Stabilization and Crisis Unit SACU Safety Plan



|[pic] |Stabilization and Crisis Unit (SACU) |

|Aging and People with Disabilities |Safety Plan |

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|Name: |      | |Date: |      |

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|In the event of a medical emergency, staff will immediately call 911 and provide emergency First Aid. At the earliest opportunity, notifications will be made to |

|the Site Manager, Program Manager, County Case Manager/Service Coordinator and Guardian or health care representative. This includes but is not limited to seizures|

|for an individual who does not have a seizure protocol, difficulty breathing, chest pains, uncontrolled bleeding or any possible life threatening event. |

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|At all times, when leaving the group home (walks, drives, purchases, etc.), a State of Oregon cell phone must accompany staff. Verify the phone is on, charged and |

|the number is recorded on the DHS 4628 Outing Log along with the destination. |

|All answers are transferred directly from the RTR notes section {delete all purple text before printing} |

|1. |Does this person need support to keep from falling and suffering from injury? (#38 on RTR) |

| | | No Yes (Describe risks and type(s) of support below): |

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|2. |Is this person able to remain at their group home without support for any length of time? ( #40 on RTR) |

| | | No Yes (Describe risks and type(s) of support below): |

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|3. |Is this person able to be away from their group home without SACU support for any length of time? |

| |( #41 on RTR) |

| | | No Yes (Describe risks and type(s) of support below.) |

| | |(If yes, describe circumstance — i.e. family/guardian visits, school, etc.) |

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|4. |Does this person need any assistance to adjust water temperature? ( # 42 on RTR) |

| | | No Yes (Describe risks and type(s) of support below): |

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|5. |Does this person need any assistance to evacuate during an emergency? |

| |(Address level of assistance this person requires if applicable): ( # 43 on RTR) |

| | | No Yes (Describe risks and type(s) of support below): |

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|6. |Does this person need any assistance to remain safe around all toxic materials, including but not limited to poisons, household chemicals, and insecticides at |

| |home and/or in the community. |

| |( # 44 on RTR) |

| | | No Yes (Describe risks and type(s) of support below): |

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|7. |Does this person need any assistance to remain safe around traffic, while getting in or out of vehicles or while riding in vehicles? (#45 on RTR) |

| | | No Yes (Describe risks and type(s) of support below): | |

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|8. |Does this person have any court mandated conditions or restrictions? ( #46 & 64 on RTR) |

| | | No Yes (Describe risks and type(s) of support below): | |

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|9. |Does this person have any other important, serious safety issues? |

| | | No Yes (Describe risks and type(s) of support below): | |

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|General house safety |

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| Alarmed door | Alarmed windows | Motion monitor | Electronic, mag lock door(s) |

| Other: |      |

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|Locked: |

| Bathroom door | Kitchen door | Gates | Hygiene supplies |

| Personal storage | Knife drawer | Other: |      |

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|Comments: |

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|Missing or separated from agency |

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|This person is considered missing if the area (group home and/or community) is searched and they are not immediately found or if they become separated while in the|

|community. |

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|If missing/separated, conduct a thorough search of the area and notify Site Manager. Staff will notify the Site Manager, Police and Program Manager immediately |

|following the search if the person still hasn’t been found. If the person is not found within 15 minutes, notify their Service Coordinator |

|and Guardian. |

|If applicable also notify: |      |

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|Update all parties of the progress and outcome of this situation. |

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|Emergency plan |

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|In the case of an event where the home has become uninhabitable, staff will follow the information listed on “DHS 0938 Summary of Emergency Plan,” located in the |

|Stabilization and Crisis Unit. (SACU) “Workplace Incident Response Procedures and Emergency Planning” book/binder. |

|Should a local or regional emergency occur while in the community, staff will call the group home or Site Manager’s cell phone to confirm whether the home is |

|uninhabitable and to seek assistance and directions. The SACU program’s “Workplace Incident Response Procedures and Emergency Planning” book/binder is at the |

|location below: |

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|Additional comments |

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|Completed by: |      |

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