The purpose of this policy is to define responsibility for the maintenance of agency facilities.

Transcription

1 Community Healthlink Section: 11 Facilities and Equipment Policy Number: Effective Date: 7/1/01 Title: Authority for Management of Facilities Review Date: 7/1 Scope: Originated: References: Revisions: Purpose: The purpose of this policy is to define responsibility for the maintenance of agency facilities. Definitions: Policy: 1. The maintenance of agency facilities is the joint responsibility of the appropriate Program Director, Division Vice President and the Facilities Director. 2. The Facilities Director is responsible for all routine and scheduled maintenance of agency facilities, and shall have the authority necessary to establish and implement procedures to these ends, subject to approval by the Executive Management Team. Responsibility: Facilities Director, Division Vice Presidents, Program Directors Procedures: 1. The Program Director or Division VP is responsible to make the Facilities Director aware of any non-urgent maintenance needs that warrant attention (use FAS Request for Assistance Form). 2. The Facilities Director will respond to FAS Request for Assistance Form within ten (10) working days. 3. Any purchasing that must be done in relation to facilities must follow Purchasing Policy. Any capital improvements in agency property require approval of the CEO. Generally, the Chief Financial Officer will determine when a purchase is a capital improvement. 4. In case of emergency building maintenance needs: a. If the administrative offices are open, the Facilities Director, assigned delegate or supervisor must be contacted. b. If the administrative offices are not open, managers of facilities should call the Facilities Director s pager number. 5. The Facilities Director shall be responsible for preparing reports, no less than annually, which provide assessment of the safety and maintenance of agency facilities and equipment. Copies of the report shall go to the Chief Executive Officer and the Director of Operations. Page 1 of 1 C:\Documents and Settings\Jshea\My Documents\transferpolicy\11 Facilities and Equipment\11-01.doc Last Updated:

2 Community Healthlink Section: 11 Facilities and Policy Number: 11-2 Effective Date: 7/1/01 Equipment Title: Fire Safety Policy Review Date: 7/1 Scope: Originated: 10/5/89 References: Revisions: 6/11/07 Purpose: To assign responsibility and define procedures for fire safety at all sites of the agency. Definitions: Policy: 1. The Facilities Director shall be responsible for implementing all laws, regulations, and procedures with regard to fire safety and for maintaining appropriate records and documentation. 2. The Program Director shall be responsible for implementing evacuation procedures in case of fire drill or real fire situation, and for assigning such responsibilities as may be specific to the program site and/or client population. 3. There shall be escape plans prominently displayed at each site. 4. There shall be a currently valid fire inspection certificate at each site. 5. Programs with handicapped clients on site who may not be assigned to specific clinicians (e.g., Emergency, Day Treatment, BUDD, Westwind, and Residences) shall have specific procedures conspicuously posted. Procedures: A. In case of fire, the Program Director or designate shall call the fire department and/or pull the alarm. B. When fire alarm sounds everyone shall evacuate the building in an orderly fashion as per escape plan posted at each site, and shall meet at designated safe meeting place outside the building. C. Program Director or designate shall take daily staff/client register to verify that all are present and accounted for at safe place. D. Staff who are working with non-ambulatory clients are responsible for providing necessary assistance to evacuate them safely and escort to safe place. Secretaries will ensure that all clients exit waiting areas. 1. Non-ambulatory Detox clients will remain on the unit, with staff until either the Fire Department or staff determine that evacuation is necessary. E. Re-enter building only after all clear signal. F. Programs will conduct, at a minimum, twice yearly fire drills, unless contractual obligations require more frequent drills. Logs will be kept of all drills. G. Residential program managers will keep a log of all fire drills. H. For Clinic settings the Director of Facility Management will maintain a log of all fire drills. Responsibility: All staff Page 1 of 1 C:\Documents and Settings\Jshea\My Documents\transferpolicy\11 Facilities and Equipment\ doc Last Updated: 6/11/07

