Risk Management Plan

Performance Improvement Indicator EFFICIENCY: Risk Management 2017

Since risk management at Whitemarsh House is a generalized procedure with overall facility goals, it is not necessary to incorporate separate plans for the Residential cluster and the Home and Community cluster. These standards and procedures apply equally to all residents, staff and visitors to the facility and to the overall sound fiscal planning necessary to support operations.

Risk Management activities at Whitemarsh House are documented in the risk management policy and procedure and the quarterly quality assurance meeting agendas as recorded by the Executive Director who chairs these meetings. These documents are provided under separate cover. Risk management activities may also be ascertained through interviews with the Executive Director, Controller, Clinical Director, Personal Care Home Administrator and Associate Program Director.

This report serves as a supplement to those activities in the sense that it is a general overview of the efficiency of the risk management process.

Goals Achieved from Prior Plan (2015 and 2016) and from Relevant CARF Recommendations
All Goals Achieved

  1. Risk Management Plans to be assessed at least annually by facility Administration: Achieved Spring 2017
  2. Assess Home and Community Cluster for any unique variables related to risk management. None found that are unique to this cluster as opposed to general population. Achieved Spring 2017
  3. Assure that Executive Director convened and documented the Quarterly Quality Assurance Review and that this was attended by facility management personnel. Also assure documentation of the agenda regarding these meetings. Achieved Spring 2017 and Ongoing
  4. Management should assess implementation of risk management measures described in first paragraph above. Achieved Spring 2017
  5. Input on risk management to be solicited from families and other stakeholders as well as various team meetings and administrative contacts. Achieved Through revised Satisfaction Surveys (See Satisfaction Performance Improvement Report)
    as in the prior reports, this group offered new proposals for risk management.
  6. Obtain input on risk management activities from residents. Achieved Through Revised Satisfaction Surveys, Day Program Discussions, Individual Counseling Sessions, and Residence Meetings etc. Spring 2017 and Ongoing as noted in report on resident satisfaction, residents were mainly concerned with every day issues such as recreation, food service, roommate relationships etc. and not with risk management issues. As also noted, Home and Community Cluster risk issues did not differ from overall population attitudes.
  7. Educate staff and obtain input from staff on risk management. Achieved Throughout 2016 and 2017 via the following staff training activities: Health and Safety, Identification of Unsafe Environmental Factors, Emergency Procedures, Evacuation Procedures, Fire Safety, Identification/Reporting of Critical Incidents, Medication Management, Decreasing of Physical Risks, Infection Control, Communicable Diseases, Universal Precautions, Promoting Wellness, Recognition and Reporting of Suspected Abuse or Neglect, Risks Associated with Brain injury, Emergency Medical Plan, DPW Training Course, AIDS/IADL’s, Nutrition, food handling, Sanitation and Falls and Accident Prevention.

    Please note: In most recent staff meeting related to risk management, staff input was that reporting of, and response to, client critical incidents had become somewhat “top-heavy” and the system was in danger of losing important information from staff that was on the line every day with residents. Systems were put in place to assure this feedback loop. If surveyors wish to obtain further specifics on this feedback system, please do so during interviews with Associate Program Director, Clinical Director and Personal Care Home Administrator.


Performance Improvement Targets 2018

  1. Only after consideration of input from residents, families, stakeholders and staff, update current risk management procedures Target Date: April 11, 2018.
  2. Share the new risk management plan with residents, families, stakeholders and staff. This will be accomplished via the web site and through the other means described above. Target Date: April 15, 2018.
  3. Be prepared for further revision of this “final” set of procedure in the event that this publishing of the procedure provokes further suggestions for revision. Target Date: April 22, 2018.
  4. Continue with all risk management activities as described in #1-7 above. Target Date: Ongoing and Through Spring of 2018.
  5. Continue to implement revised feedback loop from line staff on critical resident incidents Target Date: Ongoing and Through Spring of 2018.