Risk Management Guidelines
to protect clients, staff, and organizational operations by establishing clear procedures for responding to emergencies, behavioral health crises, and operational disruptions while maintaining ethical, legal, and clinical standards.
1. Emergency Procedures
Medical Emergencies (Client or Staff)
Immediate Actions
- Call 911 immediately
- Provide:
- Office address
- Nature of the emergency
- Individual’s condition
- Do not leave the individual unattended
- Provide first aid if trained
- Clear access for emergency responders
Staff Responsibilities
- Front desk directs emergency personnel to the appropriate location
- Clinician remains with the individual until responders arrive
Documentation
- Incident report completed within 24 hours
- Clinical note entered in client record (if applicable)
- Notify Clinical Director as appropriate
2. Suicidal or Homicidal Risk
If a client expresses intent to harm self or others:
Clinical Response
- Conduct immediate risk assessment:
- Intent
- Plan
- Means
- Timeframe
- Do not leave client alone if risk is imminent
Interventions (as appropriate)
- Safety planning
- Contact emergency contact
- Referral to crisis services or mobile crisis unit
- Call 911 for imminent danger
- Initiate involuntary hospitalization (Baker Act – Florida) if criteria met
3. Threats of Violence in the office
- Remain calm and attempt verbal de-escalation
- Maintain safe physical distance
- Alert staff as needed
- Call 911 if safety is at risk
- Evacuate area if necessary
4. Crisis Escalation Pathways
Level Situation Required Action
Level 1 Emotional distress Provide therapeutic intervention
Level 2 Moderate risk (passive SI, no plan) Safety plan and increased monitoring
Level 3 Active SI with plan Supervisor consultation and crisis referral
Level 4 Imminent danger Contact emergency services (911)
5. After-hours Crisis Protocol
Crosspoint Counseling Center does not provide 24/7 crisis services.
Clients are instructed to contact:
- 988 Suicide & Crisis Lifeline
- Local crisis stabilization unit
- 911 in emergencies
This information is communicated via:
- Intake documentation
- Voicemail messaging
- Client portal communications
6. Supervisor and Leadership Escalation
Clinicians must escalate when appropriate by:
- Consulting Clinical Supervisor
- Notifying Director of Operations or leadership for serious incidents
- Documenting all consultations
Situations requiring escalation include:
- Suicidal or homicidal risk
- Abuse reporting
- Ethical concerns
- Threats toward staff
7. Mandatory Reporting
Clinicians are required to report suspected:
- Child abuse
- Elder abuse
- Abuse of vulnerable adults
- Credible threats to identifiable individuals (duty to warn)
Reporting Authority: Florida Abuse Hotline
Documentation must include:
- Date and time of report
- Hotline reference number
- Summary of concern
8. Disaster Response
Natural Disasters (Hurricanes, Severe Weather)
Preparation
- Maintain updated client contact information
- Ensure secure, cloud-based EHR backups
- Maintain staff contact tree
- Enable telehealth capability
Operational Response
- Notify clients of closures via:
- Phone
- Secure messaging (Therapy Notes)
- Website updates
- Transition services to telehealth when feasible
Evacuation Procedures
Applicable for:
- Fire
- Gas leak
- Active threat
- Structural damage
Procedure
- Evacuate immediately
- Assist clients calmly
- Move to designated safe location
- Check rooms if safe to do so
- Contact emergency services if needed
Fire Emergency
- Activate fire alarm
- Call 911
- Evacuate building
- Use extinguisher only if trained and fire is contained
9. Data and Operational Risk Management
Preventative Measures
Preventative Measures
- HIPAA-compliant EHR system
- Secure billing platforms
- Password-protected devices
- Annual HIPAA training for staff
Data Breach Response
- Notify leadership immediately
- Contain breach
- Assess scope and impact
- Follow HIPAA breach notification requirements
10. Data and Operational Risk Management
All significant events must be documented, including:
- Client crises
- Medical emergencies
- Injuries on-site
- Threats or violence
- Property damage
Required Elements
- Date and time
- Individuals involved
- Description of incident
- Actions taken
- Follow-up recommendations
Timeline: Within 24 hours
11. Staff Training
All staff are required to complete training in:
- Suicide risk assessment
- Crisis intervention
- De-escalation techniques
- Mandatory reporting laws
- Emergency procedures
- HIPAA compliance
Frequency
- Upon onboarding
- Annually thereafter
12. Plan Review
This Risk Management Plan will be reviewed:
- Annually
- Following any major incident
- Upon regulatory or policy changes
Responsible: Director of Operations