3 Community Healthlink Section: 11 Facilities and Policy Number: Effective Date: 7/1/01 Equipment Title: Housekeeping Review Date: 7/1 Scope: All CHL programs Originated: 10/9/89 References: Revisions: 1/14/04 Purpose: To establish a policy on housekeeping for CHL. Definitions: Policy: 1. Each unit shall have housekeeping procedures which specify a schedule of regular cleaning of the premises. 2. Where toys are used, the schedule shall specify procedures for appropriately disinfecting and cleaning the toys. These procedures shall comply with state laws and regulations. Procedures: 1. Housekeeping procedures may take the form of a contract or memo of agreement with a housekeeping service or individual, specifying nature and frequency of regular cleaning. 2. Site program manager or director is responsible to ensure that cleaning occurs per the agreement and report any issues to the Purchasing/AP Manager. Responsibility: All programs Page 1 of 1 C:\Documents and Settings\Jshea\My Documents\transferpolicy\11 Facilities and Equipment\ doc Last Updated:

4 Community Healthlink Section: 11 Facilities and Equipment Policy Number: 11-4 Effective Date: 7/1/01 Title: Refrigerator and Freezer Temperatures Review Date: 7/1 Scope: All staff who have access to a refrigerator or freezer Originated: 2/1/99 Revisions: Purpose: The purpose of this policy is to establish guidelines to insure safe storage of food, medications, and other items that may need to be kept in a refrigerator or freezer. Responsibility: All programs that utilize a refrigerator and/or freezer are responsible for following this policy. Compliance with this policy will be monitored as part of the Environmental Audits. Description of Policy: 1. Staff are required to monitor and document the temperatures of all program refrigerators and freezers, regardless of whether for staff and/or client use. 2. The acceptable range for a refrigerator is 35 to 40 degrees Fahrenheit. 3. The acceptable range for a freezer is minus 10 to 0 degrees Fahrenheit. 4. Documentation of temperatures is to be maintained on a daily basis and recorded on the Temperature Log. A copy is attached. 5. The Temperature Log must be posted on each refrigerator and freezer. 6. At the end of each month, logs should be kept in a file at the program site. 7. During Environmental Audits, reviewers will need to check the past Temperature Logs, so they must be kept accessible. 8. In the event that the temperature is outside of the acceptable range, the staff should immediately adjust the refrigerator or freezer temperature. The temperature should be rechecked within two hours to determine if the adjustment brought the temperature into the acceptable range. 9. In the event that adjustment does not bring the temperature into the acceptable range, the oncall supervisor must be notified and will report this to the Facilities Director. Staff should complete an incident report. Page 1 of 1 C:\Documents and Settings\Jshea\My Documents\transferpolicy\11 Facilities and Equipment\11-04.doc Last Updated:

5 Community Healthlink Section: 11 Facilities and Policy Number: Effective Date: 5/1/05 Equipment Title: Toy Cleaning Policy Review Date: 7/1 Scope: All staff in clinics where children s toys are utilized Originated: 5/1/05 Revisions: 5/25/05 Purpose: This policy is designed to provide consistency in cleaning and disinfecting of toys to help safeguard patients, children, and staff from transmission of infection. This policy applies to the all clinic sites that utilize children s toys. Responsibility: Program supervisor, clinician Description of Policy: 1. All toys should be stored in a dry and clean space. If toys are stored in bins, the bins themselves must also be cleaned at the same frequency as described below. 2. Waiting room toys should be cleaned once a week. Plush and porous toys should be avoided in the waiting room area. The Administrative Assistant or manager or her/his designee shall be responsible for cleaning the toys and toy bins. The site manager is responsible for monitoring compliance. 3. Toys in staff offices should be cleaned as needed, but a minimum of 2 times per year. Clinicians are responsible for cleaning the toys in their office and the site manager is responsible for monitoring. 4. After cleaning and disinfecting, toys should be stored in a clean, dry area. 5. Toys that are contaminated with blood or bodily fluids must be removed from the area and cleaned immediately; universal precautions should be used. Procedure: 1. Non-porous toys should be cleaned using disposable disinfecting wipes or soap and water. 2. Porous toys (staff offices) should be washed when possible, or cleaned using disposable disinfecting wipes or soap and water. 3. If contaminated toys can not be cleaned and/or disinfected, then they must be discarded. Page 1 of 1 C:\Documents and Settings\Jshea\My Documents\transferpolicy\11 Facilities and Equipment\ doc Last Updated:

