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Orientation and Annual Education Part II for RISF Back to Course Index

Recovery Institute of South Florida

Orientation and Annual Education Part II






The facility is responsible for protecting patients, visitors, students, and employees from the potential adverse affects resulting from fire emergencies. To fulfill this responsibility, the facility has developed extensive fire safety (life safety) policies, procedures, and education programs.

Fire Prevention

Whether at home or here at Recovery Institute of South Florida our first priority should always be fire prevention. The following are some guidelines or tips on how to prevent fires.


  • Screen Shot 2015-12-08 at 1.10.22 PMNever overload electrical circuits. Use heavy duty surge protectors with in-line circuit breakers in areas where multiple receptacles are needed.
  • Never leave open flames unattended.
  • Store flammable/combustible materials in appropriate containers and away from heat and ignition sources.
  • Dispose of trash (paper, cardboard and other combustible materials) promptly. Maintain good housekeeping.
  • All space heaters are to be Underwriter’s Laboratory (UL) listed and equipped with a tip-over cut-off switch.

Observe the no smoking policy within the organization (No smoking indoors). Smoking is permitted in designated areas only. No smoking near building entrances /exits. Compliance with the smoking policy will be continually monitored and strategies developed to address non-compliance.


Life Safety

The following guidelines have been provided to ensure personal safety during a fire emergency.


  • Keep fire exits and stairwells free from any obstruction.
  • Identify the primary and secondary evacuation routes and keep those routes unobstructed.
  • Understand the use and know the location of fire extinguishers and fire alarm pull stations (if available).
  • Participate in scheduled fire drills.


Interim Life Safety

the facility shall implement Interim Life Safety Measures during times of renovation or construction or when significant Life Safety Code deficiencies exist. Construction and renovation activities may disrupt the normal level of life safety measures. For example, smoke detectors and alarm systems may be disabled or evacuation routes may be blocked during construction or renovation activities. Additional training, drills and daily surveillance will be conducted within areas affected by these activities, as applicable.


Code Red Procedures (R-A-C-E)

Response To A Fire

In the event of a fire emergency all employees will utilize the acronym RACE.

We need to immediately call 911 in case of a Fire.

Regularly scheduled Fire Drills will be performed in order to insure employee knowledge regarding the proper procedures to take in a fire emergency.

If you see a fire, you should use the RACE acronym:


            Rescue                  Remove anyone from immediate danger.

            Alarm                    Sound the alarm with a manual pull station.

            Confine                 Close all doors and windows.

            Extinguish/            Know locations and how to use fire extinguishers.



Each employee will be familiar with the building’s exits and Fire Pull Box (if available) locations. A floor plan describing the emergency exits and evacuation routes will be posted. Use of telephone emergency system (911), Fire Pull Alarm Box (if available), will be included in staff training.

The facility will have a designated “Fire Marshall(s)” to be in charge of the evacuation for their area. This will ensure that a systematic and timely evacuation will take place and that all procedures are followed and completed per the Fire Plan.

The first person to discover a fire (or potential) should immediately assess this situation and the surroundings and then:


  1. REMOVE individuals (if any) from immediate danger to designated areas outside and away from the building.


  1. ANNOUNCE the fire by pulling the nearest Fire Alarm Box (if available), or instruct another staff member to call 911 if you are involved in removing individuals from immediate danger. Calmly notify other staff

members of the “CODE RED” emergency. Announce ‘’Code Red, Location___________, “ three times.


  1. CONFINE Staff will immediately begin closing doors and windows to help confine the fire, heat and smoke upon hearing “CODE RED ANNOUNCEMENT”. Staff will also begin to evacuate patients and personnel to the nearest emergency exit(s) that is away from the fire.


***Staff should be continuously aware of those patients or peers needing assistance in the case of an emergency situation so that their evacuation can be made as quickly as possible when necessary.




  1. 911 should be called if the situation cannot be controlled or contained by using the facility’s Emergency Fire Plan guidelines and Supervisors’/Designee’s directions.


  1. It is recommended that the facility’s Receptionist be the designed person to contact outside emergency personnel or call 911, if the situation permits.


  1. ALL CLEAR: An “All Clear” announcement will be made once the threat of danger has passed and it is determined that it is safe for patients, staff and visitors to re-enter the building. The “All Clear” announcement will be made by the Supervisor/Designee, or by the Fire Department personnel.


  1. Documentation of the event should be made and kept in the Safety Officer’s log book.


Fire Triangle

There are three elements needed to start a fire. When you have all three elements together you will complete the fire triangle and a fire will occur.

  1. The first element needed is fuel, or something that will burn. There are many different types of fuel such as paper, wood, gasoline, drapeignry and furniture.
  2. The second element needed is adequate amount of oxygen. Air is the most common source of oxygen during a fire.
  3. The final element needed to complete the “Fire Triangle” is a source of heat to ignite the flames.


Once a fire has started you must remove one of these elements to put the fire out.


Fire Extinguishers

All fire extinguishers are ABC extinguishers which means that they will put out all types of fires. Most of these extinguishers contain dry powder that leaves a residue after use.

During fire emergencies that require the use of a fire extinguisher, the P-A-S-S method should be utilized.

P-Pull the pinextinguisher

A-Aim the nozzle at the base of the fire

S-Squeeze the handle

S-Sweep the base of the fire with the spray in a back and forth motion until the fire is out.


Classes of Fires

Fire can be classified based the type of fuel being consumed. These are class A, B, and C fires.



Evacuation Procedures

It is also very important that employees understand their responsibilities and know all evacuation routes in the event that an evacuation is necessary as a result of a fire emergency. Listed below are some of the key points to remember:


  • When patients are evacuated from their rooms, check to ensure that the room is vacant then close the door.
  • Assist those requiring additional help to safely leave the building.
  • Do not use elevators, if present during a fire emergency.
  • Use primary or secondary evacuation routes to vacate the premises.
  • Avoid stairwells; first try to evacuate using connecting corridors.
  • Roll call is to be taken at the designated “safe” area to ensure all have safely been evacuated.



It is critical to the safety of everyone who enters the facility that we are compliant with all fire safety regulations. It is also critical that all employees know how to respond in the event of a fire emergency. By achieving these goals, we can minimize the potential for the occurrence of, and adverse effects resulting from, fire emergencies.


Hazard Communication (Chemical Safety)


The hazard communication, or “Right to Know”, program is designed to provide pertinent hazard information to employees who work with or around hazardous chemicals. There are three components to the hazard communication program:


  • Labels / Storage
  • Material Safety Data Sheets (MSDSs)
  • Training



The first component deals with label requirements. All chemicals in use must be properly labeled and stored in safe area. No chemicals are to be stored under sinks.



The second component of hazard communication involves MSDSs. A MSDS is a document provided by the manufacturer, importer or distributor of the hazardous chemical(s). It provides information on the hazards associated with a hazardous chemical and recommendations for safe use, handling and disposal. The MSDSs are available within the work area.

The MSDS is divided into sections. Each section is dedicated to a specific topic (i.e. Reactivity, Fire & Explosion Data, Health Hazards, etc.) Some of the sections are listed below:

  • Name of Chemical
  • Manufacturer
  • Chemical Components
  • Associated Hazards
  • Physical Characteristics
  • First Aid/Emergency Response
  • Spill and Leak Handling
  • Reactivity
  • Disposal Practices
  • Personal Protective Equipment

It is also important to know the hazards (symptoms of overexposure) of the chemicals in the work area in order to work safely with the chemical(s) or to make determinations regarding overexposure. This information is also available on the MSDS.

Exposure Routes

Knowing the primary route of entry will provide insight into how to protect against chemical exposure. There are four ways in which chemicals can enter the body:

  • Inhalation
  • Ingestion
  • Absorption through the skin
  • Injection

Personal Protective Equipment (PPE) – Personal protective equipment can provide additional protection from chemical exposure. This requires using the appropriate type of PPE for the hazard presented (i.e. latex gloves are not appropriate protection for many chemical contact hazards).

Employee Responsibilities

It is the responsibility of every employee to know:

  • The hazards associate with the chemicals in the work area.
  • The location of the MSDSs for the chemicals in the work area.
  • How to find information on the MSDS.
  • Physical and health hazards associated with the chemicals in the work area.
  • How to identify the presence (symptoms/odor) or release (monitoring) of chemicals in the work area.
  • How to work with the chemicals that they have in their work area safely.
  • The type of personal protective equipment available and how to use it.


In healthcare facilities the potential for exposure to hazardous chemicals is a potential risk. Employees who work with such chemicals have the “Right to Know” how these chemicals can adversely effect them, and how to protect themselves from such effects. The Hazard Communication Program provides employees with the tools they need to ensure that they have the information necessary to perform work with or near hazardous chemicals in a safe manner.


Security Management


The Security Management Plan outlines several measures taken by the organization to ensure patient, employee, and visitor safety.

Security Measures

Various security measures exist in order to increase overall safety and security within the buildings as well as the surrounding outdoor environment. Some of these include: exterior lighting, identification of ‘high-risk’ areas requiring additional security (medical record areas, medication rooms, business office), security rounds, visitor sign-in and identification, surveillance cameras, employee identification (picture ID badges), management of access to keys and/or door code locks, etc.


Log off when leave station. Do not remove privacy hoods.


Security is of particular concern to everyone in today’s uncertain world. It is the responsibility of all employees to do their part in maintaining the integrity of the Security Management Plan and to report any potential areas of security violation and/or vulnerability. 

Infection Prevention and Control


 All employees are required to participate in infection prevention and control training on an annual basis. This study guide is designed to assist in preparing employees to perform in a way that protects patients, employees, students, and visitors from spreading pathogens and communicable diseases to one another.


Finding Infection Prevention and Control Information

The organization has an Infection Prevention and Control Manual that is available to each employee. This manual has important information which will help you to do your work in a way that protects both you and your patients.

Every Infection Prevention and Control Manual includes:

  • The organization’s infection prevention and control program
  • Universal / Standard Precautions
  • TB Exposure Control Plan
  • OSHA’s Bloodborne Pathogen Exposure Control Plan
  • General infection prevention and control policies

Be sure that you know where to find your department’s Infection Prevention and Control Manual and policies on Infection Prevention and Control. Find out the Infection Prevention and Control information you need to do your job safely.


High Risk Diseases for Healthcare Employees


Bloodborne diseases are diseases that are spread by contact with infected blood and other infectious body fluids. Transmission of bloodborne pathogens, including HIV, Hepatitis B virus and Hepatitis C virus, may occur if infectious blood or body fluids contact the mucous membranes of the eyes, nose, or mouth. They can be transmitted by needlesticks and puncture wounds or cuts from other contaminated sharps. Non-intact skin also provides a way to contact these organisms. This is especially true if you have abrasions, cuts, rashes, or burns on your hands and you touch blood, other potentially infectious materials, or a contaminated surface with your bare non-intact hands. These pathogens can be present long before the infected person shows any signs of the disease. Sometimes they are present without the patient or the employee developing signs of the disease. Contaminated objects can transmit Hepatitis B, as the virus can live on inanimate objects for up to 4 weeks. The HIV virus, however, cannot live outside the body.

The pathogens that cause bloodborne diseases may be present in:

  • blood
  • body fluids which has visible blood
  • semen, vaginal secretions, cerebrospinal fluid, synovial fluid, plural fluid, pericardial fluid, amniotic fluid
  • blood tinged saliva in dental procedures unfixed tissue or body organs other than intact skin
  • organ cultures, HIV containing culture media, or similar solutions
  • blood, organs, and tissue from experimental animals infected with HIV or HBV
  • items contaminated with any of the above. (An item is considered to be contaminated if it is, or is being suspected of being, soiled with blood or other infectious materials.) (Only blood, semen and vaginal secretions have been shown scientifically to transmit HIV.)

Bloodborne pathogens may enter your body in a variety of ways including:

  • through open cuts, nicks, skin abrasions, dermatitis, and acne, as well as the mucous membranes of your mouth, eyes or nose
  • by touching an object soiled with infectious material and then indirectly transferring the infectious material to your mouth, eyes, nose, or open skin lesion
  • an accidental injury that results in a puncture or cut of your skin by a sharp object soiled with infectious material (for example, a needle, knife, broken glass, dental wires, etc.).

Surfaces such as walls, floors, counters and furniture that are contaminated with infectious material are a major danger for spreading diseases such as hepatitis B. The hepatitis B virus can survive on surfaces for up to 4 weeks. Infectious materials such as serum or plasma, without visible signs, can soil surfaces and objects. This is why we use standard housekeeping procedures for cleaning and disinfecting of all equipment and work surfaces outside of the host and on an environmental surface. Hepatitis B is a much stronger and more viable virus than HIV.

Some of the bloodborne diseases that healthcare employees can be exposed to on the job include:

  • Hepatitis B (HBV)
  • Hepatitis C (HCV)
  • Human Immunodeficiency Virus (HIV), the virus that causes AIDS

The most common and the most contagious of these bloodborne diseases is Hepatitis B (HBV). The other infection that is becoming of great concern to hospital employees is Hepatitis C and as in the past human immunodeficiency virus (HIV) that causes AIDS.

Hepatitis B (HBV)

Hepatitis B is an inflammation of the liver that can lead to cirrhosis and death. Hepatitis B (HBV) is a major risk for health care workers. It is estimated that 1 to 1.25 million persons in the U.S. have chronic Hepatitis B and are potentially infectious to others. It affects about 8,500 health care workers each year. Studies show the infection rate for Hepatitis B from a contaminated needle, a common mode of transmission, is as high as one in six. Symptoms include weakness, fatigue, anorexia, nausea, abdominal pain, jaundice (yellow skin), fever, headache, vomiting, diarrhea, decreased appetite, and generalized muscle aches. Hepatitis B virus may be transmitted when a person’s mucous membranes or breaks in the skin are exposed to an infected person’s blood, semen, vaginal secretions, or other potentially infectious materials.

Of those who are infected with hepatitis B, 1/3 will have no signs, 1/3 will have mild, flu-like illness, and 1/3 will have severe symptoms of the illness. The signs of severe clinical hepatitis B include: jaundice (yellowing of the skin and eyeballs), dark urine, extreme fatigue, loss of appetite, nausea, abdominal (belly) pain, joint pain, rash and fever.

The Hepatitis B virus may be spread by sexual or other contact with semen, vaginal secretions, blood, and other body fluids of an infected person. Hepatitis B can also be spread from a pregnant woman to her unborn child.

Health care workers can control the spread of Hepatitis B and protect themselves by acting as if EVERY patient they come in contact with has the disease. (Remember, 2/3 of infected people either do not have signs or have signs that can be mistaken for flu!) By using Standard Precautions, which will be discussed later in this module, health care workers can protect themselves from illnesses such as Hepatitis B.

Using Standard Precautions and becoming vaccinated is the best way to protect yourself from the Hepatitis B virus. the facility does offer, free of charge and in accordance with OSHA, the Hepatitis B vaccine for all employees who have job-related exposure to blood and other body fluids. Employees whose job description requires that they come into contact with blood and body fluids do not have to accept the vaccine. However, if they choose not to accept it, they must sign a written statement saying that it is their decision to refuse the vaccine. Employees can request the vaccine later after signing the waiver. (The Hepatitis B vaccine does not protect against other bloodborne diseases.)

Hepatitis B vaccine is used to immunize people of all ages against infection caused by all subtypes of Hepatitis B virus. There is no danger of getting Hepatitis B from the vaccine, because no human substances are used to make it.

At this point, we do not know how long the protection lasts, or whether periodic booster doses will be needed. Antibody levels that develop from the vaccine drop steadily over time. Up to 50% of adults who develop enough antibodies with the vaccine will have low or no antibody levels 7 years after the vaccination. However, it appears that they still are protected against infection and clinical disease from the Hepatitis B virus.


Human Immunodeficiency Virus (HIV)

A person who is HIV positive (HIV+) is infected with the human immunodeficiency virus. This virus causes Acquired Immune Deficiency Syndrome (AIDS). Being HIV+ does not mean that the person has AIDS, or that they will become seriously ill soon. The virus may be inactive for periods of time, sometimes for several years. During this time, an infected person may have no signs of disease. It is estimated that 33.6 million cases worldwide, 816,149 cases in the United States and 79,155 in the state of Florida.

The HIV virus attacks the immune system. It eventually affects the body’s ability to fight off “opportunistic infections” which are caused by organisms that usually do not cause disease in people who have healthy immune systems. People infected with the HIV virus are also more likely to develop contagious diseases such as tuberculosis, because the immune system is not able to fight them off.

A person infected with HIV may have the following characteristics:

  • carry the virus for years without developing any signs
  • suffer from flu-like symptoms of fever, diarrhea and fatigue
  • develop HIV-related illnesses such as nervous system problems, cancer,
  • pneumonia, tuberculosis, and opportunistic infection
  • will most likely develop AIDS

HIV is spread through contact with infected blood, semen, and vaginal fluids. HIV is not spread by casual contact such as touching or working around patients who are infected. The main behavior that transmits HIV is sexual contact. Vaginal, penile, rectal intercourse, and/or sharing of needles during I.V. drug abuse also transmit the virus. Occupational needlestick injuries show the rate of infection, after being stuck with an HIV contaminated needle, is one in 300.

Health care workers can help control the spread of HIV and protect themselves by acting as if EVERY patient they come in contact with is infected with the virus. (Remember, patients may carry the virus for years without developing any signs, or the signs can be mistaken for other health problems! Early on when an individual is exposed, and prior to any symptoms, a person is 1,000 times more infectious. Yet when tested prior to developing antibodies the test will be negative.) By using Standard Precautions, which will be addressed later in this module, health care workers can protect themselves from infections such as HIV.

Hepatitis C Virus (HCV)

Hepatitis C Virus is spread mainly through blood transfusions and intravenous drug abuse. It resembles Hepatitis B in that it attacks the liver. Symptoms of active HCV are milder than those of HBV – or may not even be present. However, HCV is more likely to cause chronic carrier state and more likely to lead to cirrhosis, liver cancer, and death.


Airborne disease are spread by breathing in air which has droplets or droplet nuclei (5mm or smaller in size), that can cause Airborne disease. Some examples of airborne diseases include:

  • tuberculosis
  • chicken-pox
  • measles
  • shingles in a person whose immune system is weak

There are many ways to protect staff and other patients from airborne diseases.

  • Patients who have airborne diseases will be discharged and/or transferred to another facility until there are free from the airborne disease.
  • Staff will be notified any airborne diseases to ensure proper care is given to individual.


Tuberculosis (TB)

Tuberculosis (TB) is an infectious disease that occurs most often in the lung. Tuberculosis is a serious and growing threat to everyone. Some tuberculosis infections are treatable with drugs. There are strains of the disease that are resistant to most drugs now available.

Although anyone can get tuberculosis, there are some groups that are at a greater risk than others. These high risk groups include: low socio-economic levels without a strong social support system, the homeless, the elderly, those who live in nursing or retirement homes, IV drug users, migrant workers, and those who live in areas where the disease is common.

In addition to a positive TB skin test the patient may have one or more of the following symptoms if infected with tuberculosis:

  • productive cough
  • coughing up blood
  • fever and chills
  • night sweats
  • recent weight loss

Patients who are HIV (AIDS) infected may have tuberculosis without showing these typical signs.

Tuberculosis is most commonly spread by breathing in the airborne droplet nuclei <5 microns. Organisms transmitted in this manner can be suspended in the air for long periods of time and can be dispensed in air currents.

An important way to control the spread of tuberculosis is to find out early who has been exposed to the disease. Persons can have a positive tuberculin skin test without being infectious with TB. This is why all employees are given either a tuberculin skin test or chest x-ray at the time of pre-employment health screening. Any patient suspected of having tuberculosis should be put on Airborne Precautions right away and be prepared for transfer to a medical facility for further evaluation and/or treatment.


Droplet Precautions

Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large particle droplets (5mm or larger in size). Droplets are generated from the person primarily during coughing, sneezing, or talking. Droplets usually travel short distances of 3 ft. or less.

Diseases that are spread by droplets include:

  • Invasive Haemophilus influenza type b disease, including meningitis, pneumonia, epiglottis and sepsis
  • Invasive Neisseria meningitides disease, including meningitis, pneumonia, epiglottitis and sepsis
  • Diphtheria (pharyngeal)
  • Mycoplasma pneumonia
  • Pertussis
  • Pneumonic plague
  • Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children
  • Adenovirus
  • Influenza
  • Mumps
  • Parvovirus
  • Rubella


Exposure Control Plan

The Occupational Safety and Health Act (OSHA) defines occupational exposure as “reasonably anticipated skin, eye, mucous membrane, or parenteral [piercing the skin] contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.” The OSHA regulations require the hospital to develop an Exposure Control Plan and to make it available to all employees.

The Exposure Control Plan is in the Infection Prevention and Control Manual and the plan is available to all employees.

Be sure to read the Exposure Control Plan. It has important information that will help you protect yourself from getting diseases that you might be exposed to because of your work. The Exposure Control Plan lists tasks and procedures, which could cause you to be exposed to infectious diseases. Let this list serve as a reminder for you to protect yourself when doing these tasks or procedures.

Because we do not always know what diseases or pathogens a patient may have, we need to learn to lower our risk and protect ourselves. We need to act as if EVERY patient has an infectious disease such as hepatitis, malaria, syphilis, and HIV/AIDS. (This behavior is part of Standard Precaution, which is discussed in detail later in this module.) It is harmful and may be life threatening not to protect ourselves from these diseases or pathogens.


Controlling Exposures

There is no way to tell with certainty that any person is free of Bloodborne disease. Any person can be infected without being aware of the infection. The infected person may not have any signs or symptoms of disease. We cannot make safe judgements about absence of infection by appearance, age, sex, socioeconomic level, or any other factor. The best way for health care workers to protect themselves from exposure to bloodborne infections is to treat ALL patients as if they were infected with Hepatitis B, Hepatitis C, HIV, or other bloodborne diseases.

Some major ways to reduce the risk of exposure to bloodborne organisms on the job are:

1) Engineering Controls are physical or mechanical systems designed to stop hazards before they start. Examples of engineering controls are: self-sheathing needles, bio-safety bags, sharps disposal containers, appropriate hand washing facilities.

2) Personal Protective Equipment is intended to protect you from contact with possible infectious materials. Examples of such equipment include: gloves, masks, protective eye wear, fluid resistant gowns, resuscitation bags and other resuscitation devices.

To be effective, personal protective equipment must be fluid resistant and help prevent blood or other potentially infectious materials from passing through to the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, and other mucous membranes. This protection should be effective under normal conditions of use for the length of time for which it will be used.

Some general guidelines for selection and use of protective equipment are:

  • The employee must be taught to use it properly.
  • Appropriate protective equipment must be used each time a task is done.
  • The equipment must be free of flaws that would make it unsafe.
  • Gloves must fit properly.
  • If infectious materials go through the protective equipment, remove it as soon as possible and wash the exposed intact skin surface with an antimicrobial soap for 10 minutes.
  • When the task is complete, remove all protective equipment and place it in the appropriate place or container for washing, decontamination, or disposal.

Once personal protective equipment has been used, it must be properly disposed of. Disposable items (for example gloves, masks, fluid resistant gowns,) should be handled as follows:

  • If items are visibly contaminated and could cause dripping with blood or other body fluids, they are disposed of in red plastic bags for medical service waste disposal.
  • If items are not contaminated and cannot cause dripping, splattering or splashing, they are disposed of in regular trash.


3) Housekeeping Practices:

  • When cleaning up broken glass, do not pick it up with gloves or bare hands. Use tongs or a brush and dust pan.
  • Spill kits may be used for blood and body fluid spills.
  • Do not place contaminated laundry on the floor. Handle contaminated laundry as little as possible. Do not hold up to the body. Place all contaminated laundry in blue laundry bags.
  • Place ALL sharps in a sharps container.
  • Clean up contaminated areas first with soap and water (while wearing PPE) follow with a EPA registered disinfectant or a fresh solution of 5.25% of sodium hypochlorite mixed 1:10 with water.

All bio-medical waste will be placed in red bags that have a biohazard symbol on it. Red bags will be located for disposal in various locations. Sharps container must be properly closed when line indicates FULL, for pick-up.

4) Employee Work Practices are specific procedures that are aimed at reducing the chances of exposure to infectious material. Examples of employee work practices are:

Handwashing: Comply with current CDC hand hygiene guidelines in order to reduce the risk of healthcare acquired infections. The generally accepted correct handwashing time and method is a 10-15 seconds vigorous rubbing together of all soapy surfaces followed by rinsing in a flowing stream of water. If hands are visibly soiled, more time may be required. Handwashing should occur after every patient contact, each time gloves are removed, and when skin or mucous membranes come in direct contact with blood or other body fluids. Handwash with an antimicrobial soap or flush eyes and mucous membranes immediately with water for 10 minutes in the event direct contact with blood or other body fluids. Purell handwashing stations are available on each unit.

Avoiding injuries from needlesticks and other sharps: use only safe needle devices, do not bend, hand-recap, shear or break contaminated needles or other sharps; and dispose of sharps promptly in puncture-resistant, leak-proof containers.

Personal hygiene: do not eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses, where you may be exposed to potentially infectious materials; avoid petroleum-based lubricants that may “eat” through latex gloves; do not keep food or drinks in refrigerator, freezers, cabinets, or on shelves, counter tops or bench tops where possible infectious materials may be present.

Standard Precautions

Standard Precautions are meant to protect workers from biohazards and is inclusive of Body Substance Isolation and Universal Precautions. the facility has adopted Standard Precautions as its isolation technique for all patient care that is based on the idea that “Anything that’s wet and not yours is potentially infectious!”

Three basic principles apply in Standard Precautions:

1) Strict hand washing technique is used in all cases of contact with patients, blood/body fluids, secretions, excretions and contaminated items. Wash hands after removing gloves.

2) Contaminated needles and sharps are handled and disposed of according to policy and procedure.

3) Personal protective equipment that is adequate and appropriate is used. The type of protective equipment appropriate for a given task depends on the expected exposure.

* If you expect to be splashed, sprayed, or spattered with droplets of infectious material, use a mask, eye protection, and fluid resistant gown, gloves.


Signs and Labels

RedThe universal biohazard symbol shown below is used on all containers of medical waste, refrigerators, and freezers that hold blood or other infectious material. There are several ways to warn that a piece of equipment or material is contaminated or possibly contaminated. You can attach a biohazard symbol or warning label, or put it in a red bag or red container. Also, you should always treat all blue bagged linen as contaminated.


Exposure Incidents

When an employee is exposed to blood or potentially infectious body fluids the employee should:

  1. Remove all contaminated clothing as soon as possible (The employee’s supervisor will provide alternate clothing).
  1. Immediately wash or flush contaminated skin with antimicrobial soap and water for 10 minutes. If you obtained a needlestick squeeze/milk the area of blood and then wash for 10 minutes.

  2. Employees are responsible for reporting incidents to their supervisors immediately after they happen and reporting to Employee Health immediately.
  1. You and the source will be tested for HIV, HBV after the consents and counseling is completed.
  1. You will be seen by the workmen’s compensation physician for an evaluation and any treatment. You will receive a written opinion in 15 days.
  1. The protocol that will be followed is detailed in the exposure control plan.


Reporting Employee Signs of Disease

Employees who have any of the following signs of disease should contact the Infection Control Nurse: eye infection (conjunctivitis); signs of respiratory illness; skin rashes, open lesions, cold sores; recent exposure to chickenpox, mumps, measles, whooping cough; cast, and/or bandages that prevent effective handwashing.   Employees who feel that they are infectious or who are to sick to work are encouraged not to come to work.



If you have questions or concerns about the material in this study module, or any other infection prevention and control issue, please call the Infection Control Nurse.  

Patient Rights

It is the policy of the organization to support and protect the rights of all patients at all times.

Upon entry into the system, each patient and legal guardian (if appropriate) are informed verbally and in writing of their rights. Each individual signs and is given a copy of the form. Patient Rights are posted in visible areas of all treatment sites.


Confidentiality is one of the most basic rights that patients have. It is a condition of employment that you protect patient confidentiality. We are not only concerned with what information might leave the facility, but also how information may be transmitted throughout the facility.

No information pertaining to the patient shall be given to anyone without proper authorization. The fact that a patient is here or not here or has ever been here is strictly confidential.

Patient’s complete names are not posted on any boards files or doors anywhere in the facility to avoid a breach of confidentiality.

You should be careful of what you say in the facility and where you say it. Hallways are not good places to share patient information. Use a conference room or go into an office and close the door.

No written information is released from the facility without proper written authorization. All release of information forms must be completed in full prior to acquiring a patient’s signature.

Patient Neglect and/or Abuse

Neglect or abuse will not be tolerated in any manner. Any incident of suspected abuse must immediately be reported. Also, an Incident Report is completed by the individual and/or their immediate supervisor.

Neglect is defined as the withholding of treatment necessary for the patient and to support their individual dignity.

Abuse is the application of anything that is destructive to the patient, their treatment, their dignity and the therapeutic relationship. It can be physical, verbal, or psychological.

*Refer to reporting abuse or neglect policy and procedures for further details including: criteria for assessing suspected abuse/neglect and reporting responsibilities.

Patient or Family Concern System

There is a specific protocol for appropriately receiving and responding to concerns by patients or family members. If the concern is unable to be resolved on a verbal basis, the patient/family member will be asked to submit the concern in writing. All pertinent documents and details will be gathered for review. Prior to a written response to the complaint, the Administrative staff will review all facets of the complaint.  Patients are encouraged to and may contact The Joint Commission at (630) 792-5000.


Ethical Behavior

All staff are expected to have ethical behavior at all times. Unethical Behavior is grounds for immediate termination. Any patient grievances regarding unethical behavioral or any type of sexual harassment or sexual inappropriateness will be grounds for immediate behavior. Examples of unethical behavior include:

  • Giving a patient your home phone number.
  • Meeting a patient or an ex-patient at a self-help group meeting.
  • Any type of a relationship with a patient or an ex-patient.
  • Phoning a patient or an ex-patient.
  • Having any type of contact by phone or in person with a patient who has completed treatment at the facility at any time.
  • Accepting a gift of any kind from a patient.
  • Inviting a patient or an ex-patient to a party at your house.
  • Sponsoring either a current or past patient of Recovery Institute of South Florida.
  • Telling a patient your personnel problems or your personnel history regarding any type of personnel nature (marriage, relationships, or any type of an issue of a sensitive nature)
  • Touching a patient inappropriately – Rule never touch a patient, this includes giving a patient a hug.
  • Telling a patient or an ex-patient that you are attracted to them.
  • Any type of breach of confidentiality.

If you are unsure of an unethical situation please contact your supervisor.

Risk Identification Report (RIR) (Unusual Occurrence Incident Report)

An “Incident Report” Form should be completed on any Unusual Occurrence or Incident that is observed.  An “Incident Report” Form can be completed by anyone. The form should be completed by the person who observed the incident and given to the supervisor immediately. Additionally, the “Incident” should be verbally communicated to the supervisor at the time of the occurrence.

An Unusual Occurrence Report is completed immediately by the person witnessing the event, given to your supervisor and forwarded to the Risk Manager/designee (no later than 24 hours). RIRs shall be completed stating only objective facts. No subjective information is given or any conjecture about what might have happened.

The RIR is a confidential document and is to be protected from discovery. It is never placed in the file nor is it referred to in the progress notes/medical record. Do not advise patients or others that a report has been or will be prepared. In those cases where follow-up information is required, a follow-up report is to be completed.


Unusual Event – Any unusual event that occurs involving a patient, staff member, or visitor that transpires in or on the premises of the facility (including the apartments). This includes but is not limited to: Any type of an altercation verbally or physically with either a staff member and/or patient, staff or patient abuse or neglect towards another patient or staff member, psychiatric emergency, any type of self destructive behavior by a patient, AWOL, Medication Error, Seizure, Rule Violation, Slip and/or fall, alcohol or drug use by a patient or staff, contraband found in a patient’s room or on their person, weapon, pharmacy error, procedure break, patient or staff injury, medical problem, emergency call for 911, vehicle accident, property damage, patient or staff cut or injury, trespassing, and any type of violent action and/or threat to an employee or patient.

Adverse Events – Adverse events are untoward incidents, therapeutic misadventures, injuries or other adverse occurrences directly associated with care or services provided. Adverse events may result from acts of commission or omission (i.e.: administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, etc.). Some examples of adverse events include: falls, medication errors, procedural errors/complications, suicide/homicide attempt or gesture, alleged abuse, AMA, etc.

Sentinel Event – A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome.

Near Misses – A Near Miss is an event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. An example of a Near Miss would be: A procedure almost performed on the wrong patient due to lapses in verification of patient identification, but caught at the last minute by chance. Near Misses are opportunities for learning and afford the chance to develop preventive strategies and actions. Near Misses will receive the same level of scrutiny as adverse events that result in actual injury or negative outcome.

Intentional Unsafe Acts – Intentional unsafe acts, as they pertain to patients, are any events that result from: a criminal act; a purposefully unsafe act’ an act related to alcohol or substance abuse, impaired provider/staff; or events involving alleged or suspected patient abuse of any kind.

Root Cause Analysis – Root Cause Analysis (RCA) is a process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or near misses. RCA will be the form of focused review that is used for all adverse events or near misses requiring analysis.

Driver Safety

Safety is Our Number One Priority. Anyone driving patients should adhere to these guidelines at all times.

  1. Before loading passengers:
  2. The vehicle is parked in a safe parking spot away from traffic.
  3. The vehicle is in good operating condition. Do a walk through each time before driving.
  4. The gas tank is at least ¼ full.
  5. The vehicle is in park, emergency brake is on, radio is off and air conditioning or heat is on (as appropriate).
  6. Complete a vehicle checklist each day.
  7. While loading passengers:
  8. No food, drinks or smoking allowing on board.
  9. Each person on the bus is assigned and accounted for on a seat.
    1. Every patient puts on a seatbelt before vehicle is in motion.
    2. While Driving:
  10. Slow and careful at all times.
  11. All passengers must be seated at all time while the vehicle is moving.
  12. Seatbelts must worn by drivers/passengers when appropriate.
  13. In Florida, do not drive on I-95 or The Florida Turnpike and do not drive on Linton Blvd. between US-1 and Congress; take 10th Avenue instead.
  14. The radio can be on at a discrete volume level and the station at the driver’s discretion.
  15. All passengers will remain seated, talk in low tones, keep all hands and body parts in the vehicle and are expected to behavior appropriately. In the event these rules are broken, the driver reserves the right to safely pull the vehicle over until it is safe to drive again.
  16. While unloading passengers:
  17. The vehicle is parked in a safe parking spot away from traffic.
  18. The vehicle is in park, emergency brake on, radio off and air conditioning or heat is on.
  19. What is an emergency and what do you do?

  • All these constitute an emergency:
  1. The vehicle is not running properly (i.e., foreign noises, pulling to one side, overheating, etc).
  2. One or more patients are complaining of a medical problem.
  3. One or more patients are behaving inappropriately and disturbing the safety of the vehicle.
  4. The driver does not feel well enough or in control of the vehicle.
  5. You are involved in any type of accident or police stop.
  • Emergency procedure: Promptly and safely pull the vehicle off the road, park in safe spot, turn vehicle off, and call your supervisor for further instructions

Drug-Free Workplace

Our organization is a Drug-Free Workplace and is committed to providing a safe work environment and promoting the well-being and health of our employees. Drug abuse not only affects individual users and their families, but it also presents new dangers in the workplace. Illegal drug use jeopardizes this commitment, and undermines the capability of providing quality service. A policy regarding the illegal use of drugs is in place. Our policy formally and clearly states that illegal use of drugs and abuse of alcohol will not be tolerated. This policy was designed with two basic objectives in mind:

  1. Employees deserve a work environment that is free from the effects of drugs and the problems associated with their use.
  2. This organization has a responsibility to maintain a healthy and safe workplace. The following types of testing will be performed:
  1. Job Applicant Testing
  2. Reasonable Suspicion Testing
  3. Follow-Up Testing

Confidentiality – All information, interviews, reports, statements, memoranda, and drug and alcohol test results will remain confidential. Consequences of Testing Positive or Refusal to Allow Test – Job Applicants will not be hired.



May be subject to one or more of the following requirements:

  • Attend educational seminars and courses and participate in an employee assistance program;
  • Require attendance at rehabilitation program;
  • Job transfer to a less hazardous position, probationary employment and/or reduction on compensation;
  • And immediate discharge from employment


  • Forfeit their eligibility for medical and indemnity benefits under the Workmen’s Compensation Act;
  • Forfeit their eligibility for unemployment benefits;
  • Be terminated from employment;
  • And otherwise subject to the sanctions provided from employment; and otherwise subject to the sanctions provided above for an employed worker who is not injured.



If convicted of any drug related crime (sale, use or possession), you must notify Administration within 5 days of your conviction. Failure to notify Administration of such conviction is grounds for termination.



Controlled Substance – any substance which is not legally obtainable or which can only be legally obtained by prescription from a licensed medical practitioner.

Drug – means alcohol, amphetamines, cannabinoids, cocaine, PCP, hallucinogens, methaqualone, opiates, barbiturates, benzodiazepines, synthetic narcotics, designer drugs, or a metabolite of any substance listed herein.

Reasonable suspicion drug testing – drug testing based on a belief that an employee is using or has used drugs in violation of the employer’s policy, drawn from specific objective and verbalized facts and reasonable inferences drawn from those facts in light of experience.



The performance improvement (PI) process is based on a few simple concepts:

  1. The ultimate judge of quality is your patient/service user/customer.
  2. All activities must add value.
  3. Performance improvement is a ongoing process.

Quality is part of PI. Quality has a variety of definitions, but all definitions have two basic components 

Doing the right things, and doing them well.

 In addition to the above we also include our customer requirements –

The degree to which we satisfy our patients’ and other customers’ needs.



Quality does not happen by accident. PI requires conscious performance. The success of PI is judged on the following factors:

  1. Increased patient, employee and customer satisfaction.
  2. More efficient care.
  3. Enhanced employee ownership and commitment.
  4. Improved interdepartmental teamwork.
  5. Broaden the quality of work life.


The model of PI consists of the following steps:

Step 1.            Design:             Identify your process and your customers.

Step 2.            Measure:            Establish meaningful indicators.

Step 3.            Assess:                           Determine process reliability and quality.

Step 4.            Improve:            Plan, test and implement.


Priorities for PI are based on various factors, some of which are the following:

Our mission, vision, strategic plan, customer feedback, results of the ‘Priority Grid’, and the JCAHO dimensions of performance.

Dimensions of performance include the following factors for performance and ask these questions:

  1. Efficacy: Will you improve the degree to which care/service accomplishes the desired outcome?
  2. Appropriateness: Will you improve the degree to which care/service is relevant to the patient’s general condition?
  3. Availability: Will you increase the availability of services to the patient and the community?
  4. Timeliness: Will you provide the service or complete the task in a timely manner?
  5. Effectiveness: Will you improve the effectiveness of the service or the task?
  6. Continuity: Will you improve the continuity of service over time and coordination and collaboration of services?
  7. Safety: Will you reduce risk of danger in the environment?
  8. Efficiency: Will you reduce the cost or the utilization of resources to provide care/service?
  9. Respect & Caring: Will you increase the patients’ or significant others’ involvement in care? Will you increase the sensitivity to understanding and exceeding the patients’ and others’ needs, wants, and expectations?

This particular dimension of performance will be included in all relevant PI efforts.



The facility promotes a working environment FREE of sexual harassment.


  1. What is Harassment?
  2. Making derogatory comments, including telling jokes, about someone’s age, color, race, religion, sexual preference, national origin, disability, or sex.
  3. Sexual Harassment is defined as:
  4. Unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature, when one of the following criteria are met:
    • Submission to the conduct, either implicitly or explicitly, is made as a condition of term of employment.
    • An individual’s submission to or rejection of the conduct is used as the basis for employment decisions affecting that individual.
    • Such conduct has the purpose or effect of unreasonably interfering with the employee’s work performance or creating a hostile, intimidating, or offensive working environment.
  5. What is Third Party sexual harassment?
  6. It is defined as unwelcome sexual behavior that is not directed at the employee personally, but is part of his or her work environment. For example, when sexual behaviors between two employees, although not directed at anyone else, is offensive to a third employee.
  7. Is it considered sexual harassment if a vendor or customer is making derogatory remarks or offensive actions?
  8. Yes. If a customer or vendor continually comes into contact with an employee and repeatedly harasses him or her, a hostile work environment has been created. If this happens to you, notify your manager immediately. Your manager, along with the Director of Human Resources, will investigate.
  9. Does this mean I can’t date someone at work?
  10. the facility discourages dating between employees. If a co-worker for a date and the answer is no, don’t pursue it. If you repeatedly ask out a fellow employee, and he or she repeatedly says not, then you may be creating a hostile work environment.
  11. Is this another case of male bashing?
  12. No. Sexual harassment is real and detrimental to morale and productivity. It can be male to female, female to male, male to male or female to female.
  13. Do I have to take down my posters, pictures, and cartoons?
  14. Yes, displaying sexually suggestive objects, pictures and cartoons may constitute sexual harassment.
  15. Can I tell someone they look nice?
  16. Yes. You may still compliment someone on his or her outfit or appearance as long as the compliment is in good taste.
  17. I kid around a lot and tell jokes and everyone likes it. I really don’t mean anything by my comments … do I have to stop?
  18. Not necessarily, you can continue to have fun while you work, but you must make sure your remarks and jokes aren’t offensive to anyone and can’t be overheard by anyone who may take offense. If your behavior is offensive to someone, you must stop. The intent of your actions does not matter; the impact does.
  19. If I file a sexual harassment claim, will it be part of my personnel file or get the accused person fired?
  20. Whether or not it goes into your personnel file depends on the outcome of the investigation. The outcome also determines what happens to the accused person. Your manager may tell the person to stop their offensive behavior. Disciplinary actions may be necessary up to and including dismissal to stop the behavior.
  21. What if I am not being harassed, but others are? Should I do anything about it?
  22. Absolutely? You should inform your manager. Sometimes the others may not say anything because they are too embarrassed or fearful of losing their jobs. Additionally, the harassment of others may create a hostile work environment for you.
  23. What should you do if you are harassed?
  24. 1. Tell the person who is doing the harassing to stop. Sometimes the harasser may not know his or her behavior is harassing.
  25. If the harassment does not stop, call your supervisor (or your supervisor’s boss if your manager is doing the harassing).
  26. If the situation is not resolved, contact the Director of Human Resources.



 The facility values the diversity we have in our community and the employees we serve. We are committed to fostering cultural competence and therefore provide education in this area to our employees. By incorporating cultural sensitivity and other diversity issues into our educational programs and other organizational initiatives, we foster behavioral qualities such as respect, dignity, individual consideration and spiritual/religious acceptance and support.

As the needs of the community continue to change, our goal is to adapt in order to meet the needs of our customers by advancing cultural competence. Cultural competence includes examining the impact of attitudes on patient care, accepting different values, expanding communication styles to accommodate the needs of others, and the ability to intervene appropriately and effectively while demonstrating sensitivity. Each employee must understand and be given guidance on his/her role in supporting a positive customer experience as it relates to cultural diversity. Safeguarding our customers’ values and beliefs is the cornerstone of our diversity programs.

In recognition of the changing workforce as well as our diverse customer base, we understand the importance of a multi-cultural perspective when providing service. In our commitment to support diversity, we acknowledge that culture impacts how we perform as employees as well as the implications for recovery and care for our patients. We encourage our employees to contribute to the well-being of others by working with integrity and continually striving to be culturally sensitive to the needs of others.

Traditional work styles and archaic viewpoints can decrease productivity, create interpersonal conflicts, and lower job satisfaction because of lack of respect for differences. Therefore, as an organization we understand that we must now rethink old attitudes and assess whether or not current practices support the current business culture. Our organizational values and principles are designed to provide an environment where all employees are heard and motivated to work together to perform at the highest level and achieve professional fulfillment.

As an employee, we understand that each of us is responsible for safeguarding organizational ideals and the value system of the individual. We are able to achieve this by demonstrating behaviors that promote the following:

Professionalism – Acknowledging the presence of others

Empathy – Demonstrating sensitivity and cultural responsiveness to the diverse needs of others

Action – Respond to customers and departmental needs in a timely manner

Conflict Resolution – Deal with conflict as an opportunity to improve relations

Evaluation – Assess results of each customer interaction



We all deserve a workplace that is free from violence or threats of violence. While we can’t predict when violence will occur, there are some warning signs that may help us recognize the potential for violence in patients and co-workers or others coming into our organization.

Personal Factors:

  • Chronic or acute mental illness
  • History of violent behavior
  • Drug or alcohol problems
  • Medical condition or medication side-effects
  • Recent divorce or separation

Take Precautions – Think Prevention:

Violence can often be avoided if you take necessary precautions. When dealing with patients and visitors:

  • Wear clothing such as low-heeled shoes to reduce your risk of injury
  • Avoid wearing jewelry to work
  • Keep keys and pens, which may be used as weapons, out of sight
  • Report all threats to your supervisor
  • Use the “buddy” system anytime you think that your personal safety may be at stake

Take Precautions – Defuse the Situation:

It is important to know how to defuse a potentially violent situation. If an angry, out of control person confronts you, what should you do?

  • Back off; give the person plenty of space
  • Speak in a calm voice
  • Work to build trust
  • Let the person talk about why they are upset
  • Listen carefully
  • Help define the problem by asking for examples of what the person means
  • Explore solutions by asking open-ended questions
  • Provide clear, responsive feedback

Organizational workplace violence policy – a policy of “zero tolerance” for workplace violence has been adopted. Any employee, regardless of position in the organization, will be disciplined up to and including termination for any violation of the workplace violence policy.


  1. Violent acts, such as hitting, shoving or stabbing
  2. Possession of weapons on the property, such as a bomb or gun
  3. Verbal or nonverbal threats, such as “I’ll take care of you” or shaking fists or waving a knife
  4. Intentional damage to property, such as slamming doors, hitting walls or breaking equipment


Property – Employees should have NO EXPECTATION of privacy for organizational property. This includes: offices, desks, lockers, computers, phones, e-mail, etc.

Report – Report ALL violations to your supervisor.

Investigate – ALL allegations will be investigated. It is every employee’s responsibility to cooperate with investigations.