October 10, 2012 Maria Laurence, MPA, Monitor Patrick ... · Monitoring Report for Corpus Christi State Supported Living Center – October 10, 2012 3 (a) Onsite review – During

UnitedStatesv.StateofTexas

MonitoringTeamReport

CorpusChristiStateSupportedLivingCenter

DatesofReview:July9ththrough12th,2012

DateofReport:October10,2012

SubmittedBy:MariaLaurence,MPA,Monitor

MonitoringTeam:PatrickHeick,Ph.D.,BCBA‐DVictoriaLund,Ph.D.,MSN,ARNP,BCEdwinJ.Mikkelsen,MDAntoinetteRichardson,MA,JDNancyWaglow,MS,MEdWayneZwick,MD

MonitoringReportforCorpusChristiStateSupportedLivingCenter–October10,2012 1

TableofContentsI. Background 2II. Methodology 2III. OrganizationofReport 3IV. SubstantialComplianceRatingsandProgress 4V. ExecutiveSummary 5VI. StatusofCompliancewithSettlementAgreement 22

SectionC:ProtectionfromHarm–Restraints 22SectionD:ProtectionfromHarm‐Abuse,NeglectandIncidentManagement 49SectionE:QualityAssurance 81SectionF:IntegratedProtection,Services,TreatmentandSupports 92SectionG:IntegratedClinicalServices 134SectionH:MinimumCommonElementsofClinicalCare 144SectionI:At‐RiskIndividuals 157SectionJ:PsychiatricCareandServices 174SectionK:PsychologicalCareandServices 216SectionL:MedicalCare 249SectionM:NursingCare 288SectionN:PharmacyServicesandSafeMedicationPractices 331SectionO:MinimumCommonElementsofPhysicalandNutritionalManagement 355SectionP:PhysicalandOccupationalTherapy 399SectionQ:DentalServices 413SectionR:Communication 437SectionS:Habilitation,Training,Education,andSkillAcquisitionPrograms 455SectionT:ServingInstitutionalizedPersonsintheMostIntegratedSettingAppropriatetoTheirNeeds480SectionU:Consent 518SectionV:RecordkeepingandGeneralPlanImplementation 528

VII. ListofAcronyms 537


I. Background

In2009,theStateofTexasandtheUnitedStatesDepartmentofJustice(DOJ)enteredintoaSettlementAgreementregardingservicesprovidedtoindividualswithdevelopmentaldisabilitiesinstate‐operatedfacilities(StateSupportedLivingCenters),aswellasthetransitionofsuchindividualstothemostintegratedsettingappropriatetomeettheirneedsandpreferences.TheSettlementAgreementcovers12StateSupportedLivingCenters(SSLCs),includingAbilene,Austin,Brenham,CorpusChristi,Denton,ElPaso,Lubbock,Lufkin,Mexia,Richmond,SanAngeloandSanAntonio,aswellastheIntermediateCareFacilityforPersonswithMentalRetardation(ICF/MR)componentofRioGrandeStateCenter.PursuanttotheSettlementAgreement,thepartiessubmittedtotheCourttheirselectionofthreeMonitorsresponsibleformonitoringthefacilities’compliancewiththeSettlement.EachoftheMonitorswasassignedresponsibilitytoconductreviewsofanassignedgroupofthefacilitieseverysixmonths,andtodetailfindingsaswellasrecommendationsinwrittenreportsthataresubmittedtotheparties.InordertoconductreviewsofeachoftheareasoftheSettlementAgreement,eachMonitorhasengagedanexpertteam.Theseteamsgenerallyincludeconsultantswithexpertiseinpsychiatryandmedicalcare,nursing,psychology,habilitation,protectionfromharm,individualplanning,physicalandnutritionalsupports,occupationalandphysicaltherapy,communication,placementofindividualsinthemostintegratedsetting,consent,andrecordkeeping.AlthoughteammembersareassignedprimaryresponsibilityforspecificareasoftheSettlementAgreement,theMonitoringTeamfunctionsmuchlikeanindividualinterdisciplinaryteamtoprovideacoordinatedandintegratedreport.Teammembersshareinformationroutinelyandcontributetomultiplesectionsofthereport.TheMonitor’sroleistoassessandreportontheStateandthefacilities’progressregardingcompliancewithprovisionsoftheSettlementAgreement.PartoftheMonitor’sroleistomakerecommendationsthattheMonitoringTeambelievescanhelpthefacilitiesachievecompliance.ItisimportanttounderstandthattheMonitor’srecommendationsaresuggestions,notrequirements.TheStateandfacilitiesarefreetorespondinanywaytheychoosetotherecommendations,andtouseothermethodstoachievecompliancewiththeSettlementAgreement.

II. Methodology

InordertoassesstheFacility’sstatuswithregardtocompliancewiththeSettlementAgreementandHealthCareGuidelines,theMonitoringTeamundertookanumberofactivities,including:


(a) Onsitereview–Duringtheweekofthetour,theMonitoringTeamvisitedtheStateSupportedLivingCenter.Asdescribedinfurtherdetailbelow,thisallowedtheteamtomeetwithindividualsandstaff,conductobservations,reviewdocuments,aswellasrequestadditionaldocumentsforoff‐sitereview.

(b) Reviewofdocuments–Priortoitsonsitereview,theMonitoringTeamrequestedanumberofdocuments.ManyoftheserequestswerefordocumentstobesenttotheMonitoringTeampriortothereview,whileotherrequestswerefordocumentstobeavailablewhentheMonitorsarrived.TheMonitoringTeammadeadditionalrequestsfordocumentswhileonsite.Inselectingsamples,arandomsamplingmethodologywasusedattimes,whileinotherinstancesatargetedsamplewasselectedbasedoncertainriskfactorsofindividualsservedbytheFacility.Inotherinstances,particularlywhentheFacilityrecentlyhadimplementedanewpolicy,thesamplingwasweightedtowardreviewingthenewerdocumentstoallowtheMonitoringTeamtheabilitytobettercommentonthenewprocedures.

(c) Observations–Whileonsite,theMonitoringTeamconductedanumberofobservationsofindividualsservedandstaff.Suchobservationsaredescribedinfurtherdetailthroughoutthereport.However,thefollowingareexamplesofthetypesofactivitiesthattheMonitoringTeamobserved:individualsintheirhomesandday/vocationalsettings,mealtimes,medicationpasses,PersonalSupportTeam(PST)meetings,disciplinemeetings,incidentmanagementmeetings,andshiftchange.

(d) Interviews–TheMonitoringTeamalsointerviewedanumberofpeople.Throughoutthisreport,thenamesand/ortitlesofstaffinterviewedareidentified.Inaddition,theMonitoringTeaminterviewedanumberofindividualsservedbytheFacility.

III. OrganizationofReport

ThereportisorganizedtoprovideanoverallsummaryoftheSupportedLivingCenter’sstatuswithregardtocompliancewiththeSettlementAgreement,aswellasspecificinformationoneachoftheparagraphsinSectionsII.CthroughVoftheSettlementAgreement.ThereportaddresseseachoftherequirementsregardingtheMonitors’reportsthattheSettlementAgreementsetsforthinSectionIII.I,andincludessomeadditionalcomponentsthattheMonitoringPanelbelieveswillfacilitateunderstandingandassistthefacilitiestoachievecomplianceasquicklyaspossible.Specifically,foreachofthesubstantivesectionsoftheSettlementAgreement,thereportincludesthefollowingsub‐sections:

(a) StepsTakentoAssessCompliance:Thesteps(includingdocumentsreviewed,meetingsattended,andpersonsinterviewed)theMonitortooktoassesscompliancearedescribed.Thissectionprovidesdetailwithregardtothemethodologyusedinconductingthereviewsthatisdescribedaboveingeneral;

(b) FacilitySelf‐Assessment:Nolaterthan14calendardayspriortoeachvisit,theFacilityistoprovidetheMonitorandDOJwithaFacilityReportregardingtheFacility’scompliancewiththeSettlementAgreement.


Thissectionsummarizestheself‐assessmentstepstheFacilitytooktoassesscomplianceandprovidessomecommentsbytheMonitoringTeamregardingtheFacilityReport;

(c) SummaryofMonitor’sAssessment:AlthoughnotrequiredbytheSettlementAgreement,asummaryoftheFacility’sstatusisincludedtofacilitatethereader’sunderstandingofthemajorstrengthsaswellasareasofneedthattheFacilityhaswithregardtocompliancewiththeparticularsection;

(d) AssessmentofStatus:AdeterminationisprovidedastowhethertherelevantpoliciesandproceduresareconsistentwiththerequirementsoftheAgreement,anddetaileddescriptionsoftheFacility’sstatuswithregardtoparticularcomponentsoftheSettlementAgreement,including,forexample,evidenceofcomplianceornoncompliance,stepsthathavebeentakenbytheFacilitytomovetowardcompliance,obstaclesthatappeartobeimpedingtheFacilityfromachievingcompliance,andspecificexamplesofbothpositiveandnegativepractices,aswellasexamplesofpositiveandnegativeoutcomesforindividualsserved;

(e) Compliance:Thelevelofcompliance(i.e.,“noncompliance”or“substantialcompliance”)isstated;and(f) Recommendations:TheMonitor’srecommendations,ifany,tofacilitateorsustaincomplianceare

provided.TheMonitoringTeamoffersrecommendationstotheStateforconsiderationastheStateworkstoachievecompliancewiththeSettlementAgreement.ItisintheState’sdiscretiontoadoptarecommendationorutilizeothermechanismstoimplementandachievecompliancewiththetermsoftheSettlementAgreement.

(g) IndividualNumbering:Throughoutthisreport,referenceismadetospecificindividualsbyusinganumberingmethodologythatidentifieseachindividualaccordingtorandomlyassignednumbers(forexample,asIndividual#45,Individual#101,andsoon.)TheMonitorsareusingthismethodologyinresponsetoarequestformthepartiestoprotecttheconfidentialityofeachindividual.

IV. SubstantialComplianceRatingsandProgress

AcrosstheState’s13Facilities,thereisvariabilityintheprogressbeingmadebyeachFacilitytowardssubstantialcomplianceinthe20sectionsoftheSettlementAgreement.Thereadershouldunderstandthattheintent,andexpectationofthepartieswhocraftedtheSettlementAgreementwasfortheStatetomakesystemicchangesandimprovementsattheSSLCsthatwouldresultinlong‐term,lastingchange.Thepartiesforesawthatthiswouldtakeanumberofyearstocomplete.Forexample,intheSettlementAgreementthepartiessetforthagoalforcompliance,whentheystated:“ThePartiesanticipatethattheStatewillhaveimplementedallprovisionsoftheAgreementateachFacilitywithinfouryearsoftheAgreement’sEffectiveDateandsustainedcompliancewitheachsuchprovisionforatleastoneyear.”Eventhen,thepartiesrecognizedthatinsomeareas,compliancemighttakelongerthanfouryears,andprovidedforthispossibilityintheSettlementAgreement.


Tothisend,large‐scalechangeprocessesarerequired.Thesetaketimetodevelop,implement,andmodify.Thegoalisfortheseprocessestobesustainableinprovidinglong‐termimprovementsattheFacilitythatwilllastwhenindependentmonitoringisnolongerrequired.ThisrequiresaresponsethatismuchdifferentthanwhenaddressingICF/DDregulatorydeficiencies.Forthesedeficiencies,facilitiestypicallydevelopashort‐termplanofcorrectiontoimmediatelysolvetheidentifiedproblem.ItisimportanttonotethattheSettlementAgreementrequiresthattheMonitorrateeachprovisionitemasbeinginsubstantialcomplianceorinnoncompliance.Itdoesnotallowforintermediateratings,suchaspartialcompliance,progressing,orimproving.Thus,aFacilitywillreceivearatingofnoncomplianceeventhoughprogressandimprovementsmighthaveoccurred.Therefore,itisimportanttoreadtheMonitor’sentirereporttoidentifytheFacility’sprogressorlackofprogress.Furthermore,merelycountingthenumberofsubstantialcomplianceratingstodetermineiftheFacilityismakingprogressisproblematicforanumberofreasons.First,thenumberofsubstantialcomplianceratingsgenerallyisnotagoodindicatorofprogress.Second,notallprovisionitemsareequalinweightorcomplexity.Somerequiresignificantsystemicchangetoanumberofprocesses,whereasothersrequireonlyimplementationofasingleaction.Forexample,SectionL.1addressesthetotalsystemoftheprovisionofmedicalcareattheFacility.ThisisincontrastwithSectionT.1c.3.,whichrequiresthatadocument,theCommunityLivingDischargePlan,bereviewedwiththeindividualandLegallyAuthorizedRepresentative(LAR).Third,itisincorrecttoassumethateachFacilitywillobtainsubstantialcomplianceratingsinamathematicallystraight‐linemanner.Forexample,itisincorrecttoassumethattheFacilitywillobtainsubstantialcompliancewith25%oftheprovisionitemsineachofthefouryears.Morelikely,mostsubstantialcomplianceratingswillbeobtainedinthefourthyearoftheSettlementAgreement.Thisisduetotheamountofchangerequired,theneedforsystemicprocessestobeimplementedandmodified,andbecausesomanyoftheprovisionitemsrequireagreatdealofcollaborationandintegrationofclinicalandoperationalservicesattheFacility(aswastheintentoftheparties).

V. ExecutiveSummaryTheMonitoringTeam’sreviewofCCSSLCidentifiedanumberofareasofprogress.Atthesametime,therewereanumberofareasinwhichadequateprogresshadnotoccurred.Insomeoftheseareas,planshadbeendevelopedand/orwerebeingimplementedtoaddresstheremainingissues.However,insomecases,morecollaborationneededtooccurwithintheFacilityand/orwithStateOfficestafftoensureadequateplansweredevelopedandimplementedtoaddressoutstandingissues.


TheMonitoringTeamrecognizesthatsubstantialeffortisneededtoachievecompliance,andthatitcanbeeasytobecomediscouraged.TheMonitoringTeamencouragestheFacilitytotaketimetocelebratethesuccessesithasachieved,andputforthrenewedeffortinareasinwhichmorefocusedsolutionsareneeded.AstheFacilitytacklestheareasinwhichproblemscontinuetoexist,itwillbeessentialthatthevariousdepartmentsworktogether,alwayskeepinginmindtheendgoalofimprovingthelivesofindividualstheFacilitysupports.Aswithpreviousreviews,theMonitoringTeamwouldliketothankthemanagementteam,allofthestaff,andtheindividualswholiveatCCSSLCfortheirassistanceduringtheonsitemonitoringvisit,aswellasinpreparationbeforethevisit,andtheproductionofmanydocumentsafterthevisit.EveryonewithwhomtheMonitoringTeamspenttimeduringtheonsitereviewwashelpfulinprovidingvaluableinformationtoassisttheMonitoringTeaminreviewingtheFacility’sstatuswithregardtotheSettlementAgreement.

ThefollowingisabriefsummaryofCCSSLC’sstatuswithregardtorelevantthesectionsoftheSettlementAgreement:Restraints

TheStatehadissuedarevisedpolicyonrestraintandtraininghadbegunonitsrevisions.ThethreeMonitoring

Teamswillprovideanycommentsonitjointly. TheFacility’sAvatardatasystemwasnotproducingreliablerestraintdataandhadnotproducedtrendreports

forJune.TheMonitoringTeamlearnedthattheAvatarsystemwasbeingupgradedtoallowdirectentryofrestraintreports,replacingthesystemofhandwrittenreports.Theconversionprocesswasunderway.However,someissuesstillexistedwithreportingthatneededtobeaddressed.

TheFacilitywasidentifyingissueswithrestraintsthatneededtobeaddressed,suchasunderstandingwhattriggeredthebehaviorthatledtorestraintsothattheycouldbeaddressed.Forexample,oneantecedenttorestraintappearedtobetheuseofcigarettes:nothavingthem,wantingthematunauthorizedtimes,andnotsharingthem.Foronewoman,anantecedentconditionwasherdesiretostayoutdoorsafter8p.m.whentheresidencesweresupposedtobelocked.TheFacilityneededtoanalyzeitsdataonrestraintstobetterunderstandtheseantecedents,anddevelopwaystoaddressthemsystemicallyaswellasindividually.

Theassignmentofrestraintmonitorshadbeenchanged,andthetrainingoftheadditionalmonitorshadbeendone.However,thelistoftrainedrestraintmonitorswasprovided,butthenamesreporteddidnotmatchthenamesofrestraintmonitorsintherestraintdocumentation.

Ingeneral,theFacilityhadsystemsinplaceforrestraintreporting,monitoring,andreviewprocesses.Concernswerenotedwithregardtohowwellthosesystemswereworking,aswellaswithdataintegrity,andwithregardtotheadequacywithwhichstaffdescribedtheantecedent‐andconsequence‐basedinterventionsusedpriortotheimplementationofrestraint.


Abuse,NeglectandIncidentManagement Actionstoprotectindividualswhowereinvolvedinunusualincidentsorallegationofabuseorneglectwere

takenquickly.Localprocedureshadbeenmodified,andtherelatedpolicywasbeingmodified,toassurethatstaffallegedtohavebeenabusiveorneglectfulwereroutinelyputontemporaryworkreassignment(TWR)toremovethemfromdirectcontactwithindividualsserved,ormonitoringwasputinplacewhenallegedperpetratorswerenotidentifiedorthecasewashandledas“streamlined”duetoaanindividualbeingidentifiedaschroniccaller.AnActionPlanwasinplacetoformallyamendtheFacilityprocedures.

TheUnusualIncidentReport(UIR)hadbeenmodifiedtoprintoutalistofallegedperpetratorssothatitcouldbeeasilydeterminediftheyhadbeenplacedontemporaryworkreassignment.

TheUIRwasfurthermodifiedtoincludeacharttotracktherecommendationsresultingfromtheinvestigation. TheReviewAuthorityTeamnoteswereincludedinfilestodocumentthereviewofanyactionstaken. TherecordscontainedsupervisorynotesforUIRsindicatingtheIncidentManagementCoordinator(IMC)had

reviewedandrequestedclarificationsoradditionalinvestigationinsomereports. TheFacilitywasstillintheprocessofdevelopingandimplementingasemi‐annualauditofinjuries; AlthoughimprovementswereseenintheFacility’seffortstofollow‐upandtrackprogrammatic

recommendationsfrominvestigativereportsanddocumentthemtoconclusion,thisremainedaworkinprogress.Fullimplementationwasessentialtopotentiallypreventrecurrenceofincidentsandallegations.

TheFacilityneededtoexpandtheanalysisandtrendingofdatatodeterminewherecorrectiveactionplansmightbeneededtoaddressemergingtrendsinabuse/neglectfindings.

QualityAssurance CCSSLCwasintheprocessofamendingitspoliciesandprocedurestoalignwiththerevisedStatePolicyon

QualityAssurance.TheredidnotappeartobeacurrentQualityAssurancePlaninplace,althoughaplanhadbeenprovidedandreviewedduringtheMonitoringTeam’slastreview.

MonitoringtoolstomeasurequalityhadbeenadoptedbasedonthetoolstheMonitoringTeamsused,andadaptedforuseintheFacility.Someguidelinesfortheuseofthetoolshadbeenwritten,andProgramAuditorswereusingthetoolsinthefield,meetingwithdisciplineheadstoshareandcompareresultsofmonitoring,anddevelopingideasforimprovementstothetoolsandguidelines.Continuedworkwasneededwithregardtointer‐raterreliability,aswellastheaccuracyofthemonitoring.SomesectionsoftheFacility’sSelf‐AssessmentwereusingdatagainedfromthemonitoringtoolsasevidenceoftheFacility’scompliancestatus.ThisshouldbecomeastandardpartoftheassessmentofeachsectionoftheSettlementAgreement.

InitialeffortshadbeenmadetoidentifydataavailableattheFacility.SomedatathatwasbeingreportedtotheStateOfficecouldbeusedasthebasisfordevelopingkeyindicators.However,theFacilitywasintheinitialstagesofthisprocess.

TheQualityAssurance/QualityImprovement(QA/QI)Councilhadbeenorganizedtodevelop,revise,andimplementqualityassuranceprocedures.Duringpreviousvisits,thePerformanceImplementationTeam(PIT)


andthePerformanceEnhancementTeams(PETs)wereinevidence.Duringthisvisit,theseteamsappearedhavebeensuspendedwithnominutesormeetingdates.Insteadtherewerethreegroupsofsectionleadsthatweresupposedtobemeetingtoworkoncomplianceissues.ThesegroupsweretoreporttotheQA/QICouncil,butitwasnotclearwhethertheyweremeetingandreporting.

CCSSLCcontinuedtoreporttrenddataandanalysesonaquarterlyscheduleforsomekeyissues,suchasrestraints,abuseallegations,incidents,andinjuries,andriskshadbeenadded.Informationwasavailabletoshowsomespecificcharacteristicsofincidents,suchaswhereincidentswereoccurring,whattimeofday,andonwhichlivingunits.Breakdownsofdatawereavailablebyunitandbyresidence,makingitpossibleforunitsandresidencestousethedataasatoolinanalyzingandaddressingundesirabletrends.However,whiledisplayingthedataoverayear‐longperiodwashelpful,therewasnoactualtrendingordisplayofperformanceovertime.

DataforsomeofthesectionshadbeenanalyzedandreportedtothesectionleadsandtheQA/QICouncil.However,formuchofthedatabeingcollected,analyseshadnotbeencompleted.Basedonobservationandreviewofdocumentation,itdidnotappeartheQA/QICouncilwasyetusingdataeffectivelytoidentifyissuesrequiringcorrectiveactionplansoreffectivelydevelopingsuchplans.

ThenextstepsshouldincludecompletingtheCorrectiveActionPlanprocess,usingthedatasystemtoreportoninformationthemonitoringactivitiesgenerate,anddevelopingasetofkeycriteriatomeasureprogressonserviceoutcomes.

IntegratedProtections,Services,TreatmentsandSupports InMay2012,theStateOfficeprovidedadditionaltrainingonarevisedISPformatandprocesstoCCSSLC’s

QualifiedDevelopmentalDisabilityProfessionals(QDDPs)andotherteammembers.ArevisedISPMeetingGuide(Preparation/Facilitation/DocumentationTool)wasintroducedtoassisttheQDDPsinpreparingforthemeetingsandinorganizingthemeetingstoensureteamscoveredrelevanttopics.Inaddition,accordingtothenewprocedures,morepre‐planningwastobegin90dayspriortotheISPmeeting.

AtthetimeoftheMonitoringTeam’sreview,twoteamshadbeenselectedtopilotthenewprocess,includingthenewat‐riskprocess.TwoISPshadbeenfullycompletedusingthenewprocess.Althoughthenewprocessshowedsomeimprovements,aswouldbeanticipatedwithanewprocess,moreworkwasneededtocontinuetomakenecessarychangesandrefinetheteammeetingsaswellastheISPdocuments.

AtCCSSLC,teamscontinuedtobeatadisadvantage,becausetheydidnotyethaveadequateassessmentsfromwhichtodevelopindividuals’ISPs.Inadditiontoproblemswiththequalityoftheassessments,teamswerenotconsistentlyidentifyingtheneedforand/orreceivingallofthenecessaryassessments.Althoughsomeimprovementwasbeingrealized,anumberofassessmentscontinuedtobesubmittedlate,makingitmorechallengingforQDDPsandotherstocompletepreparationactivitiespriortotheannualmeetings.TheFacilityandStateOfficeweretakingsomeactionstoaddresstheseconcerns.Specifically,usingadatabaseinwhichinformationrelatedtothetimelinessofassessmentswastracked,CCSSLChadbegunreviewingthisinformation


aspartofitsQA/QICouncilactivities,anddiscussingpotentialbarriersandsolutions.Inadditiontoworkingonnewformatsforassessments,theStateOfficewasdevelopingasetofqualityindicators,anditwasanticipatedCCSSLC’sdisciplineheadswouldusethesetoevaluatethequalityoftheassessments.

Withregardtoindividuals’ISPs,althoughteamswereidentifyingsomepreferencesandstrengthsofindividuals,theseremainedlimited.Inaddition,teamswerenotyeteffectivelyincorporatingindividuals’preferencesandstrengthsintoactionplans,orusingthemcreativelytoexpandindividuals’opportunitiesoraddresstheirneeds.Prioritizationofindividuals’needswasnotevidentintheISPsreviewed.Moreindividualshadactionplansthataddressedcommunityskillacquisitionplans,butthesevariedinquality.

Someprogresshadbeenmadeintheexpansionofthescopeofmeasurableobjectives,andeffortsclearlywerebeingmadetoimprovethemeasurabilityandindividualizationofobjectivesandactionsteps.However,astheFacilityrecognized,theseremainedareasinwhichsignificantworkwasneeded.

GiventhelimitedimplementationofthenewISPprocess,itremainedtobeseeniftherevisedISPMeetingGuideandprocesswouldresultwouldresultinISPsthatmorecomprehensivelyaddressedtheindividual’sarrayofneeds.Basedonthereviewofthetwoplansthatusedtherevisedprocess,someprogresswasseenwithregardtotheintegrationofamorecomprehensivesetof“protections,servicesandsupports,treatmentplans,clinicalcareplans,andotherinterventions.”However,manysupportswerestillmissingorwereinadequatelydefined.Teamswillneedcontinuedtrainingandcoachingtoimplementtherevisedprocessfully.

TheFacilitycontinuedtodevelopitsqualityassurancesystemrelatedtotheISPprocess.TheQADepartmentaswellastheQDDPCoordinatorcontinuedtomonitorISPmeetings,aswellasISPdocumentsandimplementation.Thesystemneededcontinuedrefinement,developmentandpresentationofreportsofthedatacollectedthatwouldberelevanttothevariousaudiences,analysisofdata,anddevelopmentandimplementationofcorrectiveactionplans,asappropriate.

IntegratedClinicalServices TheFacilityhadbegunassessingitselfinareassuchasattendance,qualityofIndividualSupportPlanAddenda

(ISPAs)relatedtomedicalissues,andconsultreview.Thesewereimportantareas.ItremainedunclearhowthisvaluableinformationwassharedwiththeMedicalDepartmentstafforotherdepartments.TheroleoftheMedicalDirectorinprovidingguidanceisimportantinthismedicaladministrativearea,andthecontinuedlackofaMedicalDirectorwasproblematic.

TheFacilityhadanumberofforumsinwhichintegratedservicescouldbefacilitated,including,forexample,thedailyIntegratedClinicalServicesMeeting,ISPandISPAmeetings,andcross‐disciplinecommittees.However,manyoftheselackedthefullparticipationofmembers,ordidnotresultinadequatefollow‐throughtodevelopintegrated,interdisciplinaryplanstoaddressindividuals’needsoneitheranindividualorsystemiclevel.

Improvementshadbeenmadeinprimarycarepractitioners(PCPs)reviewingconsultationreportsinatimelymanner.Althoughmoreworkwasneeded,PCPsalsoweremoreoftendocumentingtheiragreementornotwith


recommendations.However,whereadditionalworkremainedwasinensuringthatinterdisciplinaryteams(IDTs)met,reviewedrecommendations,anddevelopedISPAs,asappropriate.

MinimumCommonElementsofClinicalCare AlthoughCCSSLCwasputtingsomesystemsinplacetoensurethatassessmentsandevaluationswere

completedtimely,thesystemscontinuedtobeinthedevelopmentstage.Inaddition,thevariousdatabasescollectingthisinformationdifferedsomewhatintheresultsrelatedtotimelinessofassessments.Thismightbeduetothefactthatthedatabaseswerebeingusedfordifferentpurposes(e.g.,annualISPassessmentsasopposedtocomparisontothedateofthepreviousassessment).ChangeofstatusalsowasanareatheFacilitywastryingtobetterdefine.

Withregardtoaccuratediagnoses,reviewstheMonitoringTeamcompletedofbothmedicaldiagnosesandpsychiatricdiagnosesfoundadequatejustificationfor100%and95%,respectively.Asaresult,theFacilitywasfoundincompliancewiththisprovision.

Teamswerenotconsistentlyidentifyingclinicalindicatorstomeasuretheefficacyoftreatmentinterventionsforindividualsatrisk.Problemswiththeindicatorsincluded,attimes,alackofmeasurability.Thequalityoftheindicatorsalsowasproblematicintermsoftellingtheindividuals’teamswhetherornottheindividualsweredoingbetterorworse,orremainingthesame.Finally,individuals’teamsoftendidnotdevelopmeasurableindicatorstoaddressalloftheindividuals’areasofrisk.AlthoughtheFacilityhaddevelopedsomeAtRiskClinicalIndicatorsGuidelines,thesewerenotyetfullyinuse.

TheFacilitystilldidnothaveanadequatesystemtoeffectivelymonitorthehealthstatusofindividuals.Asoneexample,asdiscussedwithregardtoSectionM,althoughquarterlynursingassessmentswerebeingcompleted,theywereinadequate.Inaddition,day‐to‐daynursingassessmentswerenotadequatetoensurethatchangesinindividuals’statuswerepromptlyidentifiedandreportedtothePCPs.

At‐RiskIndividuals Sincethelastreview,theStateOfficehadmaderevisionstotheAt‐RiskIndividualspolicy(indraftformatthe

timeofthereview).SomeofthechangesincludedregroupingtheRiskGuidelinessothattheriskfactorsthatwereclinicallyinter‐relatedregardingoutcomesorprovisionofservicesandsupportswerelistedtogether,andlinkingeachriskfactorwithspecificclinicalindicators.Inaddition,theIntegratedRiskRatingForm(IRRF)wasrevisedtofollowthesamegroupingsequenceastheRiskGuidelines.SomeadditionalrevisionsincludedreplacingtheRiskActionPlansfortheidentifiedhighandmediumriskindicatorswithIntegratedHealthCarePlans(IHCPs)designedtoprovideacomprehensiveplanthatwillbecompletedannually;differentformsregardingIRRFandtheIHCPweredevelopedaddressingchangesinstatus;theAspirationPneumoniaEnteralNutritionwasrevisedasadatacollectiontool;andTriggerDataSheetsweredevelopedtoincludeobservableandmeasurableclinicalsignsandsymptomsthatalertthestafftopossiblechangesinstatus.

InMay2012,twoteamsatCCSSLChadbeentrainedonthenewpolicyandprocesses,andhadbeguntopilotthem.Itwasimportantthatthenewsystemwasbeingpilotedwithtwoteamstodetermineanyadditional


implementationsteps/changesthatneededtobemade,oranyadditionaltrainingthatwouldbebeneficialbeforebroadeningitsscopetotheentirecampus.ThemanychangesthathadoccurredwithregardtotheAt‐RisksystemwerereflectedinthedifferentISPdocuments,andthevaryingqualityoftheIRRFindicatedsomeconfusionamongsttheteamswiththepreviousprocess.Developingasuccessfulprogramonasmallscalethatcanthenbeimplementedacrosscampusshouldreducesuchissues.Stafffromthepilotsystemsintworesidencesalsocouldactasmentorstotheotherteams,anotherimportantstepinprovidingconsistencyacrosscampusandimprovingthequalityoftheprocess.Untilnow,thequalityoftheriskreviewsandimplementationprocessvarieddependingontheunderstandingandexpertiseofthevariousIDTs.Hopefully,theprocesswillbecomemorestandardized,whichshouldbenefittheindividualsresidingatCCSSLC.

FromreviewoftheISPandaddendumdocumentation,individuals’teamswerehavingdiscussionsoftheindividuals’status,andmorepertinentclinicalinformationwasbeingincludedintheIntegratedRiskRatingFormsthanpreviously.However,theoveralllackofcleardocumentationincludedintheISPs,theRiskActionPlans,andtheassociateddisciplines’assessmentsregardingwhatactionsweretakeninresponsetopertinenteventsorhealthissues,andthelackofdatesandsupportingdocumentationaddressingactionsandcompletionofactionplansmadetheMonitoringTeam’sreviewoftheAt‐Risksystemdifficult,andthelackofprogressnotedwastroublingatthisjunctureofthecomplianceprocess.

PsychiatricCareandServices ThePsychiatryDepartmenthadcompletedcurrentComprehensivePsychiatricEvaluationsforallofthe

individualsreceivingpsychotropicmedication,exceptforthreerecentlyadmittedindividuals.ThelocumtenenspsychiatristhadtwoprolongedstaysattheFacilitythatweredevotedsolelytothecompletionoftheinitialCPEs,aswellastheannualupdates.ItwasanticipatedthatthelocumtenensPsychiatristwouldreturninthefall,prepareannualupdatesforthecurrentCPEs,andcompleteinitialCPEsforanyindividualsnewlyadmitted.

AlthoughtheFacilitywasactivelyrecruitingfortwoopenpsychiatristpositions,theConsultingPsychiatristrecentlyhaddecreasedhisconsultingtimefrom12toeighthoursperweek,anditremainedtobeseenifthiswouldhaveanegativeimpactontheFacility’seffortstomeettherequirementsoftheSettlementAgreement.

Thepsychiatryteamhaddevelopedandimplementedapsychiatricsymptomtrackingscale.ThisnewlydevelopedtoolaugmentedtheDSM‐IVDiagnosticChecklists,whichtheDepartmentpreviouslyhadimplemented.Thefullimplementationoftheseinitiatives,coupledwiththePsychologyDepartment’sinclusionofanewsectionintheirdocumentationentitled“PsychiatricInformation”madeitpossibletodifferentiatethesymptomsofthepsychiatricdisorderforwhichthepsychotropicmedicationwasprescribedfromthechallengingbehaviorsthatwererelatedtoenvironmentalorinterpersonalfactors.

Consentswerenowobtainedforeachprescribedmedication,whichrepresentedanimprovementoverthepriorpracticeofpursuingconsentsforasmanyasfourorfivemedicationsasasinglepackage.

Atthetimeoftheonsitereview,thePsychiatrystaffwerejustbeginninganinitiativetobothattendtheIndividualSupportPlanmeetingsfortheindividualstheyfollowed,andalsodirectlycomposeandplacetheir


materialintotheISPdocumentation.Thiswasanotherimportantdevelopment,becausethelanguageoftheSettlementAgreementspecifiesthatanumberofdiscussions,suchastheriskdiscussionrelatedtothepsychotropicmedicationsandwhethertheyrepresenttheleastintrusiveintervention,shouldoccurinthecontextoftheISPandthenbedocumentedthereaswell.

Theefforttodeveloppre‐treatmentdesensitizationplanshadprogressed,butwouldstillbeclassifiedasintheearlystagesofimplementation.Therewasanefforttodeveloptheseplansformedicalinterventionsaswell.Theselectionofthebestmedicationtouseforpre‐treatmentsedationforaspecificindividualoccurredannuallyinthecontextofthePsychiatricClinics,whichmembersofthePharmacyandDentalDepartmentsalsoattendedsothattheycoulddiscusstheseissueswiththeentiretreatmentteam.

Althoughtherateofpolypharmacywithpsychotropicmedicationswasdownto50percentfrom56percentin2010,thisrepresentedincrementalprogress.AprimaryrecommendationofthisreportisthatthePsychiatryDepartmentincreasesitseffortstodevelopobjectiveevidencetosupportthecontinuedutilizationofmultiplemedicationsforthoseindividualsforwhomtheybelievethisisessential.

CCSSLCcontinuedtoexperiencenewadmissionsattherateofapproximatelyoneindividualeveryothermonth.Todate,thesehadallbeenindividualswhohadnotbeenabletobemaintainedinthecommunityduetobehavioralreasonsand,thus,wereadmittedonmultiplepsychiatricmedications.Atthetimeoftheonsitereview,therangeforthenumberofmedicationsforthesesameindividualshaddecreased.

PsychologicalCareandServices Manybehavioralservicesstaffcontinuedtoprogressthroughthenecessarycourseworkaswellobtain

necessarysupervisiontowardtheBCBAcertification.Concernsregardingthedifficultyinaccessingandutilizingtheeducationleavehoursaswellasdifficultyinreliablyaccessingcoursecontentwerenoted.

Slightprogresswasnotedintheareaofpeerreview.Althoughattendanceimprovedforsomecliniciansandcounselors,participationbyotherprofessionalsandkeystaffremainedinadequate.Externalpeerreviewprocesseshadjustbeeninitiated.

Continuedprogressintheuseofastandardizedmonthlyprogressnotewasevidenced.ThisincludedcontinuedimprovementintheareaofdatadisplayandongoingPBSPmonitoring,includingtheinitiationofinter‐observeragreementchecksonbehavioraldata.

Progresswasevidentinthecompletionofstandardizedintellectualassessmentstoensurethatpsychologicalassessmentswereupdatedatleasteveryfiveyears.However,progressinthecompletionofscalesofadaptivebehaviorwasnotasconspicuous.Inaddition,anewformatentitledtheComprehensivePsychologicalEvaluationwasdevelopedtointegratethepsychologicalassessmentandthestructuralfunctionalbehavioralassessment.Althoughconcernswerenoted,thisnewformatappearedpromising.

Limitedprogresswasnotedinthetimelycompletionofpsychologicalassessmentsfornewlyadmittedindividuals,aswellastheprovisionofcounselingsupportstoindividualsreferredforcounseling.


ProgresswasnotedintheareaofPBSPswiththedevelopmentofanewandimprovedformatthatwascurrentlybeingpiloted.ActiveeffortswerenotedwithregardtowritingPBSPssothattheycouldbeunderstoodandimplementedbydirectsupportprofessionals.

Lastly,someprogresswasnotedincompetency‐basedtraining.However,theprovisionofadequatetrainingacrosstheFacilityforallindividualsremainedinadequateand,ascurrentlydesigned,thenatureoftrainingwassignificantlyresource‐dependentandlikelynotsustainable.

MedicalCare Withregardtomedicalcare,progresshadbeenmadeinanumberofareas.Preventivemedicalproceduressuch

ascolonoscopiesandmammogramsweretrackedandcompletedatarelativelyhighrate(94to96%).Severaltrendanalyseswereavailableasaresultofmedicalcompliancemonitoring.However,theinternalqualityimprovement(QI)/medicalcompliancemonitoringofclinicalcarewasdelayedduetoalackofguidanceinchoosingclinicalindicatorstobeusedforspecificclinicalconditions/diagnoses.Atthetimeofthereview,theFacilityhadnoMedicalDirectortoprovideguidanceinanumberofareas,includingmedicalcompliance.

Themorningmedicalmeeting,whichwasrecentlyrenamedastheIntegratedClinicalServicesMeeting,providedevidencethatabasicprocesswasinplacetoprovidequalityreviewandoversightofhealthcare.However,anumberofareasrequiredfurtherdevelopmentandfine‐tuning,suchasensuringdocumentationoftheactualreasonthegroupwasmakingareferraltotheIDT,whenapplicable.Themorningteamalsoneededtofocusonaskingcriticalquestions,andconductingcriticalreviewoftheISPAsthatresultedfromtheirreferrals.Thedocumentsthemorningmedicalmeetingproducedprovidedatrackingmechanism.However,thequalityofthetrackingrequiredfurtherattention.

Inotherareas,atemplatewasneededforquarterlymedicalreviewsthatcouldbecompletedquicklyandaccurately.Formostrecordsreviewed,thesehadnotbeendone.

Althoughanexternalnon‐facilityphysicianreviewhadbeenconducted,theFacilityhadquestioneditsaccuracy.BasedontheMonitoringTeam’sreview,concernswerenotedwiththepotentialthoroughnessofthereviewofnumerousrecordsinashortperiodoftime,aswellasalackofestablishedinter‐raterreliabilityamongstreviewers.Inaddition,althoughcorrectiveactionplanshadbeendevelopedtoaddressPCP‐specificconcerns,nodocumentationwasavailabletoshowthatfollow‐uphadoccurred.Inaddition,nosystemiccorrectiveactionplansweredevelopedorimplemented.

Althoughmortalityreviewshadbeencompleted,documentationwasnotsubmittedtoshowthatfollow‐uphadoccurredtoaddresstherecommendationstheyincluded.

TheFacilitydidnotappeartohaveincorporatedtheclinicalprotocols/guidelinesintothemonitoringprocesses.Inaddition,theMedicalDepartmentwasbeginningtoanalyzesomeofthedataitwascollecting,butdidnotyethaveasystemforwritingquarterlyreportsthatfocusedattentiononareasofstrengthsandweakness.FormanyofthefunctionsandclinicalareasforwhichtheMedicalDepartmentwasresponsible,itwillbeimportant


todesignkeyindicatorsoroutcomemeasurestoassisttheFacilityinidentifyingareasofhighperformanceandareasrequiringattention.

NursingCare TheFacilitybeganimplementationofnineadditionalnursingprotocols,includingMinimalDocumentation,PICA,

SeizuresandStatusEpilepticus,AbdominalDistention/Pain,Hypothermia,TemperatureElevation,UrinaryTractInfection,EnteralFeeding,andPostAnesthesia.

DatageneratedbycomparisonsoftheInfectionControlReportsandthePharmacyreportsfortheutilizationofantibioticsreflectedaverypositivestepforwardinnotonlytrackingdiscrepanciesregardingInfectionControlinformationtoensuredatareliability,butalsoapositiveincreaseincomplianceregardingtheaccuracyofthedocumentationcontainedontheInfectionControlReports.

Inapositivestepforward,theFacilityindicatedthatblanksfoundonareviewoftheemergencycartchecklistshadsignificantlydecreasedfromJanuarytoJune2012,sinceRiskManagement,RespiratoryTherapy,andNurseEducatorshadbeencompletingmonthlyspotchecksofthisarea.

TheMonitoringTeam’sobservationsofnursesdemonstratingtheuseofemergencyequipmentattheInfirmary,andAtlanticKingfish2foundthatthenurseswerefamiliarwiththeuseandoperationsoftheFacility’semergencyequipment.Itwasclearthattheconsistentdrillsandspotchecksregardingtheemergencyequipmentwerehavingverypositiveoutcomes.

TheFacilityhadreinitiatedastructuredsystemusingthePharmacyRefillSheetstotrackthemedicationsbeingbroughttothebuildingsinanattempttoreconcilethenumberofmedicationsthatwerebeingreturnedtothePharmacywithoutexplanation.

AlthoughtheFacilityhadmadesomepositivestepsforwardintheareasnotedabove,theoveralllackofprogress,andinsomeareas,regression,foundregardingthenursingcareplans,thenursingassessmentsanddocumentationinresponsetochangesinstatus,thequalityofthequarterlyandannualComprehensiveNursingAssessments,andtheunreliablesystemsregardingmedicationvariancedatawereveryconcerningatthisjunctureinthereviewprocess.Someoftherecentsystemchanges,suchastransitioningtoanIntegratedHealthCarePlanrepresentedpositiveforwardmovement.However,theFacility’sdecisiontoremovealltheexistingHealthMaintenancePlanswithoutmodifyingthecurrentinadequateRiskActionPlanssothatalltheindividualswhoresidedatCCSSLCwouldhaveanappropriateandclinicallysoundplanofcareinplaceduringthetransitionwastroubling.

PharmacyServicesandSafeMedicationPractices ThePharmacyDepartmenthadmadeconsiderableprogressinprovidingstructureandimplementinginternal

monitoringprocesses.Forexample,ensuringanindividual’sallergiesareconsistentinalldocumentsacrosscampuswasanimportantendeavor.ImprovementsinscreeningformedicationthatshouldnotbegivenbyJejunostomy(J‐tube)alsohadbeenimplemented.TheDUEprogramwasstrong,andthefollow‐upreviewsindicatedapositiveimpactonthepracticepatternsofthePCPsandonthequalityofcareoftheindividuals.


However,considerablechallengesremained.TimelinessofcompletionoftheQDRRremainedproblematic,andaresubmissionof“corrected”dataremainedincomplete.ItdidappeartimelinessofQDRRshadimproved,butlackofadequatestatisticaldatabecameanobstacleinverifyingthis.

ChemicalrestraintreviewremainedachallengeinbothobtainingthereviewforminatimelymannerandinensuringtheBehaviorServicesDepartment’slistofchemicalrestraintsagreedwiththePharmacist’slistofchemicalrestraints.Inaddition,adequatecompletionofthechemicalrestraintformwasacontinuingproblem.

Althoughanumberofstepshadbeentakentoreducemedicationerrorsofadministrativeomissions[i.e.,blanksinthemedicationadministrationrecord(MAR)forwhichthemedicationwasadministered]andtrueadmissions,muchworkwasneededonthenumbersandreasonsofreturnedmedication.Therewasapaucityofstatisticalreviewformedicationvariancesforpharmacy,nursing,andmedical.AquarterlyreportofmedicationvarianceswouldbeimportanttoprovideguidancetothePharmacyDepartmentinrelationtofollow‐upinterventions,aswellasineducatingtheFacilityAdministrationconcerningthechallengesofthisarea.

Concerningadversedrugreaction(ADRs),nurseshadbeentrainedaswellasthetwodentistsandfourPCPs.Asof6/25/12,noADRshadgonethroughtheprotocol/process.Morerecently,threepotentialADRswereidentified,buttheFacilitywasinprocessofdeterminingiftheymetthecriteriaofADRs.

PhysicalandNutritionalSupports AlthoughalistofPNMteammembersincludedaRegisteredNurse(RN),PhysicalTherapist(PT),Occupational

Therapist(OT),RegisteredDietician(RD),andSpeechLanguagePathologist(SLP),priortotheMonitoringTeam’svisit,thePNMTSLPandPTresigned.BasedoninterviewwiththeHTDirector,thePNMTalternateSLPandPTassumedthevacantPNMTSLPandPTcorepositionsuntilthevacantpositionswerefilledand/orcurrenttherapistswereassignedtoaPNMTcoreposition.

Attendancebycoreand/oranalternatePNMTmembersfor46meetingsconductedduringthetimeframefrom1/10/12to5/29/12rangedfrom65%fortheRDto85%fortheRN.ThePNMTmemberattendancewasnotadequate,becausethePNMTwasmeetingwithouttherequiredmembershipasoutlinedintheSettlementAgreement.

TheFacilityIDTswerenotconsistentlyreferringindividualstothePNMT,and/orthePNMTwasnotconsistentlyinitiatinganassessmentwithinfiveworkingdays.Basedoninterview,theHTDirectorreportedtheIDTswouldnotbeprovidedtrainingonthedraftPNMTReferralpolicyuntiltherevisedISPandriskprocesshadbeenimplemented.

AreviewofPNMTassessmentsandactionsplansidentifiedmultiplemissingcomponents.Inaddition,individualsthePNMTdischargeddidnothaveadequatedischargeplansasmultiplecomponentsweremissing.

ListspresentedbytheFacilitytoidentifyindividualshavingphysicalandnutritionalmanagementproblemswerenotaccurate.WhencomparingliststheFacilityprovidedofindividualswithPNMneedswithalistofindividuals’riskratings,someindividualswithPNMneedsasevidencedbyahighand/ormediumriskranking


inchoking,aspiration,falls,fractures,skinintegrityand/orweightwerenotonthelistofindividualshavingPNMneeds.

TheFacilityhadupdateditsPNMPDirectionstoaddresstheplacementofmedicationadministrationinstructionsonthePNMP,addamorecomprehensivelistofadaptiveequipmenttothePNMP,andclarifythatrevisionofaPNMPrequiredthecompletionofanAssessmentofCurrentStatus,andcompletionofanin‐servicebythetherapistwiththePNMPCoordinatorontherevisedPNMP.TheseadditionstothePNMPdirectionswerepositive.However,areviewofPNMPsforindividualsrevealedPNMPsweremissingcomponentssuchasstaffinstructionstoachievesafeelevationrangesinwheelchairandalternatepositioning,bathing/showering,oralanddentalcare,andpersonalcare.Inaddition,therewasnoFacilitypolicythatspecificallyaddressedtheimplementationofindividuals’PNMPsoff‐campus(i.e.,hospitalization,communityouting,etc.).

TheMonitoringTeamandthePNMTNursecompleteddirectobservationsoftheimplementationofPNMPstrategiesintheInfirmaryandresidencesforfiveindividualsonthePNMTcaseload.ThePNMTnursehadtointervenewithstaffduringeveryobservationtocorrectstaff’sapproachforwheelchairpositioning,alternatepositioning,mealtimefluidconsistencyandpresentationtechniques,andtransfers.Theseobservationsrevealedthatstaffwerenotcompetentinimplementingindividuals’PNMPs.However,inreviewingmonitoringdataforthesesameindividuals,itdidnotidentifysimilarproblems.

Newstaffcontinuedtoberesponsibleforcompleting22PNMfoundationalperformancecheck‐offs.Basedoninterview,theFacilityannualrefreshertrainingwastobeexpanded.Currentstaffwillberesponsibleforsuccessfullycompletingperformancecheck‐offsfortransferlifts,two‐personmanuallift,bedpositioning,mechanicallift,stand‐pivottransfer,wheelchairpositioning,adaptivediningequipment,thickeningliquids,andmealtimesafety.

TheFacilityhadnotimplementedaneffectivenessmonitoringsystemtoassesstheprogressofindividualswithPNMdifficultiesorprovideevidencethatinterventionsweremodifiedifanindividualwasnotmakingprogress.Morespecifically,individuals’RiskActionPlansdidnotgenerateindividual‐specificclinicaldatatosubstantiateanindividualprogressortoassessiftheindividualwasbetterorworse;monthlyprogressnoteswerenotcompletedtoreportontheeffectivenessofanindividual’ssupportsandservices;individualsathighriskforaspirationhadmultiplemonthsthataspirationpneumoniatriggerdatasheetshadnotbeencompleted;andindividuals’whoexperiencedongoingweightlossdidnothavetheirplansrevised.

APENassessmentsforindividualswhoreceivedenteralnutritionwerenot:followingtheFacility‐establishedtemplateandcontentguidelines;consistentlycompletedwithina12‐monthperiod;includingtheparticipationofrecommendeddisciplines;and/orprovidingjustificationthatthecontinueduseofthetubewasmedicallynecessaryorassessingtheindividual’spotentialtoreceivealessrestrictiveformofenteralnutritionortransitiontooralintake,ifappropriate.


PhysicalandOccupationalTherapy Basedonareviewofindividuals’OT/PTassessments,theyweremissingimportantelementsand,consequently,

werenotconsideredadequateOT/PTassessments. OT/PTdirectinterventionsand/orprogramswerenotintegratedintoindividuals’ISPs.Inaddition,progress

noteswerenotcompletedtoprovidetheresultsofeffectivenessreview/monitoringoftheindividual’sprogresswithdirectand/orindirectOT/PTsupports.

Noevidenceofindividual‐specificcompetency‐basedtrainingfortheimplementationofindirectOT/PTprogramswasprovided.BasedoninterviewwiththeHTDirector,theFacilitywasintheprocessofdevelopingobjectivesandperformancecheck‐offstodocumentthisprocess.

TheFacilityOT/PTMaintainingAdaptive‐AssistiveEquipmentPolicy#P.3includedsomeimportantcomponents.However,itwasmissingtheprocessforidentification,training,andvalidationformonitors;theprocessofinter‐raterreliability;andaprocessfordatatrendanalysisandutilizationoffindingstodrivetrainingandproblemresolution(individualandsystemic).

DentalServices TheDentalDepartmenthadmadeconsiderablestridestowardcompliance.AlthoughtheFacilityhadnot

achievedcompliancewitheitherofthesubsectionsofSectionQ,severalspecificaspectsofdentalcarehadreachedthelevelnecessaryforcompliance,suchascompletionofannualexamsandtooth‐brushinginstruction.Oralhygienescoreshadcontinuedtoimprove.ItwillbeimportantfortheDentalDepartmenttosustaintheseeffortswhileitfocusesonareasthatremaininneedofimprovement.

Thequalityofself‐toothbrushingrequiredreviewandinterventionforthoseindividualsthatstillhadpoororalhygienescores.

Dentaldesensitizationandotherprocedurestoreducetheuseofsedationremainedunderdevelopedafterthreeyears.Thosethatwouldbenefitfromdesensitizationhadbeenmethodicallychosen,andrecently,asmallsampleofthesehadbeenselectedtobeginthedesensitizationprocess.

QuarterlyreportsreflectingtheactivityandprogressoftheDentalDepartmentwouldbebeneficialtotheDentalDepartmentandFacilityAdministration,butperiodicreportswerenotpartoftheinternalQAprogramoftheDentalDepartment.Thecurrentsoftwareprogramhadallowedthedepartmenttoadvanceandmakeimprovement.Thereweretwotothreeyearsofdataavailableandtrendanalysiswasavailable.Itappeareduser‐friendlyandmuchinformationcouldbequicklyqueriedfromit.However,thenewstatewidesystemappearedtobereplacingit,butthechallengesofimplementationweresignificantandthebenefitstotheDentalDepartmentneededclarity.Itwillbeimperativetobeabletousethepriordataandincorporatethepriordataintothenewsystemtocontinuetoprovidetrendanalysis.

Communication AFacilitypolicyentitledCCSSLC–CommunicationServices,dated10/7/09existed.However,theFacilitypolicy

didnotprovideclearoperationalizedguidelinesforthedeliveryofcommunicationsupportsandservices.


Priortothepreviousreview,theSpeechDepartmenthadestablishedaMasterCommunicationPlanscheduletore‐assesseachindividualusingaprioritysystemandtherevisedSLPassessmentformat.However,thecompletionofthisschedulewasnotinalignmentwiththeFacility’sannualISPschedule.Duetothefactthateveryindividualneededtobere‐assessedwithanupdatedSLPassessmentformatandcontent,theSpeechDepartmentmadethedecisiontoabandontheprioritylistandfollowtheFacilityISPcalendar.Basedondocumentationsubmitted,thisdecisionenabledSLPstobecontributingmembersoftheIDTandsupporttheindividual.ItwaspositivethatIDTmembersandtheindividualwouldbeprovidedwithacurrentassessmentpriortotheannualISPmeetingtoassistinannualplanning.Unfortunately,individualsidentifiedthroughtheprioritysysteminneedofcommunicationsupportswouldhavetowaitfortheseservicesuntiltheirannualISPmeeting.

Anevaluationofindividuals’SLcomprehensiveassessmentsrevealedtheseassessmentsweremissingsomekeycomponents.

ObservationsbytheMonitoringTeamandtwoFacilitySLPsofindividualswithAACsystemsdidnotrevealthepresenceand/oruseoftheAACsystem.Inaddition,individuals’skillacquisitionprogramsdidnotsupporttheuseofanAACsystem.Staffalsohadnotbeenprovidedwithindividual‐specificcompetencytrainingandperformancecheck‐offstodemonstratetheircompetencyinsupportingindividualsintheuseoftheirAACsysteminvariousenvironmentsanddailyactivities.

Habilitation,Training,Education,andSkillAcquisitionPrograms Continuedeffortandrelatedprogresswerenotedintheareaofhabilitationtrainingandservices,inparticular

withregardtothedevelopmentofskillacquisitionplans(SAPs).However,itwasevidentthatmorerobustsupportandexpertisewereneededtoimprovethequalityoftheSAPs,aswellastoeffectivelymonitortheirimplementation(i.e.,usingintegritychecks)andindividualprogress(i.e.,usingISPmonthlyprogressnotes)overtime.

Lowerthanexpectedestimatesofengagementwerenotedduringthecurrentreview. Progressinsupportingindividualsinoff‐campusvocationalpositionswasevident.Thisincludedactiveefforts

atinformaljobexplorationandtheslow,butincreasingtrendinsuccessfullyplacingindividualsinmeaningfulemploymentpositionsinthecommunity.Thistrendmightbeenhancedbyincreasedcompletionofformalsituationalassessmentwithinoff‐campussettings.

MostIntegratedSetting Individuals’ISPscontinuedtonotconsistentlyidentifyalloftheprotections,services,andsupportsthatneedto

beprovidedtoensuresafetyandtheprovisionofadequatehabilitation.Itisessential,asteamsplanforindividualstomovetocommunitysettings,thatISPsprovideacomprehensivedescriptionofindividuals’preferencesandstrengths,aswellastheirneedsforprotections,supports,andservices,andthat,asappropriate,thesebetransitionedtothecommunitythroughthecommunitylivingdischargeplans.


Asnotedinpreviousreports,oneissuethatappearedtodelayindividuals’referraltothecommunityattimeswasaLocalAuthority(LA)representativenotbeingatameetingatwhichtheteamdecidedareferralshouldbemade.NewrulessetforththeparametersforensuringLArepresentativeswereinvitedtomeetings,notificationsoftheAdmissions/PlacementCoordinatorofreferralsmadeduringmeetings,informingtheLAofreferralsmadeintheirabsence,andholdinganadditionalmeetingshouldtheLAhaveanyquestionsorconcernsaboutthereferral.Itwaspositivethatwiththesenewrules,anLArepresentative’sinabilitytoattendameetingwouldnotdelayapotentialreferral.

AnincreasingnumberofassessmentspreparedforannualISPmeetingshadbeguntoincludetheassessor’srecommendationregardingtransitiontothecommunity.However,individuals’ISPsgenerallystilldidnotincludeasummaryorconclusionoftheprofessionalteammembers’determinationwithregardtowhetherornotcommunityplacementwasappropriate.Suchrecommendationsshouldbepresentedtotheentireteam,includingtheindividualandLAR,forconsideration.Basedonteamdiscussion,includinganyoppositionfromtheindividualorhis/herLAR,theentireteamthenshouldmakeadecisionregardinganypotentialreferralforcommunitytransition.

TheFacilitysubmittedmonthlyandquarterlyaggregatetotalsoftheobstaclecategoriesStateOfficehadidentified.Basedoninterview,Facilitystaffindicatedthateducationofindividualsandtheirguardianshadbeenidentifiedasanareaofneed.However,theystatedthatformalanalysisofallofthedatawasstillinprocess.TheFacilitywouldsoonbesubmittingitssecondannualreporttotheState,whichshouldincludeananalysisofdatacollectedthusfar.

AlthoughtheFacilityhadmadesomeprogress,CommunityLivingDischargePlanscontinuedtoinadequatelydefinethenecessaryprotections,support,andservicestoensuretheindividual’shealthandsafety.ManyoftheissuesidentifiedintheMonitoringTeam’spreviousreportsregardingdeficiencieswiththeCLDPshadnotyetbeenrectified.Asaresult,individualstransitioningtothecommunitywerepotentiallyatriskduetothelackofadequatelyplannedandimplementedprotections,services,andsupports.

Post‐movemonitoringhadbeencompletedinatimelymannerforalloftheindividualswhohadtransitionedtothecommunity.ThePostMoveMonitor’scommentsgenerallyprovidedathoroughdescriptionofthemethodsusedtoevaluatetheitemandthefindings(e.g.,interviews,documentreviews,andobservations).Thiswasfurtherconfirmedthroughanobservationofapost‐movemonitoringreview.Duringthecourseofthereview,thePost‐MoveMonitoridentifiedsomeseriousissues.ThePost‐MoveMonitorhandledtheseissuesprofessionallywithcommunityproviderstaff,andtookappropriatestepstoensurethesafetyoftheindividual.

Thepost‐movemonitoringactivitiesidentifiedsomeissueswithregardtotheprovisionofservicesatthecommunitysites.Inaddition,oneoftheindividualswhohadtransitionedtothecommunityhadexperiencedseriousevents,suchaspolicecontact.However,IDTsatCCSSLCdidnotdocumentthoroughfollow‐uporattemptstoensurethattheindividualshadtheprotections,services,andsupportstheyneeded.


Consent Atthetimeofthereview,theStateOfficeGuardianshipPolicyhadbeendisseminated,butthepolicyonconsent

remainedinthedevelopmentphase.CCSSLChadadoptedtheStateOfficepolicyandhadbeguntoimplementportionsofthepolicy.AlthoughteamsattheFacilityhadcompletedIndividualSupportPlanAddendatoidentifyindividuals’prioritylevelforobtainingaguardian,anumberofconcernswerenotedwiththeprocess.Atthetimeofthereview,theprocessforassessingindividuals’“functionalcapacitytorenderadecision”andprovideinformedconsentwasstillnotbeingcompletedusinganadequatestandardizedtool.However,itwasanticipatedthattheStateOfficepolicywouldsetforthamethodicalapproachforscreeningindividualstodetermineapossibleneedforassistanceindecision‐making,and,asappropriate,assessinginmoredetailindividuals’functioninginthisarea.

AlthoughproblemswerenotedwiththeprocesstheFacilityused,CCSSLCgeneratedaprioritizedlistofindividualsneedingguardians.Itincludedatotalof263names.Ofthese,167individualswereidentifiedasadultswithnoguardians,butneedingguardians.

Sincethelastreview,noguardianshadbeenidentifiedforindividualswhoneededthem.CCSSLChadmadeeffortstoidentifypotentialguardianshipresources.However,atthetimeofthereview,noviableresourceshadbeenidentified.Itwillbeessentialthatadequateresourcesbeidentifiedtoaddressthisneed.

Onapositivenote,theFacilitywasimplementinganadvocacyprogram.Advocateshadbeenidentifiedfortwoindividuals.Thispotentiallyprovidedaresourcetoassistindividualsindecision‐makingthatwaslessrestrictivethanguardianship.CCSSLCalsocontinuedtoprovidesupporttotheSelf‐AdvocacyGroup.Someoftheiractivitiesinvolvedassistingindividualstolearnabouttheirrightsaswellasdecision‐making.

RecordkeepingandGeneralPlanImplementation CCSSLCcontinuedtomaintainActiveRecordsaswellasIndividualNotebooks.Facilitystaffalsocontinuedto

worktoconvertindividuals’historicalfilestotheMasterRecordformatStateOfficeissued.Asignificantamountofhistoricalinformationhadbeensenttoanoutsidevendortomaintain.

TheFacilitycontinuedtouseanActiveRecordsDocumentationLog.Itidentifiedtypicalitemstobefiledforeachdiscipline.Thelogallowedarecordtobemaintainedofwhendepartmentssubmitteddocuments,andwhentheywerefiled.

Asisdiscussedthroughoutthisreport,policiesandproceduresnecessarytoimplementtheSettlementAgreementwereinvariousstagesofdevelopment.Atthetimeofthelastreview,theFacilityhaddevelopedsystemstotrackdraftpoliciesthroughtofinalization.Sincethelastreview,theFacilityhadbeguntousethesystemithaddesignedtotrackthetrainingofstaffonneworrevisedpolicies.Apilotprojecttomaintaincopiesofupdatedpolicymanualsinvariousprogramandadministrativelocationsalsohadbeencompletedandwasbeingrolledoutacrosscampus.

CCSSLCwasconductingreviewsofmorethantherequiredfiverecordseachmonth.AProgramComplianceMonitorfromtheQADepartmentalsohadbeenassigned.Effortswerebeingmadetorevisethetoolsand


developguidelinestoimprovethereliabilityandvalidityofthemonitoringresults.Theprocessesforidentifyingtrendsthatneededtobeaddressedandputtingplansinplacetoaddressproblematictrendsremainedinthebeginningstagesofdevelopment.However,theRecordsDepartmentcontinuedtouseitsknowledgeofproblemswiththerecordstoworkwithsomeoftheotherdepartmentsonareasofneed.Forexample,theDayProgramDirectorwasbeginningtoimplementaplantomonitorskillacquisitiondatatoidentifymissingdata.TheChiefNurseExecutivealsohadcreatedasystemtomonitornursingstaff’sentriesintotheIntegratedProgressNotes(IPNs).


VI. StatusofCompliancewiththeSettlementAgreementSECTIONC:ProtectionfromHarm‐RestraintsEachFacilityshallprovideindividualswithasafeandhumaneenvironmentandensurethattheyareprotectedfromharm,consistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow.

StepsTakentoAssessCompliance:Thefollowingactivitiesoccurredtoassesscompliance: ReviewofFollowingDocuments:

o DADSPolicy#001.1,effective4/10/12;o CCSSLCSelf‐Assessment,updated6/25/12;o CCSSLCActionPlans,updated6/25/12;o CCSSLCProvisionActionInformation,undated;o PresentationBookforSectionC;o CCSSLCRestraints–QuarterlyTrendingReports,from1/1/12to5/31/12;o IndividualsRestrainedDuringTimePeriodBetween12/1/11and5/31/12,and6/1/12and

7/5/12;o SettlementAgreementCross‐ReferencedwithIntermediateCareFacilityforPersonswith

MentalRetardation(ICF/MR)Standards:C–ProtectionFromHarm–RestraintsGuidelines,revisedJanuary2011;

o CCSSLC:DoNotRestrainList(Noentries),dated5/29/12;o RestraintReductionCommitteeMonthlyMinutes,dated1/5/12,and2/9/12(mislabeledas

2/9/11);o RestrictivePracticesCommitteeMeetingMinutes,dated3/21/12,4/2/12,4/4/12,4/6/12,

4/13/12,4/18/12,4/20/12,4/23/12,4/25/12,4/30/12,5/2/12,5/7/12,5/9/12,5/14/12,5/16/12,5/21/12,5/23/12,5/25/12,and5/30/12;

o DADSEmployeeAlphaRoster,dated6/12/12;o DADTXCourseDue/Delinquent,forPreventionandManagementofAggressiveBehavior

(PMAB)basic,asof7/2/12;o Competency‐BasedRestraintMonitoringTraining,includinglistofstafftrained,undated;o RestraintMonitoringTraining:DidacticandDemonstrativeScores,includinglistofstaff

trained,undated;o Sample#C.1waschosenfromthelistofindividualsrestrainedasacrisisintervention

between12/1/11and5/31/12.Completedocumentationforeachrestraintwasrequested,includingtheRestraintChecklist,Face‐to‐Face/DebriefingForm,SafetyPlan,allreviewsoftheuseoftherestraint,andanyaddendumstotheindividual’sIndividualSupportPlanthatresulted.TheMonitoringTeamoriginallyrequestedasampleof32restraints.However,basedonthedocumentationsubmitted,asampleof25restraints(of156or16%)involving10people(of26or38%)withrestraintsonthedatesspecifiedwasreviewed,including:

Individual#253on3/4/12at5:20p.m.,4/11/12at1:05p.m.,5/1/12at7:07p.m.,5/17/12at12:22p.m.,and5/27/12at8:14p.m.;

Individual#61on5/17/12at1:57p.m.,and5/17/12at7:15p.m.; Individual#300on2/1/12at7:15a.m.,4/19/12at8:43p.m.,5/7/12at6:15p.m.,

and5/4/12at8:13a.m.; Individual#246on4/14/12at6:14p.m.,9:15p.m.,9:50p.m.and11:15p.m.;


Individual#169on4/24/12at7:15p.m.and7:35p.m.,and5/16/12at2:45p.m.; Individual#109on2/13/12at10:41p.m.,and5/9/12on4:12p.m.; Individual#16on4/28/12atatimenotentered,and5/7/12at6:20a.m.; Individual#26on3/29/12at8:24p.m.; Individual#238on5/28/12at8:37p.m.;and Individual#55on4/20/12at7:20a.m.;

o Sample#C.2:Thefollowingdocumentationwasobtainedforarandomsampleof25staffontheDADSEmployeeAlphaRoster,dated6/12/12:

DADTXCourseDue/Delinquent,forPMABbasicasof7/2/12; DADTXIndividualTrainingRecordsforthe25staffinthesample,dated7/10/12;

o Sample#C.3:TheRestraintChecklist,documentationofthemonitoringoftherestraint,anyreviewsoftheuseofrestraint,anydesensitizationplan,thedoctor’sorderfortherestraint,andthemonitoringscheduleusedwererequestedforthefollowingindividuals,selectedfromthelistof153medicalrestraintsinvolving70individualsthatoccurredbetween12/1/11and5/31/12.Thesampleof13represented19%oftheindividuals:

Individual#221on4/13/12at12:15p.m.,and5/23/12at8:00a.m.; Individual#210on2/3/12at12:30p.m.; Individual#147on4/25/12at3:15p.m.; Individual#304on10/12/11at8:00a.m.; Individual#198on4/3/12at6:30a.m.; Individual#87on5/3/12at2:30p.m.; Individual#141on4/1/12at9:30a.m.; Individual#307on3/19/12at10:00a.m.; Individual#225on4/16/12at7:50a.m.; Individual#228on1/9/12at7:00a.m.; Individual#156on5/30/12at2:30p.m.; Individual#187on5/21/12at9:30a.m.;and Individual#181on10/24/11at10:00a.m.;

o Sample#C.4:TheRestraintchecklist,Face‐to‐Face/DebriefingForm,anyreviewsoftheuseofrestraint,documentationofcontactbetweenthepsychologistandphysicianpriortotheuseoftherestraint,andanychangestotheISPorSafetyPlanasaresultoftherestraintfor25%(n=3)ofthe12(N)oftheinstancesonthelistprovidedbytheFacility(II.07.a)ofindividualswhowererestrainedwithchemicalrestraintotherthanpre‐treatmentsedationbetween12/1/11and5/31/12,including:

Individual#253on5/3/12at3:06p.m.; Individual#144on3/14/12at3:15p.m.;and Individual#246on4/14/12at11:15p.m.;

o Sample#C.5:Noonewasreportedtohavebeenrestrainedoff‐groundsbetween12/1/11and5/31/12.Nosamplewasdrawn;

o SectionC.4sampleofPositiveBehaviorSupportPlansfor:Individual#38,Individual#184,Individual#186,Individual#58,Individual#263,Individual#218,Individual#167,Individual#275,Individual#159,Individual#20,Individual#153,Individual#307,


Individual#46,Individual#225,Individual#7,Individual#300,Individual#226,Individual#368,Individual#353,andIndividual#315;

o Sample#C.7waschosenfromthelistofindividualsrestrainedascrisisinterventionbetween12/1/11and5/31/12.ThisincludedreviewofRestraintChecklists,Face‐to‐FaceDebriefingReports,SafetyPlanforCrisisIntervention(SPCI),PositiveBehaviorSupportPlan(PBSP),IndividualSupportPlans(ISP),ISPAddendums,MonthlyBehavioralServicesReviews,asprovided,forthefollowingthreeindividualswithrestraintsonthedatesspecified:

Individual#61on5/17/12(1:57p.m.,1:59p.m.,2:03p.m.,2:08p.m.,and7:15p.m.),and5/18/12(6:22p.m.,6:26p.m.,and6:36p.m.);

Individual#253on4/10/12(7:53a.m.and12:00p.m.),and4/17/12(6:21p.m.and6:26p.m.);and,

Individual#275on5/28/12(3:05p.m.and3:25p.m.),and5/29/12(4:47p.m.and4:59p.m.);

o ListingofCaseLoadChangesforCoralSea–DesensitizationPlanPilotCases;ando Medicalanddentaldesensitizationplans,relateddatasheets,dental/medicalbaselinefor

desensitizationplans,and/ordecisiontreeworksheets,asavailable,forthefollowing:Individual#22,Individual#273,Individual#15,Individual#334,Individual#280,Individual#292,Individual#176,andIndividual#146.

Interviewswith:o MarkCazalas,FacilityDirector;o BruceBoswell,AssistantDirectorofPrograms;o JudySutton,M.A.,BCBA,DirectorofBehavioralServices;o Dr.RobertCramer,ClinicalPsychologist,o EverettBush,AssociatePsychologistV;o Dr.GeorgeZukotynski,StateOfficeCoordinatorforBehavioralServices;o CynthiaVelasquez,DirectorforQualityAssurance(QA);o AraceliMatehuala,ProgramComplianceMonitor(PCM);o BrendaFuller,PsychiatricRN;o MichelleArteaga,PsychiatricRN;o Twentystaffmembersfromvariousresidentiallocations;ando Tenindividualsinvariousresidentialanddaylocations.

Observationsof:o RestrictivePracticesCommittee,on7/11/12;o Residences:522A,B,C,andD;524A,B,C,andD;and514;o DayandVocationalProgramsinBuildings512,513and517;o IncidentManagementReviewTeamMeeting(IMRT),at11a.m.on7/9/12;ando InterdisciplinaryTeam(IDT)meetingforIndividual#341on7/11/12.

FacilitySelf‐Assessment:BasedonareviewoftheFacility’sSelf‐AssessmentwithregardtoSectionCoftheSettlementAgreement,theFacilityfoundthatitwasinsubstantialcompliancewithnoneoftheeightprovisionsinSectionC.ThiswasconsistentwiththeMonitoringTeam’sfindings.

TheFacility’sSelf‐AssessmentforSectionCincludeddetailsdrawnfromtheapplicationoftheQuality


MonitoringToolandreferencedspecificitemsonthetooltoaddresstheelementswithineachprovisionoftheSettlementAgreement.Thesamplesizehadbeenincreasedto30.ThiswasasignificantimprovementovertherecordsampleoffivethatwasusedforthelastSelf‐Assessment.InformationfromothersourceswasreviewedtosupplementtheQATooldata.

TheSelf‐ratingswerecomparableinmostrespectstothoseoftheMonitoringTeam. TheFacilityanticipatedquestionstheMonitoringTeamwouldraise,suchasquestionsabouttheuse

ofabdominalbinders,changesinthedatasystem,andthechangesintheDoNotRestrainlist,andprovidedsomeadditionalinformation.

TheFacilityincludedActionStepsforeachprovisionoftheSettlementAgreement.

Thefollowingconcernswerenoted: ActionStepswerepresentedforeachsubsectionoftheSettlementAgreement.ActionStepswere

broadlystatedwithprojectedcompletiondatesfromthreetosixmonthsorlonger.EachActionstepcouldhavebeenbrokendownintointermediatesteps.Forexample,forSectionC.1,actionstep#1was“determineifrestraintsarecompleteandaccurate”andassignedtheresponsibilitytotheDirectorofBehavioralServices.Thestartdatewas12/1/12,andcompletiondatewas12/31/13.Itwasnotclearhowthiswastobeaccomplishedorwhythedatewassofarout.IncludingintermediatestepswouldallowtheFacilitytodetermineifprogresstowardthegoalwasontrack.

ItwasnotclearhowTheCorrectiveActionPlanTrackingrelatedtotheSelf‐AssessmentandActionPlans.

SummaryofMonitor’sAssessment:TheStatehadissuedarevisedpolicyonrestraintandtraininghadbegunonitsrevisions.TheMonitorswillcommentontherevisedpolicyatafuturedate.However,changeswerenotedwithregardtothedefinitionofrestraints,andthesechangeshavebeenaddressedinthisreport.TheFacilityadoptedanewRestraintPolicy,on6/1/12,andprovidedtrainingtoadministrative,clinical,anddirectsupportprofessionalsonthenewpolicy,aswellasandnewrestraintdocumentation.TrainingofthenewRestraintPolicyalsowasintegratedwithinNewEmployeeOrientation(NEO)training.TheFacility’sAvatardatasystemwasnotproducingreliablerestraintdataandhadnotproducedtrendreportsforJune.TheMonitoringTeamlearnedthattheAvatarsystemwasbeingupgradedtoallowdirectentryofrestraintreports,replacingthesystemofhandwrittenreports,inachangesimilartowhatwasdonewithinjuryreporting.Theconversionprocesswasunderway.However,someissuesstillexistedwithreportingthatneededtobeaddressed.Forexample:

Thereportingprocessforarestraintthatisimplemented,released,andre‐implementedinashortperiodoftimerequiredrefinement.Morespecifically,indatasubmittedforthisreview,thereweredatasystementriesformultiplerestraints,butonlyonereportwasavailable.

TheFacilityneededtoensurethatrestraintswereenteredwiththecorrectlabelratherthanan“other.”

TheFacilitywasidentifyingissueswithrestraintsthatneededtobeaddressed,suchasunderstandingwhattriggeredthebehaviorthatledtorestraintsothattheycouldbeaddressed.Forexample,oneantecedentto


restraintappearedtobetheuseofcigarettes:nothavingthem,wantingthematunauthorizedtimes,andnotsharingthem.Foronewoman,anantecedentconditionwasherdesiretostayoutdoorsafter8p.m.whentheresidencesweresupposedtobelocked.TheFacilityneededtoanalyzeitsdataonrestraintstobetterunderstandtheseantecedents,anddevelopwaystoaddressthemsystemicallyaswellasindividually.Theassignmentofrestraintmonitorshadbeenchanged,andthetrainingoftheadditionalmonitorshadbeendone.However,therewassomedeclineintheaccuracyofdocumentingrestraintsasaresult.Thelistoftrainedrestraintmonitorswasprovided,butthenamesreporteddidnotmatchthenamesofrestraintmonitorsintherestraintdocumentation.AreasofnotedprogressincludedtheinitiationoftheRestrictivePracticesCommittee,whichwasdevelopedthroughtheintegrationoftheLevelofOversightCommitteeandtheRestraintReductionCommittee.Thisnewcommitteeappearedtoofferthepotentialformorecomprehensiveoversightofbothrestrictivepractices.TheDesensitizationCommitteecontinueditsefforts,includingthedevelopmentofadatabaseofindividualsrequiringdentaland/ormedicaldesensitizationaswellasthosewithcompletedbaselines.Inaddition,apilotprojectwasinitiatedexamininganddevelopingrevisedmedicalanddentaldesensitizationplans.Ingeneral,theFacilityhadsystemsinplaceforrestraintreporting,monitoring,andreviewprocesses.Concernswerenotedwithregardtohowwellthosesystemswereworking,aswellaswithdataintegrity,andwithregardtotheadequacywithwhichstaffdescribedtheantecedent‐andconsequence‐basedinterventionsusedpriortotheimplementationofrestraint.ItwasnotclearinallcasesreviewedthatstaffimplementedspecificstrategiesfromPBSPsinanefforttoreducetargetbehaviorandpreventtheuseofrestraint.

# Provision AssessmentofStatus ComplianceC1 Effectiveimmediately,noFacility

shallplaceanyindividualinpronerestraint.Commencingimmediatelyandwithfullimplementationwithinoneyear,eachFacilityshallensurethatrestraintsmayonlybeused:iftheindividualposesanimmediateandseriousriskofharmtohim/herselforothers;afteragraduatedrangeoflessrestrictivemeasureshasbeenexhaustedorconsideredinaclinicallyjustifiablemanner;forreasonsotherthanaspunishment,forconvenienceofstaff,orinthe

TheDepartmentofJusticehasindicatedaninterestincertainstatistics.Inresponsetothisrequest,theMonitoringTeamhasincludedsomesuchnumbersinthisreport,suchasthefollowinginformationrelatedtonumbersofrestraints.TheMonitoringTeamisnotinapositiontoverifythesenumbers,orprovidein‐depthanalysisofthesenumbers.Clearly,itistheFacility’sresponsibilitytoconductsuchanalyses,andastheseanalyseshavebeenmadeavailabletotheMonitoringTeam,theyarediscussedasappropriatewithregardtothesectionsoftheSettlementAgreementtowhichtheyapply.Thefollowingnumbersareprovidedforinformationalpurposesonly,andarebasedondataavailablefromtheFacilityatthetimeofthereview.AreviewoftheTrendAnalysisReportforJune2012showed:

Noncompliance


absenceoforasanalternativetotreatment;andinaccordancewithapplicable,writtenpolicies,procedures,andplansgoverningrestraintuse.OnlyrestrainttechniquesapprovedintheFacilities’policiesshallbeused.

TypeofRestraint Daterange DaterangeSeptembertoAugust2011(12months)

SeptembertoMay2012(Ninemonths)

Personalrestraints (physicalholds)duringabehavioralcrisis

234 191

Chemicalrestraintsduringabehavioralcrisis 41 30Mechanicalrestraintsduringabehavioralcrisis

NoData NoData

TOTALrestraintsusedinbehavioralcrisis 275 221TOTALindividualsrestrainedinbehavioralcrisis

NoData NoData

Oftheaboveindividuals,thoserestrainedpursuanttoaSafetyPlan

NoData NoData

Medical/dentalrestraints 422 282TOTALindividualsrestrainedformedical/dentalreasons

NoData NoData

Duringinterviews,itwaslearnedthattheAvatarSystemwasundergoingstatewidechangesandTrendReportswerenotavailableforJune2012.ReviewofthereportssubmittedforSample#C.1indicatedthatthesystem’sdatabasecontainederrors,suchasmultipleentriesforthesamerestraint,orincorrectlycodedentries(physicalorchemicalrestraintsas“other”).DiscussionwiththeFacilityrevealedthatthiswasknownandtheimminentconversiontoanelectronicdatasystemwouldassistinaddressingtheseissues.ProneRestraintBasedonreviewoftheFacility’spolicy,prone/supinerestraintwasprohibited.BasedonreviewoftheQuarterlyTrendReportforRestraints,dated5/31/12,pronerestraintwasnotidentified.Basedonstaffinterview,staffknewthatprone/supinerestraintwasforbidden,andthatwhileanindividualwasinrestraint,ifhe/shemovedintoaprone/supineposition,staffmusteitherturntheindividualtohis/hersideorendtherestraint.Asample,referredtoasSample#C.1,wasselected(asdescribedintheDocumentsReviewedSectionabove).Thesamplewasreducedinsizefromtheoriginal32restraintsselectedto25restraints,sincethatwasthenumberoffilessubmitted.BasedonareviewoftherestraintrecordsforindividualsinSample#C.1involving10individuals,none(0%)showeduseofpronerestraint.


OtherRestraintRequirementsBasedondocumentreview,theFacilitypoliciesstatedthatrestraintscouldonlybeusediftheindividualposedanimmediateandseriousriskofharmtohim/herselforothers;afteragraduatedrangeoflessrestrictivemeasureshadbeenexhaustedorconsideredinaclinicallyjustifiablemanner;andcouldnotbeusedaspunishment,forconvenienceofstaff,orintheabsenceoforasanalternativetotreatment.RestraintrecordstheFacilitysubmittedwerereviewedforSample#C.1thatincludedtherestraintchecklists,face‐to‐faceassessmentforms,anddebriefingforms.Thefollowingaretheresultsofthisreview:

In21ofthe25records(84%),therewasdocumentationshowingthattheindividualposedanimmediateandseriousthreattoselforothers.Exampleswherethiswasnotthecaseincluded:

o Individual#61on5/17/12at7:15p.m.:itwasnotclearwhatformtheaggressiontostafftook.

o Individual#300on4/19/12at8:43p.m.:itwasreportedthattheindividualswungatstaffandranwhenshecouldnothaveacigarette.Thedocumentationdidnotcontaininformationaboutwhyrunningwasathreat(whethershewasnearthegate,forexample).

o Individual#300on5/7/12:itwasnotclearfromthedocumentationwhattheaggressioninvolved,makingitdifficulttodeterminehowimmediateandseriousthethreatofharmwas.

o Individual#238on5/28/12at8:37p.m.wasreportedtohavebeenchasingstaffwithastick,butthereportdidnotdocumentanadequatedescriptiontoallowdeterminationoftheseriousnessofthethreat,suchasdetailaboutthekindorsizeofthestick,orwhetherstaffwereabletokeepasafedistancefromtheindividual.

Forthe25restraintrecords,areviewofthedescriptionsoftheeventsleadingtobehaviorthatresultedinrestraintfoundthat16(64%)containedappropriatedocumentationthatindicatedthattherewasnoevidencethatrestraintswerebeingusedfortheconvenienceofstafforaspunishment.Exampleswherethiswasnotthecaseincludedthefollowinginadditiontothefourcasescitedabove:

o Individual#253on3/4/12at5:30p.m.:Achemicalrestraintwasusedafterabasket‐holdrestraintwastriedandfailed.TheinformationonthisRestraintChecklistwasincomplete,appearingtohavereliedonapriorreport.Ifseveralrestraintsoccurredinsuccessionandallreliedontheoriginaldescriptionofbehavior,theyneededtobepresentedtogethertoallowthereviewertounderstandthefullsituation.Alternatively,eachreportneededtocontaintheessentialfactsaboutthebehavior.

o Individual#246on4/14/12wasrestrainedseveraltimesincludingchemicalrestraints.Thereportsoftherestraintsat6:14p.m.and9:15


p.m.containeddescriptiveinformationabout thetypeandintensityofbehaviorthatcausedtherestraint.Thereportsat9:50p.m.and11:15p.m.didnot,possiblyrelyingonthedescriptionsintheearlierreports.However,ifeachrestraintwastobereviewedasaseparateevent,eachreportneededtoincludethedetailsofthebehavioratthetimeofthatparticularevent.

o Individual#16on4/28/12atanunspecifiedtime,andon5/7/12at6:20a.m.:Thisindividualwasrestrainedwithmittensforseveralhourseachtime.ThiswasapparentlydoneinconjunctionwithaSafetyPlan,buttherewerenodetailsandnoSafetyPlanwassubmitted.

In17oftherecords(68%),therewasevidencethatrestraintwasusedonlyafteragraduatedrangeoflessrestrictivemeasureshadbeenexhaustedorconsideredinaclinicallyjustifiablemanner.Exampleswherethiswasnotthecaseincluded:

o Individual#16on5/7/12at6:20a.m.:mittenswereappliedasarestraint.TheRestraintChecklistcontainedcheckedboxesforinterventionsattemptedtoavoidrestraint,butwithnoorderofattemptorperiodoftimeoverwhichthealternativestorestraintwereapplied.ThisrestraintmighthavebeenpursuanttoaSafetyPlan,butnonewaspresented.

o Individual#238wasreportedtohavebeenchasingstaffwithastick.Therewasnoindicationofthetimeoverwhichalternativesweretriedorinwhatorder.Therewereonlycheckmarksonthevariousboxes.

Otherreportswheretheredidnotappeartobesufficientinformationwere:

o Individual#253on3/4/12at5:20p.m.;o Individual#300on4/19/12at8:43p.m.,and5/7/12at6:15p.m.;o Individual#16on4/28/12timenotrecorded;o Individual#253on5/1/12at7:07p.m.:ando Individual#16on5/16/12at2:45p.m.

Facilitypoliciesidentifiedalistofapprovedrestraints.

Basedonthereviewof25restraints,involving10individuals,25(100%)wereapprovedrestraints.

Anadditionalsample(Sample#C.7)waschosenfromthelistofindividualsrestrainedascrisisinterventionbetween12/1/11and5/31/12.Ofthoselisted,threeindividualswithmorethanthreerestraintsina30‐dayperiodwererandomlyselected.ThissampleincludedIndividual#61(restraintson5/17/12and5/18/12),Individual#253(restraintson4/10/12and4/17/12),andIndividual#275(restraintson5/28/12and5/29/12).Specificrestraintsbydatearelistedaboveinthe“ReviewofFollowingDocumentation”section.Documentationrequestedforreviewincludedrestraintchecklistsandface‐to‐facedebriefingreports(forthedatesselected),thePBSPsandSPCIs(i.e.,thatwereinplaceat


thetimeoftherestraints),PBSPandSPCImonthlysummaries,theISPandanyISPAsrelatedtotherestraints.Unfortunately,onlysomeoftherestraintreportswereprovidedforIndividual#253andIndividual#61,andnorestraintreportswereprovidedforIndividual#275.Inaddition,otherrequesteddocumentationforthesethreeindividuals,includingISPs,ISPAs(e.g.,formorethanthreerestraintsin30days),PBSPs,andmonthlydatasummaries,wasnotprovided.Asaconsequenceofthemissingdocumentation,theMonitoringTeamcouldnotadequatelyevaluatethesampledrestraintstodeterminewhetherornotprogresshadbeenmadeonthisprovisionoftheSettlementAgreement,particularlywithregardtowhetherrestraintwasappliedintheabsenceoforasanalternativetotreatmentand/oronlyafteragraduatedrangeoflessrestrictiveoptionshadbeenexhausted.AlthoughdocumentationnecessaryfortheMonitoringTeam’sevaluationofthisitemwasnotavailable,themostrecentCCSSLCself‐assessment,dated6/22/12,revealedtheFacility’sreviewofitscomplianceonthisprovisionoftheSettlementAgreement.Thatis,self‐assessmentfindingssuggestedthatamajority(83%)ofsampledrestraintreportshadmissinginformationordata.Moreimportantly,reportsindicatedthattheuseoflessrestrictiveinterventionspriortotheimplementationofrestraintwasfoundinonly70%ofsampledrestraintreports.Overall,basedonthisandotherfindingswithintheself‐assessment,theFacilityratedthisprovisionasnotinsubstantialcompliance.ThisfindingisconsistentwiththecurrentfindingoftheMonitoringTeam.Cleardocumentationwasnotconsistentlyprovidedthatindividualsposedadangertoselforothers,lessrestrictivealternativeswerefollowed,orrestraintswerenotusedintheabsenceofadequatetreatment.BasedontheMonitoringTeam’sreview,theFacilitywasnotincompliancewiththisprovision.ThiswasconsistentwiththeFacility’sSelf‐Assessment.

C2 Effectiveimmediately,restraintsshallbeterminatedassoonastheindividualisnolongeradangertohim/herselforothers.

Therestraintrecordsinvolvingthe25reportsofrestraintfor10individualsinSample#C.1werereviewed.Ofthe25restraints,threeindividualswerereleasedwhentherestraintcouldnotbemaintained,andthreewerechemicalrestraintsandreleasetimecouldnotbedetermined.Asaresult,foratotalof19restraints,theappropriatenessofthetimeofthereleasecouldbeassessed.Ofthese,16ofthe19individuals(84%)werereleasedwhentheindividualwasnotadanger.Fortheremainingrestraints,itcouldnotbedeterminedwhethertheywerereleasedtimely:

OnerestraintforIndividual#238on5/28/12at8:37p.m.wascodedas“releaseunsuccessful.”Itwasnotclearwhatthismeant.

TworestraintsforIndividual#16on4/28/12timenotrecordedand5/7/12at6:20a.m.involvedtheuseofmittensinaccordancewithaSafetyPlan,butalthoughrequested,theplanwasnotsubmittedanditcouldnotbedeterminediftherequirementsforreleasewithintheplanweremet.

Noncompliance


IntheMonitoringTeam’slastreport,concernswereexpressedaboutthenumberoftimesindividualswerereleasedduetoinabilitytomaintaintherestraint.AfterconsultationwithFacilitypsychologistsandwiththeStateOffice’spsychologist,itappearedthatwhenaholdcouldnotbemaintained,thejudgmentonwhethertoattempttorestrainagainwouldbemadebasedonthebehavioraftertherelease.Iftheindividualnolongerpresentedadangertohimselforothers,thennofurtherrestraintwouldbeneeded.ToaccuratelyconcludethedocumentationontheRestraintChecklist,thecodefor“unabletomaintainrestraint”shouldbechecked.IntheMonitoringTeamlastreport,thisprovisionwasdeterminedtobeoutofcompliance,inpart,basedontheoutstandingissueoftheuseofabdominalbinders.StatePolicy#001.1,revised4/10/12,changedtherequirementsforusingmechanicalrestraint.Thepolicyincludeddefinitionsofmechanicalrestraintwhenusedasmedicalrestraint,andprotectivemechanicalrestrainttoaddressself‐injuriousbehavior.Thepolicyincludedrequirementsforplanninganddocumentationthatwouldapply.WhiletheMonitoringTeamhasnotcompleteditsreviewofthepolicy,thepolicyappearedtoprovidedefinitionsofrestraint,intowhichabdominalbindersfell,andsetforththerulesunderwhichtheymaybeused.ThisisdiscussedinfurtherdetailwithregardtoSectionC.4.TheFacilityfoundthatitwasnotincompliancewiththisprovision.TheMonitoringTeamalsofoundtheFacilityoutofcomplianceduetothelackofsupportingdocumentationinsomerecordstoindicatetimelyreleasefromrestraint.

C3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationassoonaspracticablebutnolaterthanwithinoneyear,eachFacilityshalldevelopandimplementpoliciesgoverningtheuseofrestraints.Thepoliciesshallsetforthapprovedrestraintsandrequirethatstaffuseonlysuchapprovedrestraints.Arestraintusedmustbetheleastrestrictiveinterventionnecessarytomanagebehaviors.Thepoliciesshallrequirethat,beforeworkingwithindividuals,allstaffresponsibleforapplyingrestrainttechniquesshallhavesuccessfullycompletedcompetency‐basedtrainingon:

AsnotedabovetheStateOfficehadissuedarevisedpolicyonrestraint,Policy#001.1effective4/10/12.ThethreeMonitoringTeamswillcommentjointlyonthepolicy.TheFacilitypolicieshadnotyetbeenrevisedtocorrespondtotheStateOfficepolicy.Howeverasofthelastreview,theFacilitypolicysetforth:

Policiesgoverningtheuseofrestraint; Approvedverbalandredirectiontechniques; Approvedrestrainttechniques; Adequatesupervisionofanyindividualinrestraint,and Competency‐basedtrainingrequirementsforstaffpriortotheiruseofrestraints.

CCSSLCPolicy#C.2wasrevisedon5/25/11,asnotedinthelastreport,toprovideforaRestraintRestrictionListofindividualswhocouldnotberestrained,whohadlimitationsonuseofrestraint,andwhohadSafetyPlans.Accordingtothepolicy,thelistwastobedisplayedineachresidenceinthe“attendant’sstation.”CCSSLCPolicy#C.4wasrevisedon5/25/11toimprovethecompletionandroutingofRestraintChecklistsandFace‐to‐FaceDebriefingForms.CCSSLCPolicy#C.12wasrevisedtomodifythecompletionandroutingofchemicalrestraintconsultforms.Thesechangesappearedtopresentaclearpathwayfortheseformstotravel,andonethatshouldassuretimelyreview,andidentificationandcorrectionofanyproblemswiththeuseoftheforms

Noncompliance


approvedverbalinterventionandredirectiontechniques;approvedrestrainttechniques;andadequatesupervisionofanyindividualinrestraint.

oranyissuesraisedwithintheforms.However,theunavailabilityofsomeRestraintChecklists,Face‐to‐Face/DebriefingForms,andChemicalRestraintReviewssuggestedthattheprocesswasnotyetfullyimplemented.AsdescribedintheMonitoringTeam’slastreport,reviewoftheFacility’strainingcurriculafoundadequatetrainingandcompetency‐basedmeasuresinareasofpolicy,verbalredirectiontechniques,approvedrestrainttechniques,andsupervisionofindividualsinrestraint.However,thereportnotedthatadditionaltrainingwasneededinthetechniquesofmaintainingarestraint,whennecessary.Duringthecurrentreview,noadditionalevidenceoftrainingrevisionswaspresented,andthatrecommendationremainsinplace.Sample#C.2wasselectedfromacurrentlistofstaff.AdescriptionofSample#C.2isprovidedinDocumentsReviewedsectionabove.Areviewofthetrainingtranscriptsforthesestaffshowedthat25outof25staff(100%)hadbeenprovidedtrainingonrestraintanditsrelatedtopics.Basedoninterviewswith20directsupportprofessionals,20wereabletodescribe:

Policiesgoverningtheuseofrestraint(100%); Approvedverbalandredirectiontechniques(100%); Approvedrestrainttechniques(100%);and Adequatesupervisionofanyindividualinrestraint(100%).

Asof7/2/12,theDADSCourseDue/DelinquentreportlistedallstaffthatweresupposedtohavehadPMABBasictrainingortohavebeenretrainedonanannualbasisandwereoverduefortraining.Thisreportshowedthat12people,oraboutonepercentoftheapproximately859staffattheFacility,werelatewiththeirannualtrainingorhadnotreceivedtraining.AsnotedabovewithregardtoSectionC.1oftheSettlementAgreement,68%oftherestraintrecordsreviewedshowedthatrestraintwasonlyusedafteragraduatedrangeoflessrestrictivemeasureshadbeenexhaustedorconsideredinaclinicallyjustifiablemanner.

TheMonitoringTeamfoundthattheFacilitywasnotincompliancewiththisprovision.AlthoughtheFacilitywasprovidingtrainingtostaff,itspoliciesneededtobeupdatedtoaddresschangesintheStateOfficepolicy.Inaddition,thisprovisionrequiresthatwhenrestraintwasused,itwastheleastrestrictiveoption.TheFacility’sdocumentationwasnotsufficienttoconfirmthatthiswasthecase.TheFacilitySelf‐AssessmentalsoconcludedthattheFacilitywasnotinsubstantialcompliance.

C4 Commencingwithinsixmonthsof AsdiscussedingreaterdetailwithregardtoSectionC.1,in21ofthe25records(84%), Noncompliance


theEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshalllimittheuseofallrestraints,otherthanmedicalrestraints,tocrisisinterventions.Norestraintshallbeusedthatisprohibitedbytheindividual’smedicalordersorISP.Ifmedicalrestraintsarerequiredforroutinemedicalordentalcareforanindividual,theISPforthatindividualshallincludetreatmentsorstrategiestominimizeoreliminatetheneedforrestraint.

therewasdocumentationshowingthattheindividualposedanimmediateandseriousthreattoselforothers.OfthetwentyPBSPsreviewed,20(100%)showednoevidencethatrestraintwasbeingusedforanythingotherthancrisisintervention(i.e.,therewasnoevidenceintheserecordsoftheuseofprogrammaticrestraint).Inaddition,aspresentedintheMonitoringTeam’spreviousreports,theFacilitypolicydidnotallowfortheuseofrestraintforreasonsotherthancrisisintervention.BasedondocumentationtheFacilityprovidedforthe25restraintrecordsreviewed,theMonitoringTeamcouldnotdetermineiftherestraintusedwasnotincontradictiontotheindividuals’medicalordersaccordingtothe“DoNotRestrain”list.TheDoNotRestrainListprovidedforthisreviewdidnotcontainanynames,eventhoughasnotedwithregardtoSectionC.3,theFacilityprocedurescalledforsuchalist.Uponinterview,itappearedthatpsychologyandmedicalstaffhaddeterminedthatforthemostlikelyrestraintsthatmightbeusedwithanyindividualinacrisissituation,nonewouldbecontraindicatedandnolistwasneeded.WhiletheSettlementAgreementdoesnotrequiresuchalist,itdoesrequirethatnorestraintbeusedthatisprohibitedbytheindividual’smedicalorders.Itwasunclearhoworifjustificationhadbeenprovidedinmedicalordersforindividualspreviouslyonthislist.Clearly,inthepast,primarycarepractitioners(PCPs)hadconcernsabouttheuseofrestraintorcertaintypesofrestraintforsomeindividuals.Thiswouldhaveappearedtobeappropriateforindividuals,forexample,withdiagnosesthatwouldbeexacerbatedwiththeuseofrestraint,orforthosewithtraumatichistoriesforwhomrestraintmightcausefurtherpsychologicalharm.Removingtheserestrictionswithoutadequatejustificationwouldbeinappropriate.Inaddition,theFacilitypolicyrequiresaDoNotRestrainList,andwouldneedtobereconciledwiththisapproachaswellaswithanynewrequirementsthatmightbeintheStateOfficePolicyonRestraint.Intherestraintsamplesforthisreport,noonewasrestrainedwithanabdominalbinder.AccordingtoinformationintheFacilitySelf‐Assessment(i.e.,SectionC.1),theFacilitynotedthat“priorrestraintpolicydidnotspecifytheuseofabdominalbindersasrestraint,theFacility’spracticewastoviewthemasrestraint,thispracticeceasedandthedataaboveisreflectiveofthischange.”IninterviewwiththeStatePsychologist,itwaslearnedthatbasedontherevisedpolicy,therewerethreewaystocategorizetheuseofanabdominalbinder:

Asaprotectivemechanicaldevicewhentheteamdeterminedthatthebinderwasusedtoprotecttheindividualfrominjuryassociatedwithinvoluntarymovement.AnexamplewaswhenanindividualhadaJejunostomyfeedingtube(J‐tube),andduetotheinvoluntarymovementsassociatedwithspasticity,thetubewasbeingdislodged.

Asamedicalrestraintwhenthebinderwasusedtoprotecttheindividualfrominterferingwithmedicaltreatment,suchaswhenawoundwassutured.Suchuse


wouldbesubjecttoamedicalorder,andtemporaryuntilthemedicaltreatmentorhealingwasconcluded.

Asaprotectivemechanicalrestraintwhentheindividualwasattemptingtoremoveorinterferewithachroniccondition,suchasaJ‐tubeinsertion.Whensuchrestraintwasused,therewouldneedtobeanactionplanintheISPtodescribehowthedevicewouldbefadedovertime,dataonotherinterventionstried,andincludeone‐to‐onesupervisionamongotherrequirements.

TheFacilityreportedinitsFacilitySelf‐Assessmentthat11individualshadabdominalbinders,nineofwhichwerebeingusedasadaptiveequipmentandtwowerebeingusedasrestraintwithinthedefinitionsinthenewlyrevisedstatepolicy.TheStatePolicy001.1appearedtoprecludeuseofabdominalbindersasadaptiveequipment,insteadallowingthethreeoptionsnotedabovedependingontheindividual’scircumstances.TheFacilitywillneedtobecertainthatanysuchdevicesarebeingusedasdescribedintheStatePolicy.WhethertheMonitorsagreewiththisapproachwillbedeterminedwhentheyprovideresponsestothemostrecentversionoftheRestraintPolicy.ItwillbeimportantfortheFacilitytoassurethatitslocalproceduresarecongruentwiththeStateOffice’srevisedpolicy.AsnotedintheMonitoringTeam’spreviousreportsandfoundonceagain,additionalspecificationwithregardtoconsequence‐basedinterventionsinmanyofthereviewedPBSPswouldreducethelikelihoodofstaffusingrestrictiveinterventionswhennotprescribed.Thatis,theutilizationoftheterm“physicalredirection”andotherrelateddescriptionsoftenappearedambiguousandcouldlikelyleadtomisinterpretationbystaff.Severalexamplesofambiguousstaffinstructionswerefoundwithinthecurrentsample,includingthePBSPfor:Individual#38whichstated:“directherhandsaway;”Individual#184thatdirected:“ifhedoesnotcomplywithinfiveminutes,staffshouldprompthimthattheywillbeprovidingassistancewithtwostaffescortinghimtothebathroomarea;”Individual#186stated:“immediatelymove[Individual#186]awayfromothers;”Individual#58stated:“staffwillverballyredirecthim,thentakehimtoaquietarea.”Inaddition,somePBSPs(e.g.,Individual#46)referredtothepotentialneed,ifescalationofunsafebehaviorcontinued,toimplement“agency‐approvedprocedures.”TheMonitoringTeamassumedthatthisreferredto“PMABtechniques.”Inthesecases,morespecificationinthePBSPregardingPMABtechniquesaswellaswhetherornotaCrisisInterventionPlan(CIP)(previouslySafetyPlanforCrisisIntervention)wasinplacewouldincreasethelikelihoodthatstaffwouldfindand/orutilizetheappropriateintervention(s).Inthiscase,Individual#46didhaveaSPCI,althoughitwasnotmentionedinthePBSP.Similarly,Individual#20hadaSPCIbutitwasnotmentionedinthePBSP.Thatis,thePBSPjuststated:“if(Individual#20)becomesadangertohimselforothers,PMABinterventionsmaybeneeded.”Overall,morespecificationinPBSPswouldappearhelpfulinensuringtheappropriateinterventionsareimplementedasintended.


Previousonsitevisitsevidencedaslowbutongoingevolutionwithregardtothedevelopmentofdesensitizationplans.Morespecifically,reportsfrompreviousvisitsincludedthedevelopmentofamulti‐disciplinaryDesensitizationWorkgroupaswellastheongoingrevisionofdesensitizationplansovertime.However,thesereviewsdidnotrevealanysignificantimprovementsinthequality.Thatis,reviewedplanslackedindividuationandtypicalcomponentsnecessaryforeffectiveskillacquisition.Recentreportsindicatedthat,asof6/2/12,approximately116dentaland51medicaldesensitizationplanshadbeendeveloped.However,accordingtosummarydocumentation(i.e.,IndividualswithDesensitizationBaselines,notdated),alloftheseplansweredevelopedpriortothepreviousvisit(January2012)anddidnothaveappearedtoberevised.Itshouldbenoted,however,thatseveralplanshadbeenrevised(asdiscussedbelow)andsummarydocumentationhadnotbeenupdated.Overall,however,mostdesensitizationplanshadnotbeenrevisedandcontinuedtolacksufficientqualityaspreviouslyreported.TheMonitoringTeam’spreviousreviewrevealedpasteffortsintrainingstafftoidentifyindividualsmostlikelytobenefitfromdesensitizationplans(i.e.,utilizingthe“DecisionTreeWorksheet”)aswellasattemptstoidentifycurrentlevelsofbaselineresponding(i.e.,utilizing“Dental/MedicalBaselineforDesensitizationPlans”rubric).Atthepresenttime,accordingtoprovidedsummarydocumentation(i.e.,IndividualswithDesensitizationBaselines),itappearedthatatleast157decisiontreesaswellasapproximately118baselineshadbeencompleted.Theseinitialassessmentsappearedtoassistinidentifyingthenatureandseverityoftheimpairment,whichtheninformedmoreindividualizedinterventions,ifappropriate.Thatis,theseeffortshadalsoledtotheidentificationofasubstantialnumberofindividuals(approximately60)whodidnotappeartobeappropriatefordesensitizationplans.Overall,theseeffortsappearedtofacilitatemoreeffectiveassessmentand,consequently,moreindividualizedandpotentiallyeffectiveintervention.Itshouldbenoted,however,thatthissystemmightnotbe“foolproof”assomeindividualsmightbeerroneouslyomitted,or,insomecases,mightbenefitfromdesensitizationplansinthefuture.Consequently,regularevaluationbytheISPteam(i.e.,annualreviewattheISP)isnecessarytoensurethatindividualsaregiventheopportunitytobenefitfromleastrestrictiveinterventions.Forexample,asdiscussedwithregardtoSectionF,theISPforIndividual#282andIRRFindicatedthatthebehavioralservicesstaffsaidshewasnotacandidatefordesensitization“becauseofherspasticity.”However,thedescriptionofherresistanceatdentalappointmentsdidnotappeartobedirectlyrelatedtothespasticity.TheIRFFstated:“Duringappointmentssheexhibitsanxious(sic),hasexcessivemovementandisresistivetoexams,shebendsatthewaistasavoidanceandgrabshands.”Shealsowasresistivetostaffassistingherwithbrushingherteeth,butnoproactivestrategiestoaddressthiswereincludedinherintegratedhealthcareplans.SincetheMonitoringTeam’spreviousvisit,anewpilotprojecthadbeeninitiatedinanefforttodevelopmoreindividualizedandeffectivemedicalanddentaldesensitization


plans.Thisincluded16individualsatCoralSeaandinvolvedthedevelopmentofreviseddentalormedicaldesensitizationplansforeachindividual.Atthetimeoftheonsitevisit,reportsindicatedthateightdentalandeightmedicaldesensitizationplansweredevelopedaspartofthispilot.Asrequested,eightplanswereprovidedforreview.Thisreflectedasamplesizeof50%ofthetotalnumberofrecentlydevelopeddesensitizationplans.Thissampleincludedfourdentalandfourmedicaldesensitizationplans.Oftheeightplansreviewed,100%weredevelopedbasedoncompleteddecisiontreeworksheetsaswellasdental/medicalbaselineassessments.Consequently,theyappearedtoidentifymoremeaningfulobjectivesbasedoneachindividual’sobservedperformance.Theseindividualizedobjectivesappearedtobeasubstantialimprovementoverthosefoundinpreviouslyrevieweddesensitizationplans.However,althoughtheplansincludedmoreindividualizedobjectives,interventionproceduresremainedthesameacrossallplans.Indeed,theprimaryrelaxationstrategyfoundacrossallplanswastheuseofverbalcalmingtechniquesaswellassocialpraise.Althoughthistechniqueandformofreinforcementmightworkforsomeindividuals,itmightnotworkwithothers(e.g.,thosewhodonotcommunicateverbally).Inaddition,someoftheplanscontinuedtoincludeobjectivesthatwereinadequateorperhapsunattainable.Forexample,theobjectiveforIndividual#334stated:“…[Individual#334]willinteractwithdentalpersonnel…”butdidnotadequatelydefine“interact.”Similarly,theobjectiveforIndividual#273stated“…[Individual#273]willallowdentalstafftopolishhisteeth…”,butdidnotadequatelydefine“allow.”Inaddition,100%oftheplansappearedtoidentifyobjectivesthatwerelikelyunattainable.Thatis,theyincludedanobjectivethatrequired100%successacrossalltrialsforthreeconsecutivemonths.Thisoutcomeappearedsomewhatunrealistic.Inadditiontotheaboveconcerns,notedlimitationsofpreviouslyrevieweddesensitizationplans,thatis,regardingtheomissionofelementscriticaltoeffectiveskillacquisition(e.g.,promptinghierarchy,errorcorrectionprocedures,generalizationandmaintenanceprogramming),wereconsistentfollowingreviewofthecurrentsampleofreviseddesensitizationplans.ProgresswasnotedintheeffortstodevelopanactualdesensitizationclinicwithintheAngelfishbuilding.Onsitevisittothisclinicevidencedtheinitialdevelopmentofthespaceandnecessaryequipment.TheMonitoringTeamwilllookforwardtoreviewingthecontinuedprogressofthisclinicaswellasreviewingprogressofthemedicaldesensitizationclinicatthenextreview.Itshouldbenotedthat,althoughthisspacewilllikelyresembleaclinic(i.e.,withsimilarelements),behavioralservicesstaffneedtodemonstrateitseffectivenessaswellasincludestrategiestosupportgeneralizationtoamorenormalizedclinicalsetting.Theconcernisthatitcouldbeanextraandartificialstepthatmightimpedeultimatesuccessandactualnormalization.BasedontheMonitoringTeam’sfinding,theFacilitywasnotincompliancewiththisprovisionoftheSettlementAgreement.Documentationofrestraintsneedstocontainenoughdetailaboutthebehaviortodescribethecrisis,andFacilityproceduresneedtobeamendediftheuseoftheDoNotRestrainlististobediscontinued.Facilityprocedures


relatedtotheuseofabdominalbindersshouldberevisedtoimplementtherevisedstatepolicy.Inaddition,inorderforcompliancetobeachievedinthissection,CCSSLCneedstomakesignificantimprovementsinthequalityandimplementationofdesensitizationplansand/orotherstrategiestominimizeoreliminatetheneedforrestraint.

C5 Commencingimmediatelyandwithfullimplementationwithinsixmonths,stafftrainedintheapplicationandassessmentofrestraintshallconductanddocumentaface‐to‐faceassessmentoftheindividualassoonaspossiblebutnolaterthan15minutesfromthestartoftherestrainttoreviewtheapplicationandconsequencesoftherestraint.ForallrestraintsappliedataFacility,alicensedhealthcareprofessionalshallmonitoranddocumentvitalsignsandmentalstatusofanindividualinrestraintsatleastevery30minutesfromthestartoftherestraint,exceptforamedicalrestraintpursuanttoaphysician'sorder.Inextraordinarycircumstances,withclinicaljustification,thephysicianmayorderanalternativemonitoringschedule.ForallindividualssubjecttorestraintsawayfromaFacility,alicensedhealthcareprofessionalshallcheckanddocumentvitalsignsandmentalstatusoftheindividualwithinthirtyminutesoftheindividual’sreturntotheFacility.Ineachinstanceofamedicalrestraint,thephysicianshallspecifythescheduleandtypeofmonitoringrequired.

ItwasclearfromtheActionPlanforthisprovisionthattrainingofRestraintMonitorshadbeendone,andalistofnamesofRestraintMonitorswithtestscoreswassubmitted.However,itwasnotclearwhatthetrainingcurriculuminvolved.Basedonreviewoftrainingrecords,101staffattheFacilitysuccessfullycompletedthetrainingtoallowthemtoconductface‐to‐faceassessmentofindividualsinrestraint.Thislistwasprovidedaspartofthe“PresentationBook”atthebeginningofthesitevisit.Basedonareviewof25restraintrecords(Sample#C.1),aface‐to‐faceassessmentwasconducted:

In10outof25incidentsofrestraint(40%)byanadequatelytrainedstaffmember.Recordsthatdidcontaindocumentationofthisincluded(BoldedentriesareforrecordsthatdidnotcontainaFace‐to‐Facesheet):

o Individual#253on4/11/2012at1:05p.m.,and5/1/12at7:07p.m.;o Individual#61on5/17/2012at7:15p.m.;o Individual#300on2/1/2012at7:15a.m.,4/19/12at8:43p.m.,and

5/7/12at6:15p.m.;o Individual#246on4/14/12at6:14p.m.,and9:15p.m.;o Individual#169and5/16/12at2:45p.m.;o Individual#109on2/13/12at10:41p.m.;o Individual#16on4/28/12atatimenotentered,and5/7/12at6:20

a.m.;o Individual#26on3/29/12at8:24p.m.;o Individual#238on5/28/128:37p.m.;ando Individual#55on4/20/12at7:20a.m.

In19outof25instances(76%),thedocumentationshowedtheassessmentbeganassoonaspossible,butnolaterthan15minutesfromthestartoftherestraint.Recordsthatdidnotcontaindocumentationofthisincluded:

o Individual#253at4/11/12at1:05p.m.;o Individual#169on4/24/12at7:15p.m.;o Individual#169on4/24at7:35p.m.;o Individual#16on4/28/12notimeentered;o Individual#16on5/7/12at6:20a.m.;ando Individual#238on5/28at8:37p.m.

In20instances(80%),thedocumentationshowedthatanassessmentwascompletedoftheapplicationoftherestraint.Recordsthatdidnotcontaindocumentationofthisincluded:

Noncompliance


o Individual#253on5/17/12at12:22p.m.:nocommentontheinabilityofstafftomaintainrestraint;

o Individual#253on4/11/12at1:05p.m.:incorrectFace‐to‐Faceform;o Individual#16on4/28/12:noFace‐to‐Faceform;o Individual#16on5/7/12at6:20a.m.:noFace‐to‐Faceform;ando Individual#238on5/28at8:37p.m.:noFace‐to‐Faceform.

In14instances(56%),thedocumentationshowedthatanassessmentwascompletedofthecircumstancesoftherestraint.Recordsthatdidnotcontaindocumentationofthisincluded:

o Individual#253at4/11/12at1:05p.m.:incorrectface‐to‐faceform;o Individual#253at5/1/12at7:07p.m.:incompletedescriptionofevents

precedingtherestraint;o Individual#61on5/17/12at1:57p.m.:incompleteinformationabout

eventspriortorestraint;o Individual#61on5/17/12at7:15p.m.:individualwasupsetatthe

mentionofherboyfriend’sname,buttherewasnoassessmentofthecontext,whatwassaid,andinwhatmanner;

o Individual#300on4/19/12at8:43p.m.:individualran,buttherewasnoinformationonwhyrunningwascauseforarestraint,andnocommentonthecigaretteusagethatmightbecontributingtothebehavior;

o Individual#300on5/7/12at6:15p.m.:therewasnoindicationthatthedescriptionofeventspriortothebehaviorontheRestraintChecklistwasinadequateoranyinformationtosupplementthatinformation.

o Individual#300on5/24/12:theindividualbecameupsetwhenrepeatedlyaskedtotakehermedications.Therewasnoexplanationofwhysheneededtotakethemedicationsatthattimeorwhetheradelaymighthavebeenpossibletoallowhertocalmdown;

o Individual#16on4/28/12:noFace‐to‐Faceform;o Individual#16on5/7/12at6:20a.m.:noFace‐to‐Faceform;o Individual#238on5/28at8:37p.m.:noFace‐to‐Faceform;o Individual#26on3/29/12at8:24p.m.:therewasnotenough

informationaboutwhatprecededtheyelling,cursing,andaggressiontounderstandthecircumstancesandtheassessmentdidnothingtoremedythisissue.

Therewerenorecordsforwhichphysicianshadorderedalternativemonitoring.Basedonareviewof18restraintrecordsfornineindividualsforrestraintsthatoccurredattheFacility(i.e.,Individual#253,Individual#169,Individual#109,Individual#26,Individual#238,Individual#55,Individual#61,Individual#300,andIndividual#246),therewasdocumentationthatalicensedhealthcareprofessional:

Conductedmonitoringatleastevery30minutesfromtheinitiationoftherestraint


in14(78%)oftheinstanceofrestraint.Recordsthatdidnotcontaindocumentationofthisincluded:Individual#300,5/24/12;Individual#246,4/14/12;Individual#109,5/9/12,andIndividual#55,4/20/12.

Monitoredanddocumentedvitalsignsinnine(50%)episodes.Recordsthatdidnotcontainappropriatedocumentationofthisincluded:Individual#300,2/1/12,4/19/12,5/7/12,and5/24/12;Individual#246,4/14/12(twoepisodes);Individual#169,4/24/12;Individual#109,2/13/12;andIndividual#55,4/20/12.Problematicissuesresultedinnoncomplianceincludedthevitalsignsnotrecordedormarkedasrefused.Asnotedinpreviousreports,toobtainrespirations,theindividual’scooperationisnotrequired.Inaddition,noncompliancewiththisindicatorwasfoundforindividualswhoseRestraintChecklistsindicatedthatindividualshadsignificantlyhighorlowvaluesfortheirvitalsigns,anddidnotincludedocumentationthatthevitalsignswereretakentoensuretheindividualsweremedicallystable.

Monitoredanddocumentedmentalstatusineight(44%)episodes.Recordsthatdidnotcontainappropriatedocumentationofthisincluded:Individual#253,5/1/12,and5/27/12;Individual#61,5/17/12(twoepisodes);Individual#300,4/19/12;Individual#246,4/14/12(twoepisodes);Individual#169,4/24/12;Individual#238,5/28/12;andIndividual#55,4/20/12.Problematicissuesthatresultedinnoncomplianceincludedeitherthementalstatuswerenotrecorded,weregenericsuchas“alert,oriented,andaggressive”withoutaspecificdescriptionincluded,oritwasmarkedasrefused.Also,asrepeatedlynotedinpreviousreports,toobtainamentalstatus,theindividual’scooperationisnotrequired.

FromdiscussionswiththePsychiatricNurseswhoaudittheseareas,theirfindingsweresimilartotheMonitoringTeam’sfindingsregardingthelowcompliancerelatedtothedocumentationofvitalsigns,andmentalstatus.However,nursinghadnotestablishedasystemtoanalyzethesedataandaddresstheongoingproblematicissuesfoundfortheabovedata,and/orthedatarelatedtoSectionC.6addressingthedocumentationofassessmentbyalicensedhealthcareprofessionalofanyrestraint‐relatedinjuriesorothernegativehealtheffects.Atthetimeofthereview,theCNEconfirmednosystemwasinplacetoensurethatnursingwasregularlyreviewingthedataaddressingnursing’sroleregardingepisodesofrestraint.Asnotedinthedocumentsreviewedsection,theFacilityindicatedthatsincetheMonitoringTeam’slastreview,norestraintshadoccurredoffgrounds.

Sample#C.3including13recordswasselectedfromthelistofindividualswhohadmedicalrestraintinthelastsixmonths.(DetailsregardingthesampleareprovidedintheDocumentsReviewedsection.)Fortheseindividuals,thephysicians’orderswerereviewedascapturedintheSedationCarePlans,aswellasdocumentationofmonitoring.


In13outof13(100%),thephysicianspecifiedthescheduleofmonitoringrequired;and

In13outof13(100%),thetypeofmonitoringrequiredwasdescribedina“SedationCarePlan”whichwassignedbyaregisterednurse,presumablyontheordersofthephysician.TheSedationCarePlanwasaone‐pageformwithdetailstobecheckeddependingontheindividual,andwithspacestorecordmentalconditionsatprescribedintervals.ThePlanreferredtotheRestraintChecklistforthevitalsignstoberecordedevery15minutesfortwohoursoneveryrestraint.Itwasnotclearwhenthetwohourswastobegin:afterthemedicationwasadministeredwhichwouldincludethetimethemedicalprocedurewasunderway,orfromthetimetheindividualreturnedtohis/herresidence.

Assumingthattheintentwasfromthetimethemedicationwasadministered,inallbutthreereports,themonitoringhadnotbeencarriedoutasspecifiedintheSedationCarePlan,becausethedocumentationofmonitoringontheRestraintChecklistwasnotcarriedoutevery15minutesfortwohours.Forexample:

o Individual#221wasgivensedationat12:15p.m.forcompletionofamedicalappointment.Monitoringwasrecordedat12:30p.m.,3:45p.m.,4:15p.m.,4:45p.m.etc.

Thedirectionsspecifiedinthetoolneededtobefollowedanddocumented.Therewasaspaceontheformforthedoctor’sname,whichwasnotincludedinallrecords.Thereneededtobeevidencethatthescheduleandtypeofmonitoringwerebasedonaphysician’sorderasspecifiedintheSettlementAgreement.

Basedonthesefindings,theMonitoringTeamconcludedthattheFacilitywasinnoncompliancewiththisprovision.Evidencewasnecessarytoconfirmthatallstaffthatperformthedutiesofrestraintmonitor,asidentifiedontheFace‐to‐Facemonitoringforms,arequalifiedtodoso.Effortstoprovideadditionaltrainingtostaffthatfilloutrestraintchecklistsshouldcontinuetoensurethatthequalityofinformationonthechecklistscontinuestoimprove.Ofparticularimportanceistheneedtocontinuetoworkwithstafftoprovideinformationaboutantecedentstothebehaviorthatnecessitatesrestraint.WhenusingaSedationCarePlantoindicatethefrequencyofmonitoringfollowingsedation,theinstructionsontheformshouldbefollowed.TheFacility’sSelf‐AssessmentalsofoundtheFacilitywasnotincompliancewiththisprovision.