6 Community Healthlink Section: 11 Facilities and Equipment Policy Number: Effective Date: 5/1/05 Title: Storage and Disposal of Hazardous Waste in compliance with 105 CMR Review Date: 7/1 Scope: All clinic sites generating and transporting biological, infectious or dangerous Originated: 5/1/05 medical waste. Revisions: 5/25/05 Purpose: This policy is to set forth the requirements for the storage and disposal of infectious or physically dangerous medical or biological waste, as defined in chapter VIII of the state sanitary code. Definition: Hazardous Waste: Waste which because of its characteristics may cause, or significantly contribute to an increase in mortality or an increase in serious irreversible or incapacitating reversible illness; or pose a substantial present potential hazard to human health or the environment when improperly treated, stored, transported, disposed of, or otherwise managed. The following types of waste are identified and defined as infectious or physically dangerous medical or biological waste, and shall be subject to the requirements of 105 CMR SHARPS: Discarded medical articles that may cause puncture or cuts, including but not limited to all used and discarded hypodermic needles and syringes, pasteur pipettes, broken medical glassware, scalpel blades, disposable razors, and suture needles. BLOOD AND BLOOD PRODUCTS: Discarded bulk human blood and blood products in free draining, liquid state; body fluids contaminated with visible blood; and materials saturated/dripping with blood. PATHOLOGICAL WASTE: Human anatomical parts, organs, tissues and body fluids removed and discarded during surgery or autopsy, or other medical procedures and specimens of body fluids and their containers. CULTURES AND STOCKS OF INFECTIOUS AGENTS AND ASSOCIATED BIOLOGICALS: All Discarded cultures and stocks of infectious agents and pathological laboratories, cultures and stocks of infectious agents from research laboratories, wastes from the production of biologicals, and discarded live and attenuated vaccines intended for human use. CONTAMINATED ANIMAL CARCASSES, BODY PARTS AND BEDDING: The contaminated carcasses and body parts and bedding of all research animals known to be exposed to pathogens. Policy: Storage: Waste generators shall contain and store medical waste at all times in leak-proof, rodent proof, fly-tight containers which ensure that no discharge or release of such waste occurs. 2. All onsite storage of containers of waste shall be held in an area away from general traffic flow, restricting access or contact to authorized persons only. 3. Sharps shall be segregated from other wastes and aggregated in leak-proof, rigid, punctureresistant containers immediately after use. Community Healthlink utilizes standard red sharps containers. Labeling: Every container or bag of waste shall be distinctively marked with the international biohazard symbol and colored red to indicate that it contains waste. 5. Sharp wastes will be distinctively labeled to indicate that it contains sharp waste capable of inflicting punctures or cuts.

7 6. Every container or bag of waste shall bear a label which states the name, address and telephone number of the generator. The label shall be affixed in a manner which ensures that is cannot be easily removed. Disposal: Once material has been identified as infectious or physically dangerous medical or biological waste, as defined in 105 CMR , such material shall remain waste until it has been disposed of in compliance with CMR Every container or bag shall be transported to a pre-determined site, to be transported off-site by a waste treatment facility that has been approved by the Department of Environmental Protection. 9. The waste generator shall maintain records of volume and type of waste transported to approved disposal facility. Such records shall be retained for at least three years. Procedure: The waste generator shall prepare a manifest before shipping waste. The manifest is a tracking document designed to record the movement of waste from the generator through its trip with a transporter to an approved disposal facility and final disposal. The site director in coordination with Facilities Management staff are responsible for the generation of the initial manifest. 2. The manifest must include the following information: Description of waste to be shipped; total quantity of waste; and type of container in which waste is transported. Only approved, numbered CHL manifest forms should be used. Forms are available from Central Purchasing. 3. A generator shall designate on the manifest the address of the site to which the waste is to be delivered, sign it and keep white copy. 4. The transporter of the waste or an agent of the transporter shall sign the manifest to indicate that the transporter has received the waste and will comply with the generators transportation instructions, keep yellow copy and forward pink copy to the Operations Assistant, 72 Jaques Avenue, 3 rd Floor, Worcester. Only Facility Maintenance staff are permitted to transport waste. 5. The disposal facility shall pick up waste on a monthly basis from a pre-determined site, located at 12 Queen Street, 2 nd floor, Worcester, and transport waste to the approved off-site disposal facility. The Facilities Director is responsible for overseeing the pick up from this central site. 6. The disposal facility shall provide an initial generator copy at time of pick up, which shall be signed by personnel at pick up site, and forwarded to the Operations Assistant. 7. When the waste arrives at the approved off-site disposal facility, and has been disposed of, the disposal facility shall sign the final generator copy, and send to the Operations Assistant by mail, within 30 days as required. If no record is received, the Operations Assistant should contact the disposal facility to follow-up. 8. The Operations Assistant shall forward a copy of the final generator copy to the site manager at the generator s site. The Site Manager shall attach the final generator copy to the corresponding manifest, and maintain the records for at least three years.

