PREVENTION

Actions taken to minimize and/or eliminate social, psychological, or other conditions. Prevention can occur at the individual, group, community, and societal levels and enhances opportunities to achieve positive fulfillment.		  
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  MANAGEMENT

See ADMINISTRATION		  
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  PRACTICE

Established actions or ways of proceeding in the regular performance of organizational duties. Policies and procedures often guide practice.		  
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  LIABILITY

An obligation, responsibility, or debt. 		 
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  MONITORING

An evaluation involving a periodic review of consumer services, organizational activities, or conduct. Specifically, monitoring is an activity of case coordination, whereas more broadly, monitoring is an evaluation technique used in overall quality assurance. 		 
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  RISK MANAGEMENT

A systematic process of evaluating and reducing potential risks that may befall personnel, clients, an organization, or a facility. Risk management activities are directed toward reducing an organization's legal and financial exposure, especially to lawsuits.		  
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  PROCEDURES

Written instructions that outline the steps for performing a task(s) or operationalizing an administrative or service delivery process. A procedure can be written as a step-by-step set of instructions or as a narrative description of a process. A procedure tells someone how to do something not just what to do.

Unlike policies, procedures do not need to be approved or reviewed by the governing body, and need not be associated with a specific policy. For example, whereas a broad anti-discrimination policy requires grievance or other procedures in order to be operationalized within an organization, assessment procedures do not require a governing body approved assessment policy.

Note: Procedures are sometimes referred to as administrative policies.

  
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  PERSONNEL

The body of employees and/or volunteers that carries out the organization's tasks under the organization's administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards		  
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  CONFLICT OF INTEREST

A conflict between an individual self-interest and the public good. Example: an organization that operates a day treatment program awards a food services contract to a local restaurant that is owned by a governing body member. From a legal standpoint, "conflict of interest" is a term used in connection with fiduciaries and their relationship to matters of private interest or gain to them. When used to suggest disqualification of a fiduciary from performing his or her sworn duty, the term refers to a clash between public interest and private pecuniary interest of the concerned individual.		  
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Risk Prevention and Management
  
Private Org Public Agency  

RPM 2: Risk Prevention*

 

The organization identifies and reduces potential loss and liability by:

  1. conducting prevention and risk reduction activities; and
  2. monitoring and evaluating risk prevention and management effectiveness.
Interpretation: Organizations can further support their risk management activities by developing a risk management plan that is proactive and anticipates potential risks, includes strategies for managing risks, assigns responsibility for key tasks, and includes measurable goals for reducing potential risks.

RPM 2.01

 

The organization annually assesses areas of potential risk, including:

  1. compliance with legal requirements;
  2. insurance and liability;
  3. health and safety;
  4. human resources practices;
  5. contracting practices and compliance;
  6. client rights and confidentiality issues;
  7. financial risks; and
  8. conflicts of interest.
Update: Revised Standard, Deleted First Interpretation, Revised Second Interpretation, Added Note - 12/01/10

RPM 2.01 Original Standard, First and Second Interpretation:

Management, with the involvement of the governing body, conducts an internal assessment of overall risk at least annually, that includes:

  1. compliance with legal requirements, including licensing and mandatory reporting laws, fiscal accountability, and governance;
  2. insurance and liability;
  3. health and safety, including use of facilities:
  4. contracting practices and compliance;
  5. staff training regarding areas of risk;
  6. volunteer roles and oversight;
  7. research involving program participants and other clients’ rights issues;
  8. security of information, including client confidentiality;
  9. financial risk;
  10. fundraising;
  11. conflict of interest;
  12. employment practices; and
  13. interagency collaborations

Interpretation: Element (d) of the standard refers to all contracts to which the organization is a party.

Interpretation: It is acceptable for the areas of known risk outlined in the elements of RPM 2.01 to be assessed separately and at different times throughout the year, e.g., at regular management meetings, as long as management and the governing body review the results of those assessments as a whole at least once a year to evaluate overall risk.

When reviewing areas of risk, elements of RPM 2.01 may be reviewed together to ensure that a genuine understanding of potential risk is achieved. For example, a review of contracting risks may include elements (a), (b), (d), (k), and (m). In another example, elements (a), (b), (e), (f), and (l) relate to human resource management, which is known to be the greatest area of potential risk for organizations.

For more information about governing body responsibilities regarding risk see GOV 6.08.

related AD 3,  ASE 1.01,  ASE 2.01,  ASE 3,  ASE 5.01,  ASE 6,  ASE 7.04,  ASE 8.01,  BSM 1.01,  CRI 2,  ETH 2,  ETH 3,  ETH 6,  FIN 3,  FIN 7.08,  FIN 8,  GOV 6.06,  HR 1.02,  HR 3.05,  HR 5.01,  HR 5.05,  HR 6.01,  RPM 1,  RPM 4,  RPM 5,  RPM 6,  RPM 7.05,  RPM 9,  TS 2.02,  TS 2.03,  TS 2.09

Interpretation: Although the organization should assess all areas of potential risk annually, the assessments do not need to be conducted altogether, in one sitting.

Note: The results of these assessments should be provided to the governing body, for its annual review of overall risks to the organization. For more information see GOV 6.08.

RPM 2.02

 

The organization conducts a quarterly review of immediate and ongoing risks that includes a review of incidents, critical incidents, accidents, and grievances related to:

  1. administering, dispensing, prescribing, or storing medications;
  2. service modalities or other organizational practices that involve risk or limit freedom of choice;
  3. the use of restrictive behavior management interventions, such as seclusion and restraint;
  4. facility safety issues;
  5. situations where a person was determined to be a danger to himself/herself or others; and
  6. serious illnesses, injuries, and deaths.
Update: Added Note - 06/01/10
Added Note
related ASE 4,  BSM 1.03,  BSM 5,  DDS 2.02,  DDS 5.02,  DTX 5.02,  GLS 6.02,  MH 4.02,  PQI 4.02,  PSR 4.02,  RPM 3,  RTX 6.02,  SA 4.02,  WT 4.02
Note: Elements a, b and c do not apply to credit counseling organizations.

RPM 2.03

 

The organization reviews all incidents and accidents that involve the threat of or actual harm, serious injuries, and deaths, and review procedures:

  1. establish timeframes for investigation and review;
  2. require solicitation of statements from all involved individuals;
  3. ensure an independent review;
  4. require timely implementation and documentation of all actions taken;
  5. address ongoing monitoring if actions are required and determine their effectiveness; and
  6. address applicable reporting requirements.
related BSM 6.02,  PQI 4.02

RPM 2.04

 
Individuals qualified by knowledge and experience are responsible for risk prevention and management functions.

RPM 2.05

 
The organization informs external organizations that use its facilities of their obligation to minimize hazards and to assume liability for use of the facility.
NA The organization does not permit other organizations to use its facilities.

RPM 2.06

 
The organization provides, and assumes the cost of, legal assistance to personnel against whom claims are made related to lawful, authorized actions taken within the course and scope of their duties.
Interpretation: This standard does not require the organization to provide assistance to personnel who commit unlawful acts or acts that are not conducted in the course of, or in furtherance of, their employment. In addition, this standard does not require the organization to provide legal assistance to personnel if the organization’s legal counsel determines that doing so would constitute a conflict of interest.
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PURPOSE: Comprehensive, systematic, and effective risk prevention and management practices reduce the organization’s risk, loss, and liability exposure.
 
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