CDS Family & Behavioral Health Services, Inc.
Risk Management Five Year Plan
FY 2013-2018
Completed By:
Executive Management Team
which serves as
CDS’s Risk Management Committee
March 2013
This publication can be made available in multiple media formats upon request.
Mission
Strengthening Communities by Building Strong Families.Geographical Area:
Alachua, Baker, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Madison, Putnam, Suwannee, Taylor and Union Counties
CDS
1218 NW 6th Street
GAINESVILLE, FL 32601
(352) 244-0628
Table of Contents
Risk Management Philosophy 1
Risk Management Goals 1
General Safety Principles 1
Responsibility for Risk Management 1
Strategy: Maintain incorporation status. 2
Articles of Incorporation 2
Bylaws 3
Indemnification 3
Conflict of Interest Policy 3
Strategy: Maintain an active Board of Directors. 3
Board Policies 3
Board Orientation 3
Board Recruitment and Nomination 3
Board Minutes 4
Risk Financing Strategy 4
Strategy: Reduce risks and liabilities related to personnel issues. 4
Written Employment Policies 4
Communicating Changes in Policy 4
Use of Position/Job Descriptions 5
Employee Orientation 5
Additional Employee Training 5
Staff Supervision 5
Performance Appraisal Process 6
Strategy: Ensure compliance with Florida Statutes, Rules, Program Rules, and Contract Management Requirements. 6
Participant Safety 6
Incident Reporting 6
Work Rules/Code of Conduct 7
Participants Rights and Responsibility 7
Interpersonal Relationships 7
Applications 7
Interview Guide 7
Reference Checks 7
Criminal History Background Checks 7
Emergency Plan Policy and Emergency Plan 7
Facilities Access 8
Training and Supervision 8
Strategy: Reduce financial risks and liabilities. 8
Financial Responsibilities and Objectives 8
Budgeting Process 8
Financial Statements 8
Internal Controls 9
Audit 9
Investment Policy 9
Strategy: Reduce information technology risks and liabilities. 9
Safeguarding Equipment, Systems, and Data 10
Limiting Access to Confidential Information 10
Wireless IT resources 10
Passwords 10
Backups 10
Internet & E-mail System Security 10
Website Functionality and Content 10
Strategy: Reduce environmental risks and liabilities. 11
Facility Design 11
Inspections 11
Preventive Maintenance 11
Facility Rental/Lease Policy Error! Bookmark not defined.
Policy Concerning Invitees 11
Using Others' Facilities Policy 11
Strategy: Reduce travel and transportation risks and liabilities. 12
Authorized Vehicle Use Policy 12
Driver Selection Policy 12
Driver Training 12
Vehicle Maintenance 13
Accident Procedures 13
Strategy: Reduce risks and liabilities resulting from emergency situations. 13
Emergency Planning Policy 13
Business Continuity Planning (BCP) Policy, Procedures and Plan 13
Internal Distribution for BCP Policies, Procedures and Plan 14
Vital Information Backup Policy 14
Crisis Communications Policy 14
General Evacuation Policy 14
Strategy: Reduce risks and liabilities related to working with volunteers. 14
Priority Volunteer Risks 14
Addressing Risks through Recruitment, Screening and Selection 14
Supervision of Volunteers 15
Volunteer Dismissal 15
Strategy: Maintain adequate liability insurance. 15
Insurance Advisors 15
Risk Management Philosophy
Underlying the mission of CDS is a concern for the well-being of the participants, volunteers, and employees in the organization. Protecting the health, safety, and security of the people who serve and receive services is an integral part of every program. In keeping with this philosophy, activities must be chosen with the abilities of participants in mind, and staff must be selected with care and trained to carry out their activities with a high degree of safety.
Risk Management Goals
CDS seeks to involve appropriate personnel at all levels in the identification of risks and creation of practical strategies in order to make certain that CDS’s approach to risk management considers diverse perspectives and staff understand their roles and responsibilities in protecting the mission and assets of the organization.
General Safety Principles
§ CDS strives to protect the organizations assets and reduce its exposure to loss in four categories:
1. People – Participants, employees, board members, volunteers, donors and the general public.
2. Property – Buildings, facilities, vehicles, equipment and materials.
3. Income – Contracts, grants, participant fees and contributions.
4. Goodwill – Reputation, stature in the community and the ability to raise funds and appeal to prospective volunteers.
§ CDS strives at all times to operate in compliance with local, state, and federal laws and regulations.