C6 Effectiveimmediately,everyindividualinrestraintshall:becheckedforrestraint‐relatedinjury;andreceiveopportunitiestoexerciserestrainedlimbs,toeatasnearmealtimesaspossible,todrinkfluids,andtouseatoiletor

Asample(Sample#C.1)of25RestraintChecklistsforindividualsinnon‐medicalrestraintwasselectedforreview.Thefollowingcompliancerateswereidentifiedforeachoftherequiredelements:

In25(100%),continuousone‐to‐onesupervisionwasprovided; In24(96%),thedateandtimerestraintwasbegun(forIndividual#16on

4/28/12,notimewasentered); In23(92%),thelocationoftherestraint(itwasnotprovidedforIndividual#246

Noncompliance


bedpan.Individualssubjecttomedicalrestraintshallreceiveenhancedsupervision(i.e.,theindividualisassignedsupervisionbyaspecificstaffpersonwhoisabletointerveneinordertominimizetheriskofdesignatedhigh‐riskbehaviors,situations,orinjuries)andotherindividualsinrestraintshallbeundercontinuousone‐to‐onesupervision.Inextraordinarycircumstances,withclinicaljustification,theFacilitySuperintendentmayauthorizeanalternatelevelofsupervision.EveryuseofrestraintshallbedocumentedconsistentwithAppendixA.

on4/14/12at6:14p.m.,andIndividual#238on5/28/12at8:37p.m.); Inseven(28%),informationaboutwhathappenedbefore,includingthechangein

thebehaviorthatledtotheuseofrestraint.MostRestraintChecklistsprovidedinsufficientspecificityaboutwhatwashappeningbeforethebehaviorthatledtorestrainttodeterminewhatmighthavetriggeredthebehavior(examplesareprovidedwithregardtoSectionC.5);

In11(44%),theactionstakenbystaffpriortotheuseofrestraintweresufficienttopermitadequatereviewperSectionC.8.ExamplesareprovidedwithregardtoSectionC.5regardingcircumstancesofrestraint;

In16(64%),thespecificreasonsfortheuseoftherestraintweredocumented.Innine,reportsthereasonsdidnotincludeenoughdetail.Forexample:

o Individual#253on3/4/12at5:20p.m.wasreportedtobekickingandhittingstaff.Thistookplaceinherbedroom.Theneededdetailwaswhethershewaspursuingstafftokickthem,andifshewasnot,whytheyneededtoapproachher.

o Individual#61on5/17/12at1:57p.m.andat7:15p.m.,Individual#300on4/19/12at8:43p.m.andon5/7/12at6:15p.m.,andIndividual#26on3/29/12at8:29p.m.weresimilartothepreviousbullet.

o Individual#16on4/28/12andon5/7/12wasrestrainedwithmittenspursuanttoaSafetyPlan,whichwasnotprovided.TheRestraintChecklistdidnotprovidedetailsofthereasonfortherestraint.

o Individual#238on5/28/12at8:37p.m.wasdescribedaschasingstaffwithastick.Themissingdetailwasthesizeandtypeofstick,andwhetherornotstaffwereabletomaintainadistancefromtheindividual.

In25(100%),themethodandtype(e.g.,medical,dental,crisisintervention)ofrestraint;

In25(100%),thenamesofstaffinvolvedintherestraintepisode; Observationsoftheindividualandactionstakenbystaffwhiletheindividualwas

inrestraint,including:o In23(92%),theobservationsdocumentedevery15minutesandat

release.ExceptionswereIndividual#16whowasrestrainedwithmittenspursuanttoaSafetyPlanandwhowasmonitoredevery30minutesforcirculation.Mostindividualswerenotrestrainedlongenoughtorequire15‐minutechecks.

o In23(92%),thespecificbehaviorsoftheindividualthatrequiredcontinuingrestraint.TheexceptionbeingIndividual#16.

o In23(92%),thecareprovidedbystaffduringtherestraint,includingopportunitiestoexerciserestrainedlimbs,toeatasnearmealtimesaspossible,todrinkfluids,andtouseatoiletorbedpan,exceptIndividual#16,wherethereweresomeindicationsofreleasefortoiletinganditwasnotcleariftheindividualwasreleasedformealsorifhewasreceivingnutritionviaatube.


o In25(100%),thelevelofsupervisionprovidedduringtherestraintepisode;and

o In23(92%),thedateandtimetheindividualwasreleasedfromrestraint,theexceptionbeingIndividual#16.

Basedonareviewof18restraintrecordsfornineindividualsforrestraintsthatoccurredattheFacility(i.e.,Individual#253,Individual#169,Individual#109,Individual#26,Individual#238,Individual#55,Individual#61,Individual#300,andIndividual#246):

Innone(0%),theresultsofassessmentbyalicensedhealthcareprofessionalastowhethertherewereanyrestraint‐relatedinjuriesorothernegativehealtheffectswasappropriatelydocumented.Recordsthatdidnotcontaindocumentationofthisincluded:Individual#253,5/1/12,and5/27/12;Individual#61,5/17/12(twoepisodes);Individual#300,2/1/12,4/19/12,5/7/12,5/24/12;Individual#246,4/14/12(threeepisodes);Individual#169,4/24/12,and5/16/12;Individual#109,2/13/12,and5/9/12;Individual#26,3/29/12;Individual#238,5/28/12;andIndividual#55,4/20/12.ProblematicissuesthatresultedinnoncomplianceincludedeitherthePostRestraintAssessmentsectionbeingleftblank,lackingtheappropriatedocumentationregardinganassessment,orlackingappropriatenursingdocumentationregardinginjuriesorthespecificdescriptionsofinjuries.

Inasampleof25records(Sample#C.1),restraintdebriefingformshadbeencompletedfor21(84%).Intheremainingrecordstheformwasnotprovided,orforIndividual#253on4/11/12at1:05p.m.,theformwasforthewrongrestraint(i.e.,hand‐over‐handnotchemical).

Ofnote,mostoftheformsdidnotincludethedatesofthereviewsbytheUnitReviewTeamsandbytheIncidentManagementTeams.

Asampleof13individualssubjecttomedicalrestraintwasreviewed(Sample#C.3),andinnone(0%)wasthereevidencethatthemonitoringhadbeencompletedasrequiredbythephysician’sorderasfoundintheSedationCarePlanasdescribedwithregardtoSectionC.5.AsdescribedintheDocumentsReviewedSectionofthisreport,Sample#C.4wasselectedusingthelisttheFacilityprovidedofindividualswhohadhadchemicalrestraintsincethelastonsitereview.Documentationforthissampleofthreeindividualswasreviewed.Inthree(100%),therewasdocumentationthatpriortotheadministrationofthechemicalrestraint,thelicensedhealthcareprofessionalcontactedthepsychologist,whoassessedwhetherlessintrusiveinterventionswereavailableandwhetherornotconditionsforadministrationofachemicalrestrainthadbeenmet.TheFacilitywasnotincompliancewiththisprovision.Theprimaryreasonsincludedthe


lackofspecificdetailintheRestraintCheckliststoexplaintheeventspriortothebehaviorthatcausedtherestraint,theactionstakenbystaffpriortotheuseofrestrainttotrytoavoidtherestraint,andthespecificbehaviorthancausedtherestraint.Inaddition,thosemonitoringmedicalrestraintsneededtofollowtheinstructionsontheSedationCarePlan.InitsSelf‐Assessment,theFacilityidentifiedthatitwasnotincompliancewiththisprovision.

C7 WithinsixmonthsoftheEffectiveDatehereof,foranyindividualplacedinrestraint,otherthanmedicalrestraint,morethanthreetimesinanyrollingthirtydayperiod,theindividual’streatmentteamshall:

(a) reviewtheindividual’sadaptiveskillsandbiological,medical,psychosocialfactors;

Accordingtodocumentationprovided,IndividualsRestrainedDuringTimePeriodBetween12/1/11and5/31/12,dated6/3/12,atleast11individualswereplacedinrestraintmorethanthreetimesinanyrollingthirty‐dayperiod.Oftheseeleven,asampleofthreeindividuals(reflectingasampleof27%)wasselectedforreviewtodetermineiftherequirementsoftheSettlementAgreementweremet.Thissamplewasthesamesampleasdescribedpreviously(Sample#C.7)andincludedIndividual#61(restraintson5/17/12and5/18/12),Individual#253(restraintson4/10/12and4/17/12),andIndividual#275(restraintson5/28/12and5/29/12).Specificrestraintsbydatearelistedaboveinthe“ReviewofFollowingDocumentation”section.Aspreviouslypresented(withregardtoSectionC.1),themajorityoftherequesteddocumentationforthissamplewasnotprovidedand,asaconsequence,theMonitoringTeamwasnotabletoadequatelyevaluatetheselectedrestraintreportsandrelateddocumentationtodeterminewhetherornotprogresshadbeenmadeinregardSectionsC.7.athroughC.7.goftheSettlementAgreementaspresentedbelow.Overall,noevidencewasprovidedtodemonstratethattheIDTforanyoftheindividualssampledadequatelyreviewedtheselectedrestraintsthatmetthecriterionofmorethanthreerestraintsinarolling30‐dayperiod.TheMonitoringTeam’spreviousreportsfoundevidenceoftheuseofthestructuredISPaddendum(ISPA)designedtoreviewanddocumenttheIDT’sdiscussionandrecommendationsunderthesecircumstances.However,basedonthedocumentationprovided,itdidnotappearthatthisISPAformatwasusedforanyofthesampledindividualsfollowingtheselectedrestraints.Subsequently,basedondocumentationprovided,ofthethreeindividualssampled,none(0%)oftheindividuals’teamsmettoreviewtherestraintsselectedforreview.Consequently,theMonitoringteamfoundtheFacilityinnoncompliancewiththissectionoftheSettlementAgreement.ThisfindingofnoncomplianceappearedconsistentwithfindingsreportedinSectionC.7of

Noncompliance


themostrecentCCSSLCSelf‐Assessment,dated6/25/12.Morespecifically,theFacilityself‐reviewrevealedsignificantlimitationsandinadequaciesacrossallprovisionswithinSectionC.7oftheSettlementAgreementasdiscussedingreaterdetailbelow.ItshouldbenotedthatdocumentationprovidedwithintheSectionC.7ofthePresentationbookrevealedseveralexamplesofcompletedISPAsfollowingmorethanthreerestraintsina30‐dayperiod(e.g.,forIndividual#297,dated12/21/11and1/23/12;Individual#7,dated2/2/12;and,Individual#253dated3/8/12).Consequently,giventhattheappropriateISPAformatwasutilizedwithotherindividuals(orthesameindividualfordifferentrestraints),itwasunclearwhythisISPAformatwasnotutilizedfollowingtherestraintsselectedforthecurrentsample.Ofthethreeindividualsreviewed,zero(0%)oftheindividuals’teamsadequatelyreviewedtheindividual’sadaptiveskills.Ofthethreeindividualsreviewed,zero(0%)oftheindividuals’teamsadequatelyreviewedtheindividual’sbiological,medicalandpsychosocialfactors.ThesefindingswereconsistentwiththefindingsofthemostrecentCCSSLCSelf‐Assessment,dated6/25/12,thatindicatedthatprovisionC.7.awasnotinsubstantialcomplianceduetoessentialelementsmissingfromsampleddocumentation.

(b) reviewpossiblycontributingenvironmentalconditions;

Ofthethreeindividualsreviewed,zero(0%)oftheindividuals’teamsadequatelyreviewedthepotentialcontributingenvironmentalconditions.ThisfindingwasconsistentwiththefindingsofthemostrecentCCSSLCSelf‐Assessment,dated6/25/12,thatindicatedthatprovisionC.7.bwasnotinsubstantialcomplianceduetoenvironmentalvariablesnotfullydelineatedin66%ofthesampleddocumentation.

Noncompliance

(c) revieworperformstructuralassessmentsofthebehaviorprovokingrestraints;

Ofthethreeindividualsreviewed,zero(0%)oftheindividuals’teamsadequatelyreviewedand/ormaderecommendationstorevisestructuralandfunctionalbehaviorassessments.ThisfindingwasconsistentwiththefindingsofthemostrecentCCSSLCSelf‐Assessment,dated6/25/12,thatindicatedthatprovisionC.7.cwasnotinsubstantialcomplianceduetolackofadequaterevieworrevisionofSFBAsofthosesampled.

Noncompliance

(d) revieworperformfunctionalassessmentsofthebehaviorprovokingrestraints;

Ofthethreeindividualsreviewed,zero(0%)oftheindividuals’teamsadequatelyreviewedand/ormaderecommendationstorevisestructuralandfunctionalbehaviorassessments.ThisfindingwasconsistentwiththefindingsofthemostrecentCCSSLCSelf‐Assessment,dated6/25/12,thatindicatedthatprovisionC.7.dwasnotinsubstantialcomplianceduetolackofadequaterevieworrevisionofSFBAsofthosesampled.

Noncompliance


(e) develop(ifonedoesnotexist)andimplementaPBSPbasedonthatindividual’sparticularstrengths,specifying:theobjectivelydefinedbehaviortobetreatedthatleadstotheuseoftherestraint;alternative,positiveadaptivebehaviorstobetaughttotheindividualtoreplacethebehaviorthatinitiatestheuseoftherestraint,aswellasotherprograms,wherepossible,toreduceoreliminatetheuseofsuchrestraint.Thetypeofrestraintauthorized,therestraint’smaximumduration,thedesignatedapprovedrestraintsituation,andthecriteriaforterminatingtheuseoftherestraintshallbesetoutintheindividual’sISP;

Duetolackofprovideddocumentationasrequested,theMonitoringTeamcouldnotadequatelyreviewthePBSPsfortheindividualsinthesample.Morespecifically,inadditiontotheidentifiedrestraints(aslistedabove),therelatedPBSPsthatwereinplaceatthetimeoftheserestraintsfortheselectedindividualswerenotprovidedasrequested.

Noncompliance

(f) ensurethattheindividual’streatmentplanisimplementedwithahighleveloftreatmentintegrity,i.e.,thattherelevanttreatmentsandsupportsareprovidedconsistentlyacrosssettingsandfullyaswrittenuponeachoccurrenceofatargetedbehavior;and

TherewasnoevidenceinthesampleddocumentationtoindicatethattreatmentintegritywasexaminedforanyofthePBSPsofthethreeindividualsselected.AsfoundduringtheMonitoringTeam’spreviousvisits,staffreportsindicatedthattreatmentintegritywasbeingcollected,butthedatahadnotyetbeensummarizedorsystematicallyanalyzed.Asaresult,itwasnotpossibletoconfirmahighdegreeoftreatmentintegrityasrelatedtotheimplementationofPBSPsandSPCIs.

Noncompliance

(g) asnecessary,assessandrevisethePBSP.

Ofthethreeindividualsreviewed,zero(0%)oftheindividuals’teamsadequatelyreviewedand/ormaderecommendationstorevisethePBSP.ThisfindingwasconsistentwiththefindingsofthemostrecentCCSSLCSelf‐Assessment,dated6/25/12,thatindicatedthatprovisionC.7.gwasnotinsubstantialcomplianceduetolackofspecificationregardingISTdeterminationthatPBSPsshouldbereviewedorrevised.

Noncompliance

C8 EachFacilityshallrevieweachuseofrestraint,otherthanmedicalrestraint,andascertainthecircumstancesunderwhichsuchrestraintwasused.Thereview

CCSSLC’sproceduresincludedreviewofrestraints,otherthanmedicalrestraint,bytheUnitTeamandtheIMRTwithinthreebusinessdays;bytheIDTtodetermineifanyaddendatotheISPwereneeded,andbytheRestraintReductionTeamtodeterminewhatadditionalactionsmightbeneededandwhethertherewasasystemicissuethatrequiredaction.ThereappearedtobeissueswithdistributingtheRestraintChecklistsandother

Noncompliance


shalltakeplacewithinthreebusinessdaysofthestartofeachinstanceofrestraint,otherthanmedicalrestraint.ISPsshallberevised,asappropriate.

documentationtotheappropriatereviewingbodies,andassuringthatthedatawasenteredquicklyandaccuratelyintotheAvatardatasystem.Atthetimeofthesitevisit,FacilitystaffreportedthatthatanewphaseoftheAvatarsystemwasinthelaunchphase.ThiswouldallowtheRestraintChecklistsandassociatedinformationtobeenteredelectronicallyandimmediatelyratherthanbeinghand‐writtenforentrylater.Thissystemwassaidtobesimilarindesigntotheoneinuseforreportinginjuries,whichhadresultedinimprovementstothequalityofthatdata.TheMonitoringTeamwillobservethischangeatthenextreview.Asampleofdocumentationrelatedto25incidentsofrestraintwasrequested(Sample#C.1),includingallreviewsoftheuseoftherestraintandanyaddendumstotheindividual’sIndividualSupportPlanthatresulted.Thisdocumentationshowedthat:

In16(64%),thereviewbytheUnitIDToccurredwithinthreebusinessdaysoftherestraintepisode,andthisreviewwasdocumentedbysignatureontheRestraintChecklist.Asnotedbelow,fulldocumentationofthesereviewswasnotprovided.

Intwo(8%),thereviewbytheIMRToccurredwithinthreebusinessdaysoftherestraintepisode,andthisreviewwasdocumentedbysignatureontheFacetoFace/DebriefingForm.Asnotedbelow,fulldocumentationofthesereviewswasnotprovided.

AsdescribedinSectionC.5ofthisreport,in15(60%),thecircumstancesunderwhichtherestraintwasusedweredeterminedanddocumentedontheFace‐to‐FaceAssessmentDebriefingform,includingtheidentityofthestaffresponsibleforthereview.

AlthoughtheMonitoringTeamrequest“allreviews”oftherestraintsinthesample,thedocumentationofthereviewsbytheUnitTeamandtheIMRTwerenotsubmittedfortherecordsinthesample,onlytheRestraintChecklist/Debriefingforms,whichprovidedlimitedinformation.Asaresult,itcouldnotbedeterminedwhetherthereviewswereconductedbytheUnitIDTandtheIMRT,whethertheyweresufficientinscopeanddepthtodetermineiftheapplicationofrestraintwasjustified,whethertherestraintswereappliedcorrectly,andwhetherfactorsexistedthat,ifmodified,mightpreventfutureuseofrestraintwiththeindividual,includingadequatereviewofalternativeinterventionsthatwereeitherattemptedandwereunsuccessful,orwerenotattemptedbecauseoftheemergencynatureofthebehaviorthatresultedinrestraint.

SincethedocumentsdescribingthereviewsbytheUnitIDTandtheIMRTwerenotsubmittedforSampleC.1,itcouldnotbedeterminedifthereviewconductedbytheUnitIDTandtheIMRTresultedinanadditionalreferraltotheIDTforreviewandconsiderationofpossiblechangesinactivetreatment.

ItwasnotedinobservationofanIMRT/ReviewAuthorityTeammeetingthatrestraintswerebeingreviewedandminutestakenofthosereviews.


Recommendations:ThefollowingrecommendationsareofferedforconsiderationbytheStateandtheFacility:

1. Trainingshouldbeprovidedtodirectsupportprofessionalstoensurethattheyarepromptingtheuseofreplacementbehaviorsandothercopingstrategies,usingtechniquesoutlinedinthePBSPstopreventandaddressbehaviors,anddocumentingtheiruseadequately,whenappropriate,onrestraintchecklists.(SectionC.1)

2. Thequalityofthedocumentationoftheeventsprecedingtherestraintshouldcontinuetobeimprovedtoprovideanunderstandingofwhathappenedtoinitiatethechainofeventsthatresultedinrestraint,aswellasthespecificactionsstafftook,includingtheorderofthealternativestorestraintandthetimeinvolvedinthoseefforts.(SectionsC.1andC.5)

3. StaffshouldbetrainedtofollowthePBSPsandSafetyPlanspriortotheuseofrestraints,andtodocumentthestepstakenontheRestraintChecklist.WhenRestraintMonitorsnotelackofdocumentation,theyshouldaskstaffforclarificationandrecordtheinformationonthedebriefingform.(SectionsC.1andC.3)

4. DatacollectedintheAVATARsystemforrestraintsshouldbereviewedforinconsistenciesanderrors,andmodified,asappropriate,sothatitproducesaccurateinformationthatcanbereliedonbymanagementinmakingdecisionsaboutrestraintuse.(SectionC.1)

5. Staffshouldbetrainedonthenewelectronicrestraintreportingsystemtoavoidduplicateanderroneousentries.(SectionC.1)6. FacilitypolicyandpracticethataddresstheuseofabdominalbindersshouldbemodifiedtocomplywiththerevisedStatepolicy.(SectionC.2)7. WhenPMABproceduresarereferencedinconsequence‐basedinterventionsectionsinPBSPs,areferenceshouldbeprovidedastowhetheror

notaSPCIiscurrentlyinplaceandtodirectstafftorelatedstrategiesprescribedwithintheSPCI.(SectionC.4)8. InPBSPs,theterm“environmentalredirection”shouldbeclarifiedtoincludethespecifictypeofpromptprescribed(i.e.,verbal,gestural,

and/orphysical).(SectionC.4)9. InPBSPs,theterm“physicalredirection”shouldbemorespecificregardingtheacceptableamountofphysicalforce(i.e.,thatitdoesnotinclude

forceoveractiveresistance).(SectionC.4)

InMarch2012,theRestraintReductionCommitteehadbeenreformedastheRestrictivePracticesCommittee(RPC)toincludereviewofLevelsofSupportaswellasuseofrestraints.TheRPCwasscheduledtomeetonMondaystoreviewbehavioralrestrictions,Wednesdaystoreviewdentalrestraints,andFridaytoreviewmedicalrestraints.MinutesdemonstratedthattheRPChadbeenfollowingthatscheduleinAprilandMay.However,therewerenonewprocedurestodocumentthechanges.Uponinterview,itwasexplainedthatatoneofthemeetingsmid‐month,thecommitteereviewedtrendsinrestraintusefacility‐wide.MeetingminutescontainedminimalinformationaboutrestraintreviewsortrendsacrosstheFacility.Thechartsincludedintheminutestotrackrestraintsreviewswerenotcompleted(e.g.,theminutesfor3/30/12),andfollow‐uprecommendationsoverduetotheCommitteewerenotcommentedon.Forthiscommitteetoshowresults,itwillneedtohaveclearproceduresdocumented,andfollowed,withminutesthatreflectthediscussionandtrackanyfollow‐upthatresults.Basedonthesefindings,theFacilitywasnotincompliancewiththisprovision.IntheFacilitySelf‐Assessment,theFacilitysimilarlyfoundthatitwasnotinsubstantialcompliance.TherestraintreviewprocesswasoverhauledinJune2011andagaininMarch2012,andatthetimeofthereview,itwasnotclearthateachrestraintwasbeingreviewedontimeandthatthereviewswereidentifyingareasinneedofactionandfollow‐up.Therestraintreviewprocessshouldbefirmlyestablishedandconsistentlyimplemented.


10. TheFacilityshouldensurethatdesensitizationplanscontainnecessaryelementsforeffectiveskillacquisition.(SectionC.4)11. AlistofstaffthathavebeentrainedasRestraintMonitorsshouldbemaintainedwithevidenceofthetraining.(SectionC.5)12. ThecurriculumfortrainingRestraintMonitorsshouldbeenhancedtoensureunderstandingofantecedentbehaviors,documentationof

alternativesthataretriedpriortorestraint,andtheneedtoincludeindicationsofthetimespentattemptingtopreventtherestraint.(SectionC.5)

13. TheFacilityshouldensurethatrestraints,suchasmedicalrestraints,havedocumentationtosupportalternativeschedulesofmonitoring.(SectionC.5)

14. TheFacilityshouldensurethatalicensedhealthcareprofessionaltimelyandregularlymonitors,andappropriatelydocumentsthevitalsigns,andthementalstatusofanindividualinrestraintsatleastevery30minutesfromthestartoftherestraintepisode,andfortwohoursexceptforamedicalrestraintpursuanttoaphysician'sorder.(SectionC.5)

15. TheFacilityshoulddevelopandimplementasystemtoensurethatauditingdataregardingrestraintsisbeingregularlyreviewedbynursing,andthatplansofcorrectionareimplementedaddressingtheproblematicissuesidentified.(SectionC.5)

16. TheFacilityshouldensurethatnursingstaffassessesandappropriatelydocumentsanyrestraint‐relatedinjury.(SectionC.6)17. ThequalityoftheRestraintDebriefingandFace‐to‐Faceformsshouldbeimprovedbyensuringstaffcompleteformsaccurately,andfillinall

information,particularlyexplanatorycommentsanddatesofreviewbytheUnitTeamsandtheIncidentManagementTeam.(SectionC.6)18. TheFacilityshouldprovidere‐trainingforQDDPsandotherIDTmembersthatfacilitateanddocumentmeetingswhendiscussingtheuseof

morethanthreerestraintsina30‐dayperiod.(SectionC.7)19. TheRestraintReviewCommitteeshouldfollowitsprocessforreviewingformsconsistentlyandvigorouslytoidentifyerrorsand

inconsistencies.(SectionC.8)20. TheUnitIncidentManagementReviewTeamsshouldkeepminutesorinsertsufficientinformationintoitslogtodocumentitsreviewof

incidentsandanyrecommendationsthataremade,andtrackanychangesthatareneededsothatitisclearwhenissuesrelatedtoarestrainthavebeenaddressed.(SectionC.8)


SECTIOND:ProtectionFromHarm‐Abuse,Neglect,andIncidentManagementEachFacilityshallprotectindividualsfromharmconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow.


o CentersforMedicareandMedicaid(CMS)IntermediateCareFacilityforPersonswithDevelopmentalDisabilities(ICF/DD)reportsof5/14/12and6/27/12;

o CCSSLCSelf‐Assessment,updated6/25/12;o CCSSLCActionPlans,updated6/25/12;o CCSSLCProvisionActionInformation,undated;o Abuse/Neglect/Exploitation(A/N/E)Investigationsbetween1/1/12and5/31/12,dated

6/8/12;o Abuse/Neglect/ExploitationInvestigationsbetween6/1/12and7/5/12;o CCSSLCAbuseNeglectandExploitation–MonthlyTrendingReport,from5/1/12to

5/31/12;o InvestigationsConductedSolelybyFacilitybetween1/1/12and5/31/12,dated6/8/12;o CCSSLCUnusualIncidents–MonthlyTrendingReport,from5/1/12to5/31/12;o CCSSLCInjuries–MonthlyTrendingReport,from6/1/12to6/30/12;o IndividualswithInjuriesforReportingPeriodbetween1/1/12to5/31/12and6/1/12to

7/5/12;o CCSSLCStaffStatusTracking–byDate,dated6/8/12;o “ListofSevenCCSSLCclientswhoarecurrentlyonchroniccallerlist,”undated;o CourseDelinquencyListforABU0100,AbuseandNeglect,dated7/2/12;o CourseDelinquencyListforUNU0100,UnusualIncidents,dated7/2/12;o AdultProtectiveServices(APS)TrainingTranscriptCrosswalk–CorpusChristi,undated;o APSTrainingTranscriptCrosswalk–CorpusChristiforsevenAPSinvestigators,undated;o ChartofFacilityInvestigatorsandCampusAdministratorswithrequiredinvestigation

coursestaken,undated;o IndividualTrainingRecordsforeightFacilitystaffassignedtoinvestigateunusual

incidents,dated6/7/12;o IndividualSupportPlan(ISP)Meeting(FacilitationandDocumentation),dated12/3/11;o CCSSLCAnnualEmployeeRegistryCheckandFingerprintCriminalHistorySubmission,

dated10/6/11;o PacificUnitManagementReviewTeamMeetingMinutesfor5/7/12,o MemofromJonBresemanre:Monitorvs.TemporaryWorkReassignment(TWR),dated

3/12/12;o CCSSLCCoachingGuide,revised11/28/11;o Sample#D.1includedasampleof25DFPSinvestigationsofabuse,neglect,and/or

exploitationwiththeFacilityinvestigationreports.Twenty‐threeweredrawnfromthelistofA/N/EInvestigationsDuringtheTimePeriod1/1/12through5/31/12.TworeportsweredrawnfromthosepresentedattheIncidentManagementReviewTeam


(IMRT)meetingon7/9/12,andcontainedonlytheDFPS report.Investigationrecordsincluded:#41186437,#41227020,#41160939,#41280484,#41408352,#41197456,#41308284,#41470552,#41494346,#41572192,#41594760,#41678952,#41793852,#41868913,#41891452,#41982392,#42070572,#42119863,#42134752,#42160077,#42180405,#42211916,#42217152,#42357694,and#42341106;

o Sample#D.2includedasampleoffiveinvestigationreportsthatweredrawnfromthelistofInvestigationsCompletedSolelyBytheFacilitybetween1/1/12and5/31/12.Investigationrecordsincluded:#12‐347,#12‐261,#12‐294,#12‐330,and#12‐354;

o Sample#D.4includedsixteenIndividualSupportPlans,includingthosefor:Individual#155,Individual#174,Individual#226,Individual#172,Individual#88,Individual#124,Individual#290,Individual#363,Individual#184,Individual#268,Individual#282,Individual#336,Individual#26,Individual#250,Individual#63,andIndividual#228;and

o Sample#D.6includedfouroftheDFPSinvestigationsfromSample#D.1whereabuseorneglectwasconfirmedandtwooftheFacilityinvestigationsfromSample#D.2,includingthefollowingDFPSInvestigations:#41186437,#41868913,#41891452,#42160077andFacilityinvestigations#12‐261and#12‐354.

Interviewswith:o MarkCazalas,FacilityDirector;o BruceBoswell,AssistantDirectorofPrograms;o CynthiaVelasquez,DirectorforQualityAssurance;o JonBreseman,IncidentManagementCoordinator(IMC);o AraceliMatehuala,ProgramComplianceMonitor;o Twentystaffmembersfromvariousresidentiallocations;ando Tenindividualsinvariousresidentialanddaylocations.

Observationsof:o Residences:522A,B,C,andD;524A,B,C,andD;and514;o DayandVocationalProgramsinBuildings512,513,and517;o IncidentManagementReviewTeamMeeting,at11a.m.on7/9/12;ando InterdisciplinaryTeammeetingforIndividual#341,on7/11/12.

FacilitySelf‐Assessment:TheCCSSLC Self‐Assessment indicatedtheFacilitywasinsubstantialcompliancewith17ofthe22provisionsinSectionDoftheSettlementAgreement.TheMonitoringTeamfoundtheFacilitytobeincompliancewith15ofthe22.Toconducttheself‐assessment,theIncidentManagementCoordinatorreviewedthespecificrequirementsofeachprovisionandanyseparateelementswithintheprovisionbyexaminingfiles,drawingsamples,andvisitingresidences.TherewasnoreferenceintheSelf‐AssessmenttotheuseoftheQualityAssuranceMonitoringTool,althoughreferencesweremadetosamplingofdocumentsthatcorrespondedtotheQualityAssurancesamplingmatrix.TheapplicationofthetoolandtheresultingcomparisonsofscoresbetweentheIMCandtheQAProgramComplianceMonitorwouldhaveofferedauthenticationtotheIMC’sresultsorhighlightedareaswhereadditionalworkwasneeded.


TheSelf‐AssessmentresolvedmostoftheMonitoringTeam’spreviousconcernsbyincreasingthesamplesizesusedfordeterminationsofcompliance,andbyincludingassessmentofmostofthespecificelementswithineachSettlementAgreementprovision.AnexampleofthiswasinSectionD.3.ethataddressedthetimelinessoftheinitiationandcompletionofinvestigations.ThistimetheFacilityreviewedtimelinessandcompletionoftheDFPSandtheFacilityinvestigationsseparately.InadditiontotheSelf‐Assessment,theActionPlanswerereviewed.TheActionPlansdescribedactionstepsrelatedtoeachprovisionoftheSettlementAgreementandtheycontinuedtoaddresssomeimportantissues,suchaspolicyrevisions.Howeverworkwasstillneededtoreachthemoredifficultissuesofimplementation.Forexample,forSectionD.2.h,whichrequiredmechanismstopreventretaliation,theactionsstepsincludeddisplaying“ZeroTolerance”postersandassuringtheirreplacementasneeded,monitoringUnusualIncidentReports(UIRs)forevidenceofretaliation,andreportinganyidentifiedinstancestotheOfficeoftheInspectorGeneral(OIG).WhatwasneededwasadescriptionofhowtheUIRswouldbemonitored,howoften,bywhom,andwhatsignsmighttriggerareport.InSectionD.3.i,whichrequiredtheimplementationandtrackingofactionstakentoaddressdisciplinaryorprogrammaticchangesandtheoutcomesofthoseactions,thestepsfocusedonobtainingallrecommendationsfromtheReviewAuthorityTeam,whichreviewedincidents,intothetrackinglogintheUIRreportingsystem.Thenextstepsweretoaddressthoserecommendationsthatwerenotfollowed,andtorevisethosethatwereimplementedbutnotsuccessful.TheremainingunaddressedquestionwashowtheUIRsystemwouldcollectinformationaboutwhetherrecommendationshadbeenfollowedandwhethertheyweresuccessful.TheFacilityprovidedtheCCSSLCProvisionActionInformation.ThisdocumentwasdesignedtoreviewthestatusofeachprovisionoftheSettlementAgreementsincethefirstmonitoringreportwithspacetohighlightcurrenteffortstocomeintocompliance.ReviewofthedocumentforSectionDfounditincludedmultipleentries,providingaclearerviewoftheactivitiesengagedintoachievecompliancethanduringpreviousreviews.SummaryofMonitor’sAssessment:Duringthisreview,theMonitoringTeamfoundtheFacilitytobeincompliancewith15outof22provisionsofSectionD,asopposedtothe14provisionsthatwereincomplianceduringthelastreview.Progresswasnotedinanumberofareas.Highlightsofthatprogressincluded:

Actionstoprotectindividualswhowereinvolvedinunusualincidentsorallegationofabuseorneglectweretakenquickly.Localpracticehadbeenmodifiedtoassurethatstaffallegedtohavebeenabusiveorneglectfulwereroutinelyputontemporaryworkreassignmenttoremovethemfromdirectcontactwithindividualsserved,ormonitoringwasputinplacewhenallegedperpetratorswerenotidentifiedorthecasewashandledas“streamlined”duetoaanindividualbeingidentifiedaschroniccaller.AnActionPlanwasinplacetoamendtheFacilityprocedurestoreflectthemodifiedpracticeandtomatchStateOfficePolicy021.1.

TheUnusualIncidentReporthadbeenmodifiedtoprintoutalistofallegedperpetratorssothatitcouldbeeasilydeterminediftheyhadbeenplacedontemporaryworkreassignment.

TheUIRwasfurthermodifiedtoincludeacharttotracktherecommendationsresultingfromthe


investigation. TheReviewAuthorityTeamnoteswereincludedinfilestodocumentthereviewofanyactions

taken. TherecordscontainedsupervisorynotesforUIRsindicatingtheIMChadreviewedandrequested

clarificationsoradditionalinvestigationinsomereports.SomeoftheareasinwhichimprovementswerenecessaryfortheFacilitytoprogresstowardfullcompliancewiththeSettlementAgreementincludedtheneedto:

AddresstheproblemwithtimelinessofcompletionofUnusualIncidentReports; Developandimplementasemi‐annualauditofinjuries; Provideforfollow‐uponrecommendationsfrominvestigativereports,anddocumentthemto

conclusion. Expandtheanalysisandtrendingofdatatodeterminewherecorrectiveactionplansmightbe

neededtoaddressemergingtrendsinabuse/neglectfindings.

# Provision AssessmentofStatus ComplianceD1 Effectiveimmediately,each

Facilityshallimplementpolicies,proceduresandpracticesthatrequireacommitmentthattheFacilityshallnottolerateabuseorneglectofindividualsandthatstaffarerequiredtoreportabuseorneglectofindividuals.

BasedonarecentagreementofthepartiesandtheMonitors,SectionD.1hasbeeninterpretedtoonlyaddressthedevelopmentofapolicy.ImplementationofthepolicyisassessedinotherSectionDprovisions.GiventhatCCSSLChadapolicythat:

Includedacommitmentthatabuseandneglectofindividualswouldnotbetolerated;and

Requiredthatstaffreportabuseand/orneglectofindividuals.AsaresulttheFacilitywasfoundtobeincompliancewiththisprovision.

SubstantialCompliance

D2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshallreview,revise,asappropriate,andimplementincidentmanagementpolicies,proceduresandpractices.Suchpolicies,proceduresandpracticesshallrequire:

(a) Stafftoimmediatelyreportseriousincidents,includingbutnotlimitedtodeath,abuse,neglect,exploitation,

AccordingtoCCSSLCPolicy#021.IV.A,all staffwererequiredtoreportabuse,neglect,andexploitationwithinonehourbyphonetoDFPSandtotheDirectororhisdesignee.ThiswasconsistentwiththerequirementsoftheSettlementAgreement.

Noncompliance


# Provision AssessmentofStatus Complianceandseriousinjury,asfollows:1)fordeaths,abuse,neglect,andexploitationtotheFacilitySuperintendent(orthatofficial’sdesignee)andsuchotherofficialsandagenciesaswarranted,consistentwithTexaslaw;and2)forseriousinjuriesandotherseriousincidents,totheFacilitySuperintendent(orthatofficial’sdesignee).Staffshallreporttheseandallotherunusualincidents,usingstandardizedreporting.

Withregardtoseriousincidents,CCSSLCPolicy#002.2requiredstafftoreportunusualincidentswithinonehourtotheDirectorordesignee.BothSectionsD.2andDD.5oftheFacilityPolicyandProcedureManualrequiredimmediate(withinonehour)reportingtotheDirectorofseriousincidents.Sincetherewasnoreferencetothemannerofreportinginthesesections,theassumptionwasthatthereportingwastobeverbal.Policy#002.2describedhowtheFacilitywastoreportincidentstotheDADSStateOffice.ItappearedthattheprocesswasforthestaffmemberwhowitnessedorbecameawareofanincidenttocalltheIncidentManagementCoordinatorordesigneetoreporttheunusualincident,andthecalltriggeredthestartoftheUnusualIncidentReportbytheIMC’soffice.ThispolicywasconsistentwiththerequirementsoftheSettlementAgreement.However,intheMonitoringTeam’slasttworeports,itwasnotedthataclearerexplanationwasneededofwhatformareportaboutanunusualincidentwastotake(i.e.,phonecall,awrittenreport,orwhateverwasexpected).Atthetimeofthemostrecentreview,thisstillrequiredclarification.TheActionPlanforD.2.aoftheSettlementAgreementcalledforrevisionstobemadetoCCSSLCPolicies#D.2andDD.5tomakethenecessaryclarification.Therevisionprocesswasnotunderway,butwasprojectedtobecompletedby8/31/12,anextensionfromtheearlierplantobecompletedby1/31/12.Althoughintheparagraphsthatfollow,theMonitoringTeamhasprovidedsomefigureswithregardtoallegationsandincidents,itisessentialtonotethatreviewingpurenumbersprovidesverylittlemeaningfulinformation.Foreachofthesecategories,theFacilitywouldneedtoconductanalysestodeterminecauses,andtoreviewcarefullywhetherforincidentsthatwerepreventable,adequateactionhadbeentakentopreventtheirrecurrence.Determiningthereasonsorpotentialreasonsforincreasesordecreasesinnumbersalsoisessential.Althoughtheultimategoalistoreducetheoverallnumbersofpreventableincidents,careneedstobetakentoensurethattheresultofsucheffortsisnottheunderreportingofincidents.Foranincidentmanagementsystemtoworkproperly,fullreportingofincidentsisparamount,sothattheycanbereviewed,andappropriateactionstaken.TheFacility’sprogressinanalyzingdatacollected,andaddressingissuesidentifiedisdiscussedinfurtherdetailwithregardtoSectionD.4oftheSettlementAgreement.AccordingtoFacilitydataprovidedinresponsetothedocumentrequest#III.16a‐e,thefollowingnumbersofallegationshadoccurredattheFacilityfromJanuary1,2010toDecember31,2010,fromJanuary1,2011throughDecember31,2011,andfromJanuary1,2012throughMay31,2012.

1/1/10to12/31/10

1/1/11to12/31/11

1/1/12to5/31/12

Totalabuseallegations 688 836 210


# Provision AssessmentofStatus Compliance

*NotethatthenumbersofallegationsrefertothetotalnumberofcallsreceivedbyDFPS,notthenumberofcases,sincemultiplereportswerereceivedonmanyindividualincidents.ThepercentageofA/N/Eallegationsthatweresubstantiated/confirmedinthe12monthsof2010was9%(80/888).ThepercentageofA/N/Eallegationsthatweresubstantiated/confirmedinthe12monthsof2011was20%(211/1048).ThepercentageofA/N/Eallegationsthatweresubstantiated/confirmedinthefivemonthsof2012was5%(16/309).Twenty‐sixoftheA/N/Ebetween1/1/12and5/31/12weredeterminedtobe“inconclusive,”whichmeanttherewasnoconclusionordefiniteresultduetoalackofwitnessesorotherrelevantinformation.Thesefiguressuggestedthatwhileallegationsincreasedfrom2010to2011,in2012theyweredecreasingandthepercentageoftheallegationsthatweresubstantiatedwasdropping.Whileadecreaseinallegationsisgenerallypositive,adecreasecansignalinattentiontoreporting.TheFacilityshouldanalyzethedatainmoredepthtodeterminepotentialreasonsforthefairlysignificantdecrease,anddevelopactionplanstoaddressanyareasofconcernidentified.AccordingtoFacilitydataprovidedinresponsetothedocumentrequest#III.16a‐e:

UnusualIncidents1/1/10to12/31/10

1/1/11to12/31/11

1/1/12to5/31/12

Deaths 5 8 7Seriousinjuries 24 22 6Sexualincidents 18 14 10Suicidethreat– credible 11 2 1UnauthorizedDeparture 14 8 4Choking 4 6 2

Abusesubstantiated 45 98 9Totalneglectallegations 176 211 95Neglectsubstantiated 35 33 7Totalexploitationallegations

24 1 4

Exploitationsubstantiated 0 0 0


# Provision AssessmentofStatus ComplianceOther 6 2 2Basedoninterviewswith20staffresponsiblefortheprovisionofsupportstoindividuals,20(100%)wereabletodescribethereportingproceduresforabuse,neglect,and/orexploitation.Basedoninterviewswith20staffresponsiblefortheprovisionofsupportstoindividuals,20(100%)wereabletodescribethereportingproceduresforotherseriousincidents.Basedonareviewofthe30investigationreportsincludedinbothSample#D.1andSample#D.2,acomparisonofthedateandtimeoftheincidentorallegationwiththedateandtimeofthereportrevealed:

Atotalof13(43%)includedevidencethatcasesofabuse,neglect,and/orexploitationorunusualincidentswerereportedwithinthetimeframesrequiredbyFacilitypolicy.Thosethatwerenotwithinthetimeframesincluded:

o Facility‐onlycase#12‐330(i.e.,providedasa“FacilityOnly”caseforthisreview.However,itwasalsoinvestigatedbyDFPS).Thereporterappearedtohavebeenoneoftheindividualsinvolvedintheincident.

o OftheDFPSinvestigationsfivewerereportedthesamedayastheincident,butbeyondtheone‐hourlimit,eightwerereportedbetweenoneandfivedayslateandforthree,thetimeoftheincidentwasnotestablishedanditcouldnotbedeterminedwhetherthereportwastimely.

o UponreviewofthereportsthatwerelatetoDFPSbyonetofivedays,someexamplesofsituationswherestaffknewaboutthepossibilityofabuseorneglect,butdidnotreporttimelyincluded:

DFPSinvestigation#41868913,whereanindividualattemptedtoingestpaperthatwasleftwithinhisreachbystaff.Anurseandanotherstaffmembersawtheindividualchewingonpaperandintervenedtoremoveitandpieceitbacktogethertoassurethatnonewasswallowed.Thepersoninchargewasnotified,butnoonefiledareportofpossibleneglectuntiltwodayslater.Theinvestigationconfirmedneglect.Therewereseveralwitnessestothiseventandyettheydidnotreport.However,therewasnoindicationinthefilethattheFacilityInvestigatormaderecommendationstoassurethatsuchaneventwouldbereportedinthefuture.

DFPSinvestigation#41891452whereanindividualsustainedbruises,ablackeyeandabrasionstohisfacewhileintheInfirmarywith24/7nursingcoverageandstaffingsupport.Norecordwasmadeoftheinjuries,andnooneknewexactlywhen


# Provision AssessmentofStatus Complianceorhowtheyoccurredorwhytheywerenotdocumentedorreporteduntildiscoveredthenextday.AbuseandNeglectwerefoundtobeinconclusive.Threeallegationsofphysicalabusewereunconfirmedandtwoallegationsofneglectwereinconclusive.Whilestaffwereretrainedindocumentation,therewasnoinformationintheUIRfiletoindicatethatstaffhadbeenretrainedorotherwiseheldaccountableforfailuretoreportpossibleabuse/neglect.

InDFPSinvestigation#42160077,anindividualwassentfromtheInfirmarytoamedicalappointmentwithastaffmemberwhohadnotbeentrainedonthePNMP.Thestaffmember,notknowingtherewasatwo‐personpivotprocedurerequiredbythePNMP,attemptedaone‐persontransfer,whichresultedinafall.Thefallwasreportedasaninjury.However,neitherthestaffassignedtotaketheindividualtohisappointment,northenursetowhomhereportedthefallreportedtheeventaspossibleneglectuntilthenextday.Thesustainedinjurieswerereportedwithinonehourand15minutesandcodedas"seriousinjury"(i.e.,theresultingcutontheheadrequiredsevenstitches.)HowevertheIMCwasnotnotifieduntilthenextday,andDFPSwasnotnotifieduntilapproximatelytwohourslater.DFPSfoundtheFacilitytohaveneglectedtheindividualbyfailingtoprovideasystemoftransferofresponsibilitythatassuredthestaffmemberwouldhavethenecessaryinformationtofollowthePNMP.Stepsweretakentoaddresstheidentifiedproblem.However,therewasnoindicationthatstaffhadbeenretrainedordisciplinedforfailingtoreportthepossibleneglectfornearlyaday.

Atotalof30(100%)includedevidencethatcasesofabuse,neglect,and/orexploitationwerereportedtoDFPSandtheDirector.WheneverDFPSreceivedanallegation,theyreportedtotheFacilityandtheDirectorwasinformedwithinanhour.However,itwasnotclearthatstaffthatmighthavereportedanallegationtoDFPSalsohadreportedittotheFacilityDirector,asrequired.SinceallegationstoDFPSwereanonymous,itwasnotknownwhothereporterwas.However,inonecase(FacilityCase#12‐261)theinvestigatordiscoveredanadditionalincidenthadoccurredthathadnotbeenreported.

AnumberofissueswiththeUnusualIncidentReportForm,whichwereidentifiedattheMonitoringTeam’svisitinJanuary2012,hadbeencorrected.Atthisvisit,thereportscontainedchartsindicatingstaffthathadbeenplacedonTRW;aspecificplacetorecordthereview,actions,andanyfollow‐uprequiredbytheIMRT/ReviewAuthorityTeam;and


# Provision AssessmentofStatus Complianceasheetwasincludedinthefiletorecordreviewandactiontaken bytheReviewAuthorityTeam.Itwasnotclear,however,thatboththedatethereportofabusewasreceivedfromDFPS,andthedates,times,andnamesofindividualsreporting,ifknown,wererecordedintheUIR.Basedonareviewof30investigationreportsincludedinSample#D.1andSample#D.2,30(100%)containedacopyofthereportusingtherequiredstandardizedformat.Trackingoftimelyreportingremainedanissue.SincereportingofallegationsofabusecanbeanonymousandmightbemadebyindividualsorcitizensoutsidetheFacility,thereportingtimeframescannotbeenforcedwiththem.Withouttheidentitiesofreporters,itisoftennotpossibletoascertainwhetherthewitnessestotheincidentsreportedtimely.TherewasnoapparenttrackingsystemforreportsmadetotheDirectororDesignee.Therewasanactionplantodevelopsuchatrackingsystem.TheMonitoringTeamfoundtheFacilitytobeinnoncomplianceduetotheFacility’sinabilitytotrackreporting,andthelackoffollow‐upwhenaninvestigationuncoveredfactssuggestingthatstafffailedtoreporttimely.Inaddition,theFacilityhadnotclarifieditsprocedurestoemphasizethatreportingwastobeverbaltotheDirectorordesigneeasspecifiedintheFacility’sActionPlanforsectionD.2.aoftheSettlementAgreement.TheFacilityfoundthatitwasnotincompliancewiththisprovision.

(b) Mechanismstoensurethat,whenseriousincidentssuchasallegationsofabuse,neglect,exploitationorseriousinjuryoccur,Facilitystafftakeimmediateandappropriateactiontoprotecttheindividualsinvolved,includingremovingallegedperpetrators,ifany,fromdirectcontactwithindividualspendingeithertheinvestigation’soutcomeoratleastawell‐supported,preliminaryassessmentthattheemployeeposesnorisktoindividualsortheintegrityoftheinvestigation.

AccordingtoSectionD.2oftheFacilityPolicyandProcedureManual, anyemployee,agentorcontractormustacttostoptheabuse,securemedicaltreatment,secureevidence,andcomfortthevictim.AccordingtoSectionD.3ofthatpolicy,protectionsfortheindividualincludeimmediatelyplacingtheallegedperpetratoronTemporaryWorkReassignment,iftheallegationinvolvesphysicalabusethatresultsininjury,sexualabuse,orneglectthatcausesphysicalinjuryordeath.FacilityprocedureD.3didnotappeartobeconsistentwithFacilityPolicy#021.I.JthatindicatedthattheFacilitywouldimmediatelyremoveallegedperpetratorswithoutqualifications.FortheFacilityproceduretobeconsistentwiththeSettlementAgreementtheprocedurewouldneedtoincludeprovisionforapreliminaryassessmentthattheemployeeposednorisktotheindividualsortheintegrityoftheinvestigationinorderforthemnottoberemovedfromdirectsupportduties.TheFacilityhadnotrevisedtheirlocalprocedureD.3,althoughtheyhadanactionplaninplacetodoso.TheFacilityhadissuedaninstructiononMarch12,2012indicatingthepolicywouldberevisedandthatinthemeantime,staffidentifiedasallegedperpetratorswouldbeplacedonTWR.TheonlyexceptionwouldbewhentheindividualhadbeenidentifiedasmakingspuriousallegationsandDFPShadbeenauthorizedtoconductastreamlinedinvestigation.Inthosecases,anotheroptionwouldbetoputamonitorinplace.

Noncompliance



Basedonareviewof25investigationreportsincludedinSample#D.1,34allegedperpetratorsshouldhavebeenremoved,andofthese,23(68%)wereremovedfromdirectcontactwithindividualsimmediatelyfollowingtheFacilitybeinginformedoftheallegation.ThefollowingprovidesmoredetailwithregardtotheFacility’sactions:

In15casestheallegedperpetratorswereremovedaccordingtotheUIR,butthiscouldnotalwaysbeconfirmedintheStaffStatusLog.

Inthreecases,theallegedperpetratorwasnotknownandmonitoringwasputinplaceinthehome.

Fourcaseswerestreamlined.Inthreeofthesecases,amonitorwasputinplace.Inone,theFacilitycorrectlyelectedtoplacethestaffmemberonTRWeventhoughDFPShadindicateditwouldbehandledasstreamlined.Thiswasbecausethereporthadbeenmadebythevideosurveillancestaffratherthanbytheindividual.

Inthreecases,theFacilityplacedamonitorinsteadofremovingthestaffmember.TwoofthesecasesoccurredpriortotheIMC’sMarch12,2012clarifyingmemo.Onecase,DFPScase#42211916,occurredafterthememo,andalthoughtheallegationswereunconfirmed,thisdidnotfollowtheinstructionsinthememo.

AreviewoftheStaffStatusLoginconjunctionwiththeUIRindicatedthatstaffremovedfromdutywerenotreturneduntiltheinvestigationwascompleted.Thelogwouldbemoreusefulifitincludedthedatetheinvestigationconcluded,anotationofwhetherabusewasconfirmed,andanindicationofwhetherstaffwasdisciplined,terminatedorretrained.Suchadditionswouldmakeitpossibletoreviewcaseswithouthavingtocomparedateswithotherreports.Inthe15investigationcaseswherestaffhadbeenremoved,twostaffhadbeendismissedwhenabusewasconfirmed,accordingtotheFacilityreport.Theremaining13staffappearedtohavebeenclearedforreturntoworkaftertheinvestigationwascomplete.TheMonitoringTeamfoundtheFacilitywasnotincompliance.TheFacilityhadnotcompletedworkonitsprocedurerevision,althoughithadtakenstepstoassurethatstaffwouldbeplacedonTWRwhenanallegationofabuseorneglectwasmade.WhiletheIMCtookappropriateactiontoplacestaffonTWR,eventhoughacasewasdesignatedasstreamlined,whenherealizedthattheallegationhadcomefromastaffmember,inothercasestheStaffTrackingLogdidnottrackthestatusofallstaffnamedintheUIR.TheFacilityfounditselftobeincompliancewiththisprovision.However,theMonitoringTeam’sfindingsdidnotsupportthis.

(c) Competency‐basedtraining,atleastyearly,forallstaffon

AccordingtoSectionD.1oftheFacilityPolicyandProcedureManual,allstaffmustattendcompetency‐basedtrainingincourseABU0100atpre‐serviceandannuallythereafter,as



# Provision AssessmentofStatus Compliancerecognizingandreportingpotentialsignsandsymptomsofabuse,neglect,andexploitation,andmaintainingdocumentationindicatingcompletionofsuchtraining.

describedinpreviousreports. ReviewoftheCourseDelinquencyListforcourse#ABU0100,Abuse/Neglect/Exploitation,dated7/2/12,revealedthatsixstaffoutofapproximately930(lessthan1%)werepastduetoreceiveretraining.Areviewofthetrainingcurricularelatedtoabuseandneglectwasreviewedfor:a)newemployeeorientation;andb)annualrefreshertraining.Theresultsofthisreviewwereasfollows:

Inrelationtotherequirementfortrainingtobecompetency‐based,thetrainingincludedapost‐testinwhichtheemployeemustdemonstrateaworkingknowledgeofthepoliciesandproceduresrelatedtoabuseinvestigation.

Thetrainingprovidedadequatetrainingregardingrecognizingandreportingsignsandsymptomsofabuse,neglect,andexploitation.

Arandomsampleof25staff,listedasemployedontheDADSEmployeeAlphaRoster,dated6/12/12,wasdrawntodetermineiftheirtrainingonAbuse/Neglect/Exploitationwasup‐to‐date.All25(100%)hadevidenceofhavingcompletedtheirA/N/Etraining.Arandomsampleoffourvolunteerslistedon“VolunteerListforCCSSLC”revealedthatallfour(100%)hadcompletedweb‐basedtrainingforVolunteersatSSLCs,includingtrainingonA/N/E.Basedoninterviewswith20staff:

All20(100%)wereabletolistsignsandsymptomsofabuse,neglect,and/orexploitation;and

All20(100%)wereabletodescribethereportingproceduresforabuse,neglect,and/orexploitation,andforseriousincidents.

Basedonthesefindings,theMonitoringTeamfoundtheFacilityinsubstantialcompliancewiththisprovision.TheFacility’sfindingswereconsistentwiththoseoftheMonitoringTeam.

(d) Notificationofallstaffwhencommencingemploymentandatleastyearlyoftheirobligationtoreportabuse,neglect,orexploitationtoFacilityandStateofficials.AllstaffpersonswhoaremandatoryreportersofabuseorneglectshallsignastatementthatshallbekeptattheFacilityevidencing

AccordingtoSectionD.1oftheFacilityPolicyandProcedureManual,allstaffmustsignastatementacknowledgingzerotoleranceforabuse,neglect,andexploitationandtheirobligationstoreportanysuspicions.Arandomsampleof25staff,listedasemployedontheDADSEmployeeAlphaRoster,dated6/12/12,wasdrawntodetermineiftheirAcknowledgmentFormsonAbuse/Neglect/Exploitationwereup‐to‐date.All25inthesamplehadcurrentAcknowledgementFormsonfile.TheIMChadconductedchecksonformsforallnewemployeessinceJanuary2012.Hereportedlyhadfoundallformstobeinplace.



# Provision AssessmentofStatus Compliancetheirrecognitionoftheirreportingobligations.TheFacilityshalltakeappropriatepersonnelactioninresponsetoanymandatoryreporter’sfailuretoreportabuseorneglect.

Arandomsampleoffourvolunteerslistedon“ListofVolunteers”revealedthatfour(100%)hadAcknowledgementsonfile.AccordingtotheFacilitySelf‐Assessment,theActionPlanforthisprovisionhadbeencompleted.IndiscussionwiththeIMC,itwasclearthathewascheckingmonthlytoassureallnewstaffhadsignedtheirformsandstaffwhowereduetorenewtheirstatementshaddoneso.Basedonthesefindings,theFacilitywasfoundtobeinsubstantialcompliancewiththisprovision.

(e) Mechanismstoeducateandsupportindividuals,primarycorrespondent(i.e.,aperson,identifiedbytheIDT,whohassignificantandongoinginvolvementwithanindividualwholackstheabilitytoprovidelegallyadequateconsentandwhodoesnothaveanLAR),andLARtoidentifyandreportunusualincidents,includingallegationsofabuse,neglectandexploitation.

AccordingtoSectionD.19oftheFacilitypolicymanual,QualifiedDevelopmentalDisabilityProfessionals(QDDPs)weretosendacopyoftheAbuse,Neglect,andExploitationResourceGuide,andCCSSLCPreventingAbuseisEveryone’sResponsibilityflyer,revised10/22/10,tofamiliesandLegallyAuthorizedRepresentatives(LARs)priortotheannualISPmeeting,andtoprovideacopytotheindividualatthemeeting.TheQDDPwastodescribetheprocesstotheindividualatthemeeting.IntheMonitoringTeam’spreviousreports,thefindingsrelatedtothereviewoftheflyerusedtoeducateindividualsandfamiliesabouttheirrightswithregardtoreportingwasdiscussed.Itwasfoundtobeadequate.AccordingtotheISPMeetingGuide(Preparation/Facilitation/DocumentationTool)SectionIII.E,theAbuse/Neglect/ExploitationResourceGuidewastobepresentedandexplainedtotheindividualattheannualISPmeeting.IntheoneannualISPmeetingobserved,theindividualwaspresentedwithacopyoftheguide,andtheadvocate,whoattendedviaphone,wastoldabouttheguideandacommitmentwasmadetosendheracopy.Basedonareviewofsixteenindividuals’ISPs,(i.e.,Individual#155,Individual#174,Individual#226,Individual#172,Individual#88,Individual#124,Individual#290,Individual#363,Individual#184,Individual#268,Individual#282,Individual#336,Individual#26,Individual#63,Individual#228,andIndividual#250,),theISPincludeddocumentationtoshowthatfifteenoftheindividualsandtheirprimarycorrespondents/LARs(94%)hadbeeninformedoftheprocessofidentifyingandreportingunusualincidents,includingabuse,neglect,andexploitation.Foroneindividual(i.e.,Individual#250),althoughtheindividualhadbeenprovidedacopy,theISPdidnotdocumentthatherparents,whowereactivelyinvolved,hadbeengivenacopyorhaditexplainedtothem.Thiswasimportantgiventhatthisindividualappearedasifshewouldrequireassistancetorecognizeorreportabuseandneglect.




Ininterviewingasampleof10individuals,all10wereabletocommunicatewellenough,anddescribedwhattheywoulddoifsomeonehurtthem,ortheyhadaproblemwithwhichtheyneededhelp.Ofcourse,manyindividualsatCCSSLCcannotcommunicatewellenoughtoreportabuse,andmustrelyontheirfamiliesandstafftoreportontheirbehalf.InreviewingSamples#D1and#D2,itwasclearthatindividualswerenotreluctanttoreportabuse.Therewereseveralcaseswithinthesamplewhereindividualsreportedfalsely,indicatinglittlefearofreprisalsorreluctancetoseekhelptoreport.Sinceincidentsofabuse,neglect,andexploitationwerereportedanonymously,itwasdifficulttofindameasurementforwhetherorhowwellindividualswerebeingassistedtoreport.However,inthecontextofthesampleofinvestigativereports,therewereseveralmentionsofstaffescortinganindividualtothephoneoraskingifhe/shewantedtomakeareport.TheFacilityhadmadeprogress.AsampleofISPscontaineddocumentationthatmostindividualshadhaddiscussionofincidentandabusereportingattheirannualISPmeeting,andtheyandtheirprimarycorrespondents/LARshadbeenprovidedtherequiredbooklet.InadditiontheISPmeetingobservedduringtheonsitereviewincludedadiscussionwiththeindividualaboutthereportingprocess.TheMonitoringTeamconcurswiththeFacilitythatthisprovisionisinsubstantialcompliance.

(f) Postingineachlivingunitanddayprogramsiteabriefandeasilyunderstoodstatementofindividuals’rights,includinginformationabouthowtoexercisesuchrightsandhowtoreportviolationsofsuchrights.

AccordingSectionD.20 ofFacilitypolicyandproceduremanual,allresidencesanddayprogramsweretohavethe“RightsPoster”ondisplay.AreviewwascompletedofthepostingtheFacilityused.Itincludedabriefandeasilyunderstoodstatementof:1)individuals’rights;2)informationabouthowtoexercisesuchrights;and3)informationabouthowtoreportviolationsofsuchrights.ManyofthepostersinevidencehadbeenrefreshedwiththeadditionofaphotooftheHumanRightsAdvocateandcontactinformation.ObservationsbytheMonitoringTeamofasampleofresidencesanddayprogramsoncampusshowedthatallnineresidencesvisitedandthreedayprogramssitesreviewed(100%)hadpostingsofindividuals’rightsinanareatowhichindividualsregularlyhadaccess.Inaddition,allbuildingshousingofficesormeetingplaceshadsignsposted.TheActionPlanforthisprovisionreportedithadbeencompleted.TheIMCandCampusAdministratorsweremonitoringforpostersontheirroundsandrequiringthereplacementofanymissingposters.AlistofposterlocationshadbeendrawnfortheCampusAdministrators’usetoverifythatposterswereinplace.SamplesoftheIMC’sEveningDutyOfficer(EDO)logsindicatedconsistencyincheckingforposterswhile



# Provision AssessmentofStatus Compliancemakingrounds.Asaresultofthesefindings,theMonitoringTeammadeafindingofsubstantialcompliance.ThiswasconsistentwiththatoftheFacility.

(g) Proceduresforreferring,asappropriate,allegationsofabuseand/orneglecttolawenforcement.

AccordingtoFacilityPolicyD.11,allallegationsthatmightinvolvecriminalactivitymustbereportedtoDFPS,whowouldthennotifytheappropriatelawenforcementauthority.Basedonareviewof25investigationscompletedbyDFPS(Sample#D.1),inallcases(100%)forwhichareferraltolawenforcementwasnecessary/appropriate,DFPSand/ortheFacilityhadmadereferrals.BasedonareviewoffiveinvestigationscompletedbytheFacility(Sample#D.2),onereferralwasmadetolawenforcementandbecameaDFPSinvestigation.Theremainingfourwerenotreferredtolawenforcement,becausetherewasnoapparentreasontosuspectcriminalactivity.MeetingswithOIG,DFPS,andCCSSLCwerescheduledquarterlytoexchangeinformationandresolveanyemergingquestions.MinutesoftheJanuary2012meetingwereprovided.TheAprilmeetingwaspostponedduetoworkloadfactors,buttheIMCwasworkingtoschedulethenextmeeting.Thesemeetingsappearedtoaffordallparticipantswithanopportunitytodiscusschangesinpracticeandtoavoidmisunderstandings.Basedonthisreview,referralswerebeingmadetolawenforcementandtotheOIGonaregularbasis.TheMonitoringTeamfoundtheFacilityinsubstantialcompliancewiththisprovision.TheFacilityhadmadethesamefindinginitsself‐assessment.


(h) Mechanismstoensurethatanystaffperson,individual,familymemberorvisitorwhoingoodfaithreportsanallegationofabuseorneglectisnotsubjecttoretaliatoryaction,includingbutnotlimitedtoreprimands,discipline,harassment,threatsorcensure,exceptforappropriatecounseling,reprimandsordisciplinebecauseofanemployee’sfailuretoreportanincident

AccordingtoSectionD.6oftheFacilityPolicyandProcedureManual,allformsofretaliationagainstindividuals,theirfamiliesandLARs,aswellasemployeeswhoreportedallegationsofabuse/neglect/exploitationingoodfaithwasprohibited.TheseindividualscouldimmediatelyreportanyallegedincidentofretaliationtotheFacilityDirectororhisdesignee.Phonenumbersforotherreportingalternativesalsowereprovidedinthepolicy.BasedoninterviewswiththeFacilityDirector,thefollowingactionswerebeingtakentopreventretaliationand/ortoassurestaffthatretaliationwouldnotbetolerated:

IftheAssistantDirectorforProgramsreceivedareportofretaliation,heforwardedittotheOfficeoftheInspectorGeneral.

OIGwouldrespondastowhethertheywouldinvestigate.

BasedonSample#D.1,itwasclearthatsomeindividualsmadeallegationsofabusewith



# Provision AssessmentofStatus Complianceinanappropriateortimelymanner.

nofearofretaliation,andtherewerenoindicationsintheinvestigationreportsofaconcernwithretaliation.Alistofstaffthatreportedtheyhadbeenretaliatedagainstforgoodfaithreportingofabusewasrequested,andtherewerenonamesprovided(DocumentRequest#III.28).TheFacilitywasaskedforalistofstaffagainstwhomdisciplinaryactionhadbeentakenduetotheirinvolvementinretaliatoryactionagainstanotheremployeewhoingoodfaithhadreportedanallegationofabuse/neglect/exploitation.Nonameswereprovided(Documentrequest#III.29).Thefollowingdescribesactionsthatweretakeninanattempttopreventsuchretaliationinthefuture:

PostersremindingstaffthatretaliationwouldnotbetoleratedweredisplayedthroughouttheFacility;

TrainingemphasizedtheFacility’spositiononretaliation;and Thestatedpracticewasthatanyallegationsofretaliationwerereferredtothe

OIG.Basedonananonymouspollingof20staff,twoindicatedsomeconcernthattheymightberetaliatedagainstforreportingabuse,butdidnotsharewhatthoseconcernswere.The20staffinterviewedappearedtounderstandthemethodforreportingpossibleretaliationandknewtherewereposterswithnumberstocall.IninterviewandintheevidencesectionofthePresentationBookforSectionD,theIMCnotedthatstaffmemberssometimesindicatedtheyhadbeenthevictimofafalseallegationorretaliation.However,theseinstanceswerefoundtobeduetoapersonalorwork‐relatedissueandnottotheirgoodfaithreportingofanallegationofA/N/E.SincetheFacilityhadmeasuresinplacetopreventretaliation,procedurestohandleanyreportedretaliation,andnoindicationswerefoundinsamplecasesofpossibleretaliationtakingplace,theMonitoringTeamfoundtheFacilityinsubstantialcompliancewiththisprovision.TheFacility’sself‐assessmentreportedaconsistentfinding.

(i) Audits,atleastsemi‐annually,todeterminewhethersignificantresidentinjuriesarereportedforinvestigation.

Thepurposeofasemi‐annualauditofinjuriesistoensurethatsignificantresidentinjuriesarereportedforinvestigation,andtoensurethatinjuriesthatraisesuspicionsofabuseduetothenatureorlocationoftheinjury(forexample,bruisesontheinnerthighmightsuggestsexualabuse),orthefrequencyofinjuryarereportedforinvestigation.Forexample,anauditofinjuriesmightrevealthatonelocationoncampushasanunusualrecordofinjuriesorthatoneindividualhashadanunusuallyhighnumberofinjuries.Suchresultsshowingsignificantresidentinjuriesneedtobeinvestigatedtolearntheroot

Noncompliance


# Provision AssessmentofStatus Compliancecausesothatitcanbeaddressed.AreviewoftheInjuryTrendReportsforthepastyearindicatedthatreportsofinjuries,particularlynon‐seriousinjurieshavebeendecliningforthepastyear.TheTrendreportnotedthatanyindividualwiththreeormoreinjuriesin30dayswasreportedtotheIDTforreview.Whilethedownwardtrendandthepracticeofreviewinginjuriesappearedtobeimportantstepstowardprotectingindividualsfromharm,thenumberofinjuriesstillrequiredaconcertedefforttodiscoverwhatcausedpatternstoemergeandwhethersuchasignificantnumberofinjuriessuggestedpossibleabuseorneglect.TheFacilityindicatedthattheIMChadcontactedotherfacilitiesinAprilandMayof2012toreviewtheirprocessesfortrendinginjuriesandconductingaudits,butthattheprocessforCCSSLCwasstillunderdevelopment.TheActionPlanforthisprovisionprojectedregularmonthlyauditstocommencebySeptember2012.ThiswasarevisionfromthepreviousprojectionofMarch2012forthecompletionoftheseaudits.TheMonitoringTeamwillevaluatethisprocesswhenitiscomplete.TheMonitoringTeam’sfindingofnoncompliancewasconsistentwiththeFacility’sfindingthatitwasnotinsubstantialcompliancewiththisprovision.

D3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,theStateshalldevelopandimplementpoliciesandprocedurestoensuretimelyandthoroughinvestigationsofallabuse,neglect,exploitation,death,theft,seriousinjury,andotherseriousincidentsinvolvingFacilityresidents.Suchpoliciesandproceduresshall:

(a) Providefortheconductofallsuchinvestigations.Theinvestigationsshallbeconductedbyqualifiedinvestigatorswhohavetraininginworkingwithpeoplewithdevelopmentaldisabilities,includingpersonswithmentalretardation,and

AccordingtoSectionDD.1oftheCCSSLCPolicyandProcedureManual,allstaffresponsibleforFacilityinvestigationshadtoattendComprehensiveInvestigatorTraining(CIT0100)andPeoplewithMR(MEN030),priortoassignmentasaninvestigatorandpriortocompletinganUnusualIncidentReportinvestigation.Inaddition,theIncidentManagementCoordinator,CampusAdministrator,CampusCoordinator,andFacilityInvestigatorshadtocompleteConductingSeriousInvestigationsorFundamentalsofInvestigationtraining(INV0100),andaclassonRootCauseAnalysiswithinsixmonthsofemployment.CCSSLCPolicy#002.2atHrequiredstaffassignedtoinvestigationstobeoutsidethedirectlineofsupervisionoftheallegedperpetrator.



# Provision AssessmentofStatus Compliancewhoarenotwithinthedirectlineofsupervisionoftheallegedperpetrator.

TheMonitoringTeampreviouslyreviewedthecurriculafortheFacilityandtheDFPSinvestigators,andgenerallydetermineditwasadequate.Inresponsetoadocumentrequest,alistofsevenDFPSinvestigatorswiththeirhiredatesandcoursescompleted,theirtrainingtranscripts,andacrosswalktothetitlesofcourses,whichhadchangedovertime,wereprovided.Thetrainingrecordsfortheseinvestigatorswerereviewedwiththefollowingresults:

Sevenoftheseven(100%)DFPSinvestigatorswhosenameswereprovidedhadcompletedtherequirementsforinvestigationstraining.

Sevenoftheseven(100%)DFPSinvestigatorswhosenameswereprovidedhadcompletedtherequirementsfortrainingregardingindividualswithdevelopmentaldisabilities.

AreviewoftheSample#D1revealedthatall(100%)investigationsinthesamplewerecompletedbytrainedinvestigators.

CCSSLCstaffwithresponsibilitiesforconductingFacilityinvestigationsincludedtheIncidentManagementCoordinator,whooversawtheinvestigationsattheFacility,threefull‐timeinvestigators,andfourCampusAdministrators,whoreportedtotheIMC,andwhocouldbecalledupontoassistininvestigationswhenneeded,ortocarryoutinvestigationsonthesecondorthirdshifts,foratotalofeightstaff.AreviewoftheinvestigatorswhoconductedtheinvestigationsinSample#D.2indicatedthatall(100%)hadbeenconductedbyoneoftheinvestigatorslistedastrained.Thetrainingrecordsfortheseinvestigatorswerereviewedwiththefollowingresults:

SevenoutofsevenFacilityinvestigators(100%)hadcompletedtherequirementsforinvestigationstraining.

SevenoutofsevenFacilityinvestigators(100%)hadcompletedtherequirementsfortrainingregardingindividualswithdevelopmentaldisabilities.

TheIMChadcompletedallrequiredtraining.AreviewoftheinvestigatorswhoconductedtheFacilityInvestigationsthatcorrespondedtotheDFPSinvestigationsinSample#D.1indicatedthatallhadbeenconductedbyoneofthetrainedFacilityInvestigators.Therewerenonurseslistedasinvestigators.InthetwoinvestigationsinSample#D.2thatinvolveddeaths,theQAnursewasinvolvedingatheringandreviewingrecords,butdidnotsigntheinvestigationasthepreliminaryorthefinalinvestigator.Thisappearedtobeauseofnursesasexpertstoreviewdocumentsandprovideopinions.However,ifnursesaretoactasinvestigators,theyshouldbetrainedasinvestigators.


# Provision AssessmentofStatus ComplianceTheFacility’sSelf‐ Assessmentindicatedafindingofsubstantialcompliance.BasedontheMonitoringTeam’sfindings,theFacilityhasbeenfoundtobeinsubstantialcompliance.

(b) ProvideforthecooperationofFacilitystaffwithoutsideentitiesthatareconductinginvestigationsofabuse,neglect,andexploitation.

BasedonSectionDD.10oftheFacilityPolicyandProcedureManual,FacilitystaffwererequiredtocooperatewithDFPSinconductinginvestigationsofabuseandneglect.ThisincludedsuspendinginternalinvestigationsandinterviewsuntilDFPShadcompleteditsinvestigation.AsdescribedabovewithregardtoSectionD.2.aoftheSettlementAgreement,twosamplesofinvestigationfileswereselectedforreview.TheseincludedSample#D.1,theDFPSinvestigationsandthesubsampleofcorrespondingFacilityinvestigations,andSample#D.2,whichconsistedofFacilityinvestigations.

ReviewoftheinvestigationfilesinSample#D.1showedthatin25outof25investigations(100%),FacilitystaffcooperatedwithDFPSinvestigators.

ReviewoftheinvestigationfilesinSample#D.2showedthatinfouroutoffive(80%)investigations,therewasminorornoinvolvementwithoutsideentitiesandnoindicationinthefilesofanyproblemswithcooperation.Inthefifth,thecasewasinvestigatedbyDFPSandlawenforcementwasnotified.Therewerenoindicationsoflackofcooperationbetweenthevariousentities.

TheFacility’sIMCreviewedallinvestigationsandfoundsignsofcooperationinallofthem.HenotedthatameetingwasheldinJanuary2012withoutsideinvestigatingagenciesandnoconcernswereraisedrelatedtocooperation.Basedonthesefindings,theFacilityisinsubstantialcompliance.TheFacility’sfindingforthisprovisionwasconsistentwiththeMonitoringTeam’sfinding.


(c) Ensurethatinvestigationsarecoordinatedwithanyinvestigationscompletedbylawenforcementagenciessoasnottointerferewithsuchinvestigations.

TheMemorandumofUnderstanding,dated5/28/10,providedforinteragencycooperationintheinvestigationofabuse,neglect,andexploitation.ThisMOUsupersededallotheragreements.IntheMOU,“thePartiesagreetoshareexpertiseandassisteachotherwhenrequested.”ThesignatoriestotheMOUincludedtheHealthandHumanServicesCommission,theDepartmentonAgingandDisabilityServices,theDepartmentofStateHealthServices,theDepartmentofFamilyandProtectiveServices,theOfficeoftheIndependentOmbudsmanforStateSupportedLivingCenters,andtheOfficeoftheInspectorGeneral.DADSPolicy#002.2stipulatedthat,afterreportinganincidenttotheappropriatelawenforcementagency,the“Directorordesigneewillabidebyallinstructionsgivenbythelawenforcementagency.”BasedonareviewoftheinvestigationscompletedbyDFPSandtheFacility,thefollowingwasfound:

Ofthe25investigationrecordsfromDFPS(Sample#D.1),17hadbeenreferredto



# Provision AssessmentofStatus Compliancelawenforcementagencies.For17outofthese(100%),adequatecoordinationappearedtohaveoccurredtoensurethattherewasnointerferencewithlawenforcement’sinvestigations.

OfthefiveinvestigationrecordsfromtheFacility(Sample#D.2),onehadbeenreferredtolawenforcementagenciesandtherewasnoevidenceoflackofcoordination.

SincetheywerenoindicationsoflackofcooperationtheMonitoringTeamconcurredwiththeFacilitySelf‐AssessmentthattheFacilityisinSubstantialCompliancewiththisprovision.

(d) Provideforthesafeguardingofevidence.

SectionD.5oftheFacilityPolicyandProcedureManualdescribedtheprocessforsecuringevidence,whichincludedcollectinganyphysicalevidence,storingitinapaperbag,labelingit,andsafeguardingituntiltheinvestigatortookpossessionofit.EvidencewastobestoredinthesafeunderthecontroloftheIncidentManagementCoordinator.Documentaryevidencewastobestoredorcopiedtopreventalterationuntiltheinvestigatorcollectedit.SectionD.5describedindetailthesecuringofevidenceintheIMC’ssafe,andwhohadaccesstothatsafe.Accordingtothepolicy,anIncidentManagement(IM)logmustbekeptinalockedcabinetintheIMAdministrativeAssistant’sofficewithspecificinformationaboutanyaccesstotheevidence.BasedonareviewoftheinvestigationscompletedbyDFPS(Sample#D.1)andtheFacility(Sample#D.2),therewaslittleneedtosecureandstoreevidence.

InSample#D.1evidencethatneededtobesafeguardedwasproperlysecuredandsafeguardedin24ofthe25(96%)DFPSinvestigationsreviewed.Onecaseinvolvedthepossibleingestionofasubstance,believedtobehandsanitizer,byanindividual.Inthatcase(DFPSCase#42357694),theCokecantheindividualhadbeendrinkingfromwasputinthetrashbeforeitwasexaminedforhandsanitizer.However,thecanwasretrieved,examinedandthesubstancewascorrectlyidentified.Theindividualdidnotsufferilleffectsfromthisexperience.However,Facilitystaffshouldhavesecuredthecanandhelditfortheinvestigator’sexaminationbeforeitwasthrownaway.

Evidencethatneededtobesafeguardedwasproperlysecuredandsafeguardedin100%oftheFacilityinvestigations.

Mostoftheevidencethatwasnecessaryfortheseinvestigationswasdocumentaryortestimonial.Inafewcases,picturesanddiagramswerecollectedordeveloped.Inanincreasingnumberofcases,boththeFacilityandDFPSinvestigationsroutinelyrequestedvideosurveillancefootage,anddocumenteditaspartoftheevidence,ifitwasrelevant.A



# Provision AssessmentofStatus Compliancereviewoftheproceduresofthevideosurveillanceteamandareviewoftheequipmentusedindicatedaprofessionalapproachwithattentiontopreservingevidence.Apolicyonhandlingevidencewasinplace,videosurveillancefootagewasbeingproperlyidentifiedandpreserved,andstaffwerefollowingthepolicy(withoneexceptionnoted.)TheMonitoringfoundtheFacilitytobeinsubstantialcompliance.Similarly,theFacility’sSelf‐Assessmentshoweditwasincompliancewiththisprovision.

(e) Requirethateachinvestigationofaseriousincidentcommencewithin24hoursorsooner,ifnecessary,oftheincidentbeingreported;becompletedwithin10calendardaysoftheincidentbeingreportedunless,becauseofextraordinarycircumstances,theFacilitySuperintendentorAdultProtectiveServicesSupervisor,asapplicable,grantsawrittenextension;andresultinawrittenreport,includingasummaryoftheinvestigation,findingsand,asappropriate,recommendationsforcorrectiveaction.

BasedonSectionDD.10andDD.11oftheCCSSLCPolicyandProcedureManual,investigationsofseriousincidents:

Weretocommencewithin24hoursorsooner,ifnecessary; Weretobecompletedwithin10calendardaysoftheincident; RequiredawrittenextensionrequestfromtheFacilityDirectororAdult

ProtectiveServicesSupervisortobecompletedoutsideofthe10‐dayperiod,andonlyunderextraordinarycircumstances;and

Weretoresultinawrittenreportthatincludedasummaryoftheinvestigationfindings,and,asappropriate,recommendationsforcorrectiveaction.

TodeterminecompliancewiththisrequirementoftheSettlementAgreement,samplesofinvestigationsconductedbyDFPS(Sample#D.1)andtheFacility(Sample#D.2)werereviewed.Theresultsofthesereviewsarediscussedindetailbelow,andthefindingsrelatedtotheDFPSinvestigationsandtheFacilityinvestigationsarediscussedseparately.DFPSInvestigationsThefollowingsummarizestheresultsofthereviewofDFPSinvestigations:

Twenty‐fiveoutof25(100%)commencedwithin24hoursorsooner,ifnecessary.Thiswasdeterminedbyreviewinginformationincludedintheinvestigationreportsthatdescribedthestepstakentodeterminethepriorityofinvestigationtasks,aswellasdocumentationregardingthetasksthatwereundertakenwithin24hoursofDFPSbeingnotifiedoftheallegation,includingtheinitialinterviewsinvolved.ItwasnotedthatCommencementChecklistsaccompaniedmostofthereports,butmostwerenotcompleted.

Twenty‐fiveofthe25(100%)caseswerecompletedwithin10calendardaysoftheincidentwithonehavingbeengrantedanextension,andonebeingonedaylateandattachinganexplanation.

Twenty‐fiveofthe25(100%)casesresultedinawrittenreportthatincludedasummaryoftheinvestigationfindings.ThequalityofthesummaryandtheadequacyofthebasisfortheinvestigationfindingsarediscussedbelowwithregardtoSectionD.3.foftheSettlementAgreement.

In13oftheinvestigationsreviewed,recommendationswereincluded,thoughoftenphrasedas“concerns.”In12oftheseinvestigations(92%),the

Noncompliance


# Provision AssessmentofStatus Compliancerecommendationswereadequatetoaddressthefindingsoftheinvestigation.ThefollowingwasaninvestigationforwhichtheMonitoringTeamhadconcernswiththeadequacyoftherecommendations:

o Case#41186437involvedIndividual#7whoranfromthetwostaffmembersassignedaccordingtoherlevelofsupport,brokeaglassbottleandingestedsomeofthepieces.Thestaffwereunabletostopherinpartbecausetherewasamedicalrestrictiononusingabasket‐holdrestraint,limitingthemtoahand‐hold,whichdidnotpreventherfromingestingtheglass.Thenotedconcernsincludedtheinadequacyofthelightinginthearea,theineffectiveuseofmittensthattheindividualcouldeasilyremove,andtheInfirmary’srefusaltoopenthedoortotheindividualaftershehadswallowedtheglass.Whilethesewereimportantconcerns,anotherissuewastheneedfortheFacilitytoreviewandclarifywhetherstaffcouldorshouldhavestoppedtheindividualinthecrisissituationwitharestraintthat,whilemedicallycontraindicated,mighthavepreventedtheingestionofglassandresultingsurgery,orwhatothercrisisinterventiontechniquescouldbeputinplacetoprotecttheindividualinthefuture.

Anexampleofacasethatincludedanappropriaterecommendation:o Incase#41197456twostaffwerefoundtobeasleepondutywhile

providingatwo‐to‐onelevelofsupporttoanindividualknowntoingestinedibleobjectswithseriousconsequences.Theinvestigatorregisteredaconcernthatoneofthestaffhadbeenondutyfor12hourswithoutabreakaccordingtothesign‐inrecord,implyingthattheFacilityneededtoreviewitsovertimepractices.

FacilityInvestigationsThefollowingsummarizestheresultsofthereviewofFacilityinvestigations(Sample#D.2),fourofwhichwereFacility‐onlyinvestigationsandoneofthefivehadacompanioninvestigationbyDFPS:

Fiveofthefive(100%)Facility–onlyinvestigationscommencedwithin24hoursofnotificationordiscovery,orsooner,ifnecessary.ThiswasdeterminedbyreviewinginformationintheUnusualIncidentReporttodeterminewhenthefirstinterviewwasdone,orwhensomeothersignificantinvestigatoryactivitywasundertaken.

Fouroutoffive(80%)werecompletedwithin10businessdaysoftheincident,orthecompletionoftheDFPSinvestigation,includingsign‐offbythesupervisortoindicatethattheinvestigationandreportwasfinalized.Therewerenoextensionsevidentinthedocumentspresented.

Allfive(100%)resultedinawrittenreportthatincludedasummaryoftheinvestigationfindings.Thequalityofthesummaryandtheadequacyofthebasis


# Provision AssessmentofStatus CompliancefortheinvestigationfindingsarediscussedbelowwithregardtoSectionD.3.foftheSettlementAgreement.

Infourofthefiveinvestigationsreviewed,recommendationsforcorrectiveactionwereincluded.Inoneofthefivenorecommendationswereneeded.

Areviewofthe23UnusualIncidentReportsthataccompaniedDFPSinvestigationswasconducted.(NotethattworeportswereselectedduringtheonsitevisitandtheUIRswerenotrequested.)ThesereportscannotbeconcludeduntilDFPShascompleteditsinvestigation.Thefollowingsummarizesthoseresults:

Fourteenof23(61%)werecompletedwithintendaysoftheissuanceoftheDFPSreport.ThosethatwerenotcompletedwithinthetimeframeweremissingsignaturesordatesorwerelateinbeingsignedbythesupervisorandtheDirector.

Twenty‐threeof23(100%)includedsummariesoftheinvestigationfindings. For13ofthe13caseswhereDFPSnotedconcerns(100%),theUnusualIncident

reportincludedrecommendations,basedontheDFPSfindingsandconcerns.Afindingofnoncompliancehasbeenmade.TheFacility’sSelf‐Assessmentincludedafindingofnoncompliance.ThemainissuewasthecompletionofFacilityUnusualIncidentReportswithinthespecifiedtimeframes.

(f) Requirethatthecontentsofthereportoftheinvestigationofaseriousincidentshallbesufficienttoprovideaclearbasisforitsconclusion.Thereportshallsetforthexplicitlyandseparately,inastandardizedformat:eachseriousincidentorallegationofwrongdoing;thename(s)ofallwitnesses;thename(s)ofallallegedvictimsandperpetrators;thenamesofallpersonsinterviewedduringtheinvestigation;foreachpersoninterviewed,anaccuratesummaryoftopicsdiscussed,arecordingofthewitnessintervieworasummaryofquestionsposed,

BasedonareviewofCCSSLCPolicy#002.2andtherelatedprocedureatDD.11oftheCCSSLCPolicyandProcedureManual,thepolicyrequiredthat:

Thecontentsoftheinvestigationreportbesufficienttoprovideaclearbasisforitsconclusion;

Thereportutilizeastandardizedformatthatsetforthexplicitlyandseparately:o Eachseriousincidentorallegationsofwrongdoing;o Thename(s)ofallwitnesses;o Thename(s)ofallallegedvictimsandperpetrators;o Thenamesofallpersonsinterviewedduringtheinvestigation;o Foreachpersoninterviewed,anaccuratesummaryoftopicsdiscussed,a

recordingofthewitnessintervieworasummaryofquestionsposed,andasummaryofmaterialstatementsmade;

o Alldocumentsreviewedduringtheinvestigation;o Allsourcesofevidenceconsidered,includingpreviousinvestigationsof

seriousincidentsinvolvingtheallegedvictim(s)andperpetrator(s)knowntotheinvestigatingagency;

o Theinvestigator'sfindings;ando Theinvestigator'sreasonsforhis/herconclusions.

TheFacilityinvestigationswererecordedinanelectronicsystemwithscreenstocapture



# Provision AssessmentofStatus Complianceandasummaryofmaterialstatementsmade;alldocumentsreviewedduringtheinvestigation;allsourcesofevidenceconsidered,includingpreviousinvestigationsofseriousincidentsinvolvingtheallegedvictim(s)andperpetrator(s)knowntotheinvestigatingagency;theinvestigator'sfindings;andtheinvestigator'sreasonsforhis/herconclusions.

therequiredformatofthereport.SomeoftheissuesraisedintheMonitoringTeam’s lastreporthadbeenaddressedincluding:aseparatetablewasinsertedtoshowtheallegedperpetratorsandwhethertheyhadbeenplacedonTWR;andatableforenteringrecommendationsandassignmentofresponsibilitieswasincluded.Theresultingreportswereadequatetocapturetherequiredinformation.Theofficialfileswereorganizedaccordingtoachecklist.Theywereinbinders,withseparatorsbetweendocumentsdelineatedonthechecklist.TodeterminecompliancewiththisrequirementoftheSettlementAgreement,samplesofinvestigationsconductedbyDFPS(Sample#D.1)andtheFacility(Sample#D.2)werereviewed.Theresultsofthesereviewsarediscussedindetailbelow,andthefindingsrelatedtotheDFPSinvestigationsandtheFacilityinvestigationsarediscussedseparately.DFPSInvestigationsThefollowingsummarizestheresultsofthereviewofDFPSinvestigations:

In25outof25investigationsreviewed(100%),thecontentsoftheinvestigationreportweresufficienttoprovideaclearbasisforitsconclusion.

Thereportutilizedastandardizedformatthatsetforthexplicitlyandseparately:o In25(100%),eachseriousincidentorallegationsofwrongdoing;o In25(100%),thename(s)ofallwitnesses;o In25(100%),thename(s)ofallallegedvictimsandperpetrators;o In25(100%),thenamesofallpersonsinterviewedduringthe

investigation;o In25(100%),foreachpersoninterviewed,asummaryoftopics

discussed,arecordingofthewitnessintervieworasummaryofquestionsposed,andasummaryofmaterialstatementsmade;

o In25(100%),alldocumentsreviewedduringtheinvestigation;o In25(100%),allsourcesofevidenceconsidered,includingprevious

investigationsofseriousincidentsinvolvingtheallegedvictim(s)andperpetrator(s)knowntotheinvestigatingagency.

o In25(100%),theinvestigator'sfindings;ando In2(100%),theinvestigator'sreasonsforhis/herconclusions.

FacilityInvestigationsThefollowingsummarizestheresultsofthereviewofFacilityinvestigations:

Infiveoutoffiveinvestigationsreviewed(100%),thecontentsoftheinvestigationreportweresufficienttoprovideaclearbasisforitsconclusion.

Thereportutilizedastandardizedformatthatsetforthexplicitlyandseparately:o Infive(100%),eachseriousincidentorallegationsofwrongdoing;o Infive(100%),thename(s)ofallwitnesses;


# Provision AssessmentofStatus Complianceo Infive (100%),thename(s)ofallallegedvictimsandperpetrators;o Infive(100%),thenamesofallpersonsinterviewedduringthe

investigation;o Infive(100%),foreachpersoninterviewed,asummaryoftopics

discussed,arecordingofthewitnessintervieworasummaryofquestionsposed,andasummaryofmaterialstatementsmade;

o Infive(100%),alldocumentsreviewedduringtheinvestigation;o Infive(100%),allsourcesofevidenceconsidered,includingprevious

investigationsofseriousincidentsinvolvingtheallegedvictim(s)andperpetrator(s)knowntotheinvestigatingagency;

o Infive(100%)),theinvestigator'sfindings;ando Infive(100%),theinvestigator'sreasonsforhis/herconclusions.

BasedontheMonitoringTeam’sreviewofinvestigations,theFacilityremainedinsubstantialcompliancewiththisprovision.TheFacility’sSelf‐Assessmentalsofoundsubstantialcompliance.

(g) Requirethatthewrittenreport,togetherwithanyotherrelevantdocumentation,shallbereviewedbystaffsupervisinginvestigationstoensurethattheinvestigationisthoroughandcompleteandthatthereportisaccurate,completeandcoherent.Anydeficienciesorareasoffurtherinquiryintheinvestigationand/orreportshallbeaddressedpromptly.

BasedonreviewofCCSSLCPolicy#002.2andtheassociatedprocedureDD.11,itrequiredstaffsupervisingtheinvestigationstorevieweachreportandotherrelevantdocumentationtoensurethat:1)theinvestigationwascomplete;and2)thereportwasaccurate,complete,andcoherent.Thepolicyrequiredthatanyfurtherinquiriesordeficienciesbeaddressedpromptly.ThereportingformatsfortheFacilityunusualincidentsinvestigationreportsprovidedforasignatureandcommentsbythesupervisor.TodeterminecompliancewiththisrequirementoftheSettlementAgreement,samplesofinvestigationsconductedbyDFPS(Sample#D.1)andtheFacility(Sample#D.2)werereviewed.Theresultsofthesereviewsarediscussedindetailbelow,andthefindingsrelatedtotheDFPSinvestigationsandtheFacilityinvestigationsarediscussedseparately.DFPSInvestigationsThefollowingsummarizestheresultsofthereviewofDFPSinvestigations:

In23of25investigationfilesreviewed(92%),thesupervisorhadsignedthereportindicatinghe/shehadconductedareviewoftheinvestigationreport.However,therewasnothingintherecordtoprovidedetailonthenatureofthesupervision,orwhetherornoterrorswerecorrectedduetothatsupervision.WhentheMonitorsmetwithDFPSinApril2012,theyindicatedtheywouldsubmitaproposaltoaddressthisissue.

Inthetwofileswherenosignaturewasfound,theallegationswerehandledasAdministrativeReferrals,meaningthattheallegationswerereferredbacktotheFacilityforactionandnoinvestigationswereconducted.

FortheinvestigationnotedinD.3.eforwhichtheMonitoringTeamidentified

Noncompliance


# Provision AssessmentofStatus Complianceissueswiththelackofarecommendationandtheneedforaworkablecrisisinterventiontechnique,neithertheDFPSnortheFacilitysupervisoryreviewappearedtoaddressthisdeficiency.

FacilityInvestigationsThefollowingsummarizestheresultsofthereviewofFacilityinvestigations:

InfiveoffiveUnusualIncidentInvestigationfilesreviewed(100%)forSample#D.2,therewasan“InvestigationReview/ApprovalForm”indicatingreviewbytheIMC.

In22of23(96%)UnusualIncidentinvestigationfileswhichwerecompanionfilestotheDFPSinvestigationsinSample#D.1,therewasevidencethattheCCSSLCsupervisorhadconductedareviewoftheinvestigationreport.

TheFacilityActionPlanindicatedtheadoptionofanInvestigationReview/Approvalformwascomplete.TheonefilethatdidnotcontaintheformwasacasethatoccurredinJanuary2012,beforetheuseoftheapprovalformwasinfulloperation.Thecompletedformscontainedbrief,butimportantfeedbackaboutmissinginformation,spelling,andquestionsremainingtoberesolvedoranotationof“goodwork,”ifthereportreviewedwasfoundtobesatisfactory.TheFacilityhadaprocessinplaceforreviewofinvestigationsbytheIMCasevidencedbytheadoptionoftheformanditsinclusioninallbutonereport.DFPSreportsincludedasupervisor’ssignature,butnonoteswereprovidedrelatedtoissuesidentifiedandaddressedwithinvestigators.WhentheMonitorsmetwithDFPSinApril2012,DFPSindicateditwouldsubmitaproposaltoaddressthisissue.Meanwhile,thisprovisionremainsinnoncompliance.

(h) RequirethateachFacilityshallalsoprepareawrittenreport,subjecttotheprovisionsofsubparagraphg,foreachunusualincident.

ThefindingsfromtheMonitoringTeam’sreviewoftheFacility’sinvestigationofUnusualIncidentReportsarediscussedwithregardtoSectionD.3.fabove.


(i) Requirethatwheneverdisciplinaryorprogrammaticactionisnecessarytocorrectthesituationand/orpreventrecurrence,theFacilityshallimplementsuchactionpromptlyandthoroughly,andtrackanddocumentsuchactionsandthe

AccordingtoCCSSLCPolicy#002.2andprocedure#DD.13,disciplinaryorprogrammaticactionnecessarytocorrectthesituationand/orpreventrecurrencewastobetakenpromptlyandthoroughly.Inaddition,theFacilitywastohaveasystemfortrackinganddocumentingsuchactionsandthecorrespondingoutcomes.FacilityPolicyD.14,entitledParticipatingInandCompletingReviewAuthorityTeam,revisedon5/22/11,designatedtheReviewAuthorityTeamtoreviewallfinalDFPSreportsandmakerecommendationstotheDirectorforapproval.TheresponsibilitiesoftheTeamalsoincludedfollow‐uptrackingofallrecommendationsmadebytheTeam.

Noncompliance


# Provision AssessmentofStatus Compliancecorrespondingoutcomes. Thepolicyprovidedaformatformakingrecommendations,andprescribedamethodfor

trackingtherecommendationsintheIncidentManagementTeamminutes,andrecordingthemintheinvestigativereport.CCSSLC’sActionPlanforthisprovisionspecifiedfivestepstoaccomplishthetrackinganddocumentation.AccordingtotheirActionPlanstatus,threestepshadbeencompleted:toevaluateconcernsandrecommendationsinthereports,toaddanyrecommendationsfromtheFacilityinvestigators,andtoensurethatReviewAuthorityTeamrecommendationswereenteredintotheRecommendationTrackingLog.Twostepsremained:toaddressanyrecommendationsthatwerenotcompleted,andtoreviserecommendationsthatwereimplementedbutunsuccessful.Thetargetdatesfortheremainingstepswere7/31/12and12/31/12,respectively.InordertodeterminecompliancewiththisprovisionoftheSettlementAgreement,asubsampleoftheinvestigationsincludedinSample#D.1andSample#D.2,wereselectedforreview.Thissubsample,Sample#D.6,includedfourDFPSInvestigationsandtwoUnusualIncidentInvestigationsaslistedinthedocumentsreviewedsection.Thefollowingsummarizestheresultsofthisreview:

DFPSInvestigation#41186437involvedanallegationofneglectofIndividual#7forfailingtointerveneinatimelyandappropriatemannertopreventharm.Theallegations,involvingthreestaffmemberswhohadbeenunabletopreventIndividual#7frombreakingabottleandingestingsomeofthebrokenglass,weredeterminedtobeunconfirmed.However,theDFPSinvestigatorregisteredthreeconcernsthat:

o Individual#7couldeasilyremovethemittensthatwereplacedonherhandstopreventherfromingestingsmallobjects,andthatthemittens“appearedtobethemostsuccessfulitem”inpreventingtheindividualfrompickingupinedibleobjectstoingest.

o Poorlightingalongthefencepreventedstafffromscanningareasbeyondtheimmediateparameter;

o ThedenialofaccesstotheInfirmaryofIndividual#7wasaclinicalissuethatneededFacilityresolution.

TheUnusualIncidentReportnotedthattheReviewAuthorityTeamhadreviewedtheDFPSfinalreportandrecommended:

o Discontinuationofthemittens,withoutexplanation;o Nolightingtobeadded;o AccesstotheInfirmarywasaddressedinadministrativereview.

TheUnusualIncidentReportnotedinthe“RecommendationsforCurrent/FutureAction”that:“TheDFPSconcernsandrecommendationswillbeaddressed,”andsetaduedatefor2/16/12.


# Provision AssessmentofStatus ComplianceItwasnotclearfromtheReviewAuthorityTeamrecordorfromtheUIR,whythemittenswerediscontinuedwhentheDFPSinvestigatorhadindicatedtheyappearedtowork;whynolightingwouldbeprovided;orwhethertheInfirmaryaccessissuehadbeensuccessfullyaddressed.AreviewofthePersonalSupportPlanAddendumfor2/6/12indicatedthatabasketholdfollow‐downrestrainthadbeenapprovedforIndividual#7topreventfutureeffortstosearchforinedibleobjectstoingest.Thisappearedappropriatesincestaffhadbeenprohibitedbyamedicalorderfromusingthatrestrainttostopherwhenitbecameclearshewouldingestbrokenglass.HoweveritwasnotmentionedintheReviewAuthorityTeamorUIRtracking.ThefilecontainedamemorandumfromthenursetotheDirectorindicatingthattheissueofaccesstotheInfirmaryhadbeenreviewedandresolved,confirmingwhatwasincludedintheUIRtracking,althoughthetrackingdidnotincludethedateitwasresolved.Therewasnothingrecordedtoindicatewhythelightingwasnotaddressed.

InDFPSinvestigation#41868913neglectwasconfirmedwhenastaffmemberleftpaperswheretheycouldbereachedandingestedbyIndividual#307.TheReviewAuthorityTeamrecordedthatthestaffmemberhadbeenterminatedandaletteradvisingthestaffofherterminationwasonfile.TheUIRrecordedtheterminationandnotedthataclinicalissuethataroseduringtheinvestigation,involvinganLPN(allegedfailuretorespondtimelytoindividual’singestionofpaper)hadbeenreferredtotheChiefNurseExecutiveforresolution,buthadnotbeenaddressedandlistedaduedateof6/1/12(thedatethereportwasprintedwas5/27/12).SinceitwasnotclearthattheissuewiththeLPNhadbeenresolved,theactionstakenwerenotadequate.

InDFPSInvestigation#41891452,Individual#117hadreturnedtotheInfirmaryfromthehospitalwhereaG‐tubewasplaced.Staffwereassignedtohimasastandardpractice.Atsomepoint,theindividualsustainedbruisesandabrasionstohisface,butextensiveinvestigationdidnotproducesufficientevidencetosustainfindingsofabuseorneglectagainstthreeoftheallegedperpetrators,andadispositionofunconfirmedwasentered.Allegationsagainstafourthallegedperpetratorweredeterminedtobeinconclusive.TheDFPSinvestigatorlistedconcernsincluding:

o NorecordofinjurieswasnotedintheIntegratedProgressNotesintheInfirmary,butthenotesdidshownursingcareeverytwotothreehoursonthedateoftheinjuries.

o Althoughtheindividualhad24/7staffsupport,nooneseemedtohaveanyknowledgeofhowhesustainedhisinjuries.

o Individual#117sustainedtheinjuriesintheInfirmaryandwasnotprovidedwithmedicalattention(lackofdocumentation).

o Theredidnotappeartobeanycleardefinitionorunderstandingoftheterm“staffsupport.”


# Provision AssessmentofStatus ComplianceTheReviewAuthorityTeamrecordedtheDFPSconcernsandlistedstaffin‐serviceondocumentationandrevisionstoPolicyM.17toaddressstaffsupport.However,M.17addressedstaffsupporttoindividualsinthehospital,notintheInfirmary.TheUIRrecordedtheReviewAuthorityTeam’sdecision,toprovidein‐servicetrainingtostaffondocumentationandtomakerevisionstoPolicyM.17,butdidnotindicatethattheactionshadbeentaken.

InDFPSinvestigation#42160077,itwasallegedthattwostaffandthe“system”wereneglectfulofIndividual#117whentheindividualwassenttoanoff‐campusmedicalappointmentwithastaffmemberwhohadbeenpulledfromanotherresidence,wasnotfamiliarwiththeindividual’sPNMP,andwasnotin‐servicedonhisPNMPbyInfirmarynursesaswasrequired.Asaresult,thestaffmemberattemptedtoassisttheindividualtousetherestroomwithoutasecondstafftoprovidethetwo‐personpivottransferasrequiredinthePNMP,resultinginafallandinjurytotheindividual.TheDFPSinvestigatorconfirmedneglectagainstCCSSLC,butnotthetwostaffmembers.DFPSdeclinedtoinvestigatetheallegationofneglectinvolvingthenurse,becausetheyvieweditasoutsidetheirjurisdictionandreferredthematterbacktotheFacility.

TheDFPSinvestigatorindicatedthatallrecommendationswerebeinghandledthroughtheadministrativereferraltotheFacilitytodealwiththefailureofnursingstafftoin‐servicethedirectsupportprofessionalontherequirementsofthePNMP.

TheReviewAuthorityTeamindicatedthattheChiefNurseExecutivewouldaddressassistancegiventodirectsupportprofessionalsbyNursingattheInfirmary,andrequiredevidenceofactiontakenby6/15/12.TheUIRrecordedthedecisionbytheReviewAuthorityTeam,andaddedthattheFacilitywastoreviewPoliciesP.2andM.2forpossiblerevisionson6/22/12.Thefilecontainedatrainingrosterwithevidencethattrainingwasprovidedontheindividual’stwo‐personstandpivottransferto14staffattheindividual’sresidence.Therewasevidenceofaremindertostaffaboutallthoseindividualsneedingatwo‐personstandpivottransfer,andanadditiontotheAppointmentMemorandumtorequirethedirectsupportprofessionaltocheckthePNMPpriortosendinganindividualoff‐campus.Atrainingrosterindicatedthat16InfirmarynurseshadreceivedtrainingonPoliciesM.2andM.9.Anemployeedevelopmentnoteaddressedtheindividualcircumstancesofthisinvestigation.AmemorandumfromtheChiefNurseExecutivetotheDirectoron5/30/12confirmedthattheabovestepsweretaken.


# Provision AssessmentofStatus ComplianceInsummary,stepsweretakentofollow‐upontherecommendationsintheinvestigationexceptfortherecommendationtoreviewtwopoliciesforpossiblerevision.

FacilityInvestigation#12‐261involvedthedeathofIndividual#96.Individual#96wasinthehospitalforgallbladdersurgery,anddiedthedayofthesurgeryafterbeingreturnedtoherroom.ThepreliminarycauseofdeathwasCardiacArrest,buttheFacilitywasawaitinganautopsyforafinaldetermination.Inthecourseoftheinvestigation,gapswerenotedinthedocumentationofthedirectsupportprofessionalpresentduringtheindividual’sstay.Theinvestigatornotedthattheassignedstaffwasnotfamiliarwithhospitalproceduresanddidnotdocumentwhatwasbeingdone.TheinvestigatornotedthatasexualencounterthattheindividualhadwhileonahomevisitwasnotreportedtotheIMCasrequiredandrecommendedthattheIDTbere‐in‐servicedonPolicyDD.5ManagingUnusualIncidents.TheUIRcontainedfurtherrecommendationsthatthenursingstaffbein‐servicedonusingNursingProtocolCardstoguidedocumentationandthatthecasemanagersbein‐servicedonQuarterlyAssessments.TherewerenoReviewAuthorityTeamnotesinthefileandnofollow‐updocumentationintheUIRtoindicatetherecommendationshadbeencarriedout.Therewasnoindicationastohowthediscoveredfailuretoreportanincidentwasaddressed.

WhiletherehadbeenprogressintheReviewAuthorityTeam’sdocumentationoftheirdecisionsandtheUIRtrackingofsomeaspectsofthefollow‐uponrecommendations,therewasnotacleardemonstrationthatthesystemforrecordingandmonitoringfollow‐upwasoccurring.AsaresultthatMonitoringTeamhasmadeafindingofnoncompliance.ThiswasconsistentwiththeFacility’sSelf‐Assessmentthatthisprovisionwasnotinsubstantialcompliance

(j) Requirethatrecordsoftheresultsofeveryinvestigationshallbemaintainedinamannerthatpermitsinvestigatorsandotherappropriatepersonneltoeasilyaccesseveryinvestigationinvolvingaparticularstaffmemberorindividual.

SectionDD.5.2providedachecklistforinvestigationfilesmaintainedbyCCSSLC,whichwasimplementedon12/5/10.FilesoftheFacility’sinvestigationsandtheDFPSinvestigationsweremaintainedinanofficenexttotheIMC’soffice,andwerereadilyavailabletopermitinvestigatorsandotherappropriatepersonneltoeasilyaccesseveryinvestigationinvolvingaparticularindividual.Thefilesexaminedwerearrangedaccordingtothechecklist,whichfacilitatednavigationtodocumentsofparticularinterest.TheFacilityinvestigationswereenteredelectronicallyintotheFacility’scomputersystem,allowingaccesstoinvestigatorswithoutresortingtothepaperfile.DFPSfilesweremaintainedelectronicallytoallowaccesstotheirauthorizedpersonnel.It



# Provision AssessmentofStatus ComplianceappearedthattheirofficialreportsweretransmittedtoCCSSLCinhardcopy,which werefiled.BasedontheMonitoringTeam’sreview,theFacilityremainedincompliance.TheFacility’sfindingsinitsSelf‐Assessmentwereconsistentwiththisfinding.

D4 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshallhaveasystemtoallowthetrackingandtrendingofunusualincidentsandinvestigationresults.Trendsshallbetrackedbythecategoriesof:typeofincident;staffallegedtohavecausedtheincident;individualsdirectlyinvolved;locationofincident;dateandtimeofincident;cause(s)ofincident;andoutcomeofinvestigation.

TheCCSSLCQualityAssuranceofficetrackedandtrendedunusualincidentsandallegationsofabuse,neglectandexploitationby:

Typeofincident; Individualsdirectlyinvolved; Locationofincident; Dateandtimeofincident; Cause(s)ofincident;and Outcomeofinvestigation.

TheFacilityhaddiscontinuedthepracticeofreportingthenamesofstaffinvolvedinallegationsinitsmonthlyTrendReports,whichcirculatedwithintheFacility,butretainedthenamesintheelectronicfiles.Inthisway,thenameswereavailableforreviewtoselectedstaffthatcouldanalyzethem.TheFacilityprovidedtrackingreportsforincidentsandallegationsformonthsfromJanuary2012throughMay2012.Eachreportshowedthenumberofincidentsorallegationsbymonthwithanalysesofthedataforthemonth.Whilethereportsdisplayeddatabymonthforthelastandthecurrentyears(e.g.,intheMay2012report,thereweredatafromtwelvemonthsof2011andfivemonthsof2012),theanalysiswasonlyforthemostrecentmonth.Thechartsandgraphsdidnotincludetrendlinestoshowhowallegationsorincidentswerechangingovertime,nordidtheyanalyzehowallegationsorincidentsregardinganindividualorahomehadchangedovertime.Whiletheinformationinthereportwasuseful,itdidnotprovidecompletetrendingofdataasrequiredbythisprovision.TheActionPlanforthisprovisionincludedrevisingcurrentlocalpolicyregardinguseofdatabasesfortrendreporting,productionofacompletetrendreporttobesharedwiththeIMRTonamonthlybasis,andtheimplementationofcorrectiveactionplanstoaddressissuesidentifiedintheTrendReports.ThepolicyshouldincludesharingthereportwiththeQA/QACouncilaswell.TheFacility’sSelf‐AssessmentindicatedthattheFacilitywasnotyetincompliancewiththisprovision.ThiswasconsistentwiththeMonitoringTeam’sfindings.BecausetheFacility’scurrenttrendreportsdidnotincludetrending(i.e.,analysis)ofthespecifieddataovertimetoallowtheFacilitytodeterminetheneedforcorrectiveaction,theFacilityhad

Noncompliance


# Provision AssessmentofStatus CompliancenotmettherequirementsoftheSettlementAgreement.

D5 Beforepermittingastaffperson(whetherfull‐timeorpart‐time,temporaryorpermanent)orapersonwhovolunteersonmorethanfiveoccasionswithinonecalendaryeartoworkdirectlywithanyindividual,eachFacilityshallinvestigate,orrequiretheinvestigationof,thestaffperson’sorvolunteer’scriminalhistoryandfactorssuchasahistoryofperpetratedabuse,neglectorexploitation.FacilitystaffshalldirectlysupervisevolunteersforwhomaninvestigationhasnotbeencompletedwhentheyareworkingdirectlywithindividualslivingattheFacility.TheFacilityshallensurethatnothingfromthatinvestigationindicatesthatthestaffpersonorvolunteerwouldposeariskofharmtoindividualsattheFacility.

Bystatuteandbypolicy,allStateSupportedLivingCenterswereauthorizedandrequiredtoconductthefollowingchecksonanapplicantconsideredforemployment:criminalbackgroundcheckthroughtheTexasDepartmentofPublicSafety(forTexasoffenses)andaFederalBureauofInvestigation(FBI)fingerprintcheck(foroffensesoutsideofTexas);EmployeeMisconductRegistrycheck;NurseAideRegistryCheck;ClientAbuseandNeglectReportingSystem;andDrugTesting.CurrentemployeeswhoappliedforapositionatadifferentStateSupportedLivingCenter,andformeremployeeswhore‐appliedforapositionalsohadtoundergothesebackgroundchecks.InconcertwiththeStateOffice,theFacilityDirectorhadimplementedaproceduretotracktheinvestigationofthebackgroundsofFacilityemployeesandvolunteers.Documentationwasprovidedtoverifythateachemployeeandvolunteerwasscreenedforanycriminalhistory.Thiswasconfirmedinasampleof25staff.TheinformationobtainedaboutvolunteerswasdiscussedandconfirmedwiththeFacilityDirector,andconfirmedinasampleoffivevolunteers.Backgroundcheckswereconductedonnewemployeespriortoorientation.Portionsofthesebackgroundcheckswerecompletedannuallyforallemployees.CurrentemployeesweresubjecttoannualfingerprintchecksduringthemonthofOctober2011.Oncethefingerprintswereenteredintothesystem,theFacilityreceiveda“rap‐back”thatprovidedanyupdatedinformation.TheregistrycheckswereconductedannuallybycomparisonoftheemployeedatabasewiththatoftheRegistry.Inaddition,employeesweremandatedtoself‐reportanyarrests.Failuretodosowascausefordisciplinaryaction,includingtermination.Examinationoftheself‐reportinginformationdocumentedthatonepersonwasterminateduponbackgroundcheckinformationshowingafailuretoself‐reportanarrest.InaninterviewwiththeFacilityDirector,hisdecisionsregardingtheemploymentofasampleofapplicantswithanycriminalhistorywerediscussedonacase‐by‐casebasis.Ineachinstance,hisdecisionswerebasedonthefactsandweremindfulofhisresponsibilitytosafeguardtheindividualsandstaffoftheFacility.BasedontheMonitoringTeam’sreview,theFacilityremainedincompliancewiththisprovision.TheFacility’sSelf‐AssessmentalsoindicatedtheFacilitywasinsubstantialcompliancewiththisprovision.



Recommendations:ThefollowingrecommendationsareofferedforconsiderationbytheStateandtheFacility:1. WhenanincidentisreportedtoIMUwhetherbyDFPSorbysomeoneelse,thedateandtimeshouldberecordedintheUIR.Ifitwasreported

toDFPSandtoIMU,bothshouldberecordedtohelpestablishthatstaffarefollowingtheruleaboutreportingtoboth.(SectionD.2.a)2. TheFacility’sActionPlanwithregardtoSectionD.2.ishouldberevisedtoindicatehowtheFacilityintendstoreviewallinjurieseverysix

months,andreportforinvestigationthoseinjuriesthatduetofrequencyorothercriteriaraisesuspicionsofpossibleabuseorneglect,ifreportshavenotalreadybeenmade.(SectionD.2.i)

3. DFPSinvestigativereportsshouldincludeevidenceofthecontentofthereviewbythesupervisor.AsDFPShaddiscussedwiththeMonitors,DFPSwillproposeaformatforprovidingthisinformation.(SectionD.3.g)

4. TheUIRshouldcontaindocumentationofwhenanyrecommendedactionswerecompleted,andreferencedocumentationinthefilethatdemonstratesthatcompletion.Whenrecommendationsinvolvephysicalchangestoanindividual’sresidenceorspecificretrainingforstaff,theCampusAdministratorshouldconfirmthechangesortrainingduringtheirroundsandproducetheirnotesasevidenceforthefile.(SectionD.3.i)

5. TheFacilityshouldfinalizeitstrackingandtrendingsystem.(SectionD.4)6. TheFacilityshouldexpanditseffortstoconductcriticalanalysisofthetrenddatacollectedtodetermineifanyactionsshouldbetaken,or

correctiveactionplansdevelopedtoaddressanyunderlyingcausesoftrendsidentified.(SectionD.4)ThefollowingareofferedasadditionalsuggestionstotheStateandFacility:

1. AclearerexplanationshouldbeprovidedinFacilitypolicyandstafftrainingofwhatformareportaboutanunusualincidentistotake(i.e.,phonecall,awrittenreport,etc.).(SectionD.2.a)

2. Inordertomaintainthefindingofcompliance,theFacilityshouldmaintainastrongtrainingprogramonretaliationandremindstaff,forexample,atstaffmeetings,innewsletters,etc.,thatretaliationwillnotbetolerated.Inaddition,whenthereportsofinvestigationsarereviewed,theFacilityshouldfollowuponanyreferencestopossibleretaliationorexpressedfearsofretaliation.Forexampleifstaffhaveparticipatedinaninvestigation,itmightbenecessarytoofferachangeofassignmenttorelievestrainedrelationshipswithotherstaff.Thecultureamongststaffofprotectingoneanotherasopposedtoindividualsservedcanbeverystrong.FacilityAdministrationwillneedtocontinuetobecreativeaboutshiftingthisculturetooneinwhichtheindividuals’safetyandwellbeingisparamount.Continuedfocusoninstillingthefoundationalvaluesofprotectingindividualswhoarevulnerable,whileatthesametimeassistingthemtoenjoymeaningfulliveswillgreatlyhelpinthisregard.Anyeffortsthatcanbemadetorewardstaffthatdemonstratestrongvalueswouldadvancethisprocess.(SectionD.2.h)


SECTIONE:QualityAssuranceCommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,eachFacilityshalldevelop,orrevise,andimplementqualityassuranceproceduresthatenabletheFacilitytocomplyfullywiththisAgreementandthattimelyandadequatelydetectproblemswiththeprovisionofadequateprotections,servicesandsupports,toensurethatappropriatecorrectivestepsareimplementedconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow:


o CCSSLCStatewidePoliciesandProcedures:Policy#3.1effective1/26/12;o CCSSLCProceduresE.2,E.5,E.10,E.11andE.12,implemented5/24/12;o CCSSLCFacilitySelf‐Assessment,dated6/25/12;o CentersforMedicareandMedicaidIntermediateCareFacilityforPersonswith

DevelopmentalDisabilitiesreportsof5/14/12and6/27/12;o CCSSLCActionPlans,updated6/25/12;o CCSSLCProvisionActionInformation,undated;o PresentationBookforSectionE;o SummariesofCompliancefindingsandinter‐raterreliabilityscoresforSections:C,I,J,K,O,

P,R,S,andU,fromDocumentRequestResponseIV.6;o SettlementAgreementMonitoringToolforSectionE,datedApril2012;o DataCollectionatCCSSLC,dated9/30/11;o CCSSLCPlanofImplementation(POI)Submissions–FY12,undated;o CCSSLCQuarterlyTrendingReportfrom6/1/12through6/30/12forInjuries,Unusual

Incidents,andAbuse/Neglect/Exploitation;o CorrectiveActionPlanTrackingLog,undated(basedonentriesthroughMay2012);o QualityAssurance/QualityImprovement(QA/QI)CouncilMinutes,dated1/5/12,1/12/12,

1/26/12,2/2/12,2/9/12,3/1/12,4/5/12,5/3/12,6/14/12,and7/5/12;o QualityAssurance/QualityImprovementagendaandmeetingmaterials,for7/12/12;ando CustomerSatisfactionSurveyResponseReports,datedJanuary,February,March,andApril

2012. Interviewswith:

o MarkCazalas,FacilityDirector;o BruceBoswell,AssistantDirectorofPrograms;o CynthiaVelasquez,DirectorforQualityAssurance;o ProgramComplianceMonitors;o Twentystaffmembersfromvariousresidentiallocations;ando Tenindividualsinvariousresidentialanddaylocations.

Observationsof:o Residences:522A,B,C,andD;524A,B,C,andD;and514;o DayandVocationalProgramsinBuildings512,513,and517;o IncidentManagementReviewTeamMeeting,at11a.m.on7/9/12;o InterdisciplinaryTeammeetingforIndividual#341on7/11/12;ando QA/QICouncilMeeting,on7/12/12.

FacilitySelf‐Assessment: TheFacility’sSelf‐AssessmentdidnotfindtheFacilitytobeincompliancewithanyofthefiveprovisionsofSectionEoftheSettlementAgreement.ThiswasconsistentwiththeMonitoringTeam’sfindings.


TheFacilitySelf‐AssessmentaddressedeachprovisionofeachsectionoftheSettlementAgreementbylisting:1)activitiesengagedintoconducttheself‐assessment;2)theresultsoftheself‐assessment;and3)aself‐ratingusingtheinformationcitedinthesectiononresults.Inadditiontotheself‐assessment,theFacilityprovidedActionPlansforaddressingimprovements,andProvisionActionInformationtorecordactivitiesundertakentoachievecompliancebetweenmonitoringvisits.TheFacilityhadaMonitoringToolforSectionE,datedApril2012.Therewasnoindicationofthefrequencyofuseorpersonsresponsibleforcompletingit,norwerethereseparateguidelinesforuseofthetool.TheFacilitydidnotsupplyevidenceofhavingconductedtheSectionEMonitoringToolorprovideasummaryoftheresults.TheMonitoringToolresultswerenotreferencedintheFacilitySelf‐Assessmentunderindividualprovisions.ThefollowingconcernswerenotedwithregardtotheFacility’sSelf‐AssessmentofSectionE:

TheQualityAssuranceDepartmentwasnotusingthemonitoringtooltomeasureprogressonitsownperformanceandrelyingonthetoolresults,atleastinpart,tosupportitsSelf‐Assessmentanalysis.

IndeterminingwhetherornottheFacilitywasincompliancewithSectionE.1,theSelf‐AssessmentdidnotreviewtheFacility’sdatacollectionefforts,itsQAPlanmatrix,thePOIdatareports,and/orotherdatacollectionandtrackingactivities.

TheSelf‐AssessmentdidnotindicatehowmanyQualityAssuranceReportshadbeencompletedandforwhichsections,orwhetherandhowmanyCorrectiveActionPlans(CAPs)weredevelopedasaresult.

Therewasnoreferencetopoliciesthathadbeendevelopedtoclarifythedatacollectionprocesses. TherewasnoreviewofhowvarioussectionswereusingtheirQAdatatoimproveservices.