8 9. The Operations Assistant shall maintain all copies of internal manifests with corresponding initial generator copies and final generator copies, for at least three years. Responsibility: Site Manager/Facilities Manager/Operations Assistant

9 Section: 11 Facilities and Equipment Title: Electronic Surveillance Scope: References: Revisions: Community Healthlink Policy Number: Effective Date: Review Date: Originated: Purpose: To establish a policy concerning electronic surveillance that promotes the safety and security of CHL s clients, staff, visitors, and property, deterrence and the prevention of criminal activities and the enforcement of CHL policies, procedures and client rights. Definitions: Electronic Surveillance is a term that refers to video-audio-digital components of multi-media surveillance. Policy: 1. VIDEO MONITORING ON CHL PROPERTY 1) Camera Location, Operation and Control: 2) Notification i. CHL buildings and grounds may be equipped with video monitoring devices. ii. Video surveillance may be placed in areas where surveillance has proven to be necessary as a result of threats, prior property damages, or security incidents. iii. Cameras placed outside shall be positioned only where it is necessary to protect external assets or to provide for the personal safety of individuals on CHL grounds or premises. iv. Cameras shall not be used to monitor inside residential rooms and washrooms. v. The Vice President of Operations shall be the one responsible to manage and audit the use and security of monitoring cameras; monitors; tapes; computers used to store images; computer diskettes and all other video records. vi. Only individuals authorized by the VP of Operations in accordance with policy, shall have access to video monitors, or be permitted to operate the controls. i. Signs advising users of the premises of video surveillance practices should notify individuals of the area in which surveillance is conducted; the specific purpose for the surveillance; hours during which surveillance is conducted; who within the organization is responsible for conducting surveillance, and the contact person who can answer questions about the surveillance system, including a telephone number for contact purposes. ii. All staff shall be made aware of CHL s video surveillance guidelines and practices. iii. Programs managers are responsible for informing all clients and visitors that CHL may be monitoring all activity that occurs at designated monitoring and to explain the purpose for such monitoring practice. Page 1 of 3 C:\Documents and Settings\Jshea\My Documents\transferpolicy\11 Facilities and Equipment\11-07.doc Last Updated:

10 3) Use of Video Recordings i. A video recording of actions by clients and staff may be used by the administrators as evidence in any disciplinary action brought against clients or staff arising out of the their conduct in or about CHL property. ii. Video recordings of clients, staff, or others may be reviewed or audited for the purpose of determining adherence to CHL policies. iii. CHL may use video surveillance to detect or deter criminal offenses that occur in view of the camera. iv. Video recordings may be released to third parties or applicants in conformance with the provisions contained in the Freedom of Information and Protection of Privacy Act and any rules or regulations thereunder. v. CHL and its administrators may use video surveillance and the resulting recordings for inquiries and proceedings related to law enforcement, deterrence, and staff discipline. vi. CHL shall not use video monitoring for other purposes unless expressly authorized by or under an Act or enactment. 4) Protection of Information and Disclosure/Security and Retention of Tapes i. All video records not in use should be securely stored in a locked receptacle. ii. All video records that have been used for the purpose of this policy shall be numbered and dated and retained according to the camera site. iii. The Vice President of Operations or the CEO must authorize access to all video records. iv. A log shall be maintained of all episodes of access to, or use of recorded materials. v. Video records shall be retained for one month and then erased completely. Video records that contain personal information used to make a decision directly affecting an individual, however, may be retained for a minimum of one year. vi. The VP of Operations shall ensure that a tape release form is completed before disclosing tapes to appropriate authorities or third parties. Any such disclosure shall only be made in accordance with applicable legislation. Such release forms should include the individual or organization who is requesting the tape, the date of the occurrence and when or if the tape will be returned or destroyed by the authority or individual after use. 5) Disposal or Destruction of Recordings i. All recordings shall be disposed of in a secure manner. Tapes shall either be shredded, burned, or degaussed. 6) Video Monitors and Viewing Page 2 of 3 C:\Documents and Settings\Jshea\My Documents\transferpolicy\11 Facilities and Equipment\11-07.doc Last Updated:

11 7) Disclosure i. Only the VP of Operations or individuals authorized by the VP of Operations and members of Security shall have access to video monitors while they are in operation. ii. Video monitors should be in controlled access areas wherever possible. iii. Video records should be viewed on a need to know basis only, in such a manner as to avoid public viewing. i. Recordings shall not be disclosed except in accordance with this policy. Disclosure of video records shall be on a need to know basis, in order to comply with the CHL s policy objectives, including the promotion of the safety and security of clients and staff, the protection of CHL property, deterrence, and the prevention of criminal activities and the enforcement of CHL policies. 8) Access to Personal Information i. An individual who is the subject of video monitoring has the right to request access to the recording in accordance with the provisions contained under the Freedom of Information and Protection of Privacy Act. Access in full or part may be refused on one of the grounds set out within the legislation. Page 3 of 3 C:\Documents and Settings\Jshea\My Documents\transferpolicy\11 Facilities and Equipment\11-07.doc Last Updated:

12 Community Healthlink Section: 11 Facilities and Policy Number: Effective Date: 1/19/06 Equipment Title: Transportation Safety Review Date: 7/1 Scope: To ensure that vehicles are safe, insured and operated by Originated: 1/19/06 qualified and trained individuals. References: Revision: Purpose: To ensure all employees who operate personal and corporate vehicles on company business do so with maximum regard for personal safety and the safety of others. Policy: The policy of CHL is to ensure that all employees who operate corporate motor vehicles in the conduct of company business are trained and licensed to do so, and that corporate-owned, and corporate-leased vehicles are operated in a safe and responsible manner. It is also the policy of CHL to properly insure, maintain and replace, as needed, vehicles that are owned or leased by CHL.. Responsibility: Drivers of Corporate Vehicles must: 1. Be in possession, at all times, of a valid driver s license in good standing. 2. Read and comply with the regulations and procedures as outlined in this policy. 3. Immediately report all accidents to the department manager or designee. 4. Per Massachusetts state law, wear a seat belt while operating personal or CHL owned or leased vehicle during work hours. 5. Refrain from alcohol and/or the use of drugs (including prescribed and/or over-the-counter medication) that impairs the operation of a motor vehicle during work hours. (See Policy # 4-12, Drug and Alcohol Use). 6. Report items that need to be replenished in the accident/safety materials assigned to their vehicle. 7. Drive within or at the speed limit, observe all traffic regulations, or otherwise follow pertinent Massachusetts or other applicable laws, and practice safe and courteous driving habits while operating personal or corporate vehicles. Procedures: Selection and Screening of New Drivers 1. The prospective driver of corporate vehicles must be over 18 years of age. 2. The prospective driver of corporate vehicles must possess a valid driver s license in good standing from his/her state of residence. 3. The prospective driver of corporate vehicles will bring to the interview a copy of their driver s license from the Registry of Motor Vehicles of their state of residence. 4. The prospective drivers operating 7D vehicles (currently 2 CHL Flex Support vans) must meet the following criteria:

13 (a) at least 21 years of age (b) have had a driver s license for the three years immediately prior to the application (c) be able to pass a CORI check, be of good moral character, pass an eye exam, a physical exam, a written knowledge exam. (d) Must present a valid 7D license whenever operating these vehicles. Orientation and Ongoing Training of CHL Corporate Drivers 1. For all corporate drivers, a department-specific, safe driving course will be included as annual safety training. Motor Vehicle Accident Response The driver must stop at a scene of an accident in which he/she was involved. Failure to stop at the scene of an accident is considered a felony. If the accident has occurred while in traffic, the driver must call 911 immediately. If the accident was severe enough to cause injury to driver(s) and/or passengers and/or pedestrians this information and information regarding site of accident must be relayed to the police. As soon as possible, the driver must notify department manager after 911 is contacted. If the accident is minor and there are no injuries, the police may opt not to go to the scene of the accident. The CHL driver will exchange driver/vehicle/insurance/property owner information using the Massachusetts Motor Vehicle Crash Operator Report. Copies have been provided to each program site, are available from the Fleet Manager upon request, or can be downloaded at This report must be completed in a timely manner and forwarded to the Fleet Manager to be submitted to the Risk Management Department at CHL and corresponding insurance company in order for the insurance claim to be processed. Corporate Vehicle Use and Maintenance 1. Fleet Manager The Fleet manager will implement and maintain a vehicle Preventative Maintenance Program. The Fleet manager will maintain all records reflecting all maintenance and repair work on all corporate vehicles. 2. Corporate Drivers Corporate drivers will enforce the No Smoking policy in CHL corporate vehicles at all times (policy #1-04-3, Smoking Policy).

