ࡱ> #`  Nbjbj\.\. .>D>DEs\\\8D Fxx1111=/2 C< WF$GhDJt{F{FFxxx1x1xxxl dE =E\pxL9F0FxJJxJx,x{F{FdF\\ SECURITY MANAGEMENT PLAN Does the hospital have a documented Security Management Program?Is there written commitment and involvement by top management in the Security Management Program?Is the hospital required to develop and maintain a Security Management Program? (i.e. JCAHO)Is the Security Management Program a shared responsibility between other areas?If so, what percentage of time is spent daily on Security Management? Does the hospital provide 24-hour security coverage?How many officers are assigned to day shift?How many officers are assigned to afternoon shift?How many officers are assigned to evening shift?Are in-house security officers employed by the hospital?Are security officers contracted through an outside service?Are other designated employees used to augment the security force?Does the Security Management Program describe an organization- wide program to protect patients, staff, and property?Provides for the investigation of security incidents?Provides for the reporting of security incidents to the Safety Committee?Does the Security Management Program evaluate the security operation and monitor its progress?Do records track incidents or near incidents of combative behavior and establish a baseline of information for change?The Chief Executive Officer has designated the personnel responsible for the Security Management Program?Requires an annual evaluation of the objectives, scope and effectiveness of the Security Management Program?Has the Security Management Program established performance standards that measure the effectiveness of the program? TRAINING AND EDUCATIONCoordinates with the organization-wide training effort to provide new employee orientation and continuing education on security management?Are Organization-wide and Department specific security risks addressed? Are emergency procedures during a security incident addressed?Are reporting procedures that show how to contact security for patient incidents addressed?Are reporting procedures that show how to contact security for staff incidents addressed?Are reporting procedures that show how to contact security for property incidents addressed?Can a sample of staff in each of the sensitive areas describe and/or demonstrate department specific security risks?Can staff provide records to show that they have received training to reduce and report security risks?Can staff explain the proper emergency procedures to take during a security incident?Does staff maintain the knowledge and skills required to handle security responsibilities?Is a surveillance system for identifying risks and security incidents used? Is security equipment inspected, tested, and appropriate preventative maintenance provided?STAFF KNOWLEDGE & TRAININGCan a sample of staff in each of the security sensitive areas describe or demonstrate department specific security risks?Can staff provide records to show that they have received training to reduce and report security risks?Can staff explain the proper emergency procedures to take during a security incident?Is the training plan conducted in-house?Is the Hospital using the IAHSS security-training program?Do all new security officer receive new hospital-wide employee orientation? Do all new security officers receive department specific security training?Do all new security officers receive training on security sensitive areas (nursery, ED, pharmacy, pediatrics)? DOES THE SECURITY TRAINING PROGRAM INCLUDE:Hospital disaster manual?Security manual?Fire/Safety manual?Administrative manual?Does the security training program address the following security procedures?Biological ThreatsBomb ThreatsChain of CommandChemical ThreatsCommunication SystemsDefinitions (Assault, Battery, Negligence, Restraint, Slander)Delivery of Radiological AgentsFire ExtinguishersHandling unruly patients, visitors, othersHostage situationsInfant/Child AbductionsInvestigationsLost and Found articlesMoney Deposits, EscortsMonthly Departmental Staff MeetingsObscene/Harassing Telephone CallsParking Policies and EnforcementPatient ElopementPatrolling DutiesRequests for Police AssistanceResponse to Blood Bank AlarmsResponse to Burglar AlarmsResponse to Hold-up AlarmsResponse to Life-Line AlarmsResponse to LockoutsResponse to MAC Machine AlarmsResponse to Medical EmergenciesResponse to Off-Campus PropertiesResponse to Panic AlarmsSearching of FacilitiesSmoking Policy EnforcementAre specific shift duties for day shift addressedAre specific shift duties for afternoon shift addressedAre specific shift duties for evening shift addressedAre shift supervisor duties addressedUse of force (nightstick, flashlight, pepper spray/foam, Tazer, and firearms) addressedUse of Hospital Vehicles addressedUse of Restraints (Handcuffs, Leathers, and Other devices) addressedIs Vehicle Maintenance of Security Vehicles addressedWeather AlertsAre the following fire safety procedures addressed:General Fire Plan ProceduresResponses to Fire AlarmsPatient EvacuationsRequest for Fire DepartmentMaintaining Fire Protection EquipmentSecuring Sprinkler System ValvesSecuring Medical Gas ValvesAre the following disaster responsibilities addressed:Security Roles (Internal Disasters)Security Roles (External Disasters)Disaster Scene Control and AccessHow to handle the News Media and where to direct themAre the following Administrative procedures addressed?Hospital Command and OperationsSmoking Policy EnforcementIdentification of Staff, Visitors, Contractors, Vendors, Servicemen, Clergy, etc.SECURITY MANAGEMENT (POLICIES AND PROCEDURES)The Security Management Program should include policies and procedures that address:Specific emergency procedures for handling different situationsSpecific procedures to follow during a civil disturbanceSpecific procedures to follow for handling VIPs and the news mediaThe need for additional staffing to handle traffic during a disaster and/or other emergencyKEYS AND LOCKSDifferent levels of key/card accessA key/card access system is in placeA key/card access system is up-to-date All keys/cards are identified and logged into the systemKeys/Cards are never duplicated without securitys approvalMaster keys are not reproduced outside the facilityAll lock changes and repairs are handled through the security departmentContract locksmith services must be contacted through the security departmentUpon resignation and/or dismissal staff keys/cards are returned to the security departmentA hospital-wide door locking procedure is addressedA hospital-wide door opening procedure is addressedSENSITIVE, HIGH-RISK AREAS:Security provide a stationary post in these unitsHas a previous security survey been completedHave recommendations been acted upon and follow-up takenAre surveillance cameras used to monitor entrance/exit doors, isolation areas, patient waiting areas, and connecting hallways/corridorsAre there procedures for tape retrieval, storage, and useIs there controlled access to narcotics, syringesIs there departmental security related in-services conductedIs there controlled access to all unitsAre past incidents involving aggressive patients identified, trended, and analyzedIs training provided for all ED and Psych staff in the handling of aggressive patientsAre there policies and procedures for handling the following situations in place in all units:Combative PatientsWeapons CarryingUnauthorized Access to the ED (i.e. News Media)Handling Prisoners in Police CustodyPHARMACYAre narcotics kept locked and under an inventory processHas there been a review and/or revisions made to the security program within the pharmacy and satellite during the past yearIs there an Access and Protection policy and procedure in placeIs there a Transportation and Storage policy and procedure on drugs throughout the HospitalAre needles and syringes monitored and kept under an inventory processIf drug theft is suspected is there a procedure in place to address responsePEDIATRIC, NURSERY & OB FLOORSIs there an Infant/Child Abduction Plan updated and in placeAre all policies and procedures pertaining to these sections updated and in placeAll security systems and access control systems in place and operatingAre staff following manufacturer's recommendations for device maintenanceHas a drill been conducted on all three shifts within the last twelve monthsMATERIALS MANAGEMENT CONTROL SYSTEM:There is a Hospital-wide inventory and/or asset control system in place that addresses:How equipment is identified and logged into the inventory systemHigh value equipment is specially secured to prevent easy removalIn-coming equipment is identified and logged prior to its useOut-going equipment is checked and then taken out of the inventory systemLoading dock access is restrictedTruck drivers are asked to sign and date their arrivals and departuresCCTV is placed so as to monitor the Loading Dock after normal business hours?PATIENT VALUABLESThere is a system in place to control the loss of patient valuables that addresses:Prior to admission patients are advised not to bring valuables or money into the hospitalDuring the admission process patients are asked to have family members take home their valuables or moneyIf this is not possible a patients valuables or money is secured in the safeAccess to patient valuables envelopes are monitored and controlledAny patient articles that are lost or missing are reported to Security for an investigationUnknown articles that are found are sent to Security to be catalogued and maintained for their ownersValuables found as unknowns are maintained in the safe and logged into the unknown's listTo release any valuables the owner must present a valid picture ID to the Security Officer in charge of loss and found The loss and found area is secured and checked on a routine basisIDENTIFICATION CONTROL SYSTEMAn Identification Control System is in place that addresses:All staff members receive training on the ID system?All staff members are encouraged to be the 1st line of defenseActions are defined as to what to do when suspicious person is identifiedPatient ID is definedVisitor ID is definedStaff ID is definedPhysician/Medical Staff ID is definedContractor/Vendor ID is definedClergy ID is definedVolunteers ID is definedSecurity sensitive areas (i.e. nursery) have restricted accessAt the main entrance volunteers acts as a source of information and access restrictionVisiting procedures are defined and practicesVisiting hours are defined and practicedSECURITY PRACTICES:The following items are addressed:There is a hospital-wide procedure for the notification of security in emergency situationsThere is a hospital-wide procedure for the notification of security in routine situations There is a procedure for calling and alerting of security for patient restraintThere is a procedure for the handling and disposing of illegal drugsThere is a procedure for the handling of illegal weaponsThere is a procedure for the handling of other contrabandsThere is a procedure for the use of the hospital safe and/or vaultPSYCHIATRIC UNITAre areas uncrowded and provisions for isolated areas for agitated patientsRooms designed to avoid staff entrapmentDoes the nurse's station have adequate protectionAre there separate and lockable staff bathroomsIs controlled access to counseling roomsIs hardware, such as doorknobs, plumbing fixtures and electrical outlets are appropriate for the unitIs there CCTV of high-risk areasIs there a plan to identify and deal with violent patient behavior and aggression managementGENERAL PHYSICAL SECURITYAre there metal bars and protective grating on outside ground level windowsAre windows at ground level provided with inside stops to prevent accessAre doors at ground level built to withstand unauthorized accessAre there curved mirrors at hallways or areas of concealmentIs there an effective preventative maintenance program for lights, windows, and security systemsIs there preventative maintenance and tests of alarm systems monthlyAre there routine tests of all safety and security devicesAre alarm systems both visual and audibleIs there is a security response to the alarm systemsDoes the Hospital provide external patrolsAre facility access points checked during these patrolsDoes the Hospital provide security vehicle patrolsDoes the Hospital provide canine patrolsEmergency Response TeamsIs incoming staff made aware of potential problem patientsIs physical intervention limitedAre staff members allowed to file legal charges for assaults against themselvesPolicies for open and seclusion patients and monitoring high-risk patientsSecurity escorts for staffSecurity escorts for visitors and maintenance workers locked into the facilityIs there liaison and local police cooperationIs there a policy for the transfer of combative clients/patientsWORK PLACE CONTROLSPolicy for staffs clothing to prevent staff injuryPolicy on keys for staff membersPersonal alarms for staffPolicy for staff members working aloneEMERGENCY DEPARTMENTAlarm system or panic buttonsMetal detection systemSeclusion or security room for aggressive patients (monitored)Bullet resistive glass for triage, admitting, or reception areaAccess Control to ED treatment areasCCTV for concealed or problem areasWork Practices and Administrative ControlsSecurity training in human behavior and aggression managementStaff working alone in ED or walk-in clinicsAccess control limits after hours with security patrolsHostile patient management and use of restraintsDocumenting threatening, aggressive and combative patient incidentsEmployee's ID access control in the EDSecurity usage during problem patient transfersStaff permission to file assault charges on patients, visitors, or relatives Federal Student Right-To-Know and Campus Security Act (PL 101-542)Does the Hospital have to comply with this legislationIf so, has an annual report been developed and made available that addresses:Criminal Activity Report at the Hospital: Classifications of OffensesMurderRapeRobberyAggravated AssaultBurglaryMotor Vehicle TheftArrests on PropertyLiquor Law ViolationsDrug Abuse ViolationsWeapons ViolationsDoes the annual report also include:Mission Statement of Security DepartmentAuthority Statement of Security DepartmentHow to report security incidentsHow to contact security in routine or non-emergency situationsHow to access the Hospital during normal business hoursHow to access the Hospital after hours because of restricted accessHow to receive a security escort after hoursSecurity awareness training is made available at new employee orientationAdditional security and crime prevention programs are made available upon on requestIs the Hospital policy on the carrying of any lethal weapons definedIs the Hospital policy on the use, possession or sale of any alcohol or drugs definedIs the Hospital ID system definedAre call boxes or emergency telephones used on the Hospital campusIs the location of the Security Office explainedAre the normal business hours of the Security Office defined LIGHTINGLighting (External Campus)All entrances used in the evening and walkways are lightedAll parking areas lightedAll sidewalks lightedShrubbery and trees are maintained so as not to provide hiding places or shadowsLighting (Interior Hospital)Entrances and corridors are well lit Security Alarms & CCTVThe hospital maintains a 24-hour central station that monitors security alarms & CCTV?Alarms are sent to a 24 hour central station for processingPARKING GARAGESIs there a CCTV system that provides for adequate protection of the parking garage?Is there adequate lighting in the stairtowersIs the parking garage being patrolled by securityIs there an emergency callbox system in the parking garageIf so, is the system tested on a weekly basisIs there a cashier in the parking garageHELICOPTER LANDINGS:Is there a security policy and procedure that deals with helicopter landingsAre additional security officers available to respond to security emergencies during a helicopter landing     SECURITY ASSESSMENT FORM Y N NA Remarks PAGE 1 `e) . ~  6 ; n s $ ) l q " ' q v Q V 27]bPUSX fk rw;@SXhH5OJQJ\^Jh4hHhHOJQJ^JYHkd$$Iflr #"0#4 la$If$IfMN`abcdeCkd$$Iflr a#"0#"4 la$If  !$If) * + Nkd$$Iflr a#"0#"4 la$If+ , - . ~  Nkd$$Iflr a#"0#"4 la$If TNNNNN$Ifkdl$$Iflr a#"0#"4 la      TNNNNN$IfkdN$$Iflr a#"0#"4 la 6 7 8 9 : TNNNNN$Ifkd0$$Iflr a#"0#"4 la: ; n o p 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