TheactivitiesengagedinneedtodemonstratetheuseofMonitoringToolstoinformtheself‐assessment.Themonitoringtoolshouldbeausedasamechanismtogatherquantifieddataonwhichtobasefindingstogetherwithanyotherrelatedinformation,suchasthestatusofpolicydevelopment.TheActionPlanstepsshouldincludeenoughdetailtoallowunderstandingoftheobjectiveandtheprocessforaccomplishingthatobjectivealongwiththeevidenceneededtoshowachievement,responsibleperson,andprojecteddates.Ifprojectedcompletiondatesaremonthsinthefutureandwhendateshavebeenmodifiedfrompreviousreports,theyshouldhaveastatusupdate.SummaryofMonitor’sAssessment:CCSSLCwasintheprocessofamendingitspoliciesandprocedurestoalignwiththerevisedStatePolicyonQualityAssurance.TheredidnotappeartobeacurrentQualityAssurancePlaninplace,althoughaplanhadbeenprovidedandreviewedduringtheMonitoringTeam’slastreview.MonitoringtoolstomeasurequalityhadbeenadoptedbasedonthetoolstheMonitoringTeamsused,andadaptedforuseintheFacility.Guidelinesfortheuseofthetoolshadbeenwritten,andProgramAuditors


wereusingthetoolsinthefield,meetingwithdisciplineheadstoshareandcompareresultsofmonitoring,anddevelopingideasforimprovementstothetoolsandguidelines,whichshouldresultingreaterinter‐raterreliability.Dataandsummaryreportswereavailableforsomeofthereviews,aswasinter‐raterreliabilitydata.DataforsomeofthesectionshadbeenanalyzedandreportedtothesectionleadsandtheQA/QICouncil.Continuedworkwasneededwithregardtointer‐raterreliability,aswellastheaccuracyofthemonitoring.SomesectionsoftheFacility’sSelf‐AssessmentwereusingdatagainedfromthemonitoringtoolsasevidenceoftheFacility’scompliancestatus.ThisshouldbecomeastandardpartoftheassessmentofeachsectionoftheSettlementAgreement.CCSSLCcontinuedtoreporttrenddataandanalysesonaquarterlyscheduleforsomekeyissues,suchasrestraints,abuseallegations,incidents,andinjuries,andriskshadbeenadded.However,issueswerenotedwithregardtothereportonrestraints.ItcouldnotbeproducedforJuneduetochangesinthestatewideAVATARdatasystem.Informationwasavailabletoshowsomespecificcharacteristicsofincidents,suchaswhereincidentswereoccurring,whattimeofday,andonwhichlivingunits.Breakdownsofdatawereavailablebyunitandbyresidence,makingitpossibleforunitsandresidencestousethedataasatoolinanalyzingandaddressingundesirabletrends.However,whiledisplayingthedataeachmonthoverayear‐longperiodwashelpful,therewasnolongitudinaltrendingandanalysisofthedatatoidentifyifindividualsorunitshadconcerningtrends,orwhichresidencesorprogramlocationpotentiallyhadproblems.AstheFacilitycontinuedtocaptureanddisplaydataonitsTrendReports,QAmonitoringreportsandPlanofImprovementReports,ithadnotbeguntocross‐analyzedatafromthesereportstoassistindeterminingwheresystemweaknesseswereemerginginordertofocuspreventiveattentiononthoseareas.TheQualityAssurance/QualityImprovementCouncilhadbeenorganizedtodevelop,revise,andimplementqualityassuranceprocedures.Duringpreviousvisits,thePerformanceImplementationTeam(PIT)andthePerformanceEnhancementTeams(PETs)wereinevidence.Duringthisvisit,theseteamsappearedtobeinsuspensionwithnominutesormeetingdates.Insteadtherewerethreegroupsofsectionleadswhoweresupposedtobemeetingtoworkoncomplianceissues.ThesegroupsweretoreporttotheQA/QICouncil,butitwasnotclearwhethertheyweremeetingandreporting.SomeworkhadbeendoneonimprovingthequalityofthedatabeingenteredintotheStateOfficedatabasethroughtheadoptionofprocedures.Italsoappearedsomeadditionshadbeenmadetothelistofdata.Somebasicelementsofaqualityassurancesystemwereinplace,butitwasnotclearthattherewasageneralunderstandingofhowthoseelementsworkedtogether.ThenextstepsshouldincludecompletingtheCorrectiveActionPlanprocess,usingthedatasystemtoreportoninformationthemonitoringactivitiesgenerate,anddevelopingasetofkeycriteriatomeasureprogressonserviceoutcomes.


# Provision AssessmentofStatus ComplianceE1 Trackdatawithsufficient

particularitytoidentifytrendsacross,among,withinand/orregarding:programareas;livingunits;workshifts;protections,supportsandservices;areasofcare;individualstaff;and/orindividualsreceivingservicesandsupports.

InorderfortheFacilitytobeincompliancewiththiscomponentoftheSettlementAgreement,atrackingsystemneedstobeinplacetoallowidentificationofissuesacrossthemanycomponentsofprotections,supports,andservicesprovidedtoindividualsresidingattheFacility.Thiswillrequirenotonlyreviewofmonitoringdata,butalsocollectionandanalysisofkeyindicatorsoroutcomemeasures.AlthoughtheFacilityhadbeguntocollectsomedata,forexample,relatedtoincidentsandallegations,ithadnotyetdevelopedasetofkeyindicators.Thisisimportantforafewreasons,including:

ProvidingtheFacilitywiththeabilitytoidentifyobjectivelytheindividualswhorequireadditionalattentiontoensuretheyaresafeandarereceivingthesupportsandservicestheyrequire;

Identifyingproactivelyhomes,dayprograms,and/ordepartmentsthatrequireimprovement;and

Identifyingawidearrayofpotentialsystemicissues.Throughoutthisreport,therearereferencesmadetodatathatshouldbeincorporatedintosuchasystem.Forexample,dataneedstobeincorporatedintothesystemregardingat‐riskindividuals;medical,psychiatric,andnursingissues;infectioncontrol;physicalandnutritionalsupports;andoutcomesrelatedtotransitiontothemostintegratedsetting.Thisisnotanall‐inclusivelist,butismeanttoprovidetheFacilitywithideasaboutthetypeofindicatorsoroutcomemeasuresthatshouldbeincludedinsuchasystem.Atthetimeofthereview,theFacilitydidnothaveacompletesystemsuchasthisinplace.Howeveritdidhavecertainelements,including: AQualityAssurancePolicy:theFacilityhadadoptedtheStateOfficepolicy,

amendedsomerelatedFacilityproceduresandhadotherproceduresindraft. QualityAssurancePlan:thelatestversionoftheplanwasnotpresentedfor

review.However,itwasreferencedinvariousreportsandhadbeenpresentatthelastmonitoringvisit.

Monthly,quarterly,andannualTrendReportswereavailablethatshowedunusualincidents;allegations,investigations,andresultsofinvestigationsofabuse,neglectandexploitation,aswellasinjuries,andrestraints.

Thesereportsweredisplayedbytype,individualsinvolved,location,home,hour,shift,anddayofweek,andcouldbedisplayedbystaffinvolved,thoughtheFacilitychosetoredactthatinformationfromreportssharedwidelythroughouttheFacility.

CCSSLCPOISubmissions:Thesereportstrackeddataonareasofservice,including:integratedprotectionsandservices,pharmacyservices,physicalnutritionalmanagement,psychologicalservices,andothers.SpecificsoncollectionofinformationforthesereportswerefoundinFacilityProceduresE.7andE.8,whichwereindraftform.ThePOIdidcontainsomeoftheelementsofmeasurementofserviceoutcomes(e.g.,personsinvolvedinon‐campusday

Noncompliance


# Provision AssessmentofStatus Complianceprogramsoutsidetheirhome,personsinworkshopsoncampusandoffcampus).Withadditionaldefinitionoftermsused,datasources,identificationofbenchmarksanddesiredoutcomes,andsomeadditionalspecificity,thiscollectionofdatacouldbeexpandedupontoformthebasisofsetofkeycriteriatomeasureprogressonserviceoutcomes.

AuditingtoolswereinplaceforSectionsC,D,E,F,I,J,K,M(multipletools),O,P,R,S,T(multipletools),UandV.SectionswithouttoolsinplacewereL,N,andQ.

QAauditingdataresultingfromuseoftheauditingtoolswasbeingcollectedandsummarizedforSectionsC,I,O,P.DatawascollectedforSectionsJ,K,R,S,andU,butwasnotsummarized.Dataneedstobecollectedforallprotections,supportsandservices,andareasofcare,analyzed,summarizedandreportedtotheQualityAssurance/QualityReviewCouncil.Otherauditingtoolsmighthavebeenituse,butitwasnotapparentthattheresultingdatahadbeensummarized,analyzed,andsubmittedtotheQualityAssuranceDepartmentforreview.

Alldatabaseswereenumeratedinachartentitled:“DataCollectionatCCSSLC,”whichwassuppliedinresponsetoonsiteRequest#9.Thedateonthereportwas9/30/11,butitwasnotclearifthatwasthedatethereportwaswrittenorthedatethereportshellwasdeveloped.Listingssuchasthis,ifwidelydisseminated,couldhelptopreventthemultiplicationofdatabaseswiththesameinformation.ItwasimportantthattheFacilityhadtakenthisfirststepofidentifyingthedataitcurrentlyhadavailableindatabases.Itwillbeimportantgoingforwardtohaveasystemforassuringtheaccuracyofthedatainthesystem.TwoissuesdiscussedwiththeDirectorforQualityAssuranceatthetwopreviousmonitoringreviewswerehowtodisplaydatainvolvingstaffmembersandhowtodevelopdatarelatedtoareasofcare.Thefollowingsummarizesthecontentofthesediscussionswithupdatesonprogress:

Thefirstissueinvolvedhowtotrackdatainvolvingstaffmemberswithoutdisplayingtheirnamesinreports,suchastheMonthlyandQuarterlyTrendReportsforAbuse/Neglect/Exploitation,UnusualIncidents,Injuries,Restraints,andRisks.Notprintingthenamesonthereportsthatcirculateinternally,butpreservingtheminthesystemforreviewbyselectedpeopleasneededhadresolvedthisissue.TheMonitoringTeamwasabletoobtaincopieswhenrequested.

“Areasofcare”referredtointheSettlementAgreementareprogrammaticandclinicalareas,suchasresidential,vocational,medical,psychiatric,nursing,psychology,habilitationtherapies,etc.Thequestionwashowtocollectkeyindicatorsofperformanceintheseareas.ThistimetheActionPlan(E.1.5)calledforareviewofthe“MonthlyPOISubmissionReportandtheQuarterlyTrendReportstodevelopqualityindicators(keyindicators)tomeasuremany


# Provision AssessmentofStatus ComplianceareasofcareandtobereviewedduringQA/QItodevelopcorrectiveactionplans.”TheActionPlanhadspecifictimeframesandthestepwasmarkedascompletedon6/1/12.ItwasnotclearhowtheQADirectorwasgoingtoaccomplishthis,whoelsewouldbeinvolved,andwhethertherewouldbedatafromothersourcesincludedtopresentacomprehensivesetofkeyperformanceindicators.Fromreviewandinterview,itwasnotclearwhetheralltheindicatorsonthePOIlistwereconsidered“keyindicators”orwhethertherewasaplantodesignatecertainofthoseelementsas“key”andaddelementsfromotherdataliststocreatea“keyindicators”list.However,atthetimeofthereview,theFacilityhadnotyetdevelopedasetofkeyindicatorsthatweremeasurable,identifiedbaselinedata,and/orsetgoalstomeasureprogresstowardsstatedoutcomes.

Mostofthemonitoringtoolshadbeeninuseforayearorlonger.FourProgramComplianceMonitorsandonequalityassurancenurse,whoreportedtotheDirectorofQualityAssurance,wereconductingaudits.ThefourProgramAuditorsdividedtheSettlementAgreementsectionsaccordingtotheirexperiences,sothateachProgramAuditorhadaspecificsetoftoolsandresponsibilities.Eachmonth,theQAAuditordrewasampleanddisciplineheadorsomeoneassignedbythedisciplineheadappliedthemonitoringtoolsandrecordedtheresults.TheQAAuditorusedthetooltomonitorasubsampleforpurposesofdetermininginter‐raterreliability.Uponinterview,theProgramAuditors(excludingthenurseswhowerenotpresentfortheinterview)couldidentifywheresometoolswerebeginningtowork(SectionFinparticular),andwheresomeoftheissueswerestillunresolved.InsomecasessuchasSectionK,theentiretoolhadbeenmodifiedfromtheoriginal.Inothers,guidelinesorwordingchangesweremadewithoutmajorchangestothetools.ProgramAuditorswereworkingwithdisciplineheadstounderstandwherethereweredifferencesininterpretationandtoselectthemostappropriatesolutions.Therehadbeensomecombinationoftools,andeffortswereunderwaytostreamlinetoolstoavoidredundancywithintoolsandwithingroupsoftoolswheremultipletoolswereinuseforasinglesection.FromtheMonitoringTeam’sperspective,workwasstillneededtorefinethesetoolsandtheirimplementation,includingimprovingtheguidelinesorinstructionsassociatedwitheachtoolandensuringinter‐raterreliabilityandaccuracyofmonitoring,ensuringthatqualitywasmeasuredasopposedtothemerepresenceorabsenceofitems,aswellasidentifyingtheprioritiesforthetools’implementationsoastonotoverwhelmthesystemwithdatathatcouldnotbeusedeffectively.TheQADepartmenthadbeguntoworkontheneededrevisionswithsectionleads,andreportedtheprojectedcompletiondateofchangestothetoolsas9/1/12.



AsindicatedintheFacility’sSelf‐Assessment,theFacilitywasnotinsubstantialcompliancewiththissubsection.However,therewassustainedprogressintheauditingofperformance,summarizingandreportingoncollecteddatainsomesections,andmodifyingtheauditingprocess.ForprogresstocontinuetheFacilityshouldreformulateitsActionPlanforthissectiontoclarifyhowitwillidentifykeyindicatorsasdescribedabove.Inaddition,theFacilityshouldcontinuetoenhancethemonitoringtoolsandmethodologies,andcontinuetoworkonauditingprogramsandaddressinganyresultingidentifiedissues.Particularattentionisneededinthemedicalsectionstoassurethattheirdataisbeinganalyzedandused.

E2 Analyzedataregularlyand,wheneverappropriate,requirethedevelopmentandimplementationofcorrectiveactionplanstoaddressproblemsidentifiedthroughthequalityassuranceprocess.Suchplansshallidentify:theactionsthatneedtobetakentoremedyand/orpreventtherecurrenceofproblems;theanticipatedoutcomeofeachactionstep;theperson(s)responsible;andthetimeframeinwhicheachactionstepmustoccur.

TheFacilityneededtodemonstratethatthe dataintheQAmatrixweresummarized,graphed,andanalyzed.ThedataneededtobetrendedbyeachdisciplinedepartmentwithoversightandadditionalanalysisprovidedasneededbytheQADepartment.TheFacilityhadpreparedgraphsandreportsanalyzingthedataobtainedthroughapplicationofthemonitoringtoolsforsomesectionsoftheSettlementAgreement.ExamplesincludedsectionC,I,OandP.However,suchanalysesandreportswerenotavailableforallsections.TheFacilitywasanalyzingmonthlydataonrestraints(exceptforJune2012),abuse/neglect/exploitation,unusualincidents,injuries,andrisks,andproducingtrendreports.Howevertheanalyseswerenotlongitudinal.Trendsshouldbeidentifiedlongitudinallyacross,among,withinand/orregarding:

Time(bymonthusually); Programarea,livingunit,workshifts; Protections,supports,andservices; Areasofcare; Staffinvolved; Individualsinvolved.

ThePOIdatawascollectedmonthlyandthenumericaldatawasdisplayedinachartcoveringninemonths.Thisdatawasnotanalyzed.AtthetimeoftheMonitoringTeam’slastvisit,CCSSLChadthreeteamsinvolvedinthereviewandanalysisofdata,andtheproductionandreviewoftheresultingcorrectiveactionplans.Therehadbeenmodificationstotheactivitiesoftheseteamsasfollows:

TheQualityAssurance/QualityImprovementCouncilwasresponsibletodevelop,revise,andimplementqualityassuranceproceduresthatenabledtheFacilitytocomplyfullywiththeSettlementAgreement,anddetectproblemsinatimelymannerintheprovisionofadequateprotections,services,andsupportstoensurethatappropriatecorrectivestepswereimplemented.

Noncompliance


# Provision AssessmentofStatus Compliance(CCSSLCProcedure#E.5,revised5/24/12).AreviewoftheminutesoftheCouncilbetweenJanuaryandJune2012revealed:

o Meetingswereheldatleastonceeachmonthandsometimesmoreoften;

o MinutesincludedinformationaboutprogressonachievingcompliancewithICF/DDrequirements,andpoliciesandprocedureswerereviewedandapproved;

o SixActionPlansweretrackedregardingtopicssuchastheMockCodeDrillPolicy,dataproceduresforenteringpeer‐to‐peerinjuries,andtheuseoftheArjoSlings.Eachplanlistedactionstobetaken,anticipatedoutcomes,personsresponsible,andtimeframeforcompletion.AllwererecordedascompletedbytheendofMarch,andonewasreviewedinMaybytheProgramComplianceMonitortoverifytheresults.

o TheCAPswererelatedtothequalityofthesystem,butitwasnotclearfromtheQA/QICouncilminuteshowtheywereconnectedtodataanalysesbeingproducedbytheQAsystem.

TheProgramImprovementTeam(PIT)wasresponsibletoconductmonthlyreviewofthedatabyhomeanddepartmentinareasrelatedtocompliancewithactionstepsoutlinedintheSettlementAgreement(CCSSLCProcedure#E.3),andtoreportitsfindingsandrecommendationstotheQA/QICouncilatitsregularmonthlymeetings.InformationsuppliedforthismonitoringvisitindicatedthatthePIThadbeensuspended.FacilityProcedureE.10,revised5/24/12,didnotspecifyaroleforPITs,anditappearedthattheirusehadbeenended.Therewerethreesubgroupsofsectionleadsthatweresupposedtobemeetingtoreviewanddiscussprogresstowardcompliance,butitwasnotclearhowoftentheymetorwithwhatresults,sincenominutesoftheirmeetingswerepresented.

Onamonthlybasis,thePerformanceEvaluationTeams(PET)wereresponsibletoreviewtheMonitoringTeam’sassessmentofstatusatthelastvisit,theFacility’sPlanofImprovement(nowFacilitySelf‐Assessment),actionplans,evidenceofcompliance,anddatageneratedbytheMonitoringTools(CCSSLCProcedure#E.4).Theseteamshadnotmet,anditappearedthattheirfunctionshadbeencombinedintotheworkofthethreegroupsofsectionleadsasdescribedinrelationtothePITabove.

Itdidnotappearthatthesectionleadgroupswereanalyzingortrendingthedata,sincetherewasnodocumentationtosupportsuchactivity.NoCorrectiveActionPlansemergedfromdiscussionsasevidencedbythereportoftheDirectorofQualityAssuranceintheFacilitySelf‐Assessment.(HowevertheinformationinthereportappearedtobefortheJunethroughOctober2011timeperiod.)ThereweresixCAPs


# Provision AssessmentofStatus CompliancedevelopedinJanuarythroughMarch2012asevidencedbytheCorrectiveActionPlanTrackingsheetandnotedintheQA/QIminutes.FacilityProcedureE.10,revised6/17/12,calledfortheQualityAssuranceDirectorto“presentdatafromthemonthlymonitoringconductedtotherespectivesectionleadsforreviewonaquarterlybasis.”IfthatdatademonstratedthelackofsufficientprogresstowardssubstantialcomplianceonanySettlementAgreementprovisionsorneedforcompliancewithotherauditsandsafetycodes,theFacilityworkgroupsordepartment/disciplinewereinstructedtodevelopCAPsforreviewandapprovalbytheQA/QICouncil.TheProgramComplianceMonitorswereproducinganalysesofthemonitoringtooldatathatwasbeingcollectedonatleastfourSettlementAgreementsections,including:C,I,O,andP.TheseanalyseswereextensiveanddidcontaininformationthatcouldbeusedtostimulateCAPdiscussionandselection.However,withtheSectionGroupsnotregularlyproducingdataanalysesandcorrectiveactionplans,orendorsingtheonestheProgramComplianceAuditorsdeveloped,theQA/QICouncilminutesdidnotreflectactiononthem.ItwasnotclearwhetherthesixCAPSthatweretrackedbytheQA/QICouncilhademergedfromthisprocessorweredevelopedbythesectionleadsindependently.On7/12/12,membersoftheMonitoringTeamattendedanabbreviatedmeetingoftheQA/QICouncil.ThemeetingcenteredonremindingstaffaboutplansofcorrectionthatweredueinresponsetoarecentICF/DDsurveyandassessmentsthatweredueforupcomingISPmeetings.Apresentationaboutanupcomingeventtohavemuralspaintedandrecognitionofstaffaccomplishmentswerethemaintopicsforthemeeting.TherewasnodiscussionofdatareviewsorCAPs.Minutesofthe7/5/12meetingweredistributedandthoseminutesindicatedthatsectionleadshadpresentedtheirquarterlyreviewsatthatmeeting.Noplansofcorrectionwerepresentedororderedbasedonthedatapresentationsatthatmeeting.TheFacilitywasnotusingavailabledatatoidentifyindividualswithconcernsacrossmultipleareas(e.g.,injuries,incidents,hospitalizationsorERvisits,restraints,etc.),and/ortomakeconcertedeffortstoaddresstheneedsoftheseindividuals.Theredidnotappeartohavebeenanyactioninthisarea.Anin‐depthdiscussionoftheissuewasincludedintheMonitoringTeam’slastreport.BasedontheMonitoringTeam’sfindings,theFacilityremainedoutofcompliancewiththisprovision.ThiswasalsotheFacility’sassessment.IftheSectionLeadgroupshavereplacedthePITandPET,thisshouldbeformalizedinprocedures.Thegroupsneedtoreview,analyzeandpresentdata,anddevelopcorrectiveactionplanstoaddressidentifiedtrendsandissues.TheyQA/QICouncilshouldapproveplansandtrackthem.


# Provision AssessmentofStatus ComplianceE3 Disseminatecorrectiveactionplans

toallentitiesresponsiblefortheirimplementation.

TheMonitoringTeamnotedsixcorrective actionplansintheCAPTrackingsheetandreferencedintheQA/QIminutes.Forexample:

2/2/12:theissuewas“errorsonpeer‐to‐peerinjurydatabase.”Theactionstobetakenweretrainingandcorrectionoftheerrors(twoseparateCAPS).TheIMCwasdesignatedasresponsibleandtheactionswerereportedascompletedonthetrackingsheet.However,nocopyoftheplanswasprovided.TheminutesoftheFebruaryQA/QICouncilrecordedtheneedfortheCAP,butwithnootherinformationorinstructions.

3/1/12:theissuewastheneedtousesomeplasticpartswiththeArjoSlings.Again,thereweretwoplans:oneforpurchasingbagstoholdthepartsandonefortraining.BothwereassignedtotheDirectorofHabilitationTherapiesandreportedascompleted.However,therewasnoCAPpresented.

Bothoftheseissuesneededtobeaddressed.However,theydidnotappeartohavearisenfromdataandtrendanalysis.WhiletheQA/QICouncilmightwanttotrackactionssuchasthosecitedabove,theymightnothaverequiredcross‐disciplinediscussionandplandevelopment.Themorechallengingissuesmightinclude:anindividualwhohasexperiencedahighlevelofrepeatedinjuries,neglectallegationsandinfirmaryadmissions,oraresidencethathasahighlevelofchroniccallerincidentstotheDFPSor911linesandahighlevelofrefusalstoparticipateindayprograms.Tomaketheminutesusefulastrackinganddisseminationtools,theyneedtorecordtheassignmentofaCAP,theprogressalongtheway,andexplainanydeviationsfromthescheduleordecisionstoabandontheplan.Theminutesneedtoincludealistofthosewhoshouldreceiveacopyoftheplanorverifythatadisseminationlistisincludedintheplan.AlthoughtheMonitoringTeamidentifiedanumberofcorrectiveactionplans,itwasnotclearhowtheCAPsweredisseminated.Asaresult,theFacilityremainsoutofcompliancewiththisprovision.ThiswasalsotheFacility’sself‐assessment.

Noncompliance

E4 Monitoranddocumentcorrectiveactionplanstoensurethattheyareimplementedfullyandinatimelymanner,tomeetthedesiredoutcomeofremedyingorreducingtheproblemsoriginallyidentified.

TheprocedureforDeveloping,ImplementingandTrackingCorrective ActionPlanswassetforthinaDraftFacilityProcedureE.10,revised5/15/12.Accordingtothedraft:

TheQADirectorwouldpresentdatafrommonthlymonitoringtosectionleadsonaquarterlybasis.Thedraftdidnotindicatewhetherthosequarterlydatapresentationsweretoincludeanalysisoronlydata.

AnylackofsufficientprogresstowardscompliancewithanumberofinternalorexternalauditscouldbereasonforaCAP.

CenterLeadsweretodevelopandpresentCAPstotheQA/QICouncilforapprovalandtheQADirectorwastotrackandmonitorprogressandreportprogresstotheQA/QICouncilquarterly.

Noncompliance



Sincethisdraftprocedurehadnotbeenfinalizedorinoperation,andthereweresofewCAPsavailableforreview,thissectionwillbereviewedduringfuturemonitoringvisits.

E5 Modifycorrectiveactionplans,asnecessary,toensuretheireffectiveness.

AswithSectionE.4oftheSettlementAgreement,thiswillbereviewedduringfuturemonitoringvisits.

Noncompliance


1. CCSSLCshouldreviseitsmonitoringtoolstomeettheneedsoftheFacility.AsisdetailedabovewithregardtoSectionE.1oftheSettlementAgreement,thisshouldinclude,butnotbelimitedto:revisionstoindicatorsasappropriate,theenhancementofinstructionsand/orguidelines,availabilityoftrainingandtechnicalassistancefromsubject‐matterexpertsonsubstantiveissues,ensuringinter‐raterreliabilityandaccuracyofmonitoring,ensuringthatqualitywasmeasuredasopposedtothemerepresenceorabsenceofitems,aswellasidentifyingtheprioritiesforthetools’implementationsoastonotoverwhelmthesystemwithdatathatcouldnotbeusedeffectively.Ifthetoolswillbescoredoverall,considerationshouldbegiventoweightingthefactorsthatgointoproducinganoverallscore.(SectionE.1)

2. TheFacilityshoulddevelopandimplementatrackingsystemthatallowsidentificationofissuesacrossthemanycomponentsofprotections,supports,andservicesprovidedtoindividualsresidingattheFacility.Thiswillrequirenotonlyreviewofmonitoringdata,butalsocollectionandanalysisofkeyindicatorsoroutcomemeasures.Throughoutthisreport,therearereferencesmadetodatathatshouldbeincorporatedintosuchasystem.Thisisnotanall‐inclusivelist,butismeanttoprovidetheFacilitywithideasaboutthetypesofindicatorsoroutcomemeasuresthatshouldbeincludedinsuchasystem.(SectionE.1)

3. TheFacility’sActionPlanshouldberevisedtoclarifyhowtheFacilityplanstodevelopasetofkeyindicators,whichdatasourceswillbeinvolved,andhowbaselinedatawillbedetermined,goalsoroutcomemeasuresset,andthedatacollectedandtracked.(SectionE.1)

4. TheFacilityshouldproduceandimplementadatamanagementplanthatassurestheintegrityofdatausedtoproducequalityassurancereports.(SectionE.1)

5. Asproblematictrendsand/orindividualissuesareidentified,theFacilityshoulddevelop,implement,andmonitorcorrectiveactionplans.(SectionsE.2,E.3,E.4,andE.5)

6. DecisionsregardingthePITandPETandtheirreplacementbyorrelationshipwithSectionLeadgroupsshouldbeformalized.(SectionE.2)7. TheFacilityshouldstronglyconsiderinitiatingAdministration‐levelreviews,involving,forexample,theFacilityDirector,AssistantDirectorof

Programs,clinicaldisciplineheads,etc.Thiswouldinvolvereviewofaselectgroupofindividualswhometsetcriteria,includinganumberofnegativeevents.Thegoalwouldbetoprovidetheindividuals’teamswiththebenefitofreviewandtheexpertiseofamoreobjectiveandexperiencedgroup.Thegroupwouldmakerecommendationstotheindividuals’teamstoaddressissuesidentified.Individualswouldneedtobefolloweduntilpositiveoutcomeswererealized.(SectionE.2)

8. AstheFacilitymovesforwardindevelopingitsself‐assessmentprocesses,theFacilityshouldincludeadditionaldata,includingtheresultsoftheanalysesofthedata,tosubstantiateitsfindingsofeithersubstantialcomplianceornoncompliance.Thisdatawouldpotentiallycomefromavarietyofsources,including,forexample,theresultsofmonitoringactivities,andoutcomedatabeingcollectedandanalyzedbyvariousdepartments.Suchdatashouldbequantitativeaswellasqualitativeinnature.ThisdatashouldbeacorecomponentofwhattheQualityAssurance/QualityImprovementCouncilreviews,andtheanalysisofthisdatashouldformthebasisfortheactionsthattheCouncilimplements,monitors,andrevises,asappropriate,toeffectuatepositivechangesinthelivesofindividualstheFacilitysupports.ThisprovisionofdataisimportantinallsectionsoftheFacilitySelf‐AssessmentincludingtheQualityAssuranceSection.(FacilitySelf‐Assessment).


SECTIONF:IntegratedProtections,Services,Treatments,andSupportsEachFacilityshallimplementanintegratedISPforeachindividualthatensuresthatindividualizedprotections,services,supports,andtreatmentsareprovided,consistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow:


o PresentationBookforSectionF;o CCSSLCSelf‐AssessmentforSectionF,updated6/25/12;o ActionPlanforSectionF,revised3/23/12;o CCSSLCProvisionActionInformationforSectionF,undated;o DraftIndividualSupportPlan(ISP)MeetingGuideandIntegratedRiskRatingForm(IRRF)

forIndividual#341;o InstructionsforISPmeetingGuide,undated;o CCSSLCIndividualSupportPlanMeeting/DocumentationmonitoringChecklist,dated

6/12;o Forlastthreemonths,trendingreportsforSectionF;o QConstruction:FacilitatingforSuccess–QualifiedMentalRetardationProfessional

(QMRP)FacilitationSkillsPerformanceTool,withinstructions,dated6/7/11;o AlistofQualifiedDevelopmentalDisabilityProfessionals(QDDPs)whohavebeendeemed

competentinmeetingfacilitation;o CCSSLCQDDPListingwithcurrentcaseloadtotals,undated;o SettlementAgreementCrossReferencedwithIntermediateCareFacilityforPersonswith

MentalRetardation(ICF/MR)StandardsSectionF:IntegratedProtections,Services,TreatmentsandSupports,revisedAugust2010;

o CorpusChristiStateSupportedLivingCenterPersonalSupportPlanMeeting/DocumentationMonitoringChecklist,dated9/1/10;

o CCSSLCIntegratedProtections,Services,TreatmentsandSupportspoliciesrevisedsincelastreview,including:

F.15‐IndividualSupportPlanning,implemented3/22/12;and F.21–SubmittingAssessments,implemented3/22/12;

o Last10monitoringtoolscompletedbytheQDDPCoordinator,variousdates;o Last10monitoringtoolscompletedbytheQualityAssuranceDepartmentStaff,various

dates;o Forthelastyear,totalnumberofISPscompleted,totalnotheldwithin365daysof

previousmeeting,andnumbernotfiledwithin30daysofmeeting;o Forthelastthreemonths,theISPTrackingSheet;o FortrainingprovidedforSectionF,numberofstaffrequiringtrainingandnumberofstaff

whohavebeentrained;o ListofindividualswithmostrecentISPdate,previousdate,anddateofimplementation,

dated6/5/12;o Inresponsetorequestfor:“Basedonmonitoring/auditdata,orotherreviewsordatathat

theFacilityhascollectedinrelationtointegratedprotections,services,treatment,andsupports,reportsshowinganalysisofsuchdata,aswellasdescriptionsofactionstakenor


correctiveactionplansdeveloped,”theresponse:“NoEvidence;”o ISPsforIndividual#244,Individual#172,Individual#88,andIndividual#118;o IndividualSupportPlans,Sign‐inSheets,Assessments,IndividualSupportPlanAddenda,

(ISPAs),PersonalFocusAssessments(PFAs)/PreferencesandStrengthsInventory(PSI),RightsAssessments,CommunityLivingOptionsInformationProcess(CLOIP)worksheetormostrecentPermanencyPlan,skillacquisitionandteachingprograms,thelastthreemonthly,andthelasttwoquarterlyreviews,individual’sdailyschedule,SpecialConsiderationslist,andthirdquarterlymeetingdocumentationforthefollowing:Individual#290,Individual#363,Individual#184,Individual#268,Individual#282,Individual#336,Individual#26,Individual#250,Individual#124,Individual#155,Individual#174,Individual#226,Individual#160,Individual#287,andIndividual#7;and

o ISP,assessments,sign‐insheet,IntegratedRiskRatingForm(IRRF),PSI,andIntegratedHealthCarePlansforthefollowing:Individual#228andIndividual#63.

Interviewswith:o RachelMartinez,QDDPCoordinator;o KimberlyBenedict,DirectorofActiveTreatment;o IvaBenson,StateConsultant;ando SallySchultz,StateConsultant.

Observationsof:o ISPmeetingforIndividual#341.

FacilitySelf‐Assessment:BasedonareviewoftheFacility’sSelf‐AssessmentwithregardtoSectionFoftheSettlementAgreement,theFacilityfoundthatitwasoutofcompliancewithallofthesubsections.ThiswasconsistentwiththeMonitoringTeam’sfindings.SincetheMonitoringTeam’spreviousreview,theFacilityhadmadenotableimprovementinthejustificationitofferedforitsfindings.InitsSelf‐Assessment,theFacilityidentified:1)activitiesengagedintoconducttheself‐assessment;2)theresultsoftheself‐assessment;and3)aself‐ratingusingtheinformationcitedinthesectiononresults.AlthoughanumberofconcernscontinuedtoexistwiththeFacility’sselfassessmentprocess,overtime,thisformatshouldbehelpfulinsubstantiatingtheFacility’sfindingswithregardtocompliance.Thefollowingconcernswerenoted:

TheFacility’sSelf‐Assessmentdidnotconsistentlydefinehowthesampleswereselected,orwhocollectedthedatausedinthereport(i.e.,theQADepartment,theQDDPDepartment,oracombinationofthetwo).Some,butnotallsectionsidentifiedthesampleselectionprocessandthestaffthatcompletedthereview.

Forthevariousmonitoring/audittools,inter‐raterreliabilityneededtobeestablishedwiththeQAandprogrammaticstaff(e.g.,QDDPCoordinator)responsibleforconductingaudits.

Asdiscussedduringthelastreview,theneedstillexistedtoaddorrevisetheguidelines/instructionsfortheaudittools.Thiswillbeessentialtoimprovetheaccuracyofthemonitoringresults(validity),aswellasthecongruencebetweenvariousauditors(reliability).Basedoninterview,theQDDPCoordinatorandassignedProgramMonitorhadbeguntoworkon


developinginstructions. TheSelf‐Assessmentdidnotconsistentlyshowanevaluationofquality,asopposedtothemere

presenceorabsenceofanitem.Forexample,withregardtoSectionF.1.a,someoftheindicatorsassessedwhetherornotpreferenceswerediscussedattheISPmeeting,oractionplansweredeveloped.Itwasunclearwhetherornotthequalityandcomprehensivenessofsuchactivitieswereevaluated,orsimplywhetheranyrelateddiscussionhadoccurred.Similarly,forSectionF.1.e,itwasunclearwhattheindicatorsmeasuredinrelationtodiscussionaboutcommunityoptions,discussionaboutovercomingobstacles,andassessmentinformationrelatedtolivinginthemostintegratedsetting.Morespecifically,itwasnotclearifthequalityofthesediscussionsandassessmentswereevaluatedorjusttheiroccurrence/existence.Thesearejustafewexamplesofwherethisdistinctionwasnotclear.

Insomeinstances,itwouldhavebeenhelpfultobreakthedataoutmoreinordertoensurethatifproblemswerenoted,thespecificissuescouldbeidentified.Forexample,forSectionF.2.a.3,anumberofissueswereevaluatedtogether(i.e.,methodsforimplementation,timeframesforcompletion,andstaffresponsible).TheFacilitycalculateda100%compliancerate.However,asnotedintheMonitoringTeam’sassessment,problemscontinuedtoexistparticularlywithregardtotheadequacyofmethodologies,andtoacertainextenttimeframesandidentificationofstaffresponsible.Ifthesewerebrokenout,andthestandardsforacceptablepracticeestablishedagainstwhichtomonitor(i.e.,ininstructions),accurateassessmentofthissubsectionwouldbemoreattainable.ThiswouldbesimilarforSectionsF.2.a.5,F.2.a.6,andF.2.f.

ForSectionF.2.c,theFacilityhadonlylookedataccessibilityofISPstostaffresponsiblefortheirimplementation,notcomprehensibility.Similarly,thereviewforSectionF.2.d,relatedtomonthlyassessments,onlyassessedsomeportionsoftherequirement.

Thedatapresentedclearlyidentifiedareasofneed.However,theFacilitySelf‐Assessmentdidnotyetprovideanyanalysisoftheinformation,identifying,forexample,potentialcausesfortheissues,orconnectingthefindingstoportionsoftheFacility’sActionPlanstoillustratewhatactionstheFacilityhadputinplacetoaddressthenegativefindings.

Sincethelastreview,theFacilitymadesomespecificimprovementstoitsSelf‐AssessmentinresponsetorecommendationsfromtheMonitoringTeam.Theseeffortswereappreciated.Specifically:

Initsreport,theMonitoringTeamnotedthatnotallrequirementsoftheSettlementAgreementhadbeenreviewed.Morespecifically,withinasub‐section,theSettlementAgreementmighthavenumerousrequirements,butonlysomewereincludedintheFacility’sSelf‐Assessment(e.g.,SectionF.2.a.1,orF.2.e).TheFacilityhadtakenstepstocorrectthisissue.Asnotedabove,insomesub‐sectionsthiscontinuedtobeaproblem,butinothersithadbeencorrected.

Similarly,theMonitoringTeamrecommendedthattheFacilitycitetherateofcompliance(versusnoncompliance).TheFacilityhadmadethischangeaswell,whichmadeinterpretationoftheresultseasier.

Overall,initsSelf‐Assessment,theFacilityhaddemonstratedsomegooduseofthedataithadcollectedtomakecompliancedeterminations.However,basedondocumentssubmittedandinterviews,theFacilitywasnotyetusingthisdatatodeterminewhereitsbestpracticeswereand/orwhenproblemswere


identified,conductingfurtheranalysistotargetitscorrectiveactionplans.Effortstoensurethevalidityandreliabilityofthedatawillbeimportantnextsteps,aswillusingthedatatoidentifyareasinwhichfocusedattentionisneeded.TheFacility’sprogressindevelopingaqualityassuranceprocessforSectionFisdiscussedinfurtherdetailbelowwithregardtoSectionF.2.g.SummaryofMonitor’sAssessment: InMay2012,theStateOfficeprovidedadditionaltrainingonarevisedISPformatandprocesstoCCSSLC’sQDDPsandotherteammembers.ArevisedISPMeetingGuide(Preparation/Facilitation/DocumentationTool)wasintroducedtoassisttheQDDPsinpreparingforthemeetingsandinorganizingthemeetingstoensureteamscoveredrelevanttopics.Inaddition,accordingtothenewprocedures,morepre‐planningwastobegin90dayspriortotheISPmeeting.Inadditiontotheteamusinganewtooltoidentifytheindividual’spreferences,strengths,andpriorities,attheISPPreparationMeeting,theteamalsowastoreviewthepreviousISPtodeterminethestatusofactionplans.Ifplanshadnotbeencompletedand/orsuccessful,thentheteamwastodecidewhatactiontotake.Theteamalsowastomakedecisionsregardingtheteammembersthatshouldattendtheannualmeeting,andassessmentsthatneededtobecompletedpriortothemeeting.AtthetimeoftheMonitoringTeam’sreview,twoteamshadbeenselectedtopilotthenewprocess,includingthenewat‐riskprocess.TwoISPshadbeenfullycompletedusingthenewprocess.Althoughthenewprocessshowedsomeimprovements,aswouldbeanticipatedwithanewprocess,moreworkwasneededtocontinuetomakenecessarychangesandrefinetheteammeetingsaswellastheISPdocuments.Ashasbeendiscussedinpreviousreports,comprehensive,thorough,andadequateassessmentsarethecornerstoneofISPsthatadequatelyaddressindividuals’strengths,preferences,andneeds.AtCCSSLC,teamscontinuedtobeatadisadvantage,becausetheydidnotyethaveadequateassessmentsfromwhichtodevelopindividuals’ISPs.Inadditiontoproblemswiththequalityoftheassessments,teamswerenotconsistentlyidentifyingtheneedforand/orreceivingallofthenecessaryassessments.Althoughsomeimprovementwasbeingrealized,anumberofassessmentscontinuedtobesubmittedlate,makingitmorechallengingforQDDPsandotherstocompletepreparationactivitiespriortotheannualmeetings.TheFacilityandStateOfficeweretakingsomeactionstoaddresstheseconcerns.Specifically,usingadatabaseinwhichinformationrelatedtothetimelinessofassessmentswastracked,CCSSLChadbegunreviewingthisinformationaspartofitsQA/QICouncilactivities,anddiscussingpotentialbarriersandsolutions.Inadditiontoworkingonnewformatsforassessments,theStateOfficewasdevelopingasetofqualityindicators,anditwasanticipatedCCSSLC’sdisciplineheadswouldusethesetoevaluatethequalityoftheassessments.Withregardtoindividuals’ISPs,althoughteamswereidentifyingsomepreferencesandstrengthsofindividuals,theseremainedlimited.Inaddition,teamswerenotyeteffectivelyincorporatingindividuals’preferencesandstrengthsintoactionplans,orusingthemcreativelytoexpandindividuals’opportunitiesoraddresstheirneeds.Prioritizationofindividuals’needswasnotevidentintheISPsreviewed.Asisdiscussedinthesubsectionsbelow,individuals’needswerenotcomprehensivelyaddressedinactionplans.Moreindividualshadactionplansthataddressedcommunityskillacquisitionplans,butthesevariedinquality.


Someprogresshadbeenmadeintheexpansionofthescopeofmeasurableobjectives,andeffortsclearlywerebeingmadetoimprovethemeasurabilityandindividualizationofobjectivesandactionsteps.However,astheFacilityrecognized,theseremainedareasinwhichsignificantworkwasneeded.GiventhelimitedimplementationofthenewISPprocess,itremainedtobeseeniftherevisedISPMeetingGuideandprocesswouldresultwouldresultinISPsthatmorecomprehensivelyaddressedtheindividual’sarrayofneeds.Basedonthereviewofthetwoplansthatusedtherevisedprocess,someprogresswasseenwithregardtotheintegrationofamorecomprehensivesetof“protections,servicesandsupports,treatmentplans,clinicalcareplans,andotherinterventions.”However,manysupportswerestillmissingorwereinadequatelydefined.Teamswillneedcontinuedtrainingandcoachingtoimplementtherevisedprocessfully.TheFacilitycontinuedtodevelopitsqualityassurancesystemrelatedtotheISPprocess.TheQADepartmentcontinuedtomonitorISPmeetings,aswellasISPdocumentsandimplementation.TheQDDPCoordinatoralsoconductedmonitoring.Thesystemneededcontinuedrefinement,includingmodificationofreviewtoolsandtherelatedinstructions,trainingofauditorsontheiruse,establishmentofinter‐raterreliabilityaswellastheaccuracyofmonitoringresults,developmentandpresentationofreportsofthedatacollectedthatwouldberelevanttothevariousaudiences(i.e.,theQDDPCoordinator,andtheQA/QICouncil),analysisofdata,anddevelopmentandimplementationofcorrectiveactionplans,asappropriate.

# Provision AssessmentofStatus ComplianceF1 InterdisciplinaryTeams‐

CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,theIDTforeachindividualshall:

DADSwasintheprocessofrevisingPolicy#004.1:IndividualSupportPlanProcess,andhadprovidedtheMonitoringTeamswithadraftcopy,dated5/10/12.ThethreeMonitoringTeamswereintheprocessofreviewingthepolicy,andanycommentswillbeprovidedjointly.TheMonitoringTeam’spreviousreportshadidentifiedtheneedforCCSSLCtotailoritspoliciestonotonlymeettherequirementsoftheStatepolicy,butalsotodescribeinfurtherdetailsomeoftheproceduresorexpectationsthatwerespecifictotheFacility.Duringthemostrecentreview,Facilitystaffrequestedfurtherclarificationaboutthisrecommendation.TheMonitoringTeamprovidedsomeexamples,includingmemorializinginpolicyorprocedurestheprocesstheFacilityhadinplacefordeterminingthecompetencyofQDDPswithregardtomeetingfacilitation.Similarly,theFacilityhaddevelopedsomespecifictoolsandproceduresforconductingqualityassurancechecksofISPmeetingsanddocuments.WhereastheStatepolicydiscussedingeneraltermstheneedforcompetency‐basedtrainingofstaffaswellasqualityassuranceproceduresforISPs,itwouldbeimportantforCCSSLCtospelloutitsexpectationsfortheseprocessesingreaterdetailinitslocalpoliciesandprocedures.AlthoughtheFacilityhadbeguntodothisinsomeofitsSectionFpolicies,furtherdetail


# Provision AssessmentofStatus Compliancewasneededinsomeareas,andoncetheStateOfficepolicyisfinalized,reviewandrevisionoftheFacilitypoliciesmightbenecessary.InordertoreviewthissectionoftheSettlementAgreement,asampleofISPswasrequested,alongwithsign‐insheets,assessments,ISPAs,PFAs/PSIs,RightsAssessments,IntegratedRiskRatingForms(IRRFs),integratedhealthcareplans,CLOIPworksheetormostrecentPermanencyPlan,skillacquisitionandteachingprograms,thelastthreemonthly,andthelasttwoquarterlyreviews,individual’sdailyschedule,SpecialConsiderationslist,andthirdquarterlymeetingdocumentationasavailable.AsamplewasrequestedofthemostrecentlydevelopedISPs,aswellassomeadditionalplansthathadbeendevelopedsincethelastreview.Thisincludedplansforindividualswholivedinavarietyofresidencesoncampus.Therefore,avarietyofQDDPsandinterdisciplinaryteams(IDTs)hadbeenresponsibleforthedevelopmentoftheplans.Thissampleincludedplansfor:Individual#290,Individual#363,Individual#184,Individual#268,Individual#282,Individual#336,Individual#26,Individual#250,Individual#228,Individual#63,Individual#124,Individual#155,Individual#174,Individual#226,Individual#160,Individual#287,andIndividual#7.

F1a Befacilitatedbyonepersonfromtheteamwhoshallensurethatmembersoftheteamparticipateinassessingeachindividual,andindeveloping,monitoring,andrevisingtreatments,services,andsupports.

Progresshadbeenmadeand/orsustainedwithregardtothefacilitationofISPsbyonepersonfromtheteamwhoensuresthatmembersoftheteamparticipateinassessingeachindividual,andindeveloping,monitoring,andrevisingtreatments,services,andsupports.Positivedevelopmentsincluded:

DADSDraftPolicy#004.1inboththedefinitionsectionandinSectionII.F.1.bindicatedthattheQDDPwouldassisttheindividualandLAR,asappropriate,inleadingtheteaminaninterdisciplinarydiscussion.TheFacility’sPolicyF.15:PersonalSupportPlanning,implemented3/22/12,furtherdefinedtheroleoftheQDDP,includingactivitiesbefore,during,andaftertheISPmeeting.Sincethelastreview,thispolicyhadbeenmodified.TheserevisionsdefinedtheQDDP’sroleinnotifyingteammembersrequiredtoattendthemeetingofthedateandtime,ensuringthatnecessaryassessmentsweresubmitted,andifassessmentsweremissing,takingactiontoobtainthem.

TheQDDPCoordinatorconfirmedthatQDDPsfacilitatedtheteams,includingteammeetings.ObservationsofteammeetingsandreviewsofISPsalsoillustratedthattheQDDPwastheteamleaderandresponsibleforensuringteamparticipation.InthemeetingforIndividual#341,theindividualplayedaroleinraisingtopicsandensuringcertainitemswerediscussed.HisQDDPassistedhiminensuringtheteamaddressedhisconcernsandtopics.

Withregardtostaffing,inadditiontotheQDDPCoordinatorandtwoLeadQDDPs,sincethelastreview,aQDDPEducatorhadbeenhired.ThecurrentQDDPEducatorrecentlyhadacceptedanotherjobattheFacility,buta

Noncompliance


# Provision AssessmentofStatus Compliancereplacementhadbeenhired,andthatpersonwasexpectedtostartintheQDDPEducatorrolesoon.Atotalof14QDDPpositionsresultedinaQDDPsbeingassignedanaveragecaseloadof19individuals,witharangeof11to22.Atthetimeofthereview,twooftheQDDPsalsohadacceptedotherjobs,includingoneQDDPthatwouldfilltheQDDPEducatorposition.Applicationsalreadyhadbeensubmittedandscreened,andinterviewswerebeingscheduledforthetwovacantQDDPpositions.

InMay2012,theStateOfficeprovidedadditionaltrainingonarevisedISPformatandprocesstoQDDPsandotherteammembers.ArevisedISPMeetingGuide(Preparation/Facilitation/DocumentationTool)wasintroducedtoassisttheQDDPinpreparingforthemeetingandinorganizingthemeetingstoensureteamscoveredrelevanttopics.Usingassessmentandotherinformation,theQDDPusedthistemplatetodraftportionsoftheISPpriortothemeeting.Copiesofthedraftwerethenprovidedtoteammembersatthebeginningofthemeeting,andchangesweremadeasappropriate.Inaddition,morepre‐planningbegan90dayspriortotheISPmeeting.Forexample,priortothe90‐dayISPPreparationmeeting,QDDPswereexpectedtoworkwithteammemberswhoknewtheindividualbesttocompleteanewPreferencesandSkillsInventory.Theintentionofthisdocumentwastoidentifytheindividual’spreferencesandskills,aswellasprioritiessoallteammembersresponsibleforcompletingassessmentscouldutilizethisinformationintheassessmentprocess,aswellasindevelopingtheISP.Thisdocumentwouldbecomealivingdocumentthatwouldbeupdatedandrevisedovertime.AttheISPPreparationMeeting,theteamalsowastoreviewthepreviousISPtodeterminethestatusofactionplans.Ifplanshadnotbeencompletedand/orsuccessful,thentheteamwastodecidewhatactiontotake.

Atthetimeofthereview,twoteamshadbeenselectedtopilotthenewprocess,includingthenewat‐riskprocess.TwoISPshadbeenfullycompletedusingthenewprocess.TheseISPswerereviewedaspartoftheMonitoringTeam’ssample.TheyincludedtheISPsforIndividual#228andIndividual#63.Asisdiscussedinmoredetailinthesectionsthatfollow,thenewprocessshowedsomeimprovements,butaswouldbeanticipatedwithanewprocess,moreworkwasneededtocontinuetomakenecessarychangesandrefinetheprocesses.

TheQDDPCoordinatorhadcontinuedtousetheQConstruction:FacilitatingforSuccess‐QDDPFacilitationSkillsPerformanceTooltoassessQDDPs’competenceinthemeetingfacilitationprocess.Atthetimeofthereview,onlytheoutgoingQDDPEducatorhadbeendeemedcompetent.However,theprocessbeingusedappearedtobehelpfulinidentifyingareasinwhichQDDPscontinuedtorequireguidance,coaching,ormentoring.Inaddition,theFacilitywashavingtwostaff,includingtheQDDPCoordinatorandaLeadQDDP


# Provision AssessmentofStatus Compliancecompletethetools,andwhenresultsfrombothshowedtheQDDPwascompetent,thentheQDDPwasconsideredcompetent.ThisprocedurehelpedtoverifythattheQDDPwasabletodemonstratecompetenceacrossmeetingsandreviewers.

Duringtheweekofthereview,theMonitoringTeamobservedtwoteammeetings.Progresshadcontinuedtooccurwithregardtothefacilitationofmeetings.BasedontheselimitedobservationsandreviewofISPs,someoftheareasinwhichprogresshadcontinuedorbegunincluded:

o AtannualISPmeetings,anagendawasclearlysetforth,alongwithgroundrules.

o PaperhungonthewallsorwhiteboardswereusedtotrackkeycomponentsoftheISPprocess,suchastheagenda,theindividuals’preferences,andactionplansthatneededtobedeveloped.Inaddition,anote‐takerwaspresenttoallowtheQDDPtorunthemeetingwithoutneedingtomaintaindetailednotes.

o TheQDDPsmadeeffortstoelicitinformationfromallteammembers.Teammembers’participationvaried.Someteammembersparticipatedfully,andofferedideasonavarietyoftopics,eventhoseoutsideoftheirspecificareasofexpertise.IntheISPmeetingforIndividual#341,itwaspositivetoseethatanumberofteammembersparticipatedinmanyaspectsofthediscussion,andrespectfullyquestionedtheneedtoaddorrevisetreatmentstrategies.However,notallteammembersparticipatedtotheextenttheyshouldhave.Evenattimeswhenclinicalexpertisewouldhavebeenhelpfultoinformtheteam’sdecision‐making,someteammembersdidnotparticipate,andtheQDDPand/orotherteammembersdidnotseektheiropinions.

o Basedonobservationsonsite,aswellasreviewofISPdocuments,QDDPsandteamswereusingmoredatatomakedecisionsinrelationtoindividuals’riskareas.Anumberofgapscontinuedtoexist,forexamplewithregardtoteams’discussionsaboutdatarelatedtoskillacquisitionprograms,PBSPs,andmeasurableobjectivesrelatedtoriskplans.However,theteamswerediscussingmoreobjectiveclinicaldatainanumberofareas.

o BasedontheobservationsofthetwoISPmeetings,althoughproblemsstillexistedwiththedetailincludedinactionplans,teamswereobserveddiscussingactionplansinmoredetail,particularlysomeofthestrategiesthatwereinplaceorwouldbeputinplacetoaddressrisks.Again,althoughmoreworkwasneeded,thisworkwasbeginningtobeseeninthewrittendocumentsaswell.

Areasinwhichimprovementsshouldbemadeinordertoachievecompliance,included:


# Provision AssessmentofStatus Compliance Asnotedabove,theQConstruction:FacilitatingforSuccesstrainingincludeda

competency‐basedcomponent.Atthetimeofthereview,onlytheQDDPEducatorhadbeendeemedcompetent.Noneofthe14QDDPshadyetreachedthislevelofcompetency.ReviewofafewofthecompletedtoolsshowedthatsomeimportantaspectsofthefacilitationprocesshadbeenidentifiedasareasinwhichQDDPsneededtowork.

BasedonreviewofISPsaswellasduringobservationsofmeetingsheldtheweekoftheonsitereview,facilitationofteammeetingswascontinuingtoimprove,butfornoneoftheplansreviewed(0%)ormeetingsobservedwasitresultingintheadequateassessmentofindividuals,andthedevelopment,monitoring,andrevisionofadequatetreatments,supports,andservices.ThisisakeyrequirementtoachievecompliancewiththiscomponentoftheSettlementAgreement.Missedopportunitiescontinuedtobenotedwithregardto:

o Theteam,includingtheQDDP,didnotconsistentlyidentifyissuesrequiringconcertedeffortsontheteam’sparttoresolve.Forexample,atoneoftheISPstheMonitoringTeamobservedaswellasinoneofthewrittenplansreviewed,individualshadbodymassindexesof40orabove,placingtheminthemorbidlyobeserange,buttheirteamsdidnotdevelopactionplanswiththelevelofclinicalintensitythatwouldbeexpectedtoaddressahealthriskofthismagnitude.Forexample,neitherteamsetmeasurableobjectivesforweightlosstodetermineifthestrategiesputinplacewereworking.Thestrategiesidentifiedincludedexerciseanddietrelatedactivities,butwithoutaprocesstomeasureifthesewerehavingthedesiredeffect(e.g.,weightlossofsomanypoundspermonth),andchangingthemiftheydidnot,theteamhadnotdevelopedanadequateactionplan.Inaddition,neithertheteammeetingnortheISPfortheseindividualsshowedadequateintegrationofservicestodeterminethepotentialcauseandorsolutionstotheindividuals’weightissues(e.g.,psychiatry,medical,nursing,psychology,dietary,residential,andvocational).

o Asisdiscussedinfurtherdetailbelow,otherareasinwhichQDDPswillneedtoobtainfullteamparticipationandfacilitatemeaningfuldiscussionincluded,butwasnotlimitedto:

Expandingthelistofindividualpreferencestoincludepreferencesrelatedtowork,relationships,pastexperiences,etc.andusingthepreferencestooffertheindividualnewexperiences.

Similarly,identifyingacomprehensivelistoftheindividual’sstrengths,andusingthemtobuildupontheindividual’scurrentindependence,relationships,vocationalexperiences,etc.

Makingsuredecisionstheteammakesaredata‐basedtothe


# Provision AssessmentofStatus Complianceextentpossible.

Developingmeasurableobjectives.AstheQDDPCoordinatorindicatedduringinterview,teamscontinuedtostruggletodefinemeasurable,functionalobjectivesduringteammeetings,and,asaresult,theyoftenwerenotincludedinISPs.Thisfactoredintotheoverallprocessofdevelopingadequateactionplans,includingappropriatemethodologies.

Articulatingmeaningfuloutcomesforindividuals.Oftentheoutcomewasexpressedasaprocess(e.g.,Individual#63willattendcookingclass),ratherthanasachangeintheindividual’slife(e.g.,Individual#63willcookamaindishorplanamenuforahighfiber,lowfatmeal).

o Althoughthelengthofthemeetingswassomewhatdecreased,themajorityofthetimeattheISPmeetingstheMonitoringTeamobservedwasspentontheriskratingprocess.Althoughthiswasanessentialactivityinwhichteamsneededtoengage,itresultedinlittletimebeingspent,forexample,ontheteamdefiningthemeasurableoutcomestodeterminetheefficacyoftheinterventionstheteamdiscussedtoaddresstherisks,orotherimportanttopics,suchastheindividual’svocationalambitionsandplanstoachievethem,his/herplanstoincreaseskillsleadingtogreaterindependence,waysinwhichgreaterintegrationintothecommunitycouldoccur,etc.Inadditiontoestablishingestimatedtimeboundariesforeachtopicattheoutset,additionalpreparationbytheQDDPsaswellasotherteammembersbeforethemeetingsalsowasanareaforimprovement.Forexample,ifallteammembershadfamiliarizedthemselveswiththeinformationincludedinthedraftIRRF,theteamwouldnothavehadtoreviewitallindetail,butrathercouldhavediscussedanyquestionsandthenmadedecisions.

Asduringpastreviews,duringtheMonitoringTeam’sdiscussionswiththeQDDPCoordinator,shecorrectlyidentifiedareasinwhichadditionalworkwasneeded.Someofthesealreadyarementioned,andothersarementionedinthesectionsthatfollow.ItwasimportantthattheFacilitystaffhadthisinsight,andwereworkingwithStateOfficestaffonsomespecificareasinwhichtheyknewimprovementswereneeded,Progresshadbeenmade,buttheFacilityremainedoutofcompliancewiththisprovision.AdditionaltrainingandtoolshadbeenprovidedtoQDDPstoassisttheminfacilitatingmeetings.Basedonthepilotteams,althoughmuchworkwasneeded,QDDPswereworkingwithteamstoapplysomeofthenewprocesses.Thesewerebeginningtoresultinmoredata‐basedandmeaningfuldiscussionsoccurringaboutindividuals’risksand


# Provision AssessmentofStatus Compliancesomeofthestrategiesnecessarytoovercomethem.Moreoftheindividuals’strengthsandpreferenceswerebeingbroughttothetable.InordertomeettherequirementsoftheSettlementAgreement,QDDPswillneedtoplayakeyroleinfacilitatinganumberofadditionaldiscussionstoensurethatadequateactionplansarebeingdeveloped,includingindividualizedandmeasurablegoals;individuals’preferencesandstrengthsareevidentthroughouttheplan;andintegrationoccurstoensurethatindividuals’needsareadequatelyaddressed.

F1b Consistoftheindividual,theLAR,theQualifiedMentalRetardationProfessional,otherprofessionalsdictatedbytheindividual’sstrengths,preferences,andneeds,andstaffwhoregularlyanddirectlyprovideservicesandsupportstotheindividual.OtherpersonswhoparticipateinIDTmeetingsshallbedictatedbytheindividual’spreferencesandneeds.

DADSDraftPolicy#004.1describedtheinterdisciplinaryteam(IDT)asincludingtheindividual,theLegallyAuthorizedRepresentative(LAR),ifany,theQDDP,directsupportprofessionals,andpersonsidentifiedasprovidingservicesandsupportstotheindividual,asappropriate,includingprofessionalsdictatedbytheindividual’spreferences,strengths,andneedsandwhoareprofessionallyqualifiedand/orcertifiedorlicensedwithspecialtrainingandexperienceinthediagnosis,managementandtreatmentofindividualswithintellectualdisabilities.Sincethelastreview,theFacilityhadaddedprocedurestoitsPolicyF.15onIndividualSupportPlanningrequiringQDDPstosendanISPMeetingAttendanceMemo30dayspriortothescheduledISPmeetingtonotifytheteammembersthattheywererequiredtoattendtheISPmeeting.Attendancerequirementsweredeterminedatthemeeting90dayspriortotheannualmeeting.EvenwiththerecentrevisionstotheStatepolicy,theQDDPCoordinatorindicatedthatthisprocessseemedtobebeneficialinensuringthatteammembersattendedISPmeetings,sothese30‐dayremindersmightcontinuetobesent.Asnotedinthepreviousreport,adatabasehadbeensetuptotrackattendanceatISPmeetings,andwasbeingpopulatedwithinformationrelatedtoteammembers’attendanceatmeetings.WiththenewprocessforISPs,attheISPPreparationMeeting90dayspriortotheISP,theteamwastomakeadeterminationregardingwhetherateammember’sattendancewasrequiredornot.Movingforward,thisinformationwouldbeincludedinthedatabase.However,thedocumentationreviewedforthetwoindividualsforwhomthenewprocesshadbeenuseddidnotprovideexplanationsfortheexclusionofteammembersthatappearedshouldhaveattendedbasedontheindividuals’needs(i.e.,BasedontheIndividual#63’sneeds,thefollowingteammembersweremissing:psychiatrist,dietician,andpharmacy.HisPSIdidnotidentifytheseteammembersasneedingtobepresent.However,nojustificationwasprovided.Forexample,hewasprescribedsixpsychotropicmedications,soitwasunclearwhypsychiatryandpharmacywouldnotbepresent.HisBMIwas43,sodietarynotbeingpresentalsowasnoteasilyexplainable.ForIndividual#228,thePSIdidnotidentifyamemberofthedentalstaffasneedingtobepresent,butshehadafairoralhygienerating,andrequiredsedationfordentalappointments.Shealsowasresistivetostaff

Noncompliance


# Provision AssessmentofStatus Complianceassistingherwithroutinedentalcare.). ThechecklistincludedattheendofthePSIdidnotincludearationalefortheteams’decisions,sothejustificationfortheirdecisionscouldnotbedetermined.Itwouldbehelpfuliftheteamprovidedanexplanationofitsdecisions,particularlywhenanindividualhasaneedinaspecificarea,andtheteamdecidesthattheattendanceoftheteammemberwiththatareaofexpertiseisnotrequired.GiventhattheSettlementAgreementrequiresthat:“OtherpersonswhoparticipateinIDTmeetingsshallbedictatedbytheindividual’spreferencesandneeds”astheMonitoringTeamreviewsindividuals’ISPs,aswellastherelatedassessments,ifneedsareidentifiedforwhichthepresenceofateammemberwaswarranted,buttherequisiteteammemberwasnotinattendanceandnojustificationwasprovided,thentheconclusionisdrawnthatadulyconstitutedteamwasnotpresent.Basedonthesampleof17ISPstheMonitoringTeamreviewed,fornone(0%)diditappearthatadulyconstitutedteamparticipatedintheannualmeetings.Often,theindividualpresentedissuesrequiringtheattendanceofspecificteammembers,buttheseteammemberswerenotinattendance.TheFacilityremainedoutofcompliancewiththisprovision.

F1c Conductcomprehensiveassessments,routinelyandinresponsetosignificantchangesintheindividual’slife,ofsufficientqualitytoreliablyidentifytheindividual’sstrengths,preferencesandneeds.

Sincethelastreview,theFacilityhadimproveditstrackingofthetimelinessofassessments.AdatabasewasbeingpopulatedwiththedateoftheISP,thedatetheassessmentsweredue(i.e.,10dayspriortotheISPmeeting),andforeachassessment,thedateitwascompleted.Basedoninterviewswithstaff,thisdatawasbeingreviewedeachThursdayattheQA/QICouncilmeeting.Thiswasaforuminwhichthemanagementteamdiscussedchallengeswithaswellaspotentialsolutionsforissuesrelatedtothetimelinessofassessments.BasedonareviewoftheISPTrackingSheetforISPsscheduledtooccurbetween4/26/12and7/25/12,certaintrendswereevident.Assessmentsthatfrequentlyweremissingincludedmedicalandnutritionalassessments.Improvementwasnotedoverthethreemonthswiththesubmissionofotherassessments,suchaspsychologicalassessments,OT/PTassessments,andFunctionalSkillsAssessments.Howeveraccordingtothisdata,manyassessmentsweresubmittedlate.ThiswasconsistentwiththefindingsbasedontheMonitoringTeam’sreviewsofasampleofISPs.TheFacilityaswellasStateOfficerecognizedthatthequalityofassessmentswasstillhavinganegativeimpactonthequalityofteamdiscussionsandtheresultingISPs.CCSSLChadaddedacolumninitsdatabaseforthequalityofISPs.Disciplinecoordinatorswouldbetheonesresponsibleforreviewingthequalityoftheassessments.

Noncompliance


# Provision AssessmentofStatus ComplianceStaffreportedthattheStateOfficewasdevelopingalistofqualityindicatorsforeachofthediscipline‐specificassessments.Basedonareviewof17ISPfiles:

Foroneindividual(6%),itappearedthatallthevarioustypesofassessmentsnecessarytoaddresstheindividuals’strengths,needs,andpreferenceshadbeencompleted(i.e.,Individual#228).PartofthenewISPPreparationMeetingprocess,whichwassimilartothepreviousPersonalFocusAssessment(PFA)process,wasfortheteamtodefinetheassessmentsneededfortheISP.Unfortunately,manyPFAsdidnotidentifywhichassessmentsshouldhavebeencompleted,andeventhosethatdid,didnotprovideadequatejustificationfortheinclusionorexclusionofspecificassessments.Oftenthenarrativesectionsofindividuals’ISPsidentifiedissuesofconcernsforwhichassessmentswerenotfound,andtheteamhadnotprovidedajustificationforexcludingtheseassessments.SpecificallyinreviewingthePSIsandISPPreparationMeetinginformationfortheindividualsforwhomthenewprocesshadbeenused,Individual#228’steamhadidentifiedalloftherelevantassessments,andalthoughsomeweresubmittedlate,allwereavailableatthetimeofthereview.However,forIndividual#63,despitehisbeingonsixpsychotropicmedications,apsychiatricevaluationhadnotbeencompleted.AspartofhisISPPreparationmeeting,histeamdidnotrequirepsychiatricorpharmacyassessments,oraStructuredFunctionalBehaviorAssessment(SFBA)despitewhatappearedtobeasignificantneedforallthree.Histeamhadnotprovidedajustificationforitsdecisionsnottorequiretheseassessments.

TheFacilityshouldconsiderdefininginpolicyakeysetofassessmentsthatshouldbeconductedregularly,andtheexpectedtimeframesforreevaluation.Teamsshouldberequiredtoprovideajustificationforveeringfromthisschedule.Optionalassessmentsalsoshouldbedefinedwithcriteria/guidelinestoassistteamsindeterminingifsuchassessmentswouldbebeneficialtotheindividual.TheISPPreparationMeetingdocumentationshouldincludespaceforajustification,whichteamsshouldcomplete,particularlywhentheyarenotrequiringcompletionofanassessmentforwhichtheindividualhasspecificneeds.

Fornoneoftheindividuals(0%),thequalityoftheassessmentswasadequate,includingclearidentificationoftheindividuals’strengths,needs,andpreferences.AccordingtotherevisedStateOfficepolicyandprocess,atthe90‐daymeetingpriortotheannualISPmeeting,theteam,usingthePSI,wastoidentifypreferencesandstrengths,aswellasthemajorgoalstowardswhichthe


# Provision AssessmentofStatus Complianceindividualwantedtoprogress.Assessmentsthenshouldreflectthesepreferencesandstrengths,and,asappropriate,identifyanyadditionalones.Theassessmentsshouldthenincorporatetheseasappropriateintorecommendations,proposedactionplans,etc.AstheFacilityhadidentified,assessmentsdidnotconsistentlyandconciselylistindividuals’strengths,needs,andpreferences.Someassessmentsdidthisbetterthanothers,suchasthenewervocationalassessmentsthathadsectionswithinthereportsdelineatingstrengths,needs,andpreferences.However,withmostassessments,thisinformationwasintegratedthroughoutthereport,andnoanalysisorlistingoftheinformationwasprovided.Inotherinstances,assessmentsclearlydidnotprovidetheteamwiththeinformationitneededtodevelopadequateplansfortheindividual.Asnotedinanumberofothersectionsofthisreport,theMonitoringTeamfoundthequalityofassessmentstobeanareaneedingimprovement.ThisisdiscussedinfurtherdetailthroughoutthisreportwithregardtothesectionsoftheSettlementAgreementthataddresspsychology(SectionK),medicalservices(SectionL),nursingservices(SectionM),physicalandnutritionalsupportsandOT/PT(SectionsOandP),communication(SectionR),andvocational,habilitationandskillacquisition(SectionS).Inorderforadequateprotections,supportsandservicestobeincludedinindividuals’ISPs,itisessentialthatadequateassessmentsbecompletedthatidentifyindividuals’preferences,strengths,andneeds.Ofnote,althoughasdiscussedwithregardtoSectionJ,thequalityofpsychiatricassessmentshadimprovedwiththecompletionofComprehensivePsychiatricEvaluationsandtheadditionofsomenewtoolsforuseduringthequarterlypsychiatricassessmentprocess,thiswasnotevidentintheISPsreviewed.Forexample,individualsthatclearlyneededpsychiatricassessmentfortheadequatedevelopmentoftheirISPsdidnothavethem(e.g.,Individual#63,Individual#184,Individual#268,andIndividual#26).AsdiscussedwithregardtoSectionJ,littleevidencewasfoundofpsychiatricsupportsintheISPs,whichlikelywasatleastinpartduetotheassessmentsnotbeingmadeavailabletoteams.

Assessmentsalsofrequentlydidnotincludeadequaterecommendations.Someoftheissuesnotedincluded:

o Someassessmentstypicallyincludednoorlimitedspecificrecommendations.Forexample,psychologicalassessmentshadasectionforrecommendations,buttheseoftenconsistedofasummaryoftheindividual’sstrengthsandweaknesses,asopposedtorecommendations.Medicalandnursingassessmentsincludedfewrecommendations.Otherassessmentsincludedanincompletelistof


# Provision AssessmentofStatus Compliancerecommendations.

o Recommendationsfrequentlywerenotorientedtothedevelopmentofactionplans.Forexample,althoughtherapyassessmentsoftenincludedrecommendations,thetherapistshadnotrecommendedfunctionalormeasurablegoals.

FortheindividualsforwhomthenewerISPprocesswasused,theseissuescontinuedtoexist.Forexample,forIndividual#228,manyoftheassessmentsincludedlimitedornorecommendations(e.g.,psychology,nursing,educationandtraining,andtheFSA,)andinothercases,recommendationsappearedinadequatetoaddressidentifiedneeds(e.g.,thenutritionassessmentforthisindividualthathadlostweightwhennotonaweightlossprogram,ordentalforthisindividualwithafairrating).Similarly,forIndividual#63,manyoftheassessmentsincludedfew,ifanyrecommendations.ThisindividualwasnewlyadmittedtotheFacilityandcametotheFacilitywithanumberofsignificantissuesthattheteamshouldhaveaddressed.Forexample,givenhistraumaticpastanditspotentialimpactonhiscurrentbehaviors,onewouldhaveexpectedsomeassessmentstoincluderecommendationstoaddresshisrelateddiagnosis(e.g.,potentiallycounseling).However,theassessmentswerenothelpfulinthisregard.

Therewerenocases(0%)inwhichallassessmentshadbeencompletedinatimelymanner(i.e.,atleast10workingdayspriortotheISPmeeting).Forassessmentsnotsubmittedinatimelymanner,staffreportedthatanemailwouldbesenttothedisciplinecoordinator,withacopytotheFacilityDirectorandtheAssistantDirectorofPrograms.Althoughstaffreportedthattheseprocedureshadresultedinincreasedcompliancewithtimelysubmissionofassessments,basedonthereviewofrecords,concernsstillexisted.ThiswasnodifferentforthetwoISPsusingthenewerprocessandformat.Forexample,forIndividual#63,thefollowingassessmentswerelate:physical,OT/PT,Nutrition,andpsychological.ForIndividual#228,thenutritionandmedicalassessmentwerelate.

AsstatedintheMonitoringTeam’spreviousreport,somefurtherdirectionhadbeenprovidedtostaffresponsibleforassessments,includingthateachassessmentshouldincludeastatementregardingwhetherornotanindividualcouldtransitiontothecommunity,aswellasthesupportsneeded.Ifnot,theassessorneededtoidentifythereasons.Basedonthereviewofsampleplans,thiswasoccurringmoreconsistently.

TheFacilityhadaddedacomponenttoitsPolicy#F.21–SubmittingAssessments.Theadditionprovidedadefinitionofaclarifyinga“lifechangingevent,”andindicatedthattheteamwouldneedtocompleteanISPAmeetingatwhichtimeassessmentswouldbe


# Provision AssessmentofStatus Compliancereviewedtodetermineiftheyneededtoberevised/updated.ThishelpedtoaddresstheSettlementAgreementrequirementthatassessmentsbecompletedwhentheindividualexperienced“significantchanges.”Ofcourse,otherchangesinstatusmightrequiremorelimitedreviewandrevisionofassessments.Inthepast,theMonitoringTeamhadrecommendedanannualreviewofincidents,andabuse,neglect,andexploitationallegations.ThistypeofassessmenthadbeguntobeincludedintheISPs.However,thisoftenappearedtoinvolveacursoryreviewoftheincidentsandallegations.Itwasnotclearthatthegoalhadbeenmetofindividuals’teamsensuringthatalloftheprotections,supports,andservicesnecessarytoreducetotheextentpossiblesuchincidentswereinplaceandappropriatelyincorporatedintotheISP.SomeexamplesofwherethoroughreviewsdidnotappeartohavebeencompletedincludedIndividual#363,Individual#268,andIndividual#26.Theseindividualshadnumerousincidentsandinjuries,andinsomecases,allegations.However,theteamsdidnotadequatelyanalyzetheinformationand/oridentifyareasinwhichchangesmightbemadetoattempttoreducethefrequencyofsuchoccurrences.Overall,assessmentswereeithernotpresentorinadequatetoguideteamsproperlyindevelopingadequateISPs.Thisisanareathatwillrequiretheconcertedeffortsofallteammemberstoresolve.TheFacilityremainedoutofcompliancewiththisprovision.

F1d Ensureassessmentresultsareusedtodevelop,implement,andreviseasnecessary,anISPthatoutlinestheprotections,services,andsupportstobeprovidedtotheindividual.

Asindicatedinpreviousreports,althoughthenewISPprocesshadbeenspecificallydesignedtobemoreinteractiveandstaffweretrainednottoreadtheirassessmentsatthemeetings,teamscontinuedtoneedtoincorporatethoroughlytheresultsofassessmentsintheISPs.ThefollowingsummarizesconcernsrelatedtotheincorporationofassessmentsintoISPs:

Innoneofthe17plans(0%)wereallrecommendationsresultingfromassessmentsaddressedintheISPseitherbyincorporation,orevidencethattheteamhadconsideredtherecommendationandjustifiednotincorporatingit.AlthoughasectionofthereportformattheFacilityhadbeguntouseinDecember2011(priortothemostrecentrevision)includedasectioninwhichtheteamwastoreviewrecommendationsnotdiscussedpreviously,itoftenconsistedofalistingofrecommendationswithlittlediscussion,andoftennojustificationfornotimplementingarecommendationand/ornorelatedactionplantoensuretherecommendationwasaddressed(e.g.,Individual#290,Individual#268,Individual#282,andIndividual#336).

TwomajorfactorsnegativelyimpactedtheFacility’sabilitytoensurethatassessmentresultswereusedtodevelop,implement,andrevise,asnecessary,aISPthatoutlinedtheprotections,servicesandsupportsprovidedtotheindividualwere:1)basedonobservationsandreviewofdocumentationinISPs,althoughsomeimprovementwasbeginningtobeseen,therewasalackof

Noncompliance


# Provision AssessmentofStatus ComplianceconsistentinterdisciplinarydiscussionandcoordinationinthedevelopmentofISPs.Thislimitedteams’abilitytoutilizeassessmentinformationtodevelopintegratedprotections,supports,andservices;and2)asisnotedinothersectionsofthisreport,manyoftheassessmentsandevaluationsbeingconductedwereinadequate.Examplesofthisincludeinadequatenursingassessments,vocationalassessments,andassessmentsofindividuals’physicalandnutritionalmanagementsupportneeds.TheFacilityneedstoaddressthesetwoissuestoensurethatappropriateassessmentinformationisavailable,andthatteamsusesuchinformationinanintegratedfashiontodevelopthecomprehensive,individualizedplansrequiredbytheSettlementAgreement.

Toillustratetheissuesdiscussedabove,Individual#63,whohadanewformatISP,isdiscussedherespecificallywithregardtosomeoftheconcernsrelatedtohisassessmentsandtheinterdisciplinarydiscussiondocumentedinhisISPinrelationtotheassessments.OneofIndividual#63’shighriskswashisweight.HehadaBMIthatplacedhiminthemorbidlyobeserange.Hisnursingassessmentdidnotadequatelyaddressthisissue.Forexample,althoughtheBMIwaslistedintheassessmentsection,itwasnotidentifiedinthenursingproblems/diagnosissection.Inthenursingsummarysection,itwasmentioned,butnotidentifiedasasignificantproblem.Theonlyrelated“plan”inthemedicalassessmentwasto“Encourageexerciseandlowcaloriediettopromoteweightloss.”Inaddition,thenutritionassessmentofferedfewrecommendations(i.e.,reducedcalorie/lowfat/lowcholesteroldietwithadditionofapieceoffreshfruitforsnacks,and“continuewithallotherdietaryarrangements”).Despitethefactthathismotherreportedthathesnuckfoodatnightandthatshebelievedhispsychotropicmedicationwasnegativelyimpactinghisweight,theteamdidnotaddresseitheroftheseconcernsthroughactionplans.Thepsychologistdidnotaddresstheweightissue,andotherthanskillacquisitionprogramstoencouragehealthyeating,nostrategieswerediscussedforhowtoencourageexercise,agoalforhowmuchexercisewouldbehelpful,whetherornotincentiveprogramsorsupportgroupswouldbehelpfultoaddresshisweightissue,etc.Asnotedpreviously,theteamdidnotrequirepsychiatricorpharmacyassessments,orStructuredFunctionalAssessmentofthisindividual,andnoneofthesewereprovidedaspartofthepackageofassessments.Therefore,theteamdidnothaveinformationtofurtherdiscussthemother’sassertionthathispsychotropicmedicationwasaffectinghisweight.Anactionplanindicatedthatthepsychiatristwouldseehimaspreviouslyscheduled,butnoactionsteptoaddressthemother’sconcernabouttheweightissuewasincluded.AlthoughtheFacilityhadnotconductedapsychiatricassessment,thisindividualcarriedadiagnosisofPostTraumaticStressDisorder.Withoutapsychiatricassessment,theteam’sdiscussionofthisdiagnosisappearedtobenonexistent.Althoughthepsychologicalassessmentmentionedit,norecommendationsweremadeinrelationtoit.Infact,thepsychologistmadenodiscernablerecommendations,exceptinrelationtocommunityplacement.Althoughthe


# Provision AssessmentofStatus Compliancemedicalassessmentincludedinformationaboutarestrictionagainsthimhavingcontactwithhisfather,theteamhaddevelopedanactionplantoinitiatecontactwithhisfather.TheISPprovidednoreconciliationofthiscontradictoryinformation,nordiditappearthattheteamhaddiscussedthepotentialimpactthatthiscontactmighthaveonhisbehaviorand/orpsychologicalwellbeing.Similarly,withoutapsychiatricassessment,theISPdidnotaddressthesixpsychotropicmedicationshewasprescribed,andtheteamincorrectlyidentifiedhimasbeinginthelowriskcategoryforpolypharmacy.FornoneoftheseissuesdidhisISPshowadequatecollaborationorintegrationbetweendisciplines.Ashasbeenrecommendedinthepast,theStateandtheFacilityshouldensurethatperson‐centeredconceptsareincorporatedwiththeneedtodevelopcomprehensive,integratedplans.Manyindividualsrequireplanswithmultiplesupports.TheState,workinginconjunctionwiththeFacility,shouldfigureoutwaystohaveadequate,technicalteamdiscussionsandincorporatesuchdiscussionsintocomprehensiveISPs,whilefocusingontheindividualandhis/herpreferences,strengths,etc.

F1e DevelopeachISPinaccordancewiththeAmericanswithDisabilitiesAct(“ADA”),42U.S.C.§12132etseq.,andtheUnitedStatesSupremeCourt’sdecisioninOlmsteadv.L.C.,527U.S.581(1999).

BasedoninformationtheFacilityprovided,thefollowingactivitieshadoccurredtoprovideadditionaleducationtoQDDPsregardingcommunitylivingoptions:

On5/18/12,theQDDPsweretrainedonthenewrulesregardinginclusionoftheDesignatedLocalAuthority(LA)duringlivingoptionsmeetings.Morespecifically,theruleshadbeenmodifiedtoallowareferraltobemadewithouttheLApresent.TherulesalsosetforththeparametersforensuringLArepresentativeswereinvitedtomeetings,notificationsoftheAdmissions/PlacementCoordinatorofreferralsmadeduringmeetings,informingtheLAofreferralsmadeintheirabsence,andholdinganadditionalmeetingshouldtheLAhaveanyquestionsorconcernsaboutthereferral.ItwaspositivethatLArepresentative’sinabilitytoattendameetingwouldnotdelayapotentialreferral.

ThisprovisionisdiscussedindetaillaterinthisreportwithrespecttotheFacility’sprogressinimplementingtheprovisionsincludedinSectionToftheSettlementAgreement.Asubsetof10planswerereviewedincludingthosefor:Individual#290,Individual#363,Individual#184,Individual#268,Individual#282,Individual#336,Individual#26,Individual#250,Individual#228,andIndividual#63.Tohighlightsomeoftheissuesofconcern:

Teamswerenotconsistentlyprovidingindependentassessmentsofindividuals’abilitytotransitiontoamoreintegratedsetting.InorderfortheStateOfficerequirementtobemet,eachdiscipline’sassessmentneededtoincludeanopinion/recommendation.Inaddition,attheISPmeeting,theteamneededto

Noncompliance


# Provision AssessmentofStatus Compliancemakearecommendationtotheindividual/guardian.Basedonthereviewofrecords:

o Asnotedaboveinthediscussionregardingthequalityoftheassessments,someassessmentsincludedtherequiredstatements/recommendation,andothersdidnot.However,thiswasanareainwhichimprovementwasseen.Ofthe10ISPsreviewed,alloftheassessmentsforoneindividual(10%)(i.e.,Individual#228)includedtheapplicablestatement/recommendation.Forfourofindividualsmostoftheassessmentsincludedsuchastatement(i.e.,Individual#63,Individual#250,Individual#336,andIndividual#290).

o Ofthe10ISPsreviewed,oneindividual(i.e.,Individual#26)hadbeenreferredfortransitiontothecommunityafewmonthspreviously,andtheteamagreedtocontinuethereferral.Fortheremainingnineindividuals,twoindividuals’ISPs(22%)includedanindependentrecommendationfromtheprofessionalsontheteamtotheindividualandLAR(i.e.,Individual#184,andIndividual#282).Thefollowingproblemswerenotedfortheotherindividuals:

Fortwoindividuals(22%),theassessmentsand/orISPnarrativeincludedstatementsshowingdisagreementamongsttheteamregardingtheindividual’sappropriatenessforcommunitytransition(i.e.,Individual#290,andIndividual#63).Forbothoftheseindividuals,theteamrecommendationwasthattheindividualremainattheFacility.However,itwasnotclearhowtheteamdisagreementaboutthishadbeenresolved.

Foroneindividual(11%)(i.e.,Individual#228),allteammembershadincludedstatementsintheirassessmentsindicatingtheindividualcouldbesupportedinalessrestrictivesetting.IntheISPnarrative,theteamindicated:"Allthedisciplineswhoworkwith[Individual#228]agreedintheirassessmentsthatcommunityplacementwouldbeappropriateifthepropersupportswereinplacetomeetherspecialneeds.Sheisingoodhealthandadaptswelltonewsituations."Individual#228didnothaveaguardianoractivefamilyinvolvement.InotherportionsoftheISP,theteamconcludedthatsherequiredaguardianforallaspectsofdecision‐making.However,theteam"determinedthat[theIndividual]wouldnotbenefitfrommovingtoalessrestrictiveenvironmentatthistime."Thereasongivenwasthat:"Sheneedsadditionaleducationaboutcommunitylivingoptions."Theteamdidnot


# Provision AssessmentofStatus Complianceprovideadequatejustificationforitsconclusion.Inadditiontothefactthattheteamindicatedtheindividualcouldnotmakeherowndecisions,shealsohadbeenontwocommunitytoursthepreviousyear,andappearedtobe"alert,lookingaroundwithinterest,andsmiling."Moreover,herPSIindicatedinresponsetothequestionaboutwhereshewouldwanttolive:"Sheisnonverbalandtherefore,unabletogiveusthisinformation."Itwasuncleariftheteamdidnothaveenoughinformationaboutcommunityoptions(giventhatinlieuofaguardian,theteamwasresponsibleforthisdecision),oriftheteambelievedtherewasanotherbarrierthattheydidnotidentify.

Forfourindividuals(44%),basedontheassessmentsandsometimesthenarrativesintheISPs,theteammembersstatedthattheindividualcouldbesupportedinalessrestrictivesetting.However,aspecificrecommendationtotheindividualand/orLARwasnotmade(i.e.,Individual#363,Individual#268,Individual#336,andIndividual#250).

InthesectionbelowthataddressesSectionT.1.b.1,thereisextensivediscussionregardingtheFacility’sstatuswithregardtoidentifyingobstaclestoindividualsmovingtothemostintegratedsetting,andplanstoovercomesuchobstacles.Insummary,theFacilityremainedattheinitialstagesofcomplyingwiththiscomponentoftheSettlementAgreement.

Althoughteammemberswereincludingmorestatementsintheirassessmentswithregardtoindividuals’appropriatenessforcommunitytransition,theywerenotconsistentlymakingindependentrecommendationstotheindividualsand/orLARs;whendisagreementswerenoted,theirresolutionwasnotconsistentlyexplained;andtheidentificationofandplanstoovercomeobstaclestotransitionwerenotyetadequatelyaddressed.TheFacilityremainedoutofcompliancewiththisprovision.

F2 IntegratedISPs‐EachFacilityshallreview,reviseasappropriate,andimplementpoliciesandproceduresthatprovideforthedevelopmentofintegratedISPsforeachindividualassetforthbelow:

F2a CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwo


# Provision AssessmentofStatus Complianceyears,anISPshallbedevelopedandimplementedforeachindividualthat:

1. Addresses,inamannerbuildingontheindividual’spreferencesandstrengths,eachindividual’sprioritizedneeds,providesanexplanationforanyneedorbarrierthatisnotaddressed,identifiesthesupportsthatareneeded,andencouragescommunityparticipation;

ThisprovisionoftheSettlementAgreementaddressesanumberofspecificrequirements,includingidentificationanduseofindividuals’preferencesandstrengths,prioritizationofneedsandexplanationforanyneedorbarriernotaddressed,andidentificationofsupportsneededtoencouragecommunityintegration.Eachoftheseisaddressedseparatelybelow.DADSDraftPolicy#004.1atII.F.4indicatedthatactionplansshouldbebasedontheindividual’spreferences,strengths,andneeds.Thepolicyfurtherindicated:“TheIDTmusthaveacomprehensive,integrateddiscussionwithinputfromeachteammemberonhowheorshewillformallyorinformallysupporttheprioritizedactionplans.”Therevisedpolicyincludedconsiderabledetailregardingthetypesofactionplansteamsshoulddevelop(i.e.,skillacquisitionplans,participationobjectives,serviceobjectives,andspecificobjectivestoaddressindividualriskfactors);thecontentofactionplans;topicsthatactionplansshouldcover.Italsorequiredteamsto“considereveryopportunityforcommunityintegration,”aswellasensurethat“Outcomesandobjectivesareexpressedintermsthatprovidemeasurableindicesofperformance…”Asnotedpreviously,theFacilityhadreiteratedthepreviousDADSpolicyinitsFacilitypolicies.CCSSLCPolicyF.5:ActionPlans,implemented11/1/11,mightneedtobereviewedandrevisedbasedonsomeofthechangestoStateOfficepolicy.IdentificationandUseofIndividuals’PreferencesandStrengthsAsnotedinthelastreport,teamsweremakingeffortstoidentifyindividuals’preferences.The17ISPsreviewedallincludedsomeinformationregardingtheindividual’spreferences.However,thefollowingconcernswerenotedwithregardtotheidentificationandincorporationofpreferencesandstrengthsintoISPs:

All17oftheISPsreviewedincludedalistingofindividuals’preferences.Someplansincludedanobjectiveortwothat,forexamplerelatedtoapreferredactivityoftheindividual(e.g.,Individual#63).Forfouroutof17(24%),theteamhadmoreeffectivelyincorporatedtheirpreferencesintorelatedactionplans.Forexample,Individual#26wasabletostatemanyofherownpreferences,andtheteamincorporatedanumberintoheractionplans.Forexample,actionplansweredevelopedtoaddressherdesiretolearnhowtousethebustogotothebingohall(apreferredactivity),aswellasexploreFosterCare.Shealsowantedtolearnmoreaboutherhealthconditions,andtheteamincorporatedthisintoanactionplan.Individual#184’sISPshowedmoreintegrationoftheindividual'spreferences.ISPsforIndividual#226andIndividual#174wereadditionalexamplesofwhereteamshadidentifiedplacementpreferencesandsoughttoincorporateappropriateactions.For

Noncompliance


# Provision AssessmentofStatus Complianceexample,anobjectivewasincludedtoinvestigatepotentialvocationalopportunitiesthatwouldaddresshispreferences.Someleisureactivities,suchaspurchasingamagazine,aswellasfindingdecorationsthatwouldcorrespondwithhispreferencesalsowereincluded.However,inmostcases,theteamshadnotusedthesepreferencesincreativewaystoaddressindividuals’needs(e.g.,buildinginincentivesforindividualswhorefusedtoattendvocationalordayprograms,orneededtoloseweight)ortoexpandindividuals’horizons.Evenwhenworkwasapreference,teamsdidnotcapitalizeonthisbyexpandingtheindividuals’vocationalopportunities.Individualswithweightissueswerenotedaslikingtheoutdoorsorspecificsports,butteamsdidnotutilizethispreferencetobuildinregularoutdoorexerciseorparticipationinspecificsportsoractivities.Thesearejustafewexamplesofmanymissedopportunities.SpecificallywithregardtothetwonewerISPs,Individual#228hadanewPSI.Inresponsetomanyquestions,thefollowingwasstated:"Sheisnonverbalandtherefore,unabletogiveusthisinformation.”Forotherquestions,responseswereprovided.Itwasunclearwhytheteamreliedoninformationfromothersforsomequestionsandnotforothers.Ingeneral,heractionplansdidnotspecificallyincorporateherpreferences,andherstrengthswerenotusedtofurtherexpandherindependence.ForIndividual#63,somelimitedintegrationoccurredofhispreferences(e.g.,learningtocook,bicycling,etc.).

AstheMonitoringTeam’spreviousreportshavenoted,mostofthepreferencesidentifiedforindividualsrelatedtoitems,food,oractivities.Itwillbeimportantforteamstodefinewhatitistheindividualprefersaboutsuchitems,foods,oractivitiestobeabletooffertheindividualnewexperiencesbasedonthisinformation.Italsowillbeessentialtoexpandthediscussiontoincludepreferencesrelatedtoenvironments,work,relationships,pastorfutureexperiences,routines,interactionswithothers,etc.

Little,ifany,informationaboutindividuals’specificstrengthswasdiscussedinISPdocuments.Strengthswerenotregularlybuiltupontoaddressotherneedareas.Asnotedwhileonsite,fortheISPstheMonitoringTeam’sobserved,althoughlistsofstrengthswereidentified,theywerelimited.Inaddition,teamsdidnoteffectivelydiscussthem,orusetheminthedevelopmentofactionplans.

PrioritizationofNeedsandExplanationforAnyNeedorBarrierNotAddressedNoneoftheplansreviewed(0%),includingtheplanscompletedusingthenewformat,includedalistofpriorityneeds.Innoneoftheplanswasanexplanationprovidedofhowtheteamhaddeterminedwhichsupportsortrainingneededtobeprioritizedoverotherneeds.Forexample,norationalewasprovidedregardingwhyoneoftheindividual’s


# Provision AssessmentofStatus Compliancespecificneeds(e.g.,onedailylivingskillasopposedtoanother,oraparticularmedicalneed)tookprecedence.Inaddition,althoughanecdotally,teamswereconcernedaboutlackofstaffingortransportationtoaddressindividuals’needs,carefuldelineationofbarrierstoaddressingneedswasgenerallynotfound.Moreover,teamsoftencitedindividuals’behaviorsorattitudesaspreventingthemfromparticipatinginactivities(e.g.,work),butteamshadnotclearlydefinedsuchissuesasbarriers,and/orimplementedplanstoaddressthem.Morespecifically,innoneofthe17PSPsreviewed(0%)werebarriersidentifiedandaddressed.IdentificationofSupportsNeededtoEncourageCommunityIntegrationInreviewingobjectivesrelatedtoindividuals’involvementinthecommunity,theycontinuedtobelimited.Sixteenofthe17ISPsreviewed(94%)(i.e.,thosethatdidnotincludesuchobjectiveswere:Individual#268)includedspecificskillacquisitionactionplansforimplementationinthecommunity.However,thefollowingproblemswerenoted:

Theskillacquisitionprogramsgenerallyinvolvedimplementationonceaweekoronceamonth(e.g.Individual#290,andIndividual#63).

Eveninthelimitedplansreviewed,objectiveswereidenticalforthreeindividuals(i.e.,whileoncommunityouting,theindividualwastorespondtosensoryinputs).

Mostofthecommunity‐relatedobjectiveswerenotwritteninamannertoactuallyencouragetheintegrationofindividualswithnondisabledpeersand/ortheexpansionofindividuals’experiencesinthecommunity.

Someindividualshadobjectivesforgeneralcommunityinvolvementactivities,buttheyoftenwerenotmeasurable.Forexample,"DSPstosupport[individual]withopportunitiestoparticipateincommunityactivitiesthataddresshisinterestsandpreferences"didnotsetforthanactionstepthatcouldbemeasuredtoensuretheindividualwasactivelyinvolvedinthecommunityinactivitiesthathepreferred.Thetimeframeforthisactivitywas"ongoing.”

Specificallywithregardtothetwoplansusingthenewestformat,forIndividual#228,althoughsomecommunityinvolvementactionstepswereincludedintheISP,theywerenotmeasurable(i.e.,nofrequencyofcommunityoutingswasstated),norweretheyindividualizedtosupportfurtherintegrationintothecommunity.Forexample,theactionplanread:"willparticipateincommunityoutingswithpeers"withactionstepsforstafftoscheduleoutings,theindividualtoparticipateinthem,andstafftodocumentherreactions.Herskillacquisitiongoalforthecommunitywastorespondtosensoryinputswhileinthecommunity.Itwasnotclearhowthisassistedhertobemoreintegratedinhercommunityortopracticefunctionalcommunityskills.Ontheotherhand,for


# Provision AssessmentofStatus ComplianceIndividual#63,theteamidentifiedanobjectiveforhimtolearntousethebus.Thisshouldprovidehimwithfunctionalcommunityskills.Thegoalwasscheduledforimplementationjustonceaweek.Hisothercommunity‐relatedactionstepread:“[Individual]willgainexposuretodifferentcommunitylocationsthroughparticipationinoff‐campusactivities.”Nofrequencywasstated,makingthisobjectivedifficulttomeasure.

AlthoughCCSSLChadmadesomeprogress,theFacilityremainedoutofcompliancewiththisprovision.Althoughteamswereidentifyingsomepreferencesandstrengthsofindividuals,theseremainedlimited.Inaddition,teamswerenotyeteffectivelyincorporatingindividuals’preferencesandstrengthsintoactionplans,orusingthemcreativelytoexpandindividuals’opportunitiesoraddresstheirneeds.PrioritizationofindividualsneedswasnotevidentintheISPsreviewed.Asisdiscussedinthesubsectionsbelow,individuals’needswerenotcomprehensivelyaddressedinactionplans.Moreindividualshadactionplansthataddressedcommunityskillacquisition,butthesevariedinquality.

2. Specifiesindividualized,observableand/ormeasurablegoals/objectives,thetreatmentsorstrategiestobeemployed,andthenecessarysupportsto:attainidentifiedoutcomesrelatedtoeachpreference;meetneeds;andovercomeidentifiedbarrierstolivinginthemostintegratedsettingappropriatetohis/herneeds;

Althoughsomelimitedprogresswasseeninthisarea,thiscontinuedtobeanareainwhichsubstantialeffortwasneededinorderforCCSSLCtocomplywiththeSettlementAgreement.TheactionplansectionoftheISPwaswheremeasurablegoals/objectives,thetreatmentsorstrategiestobeemployed,andthenecessarysupportsweretobedetailedtoattainidentifiedoutcomesrelatedtoeachpreference,meetneeds,andovercomeidentifiedbarrierstolivinginthemostintegratedsettingappropriatetotheindividual’sneeds.AsduringtheMonitoringTeam’spreviousreviews,Facilitystaffrecognizedthatactionplanswerenotadequate.TheMonitoringTeamagreeswiththisassessment.Thefollowingsummarizestheconcernsrelatedtoactionplans:

Asnotedinthelastmonitoringreport,ISPsgenerallyincludedsomeindividualizedandmeasurablegoals/objectives,treatmentsorstrategies,andsupports.Sincethelastreview,atCCSSLC,thescopeofthesegoalsandobjectiveshadbeguntoincrease.Thiswasapositivedevelopment.TheMonitoringTeamrecognizesthattheFacilitywasintheprocessofrevisingtheISPsinaccordancewithrecenttrainingfromtheStateOffice.However,ofnote,formanyoftheindividualsinthesample,riskactionplanscontinuedtobeseenasseparatefromtheISP(i.e.,theyweresubmittedaspartoftheassessmentpackage,asopposedtobeingattachedtotheISPs).ItwillbeimportantmovingforwardforteamstoincludeallactionplanswithintheISPdocument.Actionplanscontinuedtoincludeskillacquisitionplans.Attimes,PBSPobjectiveswereincluded,butoftenonlyareferencewasmadetoimplementationofthePBSP.AsisdiscussedinfurtherdetailwithregardtoSectionI,theactionplansteamshaddevelopedforindividuals’at‐riskissuesdid

Noncompliance


# Provision AssessmentofStatus Compliancenotadequatelyaddresstheirneeds,anddidnotincludemeasurableobjectivesnecessarytodetermine:a)ifthesupportsoutlinedwereprovidedasrequired;orb)whetherornotthesupportsandstrategieswerehavingthedesiredoutcome(i.e.,weretheyeffectiveinimprovingtheindividual’shealth,ormaintaininghis/hercurrentstatus).

Noneofthe17plansreviewed(0%)includedafullcomplementofmeasurablegoalsorobjectivesand/orstrategiestoaddressthearrayofsupportsandservicestheindividualrequired.Thisnegativelyimpactedtheintensityofindividuals’activetreatment,thesupportstheywereprovided,andtheteams’abilitytomeasureprogress,orlackthereof.Morespecifically:

o Inthepast,CCSSLCISPsgenerallyincludedtheobjectivesrelatedtoskillacquisitionprograms,andoftenthesewerestatedinmeasurableterms.Now,thisvaried.Sometimesthemeasurableobjectiveswereincluded.Inotherinstances,referencetoaskillacquisitionprogramwasmadeingeneralterms,ortheskillacquisitionobjectivesdidnotincludeadescriptionofthespecificskilltheindividualwouldlearn.Forexample,thefollowingwasfairlymeaninglesswithoutthefullskillacquisitionprogram:"[individual]willimprovehisindependenceinacommunitysettingofhischoicebydemonstratingtaskanalysissteps1‐4(implementedatstep1),3outoffourtrialspermonthfor3consecutivemonths."

o Inaddition,thegreatmajorityofotherobjectivesincludedinactionplanswerenotspecificormeasurable.Justafewexamplesincludedthefollowing:"Nutrition:Followandmonitor,""willlearnhowtogainattentionfrompositivebehavior,""willparticipateinBingoatoffcampusBingohall"withnofrequencydefined,"encouragetowalkorengageinlowimpactactivities,"or"willdemonstratefewerepisodesofdisruptivebehaviorsnextquarter."

o Necessaryobjectives,supports,andservicesoftensimplywerenotincludedinactionplans.Forexample,limitedtonoobjectiveswereseeninrelationtotheimplementationofmedicaland/orpsychiatriccareplans,and,althoughsomeplansincludedobjectivestoimplementPNMPs,nursingcareplans,orPBSPs,theyoftenwereincomplete,and/orwerenotmeasurable.Inordertoprovidehealthcaresupportstoindividualsserved,directsupportprofessionalsaswellasnursingstaffneedtoprovidesupportstoanindividual.Supportssuchasensuringthatanindividualisofferedfluidthroughouttheday,orisrepositionedeverytwohours,orthattheindividual’spsychiatricsymptomsaredocumentedshouldbespecifiedinmeasurablewaysinindividuals’ISPs.

o Objectiveswerenotseeninanyoftheplansinrelationtostafftraining


# Provision AssessmentofStatus Compliancerequirements.

o Althoughmonitoringofsupportswassometimesdefined(e.g.,PNMPimplementation),thiswasnotconsistent.

o Rightsrestrictionswereanotherareainwhichverylimitedactionplanswereidentifiedtoassistinpotentiallyreducingtheneedfortherestriction.Althoughsomemoneymanagementprogramswereincluded,mostrestrictionshadnoassociatedplanidentified.

o Morefrequently,actionplansreferencedtheimplementationofphysicalandnutritionalsupportplans(PNMPs).However,therapyplans,includingwalkingprograms,useofadaptiveequipment,aswellasintegrationofalternativeoraugmentativecommunication(AAC)deviceswereinfrequentlyintheplansreviewed.Moreover,functional,measurableobjectivesand/orskillacquisitiongoalsrelatedtotherapeuticinterventionsinfrequentlywereincludedinISPs.

o ISPsshouldincludemeasurable,observableobjectivestodeterminetheefficacyofthevariousactionplans.Inotherwords,objectivesshouldbedesignedtoallowtheteamtodetermineiftheindividualisdoingbetterorworse,orremainingstable.Inreviewingtheactionplansthathadbeendevelopedtoaddressindividuals’riskareas,workhadbeendonetoimprovetheobjectives,includingindividualizingthem.However,often,itwasnotclearhowtheteamwouldmeasuretheseoutcomes,becausetheywereseparatestatements,andnotdirectlyconnectedtoanactionstep(s).Usingthetwonewestplans,acoupleofexamplesareprovided:ForIndividual#228,inrelationtochoking,aspiration,andrespiratorycompromise,thathadagoalto“maintainadequategasexchangeAEB[asevidencedby]sats[saturationrates]of95%orbetter.”Althoughthistechnicallycouldbemeasured,theteamhadnotincludedanyactionstepstoactuallymeasureheroxygensaturationrates.Theteamhadnot,forexample,definedthefrequencyofsuchassessments,whowouldberesponsible,and/orwhatwouldhappeniftheyfellbelowacertainlevel.ThisisdiscussedinfurtherdetailwithregardtoSectionIoftheSettlementAgreement.Similarly,Individual#63’sactionplanforinfections,skinintegrity,andurinarytractinfectionshadtwooverallgoals,including:“willdemonstrateadequateimmunestatusbyremainingafebrile,maintainingskinintegrity,andbykeepinghydratedandwellnourished,”and“willdemonstrateappropriatehygienepractices(bathing,propercuttingoftoenails,toothbrushing).”Althoughsomeofthesecouldbemeasuredbasedontherelatedactionplans(e.g.,nursingwastoconductskinintegrityassessmentsquarterly,andlabswouldbecompletedtodetermineifhewasreceivingadequatenutritionandhydration),itremainedunclear


# Provision AssessmentofStatus Compliancethespecificparameterstheteamexpectedwouldbemaintained(e.g.,Bradenscoreorspecificlabresults),andforothercomponentsitwasunclearhowtheteamwouldmeasuretheindividual’sstatus.Forexample,anactionstepwasincludedfordirectsupportprofessionalsto“encouragedailyhygiene,”withamonitoringfrequencyof“daily.”Observationnotesweretobemaintained.However,itwasunclearspecificallywhathygieneskillsweretobemonitored,and/orwhatdirectsupportprofessionalsweretodocument.

Ingeneral,withregardtothetwoplansdevelopedusingthenewestprocess,theplansincludedamixofmeasurableandnon‐measurablegoals,butmanywerenotmeasurable,orindividualized.Thefollowingspecificcommentsareprovided.ForIndividual#63,manyofthegoalsand/oractionstepswerenotmeasurable.Forexample,hewasapproximately100poundsabovehisIdealBodyWeightRange(IBWR).However,theoverallgoalstated:"willdemonstrateweightcontrolbygraduallyprogressingtowardstargetweightof140‐175."Theteamhadnotdefined“graduallyprogressing,andnointerimobjectiveswerearticulatedtoassisttheteamindeterminingiftheiractionplantodecreasehiscalorieintake,continuehisbikeridingskillacquisitionprogram,enrollhiminaculinaryclass,implementahealthychoicesSAP,andweighhimmonthlywasworking.Otherexamplesofactionstepsthatwerenotmeasurableincluded:"Willhavetheopportunitytotourlocalgrouphomes"withnofrequencystated,or"encouragedailyhygieneandactivity."ForIndividual#228,generally,theobjectiveswerenotmeasurable.Forexample,oneactionplanincludedtheobjective:"[Individual]willparticipateincommunityoutingswithherpeers."Theactionstepsincludedsuchactionsas"scheduletheoutings,""[Individual]willparticipateintheoutings,"etc.Thesedidnotidentifyanycriteriawithwhichtomeasuretheindividual'sprogressorlackthereof,orwhetherornotstaffwereprovidingtheindividualthesupportssherequired.However,someobjectivesweremeasurable,suchas:"Increase[individual's]ambulationprogramto4timesperweekfor15‐20minutespersession."ItwaspositivetoseethatthistherapeuticinterventionwassetforthinandISPactionplan.

InthesectionbelowthataddressesSectionT.1.b.1,thereisextensivediscussionregardingtheFacility’sstatuswithregardtoidentifyingobstaclestoindividualsmovingtothemostintegratedsetting,andplanstoovercomesuchbarriers.Insummary,theFacilitywasattheinitialstagesofcomplyingwiththiscomponentoftheSettlementAgreement.

Someprogresshadbeenmadeintheexpansionofthescopeofmeasurableobjectives,andeffortsclearlywerebeingmadetoimprovethemeasurabilityandindividualizationofobjectivesandactionsteps.However,astheFacilityrecognized,theseremainedareasinwhichsignificantworkwasneeded.TheFacilityremainedoutofcompliancewiththis


# Provision AssessmentofStatus Complianceprovision.

3. Integratesallprotections,servicesandsupports,treatmentplans,clinicalcareplans,andotherinterventionsprovidedfortheindividual;

Numerousexamplesareprovidedthroughoutthisreportregardinghowplans,supportsandserviceswerenotintegratedthroughtheISPs.ISPsappearedtointegratesome,butnotallprotections,servicesandsupportsthatindividualsrequired,asthisprovisionoftheSettlementAgreementclearlyrequires.However,someactionhadbeentakentoimprovethecomprehensivenessofISPs.Specifically,afterStaffOfficeconsultantsprovidedtraining,twoteamsatCCSSLChadbegunpilotinganewISPMeetingGuide(Preparation/Facilitation/DocumentationTool),aswellasthenewat‐riskprocess.Themeetingguidetool,alongwithanewprocessforcompletingtheIRRFanddevelopingintegratedhealthcareplans,wasdesignedtoassistteamsinmorecomprehensivelyplanningfor,discussing,anddevelopingISPsthataddressedindividuals’arrayofneedsforprotections,supportsandservices,whileapproachingthisinaperson‐centeredmannerandincorporatingtheirpreferencesandstrengths.Atthetimeofthereview,onlytwoISPshadbeencompletedusingthenewprocess(althoughseveralhadusedthenewshellfortheISPdocument).Inaddition,duringtheweekofthereview,twoISPmeetingswereheldforindividualsforwhomteamswereusingthenewprocess.Giventhislimitedimplementation,itremainedtobeseeniftherevisedISPMeetingGuideandprocesswouldresultinimprovedISPs.Basedonthereviewofthetwoplansthatusedtherevisedprocess,somelimitedprogresswasseenwithregardtotheintegrationofamorecomprehensivesetof“protections,servicesandsupports,treatmentplans,clinicalcareplans,andotherinterventions.”However,teamswillneedcontinuedtrainingandcoachingtoimplementtherevisedprocessfully.Asnotedabove,astheMonitoringTeam’sobservationsoftwoISPmeetingsonsiteindicated,themajorityofthetimewasspentontheriskratingprocess.Althoughthiswasanessentialactivityinwhichteamsneededtoengage,itresultedinlittletimebeingspent,forexample,ontheteamdefiningthemeasurableoutcomestodeterminetheefficacyoftheinterventionstheteamdiscussedtoaddresstherisks,orotherimportanttopics,suchastheindividual’svocationalambitionsandplanstoachievethem,his/herplanstoincreaseskillsleadingtogreaterindependence,waysinwhichgreaterintegrationintothecommunitycouldoccur,etc.AdditionalpreparationbytheQDDPsaswellasotherteammembersbeforethemeetingswasanareaforimprovement.Forexample,ifallteammembershadfamiliarizedthemselveswiththeinformationincludedinthedraftIRRF,theteamwouldnothavehadtoreviewitallindetail,butrathercouldhavediscussedanyquestionsandthenmadedecisions.Withregardtothetwoplansdevelopedusingthenewprocess,thefollowingcommentsareofferedwithregardtotheintegrationofacomprehensivesetofprotections,services,

Noncompliance


# Provision AssessmentofStatus Complianceandsupports:

ForIndividual#228,adequatediscussionandinclusionofactionplansrelatedtoprotections,supports,andservicesweremissinginanumberofareas.Forexample,withregardtoday/vocationalsupports,theISPindicatedsheattendedoutofhomedayservicestwohoursaday.Nojustificationwasprovidedforthislimitedschedule,andtheISPofferedminimaldefinitionofthesupportsshewouldreceiveinthissetting.Withregardtohealthriskplans,althoughtheISPindicatedtheywereattached,itwasuncleariftheywere.Theywererequestedseparatelyandsubmittedwiththeassessments.Someimprovementwasseeninthesehealthriskplansoverpreviousones(e.g.,definitionofparametersforcontactingphysician;moreproactiveinterventions,suchasfluidintakeanddevelopmentbyHabilitationTherapiesofwalkingprogramtoaddressissuesrelatedtoconstipation).However,anumberofmissingpieceswerestillmissing.Forexample,withregardtoweight,shehadlosteightpounds.Thiswasnotedinthemedicalassessment,andthePCPidentifiedagoalforhertogainweight.Thisgoaland/ortheplanforachievingitwerenotincludedintheintegratedhealthcareplan.TheISPandIRRFindicatedthatthebehavioralservicesstaffsaidshewasnotacandidatefordesensitization"becauseofherspasticity."However,thedescriptionofherresistanceatdentalappointmentsdidnotappeartohaveanythingtodowithspasticity.TheIRFFstated:"Duringappointmentssheexhibitsanxious(sic),hasexcessivemovementandisresistivetoexams,shebendsatthewaistasavoidanceandgrabshands."Shealsowasresistivetostaffassistingherwithbrushingherteeth,butnoproactivestrategiestoaddressthiswereincludedinherintegratedhealthcareplans.Onapositivenote,itappearedtheteamdiscussedtheneedtoexpandtheindividual'sopportunitiestowalk,andstandwiththeassistanceofadaptiveequipmentandstaff.TheteamdevelopedactionplansthatdescribedboththePNMPCoordinator'srole,aswellasthedirectsupportprofessionals'role.

WithregardtoIndividual#63,inthenarrativethataddressesSectionF.1.d,anumberofexamplesareprovidedofsupportsthatweremissingfromhisplan.Additionally,withregardtohisvocationalsupports,hewasonlyscheduledtoworkfrom1p.m.to4p.m.eachday.TheISPdidnotprovideareasonforthelimitedschedule,andnoplanwasputinplacetoincreasethisamountoftime.Therewasnoapparentreasonwhyhecouldnotworkfull‐time.Althoughhewasgoingbacktoschoolinthefall,theISPdidnotaddresshowhewouldspendtherestofhisdayduringthesummer,and/orwhetherornotduringtheschoolyear,hewouldworkpart‐time.Jobexplorationalsowasincludedasagoal,butwasdefinedinanactionstepthatread:“willcompletejobintroductionforoff‐campusjanitorialworkinDPSandParksandWildlife.”Althoughthiswaspositive,thecompletiondateappearedtobeayearaftertheISP,anditwasunclearwhattheexpectationswerefortheinterim.



BasedonthesampleofplanstheMonitoringTeamreviewed,noneofthe17plans(0%)integratedalloftheprotections,servicesandsupports,treatmentplans,clinicalcareplans,andotherinterventionsprovidedfortheindividual.Forexample:

Themedical,psychiatric,counseling,habilitationtherapy,PBSPs,andnursingcareplansfrequentlystillwereseparateplansthatwerenotintegratedinanymeasurablewayintotheISP,through,forexample,measurableobjectives,anddidnotshowanintegrationofvariousdisciplinesandteammembers.Eventhetwoplansusingthenewformatdidnotsuccessfullyintegrateorincludeallofthesevariouscomponents.Forexample,Individual#63’spsychiatrictreatmentplanappearedasifitwouldbeanimportantpartofhistreatment,butitwasnotintegratedintohisplan.Infact,atthepointhisinitialannualISPwasdeveloped,hehadnotyetseenthepsychiatrist.HisPBSPwasidentifiedasrequiringimplementation,butnospecificgoalsorobjectiveswereincludedintheISPactionplans.Nocounselingplanwasincluded(i.e.,onlyreferencetoparticipationina“men’sgroup”).Asnotedabove,forIndividual#228,itwaspositivethatatherapyplanwasincluded,butotherplansweremissing,suchasfullidentificationofmedicalsupports.Althoughsomenursingactionswereincludedforbothindividuals,thesedidnotrepresentfullnursingcareplans.

Actionplansoftendidnotrecognizethemultiplestaffanddisciplinesthatneededtobeinvolvedinthetrainingofstaff,implementationoftheprograms/plans,monitoringoftheimplementation,andupdating/maintenanceoftheplansand/orrelatedequipment.Frequentlyactionplanssimplystatedwhatwouldhappenwithoutdetailingallofthestepsandthestaffwhoneededtoworkinanintegratedfashiontoachievethestatedoutcome.Forexample:

o Theactionstepstating:“psychiatricmedicationswillbereviewedinpsychiatricclinic,”or“continuePNMP”didnotdetailallofthevariousrolesofstaffwhoneededtoworkinanintegratedfashiontoaccomplishtheultimateobjectivesfortheseindividualsofmaintaininggoodhealth.Oftenthepersonsresponsibleforthesebroadoutcomeswere“nursing,”or“thePNMPCoordinatorandQDDP.”Again,thisdidnotrecognizetheneedforsuchsupportstobeintegratedwiththerolesofmanydisciplines,includingdirectsupportprofessionals.SomeoftheseroleshadbeguntobebetterdefinedinsomeoftheintegratedhealthcareplansforthetwonewerISPs.However,continuedworkwasneeded,particularlybecausethe“IDT”oftenwasidentifiedashavingresponsibility,andwithoutdefiningwhichteammember(s),itremainedunclearwhowasresponsible.

o AlthoughreferencestotheneedtoimplementPBSPswereincludedin


# Provision AssessmentofStatus CompliancetheISPs,whichwaspositive,oftentheactionplansdidnotincludethespecificobjectives.Nodetailedactionstepswereincludedrelatedtostafftraining,monitoringoftheplans,sharingofinformationwiththepsychiatrist,etc.Inaddition,evidencegenerallywasnotfoundthatPBSPswereintegratedwithothersupports,suchascommunicationsupports,orhealthrelatedsupports(e.g.,weightreduction,medicationadministration,etc.).AnumberofISPsidentifiedissuesinwhichpsychologyshouldhavebeeninvolved,butwasnot.Asnotedabove,thetwonewerplansalsoillustratedconcernsinthisarea.ItwaspositivethatforIndividual#268,thepsychologistwasassistingwiththeissueofworkrefusals.However,itappearedtheSLPalsoshouldhavebeeninvolved.

o AlthoughISPshadbeguntoincludeobjectivestoimplementthePNMPs,PNMPslackedmeasurableoutcomes,and,asaresult,thesewerenotincludedinISPs.Inaddition,generallynodetailwasprovidedinrelationtoallofthevariousrolesofteammembersnecessarytoensurefullimplementation,including,forexample,integrationwithnursinganddentalplans.Thetwonewerplansalsoillustratedconcernsinthisarea.

o Ingeneral,individuals’workanddayactivitieswereinadequatelydefined.Althoughattimesanobjectivewasidentifiedforimplementationatthedayorvocationalprogram,thiswasnotconsistent.Inaddition,theobjectivesthatwereincludeddidnotadequatelydefinetheteam’sexpectationswithregardtotheprogramortrainingthatthestaffwouldoffertheindividual,ortheoutcomesthatwouldbeexpected.Littleinformationwasprovidedwithregardtorationalesforthemanyindividualsthathadlessthanfull‐timeschedulesinoff‐homeprograms.Inaddition,minimalplanningforthefuturewascompletedtoidentifynextstepsintheindividuals’vocationalpaths.Asnotedabove,thetwonewerplansalsoillustratedconcernsinthisarea.

o Individual’sstaffingneedsgenerallywereinadequatelydefined.Forexample,evenwhenanindividual’sISPindicatedthatone‐to‐onesupervisionwasnecessary,theroleofthisstaffmemberand/orthesupportsthestaffwouldprovideweredefinedinadequately.Thetwonewerplansdidnotspecificallydescribestaffingsupports.

o AsisdiscussedwithregardtoSectionU,forindividualsforwhomtheteamsidentifiedthepotentialneedforaguardianorotherassistanceinmakingdecisions,actionplanshadnotbeendevelopedtoaddressthisneed.

Examplesofissuesrelatedtothelackofintegrationcontinuedtobefound


# Provision AssessmentofStatus Compliancebetweennursing,dental,andphysicalandnutritionalsupportstoincorporatePNMPswithmedicationadministrationanddentalwork,anddental/medicalandpsychologytodevelopandimplementdesensitizationplans.

TheFacilityremainedoutofcompliancewiththisprovision.AlthoughtheFacilityhadbeguntoimplementtherevisedISPtemplateandprocess,itwasinitsinitialstagesofimplementation.Somelimitedimprovementswereseen.However,asnotedabove,teamswillneedadditionalcoachingandmentoringtofullyimplementtheprocessanddevelopISPsthatmeetthisrequirementoftheSettlementAgreement.

4. Identifiesthemethodsforimplementation,timeframesforcompletion,andthestaffresponsible;

Generally,fortheactionitemsidentifiedbyteams,timeframesandstaffresponsiblewereidentified.However,forthetwoISPsusingthenewerformat,thetimeframesoftenwereconfusing,because:1)teamshadcompletedthe“implementedby(Date)column”andthe“Completiondate”column,butoftenforitemsthatshouldnothavetakenayear(e.g.,completingajobintroduction,seeingthepsychiatrist,etc.,thebeginningdatewasthemonthoftheISPmeeting,andtheenddatewasayearlater,givingtheimpressionthattheteamhadayeartocompletetheseactivities;2)particularlybecausetheactionstepsthemselvesdidnotdefinethefrequencywithwhichactionsshouldoccur(e.g.,useofdiningplan,documentationofemesis)andthemonitoringcolumnwasnotdesignedtoaddressimplementation,theuseoftheterm“ongoing”inthecompletioncolumnforsomeactionstepsdidnotappeartobeappropriate,whenactivitiesshouldhaveoccurred,forexample,“daily,”“ateverymeal,”etc.;and3)theISPsfrequentlydidnotdistinguishbetweentimeframesforimplementationofactionsteps,andmonitoringoroversightofimplementation,althoughthisissueappearedtoberesolvedinthenewestintegratedhealthcaremanagementplans.Theyincludedacolumntoindicate“monitoringfrequencyandlocationofdocumentation.”AnissuerelatedtotheidentificationofstaffresponsiblenotedintheoneoftheISPsthatusedthenewformat(i.e.,Individual#63)wastheuseoftheterm“IDT”asopposedtoaspecificmember(s)oftheISP.Particularly,whenitcomestomonthlymonitoringofprograms/supports,itwillbeimportantforonepersontobeidentified.Inaddition,byusingthisbroaddescriptioneveryonewasresponsible,butnoonewasresponsible,reducingthelevelofaccountability.Generally,directsupportprofessionalswereidentifiedmorefrequentlyintheactionplans.Sincethelastreview,thiswasanimprovement.Itwillbeimportant,though,asdiscussedelsewheretoensurethattheirrolesareclearlydefined,aswellasthemethodologiestheyshouldusetoimplementactionsteps.Methodsforimplementationwerenotalwaysadequateorpresent.Inotherwords,the“how”wasnotprovided.Innoneofthe17plansreviewed(0%)wasthemethodology

Noncompliance


# Provision AssessmentofStatus Compliancesufficientlydescribedfortheactionplansincluded.Forexample,forplansusingtheolderformat,aswellasthetwoplansusingthenewformatandprocess:

Whenateamagreedthatadesensitizationplanwouldbedevelopedtoaddressanindividual’sdentalneeds,anumberofstepsshouldhavebeensetforthintheactionplan,includingthedevelopmentoftheplan,trainingofstaffontheplan,andimplementationoftheplan.Eachoftheseshouldhavehadaseparatetimeframeattachedtoit.Instead,suchactionplansoftenread:"Implementdesensitizationplan"withtheenddateofayear.

Similartootherplans,forIndividual#63,itwasunclearhowstaffwould"encouragefluidintakeandadequatenutrition"(italsowasunclearhowthiswouldbemeasured).Similarly,theintegratedhealthcareplansincludedmanyobjectivestomonitorlabs,obtainweights,ormeasurebloodpressurereadings.However,itwasunclearwhatwouldhappenoncethesewereobtained.Nocriteriaforactionwereprovided.

ForIndividual#228,moreofthemethodologywassetforthintheintegratedhealthcareplans.Forexample,specifictrackingofcertainhealthindicators,suchasBowelMovements,wereidentifiedwiththeactionstobetakenshouldstatedcriteriaweremet.However,attimes,nomethodologywasstated.Forexample,theindividualwasto"maintainadequategasexchangeAED[asevidencedby]O2[oxygen]sats[saturations]of95%orbetter."However,themethodologyfordeterminingthiswasnotstated(e.g.,whensaturationrateswouldbemeasured).Similarly,maintainingorimprovingheroralcareratingwasagoal.However,despiteadescriptionthatshewasresistanttostaffassistancewithtoothbrushingandthatshecouldnotbrushherteethherself,itwasunclearwhatmethodologytheteamwouldusetoachievethestatedgoal.

Inaddition,asisdiscussedwithregardtoSectionI,actionplansforindividualsidentifiedasbeingatriskfrequentlydidnotincludeadequatemethodologiestoreducetheat‐riskfactorstotheextentpossible.Theplansincludedinindividuals’riskactionplansoftenindicatedplansalreadyinplacewouldbeimplemented,orsetforthplansthatwerenotsufficientlyaggressivetoeitherfurtherevaluateand/oraddressindividuals’highandmediumrisklevels.Whenanindividualisidentifiedasbeingatrisk,teamsshoulddevelopplanswithclinicalintensitythatcorrespondswiththelevelofriskidentified.ThenewformatISPforIndividual#63wasanexampleofaplanthatshouldhaveincludedamoreassertiveplanforaddressinghishighriskforweight.Asdiscussedelsewhereinthissection,foranindividualundertheageof20withaBMIof43(i.e.,approximately100poundsoverweight,andinthemorbidlyobeserange),theclinicalplantheteamdevelopedtoaddressthiswasinadequate.TheFacilityremainedoutofcompliancewiththisprovision.Inadditiontobetterdefiningthemethodologiesinactionplans,cleartimeframesshouldbeestablishedand


# Provision AssessmentofStatus Compliancespecificteammembersshouldbeidentifiedasresponsible.

5. Providesinterventions,strategies,andsupportsthateffectivelyaddresstheindividual’sneedsforservicesandsupportsandarepracticalandfunctionalattheFacilityandincommunitysettings;and

Althoughalloftheplansincludedsomepracticalandfunctionalinterventions,noneofthe17plansreviewed(0%)effectivelyaddressedtheindividual’sfullarrayofneedsforservicesandsupports.Suchissuesarediscussedelsewhereinthisreportwithregardtoplanstoaddressconditionsthatplacedindividualsat‐risk,psychiatrictreatmentplans,nursingcareplans,PNMPs,OT/PTtreatmentplans,andPBSPs.Inaddition,asnotedinpreviousreports,duetosomeofthecharacteristicsoftheFacilityatthetimeofthereview,providingtraininginareasthatwouldbefunctionalinthecommunity,aswellasattheFacility,wasdifficult.Forexample,someofthegoalsandobjectivesdevelopedforindividualsappearedtobeconstrainedbysomeofthephysicalplantandadministrativestructuresinplace.Foodwasgenerallydeliveredfromacentralkitchen,socookingwasnotapartofdailylifeintheresidentialsettingsoncampus.Onlythreeofthe17plansreviewedincludedagoalrelatedtocooking,andthisappearedtooccurinaclassroomsetting.Noneoftheplansreviewedincludedgoalsrelatedtohousekeepingoryardwork,whichwouldbetypicalactivitiesforindependentadults.Likewise,becausepedestriansafetyskillsoncampusweredifferentthanthoseinthecommunityduetostrictspeedlimitsandminimaltrafficatCCSSLC,skillsthatindividualswerelearningorpracticingdailyoncampuswerenotpracticalorfunctionalinthecommunity.Inaddition,manyindividualsattheFacilityhadpart‐timeschedulesforworkordayactivities,andteamsdidnotappeartoviewtimelinessandattendanceissuesasprioritiestoberesolved(i.e.,inanintegratedfashionwithassistancefrompsychologystaff,whenappropriate).Similarly,lengthylunchbreaksduringwhichindividualswentbacktotheirresidencesdidnotallowopportunitiesforindividualstolearntoeitherbringlunchandeatattheirworksitesorinthevicinityoftheiractivityorvocationalsetting.Theselowexpectationsfailedtoprovideindividualswithfunctionalskillstoallowsuccessfultransitiontoacommunitysetting,whereregularparticipationinadayprogramorjobwouldbeexpected.Thedifferentsetofrulesoncampuscoupledwithindividuals’limitedexposuretothecommunitycouldbecomeadisadvantageforindividualswhodecidetotransitiontothecommunity.

Noncompliance

6. Identifiesthedatatobecollectedand/ordocumentationtobemaintainedandthefrequencyofdatacollectioninordertopermittheobjectiveanalysisoftheindividual’sprogress,theperson(s)responsibleforthe

Consistentwiththepreviousreviews,forthegoalsandobjectivesincludedinISPs,generally,theISPsspecifieddatatobecollectedand/ordocumentationtobemaintained,andspecifiedafrequencyfordatacollection.Itwasnotalwaysclearwhowasresponsibleforreviewingthedata,andwhatthatreviewmeantintermsofmakingchangeswhentherewaslittleornoprogress.However,inthetwoplansusingtherevisedformat,thiswasbecomingclearer.Morespecifically,forIndividual#228,the"PersonsResponsibleforImplementation/Documentation,""PersonResponsibleforPlanDevelopment,"and"PersonResponsibleforReviewingforProgress

Noncompliance


# Provision AssessmentofStatus Compliancedatacollection,andtheperson(s)responsibleforthedatareview.

andEffectiveness”wereidentified.However,forIndividual#63,althoughhisISPusedthenewformat,whichincludedcolumnsforbothdatacollectionanddatareview,oftenthepersonresponsiblewaslistedas"IDT."Thisdidnotmakeanyonemember(s)oftheIDTresponsible.Theoverarchingconcernwasthatmanygoalsandobjectiveswerenotspecifiedinindividuals’ISPs,orothertreatmentplansthatshouldhavebeenintegratedintotheISP(e.g.,objectivesrelatedtohealthmanagementplans,PNMPs,psychiatrictreatmentplans,etc.).Asaresult,appropriatedatawasnotbeingcollectedtoassistteamsindecision‐making.Noneofthe17ISPsreviewedappearedtobedrivenbyareviewofdata,andthepresenceorlackofprogressonmeasurableobjectivesandoutcomes.Sincethelastreview,improvementwasseenwithregardtodatabeingusedtoinformsomeoftheat‐riskdiscussions.Datathatshouldhavebeenincluded,butwasnot,relatedtoskillacquisitiongoaldata,datarelatedtotheimplementationofotherplans(e.g.,PNMPs,PBSPs,psychiatrictreatmentplans,etc.),anddetailsregardingindividuals’successesorfailures,etc.Thiswastrueforthetwonewplansaswell.AsisdiscussedbelowwithregardtoSectionsKandSoftheSettlementAgreementprocesseswerenotyetinplacetodeterminethereliabilityofthedata,buteffortswerebeginninginthisregard.However,therecontinuedtobesomeindicationsthatthedatabeingcollectedwasnotreliable.

F2b CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,theFacilityshallensurethatgoals,objectives,anticipatedoutcomes,services,supports,andtreatmentsarecoordinatedintheISP.

Asnotedinthepreviousreports,andbasedonthecurrentreviewofISPs,thiswasanareathatrequiredsubstantialimprovement.Asisdiscussedinothersectionsofthisreport,theMonitoringTeamfoundalackofcoordinatedsupportsinanumberofareas,includingbetweendental/medicalandbehavior/psychology;nursingandhabilitationtherapies;nursingandmedical;speech/communicationandpsychology;andbetweenthedisciplinesresponsiblefortheprovisionofphysicalandnutritionalsupportstoindividualsserved.AsnotedabovewithregardtoSectionF.1.a,someimprovementswerebeingseenwiththeinterdisciplinarydiscussionsthatoccurredduringISPmeetings.However,moreworkwasneededtoensureadequatecollaborationandcoordinationbetweenteammembers.

Noncompliance

F2c CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,theFacilityshallensurethateachISPisaccessibleandcomprehensibletothestaff

Atthetimeofthereview,theISPwaslocatedontheresidentialunit,butlockedinacabinetforsecurityreasons.Givenprivacyandsecurityrequirements,thiswasappropriate.Itappearedthatifstaffneededaccesstothelockedrecords,akeywaseasilyavailable.Theskillacquisitionprogramswerelocatedontheunitandaccessibletostaff,usuallyinIndividualNotebooks.

Noncompliance


# Provision AssessmentofStatus Complianceresponsibleforimplementingit. Improvementswereseeninthemannerinwhichplanswerewrittentofacilitatedirect

supportprofessionals’understanding.However,onewasratherdifficulttounderstand.Itappearedthiswasduetothewritingstyle(i.e.,Individual#282).Anotherissuerelatedtocomprehensibilityofthe17ISPsreviewedwasthelackofdelineationofresponsibilityfortheimplementationoftheplans.Asadirectsupportprofessional,itwouldbedifficulttoreadtheISPsaswrittenanddeterminewhathis/herresponsibilitieswerefortheindividualduringthecourseofthe24‐hourday.Althoughasnotedabove,theroleofdirectsupportprofessionalswasbecomingbetterdefined,thisinlargepartwasduetothefactthattheISPscontinuedtolackintegration,andmanyseparateplanscontinuedtoexistthatwerenotintegratedintotheonedocument.Althoughitwillbenecessaryfortheseparateplanstocontinuetoexist(e.g.,PBSPs,PNMPs,healthcareplans,etc.),thegoalsandobjectivesoftheseplans,andthedelineationofwhoisresponsibleforwhatwithregardtotheplansshouldbeincorporatedintotheoverallISP.Thisisnecessarytoprovideonedocumentthatclearlyidentifiesalloftheprotections,supports,andservicesthatneedtobeprovidedtotheindividual,andclearlyidentifiestheresponsibilitiesofvariousteammembers.Inaddition,withoutclearmethodologies,itwillcontinuetobedifficultfordirectsupportprofessionalstoconsistentlyimplementprogramsandsupports(e.g.,“encourage”andothersimilartermswouldbedifficulttoimplement).

F2d CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,theFacilityshallensurethat,atleastmonthly,andmoreoftenasneeded,theresponsibleinterdisciplinaryteammember(s)foreachprogramorsupportincludedintheISPassesstheprogressandefficacyoftherelatedinterventions.Ifthereisalackofexpectedprogress,theresponsibleIDTmember(s)shalltakeactionasneeded.Ifasignificantchangeintheindividual’sstatushasoccurred,theinterdisciplinaryteamshallmeettodetermineiftheISPneedstobemodified,andshallmodifytheISP,asappropriate.

BasedoninterviewswithFacilitystaff,monthlyreviewswerebeingcompletedmoreconsistently.However,theyonlyincludedtheQDDPs’reviewofskillacquisitionprograms.TheFacilityrecognizedthatthisreviewwouldneedtobeexpandedtoincludevariousteammembers’reviewof“eachprogramorsupportincludedintheISP.”TheQDDPCoordinatorwasworkingwiththeStateOfficedisciplineleadtodevelopanappropriateformatandprocess.Thiswasconfirmedthroughdocumentreview.Basedonthesampleof15recordsreviewed(excludingtheISPsforIndividual#228andIndividual#63),six(40%)hadmonthlyreviewseachmonthforthepreviousthreemonths(i.e.,Individual#184,Individual#363,Individual#26,Individual#250,Individual#124,andIndividual#155).Moreover,examplesareprovidedinvarioussectionsofthisreportofindividualsexperiencingchangesinstatusandtheirteamsnottakingappropriateactiontomodifytheirplansand/ortreatment.Numerousexamplesofthisareprovidedwithregardtomedicalandnursingcare,aswellasphysicalandnutritionalmanagementsupports.

Noncompliance

F2e Nolaterthan18monthsfromthe PreviousreportshavedescribedthetrainingthatCCSSLCstaffunderwent,including Noncompliance


# Provision AssessmentofStatus ComplianceEffectiveDatehereof,theFacilityshallrequireallstaffresponsibleforthedevelopmentofindividuals’ISPstosuccessfullycompleterelatedcompetency‐basedtraining.Oncethisinitialtrainingiscompleted,theFacilityshallrequiresuchstafftosuccessfullycompleterelatedcompetency‐basedtraining,commensuratewiththeirduties.Suchtrainingshalloccuruponstaff’sinitialemployment,onanas‐neededbasis,andonarefresherbasisatleastevery12monthsthereafter.StaffresponsibleforimplementingISPsshallreceivecompetency‐basedtrainingontheimplementationoftheindividuals’plansforwhichtheyareresponsibleandstaffshallreceiveupdatedcompetency‐basedtrainingwhentheplansarerevised.

SupportingVisions:PersonalSupportPlanning.TheQDDPCoordinatorandoneLeadQDDPhadbeencertifiedastrainersfortheQConstruction:FacilitatingforSuccesstraining.Asindicatedabove,sincethelastreview,staffatCCSSLChadparticipatedinadditionaltraining.Thisincluded:

TheQConstruction:FacilitatingforSuccesstrainingwasroutinelyprovidedtonewQDDPs.Thistrainingincludedawrittentestthateachparticipantcompletedattheendoftheclassroomtraining.Italsoincludedacompetencychecklist.Atthetimeofthereview,theQDDPCoordinatorhascompletedchecklistsontheQDDPs.BasedoninterviewwiththeQDDPCoordinator,onlytheQDDPEducatorhadbeendeemedcompetentonthefacilitationofISPmeetings.However,thetoolgenerallyprovidedagoodformatforreviewinganumberofplanningandfacilitationskills,anditappearedtheQDDPCoordinatorhadcriticallyreviewedtheskillsthattheQDDPsdemonstrated.Asindicatedinthepreviousreport,asthechecklistisimplemented,changeslikelywillneedtobemadetofurtherdefinecertaincompetencies,andtoensurereliabilityacrossreviewers.However,itsimplementationwasprovidingsomevaluableinformationtoassistQDDPsinrefiningtheirskills.

AsnotedwithregardtoSectionF.1.a,inMay2012,theStateOfficeprovidedadditionaltrainingonarevisedISPformatandprocesstoQDDPsandotherteammembers.ArevisedISPMeetingGuide(Preparation/Facilitation/DocumentationTool)wasintroducedtoassisttheQDDPinpreparingforthemeetingandinorganizingthemeetingstoensureteamscoveredrelevanttopics.Inaddition,thenewprocessonwhichtheQDDPsweretrainedincludedmorepre‐planningthatbegan90dayspriortotheISPmeeting.Aspartofthis,QDDPsweretrainedontheimplementationofanewtool/assessmententitledthePreferencesandSkillsInventory,aswellasthenewISPPreparationMeetingprocess.WritteninstructionsfortheISPmeetingguidealsowereprovidedtoQDDPs.TheseinstructionsprovidedsomehelpfulhintsanddirectiontoQDDPs.

TheQDDPCoordinatoralsocontinuedtoprovidetrainingtoQDDPsasCCSSLCpolicieswerechanged,orprocedures,suchastherulesaboutLA’sinvolvementinLivingOptionsmeetings,changed.

AreasinwhichadditionalworkwasneededtoreachcompliancewiththeSettlementAgreementincluded:

Asindicatedinpreviousreports,QDDPsshouldberequiredtodemonstratecompetencyinmeetingfacilitationandthedevelopmentofanappropriateISPdocument.Suchcompetencymeasuresshouldbeclearlydefinedandincludecriteriaforachievingcompetence.Asnotedabove,workwasunderwaytoaddressthefacilitationcomponentofcompetency‐basedtraining.AstheQDDPCoordinatorrecognized,thiswouldbeanongoingprocessuntileachQDDPdemonstratedcompetencyinthisarea.OnlytheQDDPEducatorhadachieved


# Provision AssessmentofStatus Compliancecompetence,butnoneofthe14QDDPs.CompetencymeasureshadnotbeendevelopedorimplementedwithregardtotheISPdocument.

Competencymeasuresforotherteammembersalsoshouldbeidentifiedandusedtoevaluatewhetheradditionaltrainingisneeded.

Asrecommendedinthepreviousreport,thereshouldbeadditionaltrainingonhowtothedevelopintegratedactionplans,includinghowtodrawtogethertheinformationgatheredinassessments,analyzethatinformation,incorporatetheindividual’sstrengthsandpreferences,setpriorities,providecleardirectionstothoseworkingwiththeindividual,anddevelopmeasurableobjectivestotrackprogressorlackthereof.Itwillbeimportanttoprovideteamswiththetoolsnecessarytofocusontheindividual’sinterests,prioritiesandvisionforhis/herlivingarrangements,whilereconcilingthesewiththeindividuals’medicalandsafetyneeds.

Reportedly,theStateconsultantsaswellastheQDDPCoordinatorwereconductingsomehands‐ontechnicalassistanceatteammeetings.Theseeffortsshouldcontinue,becausetechnicalassistancewillbeakeycomponentofenhancingandrefiningtheskillsofQDDPs,aswellasotherIDTmembers.

F2f Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithinoneyear,theFacilityshallprepareanISPforeachindividualwithinthirtydaysofadmission.TheISPshallberevisedannuallyandmoreoftenasneeded,andshallbeputintoeffectwithinthirtydaysofitspreparation,unless,becauseofextraordinarycircumstances,theFacilitySuperintendentgrantsawrittenextension.

BasedonsummarydatatheFacilityprovidedwithregardtoindividuals’mostrecentandpreviousISPdates,withinthelastyear259ISPmeetingshadbeenheld,andto‐date251documentshadbeencompleted.Ofthe259meetingsheld,all(100%)wereheldwithin365daysofthepreviousmeeting.TheFacilitytrackedthedatesthatISPswerecompletedandfiled.Forthelastone‐yearperiod,ofthe251completedplans,139(55%)planswerecompletedandfiledwithin30daysoftheISPdate.Asisnotedinothersectionsofthisreport,IDTsdidnotconsistentlymeettomakechangestoISPsforindividualswhoexperiencedchangesinstatus,orwhosecircumstancesshouldhaveresultedinmodificationsbeingmade(e.g.,multiplerestraints,requiringmodificationstoPBSPs).

Noncompliance

F2g CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,theFacilityshalldevelopandimplementqualityassuranceprocessesthatidentifyandremediateproblemstoensurethattheISPsaredevelopedand

Progresshadbeen sustainedwithregardtotheimplementationofqualityassuranceprocessesthatidentifyandremediateproblemstoensurethatISPsaredevelopedconsistentwiththissectionoftheSettlementAgreement.Positiveaspectsoftheprocessincluded:

DADSDraftPolicy#004.1atVcontinuedtoaddressqualityassuranceprocessestoensureISPsweredevelopedandimplementedconsistentwiththeprovisionsoftheSettlementAgreement.

CCSSLCwasconductingreviews/auditsofISPs,includingauditsusing:

Noncompliance


# Provision AssessmentofStatus Complianceimplementedconsistentwiththeprovisionsofthissection.

o ThePersonalSupportPlanMeeting/DocumentationMonitoringChecklist.TheFacilityrecentlyhadupdatedthisform,whichwasnowcalledtheIndividualSupportPlanMeeting/DocumentationMonitoringChecklist,dated6/12.ThemodificationstotheformweremadetocorrespondwiththerevisedISPprocess,andtofocusonpre‐meetingactivities,theISPmeeting,theISPdocument,andQDDPactivitiesafterimplementationbegins.Basedonareviewofthedocument,itincludedmanyimportantquestions/probesthatshouldbehelpfulinidentifyingareasofbestpractice,aswellasareasrequiringimprovement.Theonlycautionwouldbethatthoseimplementingtheformconsistentlylookforquality.Thiswillbeimportantforsomeofthequestionsthatareworded:“Didtheteam…(e.g.,discussactionplansorintegratedhealthplans,orreviewandapprovethepsychiatrictreatmentplan).Itwouldbepossibletoanswerthesequestions“yes”or“no”withoutevaluatingthequalityofthediscussionorreviews,whichwouldresultinlimitedvaluableinformation.TheFacilityintendedtobeginuseofthisforminJuly2012;and

o TheSettlementAgreementCrossReferencedwithICF/MRStandardsSectionF:IntegratedProtections,Services,TreatmentsandSupportsaudittool.

AProgramComplianceMonitorfromtheQADepartment,aswellastheQDDPCoordinatorwereconductingthereviews.Basedonthedocumentsprovided,QADepartmentandQDDPCoordinatorwereusingbothoftheaudittoolslistedabove.Facilitystaffresponsiblefortheseauditsappearedtobemakingeffortstoconductthoroughandcriticalreviews,andprovidejustificationforbothnegativeandpositivefindings.

Areasinwhichimprovementsshouldcontinuetobemadeinordertoachievecompliance,included:

TheFacility’spolicyF.10wasentitledQualityAssuranceforISPProcess,andhadanimplementationdateof11/1/11.ItreiteratedtheStatepolicyrequirementsformonitoring.However,theFacility’spolicydidnotdefineinfurtherdetailhowmonitoringwouldbecompletedatCCSSLC.

Forthevariousmonitoring/audittools,inter‐raterreliabilityneededtobeestablishedwiththeQAandprogrammaticstaff(i.e.,QDDPCoordinator)responsibleforconductingaudits.TheFacilityhadrecognizedthisneedbasedonthevariedresultsoftheauditingthathadbeencompletedthusfar,andeffortswerebeingmadetoimprovethevalidityandreliabilityofthefindings.Someoftheseactivitiesincludedattendingthesamemeetingsandcomparingfindings,meetingmonthlytodiscussmonitoringresults,andbeginningthe


# Provision AssessmentofStatus Complianceprocessofdevelopingdetailedinstructionsforthetools.Theadditionofinstructions/guidelineswillbeessentialtoimprovetheaccuracyofthemonitoringresults(validity),aswellasthecongruencebetweenvariousauditors(reliability).

Inresponsetoarequestforreportsshowinganalysisofmonitoring/auditdata,aswellasdescriptionsofactionstakenorcorrectiveactionplansdeveloped,theFacilitysubmittedthefollowingstatement:“NoEvidence.”TheFacilitywasatthebeginningstagesofutilizingthedatacollectedtoidentifyareasinneedofremediation,andtodevelopactionplanstoaddressthem.TheactionplansthatweresubmittedforSectionFappearedtobebasedlargelyonrecommendationsfromtheMonitoringTeam’sreports.Althoughthisisapositivefirststep,overtime,theFacility’sdatashouldbeusedtoidentifyareasinwhichchangeisneeded.

Initsself‐assessmenttheFacilityrecognizedthatitremainedoutofcompliancewiththisprovision,whichwasconsistentwiththeMonitoringTeam’sfindings.


1. Asappropriate,theFacilityshouldrefinefacility‐specificpoliciesandprocedurestoassistinensuringfullandconsistentimplementationoftheStatepolicyontheIndividualSupportPlanprocess.(SectionF.1)

2. Asnecessaryandappropriate,astheQDDPCoordinatorcompletescompetencychecksforallQDDPs,QDDPsshouldbeprovidedwithadditionaltechnicalassistanceortrainingongroupfacilitation,particularlyasisrelatestotheinterdisciplinaryteamprocess.(SectionF.1.a)

3. AsteamsmoveforwardwiththeimplementationofthenewISPPreparationmeetings,teamsshouldprovideanexplanationoftheirdecisionsrelatedtoteammemberattendanceattheannualISPmeetings,particularlywhenanindividualhasaneedinaspecificarea,andtheteamdecidesthattheattendanceoftheteammemberwiththatareaofexpertiseisnotrequired.SuchdecisionsshouldtakeintoconsiderationtheSettlementAgreementrequirementthat:“OtherpersonswhoparticipateinIDTmeetingsshallbedictatedbytheindividual’spreferencesandneeds.”AlthoughthisisanissuethatshouldbecarefullycoordinatedwiththeStateOffice,nowthatrisklevelsarebeingestablishedforindividuals,thismightbeonemechanismthatteamscouldusetodeterminewhichteammembersshouldattendanindividual’sannualplanningmeeting.(SectionF.1.b)

4. Assessmentsshouldincludeafullsetofrecommendationsthataredesignedtoassisttheteamsindevelopingactionplansthatdescribethearrayofprotections,supportsandservicesthattheindividualrequires.Asappropriate,assessmentsshouldrecommendspecificareasoffocusforskillacquisitionprograms,aswellasdetaildatathatneedstobecollectedandrolesandresponsibilitiesofvariousstaff.(SectionF.1.c)

5. NowthattheISPprocessincludesanannualreviewofincidents,andA/N/Eallegations,teamsshouldadequatelyconsiderhowtoaddresswhateverthemesmightberevealed,asanadditiontoreviewingnewallegationsorincidentsastheyarise.(SectionF.1.c)

6. Asindicatedinothersectionsofthisreport,focusedeffortsshouldbemadetoimprovethequalityofassessmentsthatareusedinthedevelopmentofindividuals’ISPs.Thisshouldincludeensuringthatassessmentsconsistentlyandconciselyidentifyindividuals’strengths,needs,andpreferences.(SectionF.1.c)

7. TheFacilityshouldconsiderdefininginpolicyakeysetofassessmentsthatshouldbeconductedregularly,andtheexpectedtimeframesforreevaluation.Teamsshouldberequiredtoprovideajustificationforveeringfromthisschedule.Optionalassessmentsalsoshouldbedefined


withcriteria/guidelinestoassistteamsindeterminingifsuchassessmentswouldbebeneficialtotheindividual.(SectionF.1.c)8. TheISPPreparationMeetingdocumentationshouldincludespaceforajustification,whichteamsshouldcomplete,particularlywhentheyare

notrequiringcompletionofanassessmentforwhichtheindividualhasspecificneeds.(SectionF.1.c)9. TheStateandtheFacilityshouldensurethatperson‐centeredconceptsareintegratedwiththeneedtodevelopcomprehensive,integrated

plans.Manyindividualsrequireplanswithmultiplesupports.TheState,workinginconjunctionwiththeFacility,shouldfigureoutwaystohaveadequate,technicalteamdiscussionsandincorporatesuchdiscussionsintocomprehensiveISPs,whilefocusingontheindividualandhis/herpreferences,strengths,etc.(SectionF.1.d,F.2.a.1,F.2.a.2,andF.2.a.3)

10. IDTsshouldintegratetherecommendationsfromassessmentsintoISPs,notjustreferencethem,andmakethehealthcare,therapeutic,andbehaviorsupportplansapartoftheISP,ratherthanstand‐alonedocuments.TheIDTshouldreviewandapproveallrelatedplans,andthespecificplanthathasbeenapprovedshouldbereferencedintheISP,includingthetitleanddateoftheplan.TheteamshouldapproveanymodificationsoftheapprovedplansthroughanISPA.IDTsalsoshouldincludeasetofobjectivesintheISPrelatedtoeachoftheplans,including,butnotlimitedtotheexpectedoutcomesfortheplans,anyrelatedskillacquisitionplans,aswellasdefiningwhatsupportsneedtobeimplemented,whoisresponsible,howsuccesswillbemeasured,whoisresponsiblefordatacollection,aswellaswhoisresponsibleformonitoringand/ordatareview.(SectionsF.1.d,F.2.a.2,andF.2.a.3)

11. Teammembersshouldbeprovidedongoingtrainingandtechnicalassistanceontheinterdisciplinaryprocess,includingtheintegrationofinformationanddevelopmentofstrategiestoaddressindividuals’preferences,strengths,andneeds,andtoidentifyandovercomebarriers.(SectionF.2.a.1)

12. TheFacilityshouldaddressbarrierssuchastransportation,paymentofstaff’sexpenseswhensupportingindividualstoparticipateinrecreationalandfood‐relatedactivities,andensuringadequatestaffingisavailabletoenableindividualstoparticipateincommunityactivitiesinsmallgroups.Individuals’ISPsshouldidentifytheseclearly,iftheyarebarrierstoprovidingtheindividualwithadequatesupportsandservices.(SectionF.2.a.1)

13. IDTsshouldcompleteadditionaltrainingand/orbeprovidedtechnicalassistanceonhowtothedevelopintegratedactionplans,includinghowtodrawtogethertheinformationgatheredinassessments,analyzethatinformation,incorporatetheindividual’spreferences,setpriorities,providecleardirectionstothoseworkingwiththeindividual,anddevelopmeasurableobjectivestotrackprogressorlackthereof.Itwillbeimportanttoprovideteamswiththetoolsnecessarytofocusonindividual’sinterests,prioritiesandvisionforhis/herlivingarrangements,whilereconcilingthesewiththeindividuals’medicalandsafetyneeds.(SectionsF.2.a.2,F.2.a.3,F.2.a.4,F.2.a.5,F.2.a.6,andF.2.e)

14. TheFacilityshouldbecreativeinensuringthatskillsthatarefunctionalincommunitysettings,butarenotregularlytaughtorpracticedattheFacility,suchascooking,cleaning,andrealisticcommunitysafetyskills,becomearegularpartoftrainingprogramsforindividualsserved.(SectionF.2.a.5)

15. ISPsshoulddelineateclearly:1)personsresponsiblefordatacollection;andb)personsresponsiblefordatareview.(SectionF.2.a.6)16. Giventheresponsibilitiesthatdirectsupportprofessionalshaveinimplementingtheplans,effortsneedtobemadetoensurethatISPsandall

oftheirvariouscomponentsarecomprehensible,whilestillcontainingthenecessaryclinicalrequirements,andthattheyclearlydelineatetherolesofdirectsupportprofessionals.(SectionF.2.c)

17. AstheFacilityfinalizesitsmonthlyreviewprocess,itshouldensurethatthefollowingbasicrequirementsaremet:a. Itincludesaprocessforeachteammembertoconductmonthlyreviewsoftheprogramswhichhe/sheisresponsiblethatresultsin

easyaccessforallteammemberstotheinformation;b. Monthlyreviewsshouldincorporatedata,asappropriate,toallowtheQDDPandtheteamtoassesstheefficacyoftheplansand

programsinplace,anddetermineifchangesareneeded,staffneedtoberetrained,moremonitoringneedstooccur,etc.;andc. QDDPsshoulddocumentclearlyfollow‐upactivityand/orchangesthataremadetoISPsasaresultofthesereviews.(SectionF.2.d)

18. Asthefacilitationskillsperformancetoolevolves:a. Thecriteriausedtomakedecisionsregardingwhethertorateanindicator“yes,”“needswork,”or“N/A”shouldbeclarified.b. Guidelinesshouldbeprovidedasnecessarytosupportreviewers’understandingoftheindicators.


c. TwoareasrelatedtoqualitythatshouldbeaddedtothechecklistincludetheQDDP’sabilityto:solicitdiscussionoftheindividual’scomprehensivesetofstrengths,preferences,needs,andsupports;andfacilitatetheadequateintegrationofthevariousdisciplinestoproblem‐solve,whereappropriate.(SectionF.2.e)

19. QDDPsshouldberequiredtodemonstratecompetenceinbothmeetingfacilitation,andthedevelopmentofanappropriateISPdocument.Suchcompetencymeasuresshouldbeclearlydefinedandincludecriteriaforachievingcompetence.Competencymeasuresforotherteammembersalsoshouldbeidentifiedandusedtoevaluatewhetheradditionaltrainingisneeded.(SectionF.2.e)

20. OngoingtrainingandtechnicalassistanceshouldbeprovidedtoaddressgapsinknowledgeregardingthenewISPprocess,aswellastoenhancethevariousteammembers’skills.(SectionF.2.e)

21. ConsiderationshouldbegiventoaddingexamplesofISPsthatarewelldone,whileprotectingtheidentityoftheindividual,tothetrainingmanualtoassistinteachingQDDPsandteamswhatisexpected.(SectionF.2.e)

22. WithregardtotheprocessofdeterminingwhetherornotQDDPsarecompetentwithregardtomeetingfacilitationskills,Facilitypolicyand/orprocedureshouldsetforththeparameterswithregardtoactionsthatwillbetakentoassistQDDPswhodonotoriginallymeetthecompetencyrequirements,aswellasotherstepsthatwouldneedtobetakenifcompetencycouldnotbeachieved.(SectionF.2.e)

23. TheFacility’sQAprocesseswithregardtoISPsshouldberefinedbymodifyingreviewtoolsandtherelatedinstructionsasappropriate,trainingauditorsontheiruse,establishinginter‐raterreliability,ensuringtheaccuracyofmonitoringresults,developingandpresentingreportsofthedatacollectedthatarerelevanttothevariousaudiences(i.e.,theQDDPCoordinator,andtheQA/QICouncil),analyzingdata,anddevelopingandimplementingcorrectiveactionplans,asappropriate.(FacilitySelf‐AssessmentandSectionF.2.g)


SECTIONG:IntegratedClinicalServicesEachFacilityshallprovideintegratedclinicalservicestoindividualsconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow.


o PresentationBookforSectionG,including:IntegratedClinicalServicesMeeting–AttendancesummaryforJanuary2012throughMay2012;SectionGMonitoringTools;CompletionofAssessmentsbyDiscipline(January2012throughMay2012);Rosters:annualmedicalassessments/dental/nursing/psychologyinClient’sInformationRecord(CIR)bydeadlineJanuary2012throughJune2012;consultreviewtrackingMarchtoMay2012;hospitaldischargeISPAs/InfirmaryISPAstrackingFebruarytoJune2012;ISPAttendance–Allmeetingtypes3/1/12to4/12/12,4/1/12to4/30/12,5/1/12to5/25/12,5/29/12to6/14/12;Skinintegritymeetingattendance;IntegratedClinicalServicesReportasof6/28/12;IntegratedClinicalServicesG.5:Diagnostics,AppointmentsandConsultsTrackingdraft,revision1/27/12;DiagnosticsReviewTrackingMarchtoMay2012;andChartAuditReportandTrendAnalysisfor3/12,and4/12;

o Forhospitalizationsinpriorsixmonths,copiesoffollow‐upISPAs:Individual#186on2/29/12;Individual#126on3/15/12,4/18/12,and5/17/12;Individual#223on1/2/12;Individual#244on3/26/12,3/28/12,and4/5/12;Individual#137on4/20/12,and4/24/12;Individual#167on1/20/12,5/9/12;Individual#213on2/21/12;Individual#275on3/27/12;Individual#273on4/11/12,5/7/12;Individual#21on4/18/12;Individual#89on1/9/12,1/23/12;Individual#176on4/19/12(edited4/25/12);Individual#304on4/24/12;Individual#174on2/27/12;Individual#124on3/30/12;Individual#326on1/18/12;Individual#268on3/15/12;Individual#224on5/8/12,and5/17/12;Individual#150on1/10/12,and1/17/12;Individual#282on3/26/12;Individual#270on4/17/12,and4/23/12;Individual#239on2/15/12,and2/22/12;Individual#175on3/22/12,4/25/12;Individual#367on4/3/12;Individual#130on4/6/12;Individual#163on2/16/12;Individual#87on3/26/12;Individual#181on4/23/12;Individual#293on2/24/12,2/27/12,and2/29/12;Individual#166on4/9/12;Individual#308on2/10/12;Individual#316on2/17/12,2/21/12,and3/16/12;Individual#195on3/26/12,4/12/12;andIndividual#156on5/15/12;

o Foroneindividualfromeachresidence,sincetheMonitoringTeam’slastreview,copiesofallconsultantreports(medicineandsurgery,inclusiveofsubspecialties),andallintegratedprogressnotescommentingonconsultantreports(medicineandsurgery,inclusiveofsubspecialties)(agreeingorreasonnotagreeing),andanyISPaddendumrelatedtotheconsultantreport:forIndividual#58,neurologyconsult12/10/11,ophthalmologyconsult12/9/11,neurologyconsult2/4/12,radiologyreport3/21/12,andpulmonaryconsult4/3/12;forIndividual#325,urologyconsult3/22/12;forIndividual#298,radiologyreport3/20/12;forIndividual#213,nephrologyconsult2/24/12,urologyconsult3/28/12,urologyconsult4/23/12,andneurologyconsult4/22/12;forIndividual#355,cardiologyconsult3/22/12,neurologyconsult3/31/12,


podiatryconsult4/3/12,diagnosticreport4/24/12,diagnosticreport4/28/12,anddiagnosticreport3/22/12;forIndividual#326,ophthalmologyconsult2/15/12,pulmonaryconsult2/21/12,andradiologyreport4/2/12;forIndividual#53,ophthalmologyconsult2/27/12;forIndividual#269,neurologyconsult2/4/12,cardiologyconsult2/22/12,ophthalmologyconsult4/6/12,andpulmonaryconsult4/24/12;forIndividual#291,ophthalmologyconsult1/13/12,cardiologyconsult4/17/17,andradiologyreport4/23/12;forIndividual#240,gastroenterologyreport4/24/112;forIndividual#187,endocrinologyconsult3/6/12,nephrologyconsult3/20/12,andcardiologyconsult4/24/12;andforIndividual#69,EarNoseThroat(ENT)consult1/31/12,andophthalmologyconsult3/22/12.

Interviewswith:o EugenioHernandez,MD;o SandraRodrigues,MD;ando AltheaPatStewart,RN,MedicalComplianceNurse.

FacilitySelf‐Assessment:AccordingtoCCSSLC’sSelf‐Assessment,theFacilitybegantomeasureintegrationofclinicalservices,includingcollectionofdata.Forexample,attendancesignaturesheetswereobtainedandreviewedtodeterminewhichclinicaldepartmentsattendedtheIntegratedClinicalServicesMeeting.PosthospitalISPAswerereviewed,andfoundincomplete,notfocusingonthereasonforthehospitalization.TheFacilityassessedwhetherornothealthconcernswereresolvedbythemorningclinicalmeeting’sassigneddeadlines.AnumberofotherauditswereconductedtodeterminewhetherappropriatedisciplinesreviewedtheMonitoringofSideEffectScale(MOSES)/DyskinesiaIdentificationSystem:CondensedUserScale(DISCUS),QuarterlyDrugRegimenReviews(QDRRs),andDoNotResuscitateOrders(DNRs).Theactiverecordwasreviewedtodetermineifdiagnosesandallergieswereconsistentlydocumentedacrossdocumentsandassessments.TheFacilityalsoassessedwhetherdisciplineswerecompletingassessmentsforISPsby10dayspriortotheISP.ThesewereallappropriatemeasurestoassisttheFacilityindeterminingwhetherornotintegratedclinicalserviceswereoccurringatCCSSLC.However,theFacility’sSelf‐Assessmentshouldincludeadescriptionofthesamplesselected(e.g.,howmanyISPAwerereviewedincomparisonwithhowmanyhadbeencompleted,fromwhattimeperiod,etc.),whoconductedthereviews(e.g.,departmentstaff,QIstaff),andotherdatasourcesused(e.g.,databaseorreviewmethodologyusedtodeterminetimelinessofassessments).ForSectionG.2,theFacilityusedtheSectionGMonitoringToolsandreviewedfivepercentoftheconsultations/appointmentsthatoccurredeachmonthtodeterminewhetherornotfollow‐uphadoccurredofnon‐facilityclinicianrecommendations,whethertheprimarycarepractitioner(PCP)processedconsultswithinfivebusinessdays,andiftheIDTswerereviewingthesedocuments.TheFacility’sreviewalsoincludedotherdataconcerningconsultreviewfromtheexternalpeerreviewandinternalmedicalprovideraudits.ThesewerealsoappropriateareastoreviewforSectionG.2,andwouldseemtohavethepotentialtoprovideapracticalimpact.Overall,althoughtheareasbeingmonitoredwereappropriate,theFacilityshouldexpandthescopeofinformationmonitoredtoincludeallthedepartmentslistedinSectionG.1,andnotfocussimplyonthe


MedicalDepartment.Compliancewithintegratedclinicalservicesrequiresmonitoringofallclinicalservices.TheroleoftheQADepartmentshouldbesignificantinmonitoringthemanyotherdepartmentsincludedinSectionG.1,butatthetimeofthereview,itdidnotappearthatthishadbeguntooccur.AsthequalityandoversightoftheISPAprocesswasofconcernwithregardtoindividuals’healthcare,theFacilityshouldreviewmethodsofmeasurementtotrackthequalityoftheISPAprocess.Thisisalsocloselyconnectedtothedevelopmentoftheat‐riskprocessasdiscussedwithregardtoSectionI.Basedonthesedatasets,theFacilitydetermineditwasnotcompliantwiththissection.ThiswasconsistentwiththeMonitoringTeam’sfindings.However,itwasunclearifthisinformationhadbeensharedwiththeActingMedicalDirector,ortheotherdepartments.SummaryofMonitor’sAssessment:Asnotedabove,theFacilityhadbegunassessingitselfinareassuchasattendance,qualityofISPAsrelatedtomedicalissues,andconsultreview.Thesewereimportantareas.ItremainedunclearhowthisvaluableinformationwassharedwiththeMedicalDepartmentstafforotherdepartments.TheroleoftheMedicalDirectorisimportantinprovidingguidanceinthismedicaladministrativearea,andthecontinuedlackofaMedicalDirectorwasproblematic.Medicaldepartmentstaffmeetingsshouldbeformalized.Periodic/quarterlymeetingswouldbeappropriateforumstodiscusstopicsandin‐serviceinformationspecifictomedicalstaff.Fortopicsthatgeneralizetootherdepartments,theIntegratedClinicalServicesMeetingmightbeappropriate.TheFacilityhadanumberofforumsinwhichintegratedservicescouldbefacilitated,including,forexample,thedailyIntegratedClinicalServicesMeeting,ISPandISPAmeetings,andcross‐disciplinecommittees.However,manyoftheselackedthefullparticipationofmembers,ordidnotresultinadequatefollow‐throughtodevelopintegrated,interdisciplinaryplanstoaddressindividuals’needsoneitheranindividualorsystemiclevel.ImprovementshadbeenmadeinPCPsreviewingconsultationreportsinatimelymanner.Althoughmoreworkwasneeded,PCPsalsoweremoreoftendocumentingtheiragreementornotwithrecommendations.However,whereadditionalworkremainedwasinensuringthatIDTsmetanddevelopedISPAs,asappropriate.

# Provision AssessmentofStatus ComplianceG1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithinthreeyears,eachFacilityshallprovideintegratedclinicalservices(i.e.,generalmedicine,psychology,psychiatry,nursing,dentistry,pharmacy,physicaltherapy,speech

TheMorningMedicalMeetingwasrenamedastheIntegratedClinicalServicesMeeting.Attendancewastrackedtodeterminethedegreeofrepresentationfromclinicaldepartments.TheMedicalDepartmentsubmittedatableentitled“AttendanceSummaryforJanuary2012throughMay2012.”Attendancewasdocumentedthroughasignaturesheetforeachmorningmeeting.Attendancewastrackedfordental,habilitationtherapy,nursing,medical,pharmacy,psychiatry,andpsychology.FromFebruarythroughMay2012,theDentalDepartmentwasrepresented90to100%ofthetime.Duringthissametimeperiod,forHabilitationTherapy,attendancewas43to70%.Forthemostrecent

Noncompliance


# Provision AssessmentofStatus Compliancetherapy,dietary,andoccupationaltherapy)toensurethatindividualsreceivetheclinicalservicestheyneed.

monthofMay 2012,attendancewas50%.Fornursing,fromFebruarythroughMay2012,attendancewas95to100%.FortheMedicalDepartment,attendancefromFebruarythroughMay2012,attendancewas100%.ForthePharmacyDepartment,attendancefromFebruarythroughMay2012was73to86%.ForthemostrecentmonthofMay2012,attendancewas73%.Forpsychiatry,attendancefromFebruarythroughMay2012variedfromoneto25%.ForthemostrecentmonthofMay2012,attendancewasonepercent.ForthePsychologyDepartment,attendancefromFebruarythroughMay2012variedfrom45to60%.ForthemostrecentmonthofMay2012,attendancewas45%.Itisrecommendedthatanalysisofdepartmentalattendancecontinue,andbedistributedquarterly.Additionally,attendancebyotherclinicaldepartmentsisrecommended,suchasregularattendancefromthePhysicalandNutritionalManagementTeam(PNMT).Somedepartmentsshouldberepresentedperiodically,suchasdietary,anddatashouldalsoreflecttheirparticipation.ThequalityoftheactivitiesoftheIntegratedClinicalServicesMeetingsisdiscussedwithregardtoSectionL.1.IntegratedclinicalservicesalsowerereflectedinIDTdiscussions,ISPAs,andchangesinriskplans.ThiswasmeasuredbytheMedicalDepartmentthroughtheSectionHTool.ForthoseindividualshospitalizedorplacedintheInfirmary,theMedicalDepartmenttrackedthecompletionofanISPA.BasedontheFacility’sdata,thisoccurred100%ofthetime.However,accordingtotheFacility’sSelf‐Assessment,theISPAsdidnotadequatelyaddresswaystopreventarecurrence.Thiswouldappeartoindicateseveralhealthconcernswerenottrackedtocompletion.IfanISPAdidnotaddresstheconcern,ordidnotincludestepstopreventarecurrence,thenitwouldappearthatthehealthconcernsidentifiedduringthemorningmedicalmeetingwerenottrackedtocompletionoftheconcern,butrathertoreceiptofanISPAwithoutregardforthequalityoftheISPA.AnimportantfocusofanISPAforahealthconcernisidentificationofpreventivestepsthatareclearlydefinedintheactionplan,andclearlyanswertheconcernraisedinthemorningmedicalmeeting.Theavailabledatadidnotreflectinsummaryform(similartotheIntegratedClinicalServicesCommitteeMeeting),thosewhoattendedtheIDTmeetingtodeveloptheISPA.ISPAswerereviewedforindividualsreturnedfromhospitalizationsinthepriorsixmonths.InmostISPAs,noevidencewasfoundthattheIDTdiscussedordevelopedclearactionplanstoattempttopreventanotherhospitalization,EmergencyRoom(ER)visit,orInfirmaryadmission,norwasthereevidenceofdiscussionofprecipitatingevents(i.e.,areviewofprecedingevents,signs,andsymptomsmightbeimportant).ExamplesofinadequateISPAsincludedtheISPAfor:Individual#186hospitalizedon2/29/12forpneumonia;Individual#126hospitalizedon5/17/12fordehydration(forwhichposthospitalorderswerechanged)andpneumonia;Individual#223hospitalizedon1/2/12forpneumonia;Individual#275hospitalizedon3/27/12forcolitisandfecalimpaction;Individual#273hospitalizedon5/7/12and4/11/12forpneumonia;Individual#176


# Provision AssessmentofStatus Compliancehospitalizedon4/19/12forpneumoniaandsepsis;Individual#270hospitalizedon4/23/12forpneumonia;Individual#239hospitalizedon2/15/12forpneumonia;andIndividual#87placedinInfirmaryon3/26/12forpneumonia.ThesefindingsaresimilartothedatabyMedicalDepartmentcollectedshowingthattheISPAsgenerallywerenotaddressingpreventionofacuteillness.AlthoughitwaspositivethattheMedicalDepartmentwasmonitoringtheISPAsthatresultedfromrecommendationsatthemorningmedicalmeeting,othersneededtobeinvolvedintheprocess.ThereisanurgentneedfortheQADepartmentandQDDPDepartmenttoreviewthequalityoftheISPAprocesstoensureconcernsfromthemedicalmorningmeetingareaddressed,andpreventivestepsareconsideredforthosehospitalizedorthosethathadanERvisit/Infirmaryadmission.Althoughthenewat‐riskprocessmightassistwiththisprocess,especiallyinrelationtohealthstatuschanges,atpresent,theISPAswerenotaddressingtheneedsoftheindividualinseveralinstances.Italsodidnotappearthemorningmedicalteamcriticallyreviewedallpost‐hospitalISPAsforcontentofactionstepsconcerningprevention,asmanyISPAswithoutpreventionstepswerenotreturnedtotheIDTforfurtherdiscussionandplanimplementation.TherewaslimitedinformationconcerningISPattendance,whichincluded“allmeetingtypes.”Timeperiodssubmittedoverlappedandincluded3/1/12to4/12/12,4/1/12to4/30/12,5/1/12to5/25/12,and5/29/12to6/14/12.BasedonthedatatheFacilitysubmitted,attendanceappearedtobe100%atrequiredmeetingsformostdepartments.However,nodatawasattachedtoverifythemanydepartmentsthatattended100%ofallrequiredmeetings.ItalsowasnotcleartheattendancerequirementsforvarioustypesofIDTmeetings.Inaddition,thisalsowasnotconsistentwiththeMonitoringTeam’sfindingsinrelationtoSectionF,whichaddressestheISPprocessspecifically.Forverificationofdata,itwouldbeimportanttoseparatetheISPattendancefromthe“allmeetingtypes,”andespeciallyfocusontheISPAsgeneratedasaresponsetohospitalizations,Infirmaryadmissions,andrequestsforfollow‐upfromthemorningmedicalteammeeting.TheMedicalDepartmentalsotrackedwhethertheMorningMedicalTeamMeeting/IntegratedClinicalServicesMeetingreviewedtheISPAoncecompleted.WhetheranISPAwascreatedwastracked,aswellaswhethertheMorningMedicalTeamreviewedtheISPA.BasedonthisdatatheFacilitysubmitted,theIDTs’compliancewithISPAcreationwas75%inJanuary2012,100%inFebruary2012,92%inMarch2012,and93%inApril2012.Accordingtothedata,reviewoftheISPAinthemorningmedicalteamreviewwas100%forallmonthsfromFebruarythroughApril2012.SimilardatawascollectedfortheISPAcreationfollowinganInfirmaryadmission,andtheMorningMedicalTeam’sfollow‐upreview.BasedontheFacility’sdata,theIDTs’compliancewithISPAcreationwas83%inJanuary2012,100%inFebruary2012,100%inMarch2012,96%inApril2012,and80%inMay2012.Accordingtothedata,themorningmedical


# Provision AssessmentofStatus Complianceteam’sreviewwas100%inallmonthsfromJanuarythroughMay2012.Again,asnotedabove,itdidnotappeartheIntegratedClinicalServicesMeetingmembers’reviewofthequalityoftheISPAswasadequate.TheSectionGMonitoringToolalsotrackedinterdisciplinaryinvolvementintheuseofclinicaltoolsandclinicaldecisions.Theseincludeddocumentationofreviewbynursingstaff,thePCP,neurologist,andpsychiatryoftheMOSES/DISCUSinstruments,asappropriate;reviewofDNRsforrationalewithupdatingfromthePCPandIDT;medical/psychiatricdiagnoseswithafocusonconsistencyacrossdisciplines;andtheconsistencyofdesignatedallergiesthroughouttheactiverecordandacrossdepartmentalassessments.ForMarch2012,complianceinthisareawas60%,andinApril2012was61%.Useofthisoverallcompliancescorewasfairlymeaningless.Withoutfurtherinformation,thedatadidnotassisttheFacilityinidentifyingwhich,ifany,ofthesevariousactivitieshadbeenimplementedasitshouldhavebeenandwhichrequiredattention.Inaddition,inter‐raterreliabilityforSectionG.1MonitoringToolwas0%(onlyonerecordwasreviewed).TAsnotedpreviously,therealsowasaneedfortheQADepartment’sgreaterparticipationinthisprocess.Therewereanumberofinterdisciplinaryclinicalcommitteesforwhichintegratedclinicalcollaborationwouldbeessential.ASkinIntegrityMeetingattendancerosterwassubmittedformeetingsinJanuary2012andApril2012.AttendanceincludedrepresentationofkeydepartmentsinJanuary2012,butnotinApril2012.InApril,habilitationservices,medicalservices,andfoodserviceswerenotrepresented.AlsoasdiscussedwithregardtoSectionH.1,timelycompletionofdepartmentalannualassessmentsfortheISPprocesswastracked,withsummaryinformationavailablefromJanuarythroughMay2012.BasedonthedatatheFacilitysubmitted,fortheDentalDepartment,compliancewas94to100%.FortheNursingDepartment,compliancevariedfrom50%(inFebruary2012)to93%(inMay2012).FortheMedicalDepartment,compliancerangedfrom93%inApril2012to7%inMay2012.ForthePsychiatryDepartment,compliancerangedfrom33%(January2012)to100%(inMarch2012).ForthePsychologyDepartment,compliancerangedfrom31%inFebruary2012to78%inMay2012.Asbackground,thedatasubmittedincludedlistsofcompletedassessmentdates.Thesedocumentswereentitled:“AnnualMedicalAssessmentsinCIR(Client’sInformationRecord)byDeadlineJanuary2012throughJune2012,”“DentalAssessmentsinCIRbyDeadlineJanuary2012throughJune2012,”“NursingAssessmentinCIRbyDeadlineJanuary2012throughJune2012,”“PsychiatryAssessmentsinCIRbyDeadlineJanuary2012throughJune2012,”and“PsychologyAnnualAssessmentsinCIRbyDeadlineJanuary2012throughJune2012.”AsisdiscussedinfurtherdetailwithregardtoSectionF,thelackoftimelinessofmanyassessments,aswellasissuesrelatedtotheirqualitycontinuedtointerferewithteams’abilitytodevelopadequateannual


# Provision AssessmentofStatus ComplianceISPsforindividuals.TheFacilitysubmittedanun‐namedseriesoftables,datedweekly,beginning6/7/12,thatincludedthedatesofthevariousdepartmentalannualassessmentsinpreparationfortheISPofanumberofmeetingsscheduledfor6/18/12to7/18/12.Inthefuture,theassessmentsforwhichotherclinicaldepartmentsareresponsibleshouldbetrackedsimilarthosecurrentlybeingmonitored.Forassessmentsthatmightbedueatlessfrequentintervalsthanyearly(suchasaudiology),thisinformationalsoshouldbetakenintoconsiderationincomputingtimelinessofthedepartmentalassessments.Thisdataprovidedadifferentperspectiveofwhenassessmentswerecompleted,inthatitrecordediftheywerereceivedinatimelymannerbytheISPduedate.Itmighthavereflecteddelaysindatainputaswellasdelaysincompletionofassessments.However,thedifferentdatabasesindicatedaneedforathoroughQAreviewofhowtheinformationisgenerated,andshouldincludeaninterpretationofthequalityofthedatagenerated.Insummary,althoughtheFacilitywasengaginginsomeactivitiesthatfacilitatedtheintegrationofcareandhadbeguntocollectdatainthisregarding,allclinicaldepartmentsareessentialinprovidingintegratedclinicalcare,andeachclinicaldepartmentshouldprovideevidenceoftheirparticipationinandimpactonintegratedcare.Thisshouldincludedevelopmentofmeasurableindicatorsforeachdepartmentthatreflecttheintegrationofcareacrossthecampus.TheroleoftheIDTisessential,andmeasuringthequalityoftheISPdocumentandthediscussionattheIDTmeetingswouldprovideevidencerelatedtothequalityofintegratedservices.Also,thereisconsiderablepotentialtodemonstrateintegratedclinicalcareintheriskratingprocess,includingthequalityoftheIntegratedRiskDiscussionResults,theRiskactionplans,theimplementationstepstaken,andtheoutcomes.Thiscouldbetrackedforstableconditionsaswellaschangesinhealthstatus.AtthetimeoftheMonitoringTeam’svisit,nodatawasavailabletomeasuremanyofthesecomponentsthatdemonstrateintegratedclinicalcare.

G2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,theappropriateclinicianshallreviewrecommendationsfromnon‐Facilityclinicians.Thereviewanddocumentationshallincludewhetherornottoadopttherecommendationsorwhetherto

TheFacilitysubmittedconsultantreportsforoneindividualfromeachresidence,aswellasanyIntegratedProgressNotes(IPNs)commentingontheconsultantreports.Consultationsfor12individualsweresubmitted,witharangeofonetosixconsultationsperindividual.Atotalof34consultantreportsweresubmitted.Thesearelistedaboveinthedocumentsreviewedsection.Reviewofthesedocumentsrevealedthefollowing:

Ofthe34reviewed,33(97%)includedthePCPinitials,indicatingreviewbythePCP.

Ofthe34reviewed,33(97%)includedthedateonwhichthePCPconductedthereview,indicatingtimelinessofreview.

Noncompliance


# Provision AssessmentofStatus CompliancerefertherecommendationstotheIDTforintegrationwithexistingsupportsandservices.

Todeterminewhethertherewasagreementornotconcerningconsultantrecommendations,follow‐upIPNsandISPAswererequested.Whensubmitted,thesewerereviewed.Ofthe34reviewed,therewerefiveforwhichanagreementornon‐agreementwasnotindicated(aninformationalreport).Thisleft29consultationsforwhichagreementornon‐agreementwasindicated.

o Atotalof23outof29(79%)consultsincludeddocumentationofagreementornotwiththeconsultantrecommendations.

Ofthetotalof34reviewed,24(71%)includedPCPIPNentries. Ofthese34,thereweretwoconsultantreportsforwhichanISPAwasnot

indicated.Forthe32consultantreportsforwhichanISPAwasindicated,oneoutof32(3%)ISPAsdocumentedthediscussionofthecontentsoftheconsultantreports,andthePCP’srecommendation.TheIDTsubmittedarosterofsignaturesindicatinganIDTreviewoftheconsultantreportinsixoutof34(18%).However,forthese,itcouldnotbedeterminedspecificallywhattheIDTdiscussedand/ordecided.TherewereanumberofotherISPAssubmitted,butthecontentsconcernedissuesunrelatedtotheconsultandtheIDTfollow‐upoftheconsult,andthereasonforsubmittingISPAsthatdidnotaddressthespecificconsultswasunclear.

Additionally,therewereseveralmeasurementprobesintheSectionGMonitoringTool,whichfocusedonSectionG.2.Oneoftheprobeswaswhetherthe“appropriateclinicianreviewsanddatesrecommendationsfromnon‐facilityconsultants”withinfivebusinessdays.ForbothMarchandAprilof2012,compliancewas100%.However,theIDTreviewedonly25%oftheseconsultreports.TheMedicalDepartmentconductedamorethoroughreviewofPCPreviewofnon‐facilityconsultantreportsthroughreviewofdetailedtrackingdata.ForJanuary2012,therewasalistingofonepage.ForFebruary2012,therewasalistingoffivepages.ForMarch2012,therewasalistingofsixpagesofconsultantreports.ForApril,thelistingwaseightpages.ForMay2012,thelistingwasfivepages.TheanalysisindicatedthatinJanuary2012thePCPsreviewed87.5%ofconsultreportswithinfivedaysofreceipt,82%inFebruary2012,70%inMarch2012,89.7%inApril2012,and98.5%inMay2012.TheIDTreviewed0.07%oftheconsultreportsinMarch2012,43.1%inApril2012,and46.2%inMay2012.TherewasnodataforJanuary2012orFebruary2012fortheIDTreviewofconsultreports.ThiswasvaluableforguidingtheMedicalDepartmentandtheIDTs,butitwasnotclearifthiswassharedinatimelymanner.ToassistthePCPinacknowledgingreviewofconsultreports,astampwasenteredoneachconsultreportreceived.ItincludedthedateofreviewbythePCP,thesignature/initialsofthePCP,whethertherewasagreementornot,verificationofaPCP


# Provision AssessmentofStatus ComplianceIPNcompleted,orwhetherthePCPwasoutoftheoffice.Separately,informationwasavailablefromtheMedicalProviderQualityAssuranceAudit–ExternalAuditsforRound#5.Fromquestion#27(“Aremedicaland/orsurgicalconsultantrecommendationsaddressedintheintegratedprogressnoteswithinfivebusinessdaysaftertheconsultationrecommendationsarereceived?”),resultsindicated82%compliance.An“InternalAuditforRound#5”documented86%complianceforthesameindicator.TherewereotherquestionsprobedintheSectionG.2MonitoringTool,including:“cliniciandocumentsinIPNdecisionwhetherornottoadoptrecommendations,”“clinicianwritesordersforadoptedrecommendations,”“IDTinformedofclinician’sdecisionwhetherornottoadoptrecommendationsasevidencedbysignedConsultantRecommendationsReview,”“signedconsultantrecommendationsplacedbehindoriginalconsultinAR(ActiveRecord),”and“adoptedrecommendationsareintegratedintonewISP/ISPAasindicated.”BasedontheFacility’sdata,forMarch2012,compliancewiththeseG.2probeswas55%,andforApril2012compliancewas61%.Inter‐raterreliabilitywas50%(onerecordreviewed).Therewerepolicyupdatesaspartofthesystemicchangestoimproveintegrationofclinicalcareanddocumentationofthisprocess.On1/27/12,theIntegratedClinicalServicesPolicyG.5:Diagnostics,Appointments,andConsultsTrackingwasrevised.SomeoftheareasofchangeincludedpullingtheactiverecordforPCPreviewintheClinicassoonasareportwasreceived,newdiagnosesweretoresultinanursingcareplanorhealthmaintenanceplantoaddressthediagnosis,anexpeditedprocesstoupdatetheDG1throughtheMedicalDepartment,andanadditionalcolumninthelogdatabaseforPCPreviewanddateofreviewforlabanddiagnostictestresults.Ifthispolicyweretobeconsistentlycarriedout,itwouldprovideevidencetosupportcompliancewithseveralareasoftheSettlementAgreement,includingSectionsG.2,H.2,L.1,L.3,aswellasaspectsofSectionsIandM.BasedontheMonitoringTeam’sreview,improvementshadbeenmadeinPCPsreviewingconsultationreportsinatimelymanner.Althoughmoreworkwasneeded,PCPsalsoweremoreoftendocumentingtheiragreementornotwithrecommendations.However,whereadditionalworkremainedwasinensuringthatIDTsmetanddevelopedISPAs,asappropriate.TheFacilityremainedoutofcompliancewiththisprovision.


1. TheanalysisofdepartmentalattendanceatIntegratedClinicalServicesMeetingsshouldbedistributedquarterlytoFacilityAdministrationand


thedepartmentsbeingtracked,andused,asappropriate,tomakeneededchanges.Additionally,attendancebyotherclinicaldepartmentsand/orthosenotregularlyattendingisrecommendedandencouraged,suchasPNMTorHabilitationServicesandDietary.(SectionG.1)

2. AnimportantfocusoftheISPAforahealthconcernshouldbeadeterminationofpreventivestepsthatareclearlydefinedintheactionplan.(SectionG.1)

3. AsystemshouldbedevelopedtoreviewthequalityoftheISPAtoensureitanswerstheconcernsidentifiedattheIntegratedClinicalServicesMeetings,andprovidesapreventiveplanforhospitalizations,ERvisits,etc.(SectionG.1)

4. ForISPAsthatfocusonhealthandsafety,departmentalattendanceattheISPAmeetingshouldbetrackedandanalyzed.Thisshouldbetrackedseparatelythanforothermeetings,suchasISPsorISPAsforotherreasons.(SectionG.1)

5. TheQADepartmentshouldincreaseitsmonitoringroleforSectionG.(SectionG.1)6. Timelycompletionofannualassessmentsorperiodicassessments(iflessfrequentthanannual)shouldbetrackedforallclinicaldepartments.

(SectionG.1)7. TheIntegratedClinicalServicesReportshouldbecompletedquarterlyfordistributionanddiscussionatamedicalstaffmeeting,aswellas

forwardedtotheQADepartmentandFacilityAdministrationforreviewandaction,asappropriate.(SectionG.2)8. TheFacility’sSelf‐Assessmentshouldincludeadescriptionofthesamplesselected(e.g.,howmanyISPAwerereviewedincomparisonwith

howmanyhadbeencompleted,fromwhattimeperiod,etc.),whoconductedthereviews(e.g.,departmentstaff,QIstaff),andotherdatasourcesused(e.g.,databaseorreviewmethodologyusedtodeterminetimelinessofassessments).(FacilitySelf‐Assessment)

9. TheFacilityshouldexpandthescopeofinformationmonitoredtoincludeallthedepartmentslistedinSectionG.1,andnotfocussimplyontheMedicalDepartment.(FacilitySelf‐Assessment)


SECTIONH:MinimumCommonElementsofClinicalCareEachFacilityshallprovideclinicalservicestoindividualsconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow:

StepsTakentoAssessCompliance: Thefollowingactivitiesoccurredtoassesscompliance: ReviewofFollowingDocuments:

o PresentationBookforSectionH:TexasICD‐10SiteVisitAgenda;CommonDiagnosisMedicareCodingGuide,revised4/1/03;ClinicalIndicatorGuideforat‐riskcategories;hospitaldocumentslistingJanuarytoMarch2012;ERdocumentsJantoApril2012;SectionHMonitoringTool;CompletionofAssessmentsbyDisciplineJanuary2012toApril2012;annualassessmentsinCIRbydeadlineJanuarytoJune2012:medical,nursing,psychiatry,psychology;QualityAssuranceQuestionnaire:ERvisits/hospitalizations;HospitalizationQADecember2011toMay2012;constipationtracking,diets,reason/criteriaforDNR,Down’ssyndrometracking,mammogramtracking,osteoporosistracking,tracheostomytracking,seizuretracking,consultreviewtracking,diagnosticsreviewtracking;QA/QIQuarterlySectionreviewofSettlementAgreementProgress‐SectionH,3/21/12,6/28/12;andIntegratedClinicalServicesReportasof6/28/12;

o FortwoindividualsfromeachPCP’scaseload,fourdiagnoseswithcriteriaforjustificationfromactiverecord,including:Individual#255,Individual#137,Individual#55,Individual#93,Individual#250,Individual#357,Individual#187,andIndividual#156;and

o “IndividualswithISPsscheduledbetween5/1/12and6/30/12‐AssessmentCompliance.”

Interviewswith:o NormaBrown,MD;o SandraRodrigues,MD;ando AltheaPatStewart,MedicalComplianceNurse.

FacilitySelf‐Assessment:InitsSelf‐Assessment,theFacilityhadidentifiedanumberofappropriateactivitiestomonitoritscompliancewithSectionH.Forexample,forSectionH.1,theFacilityreviewedroutineassessmentsofclinicaldepartmentstodetermineifthesewerecompletedinatimelymanner(annual).Dental,nursing,medicalandpsychiatrydepartmentswerereviewed.ThesampleincludedoneactiverecordfromeachofthePCPs’caseloadseachmonth.Also,theFacilityreviewedthequarterlydatarelatedtoMOSES/DISCUS,QDRRs,aswellasDNRs,andquarterlyreviewsbythemedical,nursing,andpsychiatrydepartments.DatarelatedtothereviewoftheMOSES/DISCUS,DNRs,andQDRRsweresummarizedasonevalue,despitethedifferentdepartmentsinvolvedinthesedocuments,andthepotentiallydifferentindicatorsthatwouldneedtobemeasuredforeachoftheseprocesses(e.g.,timelinessofcompletion,timelinessofreviewbyclinicalstaff,qualityofreviewanddocumentation,etc.).Nodatawasprovidedconcerningthequarterlyassessmentstheclinicaldepartmentscompleted.AlthoughitwaspositivethattheFacilityhadidentifiedadditionalself‐assessmentactivitiesforSectionHandmanyofthesehadmerit,theprocessrequiredfurtherrefinement.Forexample,forSectionH.2,theFacilityassessedfortrainingondiagnosticcodes,andconcludedthatthetraininghadnotoccurred.IthadnotyetconductedrecordreviewsastheMonitoringTeamwasdoingtodetermineifadequatejustification


existedforthediagnosesofrecord.TheMonitoringTeamfoundcomplianceforSectionH.2,buttheFacilitydidnot.Inotherinstances,itwasunclearwhatcriteriareviewerswereusingtodeterminecompliance.Forexample,whendeterminingwhethertreatmentswere“clinicallyappropriate,”itwasuncleariftheclinicalguidelinesStateOfficehadissuedwereused.Instillotherinstances,itdidnotappearthatwhattheFacilitywasmeasuringrelateddirectlytotherequirementsoftheSettlementAgreement.Forexample,forSectionH.4,whichrequiresthat:“clinicalindicatorsoftheefficacyoftreatmentsandinterventionsshallbedeterminedinaclinicallyjustifiedmanner,”noneoftheindicatorsappearedtorelatetoclinicalindicators(i.e.,measurableobjectives).TheFacilityidentifiedthatitwasnotinsubstantialcompliancewithanyofthesubsectionsofSectionH.However,moreworkwasneededtorefinetheFacility’sSelf‐Assessmentprocesses.TheQualityAssuranceDepartmentshouldworkwithDepartmentstafftofinalizemonitoringtoolsaswellaskeyindicatormeasures,andtoestablishreliableandvaliddatacollectionmethodologies.SummaryofMonitor’sAssessment:AlthoughCCSSLCwasputtingsomesystemsinplacetoensurethatassessmentsandevaluationswerecompletedtimely,thesystemscontinuedtobeinthedevelopmentstage.Inaddition,thevariousdatabasescollectingthisinformationdifferedsomewhatintheresultsrelatedtotimelinessofassessments.Thismightbeduetothefactthatthedatabaseswerebeingusedfordifferentpurposes(e.g.,annualISPassessmentsasopposedtocomparisontothedateofthepreviousassessment).ChangeofstatusalsowasanareatheFacilitywastryingtobetterdefine.Withregardtoaccuratediagnoses,reviewstheMonitoringTeamcompletedofbothmedicaldiagnosesandpsychiatricdiagnosesfoundadequatejustificationfor100%and95%,respectively.Asaresult,theFacilitywasfoundincompliancewiththisprovision.Teamswerenotconsistentlyidentifyingclinicalindicatorstomeasuretheefficacyoftreatmentinterventionsforindividualsatrisk.Problemswiththeindicatorsincluded,attimes,alackofmeasurability.Thequalityoftheindicatorsalsowasproblematicintermsoftellingtheindividuals’teamswhetherornottheindividualsweredoingbetterorworse,orremainingthesame.Finally,individuals’teamsoftendidnotdevelopmeasurableindicatorstoaddressalloftheindividuals’areasofrisk.AlthoughtheFacilityhaddevelopedsomeAtRiskClinicalIndicatorsGuidelines,thesewerenotyetfullyinuse.TheFacilitystilldidnothaveanadequatesystemtoeffectivelymonitorthehealthstatusofindividuals.Asoneexample,asdiscussedwithregardtoSectionM,althoughquarterlynursingassessmentswerebeingcompleted,theywereinadequate.Inaddition,day‐to‐daynursingassessmentswerenotadequatetoensurethatchangesinindividuals’statuswerepromptlyidentifiedandreportedtothePCPs.


# Provision AssessmentofStatus ComplianceH1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithintwoyears,assessmentsorevaluationsshallbeperformedonaregularbasisandinresponsetodevelopmentsorchangesinanindividual’sstatustoensurethetimelydetectionofindividuals’needs.

TheMedicalDepartmentmonitoredthecompletionofroutineassessmentstodeterminetimelinessofcompletion.Fivedepartmentswerereviewed:dental,nursing,medical,psychiatry,andpsychology.Reviewinvolveddeterminingthenumberofassessmentsduepermonth.DatafromJanuarythroughApril2012wereprovided.BasedontheFacility’sdata,theDentalDepartmentwasconsistentlycompliantfromJanuary2012throughApril2012,withacompliancerateoftimelysubmissionofassessmentsin94to100%ofcases.Accordingtothedata,theNursingDepartmentimprovedoverthefourmonthsinsubmissionofcompletedannualassessments.InJanuary2012,nursinghadcompleted67%ofannualassessmentsinatimelymanner,whichdroppedto50%inFebruary2012,increasedto86%inMarch2012,andincreasedfurtherto91%inApril2012.BasedontheFacility’sdata,theMedicalDepartmenthadasimilarcompliancecurveasnursing.InJanuary2012,67%ofannualmedicalassessmentswerecompletedinatimelymanner,whichdroppedto56%inFebruary2012,increasedto84%inMarch2012,andincreasedfurtherto93%inApril2012.Psychiatrywas33%compliantwithtimelycompletionofannualassessmentsinJanuary2012.Thisincreasedto75%inFebruary2012,and100%inMarch2012,butdecreasedto81%inApril2012.Psychologywas42%compliantwithtimelycompletionofannualassessmentsinJanuary2012,31%compliantinFebruary2012,45%compliantinMarch2012,and44%compliantinApril2012.TheMonitoringTeamdidnotconfirmthisdata.However,asdiscussedbelow,althoughfordifferenttimeperiods,someofthisdatadidnotshowsimilarimprovements.AcomputerizedlistwassubmittedseparatefromtheMedicalDepartmentreview.InformationrequestedincludeddatesofISPsforthepasttwomonths,alongwithdatesoftheassessmentsbythevariousdepartments.Achartwassubmittedentitled“IndividualswithISPsscheduledbetween5/1/12and6/3/12–AssessmentCompliance.”Itwasnotedthatfortwodepartments,thereweresignificantdocumentsnotreceived,oratleastnotnotedinthedatabaseasbeingreceived.Therewere52annualISPmeetingsscheduled.FortheMedicalDepartment,therewasarecordofonlysixupdatedassessments(12%)beingreceived.Fordietary,onlynine(17%)assessmentshadbeenreceived.Itisrecommendedthatthelistofannualassessmentsbeingtrackedbeexpandedtoincludeotherclinicaldepartmentssuchasdietaryandhabilitationtherapy.Separately,Question#17oftheMedicalProviderQualityAssuranceAuditprovidedanotherapproachtoreviewtheappropriatenessofassessmentsandevaluations:“Aremedicallyappropriatediagnostictestsand/ortherapeuticproceduresordered?”FromtheInternalAuditofRound5,therewas100%compliancewiththisaspectofcareinthechartsreviewed.

Noncompliance


# Provision AssessmentofStatus ComplianceTheMedicalDepartmentalsodevelopeddatabasesforvariousdiagnoses.Thesereflectedpreventivetestingdoneatregularintervals,aswellastreatments(e.g.,diet,medication)topreventadverseevents(e.g.,choking,acuteconstipation,etc.).TheMedicalDepartmentsubmittedthefollowingchartsasexamplesofthese:Constipationtrack(individualswithroutinemedicationtopreventconstipation),individualsrequiringdietswithspecialtexturesorfluidthickening,individualswithDNRstatus(dateoflastreview,reasonforDNRstatus),Down’ssyndrometrack(individualsanddateoflastthyroidtesting),mammogramtrack(individualsanddateoflastmammogramwithreasonsifnotcompleted),osteoporosistracking(individualswithosteoporosis/osteopenia,dateoflastDEXAscan,Tscore,treatment),individualswithtracheostomy,seizuretrack(individualswithseizuretypeandmedicationsprescribed),hospitalhistoryandphysicalandhospitaldischargesummariesreceivedandlocatedintheactiverecord,anddischargeordersfromtheERlocatedintheactiverecord.Thesemanydatabaseswereofmixedcompleteness.Thedataonmammograms,seizures,andtracheostomiesappearedtobecompleteandup‐to‐date.Thedataonosteoporosishadsignificantlyimprovedincompletenessofdata,butstilllackedcompleteinformationconcerningparenteralbisphosphonateuse.Asaresult,notalldatabaseswereadequateinguidingthePCPsandMedicalDepartment.Itwasnotclearwhenthesedatabaseswerereviewed,andthemodeofcommunicationusedtodisseminateanyanalysisofthedata,suchasquarterlyreports,medicalstaffmeetings,etc.SectionH.1includesallelementsofclinicalcare.Asisdiscussedinthevarioussectionsofthisreport,issuesremainedwithboththetimeliness,andparticularlythequalityofassessmentsandevaluations.TheQADepartmentshouldensureeachclinicaldepartmentmeasuresprogressinthetimelycompletionofrequiredmonthly,quarterlyorannualassessmentsandforms.Attendanceshouldbetrackedatinterdisciplinarymeetings.Otherclinicalindicatorsofintegratedcareofthesecommonelementsshouldbedeveloped.Theclinicalguidelinesmightassistindevelopingablueprintforevaluation.Forexample,foragivendiagnosis,thereshouldbeevidencethattheneededdisciplinesprovidedassessments,thattheteamdiscussedtheseevaluations,andthattheessentialelementsforcareforthatdiagnosiswereincludedinacorrectiveactionplan.Thecorrectiveactionplanshouldbemonitoreduntilclosure.Asindicated,thisshouldincludepsychology,psychiatry,medical,dental,nursing,habilitationtherapies,dietary,andpharmacy.AlthoughCCSSLCwasputtingsomesystemsinplacetoensurethatassessmentsandevaluationswerecompletedtimely,thesystemscontinuedtobeinthedevelopmentstage.Inaddition,thevariousdatabasescollectingthisinformationdifferedsomewhatintheresultsrelatedtotimelinessofassessments.Thismightbeduetothefactthatthe


# Provision AssessmentofStatus Compliancedatabaseswerebeingusedfordifferentpurposes(e.g.,annualISPassessmentsasopposedtocomparisontothedateofthepreviousassessment).ChangeofstatusalsowasanareatheFacilitywastryingtobetterdefine.Inadditiontoreconcilingthedata,theFacilityshouldusethedatathatwasbeingproducedtoidentifyareasofconcerninrelationtoassessments.TheFacilityremainedoutofcompliancewiththisprovisionoftheSettlementAgreement.

H2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,diagnosesshallclinicallyfitthecorrespondingassessmentsorevaluationsandshallbeconsistentwiththecurrentversionoftheDiagnosticandStatisticalManualofMentalDisordersandtheInternationalStatisticalClassificationofDiseasesandRelatedHealthProblems.

Asampleofdiagnoseslistedinindividual’sactiveproblemlistswassubmitted.ThesamplewasderivedfromtwoactiverecordsfromeachPCP’scaseload,forindividualsforwhomannualmedicalassessmentsweremostrecentlycompleted.ThePCPswereaskedtoprovidethecriteriaorevidenceusedtoshowthediagnosesclinicallyfittheinformationinthecorrespondingassessmentsorevaluationsforfourdiagnosesfromeachactiverecord.Evidencewasprovidedthroughvarioussources(e.g.,consultantreports,testreports,etc.).For32of32diagnosessubmittedwithsupportivedocumentation(100%),thecriterialistedwereconsistentwiththediagnosislisted.AsdiscussedindetailwithregardtoSectionsJ.2andJ.6,basedonthesamplereviewedforSectionJ,therewasadequateclinicaljustificationforthediagnosisofrecordfor19ofthe20individuals(95%).WiththecompletionofComprehensivePsychiatricEvaluationsaccordingtotherequirementsoftheSettlementAgreementandongoingquarterlyupdatesforeveryoneprescribedpsychotropicmedication,theFacilityhadsignificantlyimprovedinitsdiagnosticpracticesrelatedtopsychiatricdisorders.An11‐pagelistofcommondiagnosesutilizedatCCSSLCwassubmittedalongwiththecurrentICD‐9codes,whichwasusedtoassistthePCPsindeterminingthemostaccurateanddetaileddiagnosisreflectedintheIDC‐9codes.However,accordingtothePCPs,whenreviewingtheICD‐9optionsandselectingthemostappropriateanddetailedterminology,whenthisterminologyandcodewassubmittedforupdatingtheDG1,thesoftwareprogramutilizedintheStateOfficesystemattimesconvertedittoaterminologywhichwaslessspecificorlessaccurate.ItappearedthesoftwareconvertedthespecificdiagnosisprovidedbythePCPstomoregeneraldiagnosticcategories,whichpotentiallywouldleadtolessaccuratelistsofdiagnosesintheDG1database.Althoughthisdoesnotdirectlyrelatetocompliance,itisrecommendedthatthesystemsanalystcommunicatewiththecounterpartsattheStateOfficetodetermineifthemorespecificdiagnosescanbeenteredonthecomputerizedDG1.ThesystemsanalystalsoshouldreviewthenewsoftwarefortheupcomingICD10codingsystemtodetermineifthesameproblemwilloccur,orifthecodeswillmaintainspecificityanddetailincategorizingthediagnosis.


H3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwith

TheFacilityhadbeguntoreviewitsperformancewithregardtotimelyandappropriatetreatmentandinterventions.Itchoseacuteandemergentcarepresumablybecausesuch

Noncompliance


# Provision AssessmentofStatus Compliancefullimplementationwithintwoyears,treatmentsandinterventionsshallbetimelyandclinicallyappropriatebaseduponassessmentsanddiagnoses.

situationsrequiredhighlevelsofperformancetoprotectindividualsfromharm.Inordertoanalyzevariousaspectsofacuteandemergentcare,theMedicalDepartmentused“AcuteCare/EmergentCareMonitoringTool,”revised3/5/12.Subsectionsofthistoolincluded:“Respondingtoacuteillness/injury,”and“Hospitalization,Transfers,Readmissions”tomeasureacutecare.“RespondingtoAcuteIllness/Injury”includedmeasurablestepsfromthedirectsupportprofessionalreportinganillness/injurytothenurse,tothenursenotifyingthePCP,referraltotheClinic,documentationrequirementsintheIPNandintheActiveProblemlist,andupdatingRiskActionPlans.Sixteenmeasurablestepswereidentified.ForMarch2012,oneactiverecordfromeachPCPcaseloadwaschosen.Fortwooutoffour(50%),itwasnotedthatthenursedocumentedintheIPNinSOAPformatandnotifiedthePCPandIDT.ThePCPupdatedtheActiveProblemListinoneofthree.TheRiskActionPlanwasnotfoundinanyofthefourrecords.FortheApril2012review,thenursenotifiedthePCPwithinonehourofreadmissiontoCCSSLCinthreeoffourcases,theActiveProblemListwasupdatedinthreeoffourcases,andtheRiskActionPlanwasupdatedinoneoffourcases.The“Hospitalization,Transfers,Readmissions”sectionincluded17measureablesteps,suchasspecificupdateddocumentsinthetransferpacket,thePCPornursetelephoningthereceivingfacility,anursingassessmentcompleteduponreturntoCCSSLC,aPCPsummaryofhospitalization,andhospitalizationinformationreceivedoncetheindividualwasdischarged.OnerecordwasreviewedfromthecaseloadofeachPCP.BasedontheFacility’sreview,thetransferpacketappearedtobegenerallyupdatedandcomplete.Areasofconcernincludedthehospitaldischargesummarynotbeingplacedintheactiverecord,theISPAsnotdescribingstepstopreventarecurrence,andIntegratedRiskRatingFormandRiskActionPlannotbeingupdated.ForApril2012,therewasdocumentationthatthePCPand/ornursetelephonedthereceivingfacilityinonlytwooutoffourcases(50%).ThesameposthospitalconcernsasfoundinMarch2012continuedtopersistinApril2012TheMedicalDepartmentsubmitteddatausedinthemonitoringprocesstodeterminewhethertheinformationpacketsenttothereceivingfacilitywascomplete.Alistofallhospitalizationsindicatedwhethertherewascompliancewiththehospitalpacket.Thehospitalliaisonnurse,whilevisitingthehospital,reviewedthepacketofinformationthathadbeensentwiththeindividualatthetimeoftransporttotheER,andcompletedaform“ERvisits/hospitalizations:QAquestionnaire.”Sevenquestionswereincluded,suchaswhetherthefacilityreceivedahistoryandphysicalcompletedwithinthepastyear,whetherthefacilityreceivedpertinentprogressnotes,whethertherewasanactiveproblemlist,whethertherewasalistofcurrentmedications,diet,andtreatments,etc.Compliancewiththequalityoftheinformationpacketsenttothehospitalwasbrokendownbymonth.ForDecember2011,compliancewas96%.ForJanuary2012,compliancewas94%.ForFebruary2012,compliancewas80%.ForApril2012,


# Provision AssessmentofStatus Compliancecompliancewas84%.ForMay2012,compliancewas78%.Foreachofthesevenquestions,theinvolveddepartmentsshouldreviewifoneparticulardocumentwascommonlylackinginthepacket,orwhethermostpacketswerecompleteatthehospital.However,thedatareflectedthatpacketsdidnotarrivewithallindividuals.Areviewwouldassistthedepartmentsinimprovingandmaintainingqualitytransferofinformation.ISPAswereexpectedtobedevelopedposthospitalandpostInfirmaryvisit.Thepurposeinpartwastoidentifythecause,earlywarningsigns,andstepstobetakentopreventarepeatadmission.TheMedicalDepartmentreviewedsampleofactiverecordsmonthlyforeachPCP.TheresultsoftheinternalmedicalQAindicatedthatin100%ofhospitalizations/Infirmaryadmissions,ISPAswerewritteninMarch2012andApril2012.However,in0%wasthereidentificationofstepstakentopreventarecurrence.TheMedicalDepartmentused“Routine/PreventiveCareMonitoringTool,”revised3/5/12tomonitorthisaspectofcare.Subsectionsofthistoolincluded:“Expectations”whichreviewedquarterlyassessmentsaswellasposthospitalandInfirmaryassessments,“PhysicalExamandScreening,”aswellasanextensivelistofclinicalcategorieswhichwerereviewedifapplicabletotheindividual.Theseincluded:“ManagementofAspiration,”“Managementofanticoagulationtherapy,“ManagementofCoronaryArteryDisease/Hyperlipidemia,”“ManagementofConstipation,”ManagementofDiabetes,”“ManagementofDown’sSyndrome,”“ManagementofFluidImbalance,”“ManagementofGERD.”“ManagementofHypothermia,”“ManagementofOsteoporosis,”“ManagementofWeightGain/Loss,”“ManagementofPsychiatricandPsychologicalIllnesses,”“AntiepilepticMedicationusedasPsychotropicMedication,”“ProtocolLabsforAtypicalAntipsychotics,”“ProtocollabsforAntipsychotics,”“ManagementofSeizures,”and“ProtocollabsforAntiepilepticMedication.”OneactiverecordfromeachPCPcaseloadwaschosenpermonthforreview.ForMarch2012,itwasnotedthatnoneofthechartsreviewedhadquarterlymedicalreviews.OneofthreehadvitaminDlevelscompletedeverysixmonths.Overallevaluationofthisareaindicatedcomplianceof82%.ForApril2012,complianceforthisareaofhealthcarewas77.5%.However,itwillbeimportanttoconcentrateonspecificresultsandquestionsratherthanoverallcompliancescoresinordertobegintousetheinformationforsystemsimprovement.Separately,Question#20oftheMedicalProviderQualityAssuranceAudit,InternalAuditforRound#5addressedthisconcernaspartofalargermedicalqualityaudit:“Areabnormaldiagnosticteststhatneededinterventionsaddressedbytheproviderwithappropriatefollowupdocumentedintheintegratedprogressnote?”TheinternalMedicalDepartmentauditindicated100%compliancewiththisquestion.Thequestionintheaudittoolwasbroadandasaninternalpeerreviewappearedtoprovideevidence


# Provision AssessmentofStatus CompliancethatthepracticepatternsofthePCPswere similaratCCSSLC.However,itdidnotprovidespecificsforanytestordiagnosis,andcouldnotbeusedforanycomparisonwithanationalguidelineorspecificstandard.TheMedicalManagementauditwasdiagnosisspecificandbegantoreviewspecifictestsformeasuringhealthandwellness.However,additionaltoolsindependentoftheManagementAuditshouldbedeveloped.Itisrecommendedthatthemedicalstaffmeettoagreeuponstandards(e.g.,derivedfromtheStateOfficeclinicalprotocols,nationalprofessionalsocietyrecommendations,etc.).ThiswouldprovideanopportunityforthePCPstobeinvolvedindevelopingthesystemtobeusedinmonitoringtheirpracticepatterns,andtoguidethosemonitoringcompliancewithqualitymedicalcare.

H4 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,clinicalindicatorsoftheefficacyoftreatmentsandinterventionsshallbedeterminedinaclinicallyjustifiedmanner.

TheMedicalDepartmentmeasuredprocessesofclinicalcarecompletion,includingwhethertestswerereviewedbythePCPwithin24hoursofreceipt,theRiskActionPlansincludedmeasurableoutcomesandspecificclinicalindicators,andtheRiskActionPlanswerereviewedquarterlyandusedclinicalindicatorstoevaluateeffectiveness.BasedontheFacility’sdata,thePCPreviewofdiagnostictestswithin24hoursofreceiptwascompliantin513outof882(58%)ofrecordsreviewedforMarch2012.PCPreviewofdiagnostictestswithin24hoursofreceiptwascompliantin649outof728(89%)inApril2012.PCPcompliancewithreviewofdiagnostictestswithin24hoursofreceiptwas535outof596(90%)inMay2012.However,basedontheFacility’sdata,RiskActionPlanswerenotwrittenwithmeasurableoutcomesandwerenotreviewedquarterly/werenotusingclinicalindicatorstoevaluateeffectivenessin75%ofcases.AsdiscussedingreaterdetailwithregardtoSectionsIandF,thiswasamuchhigherrateofcompliancethanwhattheMonitoringTeamfoundwithregardtoboththemeasurabilityofclinicalindicatorsaswellastheirappropriateness.Oneofthechallengeshadbeentheidentificationofclinicalindicatorsthatcouldbereadilymeasured.Recommendationsincludemeetingwiththemedicalstaff,sotheycanassistininfluencingtheindicatorsbywhichtheirpracticeswillbemeasured.TheStateOfficemightalsoassist,inpartthroughtheclinicalguidelines.Reviewofrecommendationsfromnationalprofessionalorganizationsmightalsoallowforadaptationofsomeoftheserecommendationstobereflectedasclinicalindicatorsforspecificdiagnoses.AccordingtotheQA/QIQuarterlySectionReviewofSettlementAgreementProgressSectionH,dated3/21/12,anAtRiskClinicalIndicatorsGuidelinesdrafthadbeencompleted,andfinalized.TheFacilitysubmittedanumberofrisksforwhichclinicalindicatorsand/oralarmindicatorswerelisted.Risksforwhichclinicalindicatorshadbeendevelopedincluded:Bloodthinnerrisk,cardiacdiseaserisk(hypertensionand

Noncompliance


# Provision AssessmentofStatus Compliancehyperlipidemia),challengingbehaviorrisks,circulatorydiseaserisks,chokingrisk,enteralfeedingrisk,fallsrisk,fluidimbalancerisk,hypothermiarisk,GERDrisk,fracturerisk,infectionrisk,osteoporosisrisk,poly‐pharmacyrisk,pneumoniarisk,seizurerisk,andskinintegrityrisk.However,anewprocessforSectionI‐AtRisk,hadbeendevelopedandwasbeingpiloted,whichtookpriorityoverthecampus‐wideimplementationoftheAtRiskClinicalIndicatorsGuidelines.The6/28/12QA/QIQuarterlySectionReviewofSettlementAgreementProgressforSectionHalsoindicatedtherewerechallengesrelatedtomonitoring,includingthatdiagnosesineachindividual’sassessmentswerenotconsistentacrossclinicaldisciplines,andallergieswerenotconsistentthroughouttheactiverecord.Itisrecommendedthatthediscrepanciesinassessmentsberesolvedasapriority.Itwillbeachallengeforanydepartmenttobegintotrackrisks,iftherisksarenotclearinthedocumentsthatarethebasisforaction.AsdiscussedingreaterdetailwithregardtoSectionI.3,teamswerenotconsistentlyidentifyingclinicalindicatorstomeasuretheefficacyoftreatmentinterventionsforindividualsatrisk.Problemswiththeindicatorsincluded,attimes,alackofmeasurability.Thequalityoftheindicatorsalsowasproblematicintermsoftellingtheindividuals’teamswhetherornottheindividualwasdoingbetterorworse,orremainingthesame.Finally,individuals’teamsoftendidnotdevelopmeasurableindicatorsaddressalloftheindividuals’areasofrisk.AlthoughtheFacilityhaddevelopedsomeAtRiskClinicalIndicatorsGuidelines,thesewerenotyetfullyinuse.AstheFacility’sself‐assessmentactivitiesshowed,theMonitoringTeamfoundthattheFacilityremainedoutofcompliancewiththisprovision.

H5 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,asystemshallbeestablishedandmaintainedtoeffectivelymonitorthehealthstatusofindividuals.

TheFacilityhadbeguntodevelopadetailedsystemtofollowhealthstatuschangethroughthemorningmedicalmeeting.Thegroupreviewedreportsdailyasaclinicalinterdisciplinaryteam,includingthePCPon‐callconcerns,thoseadmittedtotheInfirmary,andthosehospitalized.Allofthesemajorchangesinhealthstatusappearedtobedocumentedanddiscussed.Atrackingsystemalsowasinplacetomonitorthishealthstatuschangeuntilresolutionorstabilization.Concernsthatrequiredfollow‐upwereassignedtotheappropriatediscipline,andwerebroughtbacktothecommitteeforfurtherdiscussion.Whenresolutionoccurred,thiswasdocumentedasabriefentryintheminutes,alongwiththedateofresolution.However,asdiscussedingreaterdetailwithregardtoSectionL.1,thegroupcontinuedtoneedtofocusonwhatconcernsneededtobefollowedanddocumenteduntilclosure,aswellasthequalityofthereviewprocesstoclosure,buttheprocesswasinplaceandappearedtobehavingsignificantpracticalimpactinprovidingintegratedqualitycarethatmonitoredhealthstatuschangesinallindividuals.

Noncompliance


# Provision AssessmentofStatus ComplianceHowever,theFacilitystilldidnothaveanadequatesystemtoeffectivelymonitorthehealthstatusofindividuals.Forexample:

BasedontheMonitoringTeam’sreviewofmedicalrecordasdescribedindetailwithregardtoSectionL.1,twoof19(11%)activemedicalrecordsincludedanymedicalquarterlynotes.Noneincludedmorethanonequarterlymedicalreviewfortheentireyear.

AsdiscussedwithregardtoSectionI,theFacilityremainedintheprocessofdevelopinganeffectivesystemtoaddressthehealthstatusofindividualsatriskinvariouscategories.

AsdiscussedwithregardtoSectionM,althoughquarterlynursingassessmentswerebeingcompleted,theywereinadequate.Inaddition,day‐to‐daynursingassessmentswerenotadequatetoensurethatchangesinindividuals’statuswaspromptlyidentifiedandreportedtothePCPs.

TheMedicalDepartmentdevelopedaSectionHMonitoringTool,whichincludedmonitoringofhealthstatusonanongoingbasis.Severalofthemeasurementsincludedspecificparametersoftimeliness,whichcouldbereviewedtoensurehealthstatuswasbeingmonitored.Areasinthemonitoringtoolincluded:“DiagnostictestsarereviewedbythePCPwithin24hoursofreceipt,”“riskactionplansarereviewedatleastquarterlyandusingdesignatedclinicalindicatorsevaluateeffectivenessofplans,”“Theactiveproblemlistwasupdatedasnewdiagnosesweremadeandwhenproblemswereresolved,andreviewedquarterly,”“themedicationlist,diet,protocollabsisupdatedasnewordersarewritten,toincludeorderstodiscontinue,”and“thepreventivecareflowsheetwillbecompletedannuallyandatthetimeoftheannualmedicalassessment.”AlthoughitwaspositivethattheFacilitywasbeginningtomonitorthesetypesofindicators,theimpactonindividuals’healthcarewasnotyetevident.ItwillbeimportantfortheFacilitytousethedatacollectedtoeffectivelymakesystemicchanges.TheFacilityremainedoutofcompliancewiththisprovision.

H6 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,treatmentsandinterventionsshallbemodifiedinresponsetoclinicalindicators.

Thissectionwillrequiredemonstrationofafunctionalsystem thatisbothintegratedandprovidesthefullspectrumofallelementsofclinicalcare.ThevariousprotocolsdevelopedbytheStateOfficerepresentaninitialframeworkforthissection,butthereneedstobeevidencethattheseareputintoaction,andthattreatmentreflectsongoinginterventionsandchangesininterventionsbasedonidentifiedclinicalcriteria/clinicalindicatorsthatareappropriatefortheindividual.Evidenceforthisisanticipatedtooccurbasedonreviewsofthemorningmedicalmeetingminutes,aswellastheinternalandexternalauditreviewsofclinicalcare.Discussionsatthemorningmeetingsshouldincludereviewingthechanges(deterioration)inhealthstatusreported.Thisshouldleadtoareviewofcurrenttreatmentinterventions,anddiscussionofpotentialmodificationsguidedbytheclinicalguidelines(andothernationalprofessionalrecommendations,as

Noncompliance


# Provision AssessmentofStatus Complianceappropriate).Useofrelatedclinicalindicatorswouldbehelpfulintrackingprogress.Withtheclinicalmedicalmanagementreviewsbeingaddedtotheinternalandexternalauditprocesses,measurementalsowillbeginregardingwhetherornottheFacilityisrespondingtochangesinhealthstatus(fortheconditionreviewed).ThisprocessalsowillassistinmeasuringimprovementstheFacilitymakesovertime.Althoughasdescribedbelow,theFacilityhadbeguntodevelopamonitoringsystemtoreviewthesystemasawhole,workwasneededtoensurethatthisimpactedthetreatmenttheFacilitywasprovidingtoindividuals.TheMedicalDepartmentdevelopedasetofclinicalindicatorstodeterminewhethertreatmentsandinterventionsweremodifiedinresponsetoclinicalindicators.Oneaspectofthiswasdocumentingthatachangeofhealthstatusoccurred,andasaresult,theordershadbeenwrittenformedications,diet,labs,etc.TheMedicalDepartmenthadbeguntomonitorthereviewprocessofconsultreports,andmeasuredeachstepoftheprocess,anddeterminedclinicalindicators/standardsofacceptablecare.Onceconsultreportsandlabdataarereceivedandreviewed,thePCPsmayadd/changetreatments.Assmeasureofqualitycare,thisneededtooccurwithinawindowoftime.TheMedicalDepartmenttrackedtimelinessofPCPreviewoflabandconsultreports.Forconsultreports,themeasurewaswhethertheconsultsreportswerereviewedwithinfivedaysofreceipt.Additionally,whethertheIDTreviewedtheconsultsafterPCPreviewwastracked.BasedontheFacility’sdata,forMarch2012,70%ofconsultreportswerereviewedbythePCPswithinfivedays.TheIDTsubsequentlyreviewed0.07%oftheconsults.ForApril2012,89.7%ofconsultreportswerereviewedwithinfivedaysofreceipt,and43.1%oftheseconsultreportsweresubsequentlyreviewedbytheIDT.ForMay2012,98.5%ofconsultreportswerereviewedwithinfivedaysofreceipt,and46.2%oftheseconsultreportsweresubsequentlyreviewedbytheIDT.InMarch2012,513/882(95%)oflabresultswerereviewedwithin24hoursbythePCP.ForApril2012,649/728(89%)oflabresultswerereviewedwithin24hoursbythePCP.ForMay2012,535/596(90%)oflabresultswerereviewedwithin24hoursbythePCP.AlthoughtheinternalmedicalQIprogramhadnotchosencriteriatomeasurewhetherthelabresultswereprocessedaccordingtoclinicalindicators/guidelines/nationalstandards,itdidindicatethefoundationalstepsofensuringtimelyreviewofnewinformation.AsmentionedwithregardtoSectionL.3,theMedicalDepartmentwillneedtodeterminetheclinicalindicatorsonwhichcompliancewillbemonitored.Theseshouldincludemeasurementofevaluationandtreatment,andshouldbeagreeduponbytheMedicalDepartmentandbasedontheStateOfficeclinicalprotocols/guidelinesand/orrecommendationsofnationalprofessionalsocieties/associations.Additionally,itisrecommendedthatthelabandconsultreportsbetrackedtoensuretheyareobtainedinatimelymanner,anddatashouldbegeneratedtodeterminethenumberofconsultsorlabsnotreceivedinatimelymannerasdefined


# Provision AssessmentofStatus CompliancebytheMedicalDepartment.Additionally,SectionGMonitoringToolsincludedmeasurementprobestoensurethePCPreviewedtherecommendationsofnon‐facilityconsultantsandrespondedtotherecommendations.SixquestionsfromSectionGMonitoringTooladdressedthisarea.Compliancewiththissectionwas55%inMarch2012and61%inApril2012.However,astheMonitoringTeamhasrepeatedlystated,overallcompliancescoreshavelittle,ifanymeaning.

H7 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,theFacilityshallestablishandimplementintegratedclinicalservicespolicies,procedures,andguidelinestoimplementtheprovisionsofSectionH.

TheActionPlanincludeddevelopmentofapostERvisit/hospitalizationpolicythatclearlydefinedactions/responsibilitiesandtimeframesforanindividualreturningfromtheERorreturningafterahospitalization.However,thishadnotbeendevelopedandadraftwasnotavailableforreview.

TheFacilityrevisedapolicy:MinimumCommonElementsofClinicalCareH.1:ClinicalOperations,revised1/13/12,approved1/26/12,implemented2/1/12.ChangesincludedcasemanagerresponsibilitiesoftakingallconsultsreviewedbythePCPonadailybasisanddistributingthemamongtheIDTmembersatthemorningmeetingforreviewandsignature,aswellasreturningthecompletedsignaturesheettotheClinicRN.ExhibitCofthepolicywasentitled“ConsultantRecommendationReview”andrecordedthesignatureanddateofreviewoftheconsultantreport.InattemptingtocreateasystemofpoliciestoguideCCSSLCincreatingaqualitycaresystem,itisrecommendedthatthevariouspoliciesrelatedtothissectionthathavebeendiscussedinthisandpreviousreportsbemappedtodetermineareasofoverlap,andareasofcarethatremainwithoutguidance,orhavenooversight.Thepoliciesdevelopedforintegratedcareandelementsofclinicalcareappearedtobeindependentofoneanother,anditwasnotclearhowtheyinterfacedorpotentiatedtheultimategoalofintegration.Eachwaspresentedasanisland(e.g.,morningmedicalmeeting,clinicoperations,etc.)ratherthananessentialpartofawhole.Providinganorganizationalflowchart/ladderofhowthesedifferentpolicies,ifimplementedcorrectly,wouldassistinrefiningtheintegrationofcareprocess,wouldbeinstructivetotheFacilitytoensuretherearenogapsintheprocessandallimportantinformationistrackeduntilclosure.

Itisalsorecommendedthissamemappingprocessbecompletedwithcommitteesandotheroversightbodies,toensureallclinicalareashaveanongoingmonitoringprocessinplace.TheQADepartmentalsoshoulddevelopamonitoringtoolmeasuringeffectivenessofthesevariouscommitteestoensuretheyareefficientandeffective,andprovidequalityoversightoftheclinicalareasassignedtothem.

Noncompliance



1. Foragivendiagnosis,evidenceshouldbeavailablethattheneededdisciplinesprovidedassessments,thattheteamdiscussedtheseevaluations,andthatallessentialelementsforcareofthatdiagnosishavebeenincludedinanintegratedactionplan.(SectionH.1)

2. Allclinicalareas,includingnursing,psychology,psychiatry,habilitationtherapy,etc.,shouldprovideevidencethatroutinequalityassessmentsarecompletedinatimelymanner,aswellasevidenceoftimelyresponsetochangesinhealthstatusoftheindividual.(SectionH.1)

3. TheimplementationoftheriskactionplansoftheindividualsshouldbetrackedbytheFacilitytodeterminetheinvolvementofeachclinicaldepartmentthatmighthaveimpactonthatrisk,asamethodtoprovide/ensurethatindividualshaveadequateaccesstotheminimumcommonelementsofclinicalcare.(SectionH.1)

4. ToensureappropriateidentificationofclinicalindicatorsintheRiskActionPlans/ISPaddendums,itisrecommendedthatmedicalstaffattendthemeetingandprovideinformationconcerningchoiceofindicatorsofpracticalsignificancethatcanbemeasured.(SectionH.4)

5. ChangesinhealthstatusoftheindividualsshouldbetrackedbytheFacilitytoensureallappropriateclinicaldepartmentsparticipateinresolvingthehealthconcernidentified.(SectionH.5)

6. ThevariousCCSSLCpoliciesshouldbemappedtodetermineareasofoverlap,andareasofcarethatremainwithoutguidanceorhavenooversight.(SectionH.7)

7. ThevariousCCSSLCcommitteesandoversightbodiesshouldbemappedtoensureallclinicalareashaveanongoingmonitoringprocessinplace.(SectionH.7)

8. TheQADepartmentshouldtakeamoreactiveroleinmonitoringSectionH.(FacilitySelf‐Assessment)ThefollowingareofferedasadditionalsuggestionstotheStateandFacility:

1. ThesystemsanalystshouldcommunicatewiththecounterpartsattheStateOfficetodetermineifthemorespecificdiagnosesassociatedwiththeICD9codescanbeenteredonthecomputerizedDG1.ThesystemsanalystalsoshouldreviewthenewsoftwarefortheupcomingICD10codingsystemtodetermineifthesameproblemwilloccur,orifthecodeswillmaintainspecificityanddetailincategorizingthediagnosis.(SectionH.2)


SECTIONI:At‐RiskIndividuals

EachFacilityshallprovideserviceswithrespecttoat‐riskindividualsconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow:


o DADSSSLCrevised“RiskGuidelines”laminatedrecord,dated4/17/12;o CCSSLC’sSelf‐Assessment;o CCSSLC’sProvisionActionInformation;o CCSSLCAt‐RiskIndividualslist;o DraftofrevisedAt‐RiskIndividualsPolicy,006.3;o SectionIAnalysisreportsforAprilandMay2012;o SectionImonitoringtoolandinstructions;o CCSSLCtrainingrosters;o Thefollowingdocuments:IntegratedRiskRatingForms,ActionPlansforRiskAssessments,ISPsand/or

ISPAddendums,ComprehensiveNursingAssessments,andHealthManagementPlansforthefollowingindividuals:Individual#144,Individual#183,Individual#278,Individual#9,Individual#282,Individual#378,Individual#213,Individual#327,Individual#91,Individual#221,Individual#34,Individual#210,Individual#153,Individual#211,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,Individual#26,andIndividual#95;

o SectionIPresentationBook,including:draftSSLCStatewidePolicyandProcedures#006.3:AtRiskIndividuals,dated5/24/12;flowdiagramSSLCat‐riskprocess,dated2/10/12;Instructions–RiskGuidelines;SSLCRiskGuidelines,dated4/17/12;Instructions:draftAspirationNutrition/EnteralNutritionDataSheet(APEN),dated5/24/12,andinstructions,dated6/13/12;instructionsforIRRF,dated5/24/12;draftblankIRRF,dated5/25/12;instructionsIntegratedHealthCarePlan(IHCP)processandform,draftdated5/24/12;AnnualIntegratedHealthCarePlan–RiskGroup1,dated5/24/12,andRiskGroup2,dated75/25/12;directSupportProfessionalsInstructionsRiskgroups1through7;Instructions:TriggerDataSheet,dated4/16/12,andTriggerDataSheetforeachriskcategory,dated5/25/12;ChangeofStatusIRRFdraftblankform,dated5/24/12;draftChangeofStatusIntegratedHealthCarePlan,dated5/24/12;Riskcategory:atriskcriteria/alarmindicators/clinicalindicators;CCSSLCIntegratedRiskRatings–TrendReportFY2011,2012;ComplianceandIntegratedRiskRatingQuarterlyCharts–SectionI;andSectionIAnalysis–April2012,andMay2012;

o Forthefollowingindividuals,selecteddocumentsfromtheiractiverecords,including:DG‐1,mostcurrentannualmedicalassessmentandphysicalexam,preventivecareflowsheet,mostcurrentnursingassessment,pastoneyearofIPNs,pastoneyearoflabresults,x‐rays,scans,MagneticResonanceImaging(MRIs),ultrasoundreports,hospitaldischargesummariesforpastyear,ERreportforpastyear,consultsandprocedurereportsforthelastyear,DNRformsifapplicable,physicianordersforthepastyear,mostrecentPSP/ISPandsubsequentaddendums,mostrecentBSP,pastthreemedicalquarterlyreviews,integratedriskratingformforpastyear,riskactionplan(s)forpastyearforthefollowingindividuals:Individual#215,Individual#31,Individual#244,Individual#213,Individual#144,Individual#251,Individual#103,Individual#65,Individual#294,Individual#210,Individual#86,Individual#158,Individual#299,Individual#356,Individual#181,Individual#253,Individual


#42,Individual#156,andIndividual#72;ando AnnualIntegratedRiskRatingForm,andISPforIndividual#156.

Interviewswith:o ColleenM.Gonzales,BSHS,ChiefNurseExecutive;o AngelaRoberts,Au.D.,DirectorofHabilitationTherapies;o AltheaP.Stewart,RN,MedicalServices;o BruceBoswell,AssistantDirectorofProgramming;o MarkCazalas,FacilityDirector;o IvaBenson,StateOfficeConsultant;o DanaVerhey,QualityAssuranceProgramComplianceMonitor;o JenniferUrban,RN,BSN,NursingOperationsOfficer;o AraceliAguilar,RN;o PatriciaGlass,RN,CaseManagerSupervisor;o ConnieHorton,StateOfficeConsultant,FamilyNursePractitioner;o LindaFisher,StateOfficeConsultant,FamilyNursePractitioner;ando SallySchultz,StateConsultant.

Observationsof:o ISPMeetingforIndividual#341,on7/11/12;ando ISPMeetingforIndividual#156,on7/12/12.

FacilitySelf‐Assessment:SincetheMonitoringTeam’slastreview,theFacilityhadimplementedapromisingmonitoringtoolwithinstructionsforSectionI,andhadcompletedeighttools.FromdiscussionswiththestaffleadforSectionI,sheandtheQualityAssuranceProgramComplianceMonitorhadestablishedinter‐raterreliabilityforthemonitoringtoolabove85%.However,fromdiscussionswiththePCM,shereportedshewasnotaclinicianandscoredtheitemsbasedoncompletion,andnotonthequality.Forexample,shereportedthatshereviewedassessmentstoensurethattheywerecompletedwithinfivedaysoftheidentificationofahighormediumrisk.However,shereportedthatshedidnotreviewtheclinicalappropriatenessandadequacyoftheassessmentswhendeterminingcompliance.AsnotedduringseveralpastreviewsandinpreviousMonitoringTeam’sreports,thequalityandadequacyoftheassessmentsconductedbyanumberofdisciplinesregardingtheat‐riskindividualswereconsistentlyfoundtobesignificantlyinadequate.Unfortunately,theFacility’scurrentprocessofmonitoringSectionIdidnotcapturethisessentialissue.TheFacilityshouldevaluatewhowouldbebesttoauditthishighlyclinicalareainordertogenerateaccurateinformationregardingclinicalissuesrelatedtotheindividualsatrisk.TheFacility’sSelf‐Assessmentindicatedthatfouroffour(100%)monitoringtoolsthatwerecompletedforSectionIwereanalyzed,trended,andaggregated.However,nofindingswerepresentedintheFacility’sSelf‐Assessmentindicatingthetrends,analysis,orcompliancestatusoftheitemscontainedonthemonitoringtools.AreviewofthePresentationBookforSectionIfoundtworeportsentitled:SectionIAnalysisApril2012,andSectionIAnalysisMay2012.ThesereportsprovidedanarrativedescriptionofthenumberofthereviewedISPsamplesthatwereincompliancewithspecificitemsonthetool.However,“combined”compliancescoresfortheoveralltoolswerereportedbyindividualandcollectively,whichprovidednointerpretableinformationforanalysis.ConsiderationshouldbegiventostandardizingthepresentationofdataacrosstheFacilityforconsistencyininterpretationusing,forexample,tablestoreportmonitoringfindingsratherthananarrativeformatthatismoreappropriateforpresentingtheanalysisofthe


data.Withthatbeingsaid,theMonitoringTeamnotedthattheAnalysisReportsdidnotcontainanyanalysisofthefindingsorwhatactionswerebeingtakingtoaddresstheproblematictrendsidentified.Also,theFacilitySelf‐AssessmentindicatedthattherewerenodataavailableregardingthereviewofthreeoftheIntegratedHealthCarePlansthathadbeenpilotedon524Atodetermineifinterventionswereconsistentlyimplemented.ThereasongivenwasthatthepilotwasimplementedJune1,2012,anddatawouldnotbeavailableuntilJuly9,2012.TheFacilityindicatedthatareviewofthreeIntegratedRiskRatingFormscurrentlypilotedon524Afoundthatnone(0%)containedthefollowingrequiredcomponents:a)data;b)currentsupports;c)baselineinformation;d)discussionandanalysis/needfornewsupports;e)rationale/riskrating;f)triggers;andg)criteriaforIDTReview.However,noindicationwasprovidedregardinghowtheseproblematicissuesweretobeaddressed.TheFacility’sSelf‐Assessmentindicatedthatbasedonitsfindingsfromitsself‐assessment,thisprovisionwasnotincompliancesincetheenhancedriskprocesswasstillinthepilotphase,andhadnotyetbeenimplementedacrosstheFacility.AlthoughtheMonitoringTeam’sfindingssupportedtheFacilityinfindingthatitwasnotinsubstantialcompliancewiththeSettlementAgreementrequirementsforSectionI,thisfindingwasbasedonareviewofthecurrentdocumentationforindividualsthatwereidentifiedasbeingatriskbytheirteams,andnotbasedonthefactthattheFacilityhadonlyrecentlyimplementedthepilotsystem.Theimplementationofnewsystemchangeswerenecessarytoimprovethesystem,butdidnotsupersedetheneedsoftheindividualsregardingtheprovisionanddocumentationofclinicalcareasrequiredbytheSettlementAgreement.SummaryofMonitor’sAssessment:Sincethelastreview,theStateOfficehadmaderevisionstotheAt‐RiskIndividualspolicy(indraftformatthetimeofthereview).SomeofthechangesincludedregroupingtheRiskGuidelinessothattheriskfactorsthatwereclinicallyinter‐relatedregardingoutcomesorprovisionofservicesandsupportswerelistedtogether,andlinkingeachriskfactorwithspecificclinicalindicators.Inaddition,theIntegratedRiskRatingFormwasrevisedtofollowthesamegroupingsequenceastheRiskGuidelines.SomeadditionalrevisionsincludedreplacingtheRiskActionPlansfortheidentifiedhighandmediumriskindicatorswithIntegratedHealthCarePlansdesignedtoprovideacomprehensiveplanthatwillbecompletedannually;differentformsregardingIRRFandtheIHCPweredevelopedaddressingchangesinstatus;theAspirationPneumoniaEnteralNutritionwasrevisedasadatacollectiontool;andTriggerDataSheetsweredevelopedtoincludeobservableandmeasurableclinicalsignsandsymptomsthatalertthestafftopossiblechangesinstatus.InMay2012,twoteamsatCCSSLChadbeentrainedonthenewpolicyandprocesses,andhadbeguntopilotthem.Itwasimportantthatthenewsystemwasbeingpilotedwithtwoteamstodetermineanyadditionalimplementationsteps/changesthatneededtobemade,oranyadditionaltrainingthatwouldbebeneficialbeforebroadeningitsscopetotheentirecampus.ThemanychangesthathadoccurredwithregardtotheAt‐RisksystemwerereflectedinthedifferentISPdocuments,andthevaryingqualityoftheIRRFindicatedsomeconfusionamongsttheteamswiththepreviousprocess.Developingasuccessfulprogramonasmallscalethatcanthenbeimplementedacrosscampusshouldreducesuchissues.Stafffromthepilotsystemsintworesidencesalsocouldactasmentorstotheotherteams,anotherimportantstepinprovidingconsistencyacrosscampusandimprovingthequalityoftheprocess.Untilnow,thequality


oftheriskreviewsandimplementationprocessvarieddependingontheunderstandingandexpertiseofthevariousIDTs.Hopefully,theprocesswillbecomemorestandardized,whichshouldbenefittheindividualsresidingatCCSSLC.FromreviewoftheISPandaddendumdocumentation,individuals’teamswerehavingdiscussionsoftheindividuals’status,andmorepertinentclinicalinformationwasbeingincludedintheIntegratedRiskRatingFormsthanpreviously.However,theoveralllackofcleardocumentationincludedintheISPs,theRiskActionPlans,andtheassociateddisciplines’assessmentsregardingwhatactionsweretakeninresponsetopertinenteventsorhealthissues,andthelackofdatesandsupportingdocumentationaddressingactionsandcompletionofactionplansmadetheMonitoringTeam’sreviewoftheAt‐Risksystemdifficult,andthelackofprogressnotedwastroublingatthisjunctureofthecomplianceprocess.

# Provision AssessmentofStatus ComplianceI1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithin18months,eachFacilityshallimplementaregularriskscreening,assessmentandmanagementsystemtoidentifyindividualswhosehealthorwell‐beingisatrisk.

Sincethelastreview,interviewswiththeFacilitystaff,CCSSLC’sSelf‐Assessment,andProvisionActionInformationdocumentsindicatedthatthefollowingstepshadbeenimplemented,andassessmentsconductedregardingtheAt‐Riskprocess:

Sincethelastreview,theStateOfficehadmaderevisionstotheAt‐RiskIndividualspolicy(indraftformatthetimeofthereview).SomeofthechangesincludedregroupingtheRiskGuidelinessothattheriskfactorsthatwereclinicallyinter‐relatedregardingoutcomesorprovisionofservicesandsupportswerelistedtogether,andlinkingeachriskfactorwithspecificclinicalindicators.Inaddition,theIntegratedRiskRatingFormwasrevisedtofollowthesamegroupingsequenceastheRiskGuidelines.Sevengroupingsofriskcategorieswereidentified.ThetemplateofthedraftIntegratedRiskRatingFormincludedbulleteditemstobeaddressedforeachriskfactor,including:data,supports,baseline,discussionandanalysis/needfornewsupports,rationale/riskrating,triggers(triggersheetindicated/notindicated),andcriteriaforIDTreview.Thisdraftwasdated5/25/12.SomeadditionalrevisionsincludedreplacingtheRiskActionPlansfortheidentifiedhighandmediumriskindicatorswithIntegratedHealthCarePlansdesignedtoprovideacomprehensiveplanthatwillbecompletedannually;differentformsregardingIRRFandtheIHCPweredevelopedaddressingchangesinstatus;theAspirationPneumoniaEnteralNutritionwasrevisedasadatacollectiontool;andTriggerDataSheetsweredevelopedtoincludeobservableandmeasurableclinicalsignsandsymptomsthatalertthestafftopossiblechangesinstatus.Whentherewasachangeofstatus(accordingtothedefinitionprovidedintheinstructions),achangeofstatusintegratedriskratingformwastobecompleted.Adrafttemplate,dated5/24/12,ofthisformwassubmitted.

InMay2012,twoteamsfromCCSSLCweretrainedonthe“EnhancedRiskProcess”describedabovewhichwasimplementedat524AandPorpoiseinJune2012.Sincethesystemhadonlybeenrecentlyimplementedatthetimeofthe

Noncompliance


# Provision AssessmentofStatus Compliancereview,theMonitoringTeamwasnotabletoadequatelyassessanyprogressmadefromthesystemrevisions.

InMay2012,theFacilityreportedthatithostedtheStatewideNurseEducatorMeetingwherecompetency‐basedtrainingwasprovidedregardingmedicationadministration,andNursingCarePlans.AlthoughtrainingrosterswereincludedinthePresentationBookforSectionI,nocurriculumwasincludedfortheMonitoringTeamtoevaluatethequalityofthecompetency‐basedtraining,andtherewasnoindicationfromthetrainingrostersastohowmanystaffwererequiredtoattend(N),andhowmanyactuallyattendedandpassedthetraining(n)toaccuratelydetermineacompliancepercentagefortraining.

FromthesignificantlyproblematicfindingsnotedbelowforSectionI,thenumerouschangestotheAt‐Risksystemhadresultedinfragmenteddocumentationthatmadeitdifficult,ifnotimpossibletosequentiallyfollowtheassessmentandactionplanprocessesforasampleof27individualsinSectionsI.2,andI.3,whotheFacilitydeterminedtobeathighriskregardinghealthand/ormentalhealthissues.FromreviewoftheISPandaddendumdocumentation,individuals’teamswerehavingdiscussionsoftheindividuals’status,andmorepertinentclinicalinformationwasbeingincludedintheIntegratedRiskRatingFormsthanpreviously.However,theoveralllackofcleardocumentationincludedintheISPs,theRiskActionPlans,andtheassociateddisciplines’assessmentsregardingwhatactionsweretakeninresponsetopertinenteventsorhealthissues,andthelackofdatesandsupportingdocumentationaddressingactionsandcompletionofactionplansmadetheMonitoringTeam’sreviewoftheAt‐Risksystemdifficult,andthelackofprogressnotedwastroublingatthisjunctureofthecomplianceprocess.ToassesstheFacility’srevisedriskscreeningprocess,membersoftheMonitoringTeamobservedtwoindividuals’ISPsmeetings(i.e.,Individual#341,andIndividual#156)whileonsite.AlthoughtherewereotherISPsconductedduringtheweekoftheMonitoringTeam’sreview,thetwoISPsobservedwerereflectiveofthenewISPformatandprocess,andthuswerechosenforthatreason.Specifically,theobservationsoftheISPmeetingsindicatedthat:

Allappropriatedisciplineswerepresentatboth(100%)oftheobservedISPs. ThestaffpresentattheISPsmeetingsweretheactualstaffthatworkedwiththe

individual,andnotsubstitutestaffsittinginforotherstaffmembersforall(100%)oftheISPs.

Theindividualwaspresentatboth(100%)oftheISPsmeetingsobserved.AlthoughIndividual#156wasintheInfirmaryatthetimeoftheISP,thestaffwasabletohaveheravailablebyconferencecallduringthemeeting.However,itwasnotclearwhytheteamcouldnotholdthemeetingattheInfirmary.

TheIDTconsistentlyusedtheRiskLevelGuidelineswhendeterminingrisk


# Provision AssessmentofStatus Compliancelevelsatone(50%)oftheISPmeetings.TheIDTforIndividual#341didnotappeartoconsistentlyusetheRiskLevelGuidelinestodeterminerisklevelssincesomeoftherisklevelsassignedwerenotinalignmentwiththeGuidelineswithoutjustificationprovidedbytheteam.

TheIDTconsistentlyusedsupportingclinicaldatawhendeterminingriskslevelsforbothoftheISPsobserved(100%).TheMonitoringTeamnotedthattherehadbeenconsistentimprovementforthisindicatorsincethelastreview.

Overall,therisklevelstheIDTdesignatedwereappropriateforeachcategoryfornoneoftheISPsobserved(0%)frominformationanddataprovidedbytheIDTs.Theindividuals’IDTsthatdidnotconsistentlydesignateappropriaterisklevelsforeachriskcategoryincludedIndividual#341andIndividual#156.

Therewasadequateandappropriateclinicaldiscussionamongappropriateteammembersindecisionsregardingrisklevelsinboth(100%)oftheISPsmeetingsobserved.

TeamdisagreementsregardingrisklevelswerenotedinneitheroftheISPmeetingsforIndividual#341,andIndividual#156,andthus,theMonitoringTeamdidnotobservetheprocessofresolvingissues.Inevaluatingthisindicator,whenteamdisagreementsareobservedtheMonitoringTeamevaluatestheprocessofresolutionbasedontheuseofspecificclinicaldata,theuseoftheRiskGuidelines,appropriateclinicaljudgment,andtheuseofaperson‐centeredfocustodeterminecompliance.

BasedonbothISPsobservedbytheMonitoringTeam,theISPfacilitatorkepttheteamfocusedinall(100%)oftheISPsmeetingsobserved.AreasforcontinuedfocusincludedtimemanagementsincebothoftheISPsobservedwereexceptionallylengthy,presentingjustificationforriskslevelsinalignmentwiththeRiskGuidelinesandindividual‐specificclinicalinformation,andcontinuingtoincreaseteamdiscussionsofriskindicators.

Inaddition,otherpositiveobservationsfromtheMonitoringTeamincluded: AttheISPmeetingforIndividual#341,manyofthedisciplineswereactively

involvedinthediscussionsaboutrisk,andofferedcomments,suggestions,andopinionsinareasoutsideoftheirdirectpurview.Thesediscussionswerenotedtoberespectful,andthedifferentviewpointsandrecommendationswereappropriatelyincorporatedintotheresultingactionplans.However,thisremainedanareathatneededcontinuedgrowth.FromtheobservationsoftheMonitoringTeam,thereweresomedisciplinesthatdidnotparticipatemeaningfullyinthediscussions,evenwhentheirexpertisepotentiallywouldhavebeenhelpful;

TheActiveTreatmentteammemberforIndividual#341consistentlylookedforwaystoincorporateskillacquisitionprogramsintotheISP,includingduringrisk‐relateddiscussions.Althoughconcernswerenotedwithregardtotheuse


# Provision AssessmentofStatus Complianceofdatafromlastyear’splansortheFunctionalSkillsAssessment,aswellasalackofsomedisciplinesprovidingneededinput,itwaspositivethattheteamdiscussedmoreskillacquisitionprogramsthroughoutthevariousteamdiscussions;

TheguardiansforIndividual#156wereabletotakepartintheISPandwerekeptengagedandwellinformedbytheNursePractitionerwhodidanexceptionaljobofdiscussinganumberofcomplicatedmedicalissuesanddiagnosesduringthemeeting.Inaddition,sincetheindividualwasintheInfirmaryatthetimeoftheISPmeeting,sheandherdirectsupportprofessionalwereabletoparticipateinthemeetingviaconferencecall;

Duringsomeoftheteam’sdiscussionsforIndividual#156,anumberoftheteammembersremainedcognizantofallowingtheindividualtomaintainasmuchindependenceaspossible;

Generally,facilitatorsforIndividual#341andIndividual#156promotedteamparticipationandkeptthemeetingsappropriatelyfocused;and

Therecontinuedtobeanotedincreaseintheuseofspecificclinicaldatatosupportriskratings.

Problematicareasneedingfocusorimprovementincluded:

TherewasalackofintegratedsupportsnotedinsomeinstancesattheISPforIndividual#341.Forexample,theindividualhadaPNMPthataddressedtheneedforstaffsupervisionduringmealtimesduetohisfastpacewhileeating.Theindividualstatedthatheatefastbecausepreviouslypeoplehadtakenfoodfromhim.However,nopsychologyoractivetreatmentinvolvementwasnotedwithregardto,forexample,askillacquisitionprogramtohelphimslowhiseatingpace.

Overall,althoughtheteamdiscussedactionplansrelatedtoriskforIndividual#341,somecriticalpiecesweremissing.Forexample,althoughtheteamidentifiedweightasahigh‐riskarea,andonethatimpactedmanyoftheindividuals’otherriskfactors,therelatedactionplanlackedtheclinicalintensitytocorrespondwiththelevelofrisk.HehadaBodyMassIndex(BMI)of41,placinghimintheseverelyobeserange.Hisweighthadincreasedoverthepreviousyear.Otherthanmodifyinghissalarycapfrom$40to$25perweektopotentiallydecreasetheamountoffoodhecouldbuyoutsideofhisprescribeddiet,havingstaffremindhimtoexercise,developingtwoskillacquisitionprogramstohelphimidentifyhealthychoices,andeducatinghisfamilyabouthealthoptions,theteamdidnotdevelopaplantoaggressivelyaddressthishigh‐riskindicator.Itwasunclear,forexample,howmuchexercisehecurrentlywasgettingandifthiscouldbeincreased.Italsowasuncleariftheteamhadconsideredtypicalmethodsthathisnondisabledpeerswouldhaveusedtoassistwithweightloss,suchassupportgroupsorspecificdietprograms.Similarly,the


# Provision AssessmentofStatus Complianceteamdidnotdiscussincorporatingincentivesforweightlossintohisprogram,and/orusingsomeofhislengthylistofpreferencesasfurtherincentiveforreducinghisweight.Althoughtheteamdiscussedthepotentialimpactofhispsychotropicmedicationsonhisweight,itwasalsonotcleariftheteamhadaplantoaddressthisissue.Aswithalloftheotherriskactionplansdiscussed,forweight,nomeasurableobjectivewasdiscussedtoassisttheteamindeterminingiftheplansinplacewerehavingthedesiredeffect,orifchangeswereneeded.

TeamdiscussionsforIndividual#156indicatedthatshehadseveralmissingteeth,hadmoderateperiodontitis,exhibitedanxietyandsensitivityduringexamsandrequiredpre‐sedationandanesthesiafordentalworktobecompleted.Althoughherdentalriskhadbeenratedashighinthepastandthedentisthadrecommendedadentaldesensitizationprogram,theteamreportedthatshewasdeemedasnotbeingacandidatefordesensitizationwithoutexplanation.Thediscussionoftheteamindicatedthatstaffwould“monitor”hertoothbrushing.However,therewasnodiscussionregardingwhatcriteria/clinicalindicatorswouldbeusedtodetermineifshewaseffectivelybrushingherteeth.Inaddition,therewasnodiscussionaddressingtheoriginalproblemregardingheranxietyduringdentalprocedures.

WhiletheteamdiscussedtheneedforTriggerSheetstobeimplementedforeachoftheRiskFactorsforIndividual#156tocollectdataregardingspecificsymptoms,theteamappearedtohavelittleunderstandingthatthecollectionofdatawasonlythefirststepinthemonitoringofaparticularhealthindicator.Therewasnodiscussionsobservedindicatingwhowouldberegularlyreviewingthisinformation;howoftenitwouldbereviewed;who,how,andhowoftenthisinformationwouldbepresentedtotheteam;andwhatthecriteriaweretoindicatetheteamneededtotakeadditionalactions.

AlthoughitwaspositivethatthefamilymembersforIndividual#156werepresentfortheISP,itwasobviousthattherehadnotbeenregularcommunicationbetweentheteamandthefamilybasedontheactivitiesthefamilythoughtwereinplacecomparedtowhattheteamreportedduringthemeeting.Forexample,thefamilybelievedthattheindividualhadahospitalbedfromadiscussionofneedsatherpreviousISP.However,onceitwasverifiedthatshedidnothavethistypeofbed,noonefromtheteamcouldprovidethefamilywitharationaleforwhyshewasnotprovidedahospitalbed.

Overall,theIDTforIndividual#156hadlimitedandincompletediscussionsofactionplansrelatedtothehighandmediumriskratings.Inseveralcases,theobjectiveswerenotfunctionaland/ormeasurable,andadequatepreventativemeasureswerenotdiscussed.

Overall,anyactionplansthatweredevelopedintheISPmeetingswereweak,inthattheobjectiveswerenotdiscussedbytheIDTsinordertoestablishameasureofsuccessorfailureoftheactionplansdeveloped,andthe


# Provision AssessmentofStatus Complianceinterventionsdidnotreflecttheclinicallyintensityinalignmentwiththelevelofriskdesignatedbytheteams.

Inaddition,asampleof19records(13randomlyselectedandsixchosenaccordingtohighriskcategories,includingthoseforIndividual#215,Individual#31,Individual#244,Individual#213,Individual#144,Individual#251,Individual#103,Individual#65,Individual#294,Individual#210,Individual#86,Individual#158,Individual#299,Individual#356,Individual#181,Individual#253,Individual#42,Individual#156,andIndividual#72)wasreviewedwithregardtotheintegratedriskratingprocess.Forthe19individuals,theactiverecordwasreviewedalongwiththeintegratedriskratingform.TheattendancesheetfortheISPwasalsoutilizedinmakingthefollowingfindings:

Forsevenoutof19(37%)activerecords,theappropriatedisciplineswerepresentattheISP.

For14outof19(74%)activerecords,theindividualwaspresentattheISP. For13outof19(68%)activerecords,theIDTusedtheRiskLevelGuidelines

whendeterminingrisklevels. For14outof19(74%)activerecords,theIDTusedsupportingclinicaldata

whendeterminingrisklevels. For12outof19(63%)activerecords,thedesignatedrisklevelswere

appropriateforeachcategory(i.e.,theteamprovidedadequatejustification).FromtheMonitoringTeam’sobservationsandrecordreviews,therehadbeensomepositivestepsmaderegardingthestructureandformatoftheISPs,specificallytheincreaseduseandteamdiscussionsofsupportingclinicaldatawhenassessingrisklevels.However,thereneedstobesignificantlymoreeffortsmadetoensurethattheriskslevelisaccurate,thattheactionplansthatreflecttheneededclinicalintensityinalignmentwiththeappropriatedesignatedrisklevels,thatobjectivesincludedarefunctionaland/ormeasurable,thatadequatepreventativemeasuresarediscussedandareincludedintheactionplans,andteamsclearlydocumentthisprocess.Inaddition,theFacilityshouldimplementasystemaddressingthereassessmentofriskfactorsforindividualsexperiencingsignificantchangesinstatus.Itshouldbeinclusiveofacutechangesinstatusforat‐riskindividuals,andnotonlyactivatedinresponsetohospitaladmissions.CCSSLCshouldcontinuetoprovidetrainingandmentoringfortheIDTsregardingtheAt‐Riskprocess.

I2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshallperformaninterdisciplinaryassessmentofservicesandsupportsafteran

Basedonareviewofrecordsfor27individualsdeterminedtobeatrisk(i.e.,Individual#144,Individual#183,Individual#278,Individual#9,Individual#282,Individual#378,Individual#213,Individual#327,Individual#91,Individual#221,Individual#34,Individual#210,Individual#153,Individual#211,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,Individual#26,and

Noncompliance


# Provision AssessmentofStatus Complianceindividualisidentifiedasatriskandinresponsetochangesinanat‐riskindividual’scondition,asmeasuredbyestablishedat‐riskcriteria.Ineachinstance,theIDTwillstarttheassessmentprocessassoonaspossiblebutwithinfiveworkingdaysoftheindividualbeingidentifiedasatrisk.

Individual#95),therewasdocumentationthattheIDTstartedtheassessmentprocessassoonaspossible,butwithinfiveworkingdaysoftheindividualsbeingidentifiedasatriskfornoneofthese(0%)individuals.Problematicissuesthatresultedinnoncomplianceincluded:

IntegratedRiskRatingformsdidnotconsistentlyincludespecificclinicaldata,suchasthenumberofbowelmedicationsandsupplementallaxatives/stoolsoftenersregardingconstipationrisks,ordatesandthetypesofinjuries/fractureswhenaddressingfalls,tosupporttheriskratingsforthehealthindicators.Asaresult,itwasunclearwhetherfurtherassessmentwasneeded;

Therewereinconsistenciesfoundbetweentherisklevelsfoundontheindividuals’IntegratedRiskRatingforms,ComprehensiveNursingAssessments,ISPs,andtheCCSSLC’sAt‐RiskIndividualslist.Reconciliationofthesedifferenceswasnotfound;

Duetothelackofdocumenteddatesonthevariousforms,theMonitoringTeamwasunabletoconsistentlydeterminewhatnewinformationwasaddedtoarevisedIntegratedRiskRatingform,andwhatadditionalassessmentswereneededand/orconductedinresponsetotherevisedinformationorpossiblechangeofstatus;and

WhenrecommendationsforfurtherassessmentwerefoundontheRiskActionPlans,thedateofcompletionwasfrequentlyleftblank,orthedatesthatwerelistedontheActionPlansdidnotcorrespondtodatesontheIntegratedRiskRatingforms,ISPs,orISPaddendums.Thus,itwasimpossibletodeterminewhatprecipitatedtherecommendedassessment,andifitwastimelycompleted.

NursingAssessmentsBasedonareviewof27individuals’recordsforwhichassessmentsweretobecompletedtoaddresstheindividuals’atriskconditions,none(0%)includedanadequatenursingassessmenttoassisttheteamindevelopinganappropriateplan.Recordsthatdidnotcontaindocumentationofthisrequirementincluded:Individual#144,Individual#183,Individual#278,Individual#9,Individual#282,Individual#378,Individual#213,Individual#327,Individual#91,Individual#221,Individual#34,Individual#210,Individual#153,Individual#211,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,Individual#26,andIndividual#95.Asnotedbasedonthepastpreviousfivereviews,theFacilitycontinuedtousethelastquarterlyorannualComprehensiveNursingAssessmenttomeetthenursingassessmentrequirement.Inaddition,areviewofthemostcurrentquarterlyorannualComprehensiveNursingAssessmentsfortheabove27Individualsfoundthatnoneofthem(0%)containedan


# Provision AssessmentofStatus Complianceadequateassessmentsofthespecifichigh‐riskhealthindicatorsorprovidedanytypeofanalysisofthehigh‐riskhealthindicatorsintheSummarySectionoftheComprehensiveNursingAssessmentform.Infact,theComprehensiveNursingAssessmentstheMonitoringTeamreviewedwerenotedoveralltobeworsethanthepreviousreviewinthatsomeofthenursingassessmentsdidnotreflectthecorrectriskrating,andsomenursingassessmentsdidnotevenincludetheparticularhealthriskintheSummarySection,especiallyregardinghigh‐riskratingsfordentalissues.Asnotedbasedonthepreviousfivereviews,nursinghadnospecificprocedureinplaceaddressingtheprocessregardingthenursingassessmentsandtheanalysisoftheidentifiedriskindicators.Fromsomeoftheproblematicissuesnotedaboveregardingmissingorinaccurateriskratings,itwasclearthatsomeoftheCaseManagerscompletingtheComprehensiveNursingAssessmentswereusingpastquarterlyorannualinformationwithoutprovidinganytypeofupdateandanalysisregardingthecurrentstatusofthehealthriskindicators.Asnotedbasedonpastreviews,thenursingassessmentsfortheAt‐Riskindividualswerenotadequateinaddressingthehealthrisksoftheindividualsreviewed.Inaddition,regardingtheIntegratedRiskRatingforms,althoughoverallmorespecificclinicalinformationwascontainedontheforms,someoftheareasthatnursingwasresponsibleforassessingand/orprovidinginformation,suchasforconstipationanddatesofinjuries/fractures,adecreaseinthisindividual‐specificinformationwasnotedfromthepreviousreview.WhenreviewingsometheIntegratedRiskRatingformsthatincludeddatesofrevisions,theareasthatcontaineddeficitsinindividual‐specificinformationremainedunchanged.Aspreviouslyrecommended,theFacility,inconjunctionwiththeState,shouldspecificallydefinethenursingassessmentanddocumentationprocessregardingat‐riskindividuals.MedicalAssessmentsAtriskcriteriaandalarmindicatorshadbeendevelopedtoassisttheIDTsinidentifyinganindividual’sat‐riskcategoriesandwhentherewasachangeinstatus.Theseat‐riskcriteria,alarmindicators,andclinicalindicatorswerecreatedforeachofthemajorriskareas(i.e.,choking,aspiration,enteralfeeding,pneumonia,dental,GERD,constipation,cardiacdisease,circulatorydisease,bloodthinner,fluidimbalance,weight,diabetesmellitus,osteoporosis,falls,fracture,infection,urinarytractinfections,skinintegrity,seizures,polypharmacy,challengingbehavior,andhypothermiarisk).ThesewerediscussedwithregardtoSectionH,andwerebeingpilotedattwohomesbeforefullimplementationcampuswide.Asampleof19individuals’records(i.e.,Individual#215,Individual#31,Individual#244,Individual#213,Individual#144,Individual#251,Individual#103,Individual#65,Individual#294,Individual#210,Individual#86,Individual#158,Individual#299,Individual#356,Individual#181,Individual#253,Individual#42,Individual#156,and


# Provision AssessmentofStatus ComplianceIndividual#72)wasreviewed.Basedonareviewofthese19records,therewasdocumentationthattheIDTstartedtheassessmentprocessassoonaspossiblebutwithinfiveworkingdaysoftheindividualbeingidentifiedasatriskfornoneoftheindividuals(0%).Therewaslittleinformationinthesystemtoprovidedocumentationtoshowtheassessmentprocessbeganwithinfiveworkingdays.Eveniftheteamhadstartedanassessmentprocessduringthattime,thedocumentsdidnotreflectthat,anditappearedtherewasnostandardsystemapproachtothisdocumentation.Itdidappearthatmostplansdidnothavedirectstatementsthatfurtherassessmentswereneeded.Basedonareviewoftwoindividuals’recordsinresponsetochangesinanat‐riskindividual’scondition(i.e.,Individual#213,andIndividual#158),therewasdocumentationthattheIDTstartedtheassessmentprocessassoonaspossiblebutwithinfiveworkingdaysoftheindividualchangesinanat‐riskconditionfornoneoftheindividuals(0%).Similarly,theredidnotappeartobeasystembywhichtoidentifyrequestsforassessments,orprovideatrackingmechanismwithdatestoensurethisaspectoftheSettlementAgreementwasmet.Basedonareviewof19individualrecordsforwhomassessmentshadbeencompletedtoaddresstheindividuals’atriskconditions,10(53%)includedanadequatemedicalassessmenttoassisttheteamindevelopinganappropriateplan.However,thisreviewincludedanarrowfocusofonlymedicalassessments.Otherclinicalareassuchasnursing,OT/PT/SLP,psychiatry,andpsychologywerenotpartofthefocusedreviewofmedicalassessments.TheFacilityindicatedthatitwasnotincompliancewiththerequirementsoftheSettlementAgreementforthisarea.ThiswasconsistentwiththefindingsoftheMonitoringTeam.

I3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshallestablishandimplementaplanwithinfourteendaysoftheplan’sfinalization,foreachindividual,asappropriate,tomeetneedsidentifiedbytheinterdisciplinaryassessment,includingpreventiveinterventionstominimizetheconditionofrisk,exceptthattheFacilityshalltake

TheEnhancedRiskProcessincludedareplacementoftheRiskActionPlanswithIntegratedHealthCarePlans.Componentsincludedgoals,neededservicesandsupports,thedateofimplementation,thepersonresponsiblefortheimplementationanddocumentation,thedatatobecollected,thedeterminationofhowoftenthedatawastobecollected,thepersonresponsiblefortheplan,thepersonresponsiblefortheplan’seffectiveness,completiondate,follow‐uptoanyidentifiedneeds,andoutcome.AnIntegratedHealthCarePlanwastobecreatedforanymediumorhigh‐riskcategory.Accordingtosubmittedinstructionsforthisprocess,theIntegratedHealthCarePlanwastobedevelopedduringtheIDT/ISPmeetingandfinalizedbythenursecasemanagerfortheindividual.AtemplatefortheAnnualIntegratedHealthCarePlanforRiskGroup1,dated5/24/12,andforRiskGroups2through7,dated5/25/12,weresubmitted.Thisprocesswasinitiatedon5/18/12.AspartoftheIntegratedHealthCarePlan,atemplate

Noncompliance


# Provision AssessmentofStatus Compliancemoreimmediateactionwhentherisktotheindividualwarrants.SuchplansshallbeintegratedintotheISPandshallincludetheclinicalindicatorstobemonitoredandthefrequencyofmonitoring.

wassubmittedfor“DirectSupportProfessionalsInstructions,”withsignatureofthehomemanager/chargeandeachofthedirectsupportprofessionalsreviewingtheinstructions.TherewasaseparateformforeachofthesevenRiskGroups.Theredidnotappeartobeadesignatedareaforthedatewhentheinstructionsweretobeimplemented.Similarly,atemplate,dated5/25/12,forthetriggersheetsforeachoftheRiskGroupswasalsosubmitted.TheshiftnursewastoreviewthedirectsupportprofessionaldocumentationontheTriggerSheetattheendofeachshift,andinitialasevidenceofreview.TheSSLCAt‐RiskProcess,dated2/10/12,wasillustratedthroughaflowdiagram,whichwasanaidforunderstandingtheseveralstepsintheenhancedriskassessmentprocess.Atthesametime,aprocess/pathwaywascreatedtoensureachangeinhealthorbehavioralstatuswouldbepartoftheenhancedriskprocess,andwouldbereflectedintheIDT/RiskprocessandtheIntegratedHealthCarePlan.AspartoftheannualISPprocess,atriggerdatasheetwastobeimplemented.Thissheetwastolistclinicalindicators,andmeasurableobservationsthatwouldguidestaffinearlyrecognitionofhealthstatuschange.Triggerdatasheetsweretobedevelopedforallhigh‐riskcategoriesbytheIDT.Basedonareviewof27recordsforindividualsdeterminedtobeatrisk(i.e.,Individual#144,Individual#183,Individual#278,Individual#9,Individual#282,Individual#378,Individual#213,Individual#327,Individual#91,Individual#221,Individual#34,Individual#210,Individual#153,Individual#211,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,Individual#26,andIndividual#95),therewasdocumentationthattheFacility:

Establishedanappropriateplanwithinfourteendaysoftheplan’sfinalization,foreachindividual,asappropriate,innoneofthecases(0%)reviewed.

Implementedaplanwithinfourteendaysoftheplan’sfinalizationforeachindividual,asappropriateinnone(0%)ofthecasesreviewed.AlthoughtheActionPlansreviewedusuallyincludedadateofimplementation,therewasnosupportingdocumentationverifyingthattheactionstepscontainedintheplanhadinfact,beenimplemented.Inaddition,anumberoftheactionstepsweresononspecificandgenericallywritten,theirimplementationessentiallywouldbeimpossibletoverify.

ImplementedaplanthatmettheneedsidentifiedbytheIDTassessmentinnoneofthesecases(0%).

Includedpreventativeinterventionsintheplantominimizetheconditionofriskinnoneofthecases(0%).AlthoughsomegenericinterventionswerefoundinsomeISPsaddressingtheneedforexerciseorfluidsthatwouldhaveledtoa


# Provision AssessmentofStatus Compliancepreventativeintervention,becausetheseinterventionswerenotwritteninmeasurabletermstoallowimplementationandtracking,theywerefoundnottobeincompliancewiththisindicator.

Whentherisktotheindividualwarranted,tookimmediateactioninnoneofthecases(0%).

IntegratedtheplansintotheISPsinthreeofthecasesreviewed(11%).IndividualswhohadnothadtheirRiskActionPlansintegratedintotheirISPsincluded:Individual#183,Individual#278,Individual#9,Individual#282,Individual#378,Individual#213,Individual#327,Individual#221,Individual#34,Individual#210,Individual#153,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,Individual#26,andIndividual#95.

None(0%)oftheplansshowedadequateintegrationbetweenalloftheappropriatedisciplines,asdictatedbytheindividual’sneeds.

Noneoftheplans(0%)hadappropriate,functional,andmeasurableobjectivesincorporatedintotheISPtoallowtheteamtomeasuretheefficacyoftheplan.

Noneoftheplans(0%)includedthespecificclinicalindicatorstobemonitored. Thefrequencyofmonitoringwasincludedintheplansfornoneofthe

individuals(0%).AlthoughtheActionPlanscontainedaheadingaddressing“MonitoringFrequency,”thefrequencywasnotedgenerallyasdailyorweeklywithoutthespecificshiftordayincludedtoensureaccountability.

Thesignificantproblematicissuesthatresultedinnoncompliancewiththeabovecomplianceindicatorsincluded:

ThereappearedtobenoformatinplacetoindicatewhenActionPlanscontainedintheISPswererelatedtoahighormediumriskdesignationtoeasilyidentifytheindividuals’interventionsaddressingtheirsignificanthealth/behavioralrisks;

ManyoftheRiskActionPlansincludedintheISPsonlyincludedaportionoftheinterventionscontainedontheseparateRiskActionPlansgeneratedfromthepreviousindependentriskmeetingsheldbytheteamstodeterminethelevelofrisk;

WhenadditionaldatesaddedtotheIntegratedRiskRatingFormsindicatedrevisionsweremade,theMonitoringTeamwasunabletodeterminewhatinformationontheformwasactuallyrevised,whichinturn,madeitimpossibletodetermineiftherehadbeenappropriateandtimelyassociatedchangesmadetotheRiskActionPlans;

SincemanyofthedatesontheRiskActionPlansdidnotcoordinatewithanyoftherevisiondatesontheIntegratedRiskRatingforms,theISPdate,oranISP


# Provision AssessmentofStatus Complianceaddendumdate,itwasimpossibletodetermineexactlywhenandinresponsetowhateventtheActionPlanwasdeveloped;

RiskActionPlansweregeneric,andnon‐specificinaddressingthehealthrisksoftheindividual;

SpecificandmeasurablepreventativeinterventionswerenotincludedintheRiskActionPlans;

InterventionslistedontheRiskActionPlansdidnotincludespecificclinicalindicatorstobemonitoredorthespecificfrequencyincluded;and

BasicallyalloftheinterventionsontheRiskActionPlansreviewedwerenotinalignmentwiththedesignatedriskratingofhighormediumrisks.

TheMonitoringTeamhadafewadditionalgeneralobservationsforSectionIthatwouldassistinguidingtheIDTsandininterpretationofthedocumentsbyallreviewers.

ThereneededtobeasystemtodocumenttimelinessofstepsoutlinedintheSettlementAgreement(i.e.beginningtheassessmentprocesswithinfivedays,proofofimplementationwithin14days,etc.).

Forseveralindividuals,therewerenumerousrevisionsoftheIRRFandriskactionplansinthepastyear.Itisimportanttodifferentiatenewinformation(withdatethatparagraphorstatementwasupdated)frompriorinformation.Itwasdifficulttodeterminewhathadchangedfromoneversiontothenextversion.

Teamsneededtoclearlydefinetheassessmentsbeingrequestedtocreateafinalriskactionplan.FormostIRRFdocuments,itwasdifficulttodetermineifadditionalassessmentswerebeingrequested,andwhentherequestwasmade,whichisespeciallyimportantforthefive‐daytimeperiodtobegintheassessmentprocess.

Itwouldbehelpfultohaveachartattheendofthedocumentlistingtheassessmentswithcolumnstoindicatewhenitwasrequested,whenitwascompleted,whenitwasreceivedbytheIDT,andwhenitwasdiscussedatanIDTmeeting,andthedateoftheISPAatwhichitwasdiscussedandactedupon.

TheIRRFandriskactionplanwereinconsistentaboutincludingmonthly/quarterlyupdatesinthedocuments.Thereshouldbeconsistencyacrossthecampusaboutwhethertoincludetheseinthereportsornot.

TheISPdidnotcaptureinterdisciplinarydiscussionformostrisksdefinedfortheindividual,butsimplycopiedtheriskfromtheIRRF.Formanyentries,thefocuswasonacontributionofadepartmenttotheISP(i.e.,medical,nursing,etc.),asopposedtoafocusontheriskandhoweachdepartmentcouldcontributetopreventingorminimizingtherisk.

TheISPsdidnotappeartoreflecttheprocessforhealthstatuschange,orthequestionsraisedatthemorningmedicalmeetingthatresultedinanIDTmeeting


# Provision AssessmentofStatus CompliancefollowedbyanISPA.DocumentationofthehealthstatuschangeandtheeffectivenessofanystepstakenasaresultofimplementationoftheISPAwouldbeexpectedtobepartofanamendedorfutureISPforthatparticularrisk.Foreachhospitalization/ERvisit,thegoalwouldbetohaveadiscussionofpreventingarecurrence,withactionstepsthatcanbemeasured.

Thepurposeofincludingtransitioninformation(especiallydental)intheIRRFwasnotclear.Transitioninformationmightneedtobeplacedinadifferentdocumentorinacategoryofriskfortransitions.However,whentherewerenoimmediatewell‐definedplansthatwereunderwayforatransitionfortheindividual,itwasunclearwhyitwouldbeincludedintheIRRF.

Atthetimeofthereview,theFacilityindicateditwasnotincompliancewiththerequirementsoftheSettlementAgreementforthisarea.ThisfindingwasconsistentwiththefindingsoftheMonitoringTeam.However,theincreaseintheinconsistentandfragmenteddocumentationregardingtheAt‐Riskindividualswasofsignificantconcern.Thismadedeterminingthechronologicalclinicalsequenceofeventsconfusingandcomplicatedinthemidstoftheever‐changingAt‐Risksystem.CCSSLCshouldcontinuetofocusitseffortsontheprocessofdevelopingspecificandclinicallyappropriateriskactionplansforeachindividualbythenextreview.TheseRiskActionPlansshouldmeettheindividuals’needs,containfunctional,andmeasurableobjectives,includeclinicalindicatorstobemonitoredandthespecificfrequencyofthatmonitoring,includepreventativeinterventions,andbefullyintegratedintotheISPs.


1. InprioritizinginvolvementintheISP/at‐riskprocess,PCPsshouldbeexpectedtoattendtheat‐riskdiscussiontoensureteamsarriveatclinicallyappropriateconclusions.(SectionI.1)

2. ThePCPshouldprovidebackgroundinformationconcerningthediagnostictestsalreadycompleted,thedatesofcompletion,withabriefentryconcerningresults.TheIDTscannotarriveatcorrectriskratingswithoutsufficientinformation,norcanfurtherassessmentsberecommendedifitisnotknownwhatassessmentshavealreadybeencompleted.(SectionI.1)

3. TheStateOfficeshouldconsiderexpandingthe“infection”categorytoprovideadditionaloptionstoprovideguidancetothePSTs.Currently,thedescriptionofhighriskforinfectionrequirestwoormoreMultipledrugresistantorganism(MDRO)infections,oranopenwound.Itwouldbehelpfultoexpandthistoanyhospitalizationforaninfection(e.g.,sepsis,UTI,diverticularabscess,empyema,meningitis,etc.),becauseinfectionsrequiringhospitalizationindicatetheneedforintensereviewforriskreduction,notonlythosewithMDROorasurgicalwound.(SectionI.1)

4. Additionaltrainingontheat‐riskprocessshouldbeprovidedtotheIDTs.Thisisnecessarytoensurethattheat‐riskprocessadequatelyidentifiesthecriticalissues,andthatappropriateandclinicallysoundactionplansaredevelopedtoaddresstherisksidentified.(SectionsI.1,I.2,andI.3)

5. Whentheteamconvenesaboutanindividual,thedepartmentsresponsibleforbackgroundinformationconcerningariskcategoryshouldbesufficientlyknowledgeableaboutthatcategorytoexplaintherisktotheremainderoftheteam.(SectionI.1)


6. EachIDTmembershouldobtainallrelevantinformationaheadofthemeeting,especiallyinformationonwhichtheteamwillbaseariskrating.(SectionI.1)

7. Thereshouldbeevidencetoconfirmtheteam’srationaleforeachcategoryofriskreviewed.(SectionI.1)8. Whenthereisachangeinhealthstatus,theIDTshouldreconvenetoratethecategoriesofrisk,andincorporateanychangesinhealthintothe

riskcategoriesandintoariskactionplan.Particularly,whenanindividualishospitalizedandsubsequentlydischargedhome,theIDTshouldmeetpromptlyaddressanychangesinhealthandfunctionalstatus.(SectionsI.1,I.2,andI.3)

9. Itisimportanttocreateastandardizedapproachtodifferentiatetheoriginalplan/informationfromupdatesandotherinformationthatisenteredintotheplan,withdatesofeachadditionalentry.(SectionsI.1,I.2,andI.3)

10. ThePCPsshouldensurecompleteandtimelyassessmentsareordered,andresultsincorporatedintotheindividual’streatmentandcare.TheriskactionplanrequirescriticalclinicalthinkingonhowtopreventrecurrencessuchasERvisitsorhospitalizationstoimprovethequalityoflifebyimprovingthehealthoftheindividual.(SectionsI.2andI.3)

11. TheFacilityshouldcreateatrackingsystemlistingdatesofactionthatfollowtheidentificationofindividualsatrisk,includingtheassessmentprocessandthedevelopmentandimplementationofriskactionplans.(SectionsI.2andI.3)

12. TheareasthattheAt‐RiskIndividualspolicydesignatesthatnursingistoassessshouldbereviewedtodeterminewhichdisciplineisthemostappropriatetoconductthoseassessments.(SectionI.2)

13. TheFacility,inconjunctionwiththeState,shoulddefinespecificallytheassessmentprocessregardingat‐riskindividualsforalldisciplines.(SectionI.2)

14. GiventhatIDTs,attimes,donotrealizewhenmoreassessmentisindicated,departmentheadsshouldreviewIDTfindingsrelevanttotheirdepartmenttoensureappropriateguidanceisprovidedtotheteamsindeterminingneededassessments.(SectionsI.1,andI.2)

15. Asummarylistoftheassessment(s)beingrequestedasaresultoftheIRRForISPAshouldbecreatedtoassistintrackingthecompletionoftheassessment.Tousethisasatrackingtool,itwouldbehelpfulifitincludedthedateofrequest,datecompleted,datereceivedbytheIDT,datediscussedatanIDTmeeting,anddateofISPAatwhichitwasdiscussedandactedupon,ifapplicable.(SectionI.2)

16. TheFacilityshoulddecideuponasystemforquarterly/monthlyupdates,includingwhethertheseshouldbemaintainedinthedocumentsthemselves,orinaseparatedocument.(SectionI.3)

17. TheISPandrelatedactionplansshouldcapturetheinterdisciplinarydiscussionabouttherisksdefinedfortheindividual.(SectionI.3)18. Asindividuals’risksareidentified,andriskactionplansaredeveloped,teamsshouldensurethatmeasurableobjectivesorindicatorsare

establishedtoallowtheteamtomeasurewhetherornottheindividualisbetterorworse,andifhis/herrisklevelisreduced.Ifaplanisnotworking,theteamneedstoreevaluateit,andpotentiallyreviseit.(SectionI.3)

19. TheFacilityshouldmonitortheISPstoensuretheriskratingsandactionplansareintegratedintoindividuals’ISPs.(SectionsI.1,I.2,andI.3)20. RegardingtheFacility’sself‐assessmentsystemaddressingSectionI,theFacilityshouldevaluatewhowouldbebesttoauditthishighlyclinical

areainordertogenerateaccurateinformationregardingclinicalissuesrelatedtotheindividualsatrisk.(FacilitySelf‐Assessment)21. ConsiderationshouldbegiventostandardizingthepresentationofdataacrosstheFacilityforconsistencyininterpretation,using,forexample,

tablestoreportmonitoringfindingsratherthananarrativeformatthatismoreappropriatelyusedtosummarizetheanalysisofthedata.(FacilitySelf‐Assessment)

22. AstheFacility’sself‐assessmentprocessesevolve,additionaldatashouldbeanalyzed,addressed,andincludedintheSelf‐AssessmenttosubstantiatecomplianceornoncompliancewiththeSettlementAgreement.Suchdatacouldcomefromavarietyofsources,includingaudits,aswellasotherdatasources,suchasdatabasesoroutcomeindicators.(FacilitySelf‐Assessment)


SECTIONJ:PsychiatricCareandServicesEachFacilityshallprovidepsychiatriccareandservicestoindividualsconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow:


o Policiesrelatedtotheuseofpre‐treatmentsedationmedication;o Spreadsheetofindividualswhohavereceivedpre‐treatmentsedationmedicationinthe

lastsixmonthsformedicalordentalprocedures,nameanddosageofmedication,includingdateofadministration;

o JobDescriptionsofPsychiatrists;o Listofindividualswhosepsychiatricdiagnoseshavebeenrevised,alongwiththe

Psychiatrist’srationaleforthenewdiagnosis;o Listofindividualsprescribedintra‐classpolypharmacy,withtotalnumberofmedications

prescribed;o ListofallmeetingsandroundsthatthePsychiatristtypicallyattends,includingother

professionaldisciplinesthatusuallyattendthosemeetings;o ListofsupportservicesforPsychiatryDepartment;o MinutesofPolypharmacyMeetingsReview,forthelastsixmonths;o InresponsetoMonitoringTeam’srequestfordocumentationpertainingtocomplaints

aboutthepsychiatricandmedicalcareatCCSSLC,documentindicatingnocomplaints;o Listsofindividualswithtardivedyskinesia,andindividualsbeingmonitoredfortardive

dyskinesia;o Listofallindividualsprescribedpsychotropicmedication,includingdiagnosis,nameof

medication,anddosage;o Listofallindividualsprescribedanticonvulsantmedicationasapsychotropicmedication;o Listofindividualswhowerepsychiatricallyhospitalizedwithinthepriorsixmonths;o ListofIndividualSupportPlanMeetingsattendedbymembersofthePsychiatry

Departmentwithinthepriorsixmonths;o Consentdatabaseforpsychotropicmedication;o Examplesofthemedicationsideeffectsmonographsforfivepsychotropicmedications;o Psychiatricsymptomstrackingscaledefinitions,updated6/29/12;o ReissScoringSheetswithresultsforeverysixthindividuallistedontheReissStatus

Spreadsheetproducedon7/10/12;o Chemicalrestrainttrendingdataforthelastsixmonths,andthechemicalrestraint

administrationdocumentationforthelastsixmonths;o ComprehensivePsychiatricEvaluation(CPE)completionstatusspreadsheetandten

examplesofrecentlycompletedCPEs,whichincludedIndividual#186,Individual#169,Individual#183,Individual#326;Individual#46,Individual#20,Individual#88,Individual#34,Individual#332,andIndividual#12;

o SpreadsheetlistingthedatesoftheNeurologyConsultationsandthecorrespondingPsychiatricClinicReviewforthelastsixmonths;

o NeurologyClinicnotesandthecorrespondingQuarterlyPsychiatricClinicnotesforthe


followingindividuals:Individual#285,Individual#78,Individual#55,Individual#7,Individual#243,Individual#198,Individual#363,andIndividual#213;

o SpreadsheetofReissScreenExaminationsforallCCSSLCindividuals;o Listofindividualsreceivinganticholinergicmedication;o Listofindividualsprescribedbenzodiazepines;o Thefollowingsectionsfromtheactiverecord:FaceSheet;SocialHistory;Rights

Assessment;ConsentsforPsychotropicMedication;ConsentsforPre‐TreatmentSedationMedication;HumanRightsCommittee(HRC)sectionandReferralForm,aswellasAddendumsrelatedtoPsychotropicMedication;thePsychologysection,includingthePBSPandanyaddendumsaswellastheFunctionalAssessment;theIndividualSupportPlanandAddendums;Hospitalsection;Psychiatrysection;SideEffectsection;Pharmacysection;andtheNeurologyConsultationsectionfor:

ThefollowingindividualswhowererecentlyadmittedtotheFacility:Individual#97,Individual#63,Individual#61,Individual#40,andIndividual#5;

ThefollowingindividualswhotheFacilityselectedforthepre‐reviewdocumentrequest:Individual#231,Individual#359,Individual#237,Individual#13,Individual#112,Individual#279,Individual#158,Individual#298,Individual#295,andIndividual#145;

Thefollowingindividualswhowereselectedbasedontheacuityoftheirpsychiatricpresentation:Individual#147,Individual#348,Individual#71,Individual#318,Individual#253,andIndividual#145;

o ThemasterspreadsheetforcompletionoftheMonitoringofSideEffectsScale(MOSES)andtheDyskinesiaIdentificationSystem:CondensedUserScale(DISCUS)forthelastsixmonths;

o ListofindividualsreceivingReglanasof7/10/12withnotationastowhichindividualsarealsofollowedinthePsychiatricClinics;

o CurriculumVitae(CV)andContractsforthelocumtenensPsychiatrist,Dr.JasonKirkpatrick;andtheConsultingPsychiatrist,Dr.MichaelHernandez;

o ListofindividualswhoareprescribedReglanandwhoarenotfollowedinthePsychiatryClinic,aswellasthelistofindividualswhoareprescribedReglanandarefollowedinthePsychiatryClinicasofJuly2012;

o MOSESandDISCUSsideeffectratingscoresforthelastyearforthefollowingindividualsreceivingReglanwhowerenotalsoreceivingapsychotropicmedication:Individual#43,Individual#205,Individual#252,Individual#113,andIndividual#239;

o CCSSLCPresentationBookforSectionJ‐PsychiatricServices,whichcontainedthefollowingsections:a)ComplianceReview;b)PlanofImprovement;c)MonitoringTools;d)EvidenceJ.1throughJ.15;ande)Recommendations1through3andRecommendations7through10;

o Chemicalrestraintdocumentationrelatedtotheadministrationofthefollowingfiveincidentsofchemicalrestraint:Individual#147on7/14/12,Individual#147on7/6/12,Individual#147on7/6/12,Individual#147on7/8/12,andIndividual#237on7/7/12;

o Documentationfromthe7/11/12HumanRightsCommitteeMeeting;


o Thematerialpresentedatthe7/10/12PolypharmacyCommitteeMeeting;o Theclinicalinformationdiscussedatthe7/11/12and7/12/12morningMedical

Meetings;o Thematerialthatwaspresentedanddiscussedatthe7/9/12PharmacyandTherapeutics

CommitteeMeeting;ando TheminutesoftheInformedConsentCommitteeMeetingsof4/10/12and6/25/12.

Interviewswith:o GlynnBogard,PsychiatricAssistant;MichelleP.Lora‐Arteaga,R.N.,PsychiatricNurse;

BrindaFuller,R.N.,PsychiatricNurse;andJosephWard,PsychiatricAssistant,on7/9/12and7/12/12;

o MichaelHernandez,M.D.,ConsultingPsychiatrist,on7/10/12; o JudySutton,MS,BCBA,DirectorofBehavioralServices;andRobertCramer,Psy.D.,Clinical

Psychologist,on7/9/12;o DonaldKocian,R.Ph.,andKendaPittman,RPh,on7/10/12;o SandraRodriguez,M.D.,on7/10/12;o EnriqueVenegas,D.D.S.;andKathyRoach,DentalHygienist,on7/10/12;o KarenForrester,HumanRightsOfficer,on7/11/12;o GlynnBogard,PsychiatricAssistant;BrendaFuller,R.N.,PsychiatricNurse;andJoseph

Ward,PsychiatricAssistant,on7/11/12;o GlynnBogard,PsychiatricAssistant,toreviewFacilitySelf‐Assessment,on7/12/12;o AraceliMatehuala,ProgramComplianceMonitorforPsychiatry,on7/12/12;o MarkCazalas,FacilityDirector,on7/10/12.

Observationsof:o HRCMeeting,on7/11/12;o PolypharmacyCommitteeMeeting,on7/10/12;o IndividualtransactionsattheReinforcementTokenEconomyStore,KingfishLivingUnit,

on7/11/12;o MedicalMorningMeetings,on7/11/12and7/12/12;o PharmacyandTherapeuticsCommitteeMeeting,on7/9/12;ando ThefollowingindividualswereobservedduringtheonsitereviewoftheLivingUnitsand

programsites:Individual#30,Individual#368,Individual#267,Individual#34,Individual#29,Individual#13,Individual#118,Individual#61,Individual#242,Individual#166,Individual#318,Individual#255,Individual#243,Individual#94,Individual#40,Individual#94,Individual#44,Individual#78,Individual#218,Individual#169,Individual#329,Individual#359,Individual#323,Individual#332,Individual#177,Individual#72,Individual#95,Individual#246,Individual#158,Individual#97,Individual#151,Individual#12,Individual#172,Individual#208,Individual#186,Individual#106,Individual#184,Individual#237,Individual#268,Individual#162,Individual#246,Individual#296,Individual#90,Individual#273,Individual#336,Individual#19,Individual#295,Individual#47,Individual#109,Individual#279,Individual#300,Individual#339,andIndividual#11.


FacilitySelf‐Assessment: AmemberoftheMonitoringTeamreviewedtheFacilitySelf‐AssessmentwiththememberofthePsychiatryDepartmentwhowastheprimaryauthorofthedocument,andalsohadcompiledthestatisticalinformationfromwhichtheresultsoftheself‐assessmentwerederived.ThemethodologythatthePsychiatryDepartmentutilizedinvolvedbothadata‐basedapproach,aswellascasesamplingmethodology.TheFacilitymaintaineddetaileddatabasesrelatedtospecificdocuments,suchastheCPEsandthenewdiagnosticcheckliststhatwereusedtoestablishthepsychiatricdiagnosis(SectionsJ.2,J.6,andJ.13),thepolypharmacystatistics(SectionJ.11),theMOSES/DISCUSmonitoring(SectionJ.12),andtheReissScreeningevaluations(SectionJ.7).Theywereabletoutilizethisinformationtodocumentcompletionratesfortheentirepopulationofindividualsreceivingpsychotropicmedication.ThesamplingmethodologyfortheindividualcasesconsistedofselectingthreeindividualspermonthforthetimeperiodofDecemberthroughMay2012.Thisproducedatotalof18individuals,whichformedthebasisfortheanalysis.MembersofthePsychiatryDepartmentthenscoredtherecordsinrelationtothe15provisionsoftheSettlementAgreement.Forexample,forSectionJ.10,teammembersreviewedProgressNotesforindividualswhohadstartedusinganewpsychotropicmedicationwithinthistimeframe.Thesenoteswerethenanalyzedtodeterminedisciplinerepresentationintheprocessofdeterminingwhetherornotthepotentialharmfuleffectsofthementalhealthconditionoutweighedthepotentialrisksofthemedication.Thepresenceandqualityoftheriskanalysisalsowasassessed.ThepresenceoftheGuardianConsentwastrackedviaaseparatespreadsheetwithregardtoSectionJ.14.TheinternalreviewforSectionJ.14alsoincludedanassessmentofthequalityofthe“consentformpacketsforpsychotropicmedication.”Thesepacketsincludedtherisk‐benefitanalysis,therationaleforthemedication,thepotentialsideeffectsofthemedication,andtheactualsignedconsentform.Whereappropriate,bothmethodologieswereemployed.Forexample,forSectionJ.12,theFacilitymaintainedandreviewedadetaileddatabaseoftheMOSESandDISCUSstatusforallindividualswhorequiredthoseassessments,andtheyalsoreviewedtherecordsof25individualstodetermineiftheseassessmentscouldthenbelocatedintheindividuals’records.Theself‐assessmentfollowedtheformatoftheSettlementAgreementandthepriormonitoringreviews.Morespecifically,eachsectionwasbrokendownintoitskeycomponentsandthenthepresenceorabsence,aswellasthequalityofthoseitemswereassessed.Forexample,forSectionJ.6theteamdeterminedwhethertheCPEfollowedtheprescribedoutlineintheSettlementAgreementandoccurredwithintheannualtimeframe.TheteamalsoassessedifaqualifiedPsychiatristhadcompletedit.ThesamegeneralprocesswasappliedtotheassessmentoftheMonthlyandQuarterlyReviewsforSectionJ.13.TheFacility’sself‐ratingsfortheindividualprovisionsparalleledthoseoftheMonitoringTeam,withonlyafewexceptions.Thislikelyrelatedtothesimilarityinthecombinationofadatabaseandsamplingapproach.AtthetimeofthepreviousMonitoringReview,theFacility’sSelf‐AssessmentofsubstantialcompliancewassimilartotheMonitoringTeam’sassessment,withonlyoneexception.Theratingsforthecurrentreviewweresomewhatmoredivergent.Specifically,whiletheFacilityandMonitoringTeam’sindependentratingswerecongruentfor12ofthe15provisions,theyweredivergentforSectionsJ.3,J.6,andJ.13.


WithregardtoSectionJ.3,theFacility’sSelf‐Assessmentofsubstantialcompliancedidnotfactorintheassessmentofthechemicalrestraintdata,whichwasdeficientand,thus,ledtotheMonitoringTeamtomakeafindingofnoncompliance.GiventhatthequalityofthedocumentationrelatedtotheuseofchemicalrestraintrelatesdirectlytothecomponentsofSectionJ.3,theFacilitymightwanttoconsideraddingananalysisofthesedocumentstotheirself‐assessmentprocess.

ThediscrepancybetweentheFacility’sratingsforSectionJ.13ofSubstantialComplianceandtheMonitoringTeam’sfindingofnoncompliancewasprimarilyduetofactthatamemberofthePsychiatryteamdidnotroutinelyattendtheISPMeetingsandtheefficacyofmanyoftheprescribedmedicationscouldnotbesubstantiated.

WithregardtoSectionJ.6,theMonitoringTeam’sfindingofsubstantialcompliancewasdifferentfromtheFacility’s,becausetheFacilityfocusedonthelackofacompletedCPEforthethreeindividualsmostrecentlyadmittedtoCCSSLCfromthecommunity.TheMonitoringTeamnotedthattheseindividualsallhadbeenadmittedwithinsixweekspriortotheonsitereview,andeventakingthesethreeindividualsintoaccount,theFacility’soverallpercentagerateforCPEcompletionwasstill98percent.

TherepresentativeofthePsychiatryDepartmentindicatedthattheydidnotenlisttheassistanceoftheQualityAssuranceDepartmentincarryingouttheirself‐assessmentforthismonitoringreviewcycle.TherationalewasthattheQualityAssurancecomponenthadonlybeenconsistentlypresentsinceMarch2012.However,theinterviewwiththememberoftheQualityAssuranceDepartmentwhowillbeworkingwithPsychiatry,aswellasthereviewoftheQualityAssurancemonitoringdatafromMarchthroughthepresenttimesuggestedthatthecollaborationbetweenthePsychiatryteamandtheQualityAssuranceDepartmentshouldenhancetheFacilitySelf‐Assessmentprocess.SummaryofMonitor’sAssessment: ThePsychiatryDepartmenthadcontinuedtomakeprogressinanumberofthe15provisionsofSectionJoftheSettlementAgreement.PerhapsthemostnotableofthesewasthecompletionofcurrentComprehensivePsychiatricEvaluationsforalloftheindividualsreceivingpsychotropicmedicationpriortotheApril2012departureofthelocumtenensPsychiatrist.ThelocumtenenspsychiatristhadtwoprolongedstaysattheFacilitythatweredevotedsolelytothecompletionoftheinitialCPEs,aswellastheannualupdates.ThreeoftheindividualswhohadbeenadmittedtotheFacilitywithinthesix‐weekperiodprecedingtheonsitereviewdidnothavecompletedCPEs,althoughtheyhadbeenseenandevaluatedinthePsychiatryclinicandreceivedinitialsideeffectmonitoring.Thisresultedinanoverallcompletionrateof98percent.ItwasanticipatedthatthelocumtenensPsychiatristwouldreturninthefall,prepareannualupdatesforthecurrentCPEs,andcompleteinitialCPEsforanyindividualsnewlyadmitted.TheCPEs,inconjunctionwiththeQuarterlyPsychiatryReviewdocumentationdirectlyappliedto10ofthe15provisionsoftheSettlementAgreement.TheConsultingPsychiatristrecentlyhaddecreasedhisconsultingtimefrom12toeighthoursperweek,anditremainedtobeseenifthiswouldhaveanegativeimpactontheFacility’seffortstomeettherequirementsoftheSettlementAgreement,orifthefourmembersofthepsychiatricsupportteamwouldbeabletocompensateforthis.TheFacilitywascontinuingtoactivelyrecruitfull‐timePsychiatristsforthetwoopenPsychiatristpositionsthatwereavailable.


Thepsychiatryteamhaddevelopedandimplementedapsychiatricsymptomtrackingscalethatdefined21symptomsoftheMajorAxisIpsychiatricdiagnosticcategories.Thisscalewasdesignedtoallowthetreatmentteamtobetterdocumentthesymptomsthatsupportedthepsychiatricdiagnosisandalsotrackthefrequencyandintensityofthesesymptomsovertime.ThisnewlydevelopedtoolaugmentedtheDSM‐IVDiagnosticChecklists,whichtheDepartmentpreviouslyhadimplementedfully.Thefullimplementationoftheseinitiatives,coupledwiththePsychologyDepartment’sinclusionofanewsectionintheirdocumentationentitled“PsychiatricInformation”madeitpossibletodifferentiatethesymptomsofthepsychiatricdisorderforwhichthepsychotropicmedicationwasprescribedfromthechallengingbehaviorsthatwererelatedtoenvironmentalorinterpersonalfactors.TheseparationoftheconsentforthepsychiatricmedicationsfromtheBehavioralSupportPlanshadbeenfullyimplemented.Theconsentswerenowobtainedforeachprescribedmedication,whichrepresentedanimprovementoverthepriorpracticeofpursuingconsentsforasmanyasfourorfivemedicationsasasinglepackage.Aspartofthisdevelopment,anurseobtainedtheconsentforthemedication,wherepreviouslytheAssociatePsychologisthadbeenresponsibleforthistask.Atthetimeoftheonsitereview,thePsychiatrystaffwerejustbeginninganinitiativetobothattendtheIndividualSupportPlanmeetingsfortheindividualstheyfollowed,andalsodirectlycomposeandplacetheirmaterialintotheISPdocumentation.Thiswasanotherimportantdevelopment,becausethelanguageoftheSettlementAgreementspecifiesthatanumberofdiscussions,suchastheriskdiscussionrelatedtothepsychotropicmedicationsandwhethertheyrepresenttheleastintrusiveintervention,shouldoccurinthecontextoftheISPandthenbedocumentedthereaswell.Thisinitiativewasnotapparentinthecurrentreviewoftherecordsofindividualswhowerereceivingpsychotropicmedication,butitshouldbepresentinthenextreviewcycle.Theefforttodeveloppre‐treatmentdesensitizationplanshadprogressed,butwouldstillbeclassifiedasintheearlystagesofimplementation.Therewasanefforttodeveloptheseplansformedicalinterventionsaswell.Thiswasimportantinlightofthefactthattheordersforpre‐treatmentsedationformedicalproceduresoutnumberedthosefordentalproceduresbyasignificantmargin.Theselectionofthebestmedicationtouseforpre‐treatmentsedationforaspecificindividualoccurredannuallyinthecontextofthePsychiatricClinics,whichmembersofthePharmacyandDentalDepartmentsalsoattendedsothattheycoulddiscusstheseissueswiththeentiretreatmentteam.Therateofpolypharmacywithpsychotropicmedicationswasdownto50percentfrom56percentin2010.However,progresswasincrementaldespiteamonthlyreviewinthePolypharmacyCommitteeMeetings,whichwasquitethorough.AprimaryrecommendationofthisreportisthatthePsychiatryDepartmentincreasesitseffortstodevelopobjectiveevidencetosupportthecontinuedutilizationofmultiplemedicationsforthoseindividualsforwhomtheybelievethisisessential.CCSSLCcontinuedtoexperiencenewadmissionsattherateofapproximatelyoneindividualeveryothermonth.Todate,thesehadallbeenindividualswhohadnotbeenabletobemaintainedinthecommunity


dueto behavioralreasonsand,thus,wereadmittedonmultiplepsychiatricmedications.Therangeofpsychiatricmedicationstheseindividualshadbeenreceivingonadmissionrangedfromthreetoseven,withanaverageof4.8perperson.Atthetimeoftheonsitereview,therangeforthenumberofmedicationsforthesesameindividualswasthreetofour,withanaverageof3.4perperson,sotheteamhadmadeconsiderableprogressinreducingthepolypharmacyforthesecomplexindividuals.TheQualityAssuranceDepartmentwasnowactivelyinvolvedwiththePsychiatryteamandhaddevelopedathoroughmonitoringtoolandformat.ThecollaborationbetweentheQualityAssuranceDepartmentandthePsychiatryDepartmentshouldbeasignificantadditiontotheDepartment’songoingself‐assessmentefforts.Thus,insummary,theDepartmentcontinuedtomakeprogressinanumberofareas.Thisprogressisbothrecognizedanddocumentedinthisreport.Asnotedabove,theFacilityshouldfocusonthematterofpolypharmacy(SectionJ.11).Theseissuesalsoimpacttherisk‐versus‐benefitprocess(SectionsJ.9andJ.10),theinformedconsentprocess(SectionJ.14),andthedeterminationthatthemedicationsareeffective(SectionJ.13).

# Provision AssessmentofStatus ComplianceJ1 Effectiveimmediately,eachFacility

shallprovidepsychiatricservicesonlybypersonswhoarequalifiedprofessionals.

Atthetimeofthereview,Dr.MichaelHernandez,whowasBoardCertifiedinAdultPsychiatrybytheAmericanBoardofPsychiatryandNeurology,wasCCSSLC’sConsultingPsychiatrist.Duringtheinterview,whichtookplaceon7/10/12,heindicatedthat,inadditiontohisconsultationatCCSSLC,healsohadprovidedpsychiatricservicestoindividualswithintellectual/developmentaldisabilities(ID/DD)throughhisprivatepractice,aswellashisworkforacommunityproviderofresidentialservices.Inaddition,hehadevaluatedandtreatedoutpatientswithID/DDthroughalocalcommunitymentalhealthclinic.Dr.HernandezestimatedthathehadengagedinprovidingpsychiatricservicestoindividualswithID/DDforoverfiveyears.HehadbeenapsychiatricconsultanttoCCSSLCforapproximatelyfiveyears.Thus,inadditiontobeingBoardCertifiedinAdultPsychiatry,healsohadsubstantialclinicalexperienceinworkingwiththispopulationandtheiruniqueneeds.Duringthetimeperiodsbothbeforeandfollowingthelastreview,theFacilityhadcontractedwithDr.JasonKirkpatrickthroughalocumtenensphysicians’agency.Mostrecently,on12/16/11,Dr.KirkpatrickhadreturnedtoCCSSLC,andcontinuedtoworkattheFacilityuntilhisdepartureon4/6/12.DuringDr.Kirkpatrick’stenureatCCSSLC,Dr.Hernandezcontinuedtoprovidethedirectpsychiatricservicestotheindividualsreceivingpsychotropicmedication,whileDr.KirkpatrickfocusedoncompletionoftheComprehensivePsychiatricEvaluationsfortheindividualsreceivingpsychotropic



# Provision AssessmentofStatus Compliancemedication.ThereviewofDr.Kirkpatrick’sCVindicatedthathewasBoardEligibleinPsychiatry,havingcompletedaresidencyattheInstituteofLivinginHartford,Connecticut.However,hewasnotBoardCertifiedinAdultPsychiatrybytheAmericanBoardofPsychiatryandNeurology.TheCVdidnotspecificallyindicateifhehadanysubstantialexperienceworkingwithindividualswithintellectualdeficits.Dr.Kirkpatrickwasworkingon‐siteatthetimeoftheprioronsitereviewoftheFacility,andthus,itwaspossibletointerviewhimon1/2/12.Duringthisinterview,heindicatedthathedidnothaveanyextensiveclinicalexperienceinworkingwithindividualswhohavebothintellectualdeficitsandmentalillness.However,theformatfortheCPEswasfamiliartohim,bothfromhispsychiatrictrainingattheInstituteofLivinginHartford,CT,aswellashissubsequentpsychiatricpractice.Inaddition,thereviewoftheCPEsthathehadcompletedindicatedareasonabledegreeofclinicalfamiliaritywiththispopulation,asevidencedbythedifferentialdiagnosesthatheconsideredandtheBio‐Psycho‐Social‐SpiritualFormulationsthathehaddevelopedfortheindividualsthathereviewed.ThestatusoftheprogressincompletingtheCPEswillbediscussedbelowwithregardtoSectionJ.2.Asnotedabove,Dr.KirkpatrickhaddepartedpriortothecurrentMonitoringReviewand,thus,itwasnotpossibletointerviewhimagain,duringthecurrentreview.TheFacilitywasfoundtobeinsubstantialcompliancewiththisprovisionbasedontheobservationthatDr.HernandezwascertifiedinAdultPsychiatrybytheAmericanBoardofPsychiatryandNeurology,andDr.KirkpatrickwasBoardEligible,havingcompletedapsychiatricresidencyatafullyaccreditedtrainingprogram.Inaddition,Dr.Hernandezhadsignificantclinicalexperiencewiththisspecificpopulation.WhileDr.Kirkpatrickdidnothavethisclinicalexperience,thereviewoftheCPEsthathehadcompletedindicatedthathehadasolidgraspoftheclinicalissuespresentedbyindividualswhohavebothmentalillnessandID/DD.

J2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshallensurethatnoindividualshallreceivepsychotropicmedicationwithouthavingbeenevaluatedanddiagnosed,inaclinicallyjustifiablemanner,byaboard‐certifiedorboard‐eligiblepsychiatrist.

Asnotedabove,atthetimeofthereview,theprimaryPsychiatristwhodiagnosedandtreatedtheindividualswhoresidedatCCSSLCwasBoardCertifiedinAdultPsychiatrybytheAmericanBoardofPsychiatryandNeurology.ThisPsychiatristalsohadextensivepriorexperienceinthediagnosisandtreatmentofpsychiatricdisordersinindividualswithID/DD.ThelocumtenensConsultingPsychiatrist,whosesolefunctionwastocompletetheCPEs,wasBoardEligibleinAdultPsychiatry,havingcompletedaresidencyinAdultPsychiatryatanaccreditedPsychiatryResidencyProgram.ThebackgroundwithregardtothetwoPsychiatristsisdiscussedinmoredetailwithregardtoSectionJ.1.Althoughthepsychiatricdiagnosesappearedinanumberofsectionsoftheindividuals’records,theclinicaljustificationthatsupportedthevalidityofthediagnosisprimarilyappearedintherelatedsectionsoftheCPEsandtheQuarterlyPsychiatryReviews.The



# Provision AssessmentofStatus ComplianceQuarterlyPsychiatryReview processanddocumentationisdiscussedindetailwithregardtoSectionJ.13,becauseitismorepertinenttothatsection.Asnotedinthepriorreviews,theFacilityhadbegunaninitiativetocompleteathoroughCPEthatwouldcomplywiththetermsoftheSettlementAgreementforalloftheindividualswhowerereceivingpsychotropicmedication.TheFacility’sstatuswithregardtotheCPEsisdiscussedindetailinSectionJ.6.Thediscussionhereprimarilyrelatestotheresultsobtainedbythecomprehensivereviewofrecordsof16percent(n=20)ofthe128individualswhowerereceivingpsychotropicmedicationatthetimeoftheonsitereview.Thesampleisdescribedinmoredetailaboveinthesectionofthisreportthatdetailsthedocumentsthatwerereviewed.Thesub‐sectionsoftheindividualrecordsthatwerereviewedarealsospecified.Thereviewoftheclinicalrecordofthese20individualsindicatedthattherewasadequateclinicaljustificationforthediagnosisofrecordfor19ofthe20individuals(95%).ThisdocumentationcouldbefoundinthesectionsoftheCPEthatspecificallyweredevotedtothepsychiatricdiagnosisandtherelatedsectionthatdiscussedthe“Bio‐Psycho‐Social‐SpiritualFormulation.”ThematerialintheQuarterlyPsychiatricReviewdocumentationthatspecificallyaddressedthiswerethediagnosticsections,whichincludedalistingoftheovertsymptomsofthedisorderthattheindividualpresentedwith,aswellasthe“DSM‐IVDiagnosticChecklist.”Thechecklistsreproducedthediagnosticcriteriaforthatindividual’sdiagnosisaslistedintheDSM‐IVcriteria,andthenthespecificsymptomsmanifestedbytheindividualwerecheckedoffsothatitwaseasytodetermineiftheDSM‐IVcriteriaforthatdiagnosishadbeenmet.Inaddition,CCSSLChaddevelopedpsychiatricsymptomtrackingscales.Thesescalesprovidedoperationaldefinitionsof21symptomsthatarecommontomanyofthemostprevalentAxisIpsychiatricdisorders.TheIDT,membersofwhichroutinelyattendedthePsychiatricClinics,workinginconjunctionwiththeConsultingPsychiatristandthebroaderpsychiatryteamtailoredthespecificsymptomsthatweremonitoredforeachindividual.Therevisedpolicyrelatedtothepsychiatricreview,whichwasupdatedon4/27/12,discussedthesechecklistsunderthesub‐heading:“EnsuringClinicallyJustifiedPsychiatricDiagnosis.”ThePresentationBookforSectionJalsocontainedinformationrelatedtothetrainingthatwasprovidedtothenursesregardinghowtoutilizethisinstrument,includingtherosterfortheinitial4/20/12training.TheUnitNursesmonitoredthefrequencyandintensityofthesesymptomsandtheresultswerepresentedattheQuarterlyPsychiatricClinics,whichdirectsupportprofessionalsalsoattended.Theyalsowouldbeabletocommentonthefrequencyandintensityofthesesymptomsinthatformat.Therawdataforthisinformationwasnotincludedintheindividual’srecord,butwascommentedoninthenarrativeportionofthequarterlypsychiatrydocumentation,whichwaspreparedbytheConsultingPsychiatrist.ThePsychiatryDepartmentmightwanttoconsiderdevelopingamethodtoincludea


# Provision AssessmentofStatus Compliancesummaryoftherawdataintherecordand/orincorporateasynopsisofthisinformationintotheQuarterlyPsychiatricdocumentationinamannerthatwouldcomplimentthebehavioraldatathatthePsychologyDepartmentcontributes.TherecordoftheindividualthatdidnotcontainadequatedocumentationtosupportthepsychiatricdiagnosiswasthatofIndividual#295.TherecordofIndividual#295containedadifferentpsychiatricdiagnosisintheCPEandtheQuarterlyPsychiatricClinicdocumentation.Specifically,thediagnosticandrelated“Bio‐Psycho‐Social‐Spiritual”sectionoftheCPElistedadiagnosisof“AdjustmentDisorderwithmixeddisturbancesofemotionsandconduct.”Theformulationexplainedhowtheindividual’sbehavioralstatushadimprovedfollowinganenvironmentalinterventionand,inlightofthat,questionedwhetherthepriordiagnosisofaBipolarDisorderwasaccurate,andinsteadproposedtheAdjustmentDisorder.TheQuarterlyPsychiatricClinicdocumentationcontinuedtocarryforwardtheBipolarDisorderdiagnosis.Thiswasanunusualoccurrence,becausethepolicyofthelocumtenensPsychiatristwastodiscussanydiscrepanciesbetweenhisdiagnosisandthatoftheConsultingPsychiatristinajointmeetingbetweenthetwoofthem.Thispracticehadresultedinconcordanceintheotherrecordscontainedinthesample,exceptforIndividual#97,whohadbeenadmittedsorecentlythataCPEhadnotyetbeenperformed.CCSSLCalsomaintaineddataonthenumberofpsychiatricdiagnosesthathadbeenmodifiedorchangedoverthelastsixmonths,andthisdataindicatedthattherehadbeen16diagnosticchanges.Thismaterialalsocontainedadescriptionoftherationaleforthosechanges,allofwhichappearedtobereasonable.Thereviewofthisinformation,aswellastheclinicalmaterialinthesampleof20individualsindicatedthatthePsychiatryDepartmentatCCSSLCdidnotutilize“NOS”(NotOtherwiseSpecified)diagnosis,nordidtheyuse“R/O”(RuleOut)qualifiersunlesstheywereindicatedforabriefperiodoftimeforanewlyadmittedindividual.Thereviewofthespreadsheetthatlistedthenames,psychiatricmedications,andpsychiatricdiagnosisforalloftheindividualswhowerereceivingpsychotropicmedicationalsoconfirmedtheseobservations.AnissuethathadbeenidentifiedintheMonitoringTeam’spreviousreportswithregardtopsychiatricdiagnosesrelatedtotheobservationthattheidentifiedtargetbehaviorsofthepsychiatricmedicationswerefrequentlydescribedinthePsychologysectionoftherecordasstemmingfromlearnedbehavioraland/oranenvironmentalissue.Thecurrentreviewfoundthatthisproblemhadbeenrectifiedanddidnotoccurin19(95%)oftheindividualrecordsreviewed.TheoneexceptionwasthatofIndividual#295,becausethePsychologysectionoftherecordhadmaintainedtheBipolarDisorderasapsychiatricdiagnosis,whichwasconsistentwiththeQuarterlyPsychiatricClinicdocumentation,butwasdifferentfromtheCPE.Theexplanationthatwascontainedin


# Provision AssessmentofStatus CompliancetheCPEwascompellingwith regardtotherationalefortheAdjustmentDisorderdiagnosis.TheFacility’simprovementinthisregardwasprimarilyduetotwosystematicchangesthatthePsychiatryDepartmentandPsychologyDepartmenthadimplementedintheirrespectivedocumentation.ThesechangeswerealsodirectlyresponsivetorecommendationsthathadbeenmadeintheMonitoringTeam’spreviousreports.Asmentionedabove,thePsychiatryDepartmentnowidentifiedthesymptomsofthepsychiatricdiagnosisforwhichthemedicationwasprescribed,andtodeterminetheefficacyofthemedication,itwasthefrequencyandintensityofthosesymptomsthatwasprimarilymeasured.ThelinkbetweenthesymptomsofthepsychiatricdisorderandthemonitoredbehaviorsalsowasclarifiedinboththeCPEandthePsychiatricQuarterlyReviewdocumentation.ThePsychologyDepartmenthadaddedasectiontotheirdocumentationentitled:“PsychiatricInformation,”whichincludedthepsychiatricdiagnosisaswellastheimpactofthatpsychiatricdisorderontheindividual’schallengingbehaviors.Thus,itwaspossiblefromthesesourcestoascertainwhichbehaviorstheteamjudgedtoberelatedtothesymptomsofthepsychiatricdisorder,asopposedtobeingpresentonapurelybehavioralbasis,orinfluencedbybothbiologicalandbehavioralfactors.Thefindingofsubstantialcompliancewasbasedontheconsistencywithwhichtheseassessmentswerecarriedout,thethoroughnessoftheclinicaldocumentation,andtheconcordancebetweenthediagnosticmaterialthatwascontainedintheQuarterlyPsychiatricdocumentation,theCPEs,andthePsychologysectionoftheindividualrecords.AnimportantcomponentofmaintainingsubstantialcompliancewiththisprovisionistheregularupdatingoftheCPEs.DuetothefactthatthefirstroundofthecompletionofCPEsrecentlyhadbeencompleted,thisrequirementhadonlybeenpartiallytested.However,duringupcomingreviews,annualupdatestoCPEswillbenecessaryforsubstantialcompliancetobemaintained.

J3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,psychotropicmedicationsshallnotbeusedasasubstituteforatreatmentprogram;intheabsenceofapsychiatricdiagnosis,neuropsychiatricdiagnosis,orspecificbehavioral‐pharmacologicalhypothesis;orfortheconvenience

TheindividualinterviewswiththePsychiatryDepartment,aswellasthereviewoftherecordsof20individualswhowerereceivingpsychotropicmedication,didnotrevealanyevidencethatpsychotropicmedicationwasbeingovertlyusedfortheconvenienceofthestaff,orasaformofpunishment.NoPsychiatricClinicswerescheduledduringthecurrentonsitereviewand,thus,itwasnotpossibletomakedirectobservationsoftheprocedures.However,theseClinicshadbeenobservedonnumerousoccasionsduringpreviousreviews.Thosepriorobservationsindicatedthattheindividual’sPsychologistwasanessentialmemberoftheinterdisciplinaryteampresentatthePsychiatricClinics.

Noncompliance


# Provision AssessmentofStatus Complianceofstaff,andeffectiveimmediately,psychotropicmedicationsshallnotbeusedaspunishment.

Duringtheonsitereview,amemberoftheMonitoringTeamdirectlyobservedapproximately49percentofthe128individualswhowereprescribedpsychotropicmedication.Theidentifyinginformationfortheseindividualsislistedaboveinthesectionentitled:“Observationsof.”Theseobservationsdidnotidentifyanyindividualswhoappearedtobegrosslyover‐medicatedwithpsychotropicmedication,asmighthavebeenexpected,ifthesemedicationswereroutinelyusedfortheconvenienceofthestaff.ThepresenceofanappropriatepsychiatricdiagnosisthatwouldwarranttheuseofpsychotropicmedicationisdiscussedwithregardtoSectionsJ.2,J.6,andJ.13.Inaddition,thereviewofthespreadsheetlistingalloftheindividualsprescribedpsychotropicmedicationsindicatedthateachoftheseindividualshadapsychiatricdiagnosisofrecord.The20recordsthatwerereviewedindicatedthatanactivePositiveBehaviorSupportPlan(PBSP)wasinplaceforeachindividualwhowasprescribedpsychotropicmedication.TheadequacyofthePBSPsisdiscussedindetailwithregardtoSectionK.9.However,theMonitoringTeam’spreviousreportshadnotedasignificantconcerninthatbehaviorsidentifiedasthe“targetbehaviors”ofthepsychotropicmedicationalsowereidentifiedintheFunctionalAnalysisandrelatedPBSPasbeingpresentonabehavioralbasisand/orrelatedtoenvironmentalfactors.Thisobservationsuggestedthatfortheseindividuals,theprescribedpsychotropicmedicationcouldhavebeenutilizedtosuppressbehaviorsthatwerenotdirectlyderivedfromapsychiatricdiagnosis,whichwouldnotbeconsistentwiththetermsofthisprovisionoftheSettlementAgreement.Inotherwords,theypotentiallywerebeingusedintheabsenceofadequatebehavioraltreatmentsorinterventions.However,thePsychiatryDepartment,workinginconjunctionwiththePsychologyDepartmenthadnoweffectivelyaddressedthisproblemthroughthedevelopmentofcollaborative,systemicmethods.ThesemethodsaredescribedindetailwithregardtoSectionJ.2andsummarizedinrelationtoSectionsJ.8,J.9,andJ.13.Theuseofchemicalrestraintcouldbeconstruedaspunishment,becauseitfrequentlyinvolvedtheintramuscular(IM)injectionofapsychotropicmedicationagainstanindividual’swill.Thus,thedescriptionofthecircumstancessurroundingtheinvoluntaryadministrationofintramuscularantipsychoticand/oranxiolyticmedicationwasextremelyimportantindifferentiatingbetweenthenecessaryutilizationoftheseinterventionstopreventphysicalharmtotheindividualand/orothers,asopposedtobeingusedtopunishanindividualforaggressivebehavior,orfortheconvenienceofstaffinrespondingtoadifficultsituation.Inordertofurtherassessthecircumstancessurroundingtheuseofchemicalrestraintat


# Provision AssessmentofStatus ComplianceCCSSLC,therelateddocumentationwasrequestedforthemostrecentfiveincidentsthatinvolvedtheuseofchemicalrestraint,assummarizedbelow:INDIVIDUAL DATE TIME MEDICATIONIndividual#147 7/4/12 11:10p.m. Ativan2 milligrams(mg)IMIndividual#147 7/6/12 11:15a.m. Zyprexa5mgIMIndividual#147 7/6/12 3:00p.m. Ativan2mgIMIndividual#147 7/8/12 1:00p.m. Ativan2mgIMIndividual#237 7/7/12 8:23p.m. Zyprexa10mgIM **TheRestraintFormdidnotcontainthisinformation,asthesectionwasblank.ThisinformationwasobtainedfromthePhysician’sOrders,dated7/7/12at19:55hours(7:55p.m.).TheindividualrestraintdatawasreviewedforthepresenceandqualityofthefivecomponentsofthedocumentationthattheFacilityutilizedtorecordtheeventspreceding,during,andfollowingtheadministrationofchemicalrestraint.Thesesectionsandtheresultsofthisreviewwereasfollows:

1. Theinformationcontainedinthesectionoftheformfollowingtheprompt:“Descriptionofbehaviorspriortorestraint”wasreviewed.Thissectionofthedocumentationhadbeencompletedforallfiveoftheseindividuals.However,thedocumentationfortheseindividualsonlydescribedtheovertbehaviorthatnecessitatedtherestraint,andnotthe“events”thatprecipitatedthisbehavior.Forexample,theinformationcontainedinthissectionforthe7/6/12(3:00p.m.)chemicalrestraintforIndividual#147wasasfollows:“SIB,pullinghair,hittingselfonfaceandchest.Hittingandscratchingself.”Thisdescription(whichwassimilartotheothersinthissample)couldbeconsideredtoberesponsivetothepromptthatappearedinboldtypetotheleftofthesection,whichstated:“Descriptionofbehaviorspriortorestraint.”However,withintheresponsearea(butinasmallerfont)thefollowing,moreprecisedirectionsappeared:“Describetheindividual’senvironment,actionsandinteractionswithothersinthetimebeforeyoubegantakingstepstoavoidtheuseofrestraint.”Thenatureoftheresponsesfoundinthissample,whichweresimilartothosefoundduringpreviousreviews,suggestedthatthestaffwererespondingtotheprimaryprompt,whichappearedinboldtype,andnotthemorespecificdirectionspresentedinasmallerfont.Aresponsetothemorespecificdirectionsisessentialtoprovidetheinformationnecessarytodetermineiftheseveryintrusiveinterventionsarebeingappropriatelyutilized.Thisinformationalsowouldbeofusetotheindividual’sPsychologistindeterminingif


# Provision AssessmentofStatus Complianceprogrammaticstrategiescouldbedevelopedtopreventorminimizetheneedforchemicalrestraintsinthefuture.Basedonthecurrentavailabledocumentation,itwasimpossibletodetermineiftheaggressivebehaviorwasprovokedbyanunnecessarydemand,oranotherenvironmentalprecipitantthatmighthavebeenavoided.ThePsychologyDepartmentshouldfurtherinvestigatethisobservationtoascertainifchangesintheformatofthedocumentationand/oradditionaltrainingareneeded.

2. Thesectionthatfollowedtheprompttodescribe:“Interventionsattemptedtoavoidrestraint”wascompletedforallfiveoftheseindividuals.Thisinformationwascollectedwithachecklist.Althoughthislistcontainedanumberofoptions,itdidnotprovidethespecificitythatwouldbeprovidedbyanarrativereport.Thechecklistmenuincludedatotalof16differentitemsandwithoutsomeinternalauditingmethod,itwouldbeimpossibletodeterminetheaccuracywithwhichthesewerecompleted.Inaddition,thepresenceofthechecklistappearedtocontributetothenarrativesectionfollowingthechecklisteithernotbeingcompletedorcontaininglittleusefulinformation.

3. Theportionofthedocumentationinwhichthephysiologicalpost‐restraintmonitoringwasrecordedwasappropriatelycompletedforalloftheindividualsinthissample,withtheexceptionofIndividual#237.ThissectionofthedocumentationwasblankforIndividual#237.Themonitoringoftheindividual’sphysicalstatusaftertheadministrationoftheChemicalRestraintisnecessarytoensurethesafetyoftheindividual,andthus,isanessentialcomponentoftheprocess.

4. Theface‐to‐facepost‐restraintdebriefingalsowaspresentforalloftheseindividuals.

5. TheChemicalRestraintClinicalReviewForm,whichcontainedsectionsforthePharmacyandPsychiatristtocommentontheappropriatenessofthechemicalrestraintandanyinformationthatmightbeusedtopreventfurtherepisodeswascompletedforfourofthesefiveindividuals(80%),withtheexceptionofIndividual#237,forwhomthedocumentationwasabsent.Documentationhadbeencompletedwithin48hoursforthreeofthefourindividualsforwhomitwaspresent(75%).ThisdocumentationprimaryaddressedthepharmacologicalaspectsoftheChemicalRestraint,suchaswhetherthemedicationutilizedwasappropriateinlightoftheindividual’shistoryandtheiroverallpharmacologicalprofile.ItdidnotaddresswhetherornotthereviewerfeltthatthespecificcircumstanceswarrantedtheuseofChemicalRestraintand/orifitsusecouldhavebeenavoided.Theepisodeforwhichtherewasadelayofgreaterthan48hoursincompletingthisinformationwasthe7/6/12(3:00p.m.)chemicalrestraintforIndividual


# Provision AssessmentofStatus Compliance#147.Thepsychiatricsectionofthisreportwascompletedforthisindividualon7/10/12,andthePharmacyinformationwascompletedon7/11/12.OneofthePsychiatricNursescompletedthepsychiatricsection,andthiswasclearlyindicatedontheform,whichrequiredthesignatureofthePharmacistandPsychiatrist.However,duringtheonsiteinterview,theClinicalPharmacistindicatedthattheseformswerenowcirculatedviae‐mail,andhecompletedtheformelectronically,hencetherewasnowrittensignature.Thelackofdatarelatedtothe7/7/12chemicalrestraintforIndividual#237isworthyoffurtherdiscussion.Inlightofthemissingdataregardingthemedicationutilizedandthelackofphysiologicalmonitoring,itappearedthatthismighthavebeenthedocumentationforaphysicalrestraint,althoughitwasproducedinresponsetothedocumentrequestforasampleofthemostrecentchemicalrestraints.Inaddition,aPhysician’sOrderwasfoundfortheadministrationofZyprexa10mgIMon7/7/12at19:55hours(7:55p.m.),whichwouldconstituteachemicalrestraint.Thiswouldappeartobetemporallyrelatedtothe8:23p.m.restraintinformationonthesamedate,becausethereisusuallyadelayofseveralminutesbetweenwhentheorderisgivenandthemedicationisadministered,duetothetimerequiredforthenursetopreparethesyringeandtherelateddocumentation,andtoassemblethestaffnecessarytoensurethephysicalstabilityoftheindividualwhilethenurseadministerstheinjection.ThismoredetailedinformationisdiscussedheresothatthePsychologyDepartmentcandetermineiftherewasasignificantbreakdownofthedocumentationforthisepisodeofchemicalrestraint,oriftheseomissionsrepresentaclericalerror.

Thus,theseessentialelementsofthedocumentationneededtoverifytheappropriateutilizationoftheinvoluntaryadministrationofintramuscularmedicationswerefullycompletedinatimelymannerforonlythreeofthefiveindividualsinthissample(60%).Inaddition,theimportantsectionofthisdocumentationthatwasintendedtodescribeantecedentstotheuseofchemicalrestraint,whilecompleted,didnotcontaininformationthatwasdirectlyresponsivetothequestion,asdiscussedabove.Althoughnoinstanceswerefoundinwhichthedocumentationshowedchemicalrestraintwasdefinitivelyusedaspunishment,thedocumentationshouldbeimprovedtoallowFacilitystaffaswellasexternalreviewerstodeterminethatitwasnotusedaspunishmentorfortheconvenienceofstaff.Asdetailedabove,theFacilityhadmadeprogresswithregardtothedifferentiationofpsychiatricsymptomsandbehaviorsthatwerepresentonabehaviorbasisorinrelationtoenvironmentalfactors.Progressalsohadbeenmadeinensuringindividualshadaccuratepsychiatricdiagnosesthatjustifiedtheuseofpsychotropicmedication.


# Provision AssessmentofStatus ComplianceHowever,theratingofnoncomplianceisbasedonthefindingthatthechemicalrestraintdocumentationwasdeficient,andwithoutthisitwasnotpossibletoconcludethatchemicalrestraintwasnotbeinginappropriatelyusedforpunishmentorfortheconvenienceofstaff.

J4 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithin18months,ifpre‐treatmentsedationistobeusedforroutinemedicalordentalcareforanindividual,theISPforthatindividualshallincludetreatmentsorstrategiestominimizeoreliminatetheneedforpre‐treatmentsedation.Thepre‐treatmentsedationshallbecoordinatedwithothermedications,supportsandservicesincludingasappropriatepsychiatric,pharmacyandmedicalservices,andshallbemonitoredandassessed,includingforsideeffects.

AtthetimeoftheMonitoringTeam’spreviousreview,anewinitiativerelatedtothisprovisionoftheSettlementAgreementhadbeendevelopedandimplemented.Itinvolvedtheestablishmentofaninter‐disciplinaryprocesstoensuretheappropriatenessandsafetyofmedicationsprescribedforsedationpriortomedicalanddentalappointments.ThisprocessincludeddirectinputfromthePsychiatrist,thePsychiatricNurse,theUnitNurse,thePrimaryCarePractitioner,thePsychologist,theClinicalPharmacist,andtheDentist.ThesereviewswerescheduledtooccuratthebeginningofthePsychiatricClinics,becauseallofthedisciplinesidentifiedaboveroutinelyparticipatedinthesemeetings,withtheexceptionoftheClinicalPharmacistandtheDentist.TheschedulingofthereviewsatthebeginningofthemeetingsallowedthePharmacistandtheDentisttoparticipateinanefficientmanner.Thespreadsheettrackingtheoccurrenceofthesemeetingsindicatedtheyhadbeencompletedforthecurrentyearforalloftheindividualsthatrequiredtheseinterventions(100%).Inaddition,theQuarterlyPsychiatricReviewdocumentationforeachofthe20individualsinthereviewsample(100%)containedareferencetothismeetingandthedateonwhichitoccurred.SpecificconcernsrelatedtothequalityofthecurrentDesensitizationPlansarediscussedwithregardtoSectionC.4oftheSettlementAgreement.Atthetimeofthepriorreview,theFacilityhaddevelopedamethodologyfordeterminingwhowouldlikelybenefitfromaDesensitizationPlantoreducetheneedforpre‐treatmentsedation.TheFacility’splaninvolvedidentifyingindividualswhomtheybelievedwerenotcandidatesforaDesensitizationPlan,becausetheyhadneurologicalconditions,suchasCerebralPalsy,andrequiredabenzodiazepinemedicationpriortoadentalvisit,primarilyforthemusclerelaxantproperties.Theothergroup,whichthenewdecision‐treescreenedout,consistedofindividualswhowerethoughttohaveaninnate,organicallydriven,motorrestlessnessthatwouldmakethempoorcandidatesforaDesensitizationPlan.ThecriteriathatthePsychologyDepartmentutilizedtodefinethepopulationthatwouldnotpotentiallywouldbenefitfromadesensitizationplanincludedtheinabilitytositstillformorethanthreeminuteseitherduetomotorspasticityorwhatwasconceptualizedasanorganicallydrivenstate.Thelistofindividualsidentifiedusingthisfilterwascontainedinaspreadsheet,undated,producedinresponsetoanonsitedocumentrequest.Thisspreadsheetcontainedthenamesof57individuals.Thereasonsidentifiedforanindividualnotbeingacandidatefordentaldesensitizationincluded“Physiologicalspasticity”(N=34);“Edentulous”(N=2);and“NoSedation

Noncompliance


# Provision AssessmentofStatus ComplianceRequired”or“NoproblemsatDental(N=21).BasedontheMonitoringTeam’sreviewofISPs,thevalidityofthisscreeningprocesswasquestionable.Forexample,forIndividual#228,theISPandIRRFindicatedthatthebehavioralservicesstaffsaidshewasnotacandidatefordesensitization"becauseofherspasticity."However,thedescriptionofherresistancetodentalappointmentsdidnotappeartohaveanythingtodowithspasticity.TheIRFFstated:"Duringappointmentssheexhibitsanxious(sic),hasexcessivemovementandisresistivetoexams,shebendsatthewaistasavoidanceandgrabshands."Basedonthisexample,itwasunclearifthecriterionrelatedtoanindividual’sdiagnosiswasbeingusedwithoutregardforotherbehavioralconsiderationsthatwouldbeimportantindefiningwhichindividualsshouldhaveadesensitizationplandeveloped.Furthercomplicatingtheinterpretationofthisdata,aspreadsheet,dated6/11/12,whichwasentitled:“DeemedInappropriateforDesensitizationPlans”wasincludedinthePresentationBookforthisprovision.Thatdocumentlistedthenamesof45individuals,32ofwhichweredeemednottobecandidatesforadesensitizationplanbecauseofeither“Physiological”or“Physiological‐Spasticity.”Theotherindividualswereconsideredtonotbecandidatesbecauseeithertheywereedentulousordidnotrequirepre‐treatmentsedation.Thereasonforthesediscrepancieswasnotclear.Anotheronsitedocumentrequestedproducedaspreadsheetthatwaslabeled“CCSSLC:IndividualswithDesensitizationBaselines.”Thisspreadsheetcontainedanalphabeticallistingof182individuals,thatincluded:1)theirresidentialunit;2)whetherornottheirdecision‐treeandbaselinehadbeencompletedforaDesensitizationPlanfordentaland/ormedicalprocedures;and3)whereapplicable,thestatusofeachplan.Onthislist,thereweresomeindividualsforwhom“NA”wasindicated,butwhentheirnameswerecross‐referencedwiththelistofindividualswhowerenotcandidatesforDesensitizationPlans,theywerenotincludedonthatlist.Presumably,thismeantthattheprocesshadnotbegun.Thisspreadsheetwasnotdated,butthemostrecentdatethatappearedinanycolumnwas2/21/12.Therefore,eitherithadnotbeenupdatedsincethattime,ortherehadbeennosubstantialprogresssincethattime.Amorerecentspreadsheet,whichwasincludedinthePresentationBookforthisprovision.Thisdocumentwaslabeled:“IndividualswithDesensitizationPlans,”dated6/11/12,andcontainedanalphabeticallistingof116individualsincludingtheirresidentialunit,thedatetheirinitialplanwasdeveloped,aswellasthedateofanysubsequentupdatestothatplan.AlloftheseindividualswereidentifiedashavingsuchaplanforDentalprocedures.Thisinformationfurtherindicatedthat51oftheseindividualsalsohadadesensitizationplanformedicalprocedures.ThesenumbersareconsistentwiththosetheDirectorofBehavioralServicessuppliedduringtheonsiteinterviewon7/9/12.Thedataregardingthecompletionandcurrentstatusofthedesensitizationplanswouldbemoreusefulandcomprehensibleifitwereconsolidatedintoamasterspreadsheetthatwascontinuouslyupdated.



ThepurposeoftheDesensitizationPlansorotherstrategieswastoprovidetheindividualwiththenecessaryskillstosuccessfullyparticipateindentalormedicalprocedureswithoutreceivingsedativemedicationpriortotheappointment,ortoreducetheneedforsuchmedicationtotheextentpossible.Accordingly,theFacilityshouldtrackinformationspecificallythatidentifiesthoseindividualsforwhomtheimplementationofabehavioralDesensitizationPlanorotherstrategieshadresultedintheirnolongerrequiringpharmacologicalpre‐treatmentsedationfordentalandmedicalprocedures,orresultedinareductionintheuseofpre‐treatmentsedation.Thiswasnotoccurringatthetimeofthereview.TheDentalServicesDepartmenthadbeenmaintainingdataonthefrequencywithwhichintravenous(IV)sedationandpre‐treatmentoralsedationwererequiredtoaccomplishsuccessfuldentalappointments.AtthetimeoftheMonitoringTeam’spreviousreview,thisdataindicatedthatapproximately90percentofthetotalmonthlydentalappointmentswereaccomplishedwithouteitherpre‐treatmentsedationorIVanesthesia.DuringtheonsitemeetingwiththeFacilityDentistandtheDentalAssistant,theynotedthatthesepercentagescontinuedtobeapproximatelywithinthesamerange.ThereviewoftheFacilityordersforpre‐treatmentsedationforbothdentalandmedicalproceduresfrom1/20/12through6/30/12confirmedthatduringthattimeperiodtheorderswereprimarilyforAtivan(abenzodiazepine),inarangefrom1mgto3mg,and/orAtarax(anantihistaminewithsedativeproperties)inarangeof50mgto100mg.TheDirectorofDentalServicesindicatedthatifstandard,conservativedosagesofsedativemedicationswerenoteffective,thePsychiatrystaffand/orthePharmacywouldbeconsultedforadditionalrecommendationsand,asnotedabove,theFacilityhaddevelopedaprocedureforthemultidisciplinaryreviewofindividuals’pre‐treatmentsedationinthecontextoftheQuarterlyPsychiatricReviews.TheIVanesthesiamonitoringwasverydetailed.TheConsultantwhoactuallyadministeredtheanesthesiaalsoperformedthemonitoring.Themonitoringforthephysiologicaleffectsoftheoralpre‐treatmentsedationwasinitiatedontheresidentialunits,asthemedicationitselfwasadministeredontheresidentialunit60to90minutespriortotheappointmentintheDentalClinic.Thus,thepre‐administrationmonitoringoftheindividual’sphysiologicalstatuswasperformedattheresidenceandthentransitionedtotheDentalClinicatthetimeoftheappointment.AftertheworkintheDentalClinicwascompleted,whentheDentalstafffeltitwasappropriatetoreleasethem,theindividualreturnedtotheirresidentialunit.Thetopicofthephysiologicalmonitoringrelatedtotheuseofpre‐treatmentsedationfordentalappointmentsisdiscussedinmoredetailwithregardtoSectionQofthisreport.



Asnotedabove,theFacilityhaddevotedagreatdealofattentiontodeterminingwhichindividualsrequiredplanstominimizetheuseofpre‐treatmentsedationandmonitoringtheuseofpre‐treatmentsedationfordentalprocedures.However,thedocumentationthatdetailedtheutilizationofpre‐treatmentsedationfrom1/1/12to6/30/12indicatedthatthemajorityofpre‐treatmentsedationatCCSSLCwasutilizedformedicalappointments.Forexample,alimitedreviewofthedataofthefirst20individualslistedinthisdatabaseindicatedthatthefrequencyofordersfordentalprocedureswas13,ascomparedto27ordersforpre‐treatmentsedationformedicalappointmentsorprocedures.Thetotalnumberoftheseordersexceeded20,asthereweremultipleordersforsomeoftheindividualsduringthistimeperiod.Closeexaminationandinspectionoftheentirespreadsheetindicatedthatthisratiovariedconsiderablyovertime,buttheobservationwasconsistentthatthefrequencyofpre‐treatmentsedationordersformedicalproceduresgreatlyexceededthenumberfordentalprocedures.Aswiththeordersforpre‐treatmentsedationfordentalprocedures,themajorityoftheordersformedicalprocedureswereforAtivan,inarangeofoneto3mgand/orAtarax,inarangeof50mgto100mg.Overall,themedicationsutilizedappearedtobeappropriateandwereprescribedinmoderatedosages.Asindicatedabove,thePsychologyDepartmenthadbeguntodevelopDesensitizationPlansformedicalprocedures,butthisprocesswasnotasdevelopedasthatfordentalprocedures.TheFacilityhadanadequateprocessinplaceforcoordinatingpre‐treatmentsedationfordentalprocedureswithothermedications,supportsandservicesincludingasappropriatepsychiatric,pharmacyandmedicalservices.However,theredidnotappeartobeawell‐developedmonitoringsystemfortheuseofpre‐treatmentsedationformedicalprocedures.ThefindingofnoncomplianceforthisprovisionwasprimarilybasedontheobservationthatfullyeffectiveoperationalDesensitizationPlansorotherstrategiestoreducetheneedforpre‐treatmentsedationformedicaland/ordentalprocedureshadnotyetbeenfullydevelopedand/orfullyimplemented.

J5 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshallemployorcontractwithasufficientnumberoffull‐timeequivalentboardcertifiedorboardeligiblepsychiatriststoensuretheprovisionofservicesnecessaryforimplementationof

TheMonitoringTeam’spreviousreviewsofpsychiatricservicesatCCSSLCindicatedthattwofull‐timePsychiatrists(ortheequivalentamountofConsultingPsychiatrists)wouldberequiredtoadequatelyevaluateandprovidepsychiatricservicestotheindividualsresidingattheFacility,becausemanyoftheseindividualspresentedwithcomplexpsychiatricdisorders.Thecurrentutilizationratesofmultiplepsychotropicagentsfornumerousindividualswouldsuggestthatthisisareasonableestimate.Duringthe7/9/12interviewwiththeprofessionalsupportstaffofthePsychiatryDepartment,aspecificinquirywasmadeastowhethertheabovedeterminationwas

Noncompliance


# Provision AssessmentofStatus CompliancethissectionoftheAgreement. supportedbyanyempiricalanalysisofthetimethatwouldberequiredtofullymeetall

oftheprovisionsoftheSettlementAgreement,includingparticipationintheISPprocess.ThePsychiatryteamrespondedthatboththelocumtenensPsychiatristandtheregularConsultingPsychiatristhadcommentedonthisissueandtheywerebothinagreementthattwofull‐timePsychiatristsorequivalentswouldbeadequate.However,theseopinionswerenotbasedonanempiricaltimeallocationanalysis,butratherwereprimarilysubjectiveinnature.TheFacilityshouldconsiderperformingamoredetailedempiricalanalysisoftheamountofpsychiatrytimethatwouldberequiredtomeettherequirementsoftheSettlementAgreement.ThisanalysisalsoshouldtakeintoaccountthefunctionsthatareperformedbythePsychiatryDepartmentsupportstaff,suchasattendanceattheISPmeetings.TheFacilitywasrelyingononepart‐timeConsultingPsychiatristtoprovidetheday‐to‐daypsychiatriccaretoallofthe128individualsreceivingpsychotropicmedication.Hisweeklyallotmentoftimerecentlyhadbeendecreasedfromtwelvetoeighthours(twofour‐hourblocksperweek).Thisequatedto20percentofonefull‐timeequivalentPsychiatrist.AsnotedabovewithregardtoSectionJ.1,theConsultingPsychiatristwasBoardCertifiedinAdultPsychiatry.AnadditionallocumtenensPsychiatristhadbeenonsiteonafull‐timebasisforsixweeksfollowingtheJanuary2011review.HistimewasdevotedtocompletingtheCPEsfortheindividualsprescribedpsychotropicmedication.ThesamePsychiatristreturnedtoCCSSLCon12/16/11,andwasstillpresentatthetimeoftheJanuary2012sitevisit.HedepartedtheFacilityon4/6/12,atwhichtimecurrentCPEshadbeencompletedforalloftheindividualsreceivingpsychotropicmedication.(ThisprocessisdescribedinmoredetailwithregardtoSectionJ.6.)Heestimatedthatitrequiredeightto10hourstocompleteaCPE.Asnotedabove,withregardtoSectionJ.1,thelocumtenensPsychiatristwaseligibletotakethePsychiatryBoardExaminations,buthadnotdoneso.ThePsychiatryDepartmenthadbeenabletoaccomplishagreatdealthroughthediligentworkofthetwoPsychiatricAssistantsandthetwoPsychiatricNursesatCCSSLC.Theinfrastructurethattheyhadcreated,andtheancillaryservicesthattheyprovided,madeitpossibletomaximallyutilizethelimitedamountofpsychiatrytimethatwasavailable.However,psychiatricstaffingremainedinadequatetomeetthepsychiatricneedsoftheindividualsCCSSLCsupported.DuringtheinterviewwiththeFacility’sDirector,hedescribedtheeffortsthatCCSSLChadundertakentorecruitadditionalPsychiatrists.Thus,theFacility’sadministrationhadbeenmakinganactive,sustainedefforttoaddressthisdeficiency,buthadnotyetbeensuccessfuland,thus,thefindingofnoncompliancewascarriedforwardfromthepriorreview.


# Provision AssessmentofStatus ComplianceJ6 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshalldevelopandimplementproceduresforpsychiatricassessment,diagnosis,andcaseformulation,consistentwithcurrent,generallyacceptedprofessionalstandardsofcare,asdescribedinAppendixB.

AsindicatedintheMonitoringTeam’spreviousreports,CCSSLC haddevelopedaninitiativetocompleteathoroughCPEforeachindividualreceivingpsychotropicmedication,whichtheybelievedwouldmeettherequirementssetforthintheSettlementAgreement.Thereviewoftheactiverecordsof20individualsreceivingpsychotropicmedicationidentifiedarecentlycompletedCPEfor17ofthe20individualsinthesample(85%).However,thethreeindividualswhodidnothavecompletedCPEshadbeenadmittedtotheFacilitywithinthesix‐weekperiodpriortotheonsitereview,anditisreasonabletoconcludethatthistimeframewouldnothaveprovidedsufficienttimetocollectthenecessaryhistoricalinformationandmaketheclinicalobservationsnecessarytocompletethesecomprehensiveassessments.ItshouldbenotedthattheseindividualsdidhaveinitialPsychiatricevaluationsasdocumentedinthePsychiatricClinicnotes,andalsohadbaselinesideeffectevaluations.TheCPEsaverageapproximately10singlespacedpagesandinordertofulfillthecriteriaspecifiedintheSettlementAgreementmustcontainagreatdealofhistoricalinformation.Aswillbediscussedbelow,inadditiontotherecordreview,thePsychiatristwhoiscompletingtheevaluationalsointerviewsbothdirectsupportprofessionalsandotherprofessionalmembersoftheteamaswellasfamilymembers,ifpossible.Theseactivitiesallrequireacertainamountoftimetobothscheduleandcomplete.Inaddition,forthoseindividualsforwhomthePsychiatricDiagnosisisambiguousand/ortherearemultiplepossiblepsychiatricdiagnosesthatmustberuledout,thisdeterminationcanconsumeanextendedamountoftimeinordertobeabletoestablishthemostappropriatediagnosis.Thisprocessnaturallyvariesdependingonthecomplexityoftheindividual’spresentation,butitcouldwelltakesomewhatlongerthansixweekstocomplete.ThelocumtenensPsychiatrist(whohadlefttheFacilityinAprilof2012)hadcompletedalloftheCPEs,withtheexceptionofIndividual#40andIndividual#5,whohadbeenadmittedtotheFacilityduringtheJanuarythroughApriltimeframe.TheConsultingPsychiatristhadcompletedtheseCPEs.ThereviewofthespreadsheetthattheFacilitymaintainedtotrackthecompletedandannualupdatingoftheCPEsindicatedthatacurrentCPEhadbeencompleteforallofthe128individualsprescribedpsychotropicmedication,withtheexceptionofthethreeindividualsmentionedabove.Theseindividualswereincludedinthecurrentsampleofindividualrecords,becausetheyhadbeenadmittedtotheFacilitywithinthesixweekspriortotheonsitereview.Thus,atthetimeoftheonsitereview,aCPEhadbeencompletedfor125ofthecurrent128individualsreceivingpsychotropicmedication(98%).Inordertofurtherassesstheintegrityofthespreadsheet,anadditionalsampleoftenindividualswasselectedfromthespreadsheettoaugmentthe20individualsinthesample.ThisbroughtthetotalnumberofCPEsreviewedto27ofthe128individuals



# Provision AssessmentofStatus Compliance(21%)receivingpsychotropicmedication.TheCPEsoftheadditionaltenindividualswerethoseofIndividual#186,Individual#169,Individual#183,Individual#326,Individual#12,Individual#20,Individual#46,Individual#88,Individual#34,andIndividual#332.TheformatandcontentofthesedocumentsalsometthecriteriaspecifiedintheSettlementAgreement,andhadbeencompletedand/orupdatedbythelocumtenensPsychiatristwithintheprioryear.TheCPEsincludedthecomponentssetforthinAppendixBoftheSettlementAgreement.Theybeganwithadescriptionofthedocumentsreviewed,andthepeopleinterviewedintheprocessofgatheringtheinformationnecessarytocompletetheCPE.ThissectionoftheCPEsindicatedthat,inadditiontotheextensivedocumentreviews,thePsychiatristinterviewedbothdirectsupportprofessionalsandothermembersofthestaff,includingclinicians.Familymembersalsowerecontacted,ifpossible,andtheindividualwasinterviewed.However,iftheindividualwasincapableofverbalinteraction,therewasaperiodofdirectobservation.Thediagnosticsectionsoftherecordsprovidedathoroughdescriptionofthesymptomsthatsupportedthepsychiatricdiagnosis,andtheBio‐Psycho‐Social‐Spiritualformulationsectionpresentedacohesivedescriptionoftherationalefortheindividuals’diagnosisandtheimpactthatthispsychiatricdisorderhadonhis/herfunctionalstatus.Thequalityoftheindividuals’psychiatricdiagnosisisalsodiscussedwithregardtoSectionJ.2.Insummary,thereviewofthesampleof20individualrecordsindicatedthatthepsychiatricdiagnosisfor19oftheindividuals20(95%)receivingpsychotropicmedicationcontainedadequatedocumentationtojustifytheindividuals’psychiatricdiagnosis.AsfurthernotedwithregardtoSectionJ.2,thereviewofIndividual#295,forwhomtherewasadiscrepancybetweenthediagnosiscontainedintheCPEandtheQuarterlyPsychiatricClinicdocumentationindicatedthatthediscussioncontainedintheCPEwasmorecomprehensiveandcompellingthanthatcontainedintheQuarterlyPsychiatricClinicdocumentation.Insummary,thefindingofsubstantialcomplianceforthisprovisionwasbasedonthequalityoftheCPEs,whichmettherequirementssetforthintheSettlementAgreement,and,inaddition,thesedocumentsallhadbeencompletedandupdatedwithinthelastyearforalloftheindividualsprescribedpsychotropicmedication,withtheexceptionofthethreeindividualswhohadbeenadmittedtotheFacilitywithinthesixweekspriortotheonsitereview.Theoverallcompletionrateatthetimeoftheonsitereviewwas98percent.

J7 CommencingwithinsixmonthsoftheEffectiveDatehereofandwith

A spreadsheet,updatedon6/5/12,listedtheindividualsthat hadbeenadministeredtheReissScreenforMaladaptiveBehaviorinAprilof2012.TheFacility’spolicywasto



# Provision AssessmentofStatus Compliancefullimplementationwithintwoyears,aspartofthecomprehensivefunctionalassessmentprocess,eachFacilityshallusetheReissScreenforMaladaptiveBehaviortoscreeneachindividualuponadmission,andeachindividualresidingattheFacilityontheEffectiveDatehereof,forpossiblepsychiatricdisorders,exceptthatindividualswhohaveacurrentpsychiatricassessmentneednotbescreened.TheFacilityshallensurethatidentifiedindividuals,includingallindividualsadmittedwithapsychiatricdiagnosisorprescribedpsychotropicmedication,receiveacomprehensivepsychiatricassessmentanddiagnosis(ifapsychiatricdiagnosisiswarranted)inaclinicallyjustifiablemanner.

repeattheReissScreenforalloftheindividualswhowerenotreceivingpsychotropicmedicationeachyear.ThespreadsheetcontainedtheReissadministrationdates(in2012)forthe132individualstowhomtheReisshadbeenadministered.TheFacilitycensusatthetimeoftheJulyonsitereviewwas259,atwhichtime128individualswerereceivingpsychotropicmedication.Theminordiscrepancyinthetotalnumberofindividuals(i.e.,one)waslikelyrelatedtochangesinthecensusbetweenthetimewhentheReissScreenwasadministeredinApril2012andtheonsitereview.EachoftheMonitoringTeam’sinitialthreereportsincludedtheresultsofananalysisofadistinct20percentsampleofindividualswhohadbeenadministeredtheReissScreeninginstrument.ThismethodologyverifiedtheaccuracyofthedatabycomparingtheinformationcontainedinthespreadsheettoacopyoftheactualReissscoringsheetforeachindividualinthesample.Eachofthesepriorreviewsconfirmedthattheinformationinthespreadsheetwas100percentaccurate.ThecurrentreviewfocusedonthoseindividualsforwhomtheReissScreenhadbeenadministeredsincethepreviousmonitoringreview.Sincethelastreview,theReissScreenwasnotadministeredtoindividualsadmittedtoCCSSLCwhowerereceivingpsychotropicmedication,becausetheywereevaluatedwithapsychiatricevaluationinsteadofaReissScreenforMaladaptiveBehavior.Alloftheindividualsadmittedsincethelastreviewwerereceivingpsychotropicmedicationatthetimeoftheiradmission.ArequestforthenamesoftheindividualswhosescoreontheReiss(CCSSLCutilizedthecommerciallyavailablecomputerscoringfortheReiss)wasabovethecut‐offscorethatpromptedfurtherclinicalassessmentindicatedthatthisyeartherewerenoscoresabovetheclinicalcut‐offscorethatwouldhaveprecipitatedaCPE.InordertofurtherevaluatetheFacility’sdiligenceinfollowinguponelevatedReissscores,asampleofReissscoringsheetswasrequestedduringtheonsitereview.Specifically,theactualReissscoringsheetswererequestedforeverysixthindividualontheReissSpreadsheet,beginningwithnumbersix.Thisrequestproducedtherawdatafor21individualsofthetotalof132(16%).Therangeofthesescoreswasfromzerotofive,wellbelowtheclinicalcut‐offscoreofnine.Therefore,nonemetthecriterionforareferraltoPsychiatryforaCPE.ThisanalysisagainverifiedtheintegrityofthespreadsheetwithregardtothedatestheReissScreeningswereadministered,andalsoindicatedthatforthisrandomsampleof21individuals,thescoreswerebelowtheclinicalcutoff.Atthetimeofthepriorreview,theReissScreeningsforApril(2011)hadproducedfiveindividualswhosescoreswereabovetheclinicalcutoff,andtheywerereferredforaCPEandPsychiatric/psychologicalfollow‐upasrequired.Althoughthestatusofthesefiveindividualswasnotspecificallyinvestigatedatthetimeofthisreview,itispossiblethattheprioryearlyscreeningshadidentifiedindividualswhohadexperiencedachangeintheirpsychologicalstatus,which


# Provision AssessmentofStatus Compliancethenhad beenclinicallyaddressed.TheyearlyscreeningswiththeReissinstrumentessentiallyfunctionedasanannualscreeningofalloftheindividualsnotfollowedinthePsychiatricClinics.Thefindingofsubstantialcomplianceiscarriedoverfromthepreviousreview,becausetheannualscreeningofallindividualsnotreceivingpsychotropicmedicationprovidesamechanismforassessingifsuchindividualshaveexperiencedachangeintheirstatusthatwouldbenefitfromapsychiatricassessment.

J8 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,eachFacilityshalldevelopandimplementasystemtointegratepharmacologicaltreatmentswithbehavioralandotherinterventionsthroughcombinedassessmentandcaseformulation.

TheintegrationbetweenPsychiatryandPsychologyServiceswasapparentintheinterviewswiththeDirectorofPsychologicalServices,theConsultingPsychiatrist,andtheothermembersofthePsychiatryDepartment.Duringthisreview,PsychiatryClinicsdidnottakeplacewhiletheMonitoringTeamwasonsite.However,duringtheMonitoringTeam’spreviousreviews,ithadbeenpossibletoobservemultiplePsychiatricClinics.TheseobservationsindicatedthatthePsychologistplayedanimportantroleinboththeconductofthemeeting,andtheanalysisofthebehavioraldatauponwhichkeydecisionsrelatedtochangesinthepsychotropicmedicationswerebased.Intermsofcaseformulation,theMonitoringTeam’spreviousreportsrevealedapersistentdeficitinthiscollaboration.Specifically,thiswastheco‐identificationofthesamebehaviorsasbeingbotha“targetbehavior”oftheprescribedpsychotropicmedication,andasalsobeingpresentonalearnedorbehavioralbasisintheFunctionalAnalysisandthePBSP.Asindicatedinpreviousreports,itisentirelypossiblethatagivenbehaviorcouldbeco‐determinedbybothbiologicalandbehavioralfactors,buttherationaleforthisdeterminationshouldbedelineatedclearly.ThePsychiatryDepartment,workinginconjunctionwiththePsychologyDepartment,haddevelopedasystem,whichwasresponsivetorecommendationsinMonitoringTeam’spreviousreports,tointegratepharmacologicaltreatmentswithbehavioralandotherinterventionsthroughcombinedassessmentandcaseformulation.ThissubjectisalsorelevanttoSectionsJ.2andJ.9oftheSettlementAgreement,whereitisdiscussedinfurtherdetail.Insummary,theseinnovationsclarifiedthesymptomsofthepsychiatricdisorderforwhichthepsychotropicmedicationwasprescribed.TherelatedPBSPs,developedbythePsychologyDepartment,includedasectionentitled:“PsychiatricInformation”anddescribedhowthepsychiatricdisorderwouldaffecttheindividual’sbehavioralpresentationforthoseindividualsforwhomthiswasrelevant.Thiscoordinated,complimentarydocumentationwasevidenceofcollaborationbetweenthePsychiatryandPsychologyDepartments,withregardtocombinedcaseformulation.TheaccuracyandintegrationofthebehavioraldataintothePsychiatryClinicsand

Noncompliance


# Provision AssessmentofStatus CompliancedocumentationisdiscussedindetailwithregardtoSectionJ.13.ThePsychiatryDepartment’sutilizationofobjectivemeasurementtoolsisdiscussedinSectionsJ.2andJ.13.TheprimarydisciplinesthatattendedtheMonthlyandQuarterlyPsychiatryClinicswereNursing,Psychiatry,Psychology,Medicine,adirectsupportprofessional,andaQualifiedDevelopmentalDisabilitiesProfessional.However,disciplinessuchasOccupationalTherapyandPhysicalTherapywerenotabletoattendtheindividualPsychiatryClinicreviews,duetotimeconstraints.ThesedisciplinesoftendidattendtheindividualISPmeetings.TheISPmeetingdocumentationwasreviewedforthe20individualsinthissample.ThisreviewindicatedthatamemberofthePsychiatryDepartmentattendedarecentindividualISPmeetingforthefollowingthreeindividuals(15%):Individual#318,Individual#63,andIndividual#5.ArequestforalistofindividualISPmeetingsthatamemberofthePsychiatryDepartmenthadattendedwithinthelastsixmonthsindicatedthatamemberofthePsychiatryDepartmenthadattendedtheISPmeetingforthefollowingeightindividualsand(dateofISP):Individual#5(2/15/12),Individual#318(6/12/12),Individual#118(5/3/12),Individual#191(2/22/12),Individual#234(7/6/12),Individual#63(6/19/12),Individual#275(3/27/12),andIndividual#97(4/20/12).ThedocumentationfromtheISPmeetingsthatwerereviewedinthissampledidnotfullyreflectthepsychiatricaspectsoftheindividuals’treatmentinanyoftheindividualrecordsreviewed.Therewasadiscussionofthepsychologicaltreatmentplanandreferencetotheindividuals’psychotropicmedication,butnodetailedinformationwasincludedtoreflectthepsychiatricaspectsoftheirpresentation.Inaddition,theISPsdidnotincludeactionplansrelatedtotheimplementationofthepsychiatrictreatmentplans,including,forexample,collectionoftheobjectivedatanecessarytodeterminetheefficacyofthemedications.Asaresult,theintegrationofpsychiatricsupportswithothersupportswasnotevidentintheindividuals’ISPdocumentation.TheratingofnoncomplianceforthisprovisionoftheSettlementAgreementisduetothelackofoverallintegrationofpsychiatricservicesintoanindividual’sISP.ThePsychiatryDepartmenthadbegunaninitiativetohaveamemberoftheDepartment(eitheraPsychiatricNurseoraPsychiatryAssistant)attendtheISPofeachindividualreceivingpsychotropicmedication.TheDepartmentalsointendedtopreparethedocumentationrepresentingtheindividual’spsychiatrictreatment,andthenensurethatthisinformationwasplaceddirectlyintotheISPdocumentation,whichshouldensuretheconsistencyofthedocumentation.

J9 Commencingwithinsixmonthsof AsnotedabovewithregardtoSectionJ.8oftheSettlementAgreement,theintegrationof Noncompliance


# Provision AssessmentofStatus CompliancetheEffectiveDatehereofandwithfullimplementationwithintwoyears,beforeaproposedPBSPforindividualsreceivingpsychiatriccareandservicesisimplemented,theIDT,includingthepsychiatrist,shalldeterminetheleastintrusiveandmostpositiveinterventionstotreatthebehavioralorpsychiatriccondition,andwhethertheindividualwillbestbeservedprimarilythroughbehavioral,pharmacology,orotherinterventions,incombinationoralone.Ifitisconcludedthattheindividualisbestservedthroughuseofpsychotropicmedication,theISPmustalsospecifynon‐pharmacologicaltreatment,interventions,orsupportstoaddresssignsandsymptomsinordertominimizetheneedforpsychotropicmedicationtothedegreepossible.

psychiatricandpsychologicalbehavioralserviceswasevidentintheconductofthePsychiatricClinics,aswellasthedocumentationthatwasfoundinthesampleof20recordsofindividualsreceivingpsychotropicmedication.TheMonitoringTeam’spreviousreportsrevealedasignificantdeficiencyinthisprocessrelatedtothedegreetowhichbehaviorsthatwereidentifiedasbeingtargetsofapsychotropicmedicationalsowereidentifiedintheFunctionalAnalysisandthePBSPasbeingpresentonalearned/behavioralbasisand/orasbeingrelatedtoenvironmentalfactors.Itisentirelyfeasiblethatagivenbehaviorcouldbeco‐determinedbybothbiologicalandbehavioralfactors.However,thedualdescriptionofthebehaviorasbothatargetofthepsychotropicmedication,andasbeingpresentonapurelybehavioralbasissuggestedthatthemedicationswerebeingusedtosuppressenvironmentally‐determinedbehaviors,and/orthatthePsychiatricTreatmentPlansandthePsychologicalBehavioralTreatmentPlansweredevelopedthroughparallelprocessesthatwerenotfullyintegrated.TheFacilityhadaddressedthisproblemwithstrategiesthataredescribedwithregardtoSectionsJ.2andJ.8.Thereviewofthesampleof20recordsofindividualsreceivingpsychotropicmedicationidentifiedone(5%)forwhomthedualclassificationofbehaviorsdescribedabovewaspresent.AdetaileddescriptionofthecircumstancesthatresultedinthisfindingforIndividual#295isprovidedwithregardtoSectionJ.2.However,therecordsof19individuals(95%)containedanadequatedifferentiationofthebehaviorsthatwerepresentduetobiologicalfactors,asopposedtobehavioraldeterminants.Thedifferentiationofthemaladaptivebehaviorswithwhichtheindividualpresentedisdirectlyrelatedtotheconcludingrequirementofthisprovision,specifically:“theneedtominimizetheneedforpsychotropicmedicationtothedegreepossible.”Aswasidentifiedinpriorreviews,themisidentificationofbehaviorsthatinrealitywererelatedtobehavioral/environmentalfactorsasbeinglinkedtoapsychiatricdisorderwouldincreasetheriskthattheindividualcouldbeprescribedunnecessarypsychotropicmedication.Inaddition,theindividualwouldnotreceivethebehavioralsupportsappropriatetoaddresstheproblem.ThechangesinthePsychiatryandPsychologyDepartments’documentationaddressingthisissuearedescribedwithregardtoSectionJ.2,andsummarizedwithregardtoSectionJ.8.Initseffortstoaddresstheissuesrelatedtothemisidentificationofbehaviors,thePsychiatryDepartmenthadmodifiedtheformatfortheQuarterlyPsychiatricReviewssothatitwouldcontainmoreexplicitinformationconcerningthelinkagebetweenthesymptomsoftheindividual’spsychiatricdisorderandhis/herothermonitoredmaladaptivebehaviors.ThenewlyformattedQuarterlyReviewdocumentsnowhadbeenincorporatedintotherecordsofalloftheindividualswhoreceivedpsychotropicmedication.TheCPEsmeetingthequalitystandardsoftheSettlementAgreementalso


# Provision AssessmentofStatus Complianceprovideddiscussionsaddressing thisdifferentiation.ThesediscussionsprimarilyappearedintheBio‐Psycho‐Social‐SpiritualFormulationssectionoftheCPEs,andthediscussionsofthedifferentialpsychiatricdiagnoses,aswellastheQuarterlyReviewdocumentationdiscussedabove.Inaddition,thePsychologyDepartmenthadaddedasectiontotheirdocumentationentitled:“PsychiatricInformation,”whichalsoaddressedthisproblem.AllofthesemethodsaredescribedinmoredetailinSectionJ.2.ThisprovisionalsostipulatesthatthisdocumentationshouldbediscussedintheISPmeetingandbeincludedinthedocumentationoftheISPmeetingaswell.AsnotedwithregardtoSectionJ.8,amemberofthePsychiatryDepartmenthadonlybeenabletoattendISPsforthreeofthe20individuals(15%)inthesampleofindividualsreceivingpsychotropicmedication:Individual#318,Individual#63,andIndividual#5.NoneoftheISPsreviewedinthissamplecontainedadequatedocumentationtoaddressthestipulationscontainedinthisprovision.AmemberofthePsychiatryDepartmenthadattendedtheISPforeightindividualsoverthepriorsixmonths,asdescribedwithregardtoSectionJ.8.ThePsychiatryDepartmentrecentlyhadbegunaninitiativetohaveeitheraPsychiatricNurseoraPsychiatryAssistantattendtheISPmeetingsoftheindividualstheyserve,andthentobothcomposeanddirectlyplacetheirdocumentationintotheISPfile.Inordertofulfilltherequirementsofthisprovision,thisdocumentationshouldexplicitlydescribethedeliberationsleadingtothedecisionthattheuseofpsychotropicmedicationrepresentedtheleastintrusiveandmostpositiveinterventiontotreatthepsychiatricdisorder.Theteammustalsodeterminewhethertheindividualwillbestbeservedprimarilythroughbehavioral,pharmacological,orotherinterventions.Inaddition,thedocumentationintheISPshouldspecifynon‐pharmacologicaltreatment,interventions,orsupportstoaddresssignsandsymptomsofthedisorderinordertominimizetheneedforpsychotropicmedicationtothelowestdegreepossible.Althoughtheexistingdocumentationinthe:a)BehavioralSupportPlans;b)Quarterlydocumentation;andc)CPEs(asdiscussedindetailwithregardtoSectionsJ.2,J.6,J.8,andJ.13)contributedtothefulfillmentoftheserequirements,itwouldbehelpfultoexplicitlyrefertothesethreefactorsinboththePsychologyandPsychiatrysectionsoftheindividualrecordaswellastheISPdocumentation,inordertodirectlyaddressthisprovisionoftheSettlementAgreementandthusavoidanyconfusion.Also,asnotedabove,thedeliberationsandsupportingevidencethatledtheteamtotheseconclusionsshouldbeexplicitlystated,ratherthanasimpleopinionthatthesecriteriahadbeenmet.ThefindingofnoncomplianceforthisprovisionwasprimarilybasedonthelackofattendancebyamemberofthePsychiatryDepartmentattheISPmeetings,aswellastheinadequaciesinthedeliberationsoftheinterdisciplinaryteamsinrelationtotheuseofbehavioral,pharmacology,orotherinterventions,incombinationoralone,andthe


# Provision AssessmentofStatus Compliancerelateddocumentationin theISPs orotherdocument(e.g.,ISPA).

J10 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithin18months,beforethenon‐emergencyadministrationofpsychotropicmedication,theIDT,includingthepsychiatrist,primarycarephysician,andnurse,shalldeterminewhethertheharmfuleffectsoftheindividual'smentalillnessoutweighthepossibleharmfuleffectsofpsychotropicmedicationandwhetherreasonablealternativetreatmentstrategiesarelikelytobelesseffectiveorpotentiallymoredangerousthanthemedications.

ThisprovisionoftheSettlementAgreementaddressestherisk‐versus‐benefitconsiderationsrelatedtotheuseofpsychotropicmedicationsforaspecificindividual.TheMonitoringTeam’spreviousreportsindicatedthatthesediscussionsprimarilyappearedintheHRCsectionoftherecord,aswellasthePositiveBehaviorSupportPlan,andusuallyconcludedthatthebenefitsoftheproposedmedicationsoutweighedtheriskspresentedbytheirsideeffects.Thedescriptionsofthebenefitswereformulaicinnature,andthebenefitswereuniformlydescribedasareductioninthebehaviorsthatwereidentifiedasthetargetsofthepsychotropicmedication.Atthetimeofthemostrecentreview,theFacilityhadrespondedtotherecommendationscontainedintheMonitoringTeam’spreviousreports.TheFacilitywasprovidingmoreinformationrelatedtotherisk‐versus‐benefitequationforthepsychotropicmedicationsintheQuarterlyPsychiatricReviewsandtheCPEs.Thecurrentreviewfoundanimproveddiscussionoftherisk‐versus‐benefitanalysisin11ofthe20individualrecordsreviewed(55%)intheQuarterlyPsychiatricReviewsand/orCPEs.ThespecificrecordsthatcontainedthisinformationwerethoseofIndividual#147,Individual#71,Individual#253,Individual#5,Individual#231,Individual#359,Individual#237,Individual#13,Individual#112,Individual#145,andIndividual#279.Thesediscussionsincludedmoreinformationregardingthepotentialandrealizedsideeffects,aswellasthepotentialand/orrealizedtherapeuticbenefitsofthemedication,includingtherationaleforthosedeterminations.However,eventheseimproveddiscussionsdidnotprovideacomprehensivecomparisonoftheseriskbenefitassessmentstothosethatwouldbepresentedbyreasonablealternativestrategies.Notsurprisingly,thelistofindividualsforwhomtheseimprovedrisk‐benefitdeterminationscouldbeidentifiedparalleledthelistofindividualsforwhomitwaspossibletodiscernthattheprescribedpsychotropicmedicationshadbeeneffective.Theyalsotendedtobeindividualswhowereprescribedfewerpsychotropicmedications.Thus,thisfindingissimilartothedeterminationofefficacydiscussionrelatedtoSectionJ.13.Thefollowingnineindividualrecords(45%)didnotcontainthesufficientlydetailedinformationthatwasincludedintherecordsidentifiedabove:Individual#348,Individual#318,Individual#63,Individual#97,Individual#61,Individual#40,Individual#5,Individual#158,andIndividual298.Theseindividualstendedtobeprescribedmorepsychotropicmedications.However,fiveoftheseindividualshadbeenadmittedtotheFacilitywithinthelastsixmonths,andthisaffectedtheFacility’sabilitytofullysortouttherisk‐versus‐benefitfactorsrelatedtothemedicationstheywereprescribedinthecommunity.Inaddition,theFacilitywasstillactivelyreducingthenumberofprescribedmedicationfortheseindividuals.

Noncompliance



TheFacilityhaddevelopedatooltobeutilizedinthereviewofthepsychotropicmedicationsattheHRCMeetings.Thistoolincludedspecificpromptstofacilitatethereviewofthemajorconsiderationsthatbothclinicians,andthemembersoftheHumanRightsCommitteeshouldtakeintoaccountwhenassessingtherisk‐versus‐benefitofprescribedmedications.On7/11/12,amemberoftheMonitoringTeamattendedtheHRCmeeting.Thereviewsthatoccurredatthismeetingwerethorough,detailedandcomprehensive.TheobservationsofthedeliberationsoftheHRCmeetingsduringprioronsitereviewswerealsoconsistentwiththesefindings.AtthetimeoftheMonitoringTeam’spreviousreview,itwasnotedthatthethoroughnessofthesediscussionswasnotalwaysreflectedintheactualdocumentationsubsequentlyfoundintherecordreviews.TheFacilityhadrespondedtotheserecommendationsbychangingtheformatoftheminutesoftheHumanRightsCommitteeMeetingssotheycoveredmoreofthesalientaspectsofthediscussionsinasuccinctmanner.Sincethelastreview,theFacilityhadmadeprogress.However,thecontinuedfindingofnoncomplianceforthisprovisionwasduetothecontinueddeficienciesintherisk‐versus‐benefitdiscussionsthatoccurredin45percentofthesampleofrecordsreviewed.Asnotedabove,anumberoftheindividualswhoserecordsdidnotcontainadequaterisk‐versus‐benefitdiscussionwereprescribedmultiplepsychotropicmedications.Thisfactoralsoadverselyeffectedthedeterminationofefficacyforthesemedications,aseludedtoaboveanddiscussedwithregardtoSectionJ.13.

J11 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshalldevelopandimplementaFacility‐levelreviewsystemtomonitoratleastmonthlytheprescriptionsoftwoormorepsychotropicmedicationsfromthesamegeneralclass(e.g.,twoantipsychotics)tothesameindividual,andtheprescriptionofthreeormorepsychotropicmedications,regardlessofclass,tothesameindividual,toensurethattheuseofsuchmedicationsisclinicallyjustified,andthat

CCSSLChadcontinueditspolicyofreviewingindividualswhosepsychotropicmedicationregimensmetthecriteriaforpolypharmacyonamonthlybasis.The“MonthlyPsychiatryPolypharmacyReductionMeetingNotes”forthepriorsixmonthswerereviewed.TheConsultingPsychiatrist,DirectorofPharmacyServices,anAttendingPhysician,amemberofthePsychologyStaff,aNursefromtheQualityAssuranceDepartment,andaPsychiatryAssistantattendedthesemeetings.Themeetingnotesindicatedthatthegroupengagedindetailedcase‐centereddiscussionsofindividualswhosemedicationregimensmetthecriteriaforpolypharmacy.Thisdiscussionfocusedonthefeasibilityandcurrentstatusoftheattemptstoreducepolypharmacyforspecificindividuals.Documentationfromthe7/10/12meetingprovidedasummaryoftheFacility’sprogresstowardminimizingpolypharmacyasof6/30/12.AsperrecommendationsthatweremadeintheMonitoringTeam’spriorreports,theFacilitytrackedthestatusoftheindividualswhowereadmittedfromthecommunitywithinthelastyearinaseparatedatabaseandthosenumbersarediscussedlaterinthissection.Thedatafortheremaining121individualsindicatedthat23ofthe121individualsprescribed

Noncompliance


# Provision AssessmentofStatus Compliancemedicationsthatarenotclinicallyjustifiedareeliminated.

psychotropicmedication (19%)werereceivingtwoormoremedicationsfromthesameclass;and59individuals(49%)werereceivingthreeormoremedications,regardlessofclass.Thetotalnumberofindividualswhometthecriteriaforpolypharmacywas61,as21ofthe23individualswhowerereceivingintra‐classpolypharmacyalsoqualifiedforthethreeorgreaterdesignation.Thespecificinformationregardingthenumberofindividualsreceivingmultiplemedicationswasasfollows:

Twomedications=34individuals; Threemedications=32individuals Fourmedications=21individuals Fivemedications=fiveindividuals;and Sixmedications=oneindividual.

Historicaldatafromseveralyearsagowasnotavailableforcomparison.However,monthlycomparativedatawasavailablegoingbacktoNovember2010.Tabularrepresentationofthatdataisasfollows:

DEFINITIONSOFPOLYPHARMACYOctober2010

June2012*

Numberofindividualsreceivingtwoormoremedicationsfromthesameclass

37 23

Numberofindividualsreceivingthreeormoremedicationsregardlessofclassorindication

81 59

Totalnumberofindividualsonpolypharmacy 81 61Totalnumberofindividualsreceivingpsychotropicmedication 145 121*Percentagepatientpopulationreceivingpsychotropicmedicationwhosemedicationsmetthecriteriaforpolypharmacy 56% 50%*ThesenumbersdidnotreflectthesevenindividualswhowereadmittedsinceAugust2011andwerereceivingmultiplepsychotropicmedications,becausetheyweretrackedinaseparatedatabase.ThisprovisionoftheSettlementAgreementalsostatedthatitwasnecessary“toensurethattheuseofsuchmedicationsisclinicallyjustified,andthatmedicationsthatarenotclinicallyjustifiedareeliminated.”Thus,thisprovisionalsorelatedtothedocumentationthatallprescribedmedicationscouldbeempiricallydemonstratedtobeeffective.ThediscussionswiththePsychiatryDepartmentregardingtheindividualswhosepsychotropicmedicationregimenscontinuedtomeetthecriteriaforpolypharmacyindicatedthatthepsychiatricteambelievedthatmanyofthesemedicationswereessentialfortheindividuals’stability.ThisbeliefalsowasreflectedintheobservationsofthemonthlyPsychiatryPolypharmacyReductionCommitteeMeetingthattookplaceduringtheonsitereview.Duringthatmeeting,itwasevidentthatthequestionof


# Provision AssessmentofStatus Compliancewhetheralloftheindividuals’medicationswerenecessarywasdiscussedduringeachindividual’sreview,anditoftenwasconcludedthattheFacilitycontinuedtobelievethatthiswastrueformanyindividuals.However,theCommitteehadnotmadeaformaldistinctionbetweentheseindividualsandthoseforwhomtheybelievedfurtherreductionsmightbepossible.Asnotedabove,theFacilitytracked,asaseparatecategory,thoseindividualsadmittedfromthecommunitythatwerereceivingmultiplepsychotropicmedications.Atthetimeoftheonsitereview,thatnumbercurrentlyequaledseven.FiveoftheseindividualswereadmittedtoCCSSLCwithinthelastsixmonths.Therangeofthenumberofpsychotropicmedicationstheseindividualswerereceivingatthetimeofadmissionwasthreetoseven,withanaverageof4.8perperson.Thecurrentrangeofpsychotropicmedicationfortheseindividualswasfromthreetofour,withanaverageof3.4perperson.Withinthisgroup,adecreaseinintra‐classpolypharmacyfromtwotozeroalsohadoccurred.Thus,thePsychiatryDepartmenthadbeenabletoimplementsignificantandtimelyreductionsintheamountofpolypharmacytowhichtheseindividualswereexposed.ThenecessityofdocumentingtheefficacyofthosemedicationregimensmeetingthecriteriaforpolypharmacywasdiscussedwiththePsychiatryDepartmentduringtheonsitereview.Thisevidencedoesnotneedtoconsistofamathematicalproofofefficacy,butshouldprovidemoredocumentationthanasimpleopinionthatthemedicationscontinuetobenecessary.Therewasanextensivediscussionofthissubjectwiththemembersofthepsychiatrysupportstaffduringtheonsitereview.Anexampleofinformationthatwouldrepresentsufficientdocumentationagivenmedicationwaseffectivecouldincludedocumentationthattheindividualexperiencedasignificantdeteriorationintheirpsychiatricstatusfollowingadecreaseordiscontinuationofthemedication,andthenbenefitedfromrestorationofthatmedication.Anotherscenariowouldbetheabilitytodemonstratethatthesymptomsandbehavioralmanifestationsofanindividual’spsychiatricdisordersignificantlyimprovedfollowingtheinstitutionoftreatmentwithaspecificmedication.Asnotedabove,thePsychiatryDepartmenthadmadeonlymodestprogressinreducingtheuseofpolypharmacywithpsychotropicmedicationfortheindividualswhoresidedatCCSSLC.Thecurrentfindingofnoncomplianceforthisprovisionprimarilyrelatedtothisfinding,whichisreflectedinthecontinuedrelativelyhighrateofpolypharmacyatCCSSLC,andthelackofaprocesstoempiricallyjustifythecontinueduseofpolypharmacy,asappropriate.

J12 WithinsixmonthsoftheEffectiveDatehereof,eachFacilityshalldevelopandimplementasystem,

ThisprovisionoftheSettlementAgreementmandatessystemic, quarterlymonitoringfortheemergenceofmotorsideeffectsrelatedtotheutilizationofantipsychoticmedicationwiththeDyskinesiaIdentificationSystem:CondensedUserScale,andthemonitoringof



# Provision AssessmentofStatus ComplianceusingstandardassessmenttoolssuchasMOSESandDISCUS,formonitoring,detecting,reporting,andrespondingtosideeffectsofpsychotropicmedication,basedontheindividual’scurrentstatusand/orchangingneeds,butatleastquarterly.

moregeneralsystemicsideeffectsrelatedtopsychotropicmedicationwiththeMonitoringofSideEffectsScaleeverysixmonths.Animportantcomponentofthissideeffectmonitoringalsoincludesthelatencybetweenthetimethatthenursecompletedtheexamandthedocumentationwasreviewedandsignedbytheprescribingphysician.Thereviewofthesampleoftherecordsof20individualsprescribedpsychotropicmedicationindicatedthatthedocumentationthattheMOSESevaluationwascurrent(completedwithinthelastsixmonths)andhadbeenperformedatleasteverysixmonths,waspresentforalloftheindividualsinthissample(100%).Therecordsofthe20individualsinthesamplecontaineddocumentationthattheprescribingphysicianhadreviewedtheMOSESevaluationinatimelymannerfor18ofthe20individuals(90%).ThetwoindividualsforwhomthedocumentationofthereviewwasinadequatewereIndividual#40(missingsecondpagewithphysiciansignaturefor4/12/12evaluation),andIndividual#359(missingsecondpagewithphysiciansignaturefor3/26/12).Thus,therewasinsufficientdocumentationtoconfirmthattheMOSESevaluationswerereviewedinatimelymannerforthesetwoindividuals.ThepurposeoftheDISCUSwastodetecttheemergenceofmotorsideeffectsrelatedtotheuseofantipsychoticmedication.Thereviewoftherecordsofthesampleof20individualsindicatedthattheDISCUShadbeencompletedasspecifiedforalloftheseindividuals(100%).ThoseindividualswhoserecordsshowedasignificantdelaybetweenthedatethenursecompletedtheDISCUSevaluation,andtheprescribingphysicianreviewedandsigneditwereasfollows:Individual#279(5/11/11),nophysician’ssignature);andIndividual#359(3/26/12),alsomissingphysician’ssignature.Thus,theseevaluationshadbeenreviewedandsignedinatimelymannerfortheremaining18individuals(90%).Theseresultsindicatedsignificantprogress,ascomparedtopriorreviews.ThedatetheMOSESandDISCUSevaluationswereperformedwasrecordedinthePsychiatricQuarterlyReviewdocumentation,includingtheresultsforeachadministrationandwhetherornotanyadditionalactionwasrequired.Thepresenceofanysignificantsideeffects,aswellasanyactionrequired,wouldbediscussedinthesectionofthisdocumentthatrepresentedthePsychiatrist’snarrativesummary.EachQuarterlyReviewdocumentcontainedthehistoricalinformationfortheprioryearandwascontinuouslyupdated.TheDISCUSandMOSESalsoarenecessarytomonitorforthesideeffectsofReglan,whichalthoughprescribedforgastroesophagealrefluxdisease(GERD),haspharmacologicalpropertiesthataresimilartothoseofantipsychoticagents.OneofthePsychiatricNursesperformedtheDISCUSforthoseindividualswhowerereceiving


# Provision AssessmentofStatus Complianceantipsychoticmedication.Thus,aPsychiatricNursewouldmonitoranindividualforsideeffectsiftheywerereceivingReglan,aswellasanantipsychoticmedication.Accordingly,alistwasobtainedfromthePharmacyofallindividualsreceivingReglantodevelopthesampleforthisanalysis.Thislistwasthencross‐referencedwiththeFacility‐widelistofindividualsreceivingpsychotropicmedicationinanefforttogeneratealistofindividualsreceivingReglan,butnotalsoprescribedpsychotropicmedication.Therationaleforthisdistinctionwasthatthenursesontheindividuals’residentialunitsadministertheevaluationsfortheseindividuals,ratherthanthePsychiatricNurses.Thisprocessindicatedthat,asof7/10/12,14individualswerereceivingReglan,butwerenotprescribedmedicationforapsychiatricdisorder.Thefollowingsampleoffiveindividuals(36%)whofittheabovecriteriawasselected,including:Individual#43,Individual#205,Individual#252,Individual#113,andIndividual#239.ThereviewoftherecordsrelatedtotheMOSESevaluationsindicatedthattheexaminationhadbeenperformedeverysixmonthsasrequiredforalloftheindividualsinthissample(100%).AlloftheseMOSESevaluationshadbeenreviewedandsignedbytheprescribingphysicianinatimelymanner.ThesamesampleofindividualsreceivingReglanwasusedtoevaluatethecompletionoftheDISCUS.TheresultsofthisreviewindicatedthattheDISCUSevaluationswerecompletedeverythreemonthsasrequiredforallofthefiveindividuals(100%).Thedocumentationindicatedthattheprescribingphysicianhadreviewedfourofthefiveevaluationsinatimelymanner(80%).TheresultsforIndividual#239indicatedthatthe3/7/12DISCUShadnotbeenreviewedandsignedbytheprescribingphysicianuntil3/20/12.Duringtheonsitereview,amemberoftheMonitoringTeamalsoinquiredaboutthedegreeoftrainingthattheUnitNursesreceivewithregardtoperformingtheDISCUSevaluation.ThePsychiatryTeamindicatedthatallofthenursesreceivebothinitialtraining,aswellasannualupdates.Thistrainingwasquiteextensiveandincludedboththereviewofavideotape,aswellasarequiredpost‐trainingcompetencytesttoassessforskillacquisition.TheFacility’sPsychiatryNursesweretheinstructorsforthetraining.Inordertoverifythatthetrainingwastakingplace,theattendancefortheprioryearwasreviewed.ThePsychiatricNursesalsosuppliedtheresultsofpost‐trainingtestandtheDISCUSevaluationstheNursesconductedafterviewingthevideotapestoillustratetheywereabletoutilizethecorrectmethodsforperformingtheevaluations.Thecontentofthetrainingmaterials,thedocumentationofattendance,andtheproductionofthetestingmaterials/resultsindicatedthattheUnitNurseswerereceivingadequatetrainingonhowtocompetentlycompletetheDISCUSevaluationsforthoseindividualsprescribedReglan.


# Provision AssessmentofStatus ComplianceTheMOSESevaluationmaterialhad detailedinstructionsonhowtoconducttheevaluationembeddedintotheactualtestingmaterial.Thisevaluationwasdesignedtobecompletedbyindividualswithanursingdegree.ThefindingofsubstantialcomplianceforthisprovisionisbasedonthecontinuedhighratesofcompletionoftheMOSESandDISCUSevaluations,andthesubstantialimprovementsintheprescribingphysicians’timelyreviewoftheseevaluations.

J13 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationin18months,foreveryindividualreceivingpsychotropicmedicationaspartofanISP,theIDT,includingthepsychiatrist,shallensurethatthetreatmentplanforthepsychotropicmedicationidentifiesaclinicallyjustifiablediagnosisoraspecificbehavioral‐pharmacologicalhypothesis;theexpectedtimelineforthetherapeuticeffectsofthemedicationtooccur;theobjectivepsychiatricsymptomsorbehavioralcharacteristicsthatwillbemonitoredtoassessthetreatment’sefficacy,bywhom,when,andhowthismonitoringwilloccur,andshallprovideongoingmonitoringofthepsychiatrictreatmentidentifiedinthetreatmentplan,asoftenasnecessary,basedontheindividual’scurrentstatusand/orchangingneeds,butnolessoftenthanquarterly.

ThisprovisionoftheSettlementAgreementaddressesprocessesthatareessentialfortheappropriateuseofpsychotropicmedicationforindividualswithID/DD.Thefirstoftheserelatestotheintegrityofthepsychiatricdiagnosis,asindicatedbythefollowingterminology:“theTreatmentPlanforthepsychotropicmedicationidentifiesaclinicallyjustifieddiagnosisoraspecificbehavioral‐pharmacologicalhypothesis.”Thereviewoftherecordsofasampleof20individuals(15%ofthetotalreceivingpsychotropicmedication)indicatedthatadescriptionofthespecificsymptomsthatwouldsupportthepsychiatricdiagnosisofrecordcouldbeidentifiedfor19individuals(95%).TheonlyindividualforwhomthisdocumentationwasnotfoundwasIndividual#295.ThepsychiatricdiagnosisforIndividual#295thatwasincludedintheQuarterlyPsychiatryReviewsdifferedfromthatwhichwasincludedintheCPE,andthejustificationforthediagnosiscontainedintheCPEwasmorecompellingthantheoneaccompanyingthediagnosisintheQuarterlyPsychiatricReview.ThisissueisdiscussedinfurtherdetailwithregardtoSectionJ.2.ThenarrativerelatedtoSectionJ.2alsocontainsadetailedreviewoftheupdatedprocessanddocumentationrelatedtoestablishingapsychiatricdiagnosisatCCSSLC.ThecurrentCPEscontainedsectionsthatdiscussedthediagnosis,andtheQuarterlyPsychiatricReviewsincludedtheDSM‐IVDiagnosticChecklists,whichverifiedthatthediagnosisofrecordforthatindividualmetthespecificdiagnosticcriteriaforeachAxisIand/orAxisIIdiagnosisappliedtothatindividual.Thesechecklistshadbeendevelopedandimplementedatthetimeofthepriorreview.Inaddition,intheMonitoringTeam’spreviousreport,adiscussionhadbeenincludedoftheutilityofdevelopingamethodthatwouldmorespecificallytrackthesymptomsoftheindividualpsychiatricdisorder,aswellastheidentified“targetbehavior.”ThePsychiatryteamhadrespondedtothisbydevelopingapsychiatricsymptomstrackingscale.Itdefined21symptomsthatrelatedtotheMajorAxisIpsychiatricdiagnosis.AsdiscussedwithregardtoSectionJ.2,theseinstrumentswerenowfullyimplemented.TheUnitNursescompletedtheseratingsforthesymptomsthatwerespecifictotheindividual,asdeterminedbytheConsultingPsychiatristandtheothermembersofthemultidisciplinaryPsychiatricClinicteams.TheresultsofthesewereratingswerealsoreviewedanddiscussedinthecontextoftheMonthlyandQuarterlyPsychiatricreviewmeetingsthattookplaceonthelivingunitsandwereattendedbymembersofmultipleprofessionaldisciplinesasdescribed

Noncompliance


# Provision AssessmentofStatus Complianceelsewhereinthissection. Thisallowed forboththereviewof thematerialaswellastheinclusionofcommentsandobservationsfromothermembersoftheIDT.Thisdataprovidedameasureofthefrequencyandintensityofthesesymptoms,whichthePsychiatristreferencedinthenarrativesectionoftheMonthlyandQuarterlyPsychiatryNotes.Thetwo‐pageQuarterlyReviewdocumentationincluded18specificdomainsofclinicallyrelevantinformation,whichcollectivelycoveredthebroadcategoriesofpsychiatricdiagnosisandcurrentstatus.Theprescribedpsychiatricmedications,includingsideeffectandbehavioralconsiderations,themedicaldiagnosisaswellasthestatusofanyneurologicalinvolvementfollowed,andrecommendationsforfutureinterventionsandmonitoring.Thisinformationwaspresentedinalogicalformatthatmadeitrelativelyeasytoabsorbthecontent,despitetheamountofinformationthatwaspresented.AsdiscussedwithregardtoSectionsJ.8andJ.9,itwasnotpossibletoobserveaPsychiatricClinicduringtherecentonsitereview,butseveralPsychiatricClinicshadbeenobservedduringpriorvisitstotheFacility.ThisprovisionoftheSettlementAgreementalsoaddressedtheneedtoidentify“theobjectivepsychiatricsymptomsorbehavioralcharacteristicsthatwillbemonitoredtoassessthetreatments’efficacy.”These“symptomsorbehavioralcharacteristics”werenoweffectivelyaddressedthroughthemethodsdescribedaboveandreviewedindetailwithregardtoSectionJ.2.AsdiscussedwithregardtoSectionJ.2,thesymptomsofthepsychiatricdisorderforwhichthepsychotropicmedicationwasprescribedweremonitoredtoassesstheefficacyofthemedication.ScalestheFacilitydevelopedprovidedoperationaldefinitionsof21symptomscommontomanyofthemostprevalentAxisIpsychiatricdisorders.TheIDT,membersofwhichroutinelyattendedthePsychiatricClinics,workinginconjunctionwiththeConsultingPsychiatristandthebroaderpsychiatryteamtailoredthespecificsymptomsthatweremonitoredforeachindividual.Asnotedabove,thelivingunitnursecompletedthesescaleswithinputfromtheothermembersoftheteam.ThePsychiatricNurseworkinginconjunctionwiththePsychiatricAssistants,theconsultingPsychiatristandtheothermemberoftheIDTthatroutinelyattendedthepsychiatricclinicscompletedtheDSMIVDiagnosticchecklists.ThepsychiatricdiagnosisandthesupportingsymptomswerealsospecifiedinboththediagnosticsectionoftheCPEsandtheBio‐Psycho‐Social‐SpiritualFormulationsectionofthosedocuments.InadditiontherelationshipbetweenthepsychiatricdisorderandthebehaviorsaddressedbyPsychologywereclarifiedintheBio‐Psycho‐Social‐SpiritualformulationoftheCPE,theQuarterlyPsychiatricNotesdocumentation,andthePsychiatricInformationsectionofthePositiveBehaviorSupportPlanasdetailedwithregardtoSectionJ.9.ThesemeasureswerenotdescribedoraddressedintheISPas


# Provision AssessmentofStatus Compliancediscussedwithregardto SectionJ.8, andthiswillneedtoberemediedasthePsychiatryDepartmentreorganizesitsplansforbothattendanceattheindividualISPsandtheinformationthatisincludedintherelateddocumentation.AnotherrequirementofthisprovisionoftheSettlementAgreementrelatedtotheefficacyoftheprescribedpsychotropicmedication.In11ofthe20recordsreviewed(55%),empiricalevidencewasfoundthattheprescribedpsychotropicmedicationhadproducedasignificantdiminutioninthefrequencyofthemonitoredtargetbehaviors.Theserecordswerethoseofthefollowingindividuals:Individual#147,Individual#71,Individual#253,Individual#5,Individual#231,Individual#359,Individual#237,Individual#13,Individual#145,Individual#112,andIndividual#279.Thesetendedtobeindividualswhowerereceivingfewerpsychotropicmedications.AsnotedinthediscussionrelatedtoSectionJ.11,anumberofindividualsatCCSSLCcontinuedtobeprescribedmultiplepsychotropicmedications.Thedeterminationofefficacyforeachofthesemedications,naturally,becomesmathematicallymorecomplex,andthisproblemisthencompoundedwhenchangesinthosemedicationsaremadewithoutsufficienttimetoestablishanewbaselineforanadditionalmedication.Inadditiontothelackofsufficientchronologicaldata,themajorimpedimenttodeterminingifanindividual’smedicationswereeffectivewasthenumberofmedicationsthattheindividualwasreceivingandthefrequencyofchangesinthosemedications.TheQuarterlyPsychiatricReviewdocumentationcontainedasectionidentifyingthetimelinesbywhichtheprescribedmedicationusuallycouldbeexpectedtobegintoexertitstherapeuticeffects.Althoughthisinformationwasuniformlypresentforeachmedicationtheindividualwasprescribed,formostindividualsthiswasnolongerclinicallyrelevant,becausethemedicationsalreadyhadbeenprescribedforseveralmonthsoryears.However,thisinformationwasimportantforassessingtheefficacyofnewlyprescribedmedicationsforwhichthesetimelineswouldbeimportanttoconsider.CCSSLCPsychiatryandPsychologyProgressNotesroutinelycarriedforwardchronologicalobjectivebehavioraldata,whichpresentedthefrequencyofthesebehaviorsovertimeinbothatabularandgraphicformat.Includingasummaryofthecontemporaneousmedicationchangesand/orchangesintheBehavioralPlanastheycorrespondedwithchangesinthefrequencyofthemonitoredbehaviorwouldgreatlyenhancetheutilityofthisinformation.Thisdatabasewouldthenprovideadditionalhistoricaldatapointswithwhichtomakecomparisonswithcurrentfrequencies.ThiswouldenablethePsychiatricTreatmentTeamtoascertainifaspecificpsychotropicmedicationcouldbedeterminedtobeeffectivefromanempiricalperspective.AlthoughthePsychiatryDepartmenthaddevisedamethodformonitoringthefrequency


# Provision AssessmentofStatus Complianceandintensityofthesymptomsofthepsychiatricdisorder,theyweredependentontheindividualPsychologiststoreportthefrequencyoftheotherbehaviorspresentedinthePsychiatricClinicnotes.Directsupportprofessionalscollectedtheactualrawdataforthesebehaviorsunderthedirectionofthepsychologistassignedtotheindividual’slivingunit.ConcernswithregardtotheaccuracyandreliabilityofthisdataarediscussedinSectionK.10.ThefinalsectionofthisprovisionrelatedtothefrequencywithwhichthePsychiatristreviewedindividualsprescribedpsychotropicmedication.ThecurrentreviewofasampleofthemedicalrecordsindicatedthatQuarterlyReviewswereperformedasspecifiedinthisprovisionforallofthe20individuals(100%).TheevidencethatthePsychiatristhadevaluatedtheindividualatthetimeoftheQuarterlyReviewwascontainedinthedetailedMentalStatussectionofthesedocuments.ThePsychiatryDepartmenthadmadeprogressinrelationtoseveraloftherequirementsofthisprovisionoftheSettlementAgreement.MuchofthisprogresswasrelatedtothecompletionoftheCPEsandtheQuarterlyReviewdocumentationforthoseindividualsprescribedpsychotropicmedication.Thefindingofnoncomplianceforthisprovisiondirectlyrelatedtothelackofdocumentationinthoseparticularareasspecifiedabove.Thisincluded,thelackofempiricalevidencethattheprescribedpsychotropicmedicationhadproducedasignificantdiminutioninthefrequencyofthemonitoredtargetbehaviors,aswellasthelackofidentificationofindividualsforwhommedicationtaperingplanshadbeendevelopedandthestatusofthoseplans.

J14 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationinoneyear,eachFacilityshallobtaininformedconsentorproperlegalauthorization(exceptinthecaseofanemergency)priortoadministeringpsychotropicmedicationsorotherrestrictiveprocedures.Thetermsoftheconsentshallincludeanylimitationsontheuseofthemedicationsorrestrictiveproceduresandshallidentifyassociatedrisks.

ThereviewoftheRights/Consentssectionsofthemedicalrecordsforthesampleof20individualsreceivingpsychotropicmedicationindicatedthat10individuals(50%)hadaGuardianofthePerson.ThoseindividualswithoutaguardianreliedontheFacilityDirectortoreviewthematerialconcerningrisk‐versus‐benefitconsiderationsrelatedtotheutilizationofpsychotropicmedication,andthenprovidethenecessaryconsent.Thereviewoftheindividualrecordsindicatedthatconsentsfortheuseofpsychotropicmedicationshadbeenobtainedinatimelymannerfor15ofthe20individualsinthesample(75%).ThespecificindividualsforwhomconsentsforpsychotropicmedicationcouldnotbeidentifiedwereIndividual#253,Individual#97,Individual#40,Individual#13,andIndividual#295.OfinterestwastheobservationthatalloftheseindividualshadaGuardianofthePerson,exceptIndividual#13.CCSSLCrecentlyhadimplementedanumberofmeasurestoimprovetherisk‐benefitanalysis,aswellasthequalityoftheinformationprovidedtotheguardianorFacilityDirectorregardingthepossiblesideeffectsoftheproposedmedication.Specifically,the

Noncompliance


# Provision AssessmentofStatus CompliancemoregenericmaterialreferredtointheMonitoringTeam’spreviousreports hadbeenreplacedwithmaterialfromMicromedex,whichisanationallyrespectedsourceofpharmacologicalinformation.Inaddition,theFacilitywasimplementinganinitiativetoreplacethepracticeofobtainingconsentsandHumanRightsCommitteeapprovalforalloftheindividuals’psychotropicmedicationasapackagewithaprocessofobtainingconsentforeachmedicationasaseparateentity.ThischangeintheconsentprocesswasalsomirroredintheHumanRightsreviewprocess,inthattheHumanRightsreviewapprovalprocessnowaddressedeachmedicationasaseparateentity.However,asnotedwithregardtoSectionJ.10,thecurrentreviewfoundanimproveddiscussionoftherisk‐versus‐benefitanalysisin11ofthe20individualrecordsreviewed(55%)intheQuarterlyPsychiatricReviewsand/orCPEs.Fortheremainingindividuals,asnotedinpreviousreport,thedeficitsintherisk‐versus‐benefitdiscussionsmadeitdifficult,ifnotimpossible,foraguardianortheFacilityDirectortorenderatrulyinformedconsentregardingtheuseofpsychotropicmedication.AnimportantcomponentoftheFacility’splantoaddresstheseissuesalsoinvolvedthetransitionfromthepracticeofhavingtheindividuals’PsychologistobtaintheconsentfromtheguardiantoaprocessofhavingtheLivingUnitNursesecuretheconsent.Thecommunicationbetweenthenurseandtheguardianwasprimarilywritten,unlessverbalconsentwasrequestedbytheguardianand/orwasrequiredtoimplementthemedicationonanurgentbasis.HoweverthePsychiatristandtheothermembersofthePsychiatryDepartmentincludingthePsychiatricNursesandthePsychiatricAssistantsallcontributedtotheinformationthatwasprovidedtotheindividualwhowasprovidingconsent.TheConsultingPsychiatristdidnothaveanydirect,written,orverbalcontactwiththeguardianunlessitwasrequired,orintheeventthattheguardianattendedthePsychiatryClinics,whichwasarelativelyrareoccurrence.TheconsentsthatweresuppliedbytheFacility’sDirectorforthoseindividualswhodidnothaveguardianswereviawrittencommunication.ThefindingofnoncomplianceforthisprovisionoftheSettlementAgreementwasrelatedtothecontinuingdeficitsintherisk‐versus‐benefitdiscussions,althoughimprovementswerebeginningtobeseeninthisarea.Inaddition,thisreviewfoundthatsignedconsentsforthepsychotropicmedicationcouldnotbelocatedfor25%oftheindividualsinthesample.Thereasonforthedecreaseinthisfrequency,ascomparedtopriorreviews,wasnotclear.

J15 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationinoneyear,eachFacilityshallensurethatthe

TheMonitoringTeam’sinitialreportsidentifieddeficienciesinthecommunicationofrelevantclinicalinformationbetweenthePsychiatristandtheNeurologist,relatedtoindividualsbothdisciplinesfollowed.Inresponsetotheseobservations,thePsychiatryDepartmentdevelopedasystemintendedtoenhancethecommunicationbetweenthe



# Provision AssessmentofStatus Complianceneurologistandpsychiatristcoordinatetheuseofmedications,throughtheIDTprocess,whentheyareprescribedtotreatbothseizuresandamentalhealthdisorder.

twodisciplines.Thissystem,whichthePsychiatricNursesandthe PsychiatryAssistantsfacilitated,wasdesignedtoensurethatthePsychiatristreviewedanyrecentneurologicalconsultationsanddocumentedthisreviewduringthenextQuarterlyPsychiatricClinicforthatindividual.Furthermore,theNeurologistalsowasmadeawareoftheindividual’spsychotropicmedication,aswellasrecentchangesinthosemedications,priortothenextscheduledneurologicalconsultation.Thisprocesshadnowbeenfullyoperationalforthreereviewcycles.Inordertoassesstheefficacyofthisprocess,theneurologysectionoftherecordsforthe20individualsinthereviewsamplewererequested.ReviewofthisdocumentationindicatedthattheConsultingNeurologisthadseenthefollowingthreeindividuals(15%ofthesample)withinthelast18months:Individual#147,Individual#158,andIndividual#145.ReferencetothemostrecentNeurologyConsultwaslocatedinthePsychiatricClinicNotesforalloftheseindividuals(100%).ThemostrecentNeurologyNotesalsocontainedareferencetothepsychiatricmedications,aswellasnotationofanyrelevantchangesinthesemedicationsforalloftheseindividuals(100%).Theextentofthesediscussionsnaturallyvariedaccordingtothecontextoftheindividual’sclinicalstatus.Forexample,iftherehadbeenanincreaseinthefrequencyoftheindividual’sseizures,theNeurologyConsultationNoteandthefollowingQuarterlyPsychiatricReviewdocumentationwouldbemoreextensivethanitwouldhavebeeniftheindividualwerestablefrombothaneurologicalandpsychiatricstandpoint.Inordertoincreasethesizeofthissampletomakethereviewmorereliable,anadditionalsamplewasconstructedbyidentifyingnineindividualsfromthespreadsheettheFacilitymaintainedtotracktheoccurrenceofNeurologyConsultsfortheindividualsalsoprescribedpsychotropicmedication.ThisspreadsheetlistedtheindividualswhowerefollowedinthePsychiatricClinicsandtheConsultingNeurologistalsohadseenfrom12/1/11through6/11/12.Therewere37distinctnameslistedinalphabeticalorder,althoughsomeindividualshadmorethanoneentry.Thus,thenineindividualsrepresented24percentofthetotal.TheMonitoringTeamselectedthissamplewithouttheinputofthePsychiatryDepartment.Thenineindividualsselected,thedateoftheNeurologyConsultation,andthefollowingPsychiatricReviewdateswereasfollows:



IndividualDateofNeurologicalConsultation

DateofQuarterlyPsychiatricReview

Individual#285 2/4/12 2/7/12Individual#78 2/4/12 2/8/12Individual#55 3/31/12 4/10/12Individual#7 2/4/12 2/21/12Individual#243 2/4/12 2/21/12Individual#198 3/31/12 4/10/12Individual#363 4/28/12 5/15/12Individual#213 4/28/12 5/8/12ThedocumentationcontainedinthesecondgroupofnineindividualsalsoconfirmedthattheNeurologyConsultationNotescontainedtherelevantinformationconcerningtheindividual’spsychiatrictreatmentandthefollowingQuarterlyPsychiatricReviewNotediscussedthesalientaspectsofthepriorNeurologicalConsultation(100%).TheFacilityhadnotcarriedoutaformalassessmentoftheamountofNeurologyConsultationtimethatwouldbeneededtoaddresstheneedsofCCSSLC.However,theConsultingNeurologisthadthecapacitytoalterthefrequencyofhisvisits,ifmoreclinicaltimewasrequired.Thisdidnotappeartobeaproblemfromtheperspectiveofensuringthatadequatecoordinationoccurredbetweentheneurologyandpsychiatryconsultants.ThefindingofsubstantialcompliancewascarriedforwardfromtheMonitoringTeam’spreviousreview.ThiswasbasedontheobservationthatthesystemtheFacilityhaddevelopedtoensurethenecessarycommunicationbetweentheNeurologyandPsychiatryDepartmentsresultedintheclinicalcoordinationrequiredbythisprovisionoftheSettlementAgreement.


1. CCSSLCshouldensurethatallofthesectionsoftheirchemicalrestraintdocumentationarecompletedasspecified.(SectionJ.3)2. ThestaffmembersatFacilitywhocompletethechemicalrestraintdocumentationshouldreceivetheinstructionsnecessaryforthemto

properlycompletethesectionofthisdocumentationthatpromptsadescriptionoftheeventsthatprecipitatedtheindividual’sbehaviorthatthenledtotheneedforchemicalrestraint.(SectionJ.3)

3. TheFacilityshouldconsideraddingananalysisofthechemicalrestraintdatatoitsinternalself‐assessmentprocess.(SectionJ.3andFacilitySelf‐Assessment)

4. Proceduresandindividualizedprogramsshouldbedevelopedandimplementedthatwilldecreasetherelianceonpsychotropicmedicationforpre‐treatmentsedationofindividualsformedicalanddentalprocedures.(SectionJ.4)

5. AlthoughtheFacilityhaddevelopedadecision‐treefordeterminingwhichindividualswouldbenefitfromaDesensitizationPlan,theystillneed


todevelopandimplementDesensitizationPlansforindividualswhotheynowconsiderbeingappropriatecandidatesforthisinterventionandwillalsoneedtoexpandthisinitiativetoincludedesensitizationplansformedicalaswellasdentalprocedures/appointments.(SectionJ.4)

6. ThedatarelatedtothestatusoftheDesensitizationPlansforDentalandMedicalprocedureswouldbemorecomprehensibleandusefulifitwasconsolidatedintoamasterspreadsheet,whichwascontinuouslyupdated.(SectionJ.4)

7. TheFacilityshouldspecificallytrackinformationthatidentifiesthoseindividualsforwhomtheimplementationofabehavioralDesensitizationPlanorotherstrategiesresultsintheirnolongerrequiringpharmacologicalpre‐treatmentsedationfordentalormedicalprocedures,oradecreaseintheuseofthismedication.(SectionJ.4)

8. TheFacilityshouldensurethatthephysiologicalmonitoringrelatedtotheadministrationofpre‐treatmentsedationformedicalproceduresiscomplete.(SectionJ.4)

9. Psychiatrystaffingshouldbeincreasedtothetwofull‐timeequivalentpositionscurrentlydeterminedtobenecessary.TheFacilityshouldcontinuetoadvertiseandmakeothereffortstofillitspsychiatrypositions.(SectionJ.5)

10. ThePsychiatryDepartmentshouldundertakeananalysisoftheactualtimecommitmentsoftheConsultingPsychiatrist,andthendeterminehowmuchadditionaltimewouldberequiredtofulfillalloftherequirementsthatarespecifiedintheSettlementAgreement.ThisanalysisalsoshouldtakeintoaccountthefunctionsthatareperformedbythePsychiatryDepartmentsupportstaff.(SectionJ.5)

11. TheFacilityshouldexpanditsinitiativetohaveamemberofthePsychiatryDepartmentattendtheISPmeetingsfortheindividualsreceivingpsychotropicmedication.(SectionsJ.8andJ.9)

12. AdditionalinformationconcerningthepsychiatricmedicationandtherelatedTreatmentPlanshouldbeincludedintheindividual’sISPorISPAdocumentation.Thisdocumentationshouldstateexplicitlywhetherornottheuseofpsychotropicmedicationfortheindividual:a)representstheleastintrusiveandmostpositiveintervention;b)whethertheindividualwillbebestservedprimarilythroughbehavioral,pharmacological,orotherinterventions;andc)identifynon‐pharmacologicaltreatmentsandsupportsthatarebeingusedtoaddressthesignsandsymptomsofthedisorder.Thedeliberationsandevidencethatledtheteamtotheseconclusionsalsoshouldbestatedexplicitly,ratherthanasimplestatement/opinionthatthesecriteriahavebeenmet.Inaddition,theISPactionplansshouldincludemeasurableobjectivestoensurethecollectionofdatanecessarytoevaluateanymedication’sefficacy.(SectionsJ.8,J.9,andJ.10)

13. Therisk‐versus‐benefitanalysiscontainedinthedocumentationgeneratedbythePsychiatryDepartmentalsoshouldappearinothersectionsoftheindividual’srecordwhereapplicable,includingthePBSP,HRC,andISPdocumentation.(SectionsJ.8,J.9,J.10andJ.14)

14. TheFacilityshouldcontinueandincreasetheirattemptstodecreasetheutilizationofpolypharmacywithpsychotropicmedications.(SectionJ.11)

15. TheFacilityshouldconsiderreportingtheirprogresstowardreducingpolypharmacybyorganizingtheirdataaccordingtothefollowingfourcategories:1)continuedmonitoringofthoseindividualsadmittedtoCCSSLCfromthecommunityonpolypharmacywithinthelastyear,withnotationoftheprogressmadesincetheiradmissioninreducingthenumberofmedicationstheyreceive;2)delineationofthoseindividualsthePsychiatryDepartmentbelievesarereceivingpsychotropicmedicationregimensthatmeetthecriteriaforpolypharmacy,butthecontinuationofthesemedicationsisnecessaryfortheindividual’scontinuedstability.Thisinformationalsoshouldincludetheempiricalevidencethatsupportstheseopinions;3)identificationoftheindividualsthatcontinuetoreceivepolypharmacy,butthereisaplaninplacetochallengethosemedicationsthatmightnotbenecessary.Thisinformationshouldincludedataoncurrentandprojectedtaperingschedulesforspecificmedicationsthatmightnotbenecessary;and,4)identificationofthoseindividuals(ifany)thatdonotfitintooneofthepriorthreecategories.ThecompilationofthedatainthecategoricalformatdescribedaboveshouldprovideamoreaccuraterepresentationoftheFacility’sprogressinreducingpolypharmacy.ItalsowouldprovidetheFacilitywithinformationitneedstodetermineifadditionalactionisneededforspecificindividuals.(SectionJ.11)

16. TheFacilityshouldincreaseitseffortstoprovideadequateempiricaldatatosupporttheefficacyofpsychotropicmedicationsthattheindividuals’teamshaveconcludedareessentialfortheindividuals’continuedpsychiatricstability.(SectionsJ.11andJ.13)

17. TheFacilitymightwanttoconsideraddingasummaryofthedatarelatedtothefrequencyandintensityofthemonitoredsymptomsoftheunderlyingpsychiatricdisordertotheQuarterlyReviewdocumentationinamannerthatwouldcomplimentthebehavioraldatathatthe


BehavioralServicesDepartmentcontributes.(SectionsJ.2andJ.13)18. CCSSLCshouldinvestigatethepossiblecausesforthedecreaseinthefrequencywithwhichsignedconsentsforthepsychotropicmedications

werefoundinthecurrentsampleindividualsascomparedtotheMonitoringTeam’spreviousreviews.(SectionJ.14)19. Theimprovementsbeingmadeintherisk‐versus‐benefitanalysis,asrelatedtotheuseofpsychotropicmedication,shouldbereflectedinthe

informedconsentdocumentationthatissuppliedtotheguardianorindividualdesignatedtoprovidetheconsent.(SectionJ.14)20. Theinternalreviewprocessesshouldbefurtherrefinedtoincludequalityparametersinadditiontocompletionrates,whereappropriate.

(FacilitySelf‐Assessment)21. ThePsychiatryDepartmentshouldenlisttheassistanceoftheQualityAssuranceDepartmentindevelopinglargersamplesfortheirself‐

assessmentprocess.(FacilitySelf‐Assessment)


SECTIONK:PsychologicalCareandServicesEachFacilityshallprovidepsychologicalcareandservicesconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow.

StepsTakentoAssessCompliance:Thefollowingactivitiesoccurredtoassesscompliance: ReviewoftheFollowingDocuments:

o SectionKPresentationBook,developedbyJudySutton,M.S.,LPC,BCBA,ChiefPsychologist;

o BehaviorSupportCommittee(BSC)meetingminutes,dated12/1/11through6/29/12;o ForSectionK.4,PositiveBehaviorSupportPlans,SafetyPlansforCrisisIntervention

(SPCIs)asappropriate,andPBSPMonthlyProgressNotes,forthelastthreemonths,asavailable,for:Individual#167,Individual#263,Individual#307,Individual#218,Individual#7,Individual#353,Individual#226,Individual#72,Individual#225,andIndividual#184;

o ForSectionK.4,SafetyPlansforCrisisInterventionandPBSPMonthlyProgressNotes,forthelastthreemonths,asavailable,for:Individual#20,Individual#46,andIndividual#300;

o ForSectionK.5,StructuralandFunctionalBehaviorAssessment(SFBA),asprovidedfor:Individual#186,Individual#368,andIndividual#7;

o ForSectionK.6,PsychologicalEvaluationsandInventoryforClientandAgencyPlanning(ICAP),asavailable,for:Individual#38,Individual#184,Individual#186,Individual#58,Individual#263,Individual#218,Individual#167,Individual#275,Individual#159,Individual#153,Individual#20,Individual#254,Individual#225,Individual#46,Individual#307,Individual#226,Individual#300,Individual#7,Individual#368,Individual#353,Individual#315,andIndividual#72;

o ForSectionK.7,PsychologicalEvaluations,asavailable,for:Individual#5,Individual#40,Individual#61,Individual#63,andIndividual#97;

o ForSectionK.8,CounselingTreatmentPlans,WeeklyandMonthlyCounselingNotes,andPBSPMonthlyProgressNotes(forthelastthreemonths)asprovided,for:Individual#140,Individual#325,Individual#7,andIndividual#246;

o CCSSLClistofindividualscurrentlyreceivingcounseling;o ForSectionK.9,PositiveBehaviorSupportPlansfor:Individual#7andIndividual#186;o ForSectionK.9,onsitechartreviewofconsentsrelatedtoPBSPs,asavailablefor:

Individual#38,Individual#218,Individual#159,Individual#153,Individual#307,Individual#225,Individual#368,andIndividual#315;

o ForSectionK.9,CrisisInterventionPlansandISPActionPlans,asprovided,for:Individual#61andIndividual#253;and

o SectionK.10,PositiveBehaviorSupportPlans,SafetyPlansforCrisisInterventionasappropriate,andPBSPMonthlyProgressNotes,forthelastthreemonths,asavailable,for:Individual#167,Individual#263,Individual#307,Individual#218,Individual#7,Individual#353,Individual#226,Individual#72,Individual#225,andIndividual#184.

InterviewsandMeetingswith:o SectionKreviewwithJudySutton,M.S.,LPC,BCBA,ChiefPsychologist,on7/9/12and


7/10/12;o PsychologistsandAssistantPsychologists,includingDanielRivera,ShesheiaNeal,Tiffany

Carranza,MelinaPineda,LloydHalliburton,LindaCardwell,RobertMeza,ChristinaMautinez,EdithCahlik,LaurieRoberts,RobertCramer,GinaHawkins,AndySpear,SamanthaMendoza,JohnGuerra,GildaMontelegro,EverettBush,KarenHernandez,andTabithaAnastasi,on7/11/12;

o MeetingwithQADepartmentstaffandSectionKandSMonitors,includingJudySutton,M.S.,LPC,BCBA,ChiefPsychologist;AraceliMatehala;CynthiaVelasquez,QADirector;PearlQuintanilla,QAAdministrativeAssistant;SharonDavis,QAAdministrativeAssistant;KarenRyder,QA/ProgramComplianceMonitor;andTabithaAnastasi,on7/12/12;and,

o CoordinatorsandSupervisorsofDayTreatment,Habilitation,Vocational,andEducationalStaff,includingJanieMartinez,DeniseAguilar,MalindaValdemar,LucyTigeria,DavidMcKinney,SofiaFores,JoseSoto,BrigetteEscamilla,PatriciaZagorski,MaryClauss,ErinWillis,andKimberlyBenedict,on7/12/12.

ObservationsConducted:o ObservationanddiscussionwithstaffmembersattheSkillPlanReviewCommittee

meeting,on7/10/12;o Observationanddiscussionwithstaffmembersandindividualsatthe“TopChefo Competition,”on7/10/12;o ObservationanddiscussionwithstaffmembersattheRestrictivePracticesCommittee,on

7/11/12;o ObservationofSkillPlanIntegritychecksat524‐Aand524‐Con7/11/12,aswellasSand

Dollarand514on7/12/12;o Onsitedirectobservations,includinginteractionwithdirectsupportprofessionals,and

otherstaffandprofessionals,wereconductedthroughoutthedayand/oreveninghoursatthefollowingresidentialanddayprogramming,andhabilitationsites:

Apartment522A(Kingfish1),on7/9/12; Apartment522C(Kingfish3),on7/9/12; Apartment522D(Kingfish4),on7/9/12and7/11/12; Horizons/ALSBuilding,on7/10/12; Apartment524A(Ribbonfish1),on7/11/12; Apartment524B(Ribbonfish2),on7/11/12; Apartment518(Porpoise),on7/11/12; Gymnasium,on7/11/12; SandDollar,on7/12/12; Outerreef,on7/12/12; Apartment514(Dolphin),on7/12/12;and AngelFish(Building517)‐KaleidoscopeDayProgramandComfortZone,on

7/13/12.FacilitySelf‐Assessment:AsevidencedintheMonitoringTeam’spreviousreport,theFacilityhaddevelopedaSelf‐AssessmentwithregardtoSectionKoftheSettlementAgreement.Accordingtothe


currentSelf‐Assessment,theFacilityfoundthatitwasincompliancewithSectionK.2,butoutofcompliancewithalloftheothersubsectionswithinPsychologicalCareandServices(i.e.,SectionsK.1,andK.3toK13).ThiswasconsistentwiththeMonitoringTeam’sfindings.TheSelf‐Assessmentidentified:1)activitiesengagedintoconducttheself‐assessment;2)theresultsoftheself‐assessment;and3)aself‐ratingbasedonfindingsoftheself‐assessment.Comparedwiththepreviousassessment,thecurrentSelf‐Assessment,dated6/25/12,appearedtobeasignificantimprovement.Mostsectionsincludedobjectivedata,theuseofrandomsampling,specificationregardingtheitemsreviewed(i.e.,numbers,dates,etc.),aswellasthenumberofitemsexaminedwithineachsection.AlthoughthisformatappearedimprovedandcertainlyusefulinmonitoringtheFacility’sprogresstowardcompliance,anumberofconcernswerenoted:

MorespecificationregardinghowtheFacilitymeasurescertainitemswasneeded.Forexample,forSectionK.4:“resultsindicatedprogresstowardtreatment.”Itwasunclearhow“progress”wasbeingmeasured.

Althoughmethodsappearedtocheckfortheinclusionofrequiredcomponentsofvariousitems,thequalityofthesecriticalelementswasnotnecessarilyjudged.Forexample,forSectionK.12,althoughthenumberofstaffcompletingCBTwasprovided,dataontheirperformanceduringoraftertrainingwasnotprovided.Thatis,howeffectivewastraining?Aresomestaffbettertrainers?AretrainerscompetenttoprovideCBT?Inaddition,forK.11,itwasreportedthat:“100%ofPBSPscontainedinstructionstostaff.”Itwasunclearwhetherornotthequalityoftheseinstructionswasexamined.

ItwasunclearwhatroletheQADepartmenthadinassistingorfacilitatingthecurrentself‐assessment.Indeed,itcontinuedtobeunclearwhetherornotthepreviousmonitoringtoolwouldberevisedorreplacedbythecurrentSelf‐Assessment.

Inter‐raterreliabilityscoreswerenotprovidedonmeasuresusedtoassesscompliance.Inter‐raterreliabilityneedstobeestablishedacrossauditorstoensuretheaccuracyofthedata,aswellastheconsistencyacrossraters.

Inaddition,considerationshouldbegiventowhetherornotcomplianceindicatorsshouldbeweighted.Ifso,considerationshouldbegiventodeterminingwhichitemswouldbeweightedmoreheavily.

Overall,theFacilityhadimprovedtheSelf‐Assessmentandwascollectingandexaminingdatahelpfulinassessingprogresstowardcompliance.Indeed,theamountofdatawasimpressive.WiththeassistanceoftheQualityAssuranceDepartment,theself‐assessmentprocessshouldcontinuetobeimprovedandexpanded,whileensuringvalidityandreliabilityofthedata.SummaryofMonitor’sAssessment:ProgresswasnotedinmanyareasofSectionKoftheSettlementAgreement.However,concernsremainedthroughoutmostareas.ManybehavioralservicesstaffcontinuedtoprogressthroughthenecessarycourseworkaswellobtainnecessarysupervisiontowardtheBCBAcertification.Concernsregardingthedifficultyinaccessingandutilizingtheeducationleavehoursaswellasdifficultyinreliablyaccessingcoursecontentwerenoted.


Slightprogresswasnotedintheareaofpeerreview.Althoughattendanceimprovedforsomecliniciansandcounselors,participationbyotherprofessionalsandkeystaffremainedinadequate.Externalpeerreviewprocesseshadjustbeeninitiated.Continuedprogressintheuseofastandardizedmonthlyprogressnotewasevidenced.ThisincludedcontinuedimprovementintheareaofdatadisplayandongoingPBSPmonitoring,includingtheinitiationofinter‐observeragreementchecksonbehavioraldata.Progresswasevidentinthecompletionofstandardizedintellectualassessmentstoensurethatpsychologicalassessmentswereupdatedatleasteveryfiveyears.However,progressinthecompletionofscalesofadaptivebehaviorwasnotasconspicuous.Inaddition,anewformatentitledtheComprehensivePsychologicalEvaluationwasdevelopedtointegratethepsychologicalassessmentandthestructuralfunctionalbehavioralassessment.Althoughconcernswerenoted,thisnewformatappearedpromising.Limitedprogresswasnotedinthetimelycompletionofpsychologicalassessmentsfornewlyadmittedindividuals,aswellastheprovisionofcounselingsupportstoindividualsreferredforcounseling.ProgresswasnotedintheareaofPBSPswiththedevelopmentofanewandimprovedformatthatwascurrentlybeingpiloted.ActiveeffortswerenotedwithregardtowritingPBSPssothattheycouldbeunderstoodandimplementedbydirectsupportprofessionals.Lastly,someprogresswasnotedincompetency‐basedtraining.However,theprovisionofadequatetrainingacrosstheFacilityforallindividualsremainedinadequateand,ascurrentlydesigned,thenatureoftrainingwassignificantlyresource‐dependentandlikelynotsustainable.

# Provision AssessmentofStatus ComplianceK1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationinthreeyears,eachFacilityshallprovideindividualsrequiringaPBSPwithindividualizedservicesandcomprehensiveprogramsdevelopedbyprofessionalswhohaveaMaster’sdegreeandwhoaredemonstrablycompetentinappliedbehavioranalysistopromotethegrowth,development,andindependenceofall

SincetheMonitoringTeam’slastvisit,PsychologistsintheBehavioralServicesDepartmentcontinuedtomakeprogressinobtainingnecessaryeducationalcompetenciesandsupervisionneededtodemonstratecompetencywithinAppliedBehaviorAnalysis.AttheMonitoringTeam’spreviousvisit,nineoutof15(60%)psychologistshadcompletedatleastoneormoregraduatecourse(s)necessaryforcertification.ThisnumberwouldhavebeenhigheratthecurrentMonitoringvisit,butreportsindicatedthatthreewithdrewfromSpringcoursework.Currently,thenumberofpsychologistswhohadcompletedatleastoneormoregraduatecourse(s)remainedatnine.AtthelastMonitoringvisit,onepsychologisthadcompletedalloftherequiredcoursework.Currently,atotaloffourpsychologistshadnowcompletedalloftherequiredcoursework.ItwasanticipatedthatallfourwouldtaketheBCBAexamintheSpringof

Noncompliance


# Provision AssessmentofStatus Complianceindividuals,tominimizeregressionandlossofskills,andtoensurereasonablesafety,security,andfreedomfromundueuseofrestraint.

2013.Currently,basedondocumentationprovidedandverbalreport,threestaffweretakingsummerclassesand,ofthethreethatwithdrewthispastSpring,twowereregisteredforFallcoursework.Consequently,accordingtodocumentation,therewereonlytwopsychologistswhohadnotyetcompletedatleastonerequiredcourse,orwerenotyetregisteredforcurrentorupcomingcoursework.VerbalreportsfromtheDirectorofBehavioralServicesindicatedthataremediationplanwasputinplaceforoneofthesestaffthatincludedadditionalresponsibilitiesinlieuofcompletingexpectedcoursework.AttheMonitoringTeam’slastreview,itappearedthatsixoftheeligiblepsychologistshadstartedtoreceivethepre‐requisiteclinicalsupervisionnecessaryforcertification.Currently,itappearedthat11hadatleaststartedreceivingsupervision(i.e.,twostaffwithdrewfromclassesandstoppedsupervision).Noneofthecurrentbehavioralservicesstaffhavecompletedsupervision.VerbalreportsanddocumentationindicatedthatthesametwocontractedBCBAconsultantscontinuedtoprovidesupervision.TheDirectorofBehavioralServicesandcontractedsupervisorsshouldcontinuetoensureadequateadherencetotheBehaviorAnalystCertificationBoardsupervisionguidelinesandpolicies,includingthecompletionofsupervisorysignatureforms.Currentverbalreportsindicatedthattuitionsupportaswellastheavailabilityofeducationalleave(i.e.,uptofourhoursaweek)continuedtobehighlyvalued.However,staffcontinuedtovoiceseriousconcernaboutthedifficultyinaccessingandutilizingtheeducationleavehoursallocatedeachweek.Inaddition,staffvoiceddifficultyinreliablyaccessingcoursecontent.Accordingtoverbalreports,thisledtoimpairedperformancewiththecourses,and,insomecases,withdrawalfromcoursework.Thesechallengesappearedtorequireadditionaladministrativesupportandimmediateamelioration.ThisprovisioncontinuestoberatedasbeinginnoncompliancebecausetheprofessionalsintheBehavioralServicesDepartmentwerenotyetdemonstrablycompetentinappliedbehavioranalysisasevidencedbytheabsenceofprofessionalcertification,aswellasbythequalityoftheprogrammingobservedattheFacility.Currently,onlyonememberofthe14BehavioralServicestaffwasaBCBA.IssuesrelatedtothequalityofbehavioralprogrammingarediscussedinfurtherdetailbelowwithregardtoSectionK.9oftheSettlementAgreement.

K2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationinoneyear,eachFacilityshallmaintainaqualifieddirectorofpsychologywhoisresponsibleformaintainingaconsistentlevelofpsychological

JudySutton,MA,LPC,BCBAwashiredastheDirectorofBehavioralServices,andstartedwithinhercurrentcapacityon8/15/11.Ms.SuttonhadaMaster’sdegreeinPsychology,wasaLicensedProfessionalCounselorinTexas,andhadbeenaBoardCertifiedBehaviorAnalystsince2009.Shehadextensiveexperiencesupportingindividualswithintellectual,mental,andphysicaldisabilities,andhadworkedinthehumanservicesfieldsince1994.



# Provision AssessmentofStatus CompliancecarethroughouttheFacility. Currentverbalreportscontinuedtoreflectsupportandconfidenceintherelativelynew

DirectorofBehavioralServicesinestablishingandmaintainingaconsistentlevelofpsychologicalcarethroughouttheFacility.BasedonthecurrentpositivereportsfromexecutiveleadershipandBehavioralServicesstaffmembers,aswellasonthecontinuedprogressnotedintheprovisionofpsychologicalservicesobservedsincethelastvisit,theFacilitycontinuedtobefoundinsubstantialcompliancewiththisprovision.

K3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationinoneyear,eachFacilityshallestablishapeer‐basedsystemtoreviewthequalityofPBSPs.

SincetheMonitoringTeam’slastvisit,someprogresswasnotedintheareaofinternalandexternalpeerreviewwithinPsychologicalandBehavioralServices.Aspreviouslydescribed,peerreviewofpsychologicalserviceswasprovidedthroughtheBehaviorSupportCommittee.Thiscommitteewasscheduledtomeettwiceaweek,andpreviousreviewsnotedthatthecommitteemetfor61%,100%,and77%ofthetimeforthetimeperiodsofJunetoDecember2010,JanuarytoMay2011,andJulytoNovember2011,respectively.BasedonrecentBSCmeetingminutes,dated12/1/11to6/29/12,itappearedthattheBSCmetapproximately41(89%)outof46potentialscheduledmeetings.Thispercentageshouldbeconsidered“approximate,”becauseitwasdifficultfortheMonitoringTeamtoaccuratelydeterminetheexpectednumberofBSCmeetings.Morespecifically,itappearedthat:1)thecommitteechangedfromtwiceaweektoonceaweeksometimeinMarch2012;2)apparentlyseveralextrameetingswereheld(e.g.,3/9/12and5/15/12);3)meetingminutesweremissing(for2/23/12);4)severalmeetingswereheldwithonlytwoorthreeprofessionals(i.e.,on3/9/12and3/13/12)and5)severalminutesnoted“paperreviewdone”(i.e.,on1/19/12and1/31/12).However,thisestimatewasconsistentwiththatreportedwithinSectionK.3oftheFacility’sSelf‐Assessment.Aspreviouslyreported,CCSSLCpolicyrecommendedthattheBSChaveadiversemembership.AconsistentfindingovertheMonitoringTeam’slastfewreports,however,wasanoteddeclineinthediversityofmembership.Thisincludeddecreasingrepresentationfrompsychiatry,nursing,habilitationtherapies,andadministration.Previousimprovement,however,wasnotedintheattendanceofthecontractedBCBAs,community‐basedcounselors,aswellaspsychologyassistants.Currently,thedecliningtrendnotedwithinpsychiatry,nursing,habilitationtherapies,andadministrationcontinuedtobeobserved(lessthan11%)inmeetingattendancebetweenDecemberandJune2012.ComparativelyhigherattendanceratescontinuedtobeobservedforcontractedBCBAs(48%),community‐basedcounselors(28%),andpsychologyassistants(65%).Lastly,theattendanceoftheDirectorofBehavioralServicesimprovedfromapproximately43%to70%ofthetime.TheseestimateswereconsistentwiththosereportedwithinSectionK.3oftheFacility’sSelf‐Assessment.AsfoundinMonitoringTeam’spreviousreports,thelackofadequateattendanceofthose

Noncompliance


# Provision AssessmentofStatus Compliancewhosupervisetheimplementationofbehavioralprogramming(e.g.,ResidenceCoordinators,UnitDirectors,orotheradministrativestaff)continuedtobeconcerning.Aspresentedinpreviousreports,itisimportanttoinvolvethosewhohavedirectadministrativesupervisoryauthorityovertheimplementationoftheplans,aswellasanyonewhowasdirectlyinvolvedintheplans’designand/ortrainingattheBSCmeeting.Aspreviouslyrecommended,theFacilityshouldidentifythosekeystakeholderswhoseattendanceisbelievedtobebeneficialfortheadequatereviewofPBSPs,aswellasthosewhoensuretheirproperimplementationandmonitoring.ItappearedthattheFacilitywasresponsivetotheaboveconcernbyrecentlychangingthescheduleofBSCmeetingsfromtwiceaweektoonceaweek.ThischangeoccurredinMarch,andwasbasedontheideathatreducingthenumberofmeetingsmightimproveattendance.Currentdocumentationappearedtosupportthisideaastheattendanceofadministrativeandsupervisorystaffimprovedslightlyfollowingthischange.Itwillremaintobedeterminedifthisimprovementwillcontinueandmaintainovertime.However,reducingthenumberofBSCmeetingsislikelytodiminishcapacityofBSC.Thatis,theBSCreviewedasubstantialnumberofdocuments(e.g.,psychologicalevaluations,SFBAs,PBSPs,and/orSPCIs),andalsomonitoredreferrals,delinquentreports,monthlyprogressnotes,andcounselingnotes.Reducingthenumberofmeetingsby50%mightnegativelyimpactthisreviewprocess.VerbalreportsfromtheDirectorofBehavioralServicesindicatedthatincreasedself‐monitoringbyauthors(usingstructuredrubrics),aswellaspriorreviewbymoreseniorAssociatePsychologistswasexpectedtofacilitatemoreefficientreviewsbythetimedocumentswerepresentedatBSC.Accordingtocurrentverbalreports,externalpeerreviewbeganinJanuary2012andcontinued,somewhatinconsistently,throughJuly2012.ThisreviewinitiallystartedwiththeinclusionofprofessionalsfromoneotherTexasStatefacility(i.e.,AbileneStateSupportedLivingCenter)andhadgrownovertimetoincludeotherFacilities(i.e.,AustinandLubbock).However,documentationevidencedinfrequentinteractionbetweentheseexternalreviewers.Thisincludedpermanentproductreview(evidencedbytwoemails)andonephone‐conferencemeeting(i.e.,meetingminutesdatedMay11,2012).Consequently,thestatusoftheexternalpeerreviewcontinuedtoappearinadequate.Lastly,oncetheongoingevolutionoftheinternalandexternalpeerreviewprocessisestablished,theFacilitywillneedtoensurethatcurrentproceduresarereflectedinpolicy.TheFacilitycontinuedtobeinnoncompliancewiththisprovision,becauseoftheinadequateattendanceofprofessionalsdemonstrablycompetentinappliedbehavioranalysis,theabsenceofprofessionalsexternaltoCCSSLCcurrentlyparticipatingin


# Provision AssessmentofStatus Complianceexternalpeerreviewregularly,andthelackofguidelinesregardinginternalandexternalpeerreviewincurrentpolicies.

K4 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationinthreeyears,eachFacilityshalldevelopandimplementstandardproceduresfordatacollection,includingmethodstomonitorandreviewtheprogressofeachindividualinmeetingthegoalsoftheindividual’sPBSP.DatacollectedpursuanttotheseproceduresshallbereviewedatleastmonthlybyprofessionalsdescribedinSectionK.1toassessprogress.TheFacilityshallensurethatoutcomesofPBSPsarefrequentlymonitoredandthatassessmentsandinterventionsarere‐evaluatedandrevisedpromptlyiftargetbehaviorsdonotimproveorhavesubstantiallychanged.

Sincethelastreview,progresscontinuedtobeevidentintheareaofdatacollection.ThisincludedmethodstoregularlymonitorandreviewtheprogressofindividualsmeetingthegoalsoftheirPBSPs,aswellasotherpsychologicalsupports(e.g.,desensitization,counseling,etc.).Althoughmethodsofreviewshowedprogress,concernsremainedabouttheadequacyofdatacollectionoverall.Inanattempttoexaminethenatureofdatacollection,asampleof10PBSPswasselectedfromindividualswithPBSPsandISPsheldwithinthelastsixmonths.Inaddition,individualswereselectedtoensureadequatesamplingacrossresidentialprograms.Thatis,onlyoneindividualfromaresidencewasselected.However,notallresidenceswererepresented.ThissamplereflectedapproximatelyeightpercentofthetotalPBSPscurrentlyinplace(basedonthelisting“CCSSLCPositiveBehaviorSupportPlans,”undated).InadditiontothePBSPs,PBSPmonthlynotesfromApril,MayandJune2012alsowerereviewed.Ofthissample,10(100%)PBSPsidentifiedandoperationallydefinedoneormoretargetbehaviors.Onlyone(10%)ofthePBSPs(i.e.,Individual#7),however,identifiedandoperationallydefinedreplacementbehaviors.Althoughtargetbehaviorsweretypicallyconspicuouslyidentifiedanddefined,measurableobjectiveswererarelydetailedinthePBSPs.Morespecifically,measureableobjectivesfortargetbehaviorswereonlyfoundintwo(20%)ofthePBSPsreviewed(i.e.,Individual#7andIndividual#225).Theoppositeappearedtobetrueforreplacementbehaviors.Thatis,althoughbehavioralobjectiveswerefoundforreplacementbehaviorsinallthePBSPsreviewed,replacementbehaviorswererarelyoperationallydefined.ThisinadequacywasconsistentwithfindingspresentedintheMonitoringTeam’spreviousreportsandisfurtherdiscussedwithinthecurrentreportwithregardtoSectionK.9.Datawasdisplayedinnine(90%)ofthePBSPsreviewedusingtabularformat,graphicformat,orboth.Graphingwasusedinthemajorityofplans(80%)andallofthesegraphsincludedoneormoretargetbehaviors.However,replacementbehaviorswereonlygraphedinfour(50%)oftheseplans.Ingeneral,itappearedthatgraphicdisplaywasmorepredominatecomparedtopreviousreviews,becausetargetandreplacementbehaviors,whendisplayed,weretypicallygraphed.However,asdiscussedingreaterdetailwithregardtoSectionK.10oftheSettlementAgreement,displayeddatawasoftendifficulttointerpret,orthedatadisplaydidnotofferanymeaningfulinformation.ItshouldbenotedthattheformatofthePBSPhadchangedsincetheMonitoringTeam’spreviousreview.Indeed,theformatofPBSPshadchangedfrequentlyoverthecourseof

Noncompliance


# Provision AssessmentofStatus CompliancetheMonitoringTeam’sreviewsasevidencedbythethreedifferentformatsfoundwithinthecurrentsample.Thischange(asdescribedingreaterdetailwithregardtoSectionK.9oftheSettlementAgreement)includedthediscontinuationofdatadisplaywithinPBSPs.Thatis,themostrecentPBSPformat(i.e.,usedforIndividual#7inthecurrentsample)didnotincludeanydisplayeddata.ThischangewasacceptabletotheMonitoringTeamaslongasallofthenecessarydatawasavailablewithincurrentmonthlyPBSPprogressnotesandthatsuchdatawaseffectivelyintegratedandutilizedtosupportdata‐baseddecisionswithregardtobehavioralprogramming.AsconsistentwithfindingswithintheMonitoringTeam’spreviousreports,objectivecriteriafortherevisionordiscontinuationofPBSPswaslackinginmostoftheplansreviewed.Morespecifically,objectivecriteriafordiscontinuationwerefoundinonlyone(10%)oftheplansreviewed(i.e.,Individual#167);andobjectivecriteriaforrevisionwerenotfoundinany(0%)oftheplansreviewed.Relatedly,none(0%)oftherationalesfoundwithinthesampledPBSPsindicatedthattheplanswerere‐evaluatedand/orrevisedduetothelackofprogressorchangesinmaladaptivebehaviorasevidencedbycollecteddata(i.e.,reflectingdata‐baseddecisionmaking).Mostoftheplanscontinuedtoofferageneralstatementregardingtheneedtoaddressormanagetargetbehaviors,orincludedarationaledescribingtherevisionofthePBSPasconcurrentwiththeISP.Consequently,itwasnotevidentfromsampledPBSPsthatanyhadbeenrevisedduetoitsineffectivenessorchangeintheindividual’sfunctioningorhis/herchallengingbehavior.ProgresscontinuedtobeevidentwithregardtotheMonthlyPBSPProgressNote.Aspreviouslyreported,themonthlynoteallowedongoingevaluationofprogressrelativetoidentifiedbehavioralobjectiveslistedinthePBSP,SPCI,counselingtreatmentplans,anddesensitizationplans,ifapplicable.Inaddition,dataontargetandreplacementbehaviors,restraints,and/ormedicationswasdisplayedingraphicform,andpsychologistssummarizedprogressandprovidedrecommendations.Althoughthequalityofthegraphscontinuedtoreflectimprovement,concernsremainedregardinggraphing(thisisdiscussedindetailwithregardtoSectionK.10oftheSettlementAgreement).Currently,10(100%)oftheindividualssampledhadmonthlynotescompleted(usingthenewformat)fortherequestedtimesampleofApril,May,andJune2012.AlthoughprogresswasevidentintheuseofthePBSPmonthlynote,severalconcernswerenoted,including:

Althoughtargetbehaviorsweregraphedin100%ofthemonthlynotes,many(50%)includeddataon“severity”whichwasnotdefinedinanyplans(e.g.,Individual#167,andIndividual#263);

CorrespondencebetweentargetbehaviorsidentifiedanddefinedinPBSPs


# Provision AssessmentofStatus Compliancematchedthosegraphedinthemonthlynotesineightofthe10(80%).ThetwoforwhichthisdidnotoccurwereIndividual#218,andIndividual#7;

CorrespondencebetweenreplacementbehaviorsidentifiedanddefinedinPBSPsmatchedthosegraphedinsevenofthemonthlynotes(70%).ThethreeforwhichthiswasnotthecasewereIndividual#167,Individual#263,andIndividual#225;

Behavioralobjectivesfortargetbehavior,albeitofteninadequate,werefoundinall(100%)sampledmonthlynotes.ThebehavioralobjectivesfortargetbehaviorsidentifiedinmonthlynoteswereconsistentwithPBSPsofsevenindividuals(70%)andwereinconsistentwithPBSPsofthreeindividuals(i.e.,Individual#167,Individual#218,andIndividual#226);

Behavioralobjectivesforreplacementbehaviorswerefoundinall(100%)sampledmonthlynotes.ThebehavioralobjectivesforreplacementbehavioridentifiedinmonthlynoteswereconsistentwithPBSPsoffiveindividuals(50%)andwereinconsistentwithPBSPsoffiveindividuals(i.e.,Individual#167,Individual#263,Individual#307,Individual#7,andIndividual#184);

Althoughbehavioralobjectivesforreplacementbehaviorswerefoundinall(100%)ofthenotessampled,severalobjectivesdidnotappeartobemeasurable(e.g.,Individual#353,andIndividual#72)orrealisticallyobtainable(e.g.,Individual#307);

Thegraphicdisplayofmedicationsoftendidnotappearhelpful,becausenochangesweredisplayedorbecauseitwouldbemorehelpfultooverlaymedicationchangesagainstchangesinbehavioralfunctioning(e.g.,Individual#255,Individual#184,andIndividual#335);

Reviewcommentsshouldbemoredescriptive,robust,andaddrelevantinformationbeyondsimplydescribingthedatainagraph.Inaddition,commentsshouldaccuratelyreflectthedata.Forexample,iftrendsoftargetbehaviorsareincreasingandtrendsofreplacementbehaviorsaredecreasing,thedescription“…continuestodowellbehaviorally…”appearsinaccurateandnothelpful(i.e.,June2012monthlynoteforIndividual#226);and,

Indicatingthat:“…suitabledataisnotavailable,”butstillincludingagraphicdisplayofdata(i.e.,Individual#167)calledintoquestionthevalidityofthereport.

AsampleofthreeindividualswithSafetyPlansforCrisisIntervention(SPCIs)andISPsheldwithinthelastsixmonthswasidentified.Thissamplereflectedapproximately20%ofthetotalSPCIscurrentlyinplace(basedonalistingofindividualswithSPCIs,dated6/4/12).Ofthosesampled,two(67%)hadSPCIsthatwereupdatedwithinthepastyear(i.e.,theSPCIforIndividual#46,dated6/20/11,wasoutdated).Grapheddatarelatedtorestraintwasfoundin100%oftheSPCIssampled.However,thedataacrossgraphsvaried.Thatis,two(67%)includeddataonnumberofrestraints,injuries,andaverage


# Provision AssessmentofStatus Compliancedurationofrestraint(i.e.,Individual#20andIndividual#300).However,onegraphonlyincludeddataonthenumberofrestraints(i.e.,Individual#46).And,although100%oftheSPCIsincludedoneormoreobjectives,asisdiscussedinmoredetailbelow,theseobjectiveswereonlyconsistentwiththemonthlynotesforone(33%)oftheindividualssampled.InadditiontotheSPCIs,PBSPmonthlynotesfromApril,May,andJune2012alsowerereviewedforthethreeindividualssampled.Ofthese,100%haddatarelatedtorestraintineachofthemonthlynotesreviewed.However,thereweresomeconcernsnoted,including:

TheobjectiveslistedintheSPCIsdidnotmatchthoselistedinthePBSPmonthlyprogressnotesforsomeoftheindividualssampled(i.e.,Individual#20andIndividual#300);

TheSPCIswereinconsistentinthevariablestrackedanddatadisplayed.Thatis,someplanstrackednumber,durationandinjuriesofrestraint(i.e.,Individual#20andIndividual300),whileothersdidnottrackinjuries(i.e.,Individual#46).

TheSPCIswereinconsistentinthenumberofobjectiveslisted.Thatis,someplansprovidedobjectivesfornumberofrestraints(i.e.,Individual#20),whileothersidentifiedmultipleobjectivesrelatedtorestraint(i.e.,Individual#46).Indeed,thePBSPsprogressnotesforoneindividualdidnotlistanyobjectivesrelatedtorestraint(i.e.,Individual#300).

Theamountofdataincludedinthegraph(i.e.,sevenbehaviorsaswellasrestraintdata)intheSPCIforIndividual#46impairedtheeffectiveinterpretationoftheinformation.Inaddition,theSPCIidentifiedanobjectivetargetingrestraintduration,butthisdatawasnotprovidedordisplayedinthegraph.

ThegraphsrelatedtorestraintincludedinthePBSPprogressnotesforIndividual#46shouldmodifytheYaxistoincludeonlyrealnumbers(“‐1”ismeaningless)and“timeinrestraint”shouldidentifyaspecificamount(secondsorminutes)time,andwhetherornotitisthetotaloraverageduration.

TheFacilityshoulddeterminehowtodisplayrestraintdurationsoflessthanoneminute.Forexample,theMay2012PBSPprogressnoteforIndividual#46didnotincludetherestraintdurationinthedatadisplayorgraph.Basedonthetext,therestraintdurationwas“…lessthanaminute.”Itwascurrentlyunclearwhythisdatacouldnothavebeenincludedinthedatadisplay.Ifthispracticereflectedalargertrend,meaningfuldatamightbemissingfromdocumentation.

Descriptionsusedtoexplaintherestraintdataappearedtobecutandpastedbetweenmonthlynotes(i.e.,MayandJune2012forIndividual#300).

Overall,thevariablestrackedtypicallyincludedthenumberofrestraintsandinformationontime.However,morespecificationwouldbehelpfulregardingtheamountoftime(i.e.,secondsorminutes).Inaddition,somedatadisplays


# Provision AssessmentofStatus Complianceincludeddataon“injury”and“emergencymeds,”butthiswasinconsistentlyfoundacrossthereviewedSPCIs.

ReviewofthesampledPBSPmonthlynotesalsoevidencedthecollectionofinter‐observeragreement(IOA)data.Morespecifically,IOAestimateswerereportedinthemonthlynotesofsix(60%)oftheindividualssampled.Reportedestimateswereall100%.Althoughthiswasapromisingfinding,thedataandinformationprovidedaswellasthemethodologyutilizedappearedinadequate.ThesefindingsarediscussedingreaterdetailwithregardtoSectionK.10oftheSettlementAgreement.Lastly,methodologyaswellasproceduresinvolvedindatacollection,datadisplay,andreviewhadchangedovertimeandwillultimatelyneedtobeincludedinthecurrentpolicy.Indeed,documentationprovidedandverbalreportscontinuedtoevidencetheevolutionofdatacollectiontechniques,includingtherecentutilizationofrevisedantecedent‐behavior‐consequence(ABC)datasheets,aswellastimesamplingprocedureswithselectindividuals.Asrecommendedinthepast,behavioralservicesstaffshouldcontinuetoevaluatewhichdatacollectionsystemsprovidethemostrelevantandaccuratedatagiventheindividualandresponsestargeted.Ultimately,theFacilityshouldconsiderreviewingandrevisingpoliciesregardingdatacollectionandmonitoring.Overall,thePBSPmonthlynotedemonstratedcontinuedpromiseasaneffectivemethodofdisplayingandreviewingperformance.TheFacility,however,continuedtoberatedinnoncompliancewiththisprovision,becauseofthelackofadequatereliabilityestimatesontrackedbehavior,aswellascontinuedlimitationswithdatacollectionasdescribedabove.

K5 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationin18months,eachFacilityshalldevelopandimplementstandardpsychologicalassessmentproceduresthatallowfortheidentificationofmedical,psychiatric,environmental,orotherreasonsfortargetbehaviors,andofotherpsychologicalneedsthatmayrequireintervention.

Progresswasobservedinthecompletionofstandardizedtestsofintelligence. Inaddition,theuseofanewformat,the‘ComprehensivePsychologicalEvaluation’,wasdevelopedandinitiatedinanefforttointegratethetraditionalpsychologicalassessmentandthestructuralfunctionalbehavioralassessment.AspresentedwithregardtoSectionK.6oftheSettlementAgreement,ofthe22sampledpsychologicalassessmentsreviewed,20(91%)wereupdatedwithinthelast12months.Inaddition,psychologicalevaluationsindicatedthat13(59%)ofthesampledindividualshadanICAPevaluationcompletedwithinthelastthreeyears.However,availablerawdataindicatedthatthenumberofICAPscompletedinthelastthreemonthsforthosesampledwaslikelycloserto17(77%).Inaddition,only16(73%)ofthepsychologicalassessmentswerecompletedpriortotheISPmeeting.Closerexaminationrevealedthat22(100%)containedresultsofpreviouslycompletedstandardizedtestsofintelligence,and16(73%)ofthesewerecompletedwithinthepastfiveyears,with15(68%)ofthese

Noncompliance


# Provision AssessmentofStatus Complianceconductedwithinthepastyear.Testsofadaptivefunction(e.g.,VinelandAdaptiveBehaviorScales)werereportedin20(91%)ofthecurrentpsychologicalassessments,andseven(32%)ofthesetestswerecompletedwithinthepastfiveyears,includingsix(27%)conductedwithinthepastyear.Consequently,evidencesuggestedthatscalesofadaptivebehaviorwerenotbeingupdatedasregularlyasstandardizedtestsofintelligence.Indeed,therewasasubstantialimprovementinthenumberofintellectualassessmentcompletedoverthepastyeartoensurethesewereupdatedatleasteveryfiveyears.AsobservedduringtheMonitoringTeam’spreviousreviews,inadditiontothepsychologicalassessmentdiscussedabove,screeningforpsychopathology,emotional,andbehavioralissuescontinuedtobecompletedeitherthroughthepsychiatricclinic’scompletionofapsychiatricassessment,orthroughtheutilizationoftheReissScreenforMaladaptiveBehaviortoscreenfortheneedofapsychiatricassessment.TheReissscreeningscontinuedtobeutilizedonanannualbasistoexamineindividualswhowerenotreceivingpsychiatricservices.TheFacility’scompliancewiththeimplementationoftheReissscreeningprocessisdiscussedabovewithregardtoSectionJ.7oftheSettlementAgreement.AsdescribedbelowwithregardtoSectionK.6oftheSettlementAgreement,sincetheMonitoringTeam’slastreview,anew“comprehensivepsychologicalevaluation”formathadbeendevelopedandimplemented.AccordingtodocumentationprovidedsincetheMonitoringTeam’slastreview,13evaluationsappearedtohavebeencompletedusingthisnewformat.Todeterminethequalityofcurrentfunctionalassessments,comprehensivepsychologicalevaluationsdevelopedusingthenewformatforthreeindividualswereexamined(i.e.,Individual#7,Individual#186,andIndividual#368).Giventhatdocumentationindicatedthat13oftheseevaluationshadbeencompletedsincethelastreview,thissamplereflectedapproximately23%ofthetotalnumberofnewlyformattedcomprehensivepsychologicalevaluations.Itshouldbenotedthatthisfigure(i.e.,13evaluationscompletedsincetheMonitoringTeam’slastvisit)mightnotbeaccurate,becausetheMonitoringTeamreceivedthreedifferentsummarydocumentswithdifferentindividualsanddifferenttotalsofcompletedcomprehensivepsychologicalevaluationslisted.Unfortunately,noneofthesesummarydocumentsweredated.TheMonitoringTeamalsoreceivedatleastfouradditionalcomprehensivepsychologicalevaluations(i.e.,Individual#226,Individual#254,Individual#61,andIndividual#63)thatwerenotlistedwithinanyofthesummarydocumentation.TheMonitoringTeamwasconcernedaboutthisinconsistencyandconsiderabledisorganizationand,consequently,questionedtheaccuracyofthedataprovidedforreview.Theimportanceofthisissue,aswellasimplicationsonthecurrentreviewarediscussedingreaterdetailbelowwithregardtoSectionK.7andwithinthe


# Provision AssessmentofStatus ComplianceRecommendationsSection.DocumentationalsoappearedtoindicatethatrevisedPBSPweredevelopedandimplementedpriortothecompletionofcomprehensivepsychologicalevaluations.Thatis,thedevelopmentofrevisedPBSP(usingthenewformat)appearedtohaveoccurredpriortocompletionoftheSFBAorcomprehensivepsychologicalevaluationforatleastthreeindividuals(Individual#7,Individual363,andIndividual#117).Althoughtheremaybeanadequaterationaleforthisapproach,itappearedtotheMonitortobeillogicalandpotentiallycountertherapeutic(moredetailsarepresentedbelowwithregardtoSectionK.9oftheSettlementAgreement).Theselectedsampleofthreerecentlycompletedcomprehensivepsychologicalevaluationswasreviewed.Basedonthecurrentreview,theevaluationswereverycomprehensiveandverydetailedandincludedinformationnecessaryforatypicalpsychologicalevaluationaswellasdatarequiredwithinafunctionalbehaviorassessment.Inaddition,therelevantpsychosocialinformationwasveryinformativeandhelpfulinprovidingreaderswithdescriptionsofpreviouslifeeventsandotherfactorsthatlikelycouldfacilitateabetterunderstandingoftheindividualandtheircurrentstatus.Informationregardingstandardizedtesting(e.g.,intellectualandadaptivemeasures),medicalandpsychiatricconditions,communication,strengths,andpreferences,aswellasdataderivedfromcurrentandpreviousindirectanddirectassessmentsallprovidedinformationvaluabletoeffectiveprogramming.Overall,theseevaluationsappearedtobeasignificantimprovementoverpreviouslycompletedSFBAs.Howevertherewereafewconcernsnoted,including:

Thereasonforreferralappearedtoaboilerplateresponseandnotverymeaningfulacrossallthreeindividuals.Itishopedinthefuturethat,whenappropriate,therationalewouldbemoreindividualizedandspecifictothecurrentfunctioningofeachindividual

Sourcesofinformationwereverydetailedandlengthy,butdidnotappeartoincludemoredirectmethodsofassessment(e.g.,directobservation).

Informationrelatedtomedicalconditionsanddiagnoseswerefoundinallofthecurrentevaluations.However,therelationshipbetweencurrentmedicalconditions,includingpsychiatricdiagnoses,andanindividual’scurrentstatus(e.g.,emotionalorbehavioralresponding)wasnotalwaysevident.Indeed,manyindividualshadasubstantiallistofdiagnosesand,forsomeindividuals,manyofthesemightnothaveanyimplicationsontheircurrentfunctioning.TheevaluationforIndividual#368wasagoodexampleofdrawingimplicationsfrommedicaldiagnosisandprovidinghintsastohowconditionsmightinfluenceresponding.

Someinconsistencywasnotedacrossevaluations.Thatis,theplacementofthesectionon“currenthealthandphysiology”withinthedocumentwasnot


# Provision AssessmentofStatus Complianceconsistentwiththecurrentformat(i.e.,Individual7andIndividual#186).Thisminordifferencewaslikelyduetoformatrevisionsovertime.Althoughnotasignificantconcern,thisdifferencemightinhibitefficientpeerreviewoftheevaluation.

Duetotheoftencomprehensivereviewofpreviousandcurrentassessmentresults,itwasdifficultinsomecasestoidentifythedateinwhichspecificassessmentswerecompleted.Forexample,thedate(s)inwhichstandardizedintelligenceandadaptivetestswereconductedwasnotconspicuousintheevaluationofIndividual#7.

Althoughtherewasasectiononpreviousinterventionsandefficacyineachofthesampledevaluations,includingdata,descriptionsofbehavioralobjectives,andoverallsummaryofprogress,identificationofpreviousinterventionsandtheirrelatedeffectiveness(ornot)wasnotfoundintwoofthesampledevaluations(i.e.,Individual#186andIndividual#386).

Dataobtainedthroughinterviewsappearedratherinconsistentacrosssampledevaluations.Thatis,itdidnotappearthatastandardizedinterviewformatwasutilized.Ifso,itwasnotidentifiedinthesampledevaluations.

Thereappearedtobeconfusionregardingtheterms“direct”versus“indirect”assessment.Thatis,anumberofevaluationslistedratingscales[e.g.,MotivationAssessmentScale(MAS),FunctionalAnalysisScreeningTool(FAST),QuestionsAboutBehavioralFunctioninMentalIllness]asadirectmethod.Theyarenot.Directobservationisadirectassessmentmethod.

Althoughtherewasasectiononadaptiveskillswithintheevaluation,theinclusionofinformationonadaptiveresponding(i.e.,currentreplacementbehaviorsorskillsneedtolearn)wasnotconspicuouslytargetedwithinotherareasofthereport.Forexample,itwasnotapparentthatstaffmemberswereinterviewedaboutcurrentormissingskillsanindividualwouldneedtodemonstratetoavoidchallengingbehavior.

Sectionsoftheevaluationsappearedtocontaintoomuchspecificityandtheevaluationsweretoolong.Forexample,theassessmentforIndividual#7detailedeverysinglerestraintthatoccurred.Thisinformationcouldeasilybesummarizedwithoutlosingmeaningfuldata,andwouldpotentiallyreducethelengthoftheassessment(currently32pages).

Areplacementbehaviorisjustlikeatargetbehavior.Itneedstobeobjectiveandmeasureable,andalsoneedstobedefined.Andyet,authorscontinuedtoview“replacementbehavior”assomesortofprocess(e.g.,descriptionofreplacementbehaviorinIndividual#368’sevaluation),ratherthanaresponsethatneedstobepromptedandreinforced.

Onceagain,althoughconcernswerenoted,thisformatappearedtoreflectsignificantimprovementoverearlierSFBAs.Theseintegratedassessmentsappearverypromising


# Provision AssessmentofStatus ComplianceandtheFacilityshouldcontinuetopursuetheircompletion.However,abalancebetweentheamountanddetailofinformationprovidedandtheusefulnessofthatdatawillneedtobedetermined.Currently,itappearedthattheassessmentsweretoolongandshouldbemoreconcise.Arubricalsowasdevelopedtofacilitatereviewbypsychologistsaswellaspeerreviewerstoensurethatcomprehensivepsychologicalassessmentswerecompletedasprescribed.Thisself‐monitoringandpeerreviewtoolincluded41itemsandwasscoredusinga0‐2Likertscale.Documentationprovidedevidencedtheuseofthisrubrictomonitorandensuretheaccuratecompletionoftheevaluations.Insummary,asignificantimprovementinsampledcomprehensivepsychologicalassessmentswasobserved.Althoughthisimprovementwasnotable,themajorityofpsychologicalassessments(includingcurrentSFBAs)hadnotbeencompletedwithinthecurrentformat.Concernsregardingthepreviousformat(s)ofSFBSsareprovidedinpreviousreports.Asaresult,theFacilityremainedoutofcompliancewiththisprovisionoftheSettlementAgreement.

K6 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationinoneyear,eachFacilityshallensurethatpsychologicalassessmentsarebasedoncurrent,accurate,andcompleteclinicalandbehavioraldata.

Progresscontinuedtobemadeintheareaofpsychologicalassessments.AsdescribedintheMonitoringTeam’spreviousreports,theexpectationthateachindividualresidingatCCSSLChaveacurrentpsychologicalevaluationhadremainedunchanged.Thisrequiredthatapsychologicalassessmentbecompleted,updated,and/orreviewedatleastannuallyforeachindividualserved.ThisexpectationincludedreviewingresultsfromtheInventoryforClientandAgencyPlanningevaluationonanannualbasis,withtherequirementofconductingare‐evaluationusingtheICAPatleastonceeverythreeyears,orsooner,ifsignificanteventsappearedtoimpactadaptivefunctioning.Todeterminewhetherornotpsychologicalassessmentswerebasedoncurrent,accurate,andcompleteclinicalandbehavioraldata,psychologicalassessmentsandICAPdocumentationfromasampleof22individualswasexamined.ThissamplewasprimarilyselectedfromthoseindividualsthathadhadanISPmeetingoverthepastsixmonths,althoughtherewereafewexceptions.Giventhecurrentcensusof259individualsatthetimeofthecurrentvisit,thissamplereflectedapproximatelyeightpercentofthetotalnumberofpsychologicalassessments.Alternatively,documentationprovidedreportedthat61psychologicalevaluationshadbeencompletedsincetheMonitoringTeam’slastvisit.Since15oftheindividualssampledhadpsychologicalassessmentsupdatedwithinthelastsixmonths,thecurrentsamplemorecloselyreflectedapproximately25%ofthosecompletedsincetheMonitoringTeam’slastreview.

Noncompliance



AspresentedwithregardtoSectionK.5oftheSettlementAgreement,ofthesampledpsychologicalassessmentsreviewed,20(91%)wereupdatedwithinthelast12months.Morespecifically,psychologicalevaluationscompletedwithinthelastyearwerenotevidentforIndividual#353(dated6/30/11)andIndividual#225(documentdated3/12/12wasincomplete).Examinationofoveralldelinquencyratesofpsychologicalevaluationswasnotcompletedduetothefactthat,ascurrentlyreportedbytheDirectorofBehavioralServices,thepreviouslydevelopedBehavioralServicesdatabasecontainedinaccurateandlikelyfalsifieddata.Informationinthepsychologicalevaluationindicatedthat13(59%)ofthesampledindividualshadanICAPevaluationcompletedwithinthelastthreeyears.Thatis,datesprovidedinthepsychologicalevaluationssuggestedthat,atthetimeoftheMonitoringTeam’svisit,nineindividualshadoutdatedICAPevaluations.However,documentationprovidedforfouroftheseindividualsrevealedarecentlycompletedICAPthatwasnotdescribedinthecurrentpsychologicalevaluation(i.e.,Individual#38,Individual#263,Individual#167,andIndividual#153).Consequently,therewasevidenceofcurrentICAPevaluationsfor17(77%)ofthoseindividualssampled.ThisfindingwasconsistentwithfindingsfromseveraloftheMonitoringTeam’spreviousvisits.ItremaineduncleartotheMonitoringTeamwhytheseICAPevaluationswerenotcompletedandincludedinthepsychologicalevaluationupdates.Oneguesswouldbethattheseevaluationsarecompletedprimarilyasafundingrequirementandnottoinformprogramming.Inaddition,italsoremainedunclearwhypsychologicalassessmentswerecompletedaftertheISPmeeting.Thatis,only16(73%)ofthepsychologicalassessmentswerecompletedpriortotheISPmeeting.Asaresult,data,ortheassessment,wasnotavailabletoinformtheISPforsixindividuals(i.e.,Individual#186,Individual#218,Individual#167,Individual#225,Individual#307,andIndividual#368).Ofthepsychologicalassessmentsreviewed,22(100%)containedresultsofpreviouslycompletedstandardizedtestsofintelligence.TheseassessmentsgenerallyincludedtheuseoftheWechsler,Slosson,Toni,and/orPeabodytests.Overall,16(73%)oftheseintelligencetestswerecompletedwithinthepastfiveyears.Moreimportantly,fifteen(68%)oftheseintelligencetestswereconductedwithinthepastyear.However,three(14%)ofthesetestswerecompletedovertenyearsago(i.e.,Individual#218,Individual#153,andIndividual#353),andthedatesofcompletionofintelligencetestswerenotconspicuousfortwooftheindividualssampled(i.e.,Individual#225andIndividual#275).Themuch‐improvedprogressinupdatingstandardizedtestsofintelligencewasevidentinthecurrentsample.However,theFacilityshouldensurethatonlyqualifiedindividualsarefacilitatingtheseevaluations.Thatis,itappearedthataPsychologyAssistantcompletedatleastoneoftheevaluationslisted(i.e.,Individual#307).Itwascurrentlyunknownifthisindividualhadthecompetencytoconductthestandardized


# Provision AssessmentofStatus Complianceassessment.Testsofadaptivefunction(e.g.,VinelandAdaptiveBehaviorScales)werereportedin20(91%)ofthecurrentpsychologicalassessments.Morespecifically,scoresfromadaptivebehaviorscaleswerenotfoundintwopsychologicalevaluations(i.e.,Individual#186andIndividual#218).Overall,seven(32%)ofthesetestsofadaptivebehaviorwerecompletedwithinthepastfiveyears,includingsixofthesescales(27%)wereconductedwithinthepastyear.However,nine(41%)ofthesetestswerecompletedovertenyearsago,andthedateofcompletionforadaptivescaleswasnotconspicuousforoneoftheindividualssampled(Individual#7).DocumentationreviewedattheMonitoringTeam’spreviousvisitindicatedthattheFacilityhadprovidedtrainingonthecompletionoftheVinelandAdaptiveBehaviorScales,and,atthattime,theexpectationwasthattheVinelandwouldbeusedinsubsequentpsychologicalevaluations.Reviewofsampledpsychologicalevaluationsthatevidencedcompletionofstandardizedintelligencetestswithinthelastsixmonthssuggestedthatthistrainingwasonlyminimallyeffective,becauseadaptivescalesofbehavior(e.g.,Vineland)wereonlyupdatedinfourofthe12cases(33%)wherestandardizedtestsofintelligencewereadministered.Evidencesuggestedthatscalesofadaptivebehaviorwerenotbeingupdatedasregularlyasstandardizedtestsofintelligence.Indeed,therewasasubstantialimprovementinthenumberofintellectualassessmentcompletedoverthepastyear,butthiswasnotsimilarlyobservedwithregardtoscalesofadaptivebehavior.Overall,reviewofthesampledpsychologicalevaluationsreflectedcontinuedinconsistencyinthetemplateusedfortheevaluation.Morespecifically,itappearedthatapproximatelythree(14%),five(23%),andfive(23%)ofthepsychologicalevaluationsutilizedthe12/15/10,5/30/11,or6/1/11template,respectively.Thetemplateusedinthree(14%)ofthepsychologicalevaluationscouldnotbedetermined.Thiscontinueddiversityappearedtoaffecttheconsistencyinwhichimportantcontentwasincludedwithinpsychologicalevaluations.Forexample,theinclusionandqualityofbehavioraldatainpsychologicalevaluationswasinconsistentlyfoundacrosssampledplans.Inconsistencyintheprovisionofdataincludedtheomissionofalldata(e.g.,Individual#307),theinclusionofonlytargetbehaviordata(e.g.,Individual#38,Individual#184,andIndividual#167),orappropriately,theinclusionofdataontargetandreplacementbehaviorsaswellasmedicationdosages(e.g.,Individual#218andIndividual#226).Inaddition,thedisplayformatcontinuedtoreflecttheuseoftables(e.g.,Individual#275andIndividual#20),and,inonecase,thecontinueduseofbargraphs(Individual#153).ThediversityofformatswillhopefullydiminishovertimeasaqualitativelynewformathadbeenimplementedsincetheMonitoringTeam’slastvisit.Thisnewformatwasutilizedinsix(27%)ofthecurrentlyreviewedpsychologicalevaluationsandappearedtointegratethepsychologicalevaluationandtheSFBAintoasinglereport.Overall,thesemorecomprehensivereportsappearedofhigherqualitythattheotherevaluations


# Provision AssessmentofStatus Compliancereviewed.ThefindingsandimplicationsassociatedwiththeuseofthismostrecentlyrevisedformatisdiscussedwithregardtoSectionK.5.Duetotheongoingissuesrelatedtotheinadequacyofpsychologicalassessments,specificallyasubstantialnumberofevaluationswithoutdatedscoresfromstandardizedintellectualassessmentsandassessmentsofadaptivefunctioning,theFacilityremainedoutofcompliancewiththisprovisionoftheSettlementAgreement.

K7 WithineighteenmonthsoftheEffectiveDatehereoforonemonthfromtheindividual’sadmittancetoaFacility,whicheverdateislater,andthereafterasoftenasneeded,theFacilityshallcompletepsychologicalassessment(s)ofeachindividualresidingattheFacilitypursuanttotheFacility’sstandardpsychologicalassessmentprocedures.

Overall,someprogresswasnotedintheprovisionofpsychologicalassessmentsforallCCSSLCresidents.However,limitedprogresswasnotedinthetimelycompletionofpsychologicalassessmentsforindividualsnewlyadmittedtoCCSSLC.Todeterminewhetherornotpsychologicalassessmentswerecompleted,updatedorreviewedasoftenasneeded,documentationprovidedon22sampledindividualswasexamined.AspresentedwithregardtoSectionK.6oftheSettlementAgreement,ofthe22sampledpsychologicalassessmentsreviewed,20(91%)wereupdatedwithinthelast12months.However,aspreviouslypresented,anumberoftheseassessmentsweremissingupdatedintellectualoradaptivefunctioninginformation.Inaddition,whenthisinformationwascurrent,itoftendidnotappearavailabletoeffectivelyinformtheISPprocess.Examinationofoveralldelinquencyratesofpsychologicalevaluationswasnotcurrentlycompleted(asdoneintheMonitoringTeam’spreviousreports)duetothefactthat,asreportedbytheDirectorofBehavioralServices,theBehavioralServicesdatabasecontainedinaccurateandlikelyfalsifieddata.Thisissuewasveryserious,becausethedatabasewastheprimaryelectronicstoragemechanismfordatarelatedtotheprovisionofbehavioralservices,including,forexample,datesofcompletionaswellasapproval/consentsforassessmentsandbehavioralinterventions.AspresentedintheMonitoringTeam’spreviousreports,theBehavioralServicesDatabaseallowedstafftotrackimportantcompletion,approval,and/orimplementationdatesofPsychologicalEvaluations,StructuralFunctionalBehavioralAssessments,PositiveBehaviorSupportPlans,SafetyPlansforCrisisIntervention,andDesensitizationPlans.TheMonitoringTeam’spreviousreportnotedconcernswithincreasingdelinquencyratesforPsychologicalEvaluationsandPBSPs,aswellasasubstantialnumberSFBAsthatwerenotcompletedand/orupdatedonanannualbasis.Unfortunately,duetothecorruptionofthedatabase,delinquencyratescouldnotbeexaminedtodeterminewhetherornottheseconcernshadbeenameliorated.Indeed,theMonitoringTeam’sabilitytoexamineprogresstowardcompliancewiththeSettlementAgreementwaslimitedbytheinaccessibilityofaccuratedata.

Noncompliance


# Provision AssessmentofStatus ComplianceAccordingtodocumentationprovided,sincetheMonitoringTeam’spreviousreview,fivenewindividualswereadmittedtoCCSSLC,including:Individual#5,Individual#40,Individual#61,Individual#63,andIndividual#97.Ofthesefive,onlytwo(40%)appearedtohavehadpsychologicalassessmentsthatwerecompletedwithin30daysofadmittance(i.e.,Individual#5andIndividual#63).Although,itshouldbenotedthatthiscouldnotbeconfirmed,becausetheBSCapprovaldatecouldnotbeverified.Inaddition,oneoftheseevaluationsdidnotincludeinformationonrecentlycompletedassessmentofadaptivebehavior.Oftheotherassessments,onewasincompleteandnotdateduntilafter30daysofadmission(i.e.,Individual#40),onewassimplynotadequate(i.e.,Individual#97),andonewasnotdated(i.e.,Individual#61).Overall,likemanyoftheotherpsychologicalevaluationsreviewedinthefortheMonitoringTeam’sreport,asdiscussedwithregardtoSectionK.6,theformatandcontentvariedacrossthereports.However,noneofthereportsweresignedordatedbytheauthors.Asaresultofissuesrelatedtotheinadequacyofcurrentstandardizedintellectualtestingandassessmentofadaptivefunctioning,timelinessofinitialpsychologicalassessments,andthestatedinadequacyofthecurrentBehavioralServicesdatabase,theFacilityremainedoutofcompliancewiththisprovision.

K8 BysixweeksoftheassessmentrequiredinSectionK.7,above,thoseindividualsneedingpsychologicalservicesotherthanPBSPsshallreceivesuchservices.Documentationshallbeprovidedinsuchawaythatprogresscanbemeasuredtodeterminetheefficacyoftreatment.

NoprogresswasnotedwithregardtotheprovisionofservicestoindividualsrequiringpsychologicalservicesotherthanPBSPs,includingthewayinwhichcounselingtreatmentplansweredevelopedandmonitored.However,attendanceatBSCbyoneofthetwocontractedcounselorsappearedtoimprove.ConsistentwiththeMonitoringTeam’spreviousreview,twocommunity‐basedcounselorscontinuedtoprovideweeklycounselingsupportsbothonandoffcampus.Accordingtoverbalreportandprovideddocumentation,greaterparticipationinBSCmeetingsbythecommunity‐basedtherapistwasevidencedinthelastsixmonths.Morespecifically,acommunity‐basedtherapistwasinattendanceatBSCapproximately28%ofthemeetingssincetheMonitoringTeam’slastvisit.Thiswascomparedto23%ofmeetingsidentifiedintheMonitoringTeam’spreviousreport(asdiscussedwithregardtoSectionK.3oftheSettlementAgreement).Itappearedthatonecounselor(i.e.,oneofthetwocontractedcounselors)wasinattendancemostoftime.Accordingtoverbalreportsandpreviousdocumentation,thiswasthesamecounselorthatappearedmorewillingtodevelopcounselingtreatmentplansaswellasattempttoregularlymonitorongoingprogress.Currently,accordingtodocumentationprovided,17individualswereidentifiedasreceivingcounselingservices.Documentationindicatedthat,between12/1/11and5/31/12,sixindividualshadbeenreferredforcounselingsupports.Ofthese,accordingtoverbalreportfromtheDirectorofBehavioralServicesanddocumentationprovided,it

Noncompliance


# Provision AssessmentofStatus Complianceappearedthattwoindividualswerenotyetplacedwithacounselor(i.e.,Individual#264andIndividual#109).ReportsindicatedthattheFacilityhadbeenattemptingtocontractwithathirdcommunity‐basedtherapist,buthadnotyetbeensuccessful.Currently,fourindividuals(outofthe17individualscurrentlyreceivingcounselingsupports)wereselectedasarepresentativesample.Thisreflectedapproximately24%ofthoseindividualscurrentlyreceivingcounselingservices.Documentationprovidedwasreviewed,asavailable,includingcounselingtreatmentplans,counselingnotes,andPBSPmonthlyprogressnotes.Ofthosesampled,onlyoneappearedtohavea“treatmentplan”inplace(i.e.,Individual#140).Thatis,onlyoneindividualhadadocumentthatincludedinformationbeyondthatofanidentifiedbehavioralobjective.Thistreatmentplan,however,wasinadequate.Three(75%)oftheindividualssampledhadacounselingobjectiveidentified.However,alloftheseobjectiveswereincompleteorinconsistentcomparedtotheobjectiveslistedinthePBSPprogressnotes.Inaddition,reviewofsampledPBSPmonthlyprogressnotesforApril,May,andJuneevidencedinadequatemonitoringofprogressforallindividuals.Morespecifically,thesamedatadisplayedforAprilwasdisplayedforMayandJuneforIndividual#140,thewrongdatawasdisplayedforIndividual#325,nodatawasgraphedforthetwoobjectivesforMayandJuneforIndividual#7,andthewrongdatawasgraphedforIndividual#246.Overall,thecounselingdocumentationappearedinadequateandconsistentwiththedocumentationreviewedpreviously.Thequalityofthecounselingplansaswellasongoingmonitoringwasinadequate.BecausethisfindingwasconsistentwithobservationsreportedintheMonitoringTeam’spreviousreports,alloftheconcernsarenotrepeatedhere,andtheFacilityisstronglyencouragedtoreviewthefindingsandrecommendationsstatedwithintheMonitoringTeam’spreviousreports.ItshouldbenotedthatthecurrentfindingsweresimilartothosereportedintherecentCCSSLCSelf‐Assessment,dated6/25/12.Morespecifically,theself‐assessmentreportedthat,basedupontheFacility’sreview,severalindividualsreceivingcounselingservicesweremissingrelateddata,lackedidentifiedbehavioralobjectives,and,perhapsmostimportantly,alloftheobjectivesreviewedwerenotconsideredmeasurable.Atthecurrenttime,itdidnotappearthatanychangesrelatedtocounselingsupportswereincorporatedwithinthecurrentpolicy.Consequently,theFacilityisalsoencouragedtointegrateexpectationsrelatedtocounselingsupportswithincurrentpolicy.TheMonitoringTeam’spreviousreportshadencouragedtheFacilitytoexamineevidence‐basedassessmentpracticesthatlikelywouldfacilitatetheidentificationoffunctionalskillareasaswellasimplementevidenced‐basedpracticeswithregardtothespecializedprogrammingbeingdevelopedforindividualswithAutismorother


# Provision AssessmentofStatus Compliancedevelopmentaldisabilities.Examplesofthese,includingtheAssessmentofBasicLanguageandLearningSkills‐Revised(ABLLS‐R)andthePictureExchangeCommunicationSystem(PECS),werecitedinpreviousreports.RecentobservationswithintheComfortZoneevidenceduseofthePECSsystemwithinstructuredskillacquisitionprograms(SAPs)(e.g.,Individual#147).Thisdemonstratedsomeinitialprogresstowardtheutilizationofthisevidence‐basedpractice.Inaddition,evidencewasprovidedthattheFacilityrecentlyhadrequisitionedanABLLS‐Rassessmentkit.Duetothecontinuedinadequacyofcounselingtreatmentplans,theFacilityremainedoutofcompliancewiththisprovisionoftheSettlementAgreement.

K9 Bysixweeksfromthedateoftheindividual’sassessment,theFacilityshalldevelopanindividualPBSP,andobtainnecessaryapprovalsandconsents,foreachindividualwhoisexhibitingbehaviorsthatconstitutearisktothehealthorsafetyoftheindividualorothers,orthatserveasabarriertolearningandindependence,andthathavebeenresistanttolessformalinterventions.Byfourteendaysfromobtainingnecessaryapprovalsandconsents,theFacilityshallimplementthePBSP.Notwithstandingtheforegoingtimeframes,theFacilitySuperintendentmaygrantawrittenextensionbasedonextraordinarycircumstances.

SomeprogresswasnotedintheareaofPBSPs.Anewandimprovedformathadbeendevelopedandwascurrentlybeingpilotedwithasmallnumberofindividuals.TheMonitoringTeam’spreviousreportnotedminimalprogresswithregardtoPBSPs.Indeed,atthattime,itwasreportedthat100%ofthesampledplansweremissingoneormorecriticalcomponentsfoundineffectivePBSPs,andthattheformatsofplansvariedsignificantly.Overall,theadequacyofthecontentwithinmostsectionsofthePBSPswasquestioned,withtheexceptionofimprovementsnotedingraphicdisplays.Currently,inanefforttotargetthemostup‐to‐dateplansandavoidreviewingpreviouslyutilizedformats,onlythoseplansrevisedsincetheMonitoringTeam’slastvisitaswellasthosecompletedusingthenewestPBSPrevisedformatwerereviewed.Consequently,thecurrentreviewexaminedasmallandselectivesampleofPBSPs.Accordingtodocumentationprovided,approximately11PBSPsappearedtohavebeenapprovedandimplementedsincetheMonitoringTeam’slastvisit(i.e.,sinceJanuary9,2012).Thisisanapproximateestimate,becauseverbalreportsindicatedthattheBehavioralServicesdatabasewas“corrupted”(moredetailsareprovidedwithregardtoSectionK.7),andup‐to‐datesummarydatawasnotprovided.Nonetheless,availabledocumentationindicatedthatthenewPBSPformathadbeenutilizedforfourindividuals(i.e.,Individual#7,Individual#117,Individual#186,andIndividual#363).Ofthesefourindividuals,twowereselectedforthecurrentsample(i.e.,Individual#7andIndividual186).Thissamplereflectedapproximately50%ofthecurrentPBSPswrittenusingthenewformat,and18%oftheplanswrittensincetheMonitoringTeam’slastvisit.Currently,thenewPBSPformatwasmuchmoreconciseanduser‐friendlycomparedtopreviouslyrevieweddocumentation.Thatis,itappearedthatasubstantialamountofunnecessaryandredundantinformationwasremoved.Inaddition,theformatwasstructuredtofacilitateperformancefollowingcompetency‐basedtrainingaswellasongoingintegritychecks.Overall,thereviewevidencedanimprovementinthequalityoftheseplans.However,itshouldbenotedthatthesamplewassmallandthisnewformat

Noncompliance


# Provision AssessmentofStatus Compliancewasstillinthe“pilot”stage.EvidencesuggestedabettercorrespondencebetweenfunctionalbehavioralassessmentandthereplacementbehaviorsandstrategiesincludedinthePBSP.Inaddition,evidencedemonstratedimprovedawarenessofcriticalelements(i.e.,settingevents,andimmediateantecedents)withinpreventativeinterventions.Also,improvedoperationaldefinitionsaswellasbehavioralobjectiveswerenotedforoneofthetwoPBSPs(i.e.,Individual#186).Overall,therevisedformatappearedtobeanimprovementandappearedlikelytofacilitatemoreeffectivetrainingandimplementationintegrity.Ingeneral,thenewformathadtwomainsections,including“StaffInstructions”and“AdministrativeReview.”Thestaffinstructionssectionincludedcontentareasof:1)operationaldefinitionsoftargetandreplacementbehavior;2)functionofproblembehavior;3)preventionstrategies;4)consequence‐basedstrategies;5)datacollectionprocedures;and6)psychiatricmedicationsandcommonsideeffects.Theadministrativereviewsectionincludedcontentareasof:1)psychiatricdiagnosis;2)baselineorcomparisondata;3)behavioralobjectives;4)priorinterventionstrategiesandoutcomes;5)rationaleforcurrentinterventions;6)riskandriskanalysis;and7)signatureofauthor.AlthoughthereducedlengthandinclusionofmanyofthesesectionsinthesampledPBSPsappearedtobeanimprovementoverpreviousplans,thereweresomenotedconcerns,includingthefollowing:

ThereweresomedifferencesintheformatnotedacrossthesampledPBSPs.Forexample,thePBSPforIndividual#186hadinformationon“relevantmedicalconditions”and“outcomes”whiletheotherplandidnot(i.e.,Individual#7).Althoughthisinconsistencymighthavebeenduetotherevisionoftheformatovertime,thisappearedunlikelyasbothPBSPswereapprovedbyBSCinthesamemonth.Inaddition,thePBSPforIndividual#186hadsectionsrelatedto“priorinterventionsandefficacy”and“rationale,”whencomparedtotheotherplan.Toassistinmonitoringwhetherornotthemostup‐to‐dateformatwasbeingutilized,asubheadingwiththerevisiondateshouldbeincludedwithinthePBSPformat.

Althoughmostsectionsappearedtohavebeenincludedintherevisedplans,relatedcontentfoundwithinafewsections(withinAdministrativeReview)werenotincluded.Thatis,inseveralsectionsofthePBSPforIndividual#7,thereaderwasdirectedtofindtherelevantinformationinanotherdocument(i.e.,“SeeComprehensivePsychologicalAssessment…”).Thispracticewasnotasevidentintheotherplan.Thatis,althoughthecomprehensivepsychologicalevaluationwascited,theinformationwasbrieflysummarizedwithinthePBSP(i.e.,“BaselineorComparisonData”section)forIndividual#186.Inaddition,whenadocumentwascited(i.e.,“SeeattachedBehaviorContract”),itwasnotnecessarilyattached(i.e.,forIndividual#7).

Inconsistencyinthequalityofsomenecessarycomponentswasnotedacross


# Provision AssessmentofStatus CompliancePBSPs.Forexample,theoperationaldefinitionsfortargetandreplacementbehaviorswereinadequateasdescribedinthePBSPforIndividual#7.Thatis,althoughthedefinitionsofself‐injuryandaggressionincludeddescriptionsoftheoutcomeoftheseresponses,whichisimportant,thetopographyofthetypicalresponse(s)wasnotincluded.Afterreadingthedefinitionforself‐injury,forexample,anewdirectsupportprofessionalmightnotappreciatetheriskofeatingapieceofglassversusapreferenceofstayinginthesuntoolong.

Theseparationofoperationaldefinitionsfromactualteachingstrategiesforreplacementbehaviorsappearedtobeanimprovement(i.e.,PBSPforIndividual#186).Theinclusionofteachingstrategieswiththedefinitionsappearedtoobscuretheactualdefinitions(i.e.,PBSPforIndividual#7).

AlthoughtheprovisionofreinforcementwasnotedwithbothPBSPs,theirprescribedusewasnotalwaysconspicuous.Thatis,althoughgeneralstaffinstructionscitedtheiruse,furtherdescription(asdescribedinbehavioralcontracts)wasnotprovidedtotheMonitoringTeam(i.e.,forbothsampledPBSPs).Consequently,itcouldnotbedeterminediftheuseofreinforcersappearedrobustandlikelytosupportacquisitionofnewskills.

Lastly,authors’signatures(andrelateddates)werenotevidentonplansreviewed.ThiswasconsistentwithobservationsoftheMonitoringTeam,becauserecordreviewsevidencedPBSPsinrecordsthatwerenotsignedordated(e.g.,Individual#7andIndividual#275)

Overall,giventheconcernsnotedabove,thePBSPsappearedtoreflectanimprovementoverpreviouslyreviewedplans.TrainingsprovidedonthePBSP(e.g.,targetingsettingevents,antecedents,andrelatedinterventions,dated3/23/12,andrubricreviews,dated2/2/12and2/7/12),aswellasformalpreferenceassessments,on2/28/12appearedtobehelpful.Inadditiontothenewformat,anewCCSSLCPBSPPeerReviewrubric,basedonthenewformat,wasdevelopedtoassiststaffinreviewingPBSPs.Thisrubric,dated2/1/12,appearedlikelytoofferstaffthenecessarystructuretoadequatelyreviewthequalityofPBSPs.Thatis,examplesprovidedrevealedutilizationofthisrubricbypeerreviewerssincetheMonitoringTeam’slastvisit.AttheMonitoringTeam’spreviousvisit,itwasreportedthatanewPBSPpeerreviewrubric,dated6/1/11,hadbeendevelopedandutilizedtoensuretheinclusionofcriticalcomponentswithinallPBSPs.Indeed,pastdescriptionssuggestedthatthisrubricwasdesignedtoassistinthedevelopmentofadequatePBSPs,stafftrainingandultimately,theimprovementandmeasurementoftreatmentintegrity.Currently,arevisedPBSPpeerreviewrubric,dated2/1/12,hadbeeninplacesincethelastreview,andevidenceindicatedthatithasbeenusedtoestimateinter‐raterreliability.Thatis,summarydocumentation(examplesofinter‐raterreliabilityscoresforPBSPsandotherdocuments)evidencedtheuseofthispeerreviewrubricbyvariousstaff(i.e.,theauthor


# Provision AssessmentofStatus Complianceofthedocument,peerreviewers,andQA/QI)inanefforttoensurethequalityoftheplan.Inaddition,becausemultiplereviewerswereavailable,inter‐raterreliabilityestimatesweredeterminedaswell.Accordingtoverbalreport,however,therewasnosummarydataregardingthetotalnumberofreviewsthathadbeencompletedusingthisrubricorassociatedscores.Alistingwasprovidedthatdisplayedthenamesof45individualsforwhominter‐reliabilityratingshadoccurredasof5/31/12.However,noadditionaldatawasavailabletoindicatewhichdocumentswerereviewed,orhowmanypeerraterswereinvolvedineachreview,andnosummarydatawasprovidedtodetailtheoverallfindings.Theuseofpeerreviewrubricstoevaluatethedevelopmentofassessmentsandinterventionsappearedtobethefirststeptowardensuringadequateandconsistentprogrammingand,ultimately,improvedtreatmentintegritybystaff.Thatis,ifrobusteffortsweredirectedatcriticallyexaminingpsychologicalproductstoensuretheiradequacyandconsistency,itappearedlikelytosupporttreatmentintegrity.Itappearedthatahierarchicalsystemhadbeenimplementedwhenusingtheserubrics.Morespecifically,psychologistsinitiallyusedtherubricsastheydevelopedorupdatedassessmentsorplans.Oncecompleted,theserubricswereagainusedbymoreexperiencedPsychologistVmentorstoreviewtheproduct.Lastly,therubricswereusedbypeersatBSCmeeting,attimesfortraining,butalwaysbytheDirectorofBehavioralServicesortheClinicalPsychologistwhentheassessmentorplanwasfinallyapproved.ThedatareflectingthisprocesswasverylimitedandtheFacilityshouldconsideranefficientandmeaningfuldatacollectionmethodologytomonitorprogressontheuseofthissystemandrelatedprogressindevelopingimprovedassessmentsandplansovertime.TodeterminewhetherornotnecessaryapprovalsandconsentswereobtainedpriortotheimplementationofthePBSPs,asubsampleofplanswereselectedandrelatedapprovals(i.e.,BSCapproval,Guardianconsent,andDirectorapproval)wereexaminedduringtheonsitevisit.Thissampleofconsentsincludedeightindividualsand,consequently,representedapproximatelysevenpercentofthetotalnumberofPBSPscurrentlyimplemented(N=121).Onsitedocumentationreviewrevealedthatonlyfive(63%)oftheindividualssampledhadallofthenecessaryandcurrentconsentsintheirrecords,aswellascorrespondingdatesrecordedontheBehavioralServicesdatabase.Severalofthedateslistedwithinthedatabasedidnotmatchthedatesontheactualconsentdocuments(i.e.,wrongHRCdateforIndividual#218andwrongBSCdateforIndividual#225).Inaddition,documentationcouldnotbefoundfortheBSCapprovaldateforIndividual#368.Mostimportantly,itappearedthatthePBSPwasimplementedpriortothereceiptofatleastoneofthenecessaryconsentsorapprovalsforthreeofthesampledindividuals(38%).Althoughoneoftheindividuals(i.e.,Individual#225)appearedtohaveallofthenecessaryconsentsandapprovals,thelistedPBSP


# Provision AssessmentofStatus Complianceimplementationdatewasoveroneyearold.Consequently,itwasunclearwhenthisparticularplanwasformallyimplemented.Lastly,documentationprovidedindicatedthediscontinuationofthepreviousSafetyPlansforCrisisIntervention(SPCI)format.Thatis,concurrentwithchangesinthecurrentrestraintpolicy(asdiscussedinmoredetailwithregardtoSectionCoftheSettlementAgreement),theSPCIformathadbeenchangedtoreflectanew“CrisisInterventionPlan(CIP)”format.ThisnewformatappearedtocontaininformationthatwasverysimilartothecontentfoundinpreviousSPCIs.Indeed,reportsfromPsychologistsindicatedthat,otherthantherequirementsrelatedtotheISPactionplans,thetwodocumentswerenotqualitativelydifferent.TwoindividualswithCIPswereselectedfromallofthoseidentifiedashavingSPCIsorCIPsinplace.Thisincludedatotalof15inplaceaccordingtodocumentationprovided.Therefore,thissamplereflectedapproximately13%ofthoseplanscurrentlyinplace.ThereviewofthesetworecentlycompletedCIPsfoundthatinformationnecessaryfortherecognitionfortheneedofrestraint,aswellasdetailnecessaryfortheappropriateuseofrestraintwasadequatelyincluded(i.e.,Individual#61andIndividual#253).Morespecifically,theCIPsprovided:1)objectivedescriptionofresponsesthatnecessitatedrestraint;2)detailedinstructionsonthetypeofprescribedrestraints(inleast‐to‐mostintrusiveorder);3)releasecriteria,includingthemaximumrestraintduration;4)instructionsonwhennottoimplementrestraintandwhatnottodowhenrestraintisutilized;and5)detailonhowtoadequatelydocumenttheuseofrestraint.ItshouldbenotedthatthereviewedCPIswerenotsignedordatedbytheauthors.TheFacilityremainedinnoncompliance,becausetheadequacyofbehavioralprogramming,althoughimprovedinsomecases,wasnotfullyadequateforthenewestplansandhadnotbeengeneralizedtothemajorityofPBSPs.Morespecifically,thePBSPsampledcontinuedtoappearinadequateandtherevisedformathadonlybeenimplementedwithasmallpercentageofoverallplans.

K10 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithin18months,documentationregardingthePBSP’simplementationshallbegatheredandmaintainedinsuchawaythatprogresscanbemeasuredtodeterminetheefficacyoftreatment.Documentationshallbemaintainedtopermitclinical

ProgresscontinuedtobenotedinareaofdatadisplayandongoingPBSPmonitoring,includingconductinginter‐observeragreementchecksoncollectedbehavioraldata.AspreviouslydiscussedwithregardtoSectionK.4oftheSettlementAgreement,progresscontinuedtobeevidentintheuseofmonthlymonitoringPBSPprogressnotes.Morespecifically,themonthlyPBSPprogressnoteappearedtobewellintegratedas10(100%)oftheindividualssampledhadmonthlynotescompleted(usingthenewformat)fortherequestedtimesampleofApril,May,andJune2012.Althoughthiswasapositivefinding,concernswerenotedwithincurrentprogressmonitoring.Thatis,althoughtargetandreplacementbehaviorsweregraphedin100%ofthemonthlynotes,manyincludeddataonresponsesthatwerenotidentifiedoradequatelydefinedinthePBSP.

Noncompliance


# Provision AssessmentofStatus Compliancereviewofmedicalconditions,psychiatrictreatment,anduseandimpactofpsychotropicmedications.

Consequently,theaccuratecorrespondencebetweenimportantbehaviorsdescribedinthePBSPwereoftennotfoundinmonthlyreviewdocumentationordatadisplayedwithinprogressnoteswasnotadequatelydetailedinPBSPs.Inanattempttoexaminethenatureofdatacollectionandmonitoring,asampleof10individualswasselected.ThiswasthesamesampleasdescribedabovewithregardtoSectionK.4oftheSettlementAgreement.Thisexaminationincludedthereviewofeachindividual’sPBSPsaswellasthePBSPmonthlynotesfromApril,MayandJune2012.CloserexaminationofthegraphicdisplayswithPBSPmonthlynotesalsoevidencedprogressovertime.However,severalconcerns,manyconsistentwiththeMonitoringTeam’spreviousreports,werenoted.Therefore,theFacilityisstronglyencouragedtoreviewfindingsandrecommendationsregardinggraphingconventionsintheMonitoringTeam’spreviousreports.Currently,however,concernswerenotedwithintheselectedsampleofmonthlyPBSPprogressnotes,including:

Thegraphicdisplayofmedicationsoftendidnotappearhelpful,becausenochangesweredisplayedorbecauseitwouldbemorehelpfultooverlaymedicationchangesagainstchangesinbehavioralfunctioning(e.g.,Individual#255,Individual#184,andIndividual#335);

Thegraphicdisplayofmedicationsoftendidnotappearhelpful,becausethenecessaryrangeofdosagesmadetheinterpretationofbehavioralvariationimpossible(Individual#7);

Multiplegraphsdisplayingthesameinformationwereredundantandshouldbeeliminated,whenappropriate(e.g.,Individual#225andIndividual#184);

Theutilizationofphasechangelinestohighlightmedicationchangesmightbemorehelpfulthaninclusionofrawdataorgraphingtherawdata(e.g.,Individual#167);

Itisimportanttoensurethattheaxislabelsarereadableandmeaningful(e.g.,Individual#218,Individual#307,andIndividual#46).Forexample,theYaxisforrestraintsforIndividual#46included“‐1,”andthelabelfordurationindicated“timeinrestraints,”whichmightbeimprovedbyindicating“secondsinrestraint”or“minutesinrestraint,”asappropriate;

Considerationshouldbegiventographingmultipledatapathstofacilitatecomparison(co‐variationofresponding),aslongasgraphsremaininterpretable(e.g.,Individual#218);and

ConsiderationshouldbegiventosimplifyinggraphswhentoomanydatapathsortherangeofYaxismakethegraphuninterpretable(i.e.,Individual#353,Individual#218,andIndividual#307).

Consistentwithpreviousrecommendations,effortsshouldcontinuetothoughtfullydisplaydataandtoeliminateredundancy.Graphsshouldnotbedisplayediftheydonotoffermeaningfuldataoralloweffectiveanalysis.Asnotedduringthepreviousreview,it


# Provision AssessmentofStatus Complianceisunnecessarytodisplaytherawdatabeneathagraphifthedatacanbereasonablyandquicklyestimatedbyviewingaconspicuousdatapathonagraph(orviceversa).AspreviouslydescribedwithregardtoSectionK.4oftheSettlementAgreement,progresswasnotedintrainingstafftobegincollectinginter‐observeragreementdata.Accordingtoverbalreportsanddocumentationprovided,psychologistsandpsychologyassistantsstartedcollectinginter‐observeragreementdatainJanuary2012aspartofapilotprogramthatultimatelyhadexpandedacrosscampus.AccordingtoverbalreportsfromtheDirectorofBehavioralServices,itwasnowexpectedthatIOAdatabereportedinallmonthlyPBSPprogressnotes.Aspresentedearlier,reviewofthesampledmonthlyPBSPnotes,atthistime,evidencedthecollectionofIOAdata.Morespecifically,IOAestimateswerereportedinthemonthlynotesofsix(60%)oftheindividualssampled.ThiswasanimprovementoverobservationsattheMonitoringTeam’slastvisit,wherenoevidenceofIOAdatacollectionwasprovided.However,theinformationprovidedwasrathergeneralanddidnotspecificallystatethenumberofobservationsusedtoestimateIOA.Accordingtoverbalreports,theIOAsessiontypicallyincludeda10‐minuteobservationusingone‐minuteintervals.Thedatareviewedappearedtoreflect100%agreementononlythenon‐occurrenceofasingleselectedtargetbehavior.Inthefuture,datashouldbecollectedonmultipletargetbehaviors(perhapsallofthebehaviorstracked)andincludereplacementbehaviorsaswell.Datacollectorsshouldconsidertargetinghighfrequencybehaviorsinanattempttoexamineagreementontheoccurrenceofthesemoreprobableresponses.Inaddition,directsupportprofessionalsshouldultimatelybeintegratedintotheseobservationsessionsaswell.Indeed,thesearethestaffwherethedemonstrationofacceptableagreementestimatesismostimportant.Althoughprogresswasnotedintheareasofprogressmonitoring,theFacilityremainedoutofcompliancewiththisprovisionbecauseofthecontinuedinadequacyofIOAdatacollectionaswellasthelimitationsobservedwithinthegraphicdisplayofbehavioraldata.

K11 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshallensurethatPBSPsarewrittensothattheycanbeunderstoodandimplementedbydirectcarestaff.

SomeprogresswasevidentwithregardtowritingPBSPssothattheycouldbeunderstoodandimplementedbydirectsupportprofessionals.AsdescribedabovewithregardtoSectionK.9oftheSettlementAgreement,anewPBSPformathadbeendevelopedandwasbeingpiloted.Thisnewformatappearedhighlylikelytofacilitateamoreconciseanduser‐friendlyPBSP.Basedonverbalreport,thisnewformatwillbeutilizedfollowingthecompletionofcomprehensivepsychologicalevaluations.TheMonitoringTeamlooksforwardtoexaminingthecontinueduseofthisrevisedformatastheFacilityendeavorstoimprovethequalityofPBSPs.OneitemonthecurrentpeerreviewPBSPrubricexaminedtheestimatedreadabilitylevelofthedocument.Thatis,ratersneededtoreviewthereadabilitylevelofthePBSPwhile

Noncompliance


# Provision AssessmentofStatus Complianceconductingthepeerreview.TheFacilityhadsetareadabilityof7th gradeorlower.Ifaplanweretoexceedthatcriterion,accordingtotheDirectorofBehavioralServices,theplanwouldneedtoberevised.AsdiscussedwithregardtoSectionS.3.aoftheSettlementAgreement,inconsistentfindingswithregardtostaffknowledgeofPBSPsandSkillAcquisitionPlanscontinuedtobeobservedduringonsitevisits.Thatis,asampleofstaffmemberswereinterviewedaboutselectedindividualsandtheirprogramminginanefforttoestimatestaffknowledgeaboutresidents.Overall,althoughmanystaffappearedknowledgeableofplansandskillprogramsofrandomlyselectedindividuals,manystaffstillwereunabletoanswerbasicquestionsaboutbehavioralorskillprogrammingforsomeindividuals.Forexample,adirectsupportprofessionalwasabletoprovideaccurateinformationinresponsetoquestionsaboutIndividual#167,butwasunabletolocatetheIndividualNotebooktodescribedatacollection.StaffcorrectlyansweredquestionsregardingtargetbehaviorsandprescribedconsequencebasedinterventionsforIndividual#58andwasabletogenerallydescribetheplanforIndividual#22.However,whenasked,staffneededtoconfirmwhetherornotsomeindividualshadaPBSP(e.g.,Individual#310).Insomecases,staffreportedthatanindividual(i.e.,Individual#254)hadaPBSPwhenthatwasnotthecase.Inonecase,staffdescribedatargetbehaviorofPICAandrelatedpreventativestrategiesthatwerenotlistedinIndividual#315PBSP.AccordingtocurrentverbalreportsfromtheDirectorofBehavioralServicesaswellasreportsintheFacilitySelf‐Assessment,integritycheckswerenotcurrentlybeingcompleted.ReportssuggestedthatthenewsystemdesignedtomonitorthetreatmentintegrityofindividualplanswasexpectedbeinitiatedinJanuary2013.Althoughsomeprogresswasnotedabove,theFacilityremainedinnoncompliancewiththisprovision.ThiswasduetotheinitialandlimitedimplementationofthenewPBSPformat,inconsistencyinstaff’sverbalreportregardingknowledgeofPBSPs,andtheoveralllackofacomprehensivesystemtomonitorandensureadequatetreatmentintegrity.

K12 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationintwoyears,eachFacilityshallensurethatalldirectcontactstaffandtheirsupervisorssuccessfullycompletecompetency‐basedtrainingontheoverallpurposeandobjectivesofthespecificPBSPsforwhichthey

Someprogresswasmadewithregardtocompetency‐basedtraining.TheMonitoringTeam’spreviousreportnotedthatapilotprojecthadbeeninitiatedusingarevisedrubricthatmeasuredbothstaffknowledgeandskillsinimplementingPBSPs.Theserubricsincludedadidacticassessmentthatdirectsupportprofessionalscompletedfollowingtraining,andasecond,muchlongerandmorecomprehensiverubricwasutilizedtoassessactualdirectsupportprofessionals’competencyindemonstratinginterventionsasprescribedbythePBSPs.Bothrubricsgeneratedatotalscoreandwereindividualizedtospecificindividuals’PBSPs.Verbalreportsaswellasdocumentation

Noncompliance


# Provision AssessmentofStatus Complianceareresponsibleandontheimplementationofthoseplans.

providedatthattimeindicatedthatthepilotprojecthadprovidedcompetency‐basedtrainingandassessmentforsixindividualsacrosstworesidentialprograms.Estimatessuggestedthattodate,approximately100staffhadbeentrained.Initialsummarydataindicatedthatstaffperformancewasexceptionallyhigh.SincetheMonitoringTeam’slastvisit,itappearedthatthepilotprogramhadcontinuedandexpanded.VerbalreportsfromtheDirectorofBehavioralServicesindicatedthatthepilothadexpandedbeyondthesingleresidenceintootherresidencesacrosstheentireAtlanticUnit.Indeed,verbalreportssuggestedthat22PBSPshadbeentrainedsincetheMonitoringTeam’slastvisitusingcompetency‐basedtraining.ItwasdifficultfortheMonitoringTeamtoestimateandconfirmtheamountoftraining,becausesummaryinformationwasprovidedforonlytwoindividuals(i.e.,Individual#321andIndividual#7).Inaddition,verbalreportsabouthowcompetency‐basedtrainingwasbeingimplementedwereveryconcerning.Thatis,staffdescribedadirectservicedeliverymodelwherethepsychologist(trainer)spentapproximatelyonetotwohourswithasingledirectcarestaffmembercompletingthetraining.Thismodelisinappropriateandshouldnotbethetypicaltrainingmodelutilized.Anindirectmodelmustbeemployedwherethepsychologist(i.e.,“expert”)providescompetency‐basedtrainingtoothertrainers(e.g.,psychologyassistants,hometeamleaders,etc.)whosharetheresponsibilityintrainingthedirectsupportprofessionals.Thepsychologistoroneoftheseothercompetenttrainersshouldtraindirectsupportprofessionalsinsmallgroups.Thatis,onlyindividualswhohavesuccessfullydemonstratedcompetenceinwhattheyareteaching(e.g.,aparticularPBSP)andalsohavedemonstratedcompetenceasatrainer(i.e.,teacher)shouldconductthetraining.ThemodeltheQDDPsutilized,wheredirectobservation(bytheLeadQDDP)duringISPmeetingswasusedtoensurethatQDDPswerefacilitatingthemeetingsasexpected,couldbesimilarlyappliedtopsychologistsandothertrainerstoensurethattheyareutilizingbestpracticeteachingmethodswhenconductingcompetency‐basedtraining.Althoughsomeprogresshadbeenmade,theprovisionofadequatecompetency‐basedtrainingacrosstheFacilityforallindividualsremainedinadequate.Asaresult,theFacilityremainedinnoncompliancewiththisprovision.

K13 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,eachFacilityshallmaintainanaverage1:30ratioofprofessionalsdescribedinSectionK.1andmaintainonepsychology

Atthetimeofthemostrecentreview,basedonverbalreportanddocumentationprovided,therewere14AssociatePsychologists(i.e.,fourAssociatePsychologistVandtenAssociatePsychologistIIIpositions),aClinicalPsychologist,andBCBA‐certifiedDirectorofBehavioralServices.OnlytheAssociatePsychologistscarriedacaseload.Currently,thereweresixPsychologyAssistantsandtwoopenPsychologyAssistantpositions.

Noncompliance


# Provision AssessmentofStatus Complianceassistantforeverytwosuchprofessionals.

Asofthemostrecentonsitereview,CCSSLCserved259individuals.BasedonthisnumberandtheunderstandingthattheClinicalPsychologistandDirectorofBehavioralServicesdidnotcarryacaseload,anapproximateaveragepsychologist‐to‐individualratiowasestimatedat1:19.Givenreportsprovided,therewaslessthanonePsychologyAssistantsforeverytwoAssociatePsychologistsemployed.Inaddition,asnotedwithregardtoSectionK.1oftheSettlementAgreement,theFacilitywasratedasbeinginnoncompliancewiththisprovision,becausetheprofessionalsinthePsychologyDepartmentwerenotyetdemonstrablycompetentinappliedbehavioranalysisasrequiredbytheSettlementAgreement.Thiswasevidencedbytheabsenceofprofessionalcertification,aswellasbyissuesrelatedtothequalityoftheprogrammingobservedattheFacility.


1. CCSSLCshoulddevelop,implement,andmonitoraplanforeachstaffmemberwhoremainsreluctanttotakegraduatecourseworktowardtheBCBA.Thisshouldincludeworkingcollaborativelytoidentifyremainingobstaclesandproblem‐solveregardinghisorherunwillingnessorinabilitytopursueprofessionalcompetenciesinABA.(SectionK.1)

2. CCSSLCshouldensurethatthecontractedBCBAprofessionalshavesufficienttimetoadequatelysupervisestaffmembersenrolledincoursework,andthattheydosoaccordingtosupervisionguidelinesoutlinedbytheBehaviorAnalysisCertificationBoard.(SectionK.1)

3. BehavioralservicesstaffshouldensurethattheyaredocumentingonrequiredBACBforms,andtrackingtheirsupervisionovertime,inaccordancewithsupervisionguidelinesoutlinedbytheBehaviorAnalysisCertificationBoard.(SectionK.1)

4. CCSSLCshouldexaminewhyeligiblepsychologistscannotaccesstheallottedweeklyeducationalleaveandproblem‐solvetoensurethatallofthepsychologistsenrolledincourseworkcanutilizethetimeprescribed.(SectionK.1)

5. TheFacilityshouldattempttoidentifyandovercomebarrierstoattendancebyBSCmemberstohelpensureadequatepeerreview.(SectionK.3)

6. TheFacilityshouldcontinuetopursuearobustexternalpeerreviewthoughtheinclusionofcompetentprofessionalswithexperienceinABA.Inaddition,theFacilityshouldensureadequatedocumentationofexternalpeerreview.(SectionK.3)

7. Policesregardinginternalandexternalpeerreviewshouldbeupdatedtoreflectcurrentpractice.ThisshouldincludespecificitemsrelatedtotheagendasofBSCandexternalpeerreview,aswellasidentificationoftheprofessionalswhoneedtobeinattendancetoensureadequatecriticalpeerreview.(SectionK.3)

8. Emphasisshouldtobeplacedonexamininghowreplacementbehaviorsareidentified,defined,andmonitored.ThisshouldincludeensuringthatoperationaldefinitionsareconspicuouslyavailableandthatallreplacementbehaviorsareclearlylabeledandgraphedinmonthlyPBSPprogressnotes,aswellasotherdocumentation.(SectionK.4).

9. Morestandardizationofdatacollectionmethodologyandexpectationsisneeded.Policiesshouldbemodifiedtoincludemoredetailregardingwhatdataistobeincludedandinwhatformatacrossdocuments(e.g.,psychologicalevaluations,SFBAs,PBSPs,SPCIs,etc.).(SectionK.4)

10. Withregardtocomprehensivepsychologicalevaluations:a. Individualizewhenappropriate.Thatis,inregardtotheidentifiedrationale(reasonforreferral),providespecificationifthe

evaluationisbeingupdatedorrevisedduetoongoingbehavioralissues.b. Ensurethatsourcesofinformationincludedescriptionofdirectmethodsofassessment,includingdirectobservation.Inaddition,


considersummarizingthesesourcesmoreconcisely.c. Verybrieflyhighlightanyknowneffectsofunderlyingmedicalorpsychiatricconditions/diagnoses.Thatis,conciselydescribeany

medicalorpsychiatricconditionsorchangesthatappeartocontributetoanindividual’sfunctioning,especiallytheoccurrenceofmaladaptivebehaviors.

d. Utilizeheadersorsub‐headersondocumentstoidentifywhichformat(bydate)wasutilized.Clearlyidentifyingwhichformatwasutilizedwilllikelyassistpeerreviewerstoevaluateongoingprogressandadherencetoexpectedprocedures.

e. Ensurethatdate(s)areconspicuouslyidentified.Thatis,foreachassessment,ensurethatthedateonwhichitwasconductedisclearlyidentified(nearwheretheresultsaredescribed).

f. Ensurethatspecificdescriptionsofeffectiveand/ornon‐effectivepreviousinterventions,ifknown,aredescribedinadditiontosummarizingbehavioralprogressanddatareviewinthe“previousinterventionandefficacy”section.

g. Identifythespecificstandardizedinterviewformat,ifutilized.h. Directmethodsofassessment(e.g.,directobservation)typicallyprovidethemosthelpfulinformation.Inadditiontoprovidingspecific

descriptionsofdirectobservationsessions,authorsofevaluationsshouldattempttosummarizetheirobservations.i. Ensurethatopportunitiestodiscussadaptivebehavior(e.g.,potentialreplacementbehaviorscurrentlywithinanindividual’s

repertoire)arenotoverlookedinimportantassessmentareas(e.g.,staffinterviews).j. Ensurereplacementbehavior(s)areadequatelydefined,liketargetbehaviors,includingdefinitionsthatareobjective,measureable,

andcomplete,withexamplesandnon‐examples.k. Examinewaystomaketheevaluationmoreconcise,perhapsbyeliminatingmuchoftherawdata.Morespecifically,thisdatacouldbe

summarizedintheevaluationbutstoredforfutureuse,ifnecessary.(SectionK.5).11. OngoingtrainingshouldbeprovidedtopsychologiststoensureadequateunderstandingofelementswithintheComprehensivePsychological

Evaluation.(SectionK.5)12. TheFacilityshouldensurethatpsychologistsunderstandthedifferencebetweendirectandindirectmethodsofassessment,andwhydirect

observationiscriticaltoeffectiveassessmentanddocumenttheirobservationsaccordingly.Whenfindingsfromassessmentmethodsareunclearorinconsistent,additionalindirectand/ordirectassessmentsshouldbecompleted.Inaddition,emphasisshouldbeplacedonupdatingadaptivebehaviorassessmentsusingappropriatescales.(SectionK.5)

13. Specificpoliciesregardingtherequiredandongoingutilizationofstandardizedintellectualtestingandassessmentofadaptivebehaviorshouldbeclarifiedincurrentpolicy,ifnotalreadyinplace.ThisshouldincludeensuringthatallcomponentsofthepsychologicalevaluationarecompletedpriortotheISP.(SectionK.6)

14. TheFacilityshouldconsidertrackingthenumberofassessmentsorplansthatrequirerevisionpriortoBSCapproval.Thismightbeanindicatorofthequalityofpeerreviewandcouldinformtheinterpretationofthedelinquencyreport.(SectionK.7)

15. Counselingtreatmentplansshouldbedeveloped,expanded,and/orrefinedtoincludemeasureableoutcomes,andtreatmentsshouldbeevidenced‐based.RecentchangeswithinCCSSLCpracticesinthisareashouldbeincludedinrevisionstocurrentpolicyand/orprocedures.(SectionK.8)

16. TheempiricalsupportshouldbereviewedforanyassessmentmethodologiesortherapystrategiesprovidedtoindividualsservedbyCCSSLC,whetheronoroffcampus.Inaddition,theutilizationofevidenced‐basedassessments(e.g.,TheAssessmentofBasicLanguageandLearningSkills)and/orpractices(e.g.,functionalcommunicationtraining,pictureexchangecommunicationsystem,etc.)shouldcontinuetobepursued,utilized,andevaluatedtodetermineitseffectivenesscomparedtoalternativetherapies.(SectionK.8)

17. Theuseofevidenced‐basedinterventionswithinPBSPsshouldbemoreconspicuous.Theconspicuoususeofacceptedpractice,suchasdifferentialreinforcementstrategies(e.g.,DRO,DRA,etc.)shouldbeusedasappropriate.(SectionK.9)

18. Staffshouldensurethatabriefsectiononhistoryofpreviousinterventions,aswellasreducingrestrictiveness(ofbehavioralinterventionsandstrategies,notjustmedication)isincludedinPBSPs.Itisimportanttoprovideabackgroundonineffectiveprocedures,aswellasspecificcriteria(clearobjectives)ofbehavioralprogress(ordeterioration),andtoincludemeasurableobjectivesfortargetandreplacementbehaviors,


whichwouldidentifywhenteamreviewsorPBSPrevisionswouldbeconsidered.Levelsofsupervisionorotherrestrictiveprocedures(e.g.,useofmitts)shouldbeidentifiedwithinahierarchy,andgoalsshouldbeestablishedforthefadingofrestrictivepracticesbasedonperformance.(SectionK.9)

19. ThepilotutilizingtherevisedPBSPshouldbeexpanded.TheFacilityshouldensurethatcriticalelementsareadequatelyincludedorcitedwithinthenewPBSPformat.Emphasisshouldbeplacedonoperationallydefiningreplacementbehaviors,identifyingpreventativeteachingstrategiesthattargettheacquisitionanduseofreplacementbehaviors,andregularlyassessingreinforcers(throughpreferenceassessments),andensuringtheyareindividualized,robust,andclearlyprescribedinbothantecedentandconsequencebasedapproaches.(SectionK.9)

20. TheFacilityshouldexpandandmoveforwardwiththeassessmentandmonitoringofinter‐observeragreementforPBSPtargetandreplacementbehaviors.StaffareencouragedtoreviewthetextbookAppliedBehaviorAnalysis(2ndedition)byCooper,Heron,andHeward(2007)formorespecificinformationonconductingIOAandinter‐rateragreement.(SectionsK.4andK.10)

21. Replacementbehaviorsshould,inadditiontoformalteachingsessions,bemonitoredandtrackedastheyoccurinthenaturalenvironment.Asthisadditionaldataiscollected,itshouldbeintegratedintomonthlygraphs.(SectionK.10)

22. Inanefforttofacilitatemoreefficientandeffectivevisualanalysisofgraphs,psychologistsshould:a. Accuratelylabelbothaxesandensurethattheyarereadable;b. Usemultiplegraphsoreliminateunnecessarydata(especiallyacrossmultipleformatsofdisplay);c. Illustratedatadifferently(e.g.,providingmedicationdosagesintablesbelowgraphs),whenappropriate;d. UsemultipleY‐axestodisplaydifferentdimensionsofbehaviorandensurethattheunitsofmeasurementaremeaningful;ande. Utilizephase/conditionchangelinestodemarcatechangesintreatmentorothersignificantchangesinfunctioning.(SectionK.10)

23. Treatmentintegritydatashouldbecollected,summarized,andexamined.Thecollectionandreviewofthisdataisnecessarytoensureconfidencethatprogramsareimplementedaswritten,andthatthesystemisbeingresponsivetoissuesrelatedtopoorintegrity.(SectionK.11)

24. TheFacilityshouldensurethatstaffthatareprovidingtrainingarecompetentinprovidingcompetency‐basedtraining.Thiswouldincludemonitoringpsychologistsorothertrainersastheyprovidetrainings.Inaddition,datacollectionontheintegrityofpsychologists’completionofdidacticanddemonstrativecompetency‐checkswouldbebeneficial.(SectionK.12).

25. TheFacilityshouldcloselyexaminethemodel(s)beingutilizedtotraindirectcarestaff(i.e.,beyondNewEmployeeOrientation),anddetermineifitisappropriate.TheFacilityshouldconsiderusingamorein‐directservicedeliverymodelwherethepsychologiststrainafewkey“trainers”whowillsharetheresponsibilityofcompletingcompetency‐basedtrainingwithalldirectsupportprofessionals.(SectionK.12)

ThefollowingareofferedasadditionalsuggestionstotheStateandFacility:1. Whenappropriate,theamountofredundancyshouldbereducedwithinreportsbyintegratingandsummarizinginformationoravoidingthe

inclusionofinformationrepeatedlythroughoutreports,suchasdata,definitions,objectives,strategies,etc.Similarly,whenappropriate,theamountofredundancyshouldbereducedacrossreports.Thatis,somedataandinformationisnotneededacrossdifferentreports.Forexample,specificinformationrelatedtointelligencetestsarenotnecessaryinSFBAsorPBSPs.(AllofSectionK)

2. InprovidingdocumentationtotheMonitoringTeam,itshouldbedatedand,whenappropriate,signedbyauthors.ThisisimportantfortheMonitoringTeam’sreview,butalsotoensurethattheFacilityhasmechanismsforensuringthatdocumentsarethemostcurrentandfinal/approvedversions,andthathistoricalinformationcaneasilybetracked.(SectionK)

3. The“corrupted”BehavioralSciencesdatabasewasasignificantproblem,andinhibitedtheMonitoringTeam’sabilitytodeterminethecurrentstatusofpsychologicalservices,includingprovidinganaccuratereviewandvalidestimatesofcomplianceontheprovisionsoftheSettlementAgreement.Moreimportantly,theFacilityneedsanaccurateandup‐to‐datemechanismtomonitorthepsychologicalservices.(SectionK).


SECTIONL:MedicalCare StepsTakentoAssessCompliance:Thefollowingactivitiesoccurredtoassesscompliance:

ReviewofFollowingDocuments:o ListofallstaffwhoworkintheMedicalDepartment,includingnamesandtitles;o NameandCVofMedicalDirector,ifnewsincethelastvisit;o NameanddegreesofallprimarycareprovidersthatarenewtoFacilitysincelast

monitoring;o NumberofindividualsoneachPCP’scaseload;o EmployeeslistedunderMedicalDepartmentcompletingCardiopulmonaryresuscitation

(CPR)trainingcertificationwithdatesofcompletion,anddatesofexpiration;o Copyofanyin‐serviceforPCPtrainingonICDandDSMdiagnosticcriteriainlastsix

months;o Sincethelastonsitereview,copyofContinuingMedicalEducation(CME)foreach

primarycareprovider;listofCMEcreditsaccordingtotopicsreviewed;listperPCPoftotalCMEcreditsduringthistimeperiod(separateout/removeCMEcreditsnotearnedsincethelastonsitereview);

o CopyofanyclinicalguidelinesdevelopedandimplementedsincetheMonitoringTeam’slastvisit;

o Minutesofinfectioncontrolcommitteemeetingsduringthepriorsixmonths;o Minutesofskinintegritycommitteemeetingsduringthepriorsixmonths;o Mostrecentresults/reportofthemedicalqualityimprovementprogram,including

identificationoftrendsanddescriptionsofimprovementactionstaken.Foreachpageofdata,identifydateofauditfromwhichinformationwasretrieved;

o Foranymedicalstaffmeetings(morningmedicalmeetings,etc.)copyofallminutes,handouts,logsfromInfirmary,hospitalizations,and24‐hourreportsdiscussed,for15dayspriortotheMonitoringTeam’svisit;

o Mostrecentresults/reportoftheFacility‐widemedicalreviewsystem,includingcopyofanynon‐facilityphysicianreviewreportsordatasincetheMonitoringTeam’slastreview.Separatereports/dataofexternalmedicalpeerreviewauditsfrominternalmedicalpeerreviewaudits.Foreachpageofdata,identifydateofauditandspecificaudit(#ofauditround)fromwhichinformationretrieved;

o ListofindividualswhodiedsincetheMonitoringTeam’slastvisit.Foreachindividual,providedateofdeath,deathcertificate,whetherautopsywasdone(andifso,copyofautopsyreport),medicalproblemlistcurrentattimeofdeath,andforsevendayspriortodeathorhospitalization,allclinicaldocumentationincludingnursingandphysiciannotes,andalldiagnosticstudiesincludingradiologicandlaboratoryfor:Individual#286,Individual#289,Individual#284,Individual#175,Individual#173,Individual#96,andIndividual#316;

o MortalityReviews(clinical,administrative,andnursingreports)sincelastvisit;o CorrectiveactionsrelatedtoMortalityReviews(includestatusreportsonprevious

recommendations);


o NotesandordersforanyDNRsandrescindingofDNRs;o CurrentDNRlistwithreason/criteriaforDNR;o Listofdeathreports(clinical/administrative)thatremainincomplete/outstanding;o Twentymostrecentannualmedicalassessmentsandphysicalexaminationsandprior

annualassessmentandexamination,includingthosefor:Individual#182,Individual#343,Individual#244,Individual#372,Individual#30,Individual#160,Individual#114,Individual#287,Individual#24,Individual#56,Individual#305,Individual#214,Individual#28,Individual#250,Individual#299,Individual#324,Individual#293,Individual#291,Individual#231,andIndividual#95;

o Specialtyclinicschedulepermonthforpastsixmonths;o Listofalloutsideconsultationsformedicalpurposesforthepastsixmonths,categorized

byspecialty;o Listofindividuals(andasecondupdatedlistalsoprovidedweekofMonitoringTeam

visit): Withtracheostomies; Withfractures,dateoffracture,typeoffracture(compound,simple,stress,etc.),

bonefractured(location); WithinjuriesrequiringvisittoERorhospitalizationsincethelastonsitereview,

and Withpicaoringestinginedibleobject,dateofingestion,objectingested,whether

takentoERorhospitalized,sincethelastonsitereview;o Policiesorproceduresformedicalscreeningandroutineevaluations;o Forthoseover50,dateoflastcolonoscopy,andlistreasonforcolonoscopy(preventive

versusevaluationofactiveproblem),withreasonifnotup‐to‐date;o Forthosewomenover40,dateoflastmammogramandreasonlisted,ifnotup‐to‐date

(guardianrefusal,etc.);o Listofallwomenage40orgreaterwithdateofbirth;o Listofallindividualsage50orgreater,withdateofbirth;o Currentlistofallthosewithdiagnosisofosteopenia/osteoporosiswithmedicationsand

dosageperperson[includecalcium,VitaminD,intravenous(IV)bisphosphonate,etc.],dateoflastDEXAscanorstatenonecompleted,copyofmostrecentDEXAscanreportsforeachindividualwithdiagnosisofosteopeniaorosteoporosis;

o Formenwithdiagnosisofosteopenia/osteoporosis,copyofanylabworktestingforsecondarycauses(fromcurrentactiverecord),otherinformationindicatingcause(specificmedications,etc.)ofosteopenia/osteoporosis;

o Forwomenwithdiagnosisofosteopenia/osteoporosis,andpremenopausal,copyofanylabworktestingsecondarycauses(fromcurrentactiverecord),otherinformationindicatingcause(specificmedications,etc.)ofosteopenia/osteoporosis;

o Foreachindividualwithosteopenia/osteoporosis,anyactiverecorddocumentforcalculationofdailycalciumintake(basedondiet,averagepercentageofmealingestion,feedingformula,etc.);

o ForindividualswithDown’ssyndrome,dateoflastthyroidtest;


o ForthosegoingtotheERandnothospitalized,copyofintegratedprogressnotesfromstartofsigns/symptomstotransfertoER,ERreport,dischargeordersfromERandcopyofFacilitychartorders,integratedprogressnotes/Infirmaryprogressnotes,follow‐uptoanyrecommendations,for10mostrecentERvisitsatleast30dayspriortoMonitoringTeam’svisit(inordertoallowcompletionofrecommendations),includingthosefor:Individual#242,Individual#184,Individual#172,Individual#138,Individual#144,Individual#289,Individual#90,Individual#24,Individual#266,andIndividual#239

o Forthoseadmittedtohospital,copyofintegratedprogressnotesfromstartofsigns/symptomstotransfertoER,ERnote,hospitaladmissionhistoryandphysical,dischargesummary,copyofdischargeorders/recommendationsfromhospital,andcopyofFacilityrecordorders,integratedprogressnotes/Infirmaryprogressnotes,andfollow‐upforanyhospitaldischargeordersandrecommendations,10mostrecentlyhospitalizedindividualsthathavereturnedforatleast30days(inordertoallowcompletionofrecommendations),includingthosefor:Individual#126,Individual#167,Individual#144,Individual#224,Individual#117,Individual#266,Individual#175,Individual#155,andIndividual#156;

o Forthesesame10mostrecenthospitalizationsthathavebeencompleted,copyofhospitalliaisonnursedocumentationofhospitalization;

o LengthofstayforInfirmaryadmissionsforpastsixmonths;o Infectiousdiseasedataperquarterbycategoryofinfectionforlasttwoquarters;o Anysummaryreportortrendanalysisofinfectiousdisease/communicablediseaseforlast

twoquarters;o Avatarpneumoniatrackingformsforpastsixmonths;o Forthosewithdiagnosisofpneumoniainlastsixmonthsandtakingfood/liquidbymouth,

typeofliquid(amountofthickening),andtypeoftextureofsolidfoodordered,andlastswallowstudy;

o Absolutenumbersofnewcases(prioryear,bymonth)forthefollowing: Pneumonia; Decubitusulcers; UTIs;and Bowelobstructions;

o Individuals’names,datesofdiagnosis,specificdiagnoses(e.g.,typeofcancer,typeofsepsis)forpastyearforindividualswhohavebeennewlydiagnosedwith:

Malignancy; Cardiovasculardisease;Diabetesmellitus; Sepsis; Bowelobstructionorbowelperforation;and Pneumonia;

o Listofindividualswhohavediagnosisofconstipationorwhoarereceivinganti‐constipationmedicationatleastweekly;

o Allpoliciesandproceduresrelatedtoseizuremanagement;o Alistofindividualsbeingtreatedforseizuredisorders,including:


Nameofindividual; Residence/home; Diagnosis(typeofseizure);and Medicationregimen;

o Forpastsixmonths,forfiveindividuals,documentationofseizuremanagement(e.g.,neurologist’snotes),includingfor:Individual#48,Individual#140,Individual#239,Individual#181,andIndividual#209;

o Listofindividualsseenbyneurologistwithdatesonwhichappointmentswerecompletedandreason,sincetheMonitoringTeam’slastreview;

o ListofthosewithstatusepilepticussincetheMonitoringTeam’slastreview;o Listofseizuremedicationsperindividualfordiagnosisofseizuredisorder;o ListofthosegoingtoERforuncontrolled/prolonged/newonsetseizuresincethe

MonitoringTeam’slastvisit;o Listofindividualswithrefractoryseizuredisorder;o ListofindividualswithrefractoryseizuredisorderwhoarebeingevaluatedforVagal

NerveStimulator(VNS)placementandthestageofevaluation;o Numbersandpercentageofindividualsonone,two,three,four,andfiveantiepileptic

drugs(AEDs);o NumbersandpercentagesofpersonsonolderAEDs(Phenobarbital,Dilantin,Mysoline,

Felbamate);o Anytrackingofdataforindividualswhohavetransitionedtocommunitysincethe

MonitoringTeam’slastvisit,includinghospitalizations,ERvisits,and911calls.AnyFacilityreviewofadverseoutcomes,communicationwithprovideragency,anddescriptionoftechnicalassistanceprovided.AnydocumentationofthefinaltransferbetweenPost‐MoveMonitorandcommunityservicecoordinatorat90‐daytransfer;

o Forthethreeindividualsmostrecentlytransitionedtothecommunityforatleast90days,copyofseven,45,and90‐dayreports.Forthesethreeindividuals(i.e.,Individual#194,Individual#30,Individual#114),copyofCLDP,mostrecentISP,BSP,andsubsequentaddendums,mostrecentannualmedicalexamandmostrecentnursingassessment;

o SincetheMonitoringTeam’slastvisit,anyethicscommitteemeetingminutes,withattendancerosters,concerningDNRdecisions/changes;

o Datesoflasttwocompletedannualmedicalassessmentsandannualphysicalexaminationsforallindividuals;

o Datesoflasttwocompletedquarterlymedicalreviews/IPNscompletedforallindividuals;o Forspecialtyclinicappointments(oncampusandoffsite),listofappointmentsthatwere

completedandonenotcompleted(withreasons);o Numbersofindividualswithadiagnosisofseizuredisorderonnoanti‐epileptic

medications;o NumberofindividualswithVNSinplace,dateofplacement,dateofreplacement,if

applicable;o Forconcernsidentifiedneedingclosureatmorningprovider/medicalmeetingsforperiod

of30to60dayspriortoMonitoringTeam’svisit,copyofanydocumentsproviding


evidenceofclosure(minutesofmedicalstaffmeeting,copyofISPAaddressingconcern,etc.);

o Forthelastfiveindividualsinwhompre‐treatmentsedationwasadministeredforamedicalprocedure,allinformationrelatedtomedicalpre‐treatmentsedationusedpriortovisits,includingconsents,HRCapproval,relevantassessments,ISPentries,anygeneraldiscussionrecord,actionplan,andintegratedprogressnoteentries,includingthosefor:Individual#304,Individual#212,Individual#183,Individual#221,andIndividual#268;

o TenmostrecentPNMTrecommendationswithphysicianorders;o ISPAsaddressingmissedappointmentsorrefusalsforthepastthreemonthsfor

mammogramsandcolonoscopies;o Listofmissedmedicalappointmentswithreasonsforpastsixmonths;o SignatureSheetsdated7/10/12,and7/11/12forIntegratedClinicalServicesMeeting;o PresentationBookforSectionL,including:MedicalProviderQualityAssuranceAudit:

EssentialandNon‐EssentialCompliancebyProvider:ExternalAuditsforRound5,InternalAuditsforRound5;lasttwoannualmedicalassessmentsforallindividualsasof5/31/12;QAmedicalauditschedule2012;externalmedicalmanagementauditsforRound5[threediagnoses],externalauditsforRound5[30questions];externalauditsRound5resultsandactionplans;externalmedicalmanagementauditsforRound5resultsandactionplans;MedicalProviderExternalReview4/19/12exitsummary;ActionPlansfollow‐upbyQA:externalauditsforRound5,externalmedicalmanagementauditsforRound5,internalauditsforRound5,internalmedicalmanagementauditsforRound5;CompliancebyQuestionCategory:externalauditsforRound5,internalauditsforRound5;ResultsandActionPlans:internalauditsforRound5,internalmedicalmanagementauditsforRound5;Inter‐ratermedicalmanagementbydiagnosisRound5(diabetes,osteoporosis,pneumonia);medicalmanagementinter‐raterpercentagreementRound5perPCP;andinternal/externalauditsagreementbyquestionsforRound5;

o IPNs,physicianorders,labs,x‐rays,consults,from7/1/12through7/1012forIndividual#117

o ForIndividual#30,Individual#194,andIndividual#114,copyof45‐dayfollowup,andin‐servicetrainingformedicalandpsychiatricdiagnoses/issues;

o Preliminaryfindingsfromautopsy,updatedasof7/13/12;ando Foreachofthefollowingindividuals,copiesfromtheactiverecord:DG‐1,mostcurrent

annualmedicalassessmentandphysicalexam,preventivecareflowsheet,mostcurrentnursingassessment,pastoneyearofIPNs,pastoneyearoflabresultsx‐rays,scans,MRIs,ultrasoundreports,hospitaldischargesummariesforpastoneyear,ERreportsforpastoneyear,consultsandprocedurereportsforpastoneyear,DNRformsifapplicable,physicianordersforpastoneyear,mostrecentPSP/ISPandsubsequentaddendums,mostrecentBSP,andpastthreemedicalquarterlyreviews:Individual#215,Individual#31,Individual#244,Individual#213,Individual#251,Individual#144,Individual#103,Individual#294,Individual#210,Individual#65,Individual#86,Individual#158,Individual#299,Individual#356,Individual#181,Individual#253,Individual#42,Individual#156,andIndividual#72.


Interviewswith:o SandraRodrigues,MD;o NormaBrown,MD;o EugenioHernandez,MD;o SharonAlexander,FamilyNursePractitioner(FNP);o AltheaPatStewart,MedicalComplianceNurse;o CynthiaVelasquez,QualityAssuranceDirector;ando EsmeraldaVogt,AdmissionPlacementCoordinator.

Observationsof:o CoralSeaUnit:Individual#122,Individual#232,Individual#15,Individual#334,

Individual#101,Individual#79,Individual#126,Individual#260,Individual#303,Individual#244,Individual#340,Individual#342,Individual#21,Individual#205,Individual#205,Individual#366,Individual#176,Individual#104,Individual#212,Individual#57,Individual#124,Individual#179,Individual#189,Individual#183,Individual#160,Individual#280,Individual#70,Individual#150,Individual#24,Individual#93,Individual#207,Individual#270,Individual#305,Individual#272,Individual#307,Individual#16,Individual#266,Individual#252,Individual#276,Individual#23,Individual#28,Individual#134,Individual#239,Individual#319,Individual#250,Individual#299,Individual#25,Individual#50,Individual#113,Individual#130,Individual#146,Individual#163,Individual#292,Individual#327,Individual#328,Individual#324,Individual#350,Individual#301,Individual#236,Individual#293,Individual#139,Individual#127,Individual#240,Individual#68,Individual#201,Individual#290,Individual#37,Individual#32,Individual#195,Individual#77,andIndividual#314;

o Infirmary:Individual#311,Individual#137,Individual#43,Individual#376,Individual#181,Individual#357,Individual#308,Individual#136,andIndividual#156;

o AnnualISPmeeting,on7/12/12forIndividual#156;ando Medicalmorningmeetings,on7/11/12,7/12/12.

FacilitySelf‐Assessment:TheFacilityhadengagedinsomereasonableactivitiestomeasurecompliancewithSectionL.Forexample,tomeasurethetimelinessofroutine,preventive,andemergencymedicalcare,theMedicalDepartmenttrackedthecompletionofseveralaspectsofhealthcare,includingcompletionofon‐campusappointments,whichtheFacilitymeasuredasgreaterthan80%.TheFacilityalsolookedatwhetherornotoff‐campusappointmentswerekept.ForthosewithDownsyndrome,theFacilitylookedatwhethertheyhadtherequiredTSHscreening.TheFacilitymeasuredthisasbeingat100%.TheFacilityalsolookedatthecompletionofcolonoscopiesandmammograms,whichtheyindicatedoccurredingreaterthan90%oftheeligiblepopulation.InitsSelf‐Assessment,theFacilityalsoincludedinformationabouttheExternalMedicalProviderAudits.TheFacilityindicatedthatcomplianceofessentialcomponentsoftheauditrangedfrom80to100%.Fornon‐essentialcomponents,compliancerangedfrom89to97%.ThisprocessandtheresultsarediscussedfurtherwithregardtoSectionL.2.


However,theFacility’sSelf‐AssessmentforSectionLrequiredsignificantexpansion.Forexample,theFacilitywaslookingatsomediscreteaspectsofroutineandpreventativecareforSectionL.1.BecauseSectionL.1coversallroutine,preventative,andemergencycare,theFacilityshouldincreasethecomponentsoftreatmentandcarethatitself‐assesses.Overall,theFacility’sSelf‐AssessmentdidnotreferencetheclinicalguidelinesStateOfficehadissuedoranyassessmentofwhetherornottheFacilitywasimplementingthemeffectively.Similarly,forSectionL.4,theFacilityfocusedinonthedevelopmentofonepolicyinitsself‐assessmentactivities.However,SectionL.4requirestheestablishmentofanentiresetofpoliciesrelatedtotheprovisionofmedicalcare.Asnotedinothersections,itappearedthattheFacilitywasimplementinganumberofmonitoringtoolsrelatedtotheprovisionofmedicalservices.However,thisdatawasnotevidentintheSelf‐AssessmentforSectionL.TheFacilitydetermineditwasnoncompliantwithSectionL.ThiswasconsistentwiththeMonitoringTeam’sfindings.However,muchworkwasneededtoimprovetheFacility’sself‐assessmentactivitiesforSectionL.SummaryofMonitor’sAssessment:Progresshadbeenmadeinanumberofareas.Preventivemedicalproceduressuchascolonoscopiesandmammogramsweretrackedandcompletedatarelativelyhighrate(94to96%).Severaltrendanalyseswereavailableasaresultofmedicalcompliancemonitoring.However,theinternalqualityimprovement(QI)/medicalcompliancemonitoringofclinicalcarewasdelayedduetoalackofguidanceinchoosingclinicalindicatorstobeusedforspecificclinicalconditions/diagnoses.Atthetimeofthereview,theFacilityhadnoMedicalDirectortoprovideguidanceinanumberofareas,includingmedicalcompliance.Themorningmedicalmeeting,whichwasrecentlyrenamedastheIntegratedClinicalServicesMeeting,providedevidencethatabasicprocesswasinplacetoprovidequalityreviewandoversightofhealthcare.However,anumberofareasrequiredfurtherdevelopmentandfine‐tuning,suchasensuringdocumentationoftheactualreasonthegroupwasmakingareferraltotheIDT,whenapplicable.Themorningteamalsoneededtofocusonaskingcriticalquestions,andconductingcriticalreviewoftheISPAsthatresultedfromtheirreferrals.Thedocumentsthemorningmedicalmeetingproducedprovidedatrackingmechanism.However,thequalityofthetrackingrequiredfurtherattention.Inotherareas,atemplatewasneededforquarterlymedicalreviewsthatcouldbecompletedquicklyandaccurately.Formostrecordsreviewed,thesehadnotbeendone.Althoughanexternalnon‐facilityphysicianreviewhadbeenconducted,theFacilityhadquestioneditsaccuracy.BasedontheMonitoringTeam’sreview,concernswerenotedwiththepotentialthoroughnessofthereviewofnumerousrecordsinashortperiodoftime,aswellasalackofestablishedinter‐raterreliabilityamongstreviewers.Inaddition,althoughcorrectiveactionplanshadbeendevelopedtoaddressPCP‐specificconcerns,nodocumentationwasavailabletoshowthatfollow‐uphadoccurred.Inaddition,


nosystemiccorrectiveactionplansweredevelopedorimplemented.Althoughmortalityreviewshadbeencompleted,documentationwasnotsubmittedtoshowthatfollow‐uphadoccurredtoaddresstherecommendationstheyincluded.TheFacilitydidnotappeartohaveincorporatedtheclinicalprotocols/guidelinesintothemonitoringprocesses.Inaddition,theMedicalDepartmentwasbeginningtoanalyzesomeofthedataitwascollecting,butdidnotyethaveasystemforwritingquarterlyreportsthatfocusedattentiononareasofstrengthsandweakness.Forinstance,measuringtheimpactofthemorningmedicalmeetingbyprovidingthenumberofconcernsreferredtotheIDTs,thenumberofpost‐hospitalISPAsreviewed,thenumberpost‐hospitalISPAsapproved,thenumberofISPAsreturnedtotheIDTforfurtherreview,thenumberofconcernsprovidedclosureeachmonth,etc.wouldreflecttheactivityofthemorningmeetingandtheMedicalDepartment.FormanyofthefunctionsandclinicalareasforwhichtheMedicalDepartmentwasresponsible,itwillbeimportanttodesignkeyindicatorsoroutcomemeasurestoassisttheFacilityinidentifyingareasofhighperformanceandareasrequiringattention.

# Provision AssessmentofStatus ComplianceL1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshallensurethattheindividualsitservesreceiveroutine,preventive,andemergencymedicalcareconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare.ThePartiesshalljointlyidentifytheapplicablestandardstobeusedbytheMonitorinassessingcompliancewithcurrent,generallyacceptedprofessionalstandardsofcarewithregardtothisprovisioninaseparatemonitoringplan.

GiventhatthisparagraphoftheSettlementAgreementincludesanumberofrequirements,thissectionofthereportincludesanumberofdifferentsubsectionsthataddressvariousareasofcompliance,aswellasfactorsthathavetheabilitytoaffecttheFacility’scompliancewiththeSettlementAgreement.Thesesectionsincludestaffing,physicianparticipationinteamprocess,routinecareandpreventativecare,medicalmanagementofacuteandchronicconditions,andDoNotResuscitate(DNR)Orders.StaffingandAdministrationBasedondocumentationtheFacilityprovided,forthecensusof261asof5/18/12,therewerefourPCPsresponsibleforthispopulation.TheMedicalDirectorpositionremainedvacant.ThePCPshadcaseloadsrangingfrom59to75.AMedicalComplianceNurseandMedicalProgramSpecialistassistedtheMedicalDepartmentinmedicaladministrationandmedicalQA/QI.Threephysicianconsultants(i.e.,orthopedics,neurology,psychiatry)werelistedthatprovidedphysicianservicesonsite.AlistwassubmittedindicatingthosemembersoftheMedicalDepartmentthatremainedcurrentinCPRcertification.Thelistwasdated4/1/12.Oftheprimarycareprovidersinthedepartment,fouroutoffour(100%)werecurrentinCPR.OfthefourPCPsintheMedicalDepartment,alistofCMEcreditswassubmittedforthepriorsixmonthsfornoneofthesePCPs.VerificationwiththeformeractingMedicalDirectorconfirmedthatnoneofthePCPshadcompletedCMEcreditsinthepriorsixmonths,althoughonePCPwasscheduledtoattendamedicalconferencetheweek

Noncompliance


# Provision AssessmentofStatus CompliancefollowingtheMonitoringTeam’svisit.AllPCPshadcurrentlicensure,indicatingthenumberofCMEhoursforlicensurehadbeenmaintainedforrenewalpurposes.ThepurposeofreviewingCMEwastodetermineiftheCMEfocusedondiagnosesandtopicsthatwouldenhancethepracticepatternsofthePCPsatCCSSLC.PhysicianParticipationInTeamProcessForthetwomorningmedicalmeetingsobserved,therewasasignedattendancerosterforbothmeetings(i.e.,7/10/12,and7/11/12).Forboththe7/10/12and7/11/12meetings,sevendepartmentsattended(i.e.,medical,dental,nursing,pharmacy,psychology,psychiatry,andPNMT).Forthetwomorningmedicalmeetingsobserved,nocriticalclinicalquestionswereraisedduringdiscussionsofhealthcare.Forexample,therewasnodiscussionofreviewofpre‐hospitaleventsorassignmenttogatherinformationtoreviewthehospitalizationforIndividual#270withanadmittingdiagnosispneumonia,whichoccurredduringtheMonitoringTeammember’sattendanceatthemorningmedicalmeeting.Earlierintheweek,amemberoftheMonitoringTeamandthePNMTmadeenvironmentalobservationsofthisindividual’sroomatwhichtime“dustanduncleanenvironment”werefound.Documentationinthe7/12/12morningmedicalmeetingindicatedthatthe“roomhasbeenonenvironmentalcheckswithpoorperformancesincepriorto8/31/10.”Forthetwomorningmedicalmeetingsobserved,theon‐callPCP(fromthepriorevening)participatedbypresentingthecases.TheattendingPCPfortheindividual(whennottheon‐callPCP)participatedinthediscussions/providedadditionalinformationwithregardtotwooffourhealthstatuschanges/on‐callconcernsforindividualsthatwerehospitalized.Forthetwomorningmedicalmeetingsobserved,noassignmentsforfurtherupdateswereidentified.Forthetwomorningmedicalmeetingsobserved,updatedinformation/ISPAwaspresentedforclosureforoneindividual.Additionally,otherbusinesswasconductedduringthemorningmedicalmeetingsobserved.Forexample,thegroupcommencedaweeklyPNMTreviewatthemorningmedicalmeeting.InpreparationfortheMonitoringTeam’svisit,theFacilitysubmittedthemorningmedicalmeetingminutesfromApril2012.Theseappearedtoincludethespanofthemonth,althoughsomesubmittedinformationhadthedatecutoff,andtwoadditional


# Provision AssessmentofStatus Compliancesubmissionswerefollow‐upsinMay2012.Noattendancerosterswereincludedwiththeseinitialsubmissions.Theminutesincludedabriefdiscussionbythemorningmedicalteamwithsubsequentreviewoffollow‐upISPAsoremailsthathadbeendevelopedorsenttoclosespecificconcernsthemorningmedicalteamhadsenttoIDTs.Theseincludedclosureinformationfor:

Individual#181(ISPA4/11/12,orthopedicconsult4/18/12); Individual#247(follow‐upemail4/25/12,orthopedicconsult4/18/12); Individual#202withspecificrequestfortheIDTtoaddressherfalls(ISPA

3/27/12); Individual#194(ISPA3/30/12reviewedandwassentbacktotheIDTfor

furtherreviewofpreventingpotentialaspiration.Afollow‐upISPAwassubmitted4/17/12withmorningteamdiscussionon4/23/12.Thisisdiscussedfurtherbelow.);

Individual#326(teamrequestedPNMPreviewandreviewoffalling,withemailresponse4/23/12.Thisisdiscussedfurtherbelow.);

Individual#163(3/30/12emailconfirmingcoachingofthenurseresponsibleforamedicationerror,broughtupbythemedicalteam);

Individual#372(4/4/12ISPAwithactionplansinresponsetomedicalteamrequestforPNMPreviewoffrequentfalls);

Individual#156(theteamnotedthatintakeandrefusalswerenotbeinglogged,indicatingtheneedfordirectsupportprofessionaltraining.Thisisdiscussedfurtherbelow.);and

Individual#136hadafollowupISPAtopreventfurtherfallingfromhisbed.Thereremainedalackofdocumentationofcriticalclinicaldiscussionorcleardocumentationofclosureforthefollowingconcerns:

WithregardtoIndividual#176andeffortstoreducerepeatedhospitalizations(i.e.,minutesrecordedhospitalizationon3/12/12,3/20/12,and4/4/12)withreturnfromthehospitalon4/12/12,noteamdiscussionoccurredofprecursoreventstothehospitalization,orpreventivestepstostopfuturehospitalization.

Individual#202wasdiscussedatthemorningmeetingwithcriticaldiscussionofherfalls,especiallyasshewasprescribedCoumadin,whichcouldincreasebleedingrisk.TheIDTrespondedwithanISPA.However,therewereadditionalconcernsthattheISPAdidnotaddress,andnoadditionalinformationorrequestswereprovidedinresponsetotheISPAfindings.Forinstance,onefallwasduetoslippingonawetfloor,possiblyfrom“aleakintheceilingorleakonthewall.”TheISPAindicated:“aworkorderwassenttomaintenancedepartmenttocheckandrepairleak.”GivenadangerouscombinationofaslipperyenvironmentandanindividualonCoumadin,thereneededtobeevidenceofclosure(i.e.,datemaintenancerepairedtheproblem,orwhatwasfoundifitwasdeterminedthatitwasnotamaintenanceissue,andwhatwas


# Provision AssessmentofStatus Compliancebeingdonetoprovidesafetywhilerepairsweredoneordelayed).Anadditionalfalloccurredwhenshegotoutofbedandlostherbalance.Therewasnospecificinformationaboutheradaptiveequipmentandhowtodeterherfromtakingitoff.Therewasnospecificactionstepaboutherfallon3/18/12whensheattemptedtogetoutofbed.Theonlyitemmentionedwasachangeinherseatbeltbuckle,whichdidnotappeartoapplytoherfallingoutofbedorthefallontheslipperyfloor.Despitethehigh‐risksituationoffrequentfallinginanindividualonCoumadin,therewasnofurtherrequestforteaminterventiontopreventarecurrence.Moreproblematic,therewasnoapparentoversightoftheISPAprocessfromtheresidentialorotheradministrativeservicesinreviewingthequalityofthecontentoftheISPA.

Individual#194wasfurtherdiscussedafterthemedicalteamreviewedanupdatedISPAof4/17/12concerningaspirationrisk.ThiswasaddressedintheISPA.However,otherissuesintheISPA,suchastheJ‐tubecloggingtwotimes,andtheJ‐tubebeingpulledouttwicewerenoted.Oneofthereasonsforthetubebeingpulledoutwashisself‐repositioningwhileintherecliner,andstafftrainingwasprovidedasevidenceofproactivestepstaken.Thiswasclearevidenceofapro‐activestep.However,thecloggingoftheJ‐tubedidnotappeartobeaddressed.TherewasthephrasethattheJ‐tubewas“afaultyjtube,”whichexplainedthetubeclogging.Itwasnotclearhowitwasdecidedthatthiswastheproblem,becauseitcanbeduetomedicationsnotbeingcrushedproperly,insufficientflushesofwateraftermedicationadministration,etc.,ratherthanadefectivetube.However,iftrue,theFacilityneededtoresearchtheavailabilityofbetterqualityJ‐tubesforitsindividuals.Therewasnofurtherrequestfromthemorningmedicalmeeting.Theissuewasclosed,althoughitappearedmorestepswerenecessarytoresolvethetubecloggingorreviewingthequalityoftheJ‐tube.

Individual#326hadfrequentfalling,andtheteamrequestedfurtheraction/reviewbytheIDT.Theemailof4/23/12providedfurtherinformation.However,oneofthefallswasduetoapeerpushingtheindividualdown,buttherewasnofurtherinformationconcerningwaystopreventareoccurrence,suchasincreasedsupervisionofthepeerortheindividual,etc.Therewasnofurthermedicalteamdocumentationrelatedtoreviewoftheemailorfurtherquestionstoaddressthefalls.

Individual#315hadpossibleingestionofpartsofherfeedingtube,andanemailfromtheIDTrespondedwithanISPA,dated4/3/12,thatputinplaceanincreasedlevelofsupervision.However,thedocumentationstatedapartofthetubehadbeenfound,anditwasnotclearwhereorhowithadbeenfoundtoconfirmtherewaspicaornot.TheISPAof4/3/12indicatedfurtherfollow‐uptothepicaincidentsoccurringrepeatedlyonthe2p.m.to10p.m.shift,buttherewasnofurtherinformationastothefindingsatthe30‐dayreviewbytheIDT,or


# Provision AssessmentofStatus Complianceifthatinformationwouldbesharedwiththemedicalteam.TheISPAof4/3/12appearedtobeaninterimstepwhileinformationwasbeinggathered.TherewasnofurtherdocumentsubmittedindicatingwhathadbeentheoutcomeofthestepstakenintheISPAof4/3/12,andhowfurtherpicawouldbeprevented(e.g.,moresupervision,moreactivetreatment,etc.).

Individual#43wasdiscussedintheminutesconcerningInfirmaryconcernswiththedirectsupportprofessionalsandrepositioning.A4/3/12emaildiscussedtheRN’sconcerns,buttherewasnofurtherdocumentationofresolutionoftheconcern.

Individual#156wasreviewed,withthemorningteamrequestingtrainingofthedirectsupportprofessionals.Anemailwasreceivedon4/18/12,butdidnotprovideinformationabouttrainingcompletedorintentionstotrain,butaskedsomefurtherquestionsaboutthefluidsofferedtotheindividual.Thisremainedincomplete.

Individual#172wasreviewedandthemedicalteamquestionedhisaccesstoalighter,buttheresponseemaildated5/7/12,althoughprovidinginformationrelatedtotheeventinwhichheattemptedtolighthisclothingonfire,didnotaddresschangesinhisBSPconcerningaccesstoalighter,thementalhealthstatusoftheindividual,and/orwhetherfollow‐upwithpsychologyorpsychiatrywascompleted(“psychwasnotified”).Suchvaguestatementsas“psychwasnotified”provideevidenceofaction,butdidnotprovideevidenceofclosure.Therewasnonotethatthisinformationwasbroughtbacktothemedicalteamforreviewand/ortheresponseofthemedicalteam.

Forclarityofinformation,itisimportanttoindicateifthemorningmedicalmeetingspecificallyreviewedafollow‐updocument.AnappointedmemberoftheMedicalDepartmentcouldreviewthedocumentaheadoftimeandselectimportantstatementstoreviewatthemorningmedicalmeeting.Itisalsoimportantthatasapplicable,therebeastatement/phrasethatthemorningmedicalteamagreedwithanISPAaswritten.Ifitistobereturnedforfurtherreview,theminutesshouldbrieflyindicatethereason,andfutureclosurecanreferbacktothereasonitwassentbacktotheIDT.Itisrecommendedthatbriefconciseentriesdescribingdiscussionofcriticalquestionsatthemorningmeetingberecordedintheminutes.Thesequestionscanthenbedelegatedtoamemberoftheteam,thePCP,anotherdepartment,ortheIDT,dependingontheconcern.ThispracticewouldassisttheFacilityindocumentingafocusoncriticalquestioningoftreatmentandprevention,andprovideevidenceofqualityinthemedicalcareprocess.Thesefocusedquestionsshouldbefollowedtoclosure.Thereappearedtobeclosureoftheday‐to‐dayclinicalconcerns,buttherewaslessclosureinformationoncriticalquestions,systemsissues,andISPAs.Thesectionoftheminutesentitled:“Otherissuesdiscussed”wouldbetheexpectedlocationfordocumentingprogressonclosure.


# Provision AssessmentofStatus ComplianceForthoseareasdeterminedtobenon‐clinical(e.g.,environmental,etc.),referraltotheappropriatedepartmentwouldbeappropriate,witharequestforafinaldocumentansweringthequestionsorconcernstoallowmembersofthemorningmedicalmeetingtodiscussandclosesuchissues.Furthermorningmedicalteamminutesweresubmittedfrom6/13/12through7/12/12.Attendancerosterswereincludedforthesedocuments.Anexampleofdocumentationofanexcellentclinicaldiscussionoccurredon6/25/12concerningIndividual#239andrelatedtoapproachestopreventarepeathospitalization.Italsowasnotedthatopenbookreviewsforthosewithaspirationpneumoniacontinuedtooccur,whichwaspositive.On6/29/12,therewassuchareviewforIndividual#327.However,anexampleofaconcernneedingclosurewasa7/5/12entryforIndividual#179inwhichanursewastoaddresstheIDTandnursesconcerningtheindividual’sJ‐tuberecurrentlycomingout.Therewasnodaterecordedwhenthiswasaccomplished(neededforclosure).Additionally,inthiscase,forwardingacopyofthehandoutoroutlineofdiscussionwouldbeavaluableareaoflearningforallthemorningmedicalattendeestoassistintheirunderstandingoftheinstructionsthataregiventostaff.ItalsowouldbeanopportunitytoprovidefeedbacktotheNursingDepartmentfromotherdepartmentsonthecontentoftheinstructions.Therewerealsoconcernsthatthemorningmedicalmeetingprocesswasnotcriticallyreviewing/screeningmanyoftheISPAsthatfocusedonmedicalconcernstodetermineiftheISPAactionplanswereadequatetomeettheneedsoftheindividual.TherewasdocumentationthatsomeISPAswerereviewed(asmentionedabove)andreturnedtotheIDTforfurtheranalysis.However,itappearedthatforanumberofISPAs,theinitialreview/discussionwascursoryanddidnotchallengetheteamstoincludepreventiveactionsteps.MuchoftheroleofaddressingthequalityoftheISPAsrestedwiththeQDDPDepartment.AlthoughthemedicalmorningmeetingwasnotintendedtoprovidequalityoversightfortheISPAprocess,itdoesplayanimportantroletoprovidetechnicalguidanceandensuretheteamsaddressadequatelythehealthandsafetyoftheindividuals,withtheaddedfocusonprevention.AnexampleoftheneedfortheMedicalDepartmenttoreviewtheISPAandtorecordfindingsthroughtoclosurewasasfollows:On4/24/12,therewasanISPAforIndividual#137indicatingthattheIDTdiscussedreplacingthepaddingonthebedrails.Thepaddingwas“nolongerconsideredacceptable.”TheHabilitationDepartmentwastobeconsulted.On6/15/12,theindividualthensustainedanobliquefractureofthelowerleg,andtheconclusion/beliefwasthatthebodyhadbeenwedgedbetweenthemattressandthebedrail.Basedonthe6/15/12ISPA,themedicalmorningminutesdidnotreflectadiscussionorneedforanupdateastowhethertheoriginalbedrailconcernhadbeenresolved,wasstillpending,orthereplacementpadding/wedges,etc.neededfurther


# Provision AssessmentofStatus Compliancereview.Questionsraisedfromthe6/15/12ISPAwouldhaveuncoveredtheearlierISPAandtheneedforclosureinformationfromtheIDT.SeveralISPAshadbeenheldforthisindividualduringthistime,butnonedocumentedthefindingsandinterventionoftheHabilitationTherapyDepartment,orthetrainingthedirectsupportprofessionalsandnurseswouldneedfornewpadding/wedges,orotherequipment.ItwasnotfurthermentionedinsubsequentISPAs.Themorningmedicalmeetingparticipantswouldnotnecessarilybeawareofthe4/24/12ISPA(althoughothersattheFacilityshouldhaveensuredclosureoftheISPAconcerns),butthe6/15/12ISPAconcerningthefractureshouldhaveledtoquestionsandarequestforreviewofthepaddingandbedrails.ThegroupshouldhavechallengedtheIDTtoprovidepreventivestrategiesfortheindividual’sosteoporosiswhethertheindividual’swaslocatedinbed,inachair,inawheelchair,van,etc.TheFacilityshouldhaveproceduresinplacetoensureallactionstepsinISPAsareaddressedanddocumented,andtoensureprogressorlackofprogressiscommunicatedtotheIDT.RoutineCareAlistofdatesofthelasttwoannualmedicalassessmentsandphysicalexamsweresubmitted.Ofthese,withtheexceptionofnewadmissionsintheprioryear,153outof265(58%)oftherecentannualmedicalassessmentswerecompletedwithin365daysofthepriorassessment.Whenreviewingthemostrecentdatesofthecompletedannualmedicalassessments,234outof265(88%)werecompletedwithintheprior365days,and31wereoverdue.Thedateofthereportwaspartlycutoff,butappearedtobe6/22/12.Acutoffof30daysprior(5/22/12)wasusedasawindowoftimetorecordanycompleteddocuments.Atthetimethatthisinformationwassubmitted,itwasnotedthatthemostrecentdateofphysicalexamcompletionwasnotavailableforthisdatabasefor77individuals.Only188of265(71%)hadcompleteinformation.Thissuggestedthedatabasewasnotreviewedatregularintervals,asthiswouldhavebeeneasilycorrected,andthatthelackofdatamadeinterpretationdifficultfortheMedicalDepartment.ItwaslearnedduringtheMonitoringTeam’svisitthattheblankspacesforthemostrecentphysicalexamoccurredinpartbecause,after1/1/12,thephysicalexamwascompletedatthesametimeastheannualmedicalassessment.However,therewasnokeytointerprettheblankspacesinthedata.For20individuals,acopyofthemostrecentannualmedicalsummaryandphysicalexaminationevaluation,aswellasthepriorannualmedicalsummaryandphysicalexaminationevaluationweresubmittedforreview.Thesearelistedaboveinthedocumentsreviewedsection.Timelinesswasdeterminedifthemostrecentannualmedicalsummaryandphysicalexaminationevaluationwascompletedwithin365daysofthepriorannualevaluation.Forthe20individuals,compliancewas16outof20(80%).


# Provision AssessmentofStatus ComplianceForthe20mostrecentannualmedicalassessments,therewasanintervalhistoryincludedaspartofthedocumentin20of20reviews(100%).However,threeoftheseintervalhistorieswerenotedtobebrief.Forthe20mostrecentannualmedicalassessments,themajoractiveproblemslistedhadplansofcareaddressingeachoftheseproblemsin16of20assessments(80%).Foroneplanofcare,thedocumentationforosteoporosisappearedincompleteormayhaveindicatedunder‐treatment.Forone,thedocumentstatedtherehadbeennoseizuresinthepastyear,whentheindividualwashospitalizedwithseizuresin2012.Oneplanofcarewasconsideredbriefandneededfurtherdevelopment.Forthe20mostrecentannualmedicalassessments,19outof20(95%)addressedsmokinghistory.Familyhistorywasadequateintwooutof20(10%).For12outof20,thedocumentstated“noneavailable.”Forone,apsychiatrichistorywasprovided,butnomedicalhistory.Forfive,theinformationprovidedwaslacking,briefandincomplete,orotherwisenothelpful.ItisrecommendedthattheMedicalDepartmentinitiateaperiodicreviewoftheannualmedicalassessmentstoensureallcomponentsareincluded,aswellasdevelopcriteriatoassessqualityofthevarioussubsectionsoftheannualmedicalassessment.Aspartofthemonitoringreviewprocess,theMonitoringTeamselectedthemedicalrecordsof19individualstodeterminecompliancewithseveralrequirementsofSectionL.1.Theseindividualsarelistedinthedocumentsreviewedsection.Thereviewsselectedwerebasedonacoupleofsamplingmethods.First,every21stnamelistedonacensuswasselected,afterthefirstnamewaschosenbyrandomselection,resultingin13individualsbeingselected.Asecondgroupofsixwasselectedbyidentifyingindividualswithvariousdiagnoses/healthcareissues,andselectingoneindividualratedhighriskineachofsixatriskcategories(e.g.,aspiration,GERD,skinbreakdown,cardiacissues,etc.).ThisadditionalsamplewasdonetoallowtheMonitoringTeamtocommentontheappropriatenessofthehealthcareprovidedtoindividualswithvariousmedicalneeds.Documentsreviewedincludedthepreventivecareflowsheet,physicianordersfromthepast12monthsuptothepresent,integratedprogressnotesfromthepast12monthsuptothepresent,mostrecentBSP,lastannualISPandsubsequentaddendums,labs,x‐rays,consultformsfromthepast12monthstothepresent,themostrecenthealthmanagementplan,themostrecentannualmedicalassessmentandphysicalexam,theDG‐1,themostrecentnursingassessment,anyhospitaldischargesummaryforthepastyear,ERvisitsforthepastyear,andanyconsultreportsandprocedurereportsfromthepastyear.Eachaspectisdiscussedastherelevantpreventiveorroutinecaretopicis


# Provision AssessmentofStatus Compliancediscussed.From19medicalrecordsreviewed:

Fourteen(74%)annualmedicalassessmentshadbeencompletedinthepast365days.

Activeproblemlistsappearedtobethoroughin13(68%).Itwasnotedthatinoneannualmedicalsummary,noactiveproblemlistwasincluded,andnoseparateactiveproblemlistwassubmitted.

Fifteen(79%)hadinformationaboutsmokinghistoryand/orsubstanceabuse. Anadequatefamilyhistorywasdocumented(ortherewereattempts

documentedatobtainingthisinformation)inthreeof19(16%)records.Forthreeof19(16%),therewasalimitedfamilyhistoryprovided.For13of19(68%)charts,thefamilyhistorywas“notavailable”ornotlisted.

Seventeen(89%)hadinformation/recommendationsdiscussingrequirementsfortransition.

TheDG‐1formswerereviewed.Ofthe19DG‐1sreviewed,one(5%)hadupdatedandcompletediagnosesconsistentwiththeactiveproblemlist.

ThesemedicalrecordsalsowerereviewedtodeterminewhetherthephysicianIPNnotesusedtheSubjective,Objective,Assessment,andPlan(SOAP)format.In19(100%),theSOAPformatwasused,andincludeddateandtimeontheIPNs.Twomedicalrecords(11%)hadaPCPquarterlyreviewofmedicalprogressduringanyquarterintheprioryear.Norecordhadmorethanonequarterlymedicalreviewintheprioryear.Contentsofthequarterlymedicalreviewincluded:

Listingofnewmajordiagnosesinoneoftwomedicalquarterlyreviews(50%). Thelastthreemonthlyweightsinnoneoftwomedicalquarterlyreviews(0%). Briefcomments/entrieslistingnumbersofseizures(ifapplicable)inzeroofone

medicalquarterlyreviews(0%).Foronerecord,thiswasnotapplicable. Changesinmedicationintwooftwomedicalquarterlyreviews(100%). Important/abnormallabsanddruglevelsinoneoftwomedicalquarterly

reviews(50%). ERvisits,andhospitalizationswithdatesanddischargediagnoses/treatmentsin

oneofonemedicalquarterlyreviews(100%).Thiswasnotapplicableforonerecord.

Importantconsultationresults(brief)inoneofonemedicalquarterlyreviews(100%).Thiswasnotapplicableforonerecord.

Twooftwomedicalquarterlyreviews(100%)wereplacedintheIPNsectionoftheactivemedicalrecord,orreferencedbyanIPNconcerningdateof


# Provision AssessmentofStatus Compliancecompletioniflocatedelsewhereinrecord.

AccesstoSpecialistsThefollowingnumbersofoff–sitevisitsforconsultationorproceduresweredocumentedtohaveoccurredfromDecember2011throughMay2012:

CancerCenter:11appointments; Cardiology:62appointments; Dental:13appointments; Dermatology:eightappointments; Endocrinology:14appointments; Gastroenterology:nineappointments; Gynecology:18appointments; Nephrology:sixappointments; Neurology:30appointments; Operativereportconsultations(notfurtherdefined):31appointments; Ophthalmology:92appointments; Podiatry:21appointments; Pulmonarymedicine:11appointments;and Urology:29appointments.

Ofatotalof434appointmentsscheduled,355appointmentswerekept,and79appointmentsweremissed.Thiswasanattendancerateof82%.Ofthe79appointmentsmissed,25werecategorizedasrefusals(32%).Otherreasonsformissedappointmentsincluded:consultantnotinoffice,rescheduled,individualinhospital,pre‐visitordersnotwritten,notsedated,behavior,onfurlough,nostaffavailable,andpaperworknotcompleted.Atrackinglogshouldbemaintainedtoensureappointmentsmissedarerescheduledandsubsequentlycompletedatafuturedate,andthatmissedappointmentsarereviewedatIDTmeetings,withevidenceofthedateofthemeetingrecordedinthetrackinglog.Onsite,severalspecialtyclinicswereheldtomeettheneedsoftheindividuals.TheseincludedAudiology,Neurology,Orthopedics,andPsychiatry(furtherdiscussedwithregardtoSectionJ).ForAudiologyclinics,from1/2/12through5/10/12,therewere234completedappointmentsoutofatotalof319appointmentsscheduled.Thecompletionratewas73%.ForNeurologyclinics,from2/4/12through4/28/12,therewere68appointmentskeptand71appointmentsscheduled.Thecompletionratewas96%.ForOrthopedicsclinic,from1/18/12through4/18/12,therewere21appointmentscompletedof25appointmentsscheduled.Thiswasacompletionrateof84%.ThequalityofthebackgroundinformationprovidedbythePCPsintheconsultation


# Provision AssessmentofStatus Compliancereferralsisreviewedaspartofthepeerreviewprocess.ThisisdiscussedinfurtherdetailwithregardtoSectionsL.2andL.3.Inaddition,theMonitoringTeam’sfindingswithregardtothefollow–uponconsultationsarediscussedwithregardtoSectionG.2.PreventiveCarePreventivecareflowsheetswereinplacetofacilitatetrackingofstandardtestingandevaluationsin19outof19recordsreviewed(100%).Preventivecareflowsheetswereup‐to‐datein14outof19recordsreviewed(74%).Currentvisionscreeningwasdocumentedin19outof19oftherecordsreviewed(100%).Ofthese19,twoindividualswereblind,onewas“difficulttoassess,”andonehad“adequatevision.”Audiologicalscreeningwascurrentin19outof19recordsreviewed(100%).Twowerecompletedin2010,andwouldbeduein2013.Twelvewerecompletedin2011,andfivewerecompletedin2012.Theinfluenzavaccinationhadbeengivento19individuals(100%)inatimelymannerduring2011.Whethertheindividualneededtoreceivevaricellavaccine(dependingonbirthdateandimmunitystatus),andwhetheritwasgivenifindicated,wasrecordedin18ofthe19activerecordsreviewed(95%).Therewasoneindividualforwhomlabworkwaspendingtodetermineimmunity.WhethertheindividualneededtoreceiveahepatitisBvaccine(dependingonimmunitystatus,carrierstate,etc.)andwhethertheserieswascompletedifindicated(orbeingtrackedforcompletion)wasrecordedin19ofthe19activerecordsreviewed(100%).Alistwassubmitteddated5/18/12,indicatingwomenresidingatCCSSLCwhowereovertheageof40,alongwiththedateofthelastmammogram,andthereason,ifitwasnotdoneoroutdated.Atotalof97womenwereidentifiedasbeingovertheageof40(thelistincludedafewundertheageof40,butthesewereremovedforthisreview).TheAmericanCancerSocietyrecommendationsweretobefollowed,accordingtoaDADSSSLCpolicy#009.1,dated2/16/11.Ofthese97women,17hadreasonsnottohaveamammogram(e.g.,guardianrefusal,inabilitytophysicallyprovideproperpositioningforthetest,etc.).Oftheremaining80women,77hadmammogramswithintheprioryearorwerescheduledinthenearfuture.Thiswasacompliancerateof77outof80(96%).


# Provision AssessmentofStatus ComplianceFromthesampleof19medicalrecordsreviews,eightfemaleswereovertheageof40.Ofthese,sevenwereeligibleforamammogram.Onehadmedicalreasonsfornotcompletingamammogram.Allseven(100%)wereup‐to‐dateonmammogramtesting.Fromthesampleof19activerecordsreviewed,therewere10females.Fromthesampleofthese10activerecords,seven(70%)didnotmeetcriteria/haveriskfactorsthatnecessitatedtestinginthepriorthreeyears.Fortheremainingthreeindividuals,twofemales(67%)hadpapsmearscompletedwithinthepriorthreeyears.TheMedicalDepartmentsubmittedalistofthoseindividualsovertheageof50withthedateofthelastcolonoscopy,withthereasonforthecolonoscopy.Atotalof132namesweresubmitted.Ofthese,sixhadreasonsnottoorderacolonoscopy.Therefore,theeligiblepopulationwas126individuals.Ofthese,119completedacolonoscopywithintheprior10yearsorhadrecentlyturned50yearsofage,andanappointmentwaspending.Atotalof119outof126(94%)hadcompletedanappropriateprocedureinatimelymanner.Ofthe19activerecordsreviewed,11wereatage50orgreater.Ofthe11,10(91%)hadcolonoscopiescompletedinpastsevenyears.Oneindividualwas50yearsofageandtherewasnoinformationthatonehadbeenscheduled.Alistofindividualswithadiagnosisofosteopeniaorosteoporosiswassubmitted.Identificationofthemedicationsanddosagesofthemedicationstreatingthesediagnosesalsowasrequested.Additionally,forallthoseovertheageof50,alistofthelastDEXAscandateandcopiesofthemostrecentDEXAscanreportwererequested.Atotalof101individualswithadiagnosisofosteopeniaorosteoporosiswerereviewed.Ofthese,97(96%)hadaDEXAscanTscoresubmitted.Ofthe101individualsreviewed,91weredeterminedtohaveosteoporosis.Ofthese91individuals,68(75%)haddocumentationofadequatetreatment.FifteenindividualswereonlyreceivingcalciumorVitaminDwithoutadditionalmedication,andeighthadnodocumentationofcalciumorVitaminDsupplementation.Forthese23,therewerenonotationsprovidingrationalecontraindicatingusualrecommendedtherapy.Ofthe101,10hadosteopenia.Ofthese,itwasnotedthatsixwereprovidedmedicationand/ormedicationdosagesthatexceededrecommendeddosagesforosteopeniaandwereregimensusedforosteoporosis.Ofthese10,threedidnothavedocumentationofcalciumorVitaminDsupplementation.Formenandpremenopausalwomenwithadiagnosisofosteopeniaorosteoporosis,theFacilitywasaskedtosubmitacopyofanylabworkusedtotestforsecondarycauses(fromthecurrentactiverecord)forthisdiseaseprocess.Therewasnoinformationsubmitted.



Fromthesampleof19medicalrecordsreviewed,11hadadiagnosisofosteoporosisorosteopenia.

Ofthese11,nine(82%)hadaDEXAscanTscorerecorded. Ofthese,nineofnine(100%)hadaTscoreconsistentwiththediagnosisof

osteoporosisorosteopenia. ForthoseninewithTscoresindicatingosteoporosisorosteopenia,nine(100%)

hadbeenprescribedsupplementalcalciumandvitaminD. Ofthese,fourhadabisphosphonateordered. Ofthese,fourhadMiacalcinprescribed. Ofthese,none(0%)hadotheralternativemedicationsprescribedfortreatment

ofosteoporosisorosteopenia. Treatmentwasconsideredadequateineightofnine(89%).

AlistofthosewithDownsyndromewassubmitted,alongwiththedateofthelastthyroidtest.Atotalof12individualswereidentifiedwithadiagnosisofDownsyndrome.All12(100%)hadacurrentthyroidtest.AcuteandEmergencyCareTheactiverecordwasreviewedfor10individualswhohadmostrecentlygonetotheEmergencyRoomandreturned.Theseindividualsarelistedinthedocumentsreviewedsection.Eightofthe10hadgonetotheERfromtheirresidence.OnehadgonefromtheInfirmarytotheER.Forone,fromtheinformationprovided,thiscouldnotbedetermined.Thefollowingsummarizestheresultsofthisreview:

InformationwassubmittedindicatingthattheERwasnotifiedofthearrivaloftheindividualwithappropriatemedicalbackgroundinformationprovidedforsixof10(60%)individuals.

PriortothetransfertotheER,aPCPwasonsiteforoneofthesetransfers.Foroneindividual,itcouldnotbedeterminedifthePCPwasonsitefromtheinformationsubmitted.Inoneofone(100%)record,thePCPhadwrittenanIPNthatincludedthedateandtime.

Fornoneofone(0%),vitalsignswererecorded. Foroneofone(100%),reasonforthetransferwasdocumented. Inoneofone(100%),theSOAPformatwasutilized. AcopyoftheERreportthatwasfiledintherecordwassubmittedinsixof10

(60%). Ofthe10ERvisits,fivewerefortrauma,twowereforrespiratoryillness,one

wasforcardiacillness,andonewascategorizedasother. WhentheindividualreturnedtotheFacilityafterevaluationattheER,10ofthe

10activerecords(100%)hadanIPNwrittenbyaPCP.Ofthese,eightof10(80%)utilizedaSOAPformat.


# Provision AssessmentofStatus Compliance Thesenotesincludedthedateandtimein10of10(100%)oftheIPNswritten

bythePCP. Vitalsignswererecordedinsixof10(60%)oftheseIPNs. AsummaryofERinformationandfindingswasincludedinnineoftheseIPN

notes(90%). WhenreturningtotheFacility,sixreturnedtotheindividual’sresidence,and

fourreturnedtotheInfirmary. Sevenofthe10records(70%)hadadditionalPCPnotesasfollowuptothe

originalconcern. For10(100%),treatmentwasconsideredtimely.Therewerenoperceived

delaysincareintransferringtheindividualstotheERoncethePCPwasnotified.Severaladditionalobservationswerenotedfromreviewofthese10records.ItwasdifficulttodeterminewhichindividualswereintheInfirmaryatthetimeofthetransfertotheER.Foroneindividual,theIPNsdocumentedtheindividualwasfoundlyinglowinthebed(i.e.,notcorrectlypositioned)withtubefeedingbeingadministered.Thissuggestedtheneedforreviewoftrainingofthedirectsupportprofessionalsthatsupportindividualsthatarefedbytube,trainingofnursingstaffforpositioningrequirements,andtheneedformonitoringofhomeswithindividualsthatarefedbytube.Additionally,nineactiverecordswerereviewedforindividualsadmittedtothehospital.Therewere11hospitaladmissionsforthesenineindividuals.Thefollowingprovidestheresultsofthisreview:

Forsixof11hospitalizations(55%),thePCPwroteanevaluation/transfernotepriortothetransfer.Forfiveofthese,thetransferoccurredafterhoursoronweekends.

EightindividualshaddocumentsindicatingeighthospitalizationswerefollowedbyareturntotheFacility.Oneindividualdiedwhileinthehospital.Tworemainedhospitalizedatthetimeofsubmissionofinformation.OftheindividualsthatreturnedtotheFacility,eightofeight(100%)hadIPNsposthospitalization.

Oftheeightpost‐hospitalIPNssubmitted,five(63%)includedvitalsigns. Alleight(100%)includeddate,time,andanadequatesummaryofhospital

eventsandfindings. Sevenofeight(88%)activerecordsusedtheSOAPformat. Tenof11recordsofthehospitalizedindividuals(91%)includedacopyofthe

hospitaladmissionhistoryandphysical. Sevenoftheeight(88%)includedacopyofthehospitaldischargesummary. Sevenoftheeight(88%)includedacopyofeitherthehospitaladmissionhistory

orphysical,oracopyofthehospitaldischargesummary. Tenofthe11(91%)includedhospitalliaisonnursenotesfortheindividuals.


# Provision AssessmentofStatus Compliance ForsevenoftheeightindividualsthatreturnedtotheFacility(88%),additional

PCPfollow‐upnoteswereincludedaspartoftheposthospitalcourse. Reasonsforhospitalizationincludedhypernatremia,neutropenia,highfever,

pneumonia,pulmonaryedema,PercutaneousEndoscopicGastrostomy(PEG)insertion,bowelobstruction,diabeticketoacidosis,andcardiacarrest.

CCSSLChadanInfirmary.ThestatisticsrelatedtoadmissionsofindividualstotheInfirmaryoverthepriorsixmonthswasasfollows:

Thelengthofstayvariedfromlessthanoneday(the23houradmission)to41days.

Thenumberstayingonedayorlesswas27. Thenumberstayingtwodayswas13. Thenumberstayingthreedayswas11. Thenumberstayingfourdayswasfive. Thenumberstayingsixto10dayswas25. Thenumberstaying11to15dayswas17. Thenumberstaying16to30dayswas12. Thenumberstayingover30dayswastwo.

ThenumberofindividualsadmittedtotheInfirmarypermonthwasasfollows:

December2011–19; January2012–19; February2012–22; March2012–20; April2012–29;and May2012–23.

ThereasonsforInfirmaryadmissionsincluded:

Gastrointestinalcauses:20; Genitourinarycauses:12; Respiratorycauses:31; Infection:11; Neurologicalcauses:10; Cancer:two; Orthopediccauses:15; Ophthalmologicalcauses:one; Metaboliccauses:three; ENTcauses:one; Dentalcauses:one;and Other:16.


# Provision AssessmentofStatus CompliancePneumoniaTherewerethreedatasetsthatcompiledincidentsofpneumonia.ForthedatasetderivedfromAvatar,forthetimeperiodofDecember2011toApril2012,therewere23pneumoniasin23individuals.

FiveoccurredinDecember2011,oneoccurredinJanuary2012,fouroccurredinFebruary2012,eightoccurredinMarch2012,andfiveoccurredinApril2012.

Fourteenwereconsideredbacterialpneumoniasandninewereconsideredviralinorigin.

Fifteenoftheseindividualshadafeedingtube.Ofthese15individuals,14hadanintermittentfeedingschedule.Zerohadacontinuousfeedingschedule.Onehadabolusfeedingschedule.

Eightoftheseindividualsweretakingfoodbymouth.Ofthese,onewasonapureeddiet,onehadthickenedliquids,onewasonagrounddiet,andfivewereonaregulardiet..

Seventeenofthe23individualswerehospitalized.Fromadifferentdatasetsubmittedentitled:“IndividualsDiagnosedwithPneumonia,”therewerereportedtohavebeenfivepneumoniasinDecember2011,onepneumoniainJanuary2012,fourpneumoniasinFebruary2012,eightpneumoniasinMarch2012,fourpneumoniasinApril2012,andthreepneumoniasinMay2012.Thisdatawasconsistentwiththepreviouslydiscusseddata,exceptforApril2012.ForApril,thisdatasetincludedonelesspneumoniathantheotherdataset.FromtheInfectionControlCommitteeMeetingof1/3/12,pneumoniasinthepriorquarterincludedDecember2011‐threepneumonias.FromtheInfectionControlCommitteeMeetingof4/4/12,pneumoniasinthepriorquarterwerelistedasJanuary2012‐one,February2012–four,andMarch2012‐four.Thisdatagenerallywasnotconsistentwiththeotherinformation.Ahandoutfromthe7/912P&TCommittee,“FY2012infections,”documentedthereweresevenpneumoniasinJune2012.Thethreedatabasesprovideddifferentstatisticspermonth.TheFacilityshouldreviewthediscrepanciesandcreatesystemsthatcanverifycompleteandaccuratedatafromonesystemtoanother.TraumaAccordingtoinformationsubmittedatthestartoftheMonitoringTeam’svisit,forthepriorsixmonths,therewasonlyonefracturethatwasreportedtohaveoccurred.Thetypeoffractureandbonefracturedwasnotsubmitted.However,thiswasfoundtobeaninaccuratereport,becausetherewereseveralmorefracturesthatoccurredduringthis


# Provision AssessmentofStatus Compliancetimeperiod.AcorrectedlistwassubmittedattherequestoftheMonitoringTeam.ThreefracturesoccurredfromDecember2011throughMay2012.Allwerenon‐displacedfractures.Oneinvolvedthelowerleg,oneinvolvedthehand,andoneinvolvedtheelbow.BasedoninformationsubmittedinpreparationfortheMonitoringTeam’svisit,inthepastyear,from6/1/11through5/31/12,threeindividualswenttotheERorwerehospitalizedforinjuries.However,theMonitoringTeamrequestedcorrectedcompleteinformation.Subsequently,anewlistwasgeneratedforthetimeperiodDecember2011throughMay2012.Duringthistime,fiveindividualswerereferredtotheERforinjuries,allofwhichwerelacerationsabovetheneck.ChronicConditionsandSpecificDiagnosticCategoriesAspartofthereviewof19records,GERDwasreviewed.Ofthe19,sevenwerediagnosedwithGERD.Oftheseseven,sevenhadappropriatemedicaltreatment(100%).Sevenwereprescribedmedications,noneunderwentsurgeryinthepast,andonehadaprocedureperformedinthepastoneyear.Informationwassubmittedconcerningnewdiagnosesofchronicconditionsthatoccurredoverthepastyear.TwelveindividualswerenewlydiagnosedwithdiabetesmellitustypeII.Additionally,oneindividualwasnewlydeterminedtohaveafamilyhistoryofdiabetesmellitus,buttherewasnoinformationtheindividualhaddiabetesmellitus.Fourindividualswerenewlydiagnosedwithcardiovasculardisease.Onecaseofanewlydiagnosedcancerwasreportedinthepastyear.Twoindividualswerediagnosedwithsepsis.AccordingtoinformationprovidedbytheFacilityinpreparationfortheMonitoringTeam’svisit,between12/11and5/31/11,oneindividualwasreferredtothehospitalforpotentialpicaingestion.Subsequently,anupdatedandcompletelistofpicaoringestionofinedibleobjectswassubmittedforthetimeperiodofDecember2011throughMay2012.Thisincluded10eventsinvolvingsixindividuals.Atotalof199individualsweretreatedwithroutinemedicationforchronicconstipation.Accordingtodatasubmitted,oneindividualwasdiagnosedwithabowelobstructionorbowelperforation/complication(in5/12).SkinintegrityASkinIntegrityCommitteemeton2/15/12and5/31/12.Minutesweresubmittedforbothmeetings.Inthesemeetingminutes,forDecemberoneStage1decubituswasrecorded.ForJanuary2012,oneStage2decubituswasreported.ForFebruary2012,twodecubitiwerereported,oneStage1andoneStage2.ForMarch2012,therewereno


# Provision AssessmentofStatus Compliancedecubitireported.ForApril,therewasoneStage2decubitusreported. ForMay2012,therewerethreedecubitireported,twoStage1andoneStage2.TwoofthesewerereportedtooccurintheInfirmaryandtheremainderintheresidence.Nonewerereportedtohavebeguninthehospital.Insummary,therewerefourStage2ulcers,noStage3ulcers,noStage4ulcers,andnounstageableulcers.Separately,submittedwerenumbersofdecubitithatoccurredinthepastsixmonths.TherewasonedecubitusulcerinJanuary2012andoneinApril2012.TherewerenodecubitireportedforFebruary2012orMarch2012.TheinformationforMay2012waspending.ThesenumbersdidnotagreewiththeSkinIntegrityCommitteeminutes.Itisrecommendedthatdiscrepanciesindataberesolved.Itisrecommendedthatthedifferentdatabasesbereviewedforaccuracyandcompleteness.Itisalsorecommendedthattherebeclarificationofthenumbersofdecubitipermonththatarenewversusthosethatarecontinuingtobetreated.SeizuredisordersTheFacilitysubmittedinformationconcerningantiepilepticmedicationusage.Asof5/25/12,172individualswereprescribedantiepilepticmedication.Ofthese,62(36%)wereprescribedoneantiepilepticmedication,38(22%)wereprescribedtwoantiepilepticmedications,19(11%)wereprescribedthreeantiepilepticmedications,13(8%)wereprescribedfourantiepilepticmedications,andone(0.5%)wasprescribedfiveantiepilepticmedications.Elevenindividualswereconsideredtohavearefractoryseizuredisorder.EightofthesehadaVNSimplant.FromdatasubmittedinpreparationfortheMonitoringTeam’svisit,inthepriorsixmonths,informationsubmittedindicatednoindividualwassenttotheERforanuncontrolled/prolonged/newonsetseizure.However,whenthiswasrequestedonsite,acorrecteddocumentindicatedfourindividualshadbeensenttotheERforprolongedseizureactivityfromDecember1,2011toMay25,2012.Oneindividualhadstatusepilepticusinthepriorsixmonths.Additionally,34individualswithadiagnosisofseizureswereonnoantiepilepticmedications.Alistwassubmittedindicatingthepercentageofindividualsthatwereprescribedolderantiepilepticmedications.Atotalof23(13%)ofindividualswithseizureswereprescribedDilantin,none(0%)wereprescribedPrimidone,three(2%)wereprescribedPhenobarbital,andnone(0%)wasprescribedFelbamate.Additionally,nineindividualshadaVNSimplant.Neurologyclinicswereheldonsiteapproximatelyoncepermonth.Theonsitevisitsincludedthefollowingdates:2/4/12,3/31/12,and4/28/12.NoinformationwasprovidedforMay2012.Foreachclinic,therewere19to27individualsseenbythe


# Provision AssessmentofStatus Complianceneurologist,foratotalof68visits.TheFacilitysubmittedneurologyconsultationnotesdocumentingseizuremanagementforfiveindividuals.Theseindividualsarelistedinthedocumentsreviewedsection.Itwasnotedthattherequestwasforindividualsseenbytheneurologistinthepriorsixmonths,butnonehadbeenseensinceOctober2011.Thereasonfornotchoosingmorerecentclinicvisitswasnotstated,giventhattherewere68visitsfromwhichtoprovideasamplein2012alone.Thefollowingprovidesasummaryofthereviewoftheserecords:

Oneofthefiveindividuals(20%)hadbeenseentwiceoverthepastoneyear. Forfourindividuals(80%),thenotesincludedadescriptionoftheseizures. Five(100%)includedareviewofcurrentmedicationsforseizuresanddosages. One(20%)includedrecentbloodlevelsofantiepilepticmedications. Five(100%)includedrecommendations. Forfiveindividuals(100%),referencewasmadetothepresenceornotofside

effectsatthemostrecentvisit. Forfourindividuals(80%),referencewasmadetowellnessoradequate/good

controlofseizures.

Itwasnotedthattheneurologyconsultationreportform(whichwascompletedpriortotheneurologyvisitandincludedinformationfortheneurologist’sreview)didnotincludeanyinformationaboutdruglevelsordatesoflevels.Itcouldnotbedeterminedifthiswasattachedtotheconsultationform.However,theneurologyconsultationreportattimeseitherdidnotmentionthedruglevelsordidnotmentionthedatesoflevels.Sincethesevisitswerenotrecent,thedruglevelssubmittedaspartofthedocumentationoccurredaftertheneurologyvisitexceptforoneindividual’svisit.Itisrecommendedthatthedateofthelastneurologyvisitbeincludedonthereportform,aswellasthemostrecentlabvalueanddateofthelab.DoNotResuscitateOrdersAtotalof25individualsattheFacilityhadDNRordersinplace.For13(52%),adequateclinicaljustificationwasprovidedfortheDNR.Fiveindicatedneurologicaldecline,onerespiratorydecline,andsevenduetoosteoporosis.ItisrecommendedthattheStateOfficedevelopcriteriatoguidetheSSLCsindeterminingoptionsforresuscitativeeffortsinthosewithsevereosteoporosis,suchasintubation/ventilationwithoxygenandmedicationwithoutchestcompression.Therewere12individualswithDNRstatuswithnomedicalconditionlisted,butreasonindicated“perfamilyrequest.”Itisrecommendedthatthemedicalconditionforwhichthefamilyrequestwasgrantedbeincludedinthereason/criterialistedforDNR.IfcriteriadonotmeetSSLCstandards,thenfurtherdiscussionwithfamilyandethicscommitteedocumentationisrecommended.AsDNRreviewsoccurannually,therewasonereviewthatwasoutdated.


# Provision AssessmentofStatus ComplianceTheQA/QICouncilmeetingminutesof3/22/12documentedtheneedtoreviewDNRordersinthoseindividualswithoutterminalillness.TherewasnoinformationthattheIDTshadmettodiscussanyoftheDNRordersinthosewithoutaterminalillness.TherealsowasnoFacilitypolicyorproceduretoguidewhichdepartmentswererequiredtobeatIDTmeetingswhentherewasadiscussionofDNRstatusinthosewithoutclinicaljustification.Administrativeguidancewouldbeanimportantfirststepinthisprocess.TheFacilitywasaskedtoprovideanyethiccommitteemeetingminutes,withattendancerosters,concerningDNRdecisions/changessincetheMonitoringTeam’slastvisit.Nomeetingminutesweresubmitted.MockCodeDrillsandEmergencyResponseSystemsFindingsandrecommendationsrelatedtomockcodedrillsandemergencyresponsesystemsarediscussedwithregardtoSectionM.1oftheSettlementAgreement.TransitionstoCommunitySettingsTheFacilitysubmittedinformationdocumentingthatfromJanuary1,2012toJune2,2012,sixindividualshadtransitionedintothecommunity.Fortwoindividuals,thereweresignificantincident.TwoeachhadtwoERvisits.Onehadapolicevisit.Noseriousincidentsweresubmittedfortheotherfourindividuals.InreviewingthreerecordsofindividualswhohadtransitionedtothecommunitysincetheMonitoringTeam’spreviousvisit,thefollowingwasnoted:

Foroneofthree(33%),adequatemedicalassessmentshadbeencompletedwithin45daysoftheindividuals’transitiontothecommunity.Fromthesubmittedinformation,itappearedthatallthreehadbeentoaPCPinthefirst45daysoftransition.However,thedateofthePCPofficevisitcouldonlybelocatedinthesubmitteddocumentationinonerecord.

Fornoneofthree(0%),allrequiredspecialtyappointmentshadoccurredtimely.Specialtieswhichhadnotoccurredinatimelymannerincludedpsychiatry,andmonthlycounselingforIndividual#194;psychiatry,psychology,podiatry,andasubstanceabuseprogramforIndividual#30;anddentistry,ophthalmology,andpsychologyforIndividual#114.

Forthreeofthree(100%),theFacilityhadprovidedevidenceofdocumentationoftrainingfortheindividual’smajormedicaldiagnoses.Copiesoftrainingdocumentswerereceivedfortwoofthree(67%).

Forthreeofthree(100%),theFacilityhadprovidedevidenceofdocumentationoftrainingfortheindividual’smajorpsychiatricdiagnoses/andorbehavioralissues.

Forthreeofthree(100%),theFacilityhadprovidedevidenceofdocumentationoftrainingformedicationsprescribed,thediagnosisforwhicheachwasbeing


# Provision AssessmentofStatus Complianceused,andthesideeffectstobemonitored.

Fornone(0%),theFacilitydepartmentswereaskedtoprovideadditionalinformationoncetheindividualwasplacedinthecommunity.Forindividualsinvolvedinasignificantincident,thecommunityprovidershouldconsidercontactingtheappropriatedepartmentoftheFacilitytogainfurtherinformation/stepstobeconsideredetc.,whichmightassistinpreventingarecurrence.

Fornone(0%),theFacilitywasrequestedtoprovidespecificdepartmentalexpertise,provideasitevisit,orcommunicatewithprofessionalcounterpartsinthecommunity.

Forthreeofthree(100%),therewasdocumentationofadequatemonitoringinthe90dayperiodaftertheindividual’stransitiontoensuremedicalandpsychiatricneedswereaddressed.

Foroneofthree(33%),thereweresignificantincidentsdocumentedwithin90daysoftransition.Thesetotaledthreesignificantincidents(twoERvisitsandonepolicecall).

L2 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationinoneyear,eachFacilityshallestablishandmaintainamedicalreviewsystemthatconsistsofnon‐Facilityphysiciancasereviewandassistancetofacilitatethequalityofmedicalcareandperformanceimprovement.

Non‐facilityPhysicianCaseReviewsDuringthepriorsixmonths,theFacilitycompletedonenon‐facilityphysiciancasereviewaudit,dated4/19/12to4/20/12,whichwaslabeledasRound#5.DiscussionwiththePCPsindicatedthattheexternalpeerreviewoccurredoveroneday,duringwhich19recordswerereviewed.Additionally,thedeterminationbytheexternalpeerswasthatanumberofindicatorswerenotfoundbytheauditorsbutthatwerecorrectlylocatedintheactiverecord,accordingtomedicalstaff.Thiswouldindicatethatthereviewmighthavebeenrushed,compromisingitsquality.Asaresult,itmightnotprovideanaccuratepictureofthetruepracticepatternatCCSSLC(i.e.,thevaliditymightbequestionedbasedontheseconcerns).Therewasnoinformationsubmittedtoestablishinter‐raterreliabilityamongsttheexternalpeerreviewers.Someoftheconcernsmighthavestemmedfromtheexternalpeersbasingthereviewonexpectationsattheirhomefacilitiesregardingthelocationofdata,formsused,etc.,ratherthanrelyingonasetofacceptedorexpectedstandardsonwhichallauditorsweretrained.Thefollowingrepresentsasynopsisoftheinformation:

Fortheoneexternalpeerreviewdated4/19/12to4/20/12,PCPcomplianceinessentialareasrangedfrom80%to100%.OnePCPwasconsideredcompliantwiththeareasconsideredessential.Forareasconsiderednon‐essential,compliancerangedfrom89%to97%.AllPCPswereconsideredcompliantwiththenon‐essentialareasaudited.

ThepriorpeerreviewauditoccurredinOctober2011.Complianceatthattimeforessentialareasrangedfrom74%to100%.OnePCPwascompliant.Fornonessentialareas,compliancerangedfrom90%to98%,andallPCPswerecompliant.Theseresultsweresimilartothecurrentfindings.

Noncompliance


# Provision AssessmentofStatus Compliance Areasthatappearedtoneedimprovementarelistedhere,andarenumbered

accordingtothequestion/probenumberintheaudittool:(2)datingandsigningtheActiveProblemListwhenitwaslastreviewed,(3)updatingtheActiveProblemListwitheachnewproblemorasproblemswereresolved,(5)theannualphysicalsummarywascompleteincludingpastmedicalhistory,familyhistory,andaplanofcare,(6)thesummaryincludedsignificantmedicaleventsofcurrentandpastyears(includinghospitalizations,ERvisits,andoutpatientsurgery),(10)theappropriatescreeningserviceswereprovided,(11)documentationofthereasonfornotprovidingpreventiveservices,(15)documentationofrationalefornotfollowingrecommendationsmadebythepharmacist,(21)eachIPNandordersweresigned,datedandtimed,forconsultationreferrals,(26)thepertinentcurrentandpastmedicalhistorywasincludedinthecommunicationwiththeconsultant,(27)medicaland/orsurgicalconsultantrecommendationswereaddressedintheIPNswithinfivebusinessdaysaftertheconsultationrecommendationswerereceived,and(29)theIPNincludedaclinicalassessmentandaSOAPnotefromaPCPwithin24hoursofthereadmissiontotheSSLCfromahospital/ERorlong‐termacutecarefacility.

Theexternalauditalsoincludedamedicalmanagementcomponentinwhichthreediagnoseswereselectedandchartreviewcompletedforthreeindividualswitheachofthediagnoses,totalingninechartreviewsformedicalmanagement.Thethreediagnoseschosenforreviewwerediabetes(sixquestions),osteoporosis(sevenquestions),andaspirationpneumonia(12questions).PCPcomplianceinmedicalmanagementoftheseareasrangedfrom57%to83%.AtableofcomplianceperPCPperdiagnosiswasnotprovided,butshouldbeforfuturecomparisonwhentheFacility’smedicalmanagementteamreviewedthesesamediagnoses.

Compliancebyquestionwasprovidedinagraphform.Areasofconcernneedingimprovementarelistedherebythediagnosticcodeandnumberofthequestion:(ASP3)IsthereevidencethattheindividualhashadaModifiedBariumSwallowcompletedsinceadiagnosisofaspirationpneumonia?(ASP5)Didtheproviderorderagastrointestinal(GI)consultorapulmonaryconsultifindicated?(ASP6)Didtheproviderrecommendasuctiontoothbrushfortheindividualorrefertodental?(ASP7)DidtheproviderrefertheindividualtotheQDDPorthePNMTnurseafterthelastdiagnosisofaspirationpneumonia?(ASP8)IftheindividualhasadiagnosisofGERD,isitontheactiveproblemlist?(ASP10)Didtheproviderorderrespiratorytherapy?(ASP11)DidthePCPreviewtherisksandinterventionsfortheindividualforaspiration?(ASP12)Didtheproviderreviewthemedicationstoseeifanychangesoradditionswereneededto[remainderofstatementnotincluded](DB1)IsdiabeteslistedontheActiveProblemList?(DB2)Didtheproviderprescribetheappropriatefollowuplab?(DB3)Didtheproviderorderappropriatediagnosticsandconsultsifwarranted?(OST1)Is


# Provision AssessmentofStatus ComplianceosteoporosislistedontheActiveProblemList?(OST4)Didtheproviderorderordocumentfindingsofadentalexambeforeinitiatinga[remainderofstatementnotincluded].Thecompliancebyquestionfor(OST3)“Isthereadiagnosisofapathologicalfracture?”wasnotincludedinthegraphprovidedfortheexternalpeerreview.

Theexternalmedicalpeerreviewresultswerenotcomparedtopriorreviews,althoughtheprocesshadbeenrevamped.Itisrecommendedthatsummariesofthedatabetabulatedinacumulativemannertobeabletodetermineprogress,withacomparativeanalysisprovidedannually.

Afollow‐upsystemwasinitiatedtoensurecompliance/completionofcorrectiveactionplansforeachPCP’sareasofnoncompliance.InitialcorrectiveactionplansweredistributedtothePCPsoncetheauditresultswereplacedinadatabase.

TheQAnurse/QADepartmentcompiledinitialcompliancedatawithcorrectiveactionplans.However,therewasnofollow‐upaftertheinitialcorrectiveactionplansweredistributed.Asaresult,therewasnodeterminationwhichdeficiencieswerecorrected.

Therewasnofollow‐upevery30daystotrackprogressofthecorrectiveactionplans.AstheexternalpeerreviewauditoccurredinApril2012,bythetimeoftheMonitoringTeam’svisit,thereshouldhavebeenafollow‐upauditswithsummaryresultsavailableforMay2012andJune2012.

Thenumberofcorrectiveactionplansgeneratedbytheauditwasprovided.Theexternalauditforessentialandnon‐essentialareas(30questionmonitoringtool)generated34correctionactionplans.Theexternalmedicalmanagementauditgenerated16correctiveactionplans.ProvidingthenumbersofcompletedcorrectiveactionplanspermonthandthenumberofoutstandingcorrectiveactionplansinatableformatwouldprovideasummaryofprogressforthePCPs,theMedicalDepartment,andtheFacilityAdministration.

Therewasnoinformationprovidedthattherewereanysystemicimprovementplansdevelopedorimplementedbasedontheexternalpeerreview.ThisisanareaneedingreviewinorderfortheFacilitytoseeimprovementinitsscoresovertime.

Someofthemedicalmanagementquestionsmightneedfurtherreview.Forspecificdiagnosesreviewed,someofthequestionsmightalsoneedfurthervaliditytestingtoensuretheyarecapturingtheinformationthatisintendedtobemeasured.

FortheMedicalProviderExternalReviewconductedon4/19/12,thedatesofreviewincludedboth4/19/12and4/20/12,whichwasproblematicbecausetheresultswerebeingdiscussedon4/20/12at9a.m.,andtheMedicalDepartmentconfirmedtheauditwascompletedinoneday.Thecontentsindicatedthat24recordswereevaluated.Facilityattendanceatthisexitwasdocumented.Areas


# Provision AssessmentofStatus Complianceneedingimprovementwerelistedas:

o Consultformsneededtobedevelopedandimplementedtoincludepastmedicalhistory,andcurrenthistory,forallconsultants.Inaddition,theyshouldallbeacknowledgedintheIPN(theprecisemeaningofthisstatementwasnotclarified).

o TheactiveproblemlistshouldbeseparatefromtheAnnualExamandupdates.

o Forosteoporosis,dentalreferralbeforetreatmentshouldbedocumented.

o Gynecologyexams/Papsshouldbeencouraged.Strengthswerealsolisted,including:

o Informationintheannualwasveryhelpful,includedgoodfamilyhistory,includedsmokinghistory.

o QDRRwascomplete.o Preventiveflowsheetswerehelpfulandcomplete.o Vaccinationrecordsingoodshape.

Inter‐raterreliabilityisdiscussedinSectionL.3.The“QAMedicalAuditSchedule”includedanexternalmedicalpeerreviewauditatCCSSLCfrom1/11/12to1/13/12.UpdatedinformationindicatedtheJanuary2012externalpeerreviewauditwascanceled.Also,accordingtotheauditschedule,therewastobeaninternalaudit,includingthreemedicalmanagementdiagnosesreviews,on7/12/12.Thenextscheduledexternalauditwas11/12/12to11/16/12,andwastoincludemedicalmanagementauditingofchronicconstipation,seizures,andurinarytractinfections.MortalityReviewsAtthetimeofthereview,theFacilityhadnooutstandingclinicaldeathreviewsandoneoutstandingadministrativedeathreviewfromthemostrecentdeath.SincethestartoftheMonitoringTeam’slastvisitthroughMay31,2012,sevendeathshadoccurred:

Theaverageagewas48(variedfrom30to58). Alldiedundertheageof65. Ofthedeaths,fourwerefemales,andthreeweremales. Thecausesofdeathwerelistedas:respiratorycauseforthree(sepsisassociated

withbronchopneumonia,pneumonia,andrespiratoryfailure),cancerforone,andcardiacdiseaseforone.Twocausesofdeathwerestillpendingtheautopsyreport,althoughallhadareportofpreliminaryfindings.

Anautopsywasperformedinthreeoftheeight(38%). Fivediedinahospitalsetting.TwodiedattheFacility. Fourindividuals’recordsincludeddocumentationindicatingtheywere


# Provision AssessmentofStatus Complianceaggressivelytreated.Twowereenrolledinhospice.

Fivehadafeedingtube.Forthreeofthefive,thefeedingtubehadbeenreplacedpriortotheacutemedicaldecline.Fortwo,thefeedingtubehadbeenreplacedthedayoftherapiddecline.Inone,thedeclinebegantooccur24hourslater.Nursing,Medical,andFacilityAdministrationshouldconsiderreviewingthisaspectofcaretodeterminetherelationship,ifany,ofchangingafeedingtubeandsuddendecline.Considerationsshouldincludetechniqueofreplacement,butalsowhethertheindividualisallowedtolieflatduringthereplacement,whichcouldcauserefluxandaspirationpneumonia.Italsowasnotedthattubechangesappearedtobefrequent.TheNursingDepartmentshouldreviewthefrequencyandcausesofthereplacements.Moretrainingtopreventtubecloggingandaccidentalremovalwouldbeimportantconsiderations.

SincetheMonitoringTeam’slastvisit,sevenadministrativedeathreviewswerecompleted.Sevenclinicaldeathreviewswerecompleted.

Theclinicaldeathreviewsincludedfromonetotworecommendations,foratotalofninerecommendations.

Administrativedeathreviewsincludedfromonetothreerecommendations,foratotalof13recommendations.

All13ofrecommendationsfromtheclinicaldeathreviewsrelatedtosystemicimprovementsneededinhealthcare.Noneofthe13recommendationsrelatedtopotentialimprovementinnon‐healthcarerelatedissues.

TheFacilitysubmittedfollow‐updocumentationfornoneofthetotalof13recommendations.ItisrecommendedthattheQADepartmentcreateatrackingsystemtoensuretherecommendationsaremonitoreduntilclosure,withclearevidenceofclosure.Insummary,theFacilityremainedoutofcompliancewithSectionL.2.Althoughanexternalnon‐facilityphysicianreviewhadbeenconducted,theFacilityhadquestioneditsaccuracy.BasedontheMonitoringTeam’sreview,concernswerenotedwiththepotentialthoroughnessofthereviewofnumerousrecordsinashortperiodoftime,aswellasalackofestablishedinter‐raterreliabilityamongstreviewers.Inaddition,althoughcorrectiveactionplanshadbeendevelopedtoaddressPCP‐specificconcerns,nodocumentationwasavailabletoshowthatfollow‐uphadoccurred.Inaddition,nosystemiccorrectiveactionplansweredevelopedorimplemented.Inaddition,althoughmortalityreviewshadbeencompleted,documentationwasnotsubmittedtoshowthatfollow‐uphadoccurredtoaddresstherecommendationstheyincluded.

L3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwith

Facility’sMedicalDepartmentInternalPeerReviewSystemFortheinternalmedicalpeerreviewprocess,thefollowingprocesswasimplementedfor

Noncompliance


# Provision AssessmentofStatus Compliancefullimplementationwithintwoyears,eachFacilityshallmaintainamedicalqualityimprovementprocessthatcollectsdatarelatingtothequalityofmedicalservices;assessesthesedatafortrends;initiatesoutcome‐relatedinquiries;identifiesandinitiatescorrectiveaction;andmonitorstoensurethatremediesareachieved.

inter‐ratercomparisonandreliability: Atthetimeoftheexternalmedicalpeerreview,theinternalmedicalpeerreview

processalsobegan.However,theinternalmedicalpeerreview(Round#5)wasnotcompletedonpreciselythesamedate,becausetheexternalmedicalpeerreviewprocesswascompletedinoneday.TheinternalmedicalpeerreviewprocesswascompletedfromApril21through27,2012,accordingtothedatesoftheindividualauditdocumentssubmitted.Theinternalmedicalpeerreviewprocessincludedthesameauditof30generalquestionsandareviewofthreerecordsforeachofthreediagnoses(i.e.,aspirationpneumonia,diabetesmellitus,andosteoporosis).

PCPcomplianceinessentialareasrangedfrom77%to100%.OnePCPwascompliant.

PCPcompliancewithnon‐essentialareasrangedfrom88%to100%.AllfourPCPswereconsideredcompliant.

Resultsidentifiedthefollowingareasneedingreviewandimprovement.Thenumberprecedingtheareaofconcernisthenumberofthequestionfromtheaudittool:(Q2)IstheActiveProblemListdatedandsignedwhenitwaslastreviewed?(Q3)IsthereevidencethattheActiveProblemListwasupdatedwitheachnewproblemorasproblemswereresolved?(Q5)Istheannualphysicalsummarycompleteincludingpriormedicalhistory,familyhistory,andaplanofcare?(Q6)Doesthesummaryincludesignificantmedicaleventsofcurrentandpastyears(includinghospitalizations,ERvisits,andoutpatientsurgery?(Q8)Isdocumentationpresenttoidentifywhethertheindividualusestobaccoproductsordoesnotusetobaccoproducts.Iftheindividualusestobaccoproductswastheredocumentationofrecommendationforcessationoftobaccouse?(Q14)IsthereevidencethattheproviderrespondedtothepharmacistquarterlydrugregimenreviewrecommendationsontheQuarterlyDrugRegimenReviewFormwithin15businessdays?(Q15)Didtheproviderdocumentrationalefornotfollowingrecommendationsmadebythepharmacist?(Q26)Whenareferralforconsultationisrequested,ispertinentcurrentandpastmedicalhistoryincludedincommunicationwiththeconsultant?(Q27)Aremedicaland/orsurgicalconsultantrecommendationsaddressedintheintegratedprogressnoteswithinfivebusinessdaysaftertheconsultationrecommendationsarereceived?And,(Q29)DoestheintegratedprogressrecordincludeaclinicalassessmentandaSOAPnotefromaproviderwithin24hoursofthereadmissiontotheSSLCfromahospital/ERorlong‐termacutecarefacility?

Fortheinternalmedicalpeerreviewauditofmedicalmanagementofthreediagnoses,PCPcompliancewas79%to100%.Areasofconcernincluded:(ASP3)IsthereevidencethattheindividualhashadaModifiedBariumSwallowcompletedsinceadiagnosisofaspirationpneumonia?(ASP6)DidtheproviderrecommendasuctiontoothbrushfortheindividualorrefertoDental?And,


# Provision AssessmentofStatus Compliance(OST3)Isthereadiagnosisofapathologicalfracture?”

Theinternalpeerreviewauditofessential/non‐essentialareas(30questionmonitoringtool)generated26correctiveactionplans.Theinternalpeerreviewauditforthemedicalmanagementreviewofthreediagnosesgeneratedsixcorrectiveactionplans.TheQADepartmentdidnotfollow‐upevery30daystodetermineprogressincompletingthecorrectiveactionplans.

Inter–raterreliabilityratingbetweentheexternalandinternalmedicalpeerreviewauditorswasprovidedforthemedicalmanagementsectionoftheaudit(i.e.,aspirationpneumonia,diabetesmellitus,andosteoporosis).Fordiabetesmellitus,theexternalpeerreviewauditdemonstratedcomplianceat73%.Fortheinternalpeerreviewaudit,compliancewas100%.Fortheexternalpeerreviewauditforosteoporosis,compliancewas88%.Fortheinternalpeerreviewauditforosteoporosis,compliancewas81%.Fortheexternalpeerreviewauditofaspirationpneumonia,compliancewas62%.Fortheinternalpeerreviewauditofaspirationpneumonia,compliancewas87%.Overallagreementinthethreediagnoseswas61%.Theinter‐raterpercentagreementforPCPsrangedfrom50%to83%.ItisrecommendedtheQA/QIDepartmentandtheStateOfficereviewthesefindingsanddevelopsystemchangestoimproveinter‐raterreliability.Theremightbeaneedfordetailedguidanceandinstructioninansweringspecificquestions,aswellasidentificationofthelocationintheactiverecordwheretheevidenceistobefiled.Dataforinter‐raterreliabilityofthegeneralmonitoringtool(30questions)waslackingandisneeded.MedicalDepartmentInitiativesandImprovementProjectsTheMedicalDepartmenthadtakenthefollowingstepstoimprovetrackingsystemsandover‐allinternalqualityimprovementofcare:

TherewasexpansionoftheDG1formtoinclude20entriesforAxisIIIdiagnoses.

TheMedicalDepartmentcreatedtools/measurestomonitorcompliancewithSectionGandH.

AnumberofdatabaseshadbecomeavailabletotheMedicalDepartmentandincluded:

o Cardiovasculartracking,whichincludedthespecificdiagnosis,andmedications;

o Colonoscopytracking,whichincludedthedateofthelastcolonoscopy,thereasonnotdoneifapplicable,andwhetheritwasforapreventiverecommendationoractiveproblem;

o Mammogramtracking,includingdateoflastmammogramandreasonifnotdone;

o Constipationtracking,includingthemedicationsanddosages;o Diets,includingtexture,fluidthickening,breadconsistency,portion


# Provision AssessmentofStatus Compliancesize,andtherapeuticrequirements(e.g.,lowcholesterol,specificfeedingformula);

o ThyroidtesttrackingforthosewithDownsyndrome;o Painmanagementtracking,includingmedicationanddosage,and

diagnosticindication;o Respiratorytracking,includingdiagnosisandtreatment;ando Urinarytracttracking,includinghistoryofurinarytractinfection(UTI),

otherdiagnoses,dateoflastUTI,historyrecurrentUTI,andprophylaxistreatment.

ItwasnotedthattrackingofthePCPs’completionofquarterlymedicalreviewshadnotbeeninitiated.DiscussionswiththePCPsindicatedthatastandardizedformandcontenttemplatewasnotfinalized.Itisrecommendedthatastandardizedformbeimplemented.TherewasevidenceofanalysisbytheMedicalDepartment,suchas:

TheMedicalDepartmenthadbeguntodevelopamonthlyreportofrecordauditfindingsandtrendanalysis.TheApril2012reportincludedresultsofthemonthlyauditforSectionGMonitoringTool,aswellastrendsandcorrectiveactions.Trendsincludedimportantpracticalinformationsuchas“ISPAsarebeingcompletedforacute/emergentchangesinhealthstatus,buttheyarenotfiledintheactiverecord,“RiskActionPlansarenotbeingreviewedasrequired.TheIntegratedRiskReviewFormisalsonotbeingupdated,”and“Diagnosesarenotconsistentforeachindividual’sassessmentacrossclinicaldisciplines.”CorrectiveActionsidentifiedstepsbeingtakentoresolvesomeofthechallengesidentifiedbythetrendssuchas:indicatinganewprocesswasbeingpilotedtoreplacetheISPAwithaChangeinStatusForm,andtheConsultTrackingLogwastobesenttoQDDPsonamonthlybasisforreview.

Asimilarreport“chartauditreportandtrendanalysis4/12”reviewedtheSectionHMonitoringToolresults,alongwithtrendsandcorrectiveactions.ThetrendsweresimilartothosementionedforSectionG.Additionally,itwasnotedthat:“thePreventiveCareFlowSheetsarenotbeingconsistentlyfilledoutwhenanannualmedicalassessmentiscompleted.TheQuarterlyMedicalReviewisnotbeingcompletedonaconsistentbasis.”Itisrecommendedthatthedifferentmonitoringresultsbecompiledintoonemonthlyreportratherthanseveraldifferentreports.

TheFacilityhadmadesomenotableprogresswithregardtodevelopinghelpfuldatabasesandcontinuingtoconductinternalaudits.Inaddition,theFacilityhadbeguntoanalyzesomeoftheresultsandtakeactiontocorrectproblematicissues.However,theFacilityremainedoutofcompliancewiththisprovision.Furtherworkwasneededinanumberofareas,includingdevelopmentofkeyindicatorsoroutcomemeasuresin


# Provision AssessmentofStatus Complianceconnectionwithsomeoftheclinicalguidelines,theestablishmentofinter‐raterreliabilityforandvalidityofmonitoringtools(whichlikelyinvolvedmoreworkonthetoolsandcorrespondingguidelines/instructions),continuingdevelopmentofactionplans,andfollowingthroughtoensuretheimplementationofactionplansresultingfromthesevariousactivities.

L4 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithin18months,eachFacilityshallestablishthosepoliciesandproceduresthatensureprovisionofmedicalcareconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare.ThePartiesshalljointlyidentifytheapplicablestandardstobeusedbytheMonitorinassessingcompliancewithcurrent,generallyacceptedprofessionalstandardsofcarewithregardtothisprovisioninaseparatemonitoringplan.

Thefollowingpolicies/procedures/protocolsindicatedtherehadbeennochangeinthedocumentssincetheMonitoringTeam’slastvisit:

HCG–MedicalandNursing:SeizureManagementMedicalandNursing,LL.12.Approved11/4/10,implemented12/5/10.

ProvidingHealthCareServices:SeizureManagement,M.24,approved4/1/11,implemented5/1/11.

ProvidingHealthCareServices:SeizureManagement–VNS,M.24.3,approved4/1/11,implemented5/1/11.

SincetheMonitoringTeam’slastvisit,severalclinicalguidelineshadbeenimplementedatCCSSLC,whichhadbeencreatedattheStateOffice.Theseincluded:

AspirationRiskReductionInterdisciplinaryProtocol:Individualreceivesenteralfeedingsorventilation;

BloodThinnerInterdisciplinaryProtocol; ConstipationInterdisciplinaryProtocol; BowelManagementandConstipationPreventionProtocol; Enteral(tube)FeedingInterdisciplinaryProtocol; Gastro‐EsophagealRefluxDisease(GERD)InterdisciplinaryProtocol; PneumoniaInterdisciplinaryProtocol; SeizureManagementInterdisciplinaryProtocol;and SSLCsFractureProtocol.

ItdidnotappearthattheseprotocolshadbeenusedasasourceofclinicalindicatorsindevelopinginternalmedicalQAreviews.CopiesofpriordraftsincludedaflowchartandanarrativesectionwithconsiderabledetailguidingstandardizedexpectationsofpracticeforthePCP.Thenarrativesectionwasalsotobeutilizedasasourceofclinicalindicators.However,discussionwiththeMedicalDepartmentsuggestedtheflowchartwasavailable,butnotthenarrativesection.ItisrecommendedtheMedicalDepartmentreviewthisareawiththeStateOfficetodeterminethecurrentstatusoftheseprotocols.

Noncompliance


1. ForeachhospitalizationorERvisit,themorningmedicalmeetinggroupshouldcriticallyreview/discusstheearlyhealthstatuschangepriortotheevent,aswellaspotentialstepstopreventarepeatoccurrence.(SectionL.1)


2. Withregardtothemorningmedicalmeetinggroupsprocessesandminutes:a. Briefconciseentriesofdiscussionofcriticalquestionsatthemorningmeetingshouldberecordedintheminutes.Thefollow‐uptothe

questionscanthenbedelegatedtoamemberoftheteam,thePCP,anotherdepartment,ortheIDT,dependingontheconcern.b. Closureinthemorningmedicalmeetingminutesrequiresspecificanswerstoquestionsraised.Totrackthis,whenreferringaconcern

totheIDT,thespecificquestionofconcernshouldbedocumented.Theresponsealsoshouldbedocumented.c. Forthoseareasdeterminedtobenon‐clinical(e.g.,environmental,etc.),referraltotheappropriatedepartmentshouldbemade,witha

requestforafinaldocumentansweringthequestionsorconcerns.Themorningmedicalmeetinggroupshoulddiscussthemandclosethem,asappropriate.

d. Whenthemorningmedicalteamspecificallyreviewsafollow‐updocument,thisshouldbedocumentedintheminutes.e. ThemorningmedicalteamprocessshouldincludeareviewofthequalityofISPAstoensurehealthandsafetyoftheindividualfroma

clinicalperspective.f. Itisalsoimportantthattheminutesincludeastatement/phrasethatthemorningmedicalteamagreedwithanISPAaswritten,when

thisisthecase,oranindicationthattheISPAhasbeenreturnedtotheteamwithfurtherquestionsorrecommendations.(SectionL.1)3. TheQDDPandQADepartmentsshouldreviewtheISPAprocesstoensureallactionstepsareaddressedanddocumented,ensuringprogressor

lackofprogressiscommunicatedbacktotheIDT,andthereisdocumentationofclosureforactionsteps.(SectionL.1)4. Databasesandresultingreportsshouldbereviewedforcompleteness,andkeysshouldbeincludedwhennecessaryfortheaccurate

interpretationofthedata.(SectionL.1)5. TheMedicalDepartmentshouldinitiateaperiodicreviewoftheannualmedicalassessmentstoensureallcomponentsareincluded,aswellas

developcriteriatoassessthequalityofthevarioussubsectionsoftheannualmedicalassessment.(SectionL.1)6. ThequarterlymedicalreviewsshouldbecompletedandincludemorefocusedinformationthatwouldbehelpfultoanyotherPCPneedingto

quicklyreviewtherecord.TheStateOfficeshouldprovideguidanceinthisarea,andatemplateformforfillingintheblanksmightensureallimperativeclinicalareasarecovered.Inconstructingsuchatemplate,thefollowingshouldbeconsidered:

a. Quarterlyreviewsshouldreflectupdatedinformationfromthepriorthreemonths.b. Theyshouldprovidebriefentriesregardingthemajordiagnoses,recordthemostrecentsetofvitalsigns,thelastthreemonthly

weights(verifyingthePCPisreviewingthisinformation),afocusedbriefexamforthosewhoaremedicallycomplex,andbriefcomments/entrieslistingnumbersofseizures(ifapplicable),changesinmedication,important/abnormallabsanddruglevels,ERvisitsandhospitalizationswithdatesanddischargediagnoses/treatments,andimportantconsultations.

c. Foranyoneindividual,theyshouldbesuccinct,ideallynomorethanonepage,andshouldnottakemoretimethanwritinganIPNentry.

d. ThequarterlyreviewsshouldbeincludedchronologicallyintheIPNsection.(SectionL.1)7. TheFacility/MedicalDepartmentshouldtrackconsultantappointmentsthatweremissed,includingabreakdownofthereasons(e.g.,refusals,

transportation,insufficientstaffing,etc.)Thelogshouldincludeinformationaboutwhentheappointmentsarerescheduledtooccurandsubsequentlycompleted,andwhetherthemissedappointmentsarereviewedatIDTmeetings,withevidenceofthedateofthemeetingrecordedinthetrackinglog.(SectionL.1)

8. Forspecialtieswithsignificantpercentagesofmissedappointments,theFacilityshouldcreateandimplementaplantoreducethesemissedappointments,andtrackimprovements.(SectionL.1)

9. TheMedicalDepartmentshouldreviewthetreatmentofosteopeniaandosteoporosis.(SectionL.1)10. Infirmarynotesshouldbeidentifiedclearlytoensureclarityoftheactiverecord.(Colorcodedpagesdonotcopyanddonotreflectthe

identificationthattheIPNnotewaswrittenintheInfirmary.)(SectionL.1)11. Forthevariouspneumoniadatabases,theFacilityshouldcontinuallyreviewandreconcilethedatatoensureaccuracyandreproducibility.

(SectionL.1)12. Forthoseindividualswithpneumoniaandafeedingtube,thePCPshouldreviewthecasetoensureaGERDwork‐uphasbeencompleted,if


clinicallyindicated,andtoensurethattherapyforGERDismaximized,ifitisconsideredacontributingfactorforaspirationpneumoniaintheseindividuals.Thequalityandbreadthoftheassessmentalsoshouldbereflectedintheactionplansoftheriskprocess,andISP/ISPaddendums.(SectionL.1)

13. Forthoseindividualswithpneumoniaandafeedingtube,theMedicalDepartmentalsoshouldseekongoingsurveillanceandguidancefromthePNMTforpositioning,andtheDietaryDepartmentforrateoftubefeedingandflushes.(SectionL.1)

14. TheSkinIntegrityCommitteeminutesshouldprovideaclinicalupdateofeachulcerthathealedsincethelastmeeting,orisstillbeingtreated.(SectionL.1)

15. Fordecubitidata,thediscrepanciesindatashouldberesolved.Clarificationalsoshouldbeprovidedofthenumbersofdecubitipermonththatarenewversusthosethatarecontinuingtobetreated.(SectionL.1)

16. Inpreparationfortheneurologyvisit,thedateofthelastneurologyvisitshouldbeincludedonthereportform,aswellasthemostrecentlabvalue(e.g.,antiepilepticdruglevel,etc.),anddateofthelab.(SectionL.1)

17. ForeachoftheindividualswithaDNRstatus,aclearsummaryofcurrentdatashouldbeavailableasevidencetojustifytheseverityoftheconditionwarrantingDNRconsideration.OnlyindividualswhomeetthecriteriainStateOfficepolicyandrelatedstatutes/regulationsshouldhaveDNROrdersinplaceattheFacility.TheFacilityethicscommitteeminutesshouldbepartofthesummaryavailableintherecordtojustifyDNRstatus,iftheethicscommitteemettodiscussthatindividual.(SectionL.1)

18. TheMedicalandNursingDepartmentsshouldreviewalldocumentsforthosewithDNRentriesonvariousmedicalandnursingdocumentationtoconfirmagreementandremoveconflictinginformation.(SectionL.1)

19. TheStateOfficeshoulddevelopcriteriatoguidetheSSLCsindeterminingoptionsforresuscitativeeffortsinthosewithsevereosteoporosis.Suchindividualswouldbeathighriskofmultipleribfracturesandflailchestshouldchestcompressionsoccur,butmightbenefitfromotheraspectsofresuscitativeeffortssuchasintubation/ventilationwithoxygenandmedication.(SectionL.1)

20. ThemedicalconditionforwhichfamilyrequestsforDNRweregrantedshouldbeincludedinthereason/criterialistedforDNR.IfcriteriadonotmeetSSLCstandards,thenitisrecommendedthattherebefurtherdiscussionwithfamilyandtheethicscommittee,anddocumentationshouldbemaintainedofsuchactivities.(SectionL.1)

21. FordiscussionofpotentialDNRstatusforanindividual,theFacilityshouldprovideguidanceregardingrequiredparticipantsintheprocess(e.g.,family,memberofethicscommittee,communitylayrepresentative,PCP,nursecasemanager,stafffromanotherSSLCviaconferencecall,etc.),andthatthisguidancebeformalizedinapolicy/procedure.(SectionL.1)

22. TheStateOfficeshouldreviewthequalityoftheexternalmedicalreviewprocess,provideevidenceoftrainingconcerningstandardsandexpectedinterpretationofreviewquestions,andprovideevidenceofinter‐raterreliabilitydataofauditors.(SectionL.2)

23. Forexternalmedicalpeerreviewofmedicalmanagement(e.g.,threediagnoses),atableshowingcomplianceperPCPperdiagnosisshouldbeprovided,andfuturemedicalauditresultsadded,inordertotrackprogressperPCP.SimilardatashouldbetabulatedtoprovideasummaryoffindingsfortheentireMedicalDepartmenttotrackprogressofthedepartmentoverseveralaudits.(SectionL.2)

24. InconjunctionwiththeQADepartment,theMedicalDepartmentshoulddevelopandimplementadepartmentplandesignedtoimprovenoncompliantessentialareas.(SectionsL.2andL.3)

25. TheQADepartmentshouldcompleteanddocumenttimelyandefficientmonthlyoversightoftheMedicalDepartment’scompliancewiththeactionplansgeneratedbyinternalandexternalauditstoensuretheyarecompletedinatimelymanner.Quarterlyreportsalsoshouldbeprovided.(SectionsL.2andL.3)

26. Themedicalmanagementquestionsshouldbereviewedtoensuretheirvalidity.(SectionsL.2andL.3)27. Nursing,Medical,andFacilityAdministrationshouldreviewthetechniqueofchangingfeedingtubes.Considerationshouldbegivento

techniqueofreplacement,butalsowhethertheindividualisallowedtolieflatduringthereplacement,whichcouldcauserefluxandaspirationpneumonia.(SectionL.2)

28. TheMedicalandNursingDepartmentsshouldreviewtheproblemoftubeclogginganddisplacementoftubestominimizetheneedfortubereplacement.Furtherpolicies,procedures,andmonitoringduringtubechangeshouldbeconsidered,aswellasproofofcompetency‐based


training,andmorefrequentvitalsignsfollowingatubechange.(SectionL.2)29. TheQADepartmentshouldcreateatrackingsystemtoensuretherecommendationsfromthemortalityreviewcommittees(clinicaland

administrative)aremonitoreduntilclosure.Evidenceofclosureshouldbewelldocumented.(SectionL.2)30. TheQADepartmentandtheStateOfficeshouldreviewtheinter‐raterreliabilitydatafromtheinternalpeerauditmedicalmanagement

monitoringtool,anddetermineiffurtherguidanceandinstructionsarenecessarytoassistreviewersinansweringspecificquestions.Dataforinter‐raterreliabilityofthegeneralmonitoringtool(30questions)isalsoencouraged.(SectionL.3)

31. Astandardizedtemplateforthequarterlymedicalreviewsshouldbefinalizedandimplemented.(SectionL.3)32. Thedifferentmonitoringresultsshouldbecompiledintoonemonthlyreportratherthanseveraldifferentreports(i.e.,thoseforSectionG,H,L,

andtheinternalandexternalaudits).(SectionL.3)33. Theclinicaldatabasesshouldbeanalyzedataroutinefrequency,withinformationformallysharedwiththePCPs,includingreportscontaining

analysesofthedata.Ataminimum,quarterlyanalysesandreportsshouldbemadeavailableforeachofthedatasets(e.g.,mammograms,osteoporosis,etc.),andevidenceshouldbemaintainedthatthefindingswerediscussedamongthePCPs,includingdescriptionsofanyconclusionsmadeoractionplansdevelopedatthemedicalstaffmeetings.(SectionL.3)

34. TheMedicalDepartmentshouldclarifywiththeStateOfficethecurrentstatusoftheclinicalguidelinesthathadbeendeveloped,includingthenarrativesections,toensuretheMedicalDepartmenthasalltheavailabledocuments.(SectionL.4)


SECTIONM:NursingCareEachFacilityshallensurethatindividualsreceivenursingcareconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow:


o CCSSLC’sSelf‐Assessment;o CCSSLC’sProvisionActionInformation;o CCSSLCAt‐RiskIndividualslist;o CCSSLCtrainingrosterscontainedthePresentationBookforSectionM;o CCSSLC’sNursingDepartmentPresentationBook;o CCSSLC’sSectionIPresentationBook;o CCSSLC’sInfectionControlPresentationBook;o CCSSLC’sMonitoringToolsforNursingandrawdatasinceJanuary2012;o CCSSLC’sminimumstaffingnumbersfornursing;o CCSSLC’sInfectionControlMonitoringTooldata;o CCSSLC’sCorrectiveActionPlansforSectionM;o QualityAssuranceProgramComplianceNurse’smonitoringdata;o CCSSLC’slistsofindividualswhowereseenintheInfirmary,emergencyroom,and

hospital;o InfectionControlSummaryReport;o ResumesfortheAssistantInfectionControlNurse,NurseAdministrationCoordinator,and

CaseManagerSupervisor;o MedicationVariancesMonthlySummarydatareport;o Medicalrecordsforthefollowingindividuals:Individual#144,Individual#183,Individual

#278,Individual#9,Individual#282,Individual#378,Individual#213,Individual#327,Individual#91,Individual#221,Individual#34,Individual#210,Individual#153,Individual#211,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,Individual#26,andIndividual#95;

o FacilitylistofindividualswithMethicillin‐resistantStaphylococcusaureus(MRSA);HepatitisA,B,andC;humanimmunodeficiencyvirus(HIV);positivePurifiedProteinDerivative(PPD)converters;Clostridiumdifficile(C‐Diff);H1N1;andsexuallytransmitteddiseases(STDs);

o RealTimeAudittoolforInfectionControl;o InfectionControlImmunizationsActionPlan,dated7/12;o CCSSLCOutbreaktimeline;o InfectionControlCommitteemeetingminutes,dated4/4/12;o CCSSLC’smonthlyInfectionControlsummaryreportlist;o DrugUtilizationDiscrepancyReports;o DrugUtilizationReports‐Antibiotics;o AntimicrobialUsagebyPatientreport;o WeeklyInfectionControlReports;o PneumoniaTrackingReports,sinceFebruary2012;


o MedicationAdministrationObservationsrawdata;o NurseEducatorMedicationObservationformforonsitemedicationobservation;o MedicationVariancedatabynurse;o MedicationPeerReviewmeetingminutes,dated4/16/12;o PharmacyandTherapeuticsCommitteemeetingminutes,dated1/4/12,and4/2/11;

MedicationAdministrationObservationrawauditdatafromFebruarythroughMay2012;o MedicationCommitteemeetingminutes,dated1/5/12,2/21/12,3/28/12,4/16/12,and

5/30/12;o MedicationAdministrationObservationTrenddata;o MedicationAdministrationRecordBlankdata;o WorkgroupforInter‐raterReliabilitymeetingminutes,dated2/1/12;o ProcedureforEstablishingInter‐raterReliability,undated;o NurseEducatorTrainingonSimplyThickGelandLiquidMedicationmeetingminutes,

dated4/17/12and4/27/12;o ProtocolforMedicationCartExchange,dated2/15/12;o SectionOPMNT/AdministrationMeetingminutes,dated4/16/12;o AspirationReviewMeeting,dated6/29/12;o SSLCMedicationRoomAuditform,dated3/1/12;o MedicationRoomAuditdataandtrackingspreadsheet;o “RealTime”InfectionControlmonitoringtool;o Rawdatafrom“RealTime”InfectionControlauditsforIndividual#86,Individual#176,

Individual#276,andIndividual#156;o InfirmarySafetyMeetingminutes,dated10/19/11and2/28/12;ando CCSSLCEmergencyMedicalDrillsdata,fromJanuarythroughJune2012.

Interviewswith:o ColleenM.Gonzales,BSHS,ChiefNurseExecutive;o JenniferUrban,RN,BSN,NurseOperationsOfficer;o MarkCazalas,Director;o PeggySueMiclan,RN,ProgramComplianceNurse;o DellaCross,RN,NurseEducator;o KristenMiddleton,RN,NurseEducator;o PamTanner,RN,NurseEducator;o PamelaNichols,InfectionControl/EmployeeHealthNurse;o KarenLanfair,RN,AssistantInfectionControlNurse;o AraceliAguilar,RN,NursingAdministrationCoordinator;o BruceBoswell,AssistantDirectorofPrograms;o PattyGlass,RN,NurseCaseManagerSupervisor;o BrindaFuller,RN,PsychiatricNurse;o MichelleLord‐Arteaga,RN,PsychiatricNurse;o MaryHernandez,CompetencyTrainingDepartment,Trainer;o AngelaRoberts,Au.D.,DirectorofHabilitationTherapies;o DonaldW.Kocian,R.Ph.,PharmacyDirector;


o JoeVulgamore,RiskManagementDirector;o AnnetteMireles,LVNMT,RespiratoryDepartment;o LeslieHernandez,RRT,RespiratoryDepartment;o ConnieHorton,RN,FNP,StateConsultant;ando SallySchultz,StateConsultant.

Observationsof:o MedicationAdministrationintheInfirmary;and

UseofemergencyequipmentattheInfirmary,andAtlanticKingfish2.Facility Self‐Assessment:BasedonareviewoftheFacility’sSelf‐Assessment,withregardtoSectionMoftheSettlementAgreement,theFacilityfoundthatitremainedoutofcompliancewithallofthesub‐provisions.ThiswasconsistentwiththeMonitoringTeam’sfindings.AlthoughtheFacilityself‐assessmentofnoncompliancewasinalignmentwiththefindingsoftheMonitoringTeam,theFacility’sSelf‐Assessmentcontainedinformationthatcouldnotbeinterpretedregardingtheobservations,andespeciallythefindingsfrommonitoringdataonwhichtheFacilityhadbaseditsfindings.ItwasevidentthattheFacilitywasconductingregularauditsusingtheHealthMonitoringTools.However,theattemptstopresentdatageneratedfromtheHealthMonitoringToolscontainedintheFacility’sSelf‐AssessmentforSectionM,thePresentationBookforSectionM,andProvisionActionInformationindicatedthatstaffwerechallengedintheireffortstoreportthefindingsoftheirdata.Althoughinpastreports,theMonitoringTeamnotedthatprovidingoverallcompliancescoresforaudittoolsaddressingnursingissueswasmeaninglessandgavenoindicationoftheareasofstrength,weakness,orthestatusofprogress,severaloverallaudittoolcompliancescorescontinuedtobereportedthroughouttheFacility’sSelf‐AssessmentandintheProvisionActionInformation.Additionally,itwasoftenunclearwhatspecificcriteriawerebeingusedtomeasurecompliancewhentheitemrequiredthatsomethingwastobedone“accordingtopolicy.”Also,itwasunclearwhyonlycertainitemsfromanauditingtoolwereselectedforinclusionintheFacility’sSelf‐AssessmentorProvisionActionInformationversusotheritemsthatwouldhaveprovidedmorepertinentinformationregardingthequalityofthedocumentation.AlthoughitwasevidentthattheFacilitywasinvestingagreatdealofenergyincollectingmonitoringdata,itwasunfortunatethatduetotheoverallpresentationofthedata,itwasrenderedinmostcasesuninterpretable.TheFacilityshouldconsideradoptingastandardizedformatforpresentingdatainameaningfulwaythatfacilitatesitsinterpretationandanalysisandprovidetrainingtothedisciplinesregardinghowtoanalyzetheirdatatoidentifyproblematictrends.Inaddition,someoftrainingactivitiesthatwerecitedintheSelf‐Assessmentdidnothavetheassociatedtrainingrostersindicatinghowmanystaffwasrequiredtoattend,andhowmanyofthosestaffactuallyattendedthetraining.Itdidnothaveadescription,andcurriculumofthetrainingprovided.Thus,theMonitoringTeamcouldnotverifythequalityofsomeofthetrainings.SummaryofMonitor’sAssessment: Sincethelastreview,CCSSLChadsomechangesregardingthe


NursingDepartmentandnursingpositions,whichincludedtheadditionofafull‐timeAssistantInfectionControlNurse,apart‐timeRegisteredNursefortheNursingAdministrationCoordinatorpositiontoassistinthereviewsofNursingCarePlans,andafull‐timeRegisteredNursefortheNurseCaseManagerSupervisorposition.AlthoughthefillratesfornursingstaffinghadexperiencedsomevariabilitysinceJanuary2012forbothRNsandLVNs,nursingstaffingremainedbasicallystableatCCSSLC.SomeoftheFacility’spositivestepsforwardincluded:

TheFacilitybeganimplementationofnineadditionalnursingprotocols,includingMinimalDocumentation,PICA,SeizuresandStatusEpilepticus,AbdominalDistention/Pain,Hypothermia,TemperatureElevation,UrinaryTractInfection,EnteralFeeding,andPostAnesthesia.

FromdatageneratedbycomparisonsoftheInfectionControlReportsandthePharmacyreportsfortheutilizationofantibiotics,thefollowingrepresentedthecompliancepercentagesofantibioticsreportedinbothreports:91%,96%,97%,83%,and89%fromFebruarythroughJune2012,respectively.ThesedatareflectedaverypositivestepforwardinnotonlytrackingdiscrepanciesregardingInfectionControlinformationtoensuredatareliability,butalsoreflectedapositiveincreaseincomplianceregardingtheaccuracyofthedocumentationcontainedontheInfectionControlReports.

Inapositivestepforward,theFacilityindicatedthatblanksfoundonareviewoftheemergencycartchecklistshadsignificantlydecreasedfromJanuarytoJune2012,sinceRiskManagement,RespiratoryTherapy,andNurseEducatorshadbeencompletingmonthlyspotchecksofthisarea.

TheMonitoringTeam’sobservationsofnursesdemonstratingtheuseofemergencyequipmentattheInfirmary,andAtlanticKingfish2foundthatthenurseswerefamiliarwiththeuseandoperationsoftheFacility’semergencyequipment.Itwasclearthattheconsistentdrillsandspotchecksregardingtheemergencyequipmentwerehavingverypositiveoutcomes.

TheFacilityhadreinitiatedastructuredsystemusingthePharmacyRefillSheetstotrackthemedicationsbeingbroughttothebuildingsinanattempttoreconcilethenumberofmedicationsthatwerebeingreturnedtothePharmacywithoutexplanation.

AlthoughtheFacilityhadmadesomepositivestepsforwardintheareasnotedabove,theoveralllackofprogress,andinsomeareas,regression,foundregardingthenursingcareplans,thenursingassessmentsanddocumentationinresponsetochangesinstatus,thequalityofthequarterlyandannualComprehensiveNursingAssessments,andtheunreliablesystemsregardingmedicationvariancedatawereveryconcerningatthisjunctureinthereviewprocess.Someoftherecentsystemchanges,suchastransitioningtoanIntegratedHealthCarePlanrepresentedpositiveforwardmovement.However,theFacility’sdecisiontoremovealltheexistingHealthMaintenancePlanswithoutmodifyingthecurrentinadequateRiskActionPlanssothatalltheindividualswhoresidedatCCSSLCwouldhaveanappropriateandclinicallysoundplanofcareinplaceduringthetransitionwastroubling.


# Provision AssessmentofStatus ComplianceM1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithin18months,nursesshalldocumentnursingassessments,identifyhealthcareproblems,notifyphysiciansofhealthcareproblems,monitor,intervene,andkeepappropriaterecordsoftheindividuals’healthcarestatussufficienttoreadilyidentifychangesinstatus.

GiventhatthisparagraphoftheSettlementAgreementincludesanumberofrequirements,thissectionofthereportincludesanumberofdifferentsubsectionsthataddressvariousareasofcompliance,aswellasfactorsthathavetheabilitytoaffecttheFacility’scompliancewiththeSettlementAgreement.Thesesectionsincludestaffing,qualityenhancementefforts,assessment,availabilityofpertinentmedicalrecords,infectioncontrol,andmedicalemergencysystems.Additionalinformationregardingthenursingassessmentprocess,andthedevelopmentandimplementationofinterventionsisfoundbelowinthesectionsaddressingSectionsM.2andM.3oftheSettlementAgreement.InformationandrecommendationsaddressingnursingdocumentationregardingrestraintsisincludedabovewithregardtoSectionC.Inassessingitsprogress,CCSSLCindicatedintheFacility’sSelf‐AssessmentthatthefollowingstepswereinitiatedsincethelastreviewregardingthisrequirementoftheSettlementAgreement:

TheMonitoringTeamcouldnotinterprettheinformationcontainedintheFacility’sSelf‐AssessmentregardingtheHealthMonitoringtools(HMTs),inter‐raterreliabilityforAcuteIllnessandInjuries,UrgentCare,Documentation,Seizures,SkinIntegrity,ChronicRespiratory,InfectionControl,andPaintodetermineifthenursingcarewasprovidedaccordingtopolicy,theinter‐raterscores,thedatafromnursingprotocolaudits,dataregardingresultsofActiveRecordreviews,and/orthePharmacydatabaseregardingantibioticusage.

Basedonthefindingsfromthisself‐assessment,theFacilityindicatedthat:“thisprovisionisnotinsubstantialcompliancebecausereviewofHealthMonitoringtools,InfectionControlData,EmergencyDrilldataandEmergencychecklistauditformsshowwearenotincompliance.CCSSLCwillcontinuetotrainasconcernsareidentifiedanddevelopcorrectiveactionplans.”AlthoughtherewasnoquestionthattheFacilitywasconductingregularauditsusingtheHMTs,theattemptstopresentdatathatweregeneratedfromtheHMTsfornursingcontainedintheFacility’sSelf‐AssessmentforSectionM,thePresentationBookforSectionM,andProvisionActionInformationindicatedthatstaffwerechallengedintheireffortstoreportthefindingsoftheirdata.Althoughinpastreports,theMonitoringTeamnotedthatprovidingoverallcompliancescoresforaudittoolsaddressingnursingissueswasmeaninglessandgavenoindicationoftheareasofstrength,weakness,orthestatusofprogress,severaloverallaudittoolcompliancescorescontinuedtobereportedthroughouttheFacility’sSelf‐AssessmentandintheProvisionActionInformation.Inaddition,whendatawerereportedbyspecificitemsfromanauditingtool,itwasoftenunclearwhatspecificcriteriawasbeingusedtomeasurecompliancewhentheitemcalledforsomethingtobedone“accordingtopolicy.”Itwasalsounclearwhyonlyafew

Noncompliance


# Provision AssessmentofStatus ComplianceoftheitemsfromanauditingtoolwereselectedforinclusionintheFacility’sSelf‐AssessmentorProvisionActionInformationversusotheritemsthatwouldhaveaddressedotherpertinentissuessuchasthequalityofthedocumentation.FrompastdiscussionswiththeQADepartment,theFacility’sdatabasewascapableofpresentingcompliancedataforalltheitemscontainedonanauditingtoolbymonth,whichwouldclearlyindicatethevarioustrendsincompliancedataforboththeMonitoringTeamandtheFacility.Inaddition,itwasnotedduringthereviewthattherewasasignificantamountofconfusionregardingthedifferencebetweenpresentingthedata,andanalyzingthedata.FromdiscussionswithNursingManagementregardinghowthenursingdataisanalyzed,theyreportedthattheQADepartmentanalyzedtheirdataandincludeditintheQACommitteemeetingminutes.However,fromreviewoftheQAmeetingminutes,theQADepartmentonlyaggregatedthedatacollectedfromthenursingHMTsandthencouldpresentitinanumberofdifferentformats,suchasingraphsorcharts.However,oncethedataisaggregatedinameaningfulway,itisuptothespecificdisciplinestoregularlyreviewthecompliancescoresbyitem,bymonthinordertodeterminewhatthedatameansrelatedtotheclinicalareaitrepresents.Basedonthisanalysis,trendsshouldbeidentifieddemonstratingstrengthsandweaknesses.Thisanalysisshouldthenresultinthedevelopmentandimplementationofplansofactionaddressingareasthatreflectproblematictrends.AlthoughitwascleartotheMonitoringTeamthattheFacilitywasinvestingagreatdealofenergyincollectingmonitoringdata,becauseoftheoverallpresentationofthedata,itwasrenderedinmostcasesuninterpretable.TheFacilityshouldconsideradoptingastandardizedformatforpresentingdatainameaningfulwaythatfacilitatesitsinterpretationandanalysis,andthenprovidetrainingtothedisciplinesregardinghowtoanalyzetheirdatatoidentifyproblematictrends.StaffingAtthetimeofthereview,CCSSLChadacensusof259individuals.Sincethelastreview,CCSSLChadsomechangesregardingtheNursingDepartmentandnursingpositions,whichincluded:

InJuly2012,afull‐timeAssistantInfectionControlNurse(RN)washired; InMay2012,apart‐timeRegisteredNursewashiredfortheNursing

AdministrationCoordinatortoassistinthereviewsofNursingCarePlans; InMay2012,afull‐timeRegisteredNursewashiredfortheNurseCaseManager

Supervisorposition;and TheexistingQualityAssuranceNursehadbeenonleavesinceMay2012andwas

expectedbacktoherpositionbyAugust2012.

Inaddition,atthetimeofthereview,theNursingDepartmenthadatotalof113.2allottedpositions,including61.7forRNsand51.5forLicensedVocationalNurses


# Provision AssessmentofStatus Compliance(LVNs). Overall,thetotalnursingpositionfillratewas 97%for theRNpositions,and86%fortheLVNpositions.TheseadditionalpositivestaffingadvancementsshouldassisttheFacilityinmovingforwardinachievingpositiveclinicaloutcomesfortheindividualsresidingatCCSSLC.FromareviewoftheFacility’snursingstaffingdataanddiscussionswiththeChiefNurseExecutive,CCSSLCcontinuedtomaintainanadequateandfairlyconsistentnursingstaff.AlthoughthenursingstaffingfillrateshadexperiencedsomevariabilitysinceJanuary2012forbothRNsandLVNs,nursingstaffingremainedbasicallystableatCCSSLC.Aspreviouslyrecommended,theFacilityshouldcontinueitseffortsinrecruiting,maintaining,andevaluatingreallocationsofnursingpositionstomeettherequirementsoftheSettlementAgreement.Also,aspreviouslyrecommended,asCCSSLCpoliciesarereviewedand/orrevised,theFacilityshouldensurethatpolicies,procedures,orprotocolsaddresstheintegrationofanynewpositions.QualityEnhancementEffortsUnfortunately,atthetimeofthereview,theQualityAssuranceNurse,hadbeenonaleavesinceMay2012andwasexpectedbacktothepositioninAugust2012.Thus,theMonitoringTeamwasnotabletointerviewtheQANurseregardinganyupdatesoranalysesofherareas.However,theFacilityreportedthataworkgrouphadbeenestablishedtoaddressthearearegardinginter‐raterreliabilityprocedures.FromthedocumentationprovidedbytheFacility,itappearedthattheworkgroupmetonceonFebruary1,2012,andhaddevelopedaninitialdraftofanundateddocumenttitledProcedureforEstablishingInter‐RaterReliability.Althoughthedocumentcontainedsomegoodinformationregardingtheinter‐raterreliabilityprocess,albeitnotcompleteinformationregardingproceduresaddressingdatageneratedformonitoringtoolsthathavelowpercentagesofinter‐raterreliability,itappearedthatthedocumenthadnotbeenfinalized,andnoadditionalworkgroupminuteswereprovided.Consequently,itwasuncleartotheMonitoringTeamifaprocedureaddressinginter‐raterreliabilitywasactuallycompletedasreported.AssessmentandDocumentationofIndividualswithAcuteChangesinStatusSincethelastreview,theFacilityindicatedthatthefollowingstepshadbeenimplementedtoaddressthenursingassessmentanddocumentationofindividualswithacutechangesinhealthstatus:

TheFacilityreportedthatithadbeguntoimplementnineadditionalnursingprotocols,includingthosefor:MinimalDocumentation,PICA,SeizuresandStatusEpilepticus,AbdominalDistention/Pain,Hypothermia,TemperatureElevation,UrinaryTractInfection,EnteralFeeding,andPostAnesthesia.


# Provision AssessmentofStatus ComplianceHowever,thePresentationBookforSectionM.4didnotincludeadescriptionofthetraining,soitwasunclearwhattrainingwasprovidedpriortoimplementation,oriftheprotocolshadjustmerelybeendistributedtoallthenurses.SuchinformationshouldhavebeenprovidedeitheraspartofthePresentationBookorinresponsetotheMonitoringTeam’scomprehensiverequestfortrainingdocumentationincludedinthepre‐visitrequest.Althoughincreasingthenumberofnursingprotocolstoassistinthedevelopmentofclinicallyadequatecareplanstoguidenursingpracticeswasapositivestepforward,atthetimeofthereview,noevidencewasfoundinthecareplansorinthenursingdocumentationreviewedthatthenursingprotocolswereactuallybeingusedtodrivetheidentificationandimplementationofthespecificresponsibilitiesofdisciplines,provideclearandappropriatetimeframesforinitiatingnursingassessmentsandthetypeofassessmentsthatshouldbeconducted,assistindeterminingthefrequencyoftheseassessments,andidentifytheparametersandtimeframesforreportingsymptomstothepractitioner/physicianandPNMT,ifindicated.Thus,nosupportingdocumentationwasfoundtosubstantiatethenursingprotocolshadactuallybeenimplemented.

Apromisingauditingtoolwasdevelopedtoreviewtheuseofnursingprotocolssincethelastreview.ThisisdiscussedinmoredetailwithregardtoSectionM.4.

Areviewof13individuals’medicalrecords(i.e.,Individual#64,Individual#304,Individual#286,Individual#273,Individual#144,Individual#155,Individual#175,Individual#266,Individual#130,Individual#308,Individual#117,Individual#239,andIndividual#103)whohadbeentransferredtoacommunityhospital,emergencyroom,ortheInfirmaryfound:

Nursespromptlyandconsistentlyperformedaphysicalassessmentonanyindividualdisplayingsigns/symptomsofpotentialoractualacuteillnessinnone(0%).

LicensednursingstafftimelyandconsistentlyinformedthePCPofsymptomsthatrequiredmedicalevaluationorinterventioninnone(0%)ofthecases.

AppropriateinformationwascommunicatedtothePCPinnone(0%)ofthecases.

Thenurseconsistentlyperformedappropriateandcompleteassessmentsasdictatedbythesymptomsinnone(0%)ofthecases.

Thenurseconductedfrequentassessmentsoftheindividual’sclinicalconditioninnone(0%)ofthecases.

Anadequateplanofcarewasdevelopedincludinginstructionsforimplementationandfollow‐upassessmentsinnone(0%)ofthecases.

Thedocumentationindicatedthatacuteillness/injurieswerefollowedthroughtoresolutioninnone(0%)ofthecases.



Areviewofthese13individualsfoundbasicallythesamesignificantproblematicclinicalissuesregardingnursingassessmentsanddocumentationthattheMonitoringTeamidentifiedduringthepastfivereviews.Theoverallproblematicissuesthatwerefoundinall13recordsincluded:

Therewasaconsistentlackofrecognitionthatthesymptomstheindividualsexperiencedweresignsofchangesinstatus,andwarrantednursingassessmentsanddocumentationofthefindingsfromassessments;

Aconsistentlackofcompleteandappropriatenursingassessmentswasnotedinresponsetostatuschangesinbehaviors,vitalsigns,andoxygensaturations;

Thelackofconsistentnursingdocumentationmadeitimpossibletoaccuratelydeterminewhenchangesinstatuswereinitiallyoccurring;

Therewasaconsistentlackoffollow‐upforhealthissuesnotedinpreviousnurses’progressnotes;

Therewasconsistentinadequatedocumentationandnursingassessmentsaddressingtheadministrationandfollow‐upoftheeffectivenessofPRNmedications(asneededmedications);

Therewereconsistentinadequateassessmentsandfollow‐upaddressingindicationsand/orcomplaintsofpain;

Thenursingnoteslackedspecificdescription,size,andlocationofskinissues,suchasreddenedarea,injuries,orbruises;

Therewasalackofdocumentationofindividuals’activitiesandtoleranceforactivitiesduringtheday,evening,andnighttoindicateanyassociatedchangesinmentalstatusfromphysicalchangesinstatus;

Therewerefewmentalstatusassessmentsdocumentedduringstatuschanges; Therewasaconsistentlackofdocumentationindicatingthatlungsoundswere

regularlyassessedanddocumentedforindividualswithsignificantrespiratoryissues;

Therewasaconsistentlackofassessmentofbowelsounds,andabdomenexamsdocumentedforindividualswithconstipationorreceivingPRNlaxatives;

Thereweregapsinnursingdocumentation,whenthenurses’notesindicatedthattheywere“monitoring”theindividual’sstatus;

Physicians/Practitionerswereconsistentlynottimelynotifiedofchangesinstatus,duetonurses’inadequatefollow‐up;

TherewasconsistentlynodocumentationthatnursingcommunicatedwiththePNMTregardingchangesinstatusforindividualsatriskofaspiration/choking;

Therewasaconsistentlackofspecificdescriptionsoftheindividuals’behaviors,assumingthatallstaffreadingtheprogressnoteswerefamiliarwiththeindividuals;

Thereweremissingweights,andintakeandoutputvaluesforindividualswithsignificantweightlossissues;


# Provision AssessmentofStatus Compliance Manyinappropriateabbreviationswereusedthatcouldnotbeinterpreted; Aconsistentlackofcommunicationwasnotedbetweenshiftsregardingstatus

changes,andtheneedforregularassessmentsandfollowup; Therewasinadequatedocumentationnotedregardingtheindividual’sstatus

andassessmentatthetimeoftransfertothehospitalorInfirmary,oremergencyroom;

Intheprogressnotes,therewasinconsistentdocumentationofthetime,date,and/ormethodoftransfertothereceivingfacility;

Inthenursingnotes,therewasaconsistentlackofanalysisofcontributingproblematicissuesaffectingchangesinstatusdocumented;

TherewasinadequatedocumentationofacompletenursingassessmentuponreturntotheFacility,especiallyaddressingthesamesymptomsthatprecipitatedthetransfertoacommunityhospital;

Therewasinconsistentdocumentationthatthenurseorphysiciannotifiedthereceivingfacilityoftheindividual’stransfer;

Therewasaconsistentlackofregularfollow‐updaysafterthetransferoccurredforsymptomsrelatedtotheinitialreasonforthehospitalization;

NursingCarePlansaddressinghealthissueswereconsistentlyinadequatewithregardtoindividualizedgoalsandnursinginterventions,andwerenoteffectivelymodifiedafterhospitalizations;

Datesandtimeswerenotconsistentlydocumentedforprogressnotes; Asignificantnumberofnursingprogressnotesandsignatureswereillegible;

and Therewasinconsistentdocumentationaddressingthecareofhealthcare

equipmentindividualsrequired,suchascatheters,tracheotomies,andG‐tubes.ThereweresomeIntegratedProgressNotes(IPNs)thatcontainedanadequatenursingassessment,andassociatedfindings.However,duetotheinconsistencyoftheseadequatenotes,itwasclearthatthesewerenottheresultofanytypeofstructuredsystem.AlthoughtheFacilityreportedthatNursingProtocolshadbeenimplemented,therewasnoindicationthattheywerebeingusedtoguidenursingassessmentsanddocumentation.TheFacilityshouldcontinuetoimplementandexpandtheuseofnursingprotocols(asisdiscussedinfurtherdetailwithregardtoSectionM.4)toguidenursingpractices.Inconjunctionwiththecontinuationoftheadequatecompetency‐basednursingskillstrainingbeingprovidedbytheStateOfficeNursePractitionerGroup,mentoringandsupervisionofnursesshouldfocusontheexpandeduseoftheprotocols.Asnotedinpreviousreports,duetothenumberofindividualswithcomplexmedicalneedsatCCSSLC,thisareashouldbeconsideredapriorityforFacilityreview,andthedevelopmentandimplementationofactionplansaddressingthesignificantdeficitsthatexistinthenursingcare.TheFacility’sSelf‐Assessmentindicatedthatitwasnotin


# Provision AssessmentofStatus Compliancecompliancewiththese elementsofthisrequirement,whichwasconsistentwiththeMonitoringTeam’sfindings.AvailabilityofPertinentMedicalRecordsFromalimitedreviewofrecordswhileonsite,itwasnotedthatfewdocumentsweremissingfromtheactiverecords.However,informationcontainedintheFacility’sSelf‐AssessmentindicatedthatfromareviewofQuarterlyandAnnualNursingassessmentsconductedmonthlytodetermineiftheyhadbeencompletedontimeandwereintheActiveRecord,theFacilityfoundthatalthoughtheassessmentsweretimelycompleted,theywerenotbeingconsistentlyfoundintheActiveRecords.TheFacilityshouldcontinuetoensurethatdocumentsareavailable,andfiledinatimelymannerintheindividuals’records,sothatpertinentclinicalinformationisreadilyavailabletocliniciansneedingthisinformationwhenmakingdecisionsregardingtreatmentsandhealthcareservices.InfectionControl(IC)Atthetimeofthereview,theFacilityrecentlyhadhiredafull‐timeRNinthepositionoftheAssistantInfectionControlNursewhohadminimalpreviousexperienceinInfectionControl.FromdiscussionswiththeICNurse,thenewAssistantInfectionControlNursehadreceivedsomeinitialcompetency‐basedtrainingregardinginfectioncontrolprinciplesandwasinprocessofcompletingon‐linemodulesregardingclinicalissuesrelatedtoinfectioncontrol.Thisshouldbecontinuedanddocumentedinordertoensurecompetencyinthisspecificclinicalarea.FromtheFacility’sSelf‐Assessment,areviewofCCSSLC’sActionProvisionInformationreport,andthedocumentationcontainedinthePresentationBookaddressingInfectionControl,aswellasinterviewswiththeICNurse,reviewofthedocumentation,andinformationgatheredduringthereview,somepositivestepsforwardhadbeenmaderegardingtheprocessofbuildinganinfrastructuretomeettherequirementsoftheSettlementAgreement.Someoftheprogressnotedincluded:

TheFacilitycreatedaseparatePresentationBookaddressingInfectionControl.ItwasveryorganizedandcontainedasignificantamountofinformationregardingtheactivitiesoftheICNursessincethelastreview.

Priortothelastreview,theICNursehadinitiatedaprocessaddressingdatareliability,toaccuratelyidentifytheFacility’strendsrelatedtoinfectiousandcommunicableissues.FromdatageneratedbycomparisonsoftheInfectionControlReportsandthePharmacyreportsfortheutilizationofantibiotics,thefollowingrepresentcompliancepercentagesofantibioticsincludedinbothreports:91%,96%,97%,83%,and89%fromFebruarythroughJune2012,respectively.ThesedatanotonlyreflectedaverypositivestepforwardintrackingdiscrepanciesregardingInfectionControlinformationtoensuredata


# Provision AssessmentofStatus Compliancereliability, butalsoapositiveincreaseincomplianceregardingtheaccuracyofthedocumentationcontainedontheInfectionControlReportscompletedbytheresidentialstaff.However,atthetimeofthereview,therewasnowrittenprocedurethatoutlinedCCSSLC’sprocesstoensuretheICdatawasreliable.AformalprocedureaddressingthisprocessshouldbewrittenandincludedintheFacility’sInfectionControlManual.

Atthetimeofthereview,theFacilityhadbeguntoreviewmonthlytheICDiscrepancyReportswiththeCaseManagersregardingpertinentmissingICinformationfoundontheweeklyInfectionControlReports.Clearly,thisstepforwardhadapositiveoutcomebasedontheincreasesincompliancepercentagesnotedabove.AlthoughtheinformationintheICPresentationBookdidnotspecifywhenthisreviewtookplace(i.e.,MonthlyNursingMeetings),theFacilityshouldconsiderformalizingthisprocesstoensureitoccursconsistently.

SinceMarch2012,theICNursedevelopedandimplementedaverypromising“RealTime”InfectionControlmonitoringtoolfocusedonissuesregardingtheoverallclinicalcareofacuteinfectiousepisodes.Atthetimeofthereview,fiveauditshadbeenconductedforfourindividualswhohadexperiencedanacuteinfectiousillness(i.e.,Individual#86,whohadtwoinfectiousepisodes;Individual#176;Individual#276;andIndividual#156).Areviewoftherawdataindicatedthatsomesignificantproblematicissueswerefound,suchasnoneofthefiveauditsindicatedthattheindividualshadanadequatenursingcareplaninplaceaddressingtheinfectiousillness,thattheappropriateprecautionswereincludedinthecareplans,orthatstafftrainingregardingthespecificillnesswasincludedasaninterventioninthecareplans.Thesedata,alongwithothermonitoringdataaddressingICissues,anddataregardingactualinfectionratesshouldbeaggregatedandanalyzedinordertobetteridentifysystematicand/orstaff‐relatedproblematictrendsthatmightbeimpactingtheratesofinfectionsattheFacility.

TheInfectionControlsurveillancedatawasaggregatedinanumberofdifferentwayssuchasbyinfectiontype,byhome,bybuilding,byindividual,bymonth,andbyorganism.

ThedocumentationtheFacilityprovidedregardinginfectiousillnessindicatedthatanumberofappropriateandtimelyin‐servicetrainingsessionswereprovidedtostaffinresponsetoacuteinfectiousillnessesbytheICNurse.

TheFacility’sSelf‐Assessmentindicatedthat99%ofindividualsand98%ofstaffwerecurrentregardingimmunizations.

TheformatandstructureoftheminutesoftheInfectionControlCommitteemeetingsprovidedclearerinformationregardingissuesdiscussed,actionsimplemented,andtheeffectivenessoftheactionsonoutcomes.

AlthoughtheICNursesmadeseveralpositivestepsforward,therecontinuedtobea


# Provision AssessmentofStatus Compliancenumberofsignificantproblematicareasregardinginfectioncontrolthatwereinneedoffurtherattention,including;

AlthoughtheFacilityhaddevelopedandimplementedanimmunizationdatabase,consistentwithpastreviews,theFacilitycouldnotgeneratealistofalltheindividualswhosepastimmunizationshadbeenresearched,andwereupdated,asappropriate.Aformalizedscheduleshouldbedevelopedclearlyindicatingwhichindividuals’immunizationstatusandimmunizationshavebeenresearchedandconfirmedorupdatedtoensureallindividualshavereceivedalltherequiredimmunizationsasoutlinedintheHealthCareGuidelines.

AreviewoftheminutesoftheInfirmarySafetyMeetingfoundthattheminutescontainedverylittleinformationthatindicatedwhattheexactmissionandpurposewasofthemeeting.Inaddition,theinformationthatwascontainedintheminuteshadnoassociatedanalysisincludedtoindicatehowtheseissueswererelatedorinterrelatedtosafetyissuesinvolvingtheInfirmary.Suchissuesincludedthenumberofaspirationpneumonias,thenumberofisolationcases,trashpick‐updaysfortheInfirmary,movingelectricaloutletsintheInfirmary,andissuesregardingstafffeedingstraycats.Inaddition,itwasdifficultfortheMonitoringTeamtodeterminehowfrequentlythesemeetingswererequiredtooccur,becausetheminutestheFacilityprovidedweredated10/19/11and2/28/12.

TheFacility’sdocumentationindicatedthatInfectionControlEnvironmentalChecklistswerebeingregularlyconducted,andthecommentsonmanyofthechecklistsindicatedthattheauditorswerebeingmorecriticallyobservantthaninthepast.Althoughanumberofsignificantproblemswerefoundsuchasbathroomssmellinglikeurine,storageroomsinneedofcleaningandorganizing,soapdispensersbrokenorempty,doorsanddrawersnotfullyclosing,andcracksinthevinylfurniture,therewasnoindicationthattheseproblemshadbeenadequatelyaddressed.Inaddition,theresultsoftheseauditswerenottrendedoranalyzedinconjunctionwithotherICdatatodetermineiftherewasacorrelationbetweentheproblematicenvironmentalissuesandratesofinfections.SuchanalysesandrelateddiscussionsaboutactionplansimplementedorpotentialsolutionsshouldbeincludedintheminutesoftheInfectionControlCommitteemeetingminutes.

Consistentwiththesameproblematicissuesthatwerefoundduringthepreviousreviewsregardingnursingcareplans,areviewoffiveindividualswithFlu‐likesymptomsinMarch2012(i.e.,Individual#46,Individual#172,Individual#186,Individual#151,andIndividual#94)wasconductedtodetermineiftheindividualshadappropriatecareplanstoaddresstheirneeds.Basedonthereview,theMonitoringTeamfoundthatofthefiveepisodes,none(0%)hadacuteHMPsaddressingtheinfectiousissue.

Inaddition,theIsolationInfectionControlReporttheFacilityprovidedfrom


# Provision AssessmentofStatus ComplianceJanuarythroughJune2012indicatedthat10Individualswereplacedoncontactprecautionsforatotalof13infectiousepisodessinceJanuary19,2012(i.e.,Individual#242,Individual#163,Individual#243,Individual#69,Individual#276,Individual#156,Individual#86,Individual#176,Individual#43,andIndividual#353).Ofthetenindividuals,one(10%)wasfoundtohavehadtwoacuteHMPsaddressingthesameinfectiousissue.OneoftheseHMPswasnotsigned,andtheothertheICNurseauthored.OfthetwoNursingCarePlansreviewedaddressingtheinfectiousdisease,neitherwasfoundtobeadequate(0%).However,theHMPcompletedbytheInfectionControlNursecontainedapromisingincreaseintheclinicalcontentandattemptstoindividualizethecareplan.

Also,areview12individuals(i.e.,Individual#287,Individual#228,Individual#137,Individual#48,Individual#44,Individual#172,Individual#83,Individual#254,Individual#157,Individual#368,Individual#359,andIndividual#95)whohadapositiveTuberculinPurifiedProteinDerivativewerereviewedtodetermineiftheindividualshadappropriatecareplanstoaddresstheirneeds.Ofthe12individuals,12(100%)werefoundtohavehadacareplanaddressingthisissue.However,thecareplansconsistedofthreeoftheHMPtemplateforpositivePPDs(i.e.,Individual#287,Individual#228,andIndividual#137)andtheremainingnineweresubmittedonRiskActionPlanswiththeassociatedIntegratedRiskRatingForms.Ofthe12CarePlansreviewedaddressingpositivePPDs,none(0%)werefoundtobeadequate.ThisisdiscussedinmoredetailwithregardtoSectionM.3.TheFacilityshoulddevelopandimplementasystemtoensuretheHMPsforindividualswithinfectious/communicablediseaseareclinicallyappropriateandconsistentlyimplemented;

AreviewoftheInfectionControlCommitteemeetingminutesfoundthatwhilethereweresomeattemptsmadeatanalyzingtheFacility’sICdata,therewereanumberofothermonitoringdatafindingsthatwerenotbeingreviewedandanalyzedtocomprehensivelyassesstheFacility’sinfectioncontrolpractices.TheFacilityshouldconductanalysesofalltheICmonitoringdata,implementplansofactionaddressingproblematicissues,anddocumenttheinterventionsimplemented,andtheresultingoutcomes.

AlthoughtheFacilityhadmadesomepositivestepsforward,therecontinuedtobeasignificantamountofworkyettobedoneregardingInfectionControlinordertomakesubstantialgainsinmeetingtherequirementsoftheSettlementAgreement.Asnotedinpreviousreports,considerationshouldbegiventohavingadditionalexpertiseinInfectionControlprovidedtotheFacilitytoassistineffectivelyoperationalizingtheInfectionControlSystemsinalignmentwithICstandardsofpracticeandtheSettlementAgreement,aswellasprovidingprofessionalfeedbackregardingthequalityand


# Provision AssessmentofStatus CompliancecompletenessoftheInfectionControlProgram.MockCodeDrillsandEmergencyResponseSystemsCCSSLCindicatedintheFacility’sSelf‐Assessmentthatsincethelastreview,thefollowingstepswereinitiatedregardingthisarea:

ItwasuncleartotheMonitoringTeamthesignificanceoftheinformationcontainedintheFacility’sSelf‐Assessmentregardingtherequirementsforpassinganemergencymockdrill.Inaddition,thedatacontainedintheFacilitySelf‐Assessmentindicatedthatitreflectedthe“averagepercentageofemployeespassingthedrillswithoutprompts,”butthegraphnotedthedataindicatedthenumberofdrillsconductedeachmonthandthepercentageofthosedrillsthatpasses.Thus,theinformationanddatacontainedintheSelf‐Assessmentaddressingtheemergencymockdrillscouldnotbeaccuratelyinterpreted.

Inapositivestepforward,theFacilityindicatedthatblanksfoundonareviewoftheemergencycartchecklistshadsignificantlydecreasedfromJanuarytoJune2012,sinceRiskManagement,RespiratoryTherapy,andNurseEducatorshavebeencompletingmonthlyspotchecksofthisarea.

TheNursingEducatorscontinuedconductingspotchecksaddressingemergencyequipmentuseandoxygenflowrates,andaddedtestingforflowratestothemockdrillprocedure.TheMonitoringTeam’sobservationsofnursesdemonstratingtheemergencyequipmentattheInfirmary,andAtlanticKingfish2foundthatthenurseswerefamiliarwiththeuseandoperationsoftheFacility’semergencyequipment.ItwascleartotheMonitoringTeamthattheconsistentdrillsandspotchecksregardingtheemergencyequipmentwerehavingverypositiveoutcomes.

Sincethelastreview,theFacilityhadpurchasedeightadditionalmanikinsforuseinemergencydrills.

TheFacilityhaddevelopedanexcellentnewMockCodeVideo2012trainingforemergencyproceduresandhadplacedseveraloftheminthebuildingstoensuretheywereassessabletoallstaff.

TheFacilityimplementedatrackingformthatclearlyindicatedthefollowinginformationregardingtheemergencymockdrills:theshiftwhenitwasconducted,thedate,time,comments/concerns,immediateplanofcorrection,systemplanofcorrection,anddrillstatus(passorfailed).

AlthoughtheFacilityimplementedsomepositivestepsaddressingtheEmergencyResponseSystem,anumberofproblematicissueswerefoundthatshouldbeaddressedinorderforadditionalprogresstobemade:

SincetheStateOfficeEmergencyResponsepolicywasimplementedinDecember2011,theFacilityceasedtheMedicalEmergencyCodeDrillmeetings.TheCNEreportedthatsincethepolicyidentifiedRiskManagementasbeingthe


# Provision AssessmentofStatus CompliancedepartmentthatwouldbereviewingthedataregardingEmergencyMockDrills,theFacilitynolongerneededtheMedicalEmergencyCodeDrillmeeting.However,fromdiscussionswiththeRiskManagementDirector,hereportedthattheonlyinformationdiscussedattheRiskManagementmeetingregardingtheEmergencyMockCodeDrillswasthenumberconducted,andthenumberthatpassedandfailed.HereportedthatduringtheRiskManagementmeetings,therewerenodiscussionsregardinganyproblematictrendsfoundduringthedrills,andtherewasnoclinicalreviewofthedrillsortheactualmedicalemergenciesthatoccurredattheFacility.Consequently,thestatusoftheFacility’semergencysystemswasnotbeingreviewed,discussed,ortrackedbyanyclinicalstaff.ForaFacilitythathadasignificantnumberofindividualswithcomplexmedicalneeds,thisfindingwasconcerning.TheFacilityinconjunctionwiththeStateOfficeshouldclarifytheroleofRiskManagementandtheroleoftheclinicalstaffregardingthereviewofEmergencyMockCodeDrilldataanddataaddressingtheactualmedicalemergenciesthathaveoccurred.

TherewasnoanalysisorassociatedplanofcorrectionfoundregardingthedataaddressingEmergencyMockDrills,especiallyinlightofsomeofthelowpasspercentagesofthedrillsconductedfromJanuarythroughJune2012.Thepassrateswere29%,37%,78%,33%,56%,and78%,respectively.

AlthoughtheCTDstaffreportedsomeimprovement,therecontinuedtobesomestaffresistantregardingparticipationintheMockDrills.Forexample,thecommentsnotedontheEmergencyDrillformfor5/15/12atHorizonsindicatedthatonestaffhadtobepromptedtoparticipateinthedrillandanotherstaffhadtobetoldtohanguphiscellphonewhenthedrillwasinitiated.

TheNurseEducatorreportedthattheonlyotherscenariosthatwereincludedinthedrillswaschoking,andthatwasonlyincludedforonemonth.Aspreviouslyrecommended,theFacilityshouldexpanditsemergencydrillstoincludeavarietyofscenariossothattheemergencydrillsaremorereflectiveofemergenciesthatwarrantactionsinadditiontoCPR.

Thedatafromthedrillsconductedsincethelastreviewwereasfollows:

17drillsconductedinJanuary2012–fivepassed(29%); 19drillsconductedinFebruary2012–sevenpassed(37%); 18drillsconductedinMarch2012–14passed(78%); 18drillsconductedinApril2012–sixpassed(33%); 15drillsconductedinMay2012–10passed(67%);and 18drillsconductedinJune2012‐14passed(78%).

TheFacilityhadmadesomepositivestepsforwardregardingCCSSLC’sEmergencyResponseSystem.However,therecontinuedtobeanumberofproblematicissuesasnotedabovethatneededtobeaddressed.TheFacilityreportedthat:“basedonthe


# Provision AssessmentofStatus Compliancefindingsfromthisself‐assessment,thisprovisionisnotinsubstantialcompliancebecausereviewofHealthMonitoringtools,InfectionControlData,EmergencyDrilldataandEmergencychecklistauditformsshowwearenotincompliance.CCSSLCwillcontinuetotrainasconcernsareidentifiedanddevelopcorrectiveactionplans.”

M2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithin18months,theFacilityshallupdatenursingassessmentsofthenursingcareneedsofeachindividualonaquarterlybasisandmoreoftenasindicatedbytheindividual’shealthstatus.

Inassessingitsprogress,CCSSLCindicatedintheFacility’sSelf‐Assessmentthatsincethelastreview,thefollowingregardingthisrequirementoftheSettlementAgreement:

FromamonthlyreviewofeightQuarterlyandAnnualNursingassessmentstodetermineiftheyhadbeencompletedontimeandwereintheActiveRecord,theyfoundthatalthoughtheassessmentsweretimelycompleted,theywerenotbeingconsistentlyfoundintheActiveRecords.Althoughthiswasaverypertinentfinding,thepresentationofthedatawasdifficulttointerpretduetotheFacility’slackofhavingastandardizedformatforpresentingdatainameaningfulmanner.Inaddition,therewasnoinformationprovidedintheSelf‐AssessmentindicatinghowtheFacilityplannedtoaddresstheproblematicissueidentified.

Inaddition,areviewwasconductedusingtheHealthMonitoringTools(HMTs)forAcuteIllnessandInjuriestodetermineifnursingcarewasprovidedaccordingtopolicy.However,thefindingslistedintheFacility’sSelf‐Assessmentstated:“QuarterlyandAnnualNursingAssessmentswerecompletedaccuratelyaccordingtoguidelines,”whichdidnotaddresstheissueregardingtheprovisionofnursingcare.Inaddition,theSelf‐AssessmentcontainedagraphwithasinglecompliancepercentageforeachmonthfromDecember2011throughMay2012foranitemlistedas“NursingAssessmentcompliance,”withoutanexplanationofwhatnursingassessmentcompliancespecificallyrepresented.Consequently,theMonitoringTeamwasnotabletoaccuratelyinterpretthedata.

AlthoughtheFacility’sSelf‐Assessmentindicatedthat“100%oftenuredCCSSLCRNshavecompletedtheStateOfficePhysicalAssessmentanddocumentationclassesasof3/16/2012andtheNurseEducatorshavecompletedtheircompetencyandhavetakenoverteachingthiscoursetoallnewhires,”itwasunclearwhatconstituteda“tenured”registerednurse,andleftthequestionunansweredregardinghowmanynurses,bothRNsandLVNshadactuallycompletedandpassedthetraining.Inaddition,thedocumentationtheFacilityprovidedattheentrancemeetingregardingtheaccomplishmentsandprogressforSectionMindicatedthat“55.7/59.7RNs”hadcompletedthistraining,whichdidnotclarifytheissueregardingwhatpercentageofnursesatCCSSLCcompletedthetraining.

SelfRating:TheFacility’sSelf‐Assessmentindicatedthat“basedonthefindingsfromthisself‐

Noncompliance


# Provision AssessmentofStatus Complianceassessment,thisprovisionisnotinsubstantialcompliancebecauseafterreviewofthedocumentationandaudits,CCSSLCwillneedtocontinuetoeducatenursesasconcernsarefoundfromtheHMT’s.”Inaddition,theattemptstopresentdatatheHMTsgeneratedfornursingintheFacility’sSelf‐AssessmentforSectionMandProvisionActionInformationclearlyindicatedthatstaffwerestrugglingintheireffortsjusttoreportthedata.Althoughinpastreportsandduringpastreviews,itwasnotedthatprovidingoverallcompliancescoresforaudittoolsaddressingnursingissueswasmeaninglessandgavenoindicationoftheareasofstrength,weakness,orthestatusofprogress,overallcompliancescorescontinuedtobereportedthroughouttheFacility’sSelf‐AssessmentandintheProvisionActionInformation.ItwasclearthattheFacilitywasinvestingagreatdealofenergyindatacollection.However,unfortunatelyinmostcases,theoverallpresentationofthedatarenderedituninterpretable.TheFacilityshouldconsideradoptingastandardizedformatforpresentingdatainameaningfulwaythatfacilitatesitsinterpretationandanalysis.AlthoughtheFacility’sfindingsofnoncompliancewasconsistentwiththeMonitoringTeam’sfindings,thereasonsfortheMonitoringTeam’sfindingofnoncomplianceasnotedbelow,werefarmorespecificregardingthesignificantproblemswiththequalityandcontentoftheComprehensiveNursingAssessmentsthanwhatwasreflectedintheFacility’sSelfAssessment.AmajorconcernthusfarinthereviewprocesswasthatCCSSLChadnotgeneratedfindingsaddressingthequalityofthedocumentationcontainedintheComprehensiveNursingAssessments,whichcontinuedtobeinadequate,andinfact,wasnotedtobeworsethanwhatwasfoundduringthepreviousreview.Inaddition,theFacility’sActionPlanaddressingSectionM.2didnotincludeanyactionstepsregardinghowthepoorqualityoftheComprehensiveNursingAssessmentswastobeaddressedbythenextreview.However,somepositivestepsforwardthattheFacilitymadesincethelastreviewincludedthefollowing:

InJanuary2012,theFacilitydevelopedandimplementedadatabasetoensurethequarterlyandannualComprehensiveNursingAssessmentsweretimelycompleted;and

InMay2012,theFacilityhiredafull‐timeRNCaseManagerCoordinatortooverseetheRNCaseManagerstoensuretheyweretimelyandappropriatelyexecutingtheirduties.TheintroductionofthisnewstatewidepositionshouldincreasetheaccountabilityofthecrucialroleoftheRNCaseManagersattheFacility.

TheQuarterly/AnnualNursingAssessmentsfor27individualswhotheFacilityidentified


# Provision AssessmentofStatus Complianceasbeingatriskforspecifichealthindicatorswerereviewed,includingthosefor: Individual#144,Individual#183,andIndividual#278forweight;Individual#9,Individual#282,andIndividual#378fordentalissues;Individual#213,Individual#327,andIndividual#91forurinarytractinfections;Individual#221,Individual#34,andIndividual#210forcardiacissues;Individual#153,Individual#211,andIndividual#38forchallengingbehaviors;Individual#182,Individual#8,andIndividual#44forfalls;Individual#224,Individual#276,andIndividual#10forfluidimbalances;Individual#138,Individual#297,andIndividual#350forgastrointestinalissues;andIndividual#268,Individual#26,andIndividual#95forpolypharmacy.

Ofthe27individuals’nursingquarterlyassessmentsreviewed,22(81%)weretimelycompleted.AssessmentsthatwerenottimelycompletedincludedIndividual#144,Individual#91,Individual#276,Individual#26,andIndividual#95.

Therewasanadequateanalysisofthehealth/mentalhealthdatabetweenthepreviousandcurrentquartersinnone(0%)oftheNursingSummariescontainedintheComprehensiveNursingAssessmentstoindicateiftheindividualwasmakingprogressrelatedtotheirhealth/behaviorissues.

Therewasanadequateassessmentofthehighandmediumriskhealthindicatorsincludedinnone(0%)oftheComprehensiveNursingAssessments.

Nursingassessmentswereupdatedasindicatedbytheindividual’shealthstatusinnone(0%)oftheComprehensiveNursingAssessmentsreviewed.

Althoughtherewereafewpositivestepsforward,asnotedpreviously,theMonitoringTeamfoundnoprogresshadbeenmaderegardingthequalityofthequarterly/annualnursingassessments,withevensomeregressionnotedfromthepreviousreview.Infact,anumberoftheComprehensiveNursingAssessmentsreviewedcontainedessentiallythesameidenticalinformationrepeatedunderthedifferentsubsectionsintheSummarySectionwithoutanytypeofanalysisoftheheathindicator.Also,considerablymorediscrepancieswerefoundbetweentheinformationcontainedinthebodyoftheassessmentsandtheSummarySection,aswellasdiscrepanciesnotedintherisklevelsfoundthenursingassessmentsascomparedtotheIntegratedRiskRatingForms,whichwasnotfoundduringthepreviousreview.Consistentwiththefindingsfromthepreviousreviews,noneoftheComprehensiveNursingAssessmentsummariesreviewedincludedanadequateorappropriateanalysisoftheindividuals’health/mentalhealthissuesbetweenquartersindicatingifthehealthissueswereimprovingorgettingworse.ThechroniclackofanalysisofprogressandregressionregardingtheComprehensiveNursingAssessments,andtheFacility’slackofestablishingaconcreteplantoaddressthisrequirementsuggestedthatnursingatalllevelswithinCCSSLClackedtheabilityandunderstandingregardinghowtoanalyze,summarize,anddocumenthealth/mentalhealthissuestodeterminewhetherornot


# Provision AssessmentofStatus Complianceprogresswasbeingmade.TheFacilityshouldprovideappropriatecompetency‐basedtrainingregardingtheQuarterly/AnnualComprehensiveNursingAssessmentsfromacompetentsourcetoensurethatthenursingassessmentsincludeanadequateclinicalanalysisoftheindividuals’progress.Withoutadequateandappropriatecompetency‐basedtrainingandongoingmentoringregardingtheprocessanddocumentationofaclinicalanalysis,merelycollectingmonitoringdataforthisareawillnotresultintheimprovementofthequalityoftheComprehensiveNursingAssessmentsasrequiredbytheSettlementAgreement.Regardingthenursingdocumentationfordischarges/individualstransitioningtothecommunity,areviewoftheNursingDischargeSummariesforsixindividualsincluding:Individual#41,Individual#364,Individual#277,Individual#151,Individual#30,andIndividual#114foundthefollowing:

None(0%)oftheNursingDischargeSummariesadequatelyaddressedthehealth/mentalissuesoftheindividuals.

Therewasadequateinformationcontainedinnone(0%)oftheNursingDischargeSummariesthatwouldguidethecommunitystaffinprovidingtheneedednursingcaretotheindividual.

Acurrentnursingassessmentwasconductedfornone(0%)oftheindividualspriortodischarge/transferringtothecommunity.

Therewasadequatedocumentationidentifyingspecificnursinginterventionsneededforallhealth/mentalissuesinnone(0%)ofthecasesreviewed.

Asclearlynotedinpastreportsandduringpastreviews,theproblematicissuesregardingthenursingassessmentsfordischarges/transitionstothecommunityhadnotbeenimpactedbytheimplementationofanewstate‐wideform.Inaddition,duetothepoorqualityoftheRiskActionPlans/HealthManagementPlans(asdiscussedwithregardtoSectionM.3),nonursingdocumentationwasfoundthatprovidedanyspecificguidanceregardingthetypeandfrequencyofnursinginterventionstheindividualsrequired.ItwasverytroublingthatfromreviewoftheFacility’sActionPlansanddiscussionswiththeCNE,theFacilityhadnoplaninplacetoaddressthisareabythenextreviewinspiteofthefactthatthelackofclearandcomprehensiveclinicalinformationwasassociatedwithagraveoutcomeforIndividual#351whoresidedatCCSSLCanddiedafterbeingtransitioned.Althoughthedetailsofthistragiccasewasoutlinedinapreviousreport,Individual#351wastransitionedtothecommunitywithoutadequateandaccurateinformationincludedintheComprehensiveNursingAssessmentregardingtheindividual’shealthstatusrelatedtohisdiagnosesofDiabetesInsipidus,Obesity,andAsthma.Theassessmentcontainednoinformationaddressingthenursinginterventionsthatwereneededtocareforthisindividual.TherewasessentiallynoinformationcontainedintheNursing


# Provision AssessmentofStatus ComplianceDischargeSummarythatwouldguidethesubsequentcommunitystaffinprovidingtheneedednursingcaretotheindividual.Inaddition,therewasnoindicationthatacurrentnursingassessmentwasconductedpriortotheindividualtransferringtothecommunity.Also,therewasnoindicationthatanynursingcareplansweresenttothecommunitystaffregardingIndividual#351’shealth/mentalhealthissues,althoughthequalityofthenursingcareplanswouldhavebeensubstandard.Sadly,lessthantwomonthsaftertransitioningtothecommunityIndividual#351diedfromdehydrationassociatedwithDiabetesInsipidus.Overall,thesameproblematicissuesthatwerefoundinthecaseofIndividual#351continuedtobefoundinallsixNursingDischargeSummaryAssessmentsreviewedbytheMonitoringTeamthatincluded:

Alackofacomprehensiveandspecificnursingassessmentforindividualsbeingdischarged/transitionedtothecommunity;

Asignificantlackofclinicalassessmentsforclinicalhealthindicators; Alackofananalysisoftheindividuals’health/mentalhealthissues; AlackofcriticalthinkingwhencompletingtheComprehensiveNursing

Assessments;and Alackofclearinformationaddressingthenursinginterventionsthatwere

neededtocareforindividuals.Thelackofattentiontothisareaatthisjunctureofthereviewprocesswasextremelyconcerning.Thereappearedtobealackofrecognitionfromnursingaswellastheteamsthatthemoreinformationprovidedtothecommunitystaffregardinganindividuals’health/mentalissues,thegreaterthepotentialforconsistencyincare,andasuccessfultransition.ItisimperativethatCCSSLCreviewandreviseitscurrentnursingdischargeproceduresanddocumentationrequirementstoensurethatuponanindividual’sdischargefromtheFacility,thenursingdocumentationisspecificanddetailedenoughtomaintaincontinuityofcare.TheFacility’sSelfAssessmentindicatedthatitwasnotincompliancewiththeelementsofthisrequirement.ThiswasconsistentwiththefindingsoftheMonitoringTeam.

M3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationintwoyears,theFacilityshalldevelopnursinginterventionsannuallytoaddresseachindividual’shealthcareneeds,includingneedsassociatedwithhigh‐riskorat‐riskhealth

Inassessingitsprogress,CCSSLCindicatedthatsincethelastreview,thefollowingstepswereinitiatedregardingthisrequirementoftheSettlementAgreement:

TheFacility’sSelf‐AssessmentindicatedthatauditswereconductedfromJanuarythroughJune2012todetermineifNursingCarePlanswerecompletedaccordingtopolicy.AlthoughtheFacilitypresentedthecompliancescoresbymonthasbeing14%,21%,30%,28%,31%,and33%,respectively,noindicationwasprovidedofwhatthespecificitemoritemswerethatdefined“completedaccordingtopolicy.”This

Noncompliance


# Provision AssessmentofStatus Complianceconditionstowhichtheindividualissubject,withreviewandnecessaryrevisiononaquarterlybasis,andmoreoftenasindicatedbytheindividual’shealthstatus.Nursinginterventionsshallbeimplementedpromptlyaftertheyaredevelopedorrevised.

preventedaccurateinterpretationofthedata.Inaddition,noinformationwasprovidedintheFacilitySelf‐Assessmentindicatinghowmanyauditswereconductedeachmonthtogeneratethedataorhowthesamplewasselected.Inaddition,therewasnomentionifinter‐raterreliabilityhadbeenestablishedforthespecificmonitoringtool.

InFebruary2012,theFacility’sSelf‐AssessmentnotedthatasystemwasimplementedtotrackthedatesanacutenursingcareplanwasdevelopedandplacedintheActiveRecord,andwhenitwasresolved.Althoughthiswasapositiveinitialstepforward,theFacilityshouldconsiderexpandingthesystemtoincludeaformatformonitoringtheactualimplementationofnursinginterventionsinalignmentwiththenursingprotocolscontainedintheacutecareplans,whichwouldprovideessentialinformationregardingthequalityofthenursingcare.

Inaddition,inFebruary2012,theFacilitydevelopedanacutecareplanqualityreviewtool.TheMonitoringTeamnotedthatthistoolwasverypromising.Thetooladdresseditemssuchasthealignmentofthegoalswiththeetiologyoftheproblem,andthespecificsofthe“who,what,andwhere”writtenintotheinterventions.However,asnotedabove,onemajormissingelementwasthemonitoringoftheactualimplementationofnursinginterventionscontainedintheacutecareplans.Addingthisitemtothetoolwouldtransitionitfromadocumentreviewtoareviewofnursingclinicalcare.

TheFacility’sSelf‐AssessmentindicatedthattheNurseOperationsOfficerhaddevelopedatrainingcurriculumaddressingNursingCarePlans.ThetrainingwasprovidedtoNurseEducatorsacrosstheStateandwillbeprovidedtotheCaseManagerSupervisorsinAugust2012.However,thecurriculumandtrainingrosterswerenotincludedinthePresentationBookforSectionM.AlthoughitappearedthattherewereafewsamplecareplanscontainedinthePresentationBook,theMonitoringTeamwasnotabletodeterminehowcompetencyregardingthedevelopmentofcareplanswasassessed.

FromdiscussionswiththeCNE,sincethelastreview,theFacilityhadmadeatransitionfromusingtheHealthManagementPlanstoaddresshighandmediumhealthandmentalhealthriskstousinganIntegratedHealthCarePlanthatwillultimatelyreplacetheRiskActionPlans.Althoughatthetimeofthereview,onlytwobuildingswereintheprocessofconductingapilotprojectregardingsomeproposedchangestotheAtRisksystem,includingtransitiontoanIntegratedHealthCarePlan(whichisdiscussedinfurtherdetailwithregardtoSectionI),theCNEreportedthatessentiallyalltheexistingHMPsintheFacilityhadbeenwithdrawnfromtheActiveRecords,exceptfortheacuteHMPs,whichcontinuedtobeutilizedatthetimeofthereview.Althoughthe


# Provision AssessmentofStatus ComplianceuseofanIntegratedHealthCarePlanwasaverypromisingclinicalmoveforward,itwasofmajorconcerntotheMonitoringTeamthatalloftheHMPswereterminatedwithoutappropriatemodificationsmadetotheexistingRiskActionPlansthathadbeenfoundtobehighlyinadequate.Inaddition,noplanwasinplaceaddressinghownursinginterventionsforcertainchronicconditionsthatdidnotrisetothelevelofahighormediumriskorwerenotacuteissueswouldbeaccountedforinaplanofcare.

Therecordsof27individualswhotheFacilityidentifiedasbeingathighriskforspecifichealthindicatorswerereviewed,including:Individual#144,Individual#183,andIndividual#278forweight;Individual#9,Individual#282,andIndividual#378fordentalissues;Individual#213,Individual#327,andIndividual#91forurinarytractinfections;Individual#221,Individual#34,andIndividual#210forcardiacissues;Individual#153,Individual#211,andIndividual#38forchallengingbehaviors;Individual#182,Individual#8,andIndividual#44forfalls;Individual#224,Individual#276,andIndividual#10forfluidimbalances;Individual#138,Individual#297,andIndividual#350forgastrointestinalissues;andIndividual#268,Individual#26,andIndividual#95forpolypharmacy.Ofthe27individuals’RiskActionPlans/IntegratedHealthCarePlans(nursingcareplans)reviewed:

All(100%)werefoundtohaveaRiskActionPlanaddressingtheirhigh‐riskhealth/mentalhealthindicator.

None(0%)ofthenursinggoalslistedintheRiskActionPlans/IntegratedHealthCarePlanswereclinicallyappropriate.

None(0%)ofthenursinginterventionscontainedintheRiskActionPlans/IntegratedHealthCarePlansindicatedwhowouldimplementtheintervention,howoftentheyweretobeimplemented,wheretheyweretobedocumented,howoftentheywouldbereviewed,and/orwhentheyshouldbeconsideredformodification.Althoughtherewerecolumnheadingsformuchofthisinformation,theinformationthatwasincludedwasbasicallygenericanddidnotaddresswhatnurse,whatshift,whatform,andwhospecificallywouldreviewtheinformationandhowoftenitwouldbereviewed.Inaddition,theoverallqualityofthenursinginterventionsweremeaninglessinthattheyweregeneric,non‐specific,andmainlyconsistedofservicesprovisionssuchas“willgivemedicationsasordered”thatisrequiredbylicensureandnotspecificinterventionsaddressingtheindividuals’healthcareneeds.Inaddition,theinterventionslistedwerenotinalignmentwithnursingprotocolsaddressingthespecifichealthissue.

None(0%)ofthe27RiskActionPlans/IntegratedHealthCarePlanswerefound


# Provision AssessmentofStatus Compliancetobeclinicallyadequate.

None(0%)ofthe27RiskActionPlans/IntegratedHealthCarePlansincludedproactiveinterventionsaddressingthehealthindicator.AlthoughsomegenericinterventionswerefoundinsomeISPsaddressing,forexample,theneedforexerciseorencouragefluids,thatwouldhaveledtoapreventativeintervention,becausetheseinterventionswerenotwritteninmeasurabletermstoallowthemtobeimplementedandtracked,theydidnotresultincompliancewiththisindicator.

None(0%)ofthe27RiskActionPlans/IntegratedHealthCarePlanswereadequatelyindividualized.

Duetothenonspecificinterventionscontainedinallofthe27RiskActionPlans/IntegratedHealthCarePlans,validatingtheimplementationoftheinterventionswasnotpossible,renderingtheRiskActionPlans/IntegratedHealthCarePlansasguidesfortheprovisionofcareinadequate.

Asnotedabove,theFacilityreportedthattheyhadtransitionedfromusingthetraditionalnursingcareplans(HealthManagementPlans)tousinganIntegratedHealthCarePlan,whichwasapositivestepforward.However,merelyremovingtheoldHMPsfromtheActiveRecordsandre‐titlingtheRiskActionPlansasIntegratedHeathCarePlanswithoutmakingtheappropriatemodificationssothattheplanswereclinicallysounddidnotresolvetheproblemsandwasextremelytroubling.Consequently,consistentwiththefindingsfromthepreviousreviews,CCSSLC’sRiskActionPlans/IntegratedHealthCarePlanscontinuedtolackthefollowingkeyelements:

Clinicallyappropriategoals/objectivesrelatedtotheetiologyoftheidentifiedhealth/mentalhealthproblems;

Specificinterventionsaddressingriskindicators; Proactiveinterventionsdirectedatpreventingorminimizingthespecifichealth

risks; Individual‐specificinterventionsbasedontheindividuals’needs;and Adequatespecificdirectionsforcaringforindividualswhowereidentifiedas

beingathighriskrelatedtotheirhealth/mentalhealthissues.

FromdiscussionswiththeCNE,theformaltransitionfromtheRiskActionPlanstotheIntegratedHealthCarePlanwouldoccuratthetimeoftheindividuals’ISPs.However,noplanwasinplacetoreviewandmodifythecurrentRiskActionPlansthattheMonitoringTeamalreadyhadidentifiedasbeinginadequateduringpastaswellasthecurrentreview.Suchmodificationswereneededtoensurethattheyreflectedthespecificclinicalcaretheindividuals’requiredaccordingtotheirhealthneeds.Thus,inessence,anindividualwithhigh‐riskhealth/mentalhealthneedscouldbefurtherdelayedfromhavinganadequateplanofcareuntilthenextISP,whichforsomeindividualscouldbeupto12months.ItisessentialthattheFacilityaddressthelackofclinicallyadequate


# Provision AssessmentofStatus Compliancecareplansfortheindividualsundertheircare.TheFacilityshouldcontinuetodevelopandimplementappropriatecareplansbasedonpriority,andriskforallindividualsatCCSSLCRegardingnursingcareplansaddressinginfectiousillness,theOutbreakReporttheFacilityprovidedtotheMonitoringTeamindicatedtherewerefiveindividualswithflu‐likesymptomsinMarch2012(i.e.,Individual#46,Individual#172,Individual#186,Individual#151,andIndividual#94).

Ofthefiveindividuals,none(0%)werefoundtohavehadacuteHMPsaddressingtheinfectiousissue.AlthoughadocumentrequestwassubmittedtotheFacilitypriortothereviewfortheHealthManagementPlansforallindividualswhowereaffectedbyanyoutbreakssincethelastreview,nonewerefoundamongthedocumentsprovidedaddressingthisissue.ThisindicatedthatnonehadbeendevelopedandimplementedfortheseIndividuals.

SincenoacuteHMPswerefound,nonewerereviewedaddressingtheinfectiousdiseases,andnone(0%)werefoundtobeadequate.

Regardingnursingcareplansaddressingotherinfectiousillness,theIsolationInfectionControlReportfromJanuarythroughJune2012indicatedthatsinceJanuary19,2012,10individualswereplacedoncontactprecautionsforatotalof13infectiousepisodes(i.e.,Individual#242,Individual#163,Individual#243,Individual#69,Individual#276,Individual#156,Individual#86,Individual#176,Individual#43,andIndividual#353).

Ofthetenindividuals,one(10%)wasfoundtohavehadacuteHMPsaddressingtheinfectiousissue.IndividualswhodidnothaveHMPsaddressingtheinfectiousissueincluded:Individual#242,Individual#163,Individual#243,Individual#69,Individual#276,Individual#86,Individual#176,Individual#43,andIndividual#353.

OfthetwoNursingCarePlansreviewedforoneindividualaddressingthesameinfectiousdisease,neitherwasfoundtobeadequate(0%).AlthoughtwoHMPsweresubmittedforIndividual#156,oneunsignedandonecompletedbytheInfectionControlNurse,reviewoftheonetheInfectionControlNurseauthoredfoundapromisingincreaseintheclinicalcontentandgoodattemptstoindividualizethecareplan.

Inaddition,areview12individuals(i.e.,Individual#287,Individual#228,Individual#137,Individual#48,Individual#44,Individual#172,Individual#83,Individual#254,Individual#157,Individual#368,Individual#359,andIndividual#95)whohadapositiveTuberculinPurifiedProteinDerivative(PPD)werereviewedtodetermineiftheindividualshadappropriatecareplanstoaddresstheirneeds.TheMonitoringTeamfoundthefollowing:

Ofthe12individuals,12(100%)werefoundtohaveacareplanaddressingthis


# Provision AssessmentofStatus Complianceissue.However,thecareplansconsistedofthreeoftheHMPtemplateforpositivePPDs(i.e.,Individual#287,Individual#228,andIndividual#137)andnineweresubmittedonRiskActionPlanswiththeassociatedIntegratedRiskRatingForms(IRRFs).AreviewoftheIRRFsnotedthatrisklevelsofmediumhadbeenassignedtothepositivePPDhealthindicatorwithoutsufficientjustification.Duringthereview,discussionswiththeCNEandnursingstaffindicatedthatthemediumrisklevelwasassignedtothisindicatorinordertojustifyaddingtheindicatortotheRiskActionPlans,whichtheFacilitywasintheprocessoftransitioningintotheIntegratedHealthCarePlan.ItwasconcerningtotheMonitoringTeamthatmanipulatingtheAtRisklevelsystemthiswaywasthecurrentplaninplacejusttobeabletointegrateahealthindicatorintotheRiskActionPlan/IntegratedHealthCarePlan.Thiscouldpotentiallydiluteoroverwhelmtherisksystemanddiverttheclinicalintensityawayfromwhatisrequiredfortheserisklevels.Ifindeedtheteamdeterminedthatahealthindicatorwasahighormediumrisk,theclinicaljustificationshouldbeadequatelyaddressedontheIRRFsandtheinterventionslistedontheRiskActionPlans/IntegratedHealthCarePlansinalignmentwiththelevelofrisk.Inaddition,riskindicatorsoflowintensitythatrequirecareplansalsoshouldbeintegratedintotheriskactionplansorintegratedhealthcareplansasappropriate.

Ofthe12CarePlansreviewedaddressingpositivePPDs,none(0%)werefoundtobeadequate.Inaddition,asmentionedabove,thosethatwereincludedontheRiskActionPlansanddesignatedasamediumriskleveldidnotreflectthespecificinterventionswarrantedforthatparticularlevelofrisk.

Consistentwithpreviousfindings,CCSSLChadnosysteminplacetoensurethatindividualswithinfectiousdiseaseswerebeingprovidedtheappropriateinfectioncontrolmeasures,orclinicallyappropriateinterventionstopreventthespreadofinfections.Asnotedinpreviousreports,itwasveryconcerningtofindthatindividualswithcontagious/infectiousillnessesdidnothavecareplansoradequatecareplansaddressingtheseillnesses.Nursing,inconjunctionwiththeInfectionControlNurseshoulddevelopandimplementasystemtoensurethatthecareplansaddressinginfectiousandcommunicablediseasesareclinicallyadequate,individualized,andarebeingimplementedconsistently.InorderfortheFacilitytomakeprogressregardingthisprovisionoftheSettlementAgreement,theHealthCarePlansshouldbe:

Individualizedtomeettheindividuals’needs,withappropriategoals,specificnursinginterventionsthatincludeproactiveinterventions,andspecificidentificationofwhowillbeimplementingtheaction,howoftenitwillbeimplemented,whereitwillbedocumented,andwhentheeffectsofthe


# Provision AssessmentofStatus Complianceinterventionswillbereviewedandbywhom;

Inalignmentwithinterventionsfromthenursingprotocols;and Accuratelyreflecttheclinicalneedsoftheindividualsregardlessoftheformat

andsystemutilized.

AsrequiredbySectionsGandFoftheSettlementAgreement,theFacilityhadtakenapositivestepbybeginningcollaborationwithotherdisciplinesregardingthedevelopmentofcareplanssothataninterdisciplinaryteamapproachwouldbeusedconsistently,andinterventionsfromotherdisciplineswouldbeintegratedinallHealthCarePlans.Inalignmentwiththiscollaboration,theFacilityshouldcontinuetogivethoughtfulandseriousconsiderationtohowtoincorporateanindividual’shealthrisksintooneplanwithoutcompromisingtheAtRisksystemortheclinicalneedsoftheindividual.TheFacilityindicatedthatitwasnotincompliancewiththisrequirementoftheSettlementAgreement.ThiswasconsistentwiththefindingsoftheMonitoringTeam.

M4 WithintwelvemonthsoftheEffectiveDatehereof,theFacilityshallestablishandimplementnursingassessmentandreportingprotocolssufficienttoaddressthehealthstatusoftheindividualsserved.

Inresponsetothisrequirement,CCSSLC’sSelf‐Assessment indicatedthefollowingactionswereimplemented:

TheFacility’sSelf‐Assessmentindicatedthatanumberoftrainingshadbeenconductedsincethelastreviewaddressingavarietyofsubjectssuchasthenewprotocolcards,trainingonDeathReviews,andtheMedicationCartExchangeprotocol.However,thedocumentationthatwasfoundinthePresentationBookforSectionM.4didnotmatchthetitlesofthetrainingsthatwerefoundintheFacility’sSelf‐AssessmentforSectionM.4.Initsresponsetoapre‐reviewdocumentationrequestrelatedtotrainingfornurses,theFacilityincludedcopiesofapolicyaddressingIntegratedProgressNotesandDocumentation,theprotocolcardsandformsindicatingthattheywerethecompetency‐basedtestsfortheprotocolcardtraining,apolicyaddressingCompleting/RoundingClientInjuryReport,andaformentitledCompetencyChecklistTrueResult.However,therewasnospecificdescriptionincludedregardinghowthesetrainingswereconducted,orexamplesofdocumentationthatconfirmedthatcompetencywasappropriatelydeterminedforeachareaonwhichtrainingwasprovided.Inaddition,therewerenoactualtrainingrostersprovidedtoindicatethelengthofthetrainingsessionsprovidedand/ortoallowtheMonitoringTeamtoverifythepercentagesofattendance.Unfortunately,therewasnowaytodeterminethequalityofthesetrainingsortoverifystaffattendance.

However,informationwasprovidedregardingtheNurseEducatorMeetingheldinMay2012,includinganagendaofthemeeting,andthecontentthatwaspresentedduringthemeeting.ThetopicsdiscussedatthemeetingincludedMosbyandPhysicalAssessment,EmergencyDrillsandMethod,

Noncompliance


# Provision AssessmentofStatus ComplianceCaseManagerTraining,PhysicalAssessmentClass,ObservingandReportingClinicalIndicators,MedicationObservationandreliability,Competency‐basedTrainingforPositioningandPresentationforMedicationAdministration,AcuteCarePlans,andIntroductiontoRiskPolicy.Areviewoftheoverallcontentfoundittobeextremelycomprehensivewithvaluableclinicalinformationincluded.

InJuly2012,theRNswereassignedcontentfromtheMosbyPhysicalExaminationBooktobeaddressedinclassesthatwerescheduledtostartinAugust2012tofurthernurses’assessmentskills.

TheFacilityreportedthattheyhadimplementednineadditionalnursingprotocols,including:MinimalDocumentation,PICA,Seizures,StatusEpilepticus,AbdominalDistention/Pain,Hypothermia,TemperatureElevation,UrinaryTractInfection,EnteralFeeding,andPostAnesthesia.However,asnotedabove,thePresentationBookforSectionM.4didnotincludeadescriptionofthetraining,soitwasunclearhowtrainingwasprovidedpriortoimplementation,oriftheprotocolshadjustmerelybeendistributedtoallthenurses.Increasingthenumberofnursingprotocolstoassistinthedevelopmentofclinicallyadequatecareplanstoguidenursingpracticeswasapositivestepforwardandshouldbecontinued.However,atthetimeofthereview,noevidencewasfoundinthecareplansorinthenursingdocumentationreviewedtoshowthenursingprotocolswereactuallybeingusedtodrivetheidentificationandimplementationofthespecificresponsibilitiesofdisciplines,provideclearandappropriatetimeframesforinitiatingnursingassessmentsandthetypeofassessmentsthatshouldbeconducted,assistindeterminingthefrequencyoftheseassessments,andidentifytheparametersandtimeframesforthereportingofsymptomstothepractitioner/physicianandPNMT,ifindicated.Thus,nosupportingdocumentationwasfoundtosubstantiatethenursingprotocolshadactuallybeenimplemented.

Inaddition,theFacility’sSelf‐AssessmentincludedcompliancedatafromtheDocumentationmonitoringtool.However,therewasnoinformationincludedthatspecificallyindicatedwhatthesecompliancescoresrepresented.Itappearedthattheymighthavebeenoverallcompliancescoresfortheentiretoolforallauditsconductedforeachmonth,whichaspreviouslymentioned,providenomeaningfulinformationandareuninterpretable.

ThePresentationBookforSectionM.4containedapromisingNursingProtocolSpotCheckAuditformtoolthatrecentlyhadbeendeveloped.Fromthedocumentationprovided,itappearedthatsomeinitialauditinghadbeenconductedtodetermineiftheprotocolfortotalintravenousanesthesia(TIVA)hadbeenappropriatelyimplemented.AlthoughonlytwocompletedauditswereincludedinthePresentationBook,bothreflected


# Provision AssessmentofStatus Compliancesignificantbreachesregardingtherequirednursingdocumentationforthisprocedure,whichindicatedthetool’spotentialforevaluatingnursingpractices.

RegardingtheFacility’sself‐rating,theinformationcontainedintheSelf‐Assessmentindicatedthat:“Basedonthefindingsfromthisself‐assessment,thisprovisionisnotinsubstantialcompliancebecauseafterreviewofdocumentationforNursingprotocolcards,DeathreviewsandotherrequireddocumentationCCSSLCisnotincompliance.Wewillcontinuetotrainasconcernsareidentifiedanddevelopcorrectiveactionplans.”

AlthoughtheFacilityreportedthatadditionalnursingprotocolswereimplementedsincethelastreview,theMonitoringTeamfoundthesameconsistentproblematicissuesregardingnursingassessments,careplans,andtheoverallnursingcareanddocumentationaswasnotedfrompreviousreviews.FromdiscussionswiththeCNEandNOO,theywereabletoarticulatehowtheyhadintegratedtheuseofnursingprotocolsintothetrainingaddressingcareplans,whichwasclearlyincludedinthecurriculum.However,itwasevidentthattherecontinuedtobeasignificantlackofunderstandingregardingtheimportanceofnursingprotocolsamongtheCaseManagersandnursingstaff.ThealreadypresentconcernregardingtheconsistentproblematicissuesfoundinpastreviewsbytheMonitoringTeamregardingindividualswithhigh‐riskhealthindicators,changesinstatuswarrantingInfirmaryadmission,andhospitaladmissionswasheightenedduringanonsitereviewofIndividual#117’shealthissues,whichendedwiththeindividual’sdeathduringtheweekofthereview.Whileonsite,areviewofIndividual#117’smedicalrecordwasconductedwithsomemembersofthenursingstaffaswellasmembersoftheFacility’sPhysicalandNutritionalManagementTeam.ThedocumentationindicatedthattheindividualwasathighriskforaspirationandwasenterallynourishedbyaG‐tubesince4/14/12,duetosilentaspirationfoundonaModifiedBariumSwallowStudyon4/10/12;cardiacdisease,sincehehadapacemakerinsertedon5/24/12forlowpulseratesinthe40s(bradycardia);fluidimbalancerelatedtolowsodiumlevels(hyponatremia);weightissuesduetosignificantweightlossfrom185poundsinJuly2011to133.8inJuly2012;osteoporosiswithaDexaScanScoreof‐3.2;fallsduetoanincreaseinfallsbeginninginJanuary2012;fracturesduetopasthistoryoffractures(notspecifiedintheIRRF),andrecentfractureson4/30/12totherightradialheadandanx‐rayon6/7/12indicatingahealingfracturetotherighthand;andpolypharmacyduetopsychotropicmedications.Inaddition,hehadbeenadmittedtotheInfirmaryfourtimesandtothehospitalthreetimessinceJanuary2012.Inaddition,thisindividualwasbeingfollowedbythePNMT.TheIPNsreviewedindicatedthatanumberofchangesintheindividual’sstatus,suchassignificantweightloss,variabilityinvitalsigns,andpotentialissuesrelatedtoskinbreakdown,increaseinfallsandinjuries,lowsodiumlevels,changesinbehaviors,andaninfectionto


# Provision AssessmentofStatus Compliancehisrighteyewereoccurring.Inreviewingthedocumentation,anumberofsignificantproblematicissueswerefoundregardingtherecentcareofthisindividual.Someoftheseproblemsincluded:

TheGrowthRecordindicatedthattheweightforJuly2011was185poundsandtheweightforSeptember2011was174.5pounds.However,theweightrecordedbyanLVNforAugust2011was271poundsindicatingthattheweightincludedtheindividual’swheelchair.Therewasnoindicationthatthenursegaveanythoughttoobtainingtheweightofthewheelchairalone,andsubtractingthesemeasurementstoobtainanaccurateweightfortheindividual.Consequently,therewasnowaytodetermineiftheindividual’sactualweightlosspatternbeganinAugust2011duetotheinaccurateweightrecorded.

TheIntakeandOutputRecordsreviewedwerenotconsistentlyfilledout,sotherewasnoaccuratewaytodeterminehowmuchfluidtheindividualwastakingineachdaytobeabletoaccuratelyassesshisnutritionalstatus.

TheComprehensiveNursingAssessment,dated4/30/12,didnotincludeanyinformationregardingtheindividual’ssignificantlossofweightintheNutritionandWeightManagementSectionortheSummarySection.Inaddition,theassessmentindicatedthatIndividual#117wasonapureeddietwithhoney‐thickenedliquids.On4/24/12anursemonitoredhismeal,anditwasnotedthathe“toleratedmeals.”However,on4/14/12,Individual#117hadaG‐Tubeinserted,whichcontradictedthedietandmealmonitoringinformationcontainedintheassessment.Inaddition,thefactthattheindividualhadaG‐TubeplacedwasnotmentionedanywhereintheComprehensiveNursingAssessment.

TheIPNscontainednoconsistentandregulardocumentationbynursingtoestablishbaselinesandpromptlyidentifychangesinbaselinesregardingphysicalassessments,mentalstatus,dailyactivities,positioning,treatmentsprovided,painassessments,vitalsigns,oxygensaturations,functioningofG‐Tube,siteinspectionsforG‐Tube,statusofeyeinfection,bowelandurinaryoutput,anddailyfluidinput.

Thereweregapsinthenursingdocumentationindicatingthatnursingwasnotregularlycheckingandassessinganindividualwithseveralhealthrisksandchangesinstatus.

Episodesoffeveranddehydrationwerenotadequatelyreassessedorfollowedupontoresolution.

TheIPNsindicatedcontradictoryinformationstatingtheindividualwasagitatedandthenstatinginthesamenotehewasinnodistress.

Therewasalackofrecognitionbynursingthatsomeofhisbehaviorswereindicativeofchangesinstatus.

Nonursingassessmentswereconductedinresponsetothesechangesinstatus.


# Provision AssessmentofStatus Compliance Therewasnoindicationthatthephysicianwasconsistentlynotifiedofchanges

instatus. TherewasnoindicationthatthePNMTwasnotifiedofchangesinstatus. NoIPNswerefoundindicatingthatIndividual#117wasbeingfollowed,

assessed,orregularlymonitoredbythePMNT,whenchangesinstatusoccurred.

NoNursingHMPsadequatelyaddressedtheindividual’scurrenthealthrisksinalignmentwiththenursingprotocols.

AdayaftertheonsitereviewofIndividual#117,hewasadmittedtothehospitalandsadlydiedlaterthatday.ADeathReviewInvestigationwasconductedbyNursingServicesandinspiteofthecriticaldeficitsfoundregardingthecareofthisindividualduringtheMonitoringTeam’sonsitereview,thefindingsfromtheFacility’sinvestigationonlyminimallynotedafractionoftheproblematicissueslistedabove.Asaresult,theneededsystematicchangestopreventtheseproblemsfromreoccurringlikelywillnotoccur.Areviewofanadditional12individualsthatwereadmittedtotheInfirmaryand/orhospital(i.e.,Individual#64,Individual#304,Individual#286,Individual#273,Individual#144,Individual#155,Individual#175,Individual#266,Individual#130,Individual#308,Individual#239,andIndividual#103)foundsimilarproblematicissuesthroughoutthenursingdocumentation.Moredetailedinformationisprovidedwithregardtothereviewoftheseindividuals’recordsinthediscussionaboutSectionM.1.TheseconsistentproblematicfindingsdidnotsupporttheFacility’sreportindicatingthatnursingprotocolswereactuallyimplemented.AlthoughCCSSLCindicatedthattheyhadimplementednursingprotocols,therewasnoindicationthatnursingwasactuallyusingtheseprotocolsaspartofastructuredsystemguidingnursingpracticeanddocumentationtoensurethat:

Clinicallyappropriatenursingassessmentswereconductedforsignificanthealthissuesanddocumentedattheappropriateclinicalfrequency;

Clinicalbaselinedatawasestablishedtoquicklyrecognizechangesinhealthstatus;

Timelycommunicationoccurredwithpractitioners/physiciansorotherdisciplinesregardingchangesinstatus;

Appropriateandclinicallyadequatecareplansweredevelopedthatoutlinedspecificnursinginterventionsforspecifichealthissues;and

AuditsaddressingnursingpracticeaccuratelyreflectedqualitystandardsbywhichtomeasuretheFacility’snursingcare,anddocumentation.


# Provision AssessmentofStatus ComplianceThefindingsfromthisreviewandthepreviousfivereviewsindicatedthatCCSSLCcontinuedtofailtoadequatelyandtimelyaddressthehealthcareneedsoftheindividualsresidingattheFacility.TheFacilityindicatedthatitwasnotincompliancewiththisrequirement.ThiswasconsistentwiththefindingsoftheMonitoringTeam.

M5 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithin18months,theFacilityshalldevelopandimplementasystemofassessinganddocumentingclinicalindicatorsofriskforeachindividual.TheIDTshalldiscussplansandprogressatintegratedreviewsasindicatedbythehealthstatusoftheindividual.

Inresponsetothisrequirement,CCSSLC’sSelf‐Assessment indicatedthatsincethelastreview,thefollowingactivitieswereimplemented:

AsnotedinSectionIinmoredetail,revisionshadbeenmadetotheAt‐RiskIndividualspolicy(indraftformatthetimeofthereview).SomeoftherevisionsincludedregroupingtheRiskGuidelinessothattheriskfactorsthatwereclinicallyinter‐relatedregardingoutcomesorprovisionofservicesandsupportswerelistedtogether,linkingeachriskfactorwithspecificclinicalindicators,andreformattingtheIntegratedRiskRatingFormtofollowthesamegroupingsequenceastheRiskGuidelines.Inaddition,theRiskActionPlansfortheidentifiedhighandmediumriskindicatorswerereplacedwithIntegratedHealthCarePlansdesignedtoprovideacomprehensiveplanthatwillbecompletedannually,supplementalformsregardingIRRFandtheIHCPweredevelopedaddressingchangesinstatus,theAspirationPneumoniaEnteralNutritionevaluationwasrevisedtobeusedasadatacollectiontoolratherthanaformatforassessments,andindividual‐specificTriggerDataSheetsweredevelopedtoincludeobservableandmeasurableclinicalsignsandsymptomsthatalertthestafftopossiblechangesinstatus.

InMay2012,twoteamsfromCCSSLCweretrainedonthe“EnhancedRiskProcess”describedabove.Itwasimplementedat524AandPorpoiseinJune2012.Sincethesystemhadonlybeenrecentlyimplementedatthetimeoftheonsitereview,theMonitoringTeamwasnotabletoadequatelyassessanyprogressmadefromthesystem’srevisions.

Also,sincethelastreview,theFacilityhadimplementedapromisingmonitoringtoolwithinstructionsforSectionI.However,thedatapresentedintheFacility’sSelf‐AssessmentforSectionM.5couldnotbeinterpreted,becausetherewasnodescriptionincludedregardingwhatthecompliancescoresrepresented,howthesampleswereselected,andwhatthetargetpopulationwasofthesamplingpool.Inaddition,theFacilityindicatedthatbecausenoindividualswerediagnosedwithAspirationPneumoniasinceJanuary2012,noauditsforAcuteIllnessandInjurywereconductedforthishealthissue.Unfortunately,onlyusingaspecificdiagnosisasthecriterionforconductingauditswillresultintheFacilitymissingcriticalclinicalinformation.AccordingtotheliststheFacilityprovided,sinceJanuary2012,anumberofindividualswithsignificanthealthrisksexperiencedrepeatedadmissionstotheInfirmaryandhospital.

AreviewoftheSectionOPNMT/AdministrativeMeetingminutes,datedApril16,2012,indicatedthatmembersofthePNMTfoundthatnursingwasnot

Noncompliance


# Provision AssessmentofStatus Complianceobtainingweights,especiallyweeklyweightsforindividualswhowereathighriskforweightissues.Interestingly,fromallthedataprovidedintheProvisionActionInformationforSectionM.5,thedatafromFebruarythroughMay2012regardingweightswasclearlyidentifiedandpresented,andindicatedthatnursingwasnotobtaininganddocumentingweightsevenbasedonasmallsampleofeightauditsconductedeachmonth.Hadthisdatabeentimelyreviewedandanalyzedbynursing,aplanofactioncouldhavebeendevelopedandimplementedatthetimetheissuewasdiscovered.However,ofgreatconcernwasthattheFacility’sdataforMay2012indicatedthatweightscontinuednottobeobtainedanddocumented.Itwasnotuntilduringitsreview,theMonitoringTeamrequestedacopyofanyrelatedactionplansthattheFacilitydevelopedaplanofactiontoaddressthiscrucialdeficit.

Inaddition,theSectionOPNMT/AdministrativeMeetingminutes,datedApril16,2012,indicatedthattheFacilityhadsignificantproblemsregardingthelackofattendancebytheindividuals’teammembersatthePMNTFollow‐Upmeetingstoallowthemtoreceivestatusupdates.Inaddition,issuesnotedrelatedtoinadequatecleaningoftheenvironmentwerebeingassociatedwithpossiblerespiratoryandinfectioncontrolhealthissues.Althoughtheminutesofthemeetingindicatedthatanumberofquestionsneededtobeexploredregardingtheseissues,andPlansofActionsaddressingtheseissueswereincluded,noadditionaldocumentationwasprovidedindicatingthecurrentstatusoftheseissues.Allowingalmosttwomonthstopasswithoutanydocumentedfollowing‐upregardingproblematicissuesaffectingthehealthofanumberofindividualswithhealthriskswasveryconcerningespeciallysincetheMonitoringTeam’sreviewcontinuedtoidentifysignificantproblemsregardingindividualsatrisk.Moreover,theFacilityhadidentifiednoneoftheseissuesinitsSelf‐AssessmentorActionPlans.

RegardingtheFacility’sself‐rating,theFacilityindicatedthat:“Basedonthefindingsfromthisself‐assessment,thisprovisionisnotinsubstantialcompliancebecauseweneedtocontinuetotrainasconcernsareidentifiedanddevelopcorrectiveactionplans.”AlthoughtheCNEreportedthattheComprehensiveNursingAssessmentformcontinuedbeingusedforthequarterlyandannualnursingassessments,andthattheyaddressedtheat‐riskindividuals’healthindicators,thefindingsfromtheMonitoringTeamnotedbelowindicatedthequarterlyandannualComprehensiveNursingAssessmentsrevieweddidnotadequatelyaddresstheriskissues.Thiswasconsistentwiththefindingsfrompastreviews.Areviewofrecordsfor27individualsdeterminedtobeatrisk(i.e.,Individual#144,Individual#183,Individual#278,Individual#9,Individual#282,Individual#378,


# Provision AssessmentofStatus ComplianceIndividual#213,Individual#327,Individual#91,Individual#221,Individual#34,Individual#210,Individual#153,Individual#211,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,Individual#26,andIndividual#95),foundthatnone(0%)includedadequatenursingriskassessments.AreviewofthemostcurrentquarterlyorannualComprehensiveNursingAssessmentsfortheabove27individualsfoundthatnoneofthem(0%)containedanadequateassessmentsofthespecifichigh‐riskhealthindicatorsorprovidedanytypeofanalysisofthehigh‐riskhealthindicatorsintheSummarySectionoftheComprehensiveNursingAssessmentform.Infact,theComprehensiveNursingAssessmentstheMonitoringTeamreviewedwerenotedtohaveregressedsincethepreviousreview.Thiswasduetosomeofthenursingassessmentsnotreflectingthecorrectriskrating,andsomenursingassessmentdidnotevenincludeallthespecifichealthriskindicatorsintheSummarySection,especiallyregardinghighrisksfordentalissues.Asnotedfromthepreviousfivereviews,nursinghadnospecificprocedureinplacetoaddressthenursingassessmentprocessandtheanalysisoftheidentifiedriskindicators.Basedonsomeoftheproblematicissuesnotedaboveregardingmissingorinaccurateriskratings,itwasclearthatsomeoftheCaseManagerscompletingtheComprehensiveNursingAssessmentswereusingpastquarterlyorannualinformationwithoutprovidinganytypeofupdateandanalysisregardingthecurrentstatusofthehealthriskindicators.Consistentwiththefindingsfrompastreviews,thenursingassessmentsfortheAt‐Riskindividualswerenotadequatetoaddressthehealthrisksoftheindividualsreviewed.Areviewofthese27individuals’recordswasconductedtoassessnursingstaff’sroleintheassessmentofthehealthcategoriesthatnursingwasresponsibleforintheIntegratedRiskRatingforms.AlthoughnotedimprovementshadbeenmadeinmanyofthecategoriesontheRiskRatingformscompletedbyotherdisciplines,someoftheareasthatnursingwasresponsibleforassessingand/orprovidinginformation,suchasforconstipationanddatesofinjuries/fractures,adecreaseintheindividual‐specificinformationincludedintheseareaswasnotedfromthepreviousreview.Inaddition,areviewofsometheIntegratedRiskRatingformsthatincludeddatesofrevisionsfoundthatthehealthindicatorcategoriesthatcontaineddeficitsinindividual‐specificinformationremainedunchanged.Inaddition,areviewof27recordsforindividualsdeterminedtobeatrisk(i.e.,Individual#144,Individual#183,Individual#278,Individual#9,Individual#282,Individual#378,Individual#213,Individual#327,Individual#91,Individual#221,Individual#34,Individual#210,Individual#153,Individual#211,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,


# Provision AssessmentofStatus ComplianceIndividual#26,andIndividual#95),therewasdocumentationthattheFacility:

Establishedanappropriateplanwithinfourteendaysoftheplan’sfinalization,foreachindividual,asappropriate,innoneofthecasesreviewed(0%).

Implementedaplanwithinfourteendaysoftheplan’sfinalizationforeachindividual,asappropriateinnone(0%)ofthecasesreviewed.AlthoughtheActionPlansincludedadateofimplementation,therewasnosupportingdocumentationverifyingthattheactionstepscontainedintheplanhad,infact,beenimplemented.Inaddition,anumberoftheactionstepswerenonspecificandthus,impossibletoverify.

ImplementedaplanthatmettheneedsidentifiedbytheIDTassessmentinnoneofthesecases(0%).

Includedpreventativeinterventionsintheplantominimizetheconditionofriskinnoneofthecases(0%).AlthoughsomegenericinterventionswerefoundinsomeISPsaddressing,forexample,theneedforexerciseorencouragefluids,thatwouldhaveledtoapreventativeintervention,becausetheseinterventionswerenotwritteninmeasurabletermstoallowthemtobeimplementedandtracked,theydidnotresultincompliancewiththisindicator.

Whentherisktotheindividualwarranted,tookimmediateactioninnoneofthecases(0%).

IntegratedtheplansintotheISPsinthreeofthecases(11%).IndividualswhohadnothadtheirRiskActionPlansintegratedintotheirISPsincluded:Individual#183,Individual#278,Individual#9,Individual#282,Individual#378,Individual#213,Individual#327,Individual#221,Individual#34,Individual#210,Individual#153,Individual#38,Individual#182,Individual#8,Individual#44,Individual#224,Individual#276,Individual#10,Individual#138,Individual#297,Individual#350,Individual#268,Individual#26,andIndividual#95.

None(0%)oftheplansshowedadequateintegrationbetweenalloftheappropriatedisciplines,asdictatedbytheindividual’sneeds.

Noneoftheplans(0%)hadappropriate,functional,andmeasurableobjectivesincorporatedintotheISPtoallowtheteamtomeasuretheefficacyoftheplan.

Noneoftheplans(0%)includedthespecificclinicalindicatorstobemonitored. Thefrequencyofmonitoringwasincludedintheplansfornoneofthe

individuals(0%).AlthoughtheActionPlanscontainedaheadingaddressing“MonitoringFrequency,”thefrequencywasnotedgenerallyasdailyorweeklywithoutthespecificshiftordayincludedtoensureaccountability.

FromdiscussionswiththeFacilitystaffandtheStateOfficeConsultants,thedraftrevisionstotheAt‐RiskIndividualsPolicyandtherecentpilotprojectinitiatedregardingtheAt‐Riskprocesshaspromisingpotential.However,thesignificantexistingdeficitsinthecurrentAt‐Risksystem,especiallyregardingthenursingcomponentsofthesystem,


# Provision AssessmentofStatus CompliancesuchastheComprehensiveNursingAssessments,theindividual‐specificinformationcontainedintheIRRFsfromnursing,andthequalityofthealltheinterventionscontainedintheRiskActionPlansneedtobeaddressedregardlessofthechangestotheprocess.Inaddition,theFacility,inconjunctionwiththeState,shouldspecificallydefinethenursingassessmentprocessregardingat‐riskindividualsandprovidetrainingandmentoringaddressingthisarea.Atthetimeofthereview,CCSSLCindicatedthattheywerenotincompliancewiththisrequirementoftheSettlementAgreement.ThiswasconsistentwiththefindingsoftheMonitoringTeam.

M6 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationinoneyear,eachFacilityshallimplementnursingproceduresfortheadministrationofmedicationsinaccordancewithcurrent,generallyacceptedprofessionalstandardsofcareandprovidethenecessarysupervisionandtrainingtominimizemedicationerrors.ThePartiesshalljointlyidentifytheapplicablestandardstobeusedbytheMonitorinassessingcompliancewithcurrent,generallyacceptedprofessionalstandardsofcarewithregardtothisprovisioninaseparatemonitoringplan.

Inresponsetothisrequirement,CCSSLC’sSelf‐Assessment indicatedthatsincethelastreview,activitiesaddressingthisprovisionincludedthefollowing:

ThedatapresentedintheFacility’sSelf‐Assessmentreflected“averageoverallmonthly”scoresfortheMedicationAdministrationObservationsconducted.TheMonitoringTeamcouldnotinterpretthesescores.AsnotedfromdiscussionsonsitewiththeCNEandNurseEducatorsregardingthedeterminationofpassingorfailingamedicationadministrationobservation,sincetheitemsonthetoolarenotweightedaccordingtopriorityandsafety,singlecompliancepercentagescouldeasilyreflectextremelyhighscores,yetthenursesobservedcouldhaveinadequatelyperformedacriticalprocedure,suchasdrawingupanexceedinglywrongdosageofinsulin,whichwiththecurrentprocedure,wouldnotbeaccuratelyreflectedinthesinglecompliancescoreforthatparticularmedicationobservation.Thus,generatingaveragescoresfortoolssuchastheMedicationAdministrationObservationtooldoesnotaccuratelyreflectthestrengthsandweaknessesofthenursingpracticesregardingmedicationadministration.However,thedatafromtheMedicationAdministrationObservationtoolthatwascontainedinthePresentationBookforSectionM.6forFebruarythroughMay2012appropriatelylistedthecompliancescoresbyitemforeachmonth.ThisenabledtheMonitoringTeamandtheFacilitytohaveaclearerpictureofspecificareasthatappearedtobestablefromtheconsistentlyhighcompliancescoresoverthefour‐monthtimeframe,andotheritemsthatreflectedvariablecomplianceinneedoffurtheranalysisandcorrectiveactionplans.Theonlymissinginformationforthisdatawasthenumberofobservationsthatwereconductedeachmonthtoaccuratelyinterpretthecompliancescoresandtrends,andtheestablishedinter‐raterreliabilitypercentagerangