LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 109.01 Security/Safety/Threat Management and Violence Prevention
 
  PROCEDURES
  1. A Security Incident Report (SIR) shall be completed whenever, but not limited to, any of the following occurrences at a DMH facility. In addition, a call shall be placed to the Los Angeles County Department of Mental Health (DMH) Human Resources Bureau (HRB), Performance Management Unit, to inform them of the incident.
     
    1. Verbally abusive or threatening language or behavior toward another employee, a supervisor, or any other person on DMH premises;
       
    2. Unauthorized entrance to County premises during non-scheduled working hours or entrance into unauthorized areas during regular working hours;
       
    3. Any verbal threats or physical acts of arson, robbery, rape, vandalism, etc.;
       
    4. Any incident that places on-duty County employees at risk of becoming a victim of violence and/or crime;
       
    5. Any incident on County property or that places County property at risk, including incidents which require action by law enforcement, Sheriff Security Officer, or contract security guard (whether they were summoned or not); and
       
    6. Any employee-related acts of violence specified in DMH Policy 605.04.
       
  2. The SIR shall be completed by the person directly involved in the incident and manager or Clinic Based/Facility Safety Officer. The SIR shall be emailed to the Clinic Based/Facility Safety Officer, the Department Health and Safety Officer (DHSO), and Security Operations Unit (SOU). A SIR must be submitted no later than the end of business on the day following the incident. In addition to completing a SIR as described in Section A, a follow-up telephone call shall be made by the manager/designee to the Clinic Based/Facility Safety Officer to briefly describe the situation and begin necessary precautions.
     
  3. Threat Management
     
    1. The manager shall perform the following to protect employees from threats or retaliation by former employees:
       
      1. Notify DMH-HRB and fellow employees of a former employee’s threats;
         
      2. Require any discharged employees to obtain special permission from management to return to the facility for any purpose, including provisions for terminated employees to follow up with the DMH-HRB regarding returning keys, ID badge, and final pay warrant per DMH Policy 560.01.
         
      3. Call and report any acts or threats of violence made by discharged or current employees to:
         
        1. The Clinic Based/Facility Safety Officer who will begin documentation which includes a log of events, notification, and any contacts initiated and maintained by the designated person at the facility;
        2. The DHSO for assessment to determine if additional steps and notifications are needed and for record-keeping;
        3. SOU staff for assistance in determining if the threat elements of Penal Code (PC) 422 (threats of violence), PC 646.9 (stalking), and PC 601 (felony trespassing) have been met; and
        4. The DMH-HRB Performance Management Unit who will work with the manager with regard to corrective action in compliance with the CDG.
           
    2. Threats by clients toward an employee: Staff shall report client threats to a manager/designee. The manager/designee shall carefully assess the client(s) to determine the nature and seriousness of the threats. The manager/designee is to determine all of the interventions necessary to ensure staff and client safety. The therapeutic nature of the services provided should be preserved to the extent possible.
       
      1. The manager/designee shall:
         
        1. Ensure that the employee is notified of the threat;
        2. Immediately discuss the situation with all relevant parties to determine the seriousness of the threat;
        3. Consider the range of interventions that would, when possible, address the provision of therapeutic services and resolve the security concern;
        4. In situations where the manager/designee determines that the security concern cannot be adequately resolved through clinical intervention, notify security personnel, the Clinic Based/Facility Safety Officer, SOU, and the District Chief of the threat;
        5. Email the SIR to the DHSO and SOU as in Section B;
        6. The DHSO, DMH Security Coordinator, and Clinic Based/Facility Safety Officer should also be contacted by phone to explain the situation; and
        7. In situations in which the threatening client is physically within the clinic, immediately contact security personnel and local law enforcement.
           
      2. The DHSO, DMH Security Coordinator, and Clinic Based/Facility Safety Officer shall assist the manager in initiating a safety/security plan which shall include:
         
        1. Offering an alternative worksite to the employee;
        2. Taking extra security measures such as having security personnel escort the threatened employee and other concerned staff to and from their vehicles; 
        3. In consultation with the manager and/or District Chief, assigning a point person at the clinic for communications with the client;
        4. In consultation with the manager/and or District Chief, consider DMH Policy 312.01 and, if indicated, transfer the client to another clinician at the clinic or another clinic/agency in the Service Area or County;
        5. Consult with SOU staff for assistance in determining if the threat elements of Penal Code (PC) § 422 (threats of violence), PC § 646.9 (stalking) and PC § 601 (felony trespassing) have been met;
        6. Consult with SOU staff and, in conjunction with the manager, assist the threatened employee in identifying his/her options which may include:
           
          • Filing a police report; and
          • If indicated by the nature of the threat and in conjunction with SOU, County Counsel, and the Crisis Management Team determining other legal options such as a temporary restraining order.
             
        7. Maintain documentation which includes a log of events, notification, and any contacts initiated and maintained by the designated person at the facility.
           
    3. The clinic manager is responsible for contacting local police where deemed appropriate (e.g., for theft, police report is necessary to substantiate a request for replacement of stolen items).
       
    4. Along with the SIR form, the following forms should be used as appropriate: Safety Intelligence Report, Accident/Incident Investigative Report (AIIR), Employer’s Report of Occupational Injury or Illness, etc.
       
    5. Any violation by employees of any of the rules set forth in this policy, or other action(s) taken contrary to the DMH’s best interest, will be sufficient grounds for corrective action in accordance with the CDG.