA: RPM 8]

As needed

See CR: Confidentiality and Privacy Protections policy and procedures. See related RPM policy included in RPM policy list at end of this document.

Case Records
[COA: RPM 7]

Results of case record review process included as component on consolidated agency report prepared by Quality Assurance staff. Standing item on committee agenda, to be addressed as issues arise

Quarterly to agency PQI Committee Annually to Board Audit Committee Annually to Board of Directors

See PQI Plan, Appendix D, Case Record Review Process. Performance standards for case record compliance are included as a Quality Assurance outcome measure on annual work plan.

Client rights and confidentiality issues

PQI Client Services Committee

[COA: RPM 2.01(f)]

Identified issues and responses included in reports as follows: Quarterly to agency PQI Committee Annually to Board Audit Committee Annually to Board of Directors Quarterly to agency PQI Committee Annually to

See CRConfidentiality and Privacy Protections and CR-Protection of Rights and Ethical Obligations policies and procedures. Concerns may be identified through the stakeholder problem resolutions process, PQI Quick Forms, or committee member input. See ASE-Facility Legal and Regulatory Compliance, FIN (particularly the Manual of Accounting

Compliance with legal requirements, including 1) fiscal accountability and governance, and 2) other applicable federal, state,

PQI Administration Committee

Standing item on committee agenda, to be addressed as issues arise,

and local laws and regulations

[COA: RPM 1, RPM 2.01(a)]

or reviewed at least once per year

Board Audit Committee Annually to Board of Directors

Policies and Procedures), and GOV policies and procedures on designated computer shared drive. See related RPM policy included in RPM policy list at end of this document. PQI Client Services Committee also reviews issues related to mandatory reporting as identified on incident/accident reports and issues related to program/service licensing. PQI Safety Committee reviews areas related to facility regulatory compliance.

Conflicts of interest

PQI Administration Committee

[COA: RPM 2.01(h)]

Standing item on committee agenda, to be addressed as issues arise, or reviewed at least once per year

Quarterly to agency PQI Committee Annually to Board Audit Committee Annually to Board of Directors Quarterly to agency PQI Committee Annually to Board Audit Committee Annually to Board of Directors

See ETH-Conflict of Interest policy on designated computer shared drive.

Contracting practices and compliance, including quality monitoring of purchased services

PQI Administration Committee

[COA: RPM 2.01(e), RPM 9, RPM 10]

Standing item on committee agenda, to be addressed as issues arise, or reviewed at least once per year

See FIN-Manual of Accounting Policies and Procedures and FIN-Procurement policy and procedure on designated computer shared drive. See related RPM policies and procedures included in RPM policy list at end of this document. PQI Client Services Committee also reviews monitoring reports with findings related to client

services. Financial risks, including those associated with fundraising PQI Administration Committee Standing item on committee agenda, to be addressed as issues arise, or reviewed at least once per year Quarterly to agency PQI Committee Annually to Board Audit Committee Annually to Board of Directors Financial risks may be identified through the regular financial reviews conducted by the Board Finance Committee, the Board Audit Committee, and/or the Leadership Team during scheduled meetings. Relevant information from these reviews will be shared with the PQI Administration Committee. See related policies:
GOV-Governance Responsibilities: Board Committees FIN-Financial Planning FIN-Financial Review FIN-Financial Reporting

[COA: RPM 2.01(g)]

Health and safety

[COA: RPM 2.01(c), RPM 2.02, RPM 2.03, RPM 3]

PQI Client Services Committee and PQI Safety Committee (see Notes box at right)

Standing item on assigned committee agendas. Incident/accident reports are reviewed by assigned committees quarterly for identification of trends and recommendations for corrective actions.

Quarterly to agency PQI Committee

PQI Client Services Committee reviews:

Annually to Board Audit Committee Annually to Board of Directors To regulatory bodies as outlined in contracts and standards issued by regulatory authorities

health and safety issues related to the service population and client services; incidents, accidents, grievances related to:

administering,
dispensing, or prescribing medications;

service
modalities or other organizational practices that involve risk or limit freedom of choice;

 use of
restrictive behavior management interventions, such as seclusion or restraint; and

situations
where a person was determined to be a danger to himself/herself or others.

serious
illnesses, injuries, and deaths. PQI Safety Committee reviews:

incident/accident reports related to facilities that involve employees, clients and volunteers; health and safety issues related to personnel, including use of facilities and equipment; compliance issues related to facilities, including externally mandated inspections and internal facilities reviews; incidents/accidents related to personnel and/or facility safety issues; grievances related to facility safety issues;

staff training regarding areas of risk related to safety and security; and disaster response plans for the agency

Also see ASE Administrative and Service Environment and BSM-Behavioral Support and Management Practices policies and procedures on designated computer shared drive. Human resources practices, including volunteer roles and oversight
[COA: RPM 2.01(d)]

PQI Administration Committee

Standing item on committee agenda, to be addressed as issues arise, or reviewed at least once per year

Quarterly to agency PQI Committee Annually to Board Audit Committee Annually to Board of Directors Quarterly to agency PQI Committee Annually to Board Audit Committee Annually to Board of Directors Quarterly to agency PQI Committee Annually to Board Audit Committee Annually to Board of Directors Quarterly to agency PQI

See HR policies and procedures on the designated computer shared drive.

Information Management and Use, including security of information

PQI Administration Committee

[COA: RPM 5, RPM 6]

Standing item on committee agenda, to be addressed as issues arise, or reviewed at least once per year

See related RPM policy and procedures included in RPM policy list at end of this document. PQI Client Services Committee also reviews security of information issues related to client services. See related RPM policy and procedures included in RPM policy list at end of this document.

Insurance and liability

PQI Administration Committee

[COA: RPM 2.01(b), RPM 4]

Standing item on committee agenda, to be addressed as issues arise, or reviewed at least once per year

Financial risks, including those associated with

PQI Administration

Standing item on committee agenda, to be

Financial risks may be identified through the regular financial

fundraising

Committee

[COA: RPM 2.01(g)]

addressed as issues arise, or reviewed at least once per year

Committee Annually to Board Audit Committee Annually to Board of Directors

reviews conducted by the Board Finance Committee, the Board Audit Committee, and/or the Leadership Team during scheduled meetings. Relevant information from these reviews will be shared with the PQI Administration Committee. See related policies:
GOV-Governance Responsibilities: Board Committees FIN-Financial Planning FIN-Financial Review FIN-Financial Reporting

Confidentiality, Records and Immunity

CONFIDENTIALITY Any and all documents and records that are part of the internal risk management program as well as the proceedings, reports, and records from any committee shall be confidential and not subject to subpoena or discovery or introduction into evidence for proceedings by the department responsible for disciplinary and/or review action of any professional. RECORDS AND IMMUNITY The facility shall maintain records concerning the operations of its risk management program. Records and files of a committee assigned responsibility for risk prevention and management activities are not discoverable or admissible. Immunity is provided for persons who act in good faith and without malice, while participating in the activities of a committee assigned responsibility for risk prevention and management activities. No individual or institution reporting or providing information, opinion, counsel, or services to a medical or incident review committee or any other medical staff, administrative, or governing body committee that evaluates quality of care issues as part of the internal risk management program shall be liable for suit for damages. This is based upon the understanding that such an individual or institution acted in good faith and with a reasonable belief that said actions were warranted in connection with or in furtherance of the internal risk management program.

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Associated RPM Policies and Procedures

In addition to the ASE (Administrative and Service Environment), BSM (Behavior Support and Management), CR (Client Rights) ETH (Ethical Practice), FIN (Financial Management), GOV (Governance), HR (Human Resources Management, and PQI (Performance and Quality Improvement) policies and procedures referenced in the table above, the following policies and procedures have been developed specifically in support of risk prevention and management activities. These documents are located in the policies and procedures folder on the designated computer shared drive.

RPM-Access to Client Case Records RPM-Agency Phone Numbers and Extensions RPM-Alliance Partnerships RPM-Case Records RPM-Client Database Management (with associated Appendices) RPM-Closed Files RPM-Computer Locking RPM-Computer Maintenance RPM-Contracts and Service Agreements RPM-Incident and Accident Reporting RPM-Information Management and Use RPM-Insurance Protection RPM-IT Asset Management RPM-Laptop Computer Policy RPM-Legal and Regulatory Compliance RPM-Medication Control and Administration RPM-Monitoring of Purchased Services RPM-Security of Information RPM-Security of Information-Employee Access to Record File Areas RPM-Use of Information Technology RPM-Wireless Internet Access

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