§ CDS adheres to the policies and standards of licensure, quality assurance, contract, financial audit, and accreditation organization in matters related to the health safety, and well-being of participants.
§ Those involved in CDS bear responsibility for the health, safety, and security of participants. This is a primary responsibility of the Board of Directors, CEO, volunteers, and program staff.
§ Safety and risk management activities are multi-faceted and include:
1. Thoughtful screening, selection and training of volunteers and employed staff.
2. Creation and enforcement of policies, standards, guidelines, and procedures as guides for planning.
3. Maintaining safe and secure facilities.
4. Establishing procedures to be followed in the event of an emergency.
5. Maintaining clear communications channels.
6. CDS purchases insurance coverage as a financing mechanism for certain risks, but recognizes that insurance is not a substitute for vigilance in planning and implementing programs.
Responsibility for Risk Management
Board of Directors
§ Adopts and establishes Employee Handbook policies and standards for employees of CDS.
§ Reviews operational reports to determine compliance and future priorities.
§ Reviews and adopts the annual audit.
§ Reviews the organization's insurance program periodically.
§ Reviews CDS financial statements.
Chief Executive Officer
§ Assigns staff to design and carry out safety and risk management activities.
§ Assigns staff to perform annual review of the safety and risk management activities.
§ Executes contracts for the organization.
§ Sets risk management goals and operating objectives.
§ Ensures compliance with agency policies and standards imposed by licensure, quality assurance, contracts, financial audit, and accreditation organization.
§ Address annual budget issues with risk management included.
§ Reviews the organization's risk management plan annually.
§ Keeps the board apprised of emerging threats and opportunities.
Chief Operations Officer
§ Responsible for organization-wide effort to protect the vital assets of CDS and engage key stakeholders in risk management activities.
§ Coordinates meetings of the EMT to address Risk Management Committee issues.
§ Develops implements and monitors loss prevention programs.
§ Conducts contract reviews; develops indemnity agreements, hold-harmless agreements and consent forms, and coordinates the purchase of insurance.
§ Monitors and evaluates the insurance program, maintaining appropriate funding levels, accurate loss forecasting, claims management, loss prevention, and cost containment programs.
§ Integrates risk management throughout the organization's programs.
Risk Management Committee: COO\EMT
§ Identifies and reports risks that may affect vital assets of CDS and engage key individuals in the protection of programs and services.
§ Convenes periodically to assess the agency's priority risks and corresponding risk management strategies.
§ Implements and monitors loss prevention programs.
Strategy: Maintain incorporation status.
Source Documents: Governance structure – refer to the Board Governance Policies and Procedures on the CDS intranet. Florida Department of Agriculture & Consumer Services
Articles of Incorporation
CDS was incorporated in the State of Florida on March 20, 1970. The articles of incorporation were last reviewed January 2007 to amend the name from Corner Drug Store, Inc. to CDS Family & Behavioral Health Services, Inc. and to ensure compliance with state laws. We have maintained our corporate status by filing a report with the state annually, as required by law. The original articles of incorporation are stored at 1218 NW 6th Street, Gainesville, Fl 32601. An authenticated copy of the articles of incorporation is stored electronically and maintained by the Chief Operations Officer.
Objectives:
1. In the third quarter of each fiscal year the agency will file a corporate status report with the state.
2. The Executive Committee of the Board will review the Articles of Incorporation and the Bylaws with the current mission and purpose of the organization during their Board schedule.
3. In December of each year, comply with the registration procedures for the Solicitation of Contributions Act (CH2834)
4. Every 5 years, update the Consumer Certificate of Exemption. (Next update due 1/31/2019)
Bylaws
The Executive Committee of the Board reviews the bylaws periodically to determine the need for any revisions and if necessary followed the proper amendment process. Any amendments are stored at 1218 NW 6th Street, Gainesville, Fl 32601. An authenticated copy of the bylaws and amendments is stored electronically and maintained by the Chief Operations Officer.
Objective:
1. Every member of the board shall receive a current copy of the bylaws when they join the board and whenever the bylaws are amended.
Indemnification
The indemnification provision is maintained through a “Directors and Officers” liability insurance policy.
Objective:
1. Directors and Officers insurance shall be evaluated in the month prior to its renewal date every year for adequacy.
Conflict of Interest Policy
The Board of Directors adopted a Conflict of Interest Policy in July 2012.
Strategy: Maintain an active Board of Directors.
Source Documents: Board Operations – Refer to the Board Governance Policies and Procedures on the CDS intranet.
Board Policies
The CDS Board of Directors has adopted a Board Manual containing the key policies and expectations of the board.
Objective:
1. The manual is reviewed by the Executive Committee of the board and updates are made on an as-needed basis.
Board Orientation
To ensure that the members of the Board of CDS are properly trained and prepared for their service, the organization conducts board orientation training for all new members.
Objective:
1. The CEO will orient new members to CDS and responsibilities of being on the Board. Current Board members share their insights and coach new members in fulfilling their board duties.
Board Recruitment and Nomination
When recruiting for new members for the Board of Directors the board strives to have a diverse and qualified board with people who bring the skills, qualities, and expertise needed to lead and govern the organization in accomplishing its mission.
Board Minutes
CDS recognizes the importance of the board meeting minutes and each board member is aware of his/her responsibility for ensuring the accuracy of the minutes. At each regularly scheduled board meeting, the minutes of the prior meeting are reviewed and adopted by the board.
Objective:
1. The board minutes are maintained in date order in a notebook by the HR Specialist.
Risk Financing Strategy
To safeguard the assets and resources of CDS, the organization purchases insurance for those insurable risks of major importance to mission-critical operations and the financial health of the organization.
Objective:
1. The COO is responsible to oversee the organization's insurance program and provide periodic insurance updates to the Board.
Strategy: Reduce risks and liabilities related to personnel issues.
Source Documents: Human Resources – Refer to HR Policies and Procedures and Forms on the CDS intranet.
Written Employment Policies
CDS has adopted a number of critical employment policies which are containedin theEmployee Handbook. The Handbook is distributed to all incoming staff on their first day of employment and employees are required to acknowledge review and receipt of the Handbook and an agreement to abide by the policies therein. It is CDS practice to review the Handbook carefully prior to taking any disciplinary action against an employee to ensure that the policies have been appropriately considered. Employees who have questions or concerns about any of the policies contained in the Handbook are encouraged to speak with their direct supervisor, the Human Resources Specialist, or COO.
Objectives:
1. Supervisors consult with the COO prior to taking disciplinary action regarding serious violations or multiple violations of work rules, staff conduct, or ethical issues. The COO will consult with the CEO and in some cases may consult with the CDS employment attorney before proceeding with a meeting with the employee.
2. The employment attorney monitors personnel records annually for compliance with state and federal employment laws. CDS uses the recommendations from the employment attorney’s, licensure, quality assurance, contract, accreditation, financial audit recommendations, board changes and EMT input to update the Employee Handbook every year.
3. Annually the employment attorney provides supervisors training on employment liability issues.
Communicating Changes in Policy
Each time a new employment policy is adopted the information is provided to employees during staff meetings. If there are major revisions to the Employee Handbook, the Handbook is updated and distributed to staff. Staff members are required to sign a new acknowledgement form upon receiving the new policy/revised Handbook.
Objective:
1. Staff members shall sign a new acknowledgement form upon receiving the new policy/revised Handbook.
Use of Position/Job Descriptions
CDS uses job descriptions for both paid and volunteer positions. These documents are developed by both line staff and supervisory personnel. The COO reviews all job descriptions on an annual basis and updates are made as needed. Employee job descriptions were updated in 2008 in total. Changes to individual job descriptions have been revised since that time based on input through the employee evaluation process and supervisors recommendations regarding change of duties.
Objective:
1. The COO will review all job descriptions on an annual basis for appropriateness. At the time of the employee’s annual evaluation, job descriptions will be reviewed by the supervisor and the employee. Any recommendations for changes will be submitted to the COO.
Employee Orientation
During orientation agency policies and procedures are reviewed, the employee is asked to provide any additional information necessary for benefits enrollment, and the employee is encouraged to ask questions about any aspect of employment policy or operations. An on-site orientation for new employees includes an introduction to other staff and the provision of an overview of the program and services, equipment and technological systems they will be required to use.
Objective:
1. The Human Resources Specialist at CDS is responsible for conducting a minimum of 7.5 hours new employee orientation/benefits training session on the first day of employment.
Additional Employee Training
Employees receive on the job training and in-service training as outlined in the staff development training plan.