14 For Lipton Academy Corporate drivers will wear a seat belt, per Massachusetts state law, and require the same of passengers while in corporate vehicles. The driver will not operate the vehicle until all are in compliance. Per departmental specific policy and procedure, corporate drivers will complete all documentation regarding condition of vehicle, mileage, gas expense, etc. and submit to the manager. Corporate drivers will be accountable for the safe condition of the vehicle they operate per departmental specific policy. 1. Transportation to and from the Lipton Academy will be contracted and provided by the sending public school. The rules and modes of transportation of each particular town or city will apply to their contracted students. 2. The Lipton Academy will provide transportation for its students to recreational activities in the summer months and for field trips. This will occur only during program hours with transportation provided by the corporate vehicle. 3. Any staff person responsible for transporting will receive in-service training on overall transportation safety and the individual needs of the students they transport. The students will be transported in a safe manner that is responsive to the individual student s needs and provisions of their IEP s. 4. In the event of a motor vehicle accident, the parents, sending school districts, involved human service agencies and the DEEC will be notified immediately, in addition to the steps outlined above under Motor Vehicle Accident Response.

15 Detoxification Unit Safekeeping Procedures Cash or check receipts (other than client personal funds or property) Upon receipt of cash or checks for services and/or nicotine patch funds, a three-part receipt is to be prepared, with one copy remaining in the receipt book and the original copy provided to the person that made the payment. If that person is different than the client, the clients name should be placed at the bottom of the receipt. If it is between the hours of 8:30 5:00, (M-F), the money should be brought over to administration immediately. If staff are not available to walk the money over, a call should be made to x124 to arrange for pickup. If the cash or check is being placed in the safe, the third copy should be placed in the same envelope as the cash or check. The third copy is to accompany the cash or check when it is brought over to Administration for deposit. Cash or check receipts are to be logged onto the cash receipt log immediately upon receipt and logged separately onto a safekeeping log that is used to record items going into and out of the safe. Each log entry needs to contain at a minimum; the name of the client, the date, the time, the amount of cash or check received, and the signature of the security guard that opens the safe and the signature of detox staff person that witnesses the deposit from the safe. All cash or checks received whether placed into the safe or not are to be brought over to Administration for deposit at least daily. After hours and on weekends, the receipts are to be deposited in the safe and included in the deposit of the next business day. Return of deposits including nicotine patch funds Upon request of the person making the deposit or upon the discharge of the client, Detox staff are to prepare a check request, approved by Detox management, requesting that the balance of funds that are to be returned to the person who paid the deposit. Each request must include the amount of the original deposit, the calculation for the amount of the deposit to apply and the balance that is to be returned to the client. In no event is actual cash to be returned to a client or the person making the original deposit. All refunds are to be made by check. Client personal belongings that are held in the safe Upon receipt of client personal belongings that are to be kept in the safe, a three-part receipt is to be prepared, with one copy remaining in the receipt book and the original copy provided to the client. The third copy should be placed in the same envelope as the personal property. As the personal property received it is to be immediately logged onto a safekeeping log that is used to record items going into and out of the safe. Each log entry needs to

16 contain at a minimum; the name of the client, the date, the time, the receipt number and the signature of the security guard that opens the safe and the signature of detox staff person that witnesses the deposit from the safe.

17 Community Healthlink Section: 11 Facilities and Equipment Policy Number: Effective Date: 6/7/07 Title: Adolescent clients Security in Thayer Review Date: 7/1 Scope: To ensure that adolescents remain safe while in the Thayer Originated: 6/7/07 building. References: Revision: Purpose: To inform staff of proper response to the presence of an adolescent in the Thayer/Jaques Avenue complex unaccompanied by a responsible adult or staff person. Responsibility: All Staff Policy: Any staff member who sees a client who appears to be under age 18 and is unaccompanied by CHL staff, will: 1. Approach the individual and inquire as to their purpose for being at CHL. All MYR clients will be required to wear an identification bracelet. This does not preclude the client from removing the bracelet, so staff should approach any person that appears under age. 2. Notify Security at or and Security will notify MYR staff. 3. Remain with the adolescent until Security or a CHL MYR staff person is physically with the adolescent and assumes responsibility for the adolescent s safety. In the event that the person is not a MYR client, the clinical director at OPD will be contacted. In the event he/she is not available, the Vice President of Outpatient & Rehabilitation Service or the Vice President of Operations will be notified. The VP will ascertain what legitimate reason, if any, the person has for being in the building and help them to find the right location. If the adolescent is a MYR client, an incident report will be immediately filed by MYR staff with the Compliance Department and the matter will be investigated. In addition, the MRY staff should contact the MYR Director about the incident. If the adolescent leaves the building prior to staff being able to confirm that they are or are not a MRY client, staff will immediately contact MYR staff and Security. When ever possible, staff will follow the adolescent, keeping them in sight, until such time as they are relieved by security or MYR staff.

18 Community Healthlink Section: 11 Facilities and Policy Number: Effective Date: 6/7/07 Equipment Title: Door Security in Thayer Review Date: 7/1 Scope: To ensure that all of the doors in Thayer are properly locked. Originated: 6/7/07 References: Revision: Purpose: The purpose of this policy is to ensure that the stairwell doors in the Thayer building remain locked at all times, and this is verified on a regular basis. Responsibility: Metro Security Policy: Stairwell doors on the 2 nd, 3 rd, 4 th and 5 th floor will remain locked at all times. This includes the doors on the West, East and Central stairwells of each floor. CHL Security (Metro) will regularly check the doors on all floors at a minimum of once per shift to ensure they remain locked. Security will utilize the room tour monitoring system to verify the checks. Staff with keys to the floors should be careful not to admit clients that are not escorted by staff onto any floor. All clients must check in with the receptionist on the first floor. In the event of a fire alarm, the doors will automatically unlock. Security will ensure all doors are re-locked as soon as the "all-clear" has been given by staff or the fire department. Any unlocked door will immediately be reported to the Director of the program(s) on the floor involved, the Director of Maintenance and the Vice President of Operations. In addition, the MYR director will be notified and will immediately conduct a client headcount. The Vice President of Operations or his designee will be responsible for auditing the door checking system on an as needed basis; at a minimum one time per month.

19 Community Healthlink Section: 11 Facilities and Equipment Policy Number: Effective Date: 6/1407 Title: Separation of MYR clients from other program clients Review Date: 7/1 Scope: Originated: 6/14/07 References: Revision: Purpose: The purpose of this policy is to ensure that MYR clients not come into contact with clients from other programs. Responsibility: All Staff Policy: The following procedures will be followed for all MYR clients to ensure that they remain separated from other CHL clients. All MYR clients will be accompanied by MYR staff at all times. Appropriate staffing levels will be maintained. MYR and all other CHL staff will be made aware, through orientation and periodic reminders, to vigilantly monitor for MYR and non-myr client interactions. MYR and non MYR staff will adhere to the numerous policies to ensure MYR client safety including, but not limited to: Adolescent clients Security in Thayer Door Security in Thayer 24-C13 Leaving the Unit 24-C23 Visitors 24-E01 Emergency Evacuation 24-E02 Client Evacuation 24-S02 Safety 24-S09 Flight Risk 24-S10 Use of Communication Devices 24-S11 Use of Unit Van 24-S14 Bed Checks 24-S15 Incoming Calls to the Unit 24-S22 Medical Bracelets 24-S35 Welcoming Clients 24-S36 Discharging to Authorized Adult 24-S37 Elevator Access

20 Regulated Medical Waste Manifest # Date: Name Address Generator Transporter Community Healthlink, Inc. 12 Queen Street Worcester, MA Disposal Facility Stericycle, Inc 369 Park East Dr Woonsocket, RI Description of Waste Type Container Quantity Sharps Container Red Bio-Hazard Bag Other: Signature of Generator Transporter Signature Storage area pre-disposal Printed Name Printed Name Printed Name Date Date Date The above signatures certify that the above names materials are properly classified, described, packaged, marked and labeled and are in proper condition for transportation according to the applicable regulations of the department of Transportation and the U.S. Environmental Protection Agency. Transferred to Stercycle Manifest # :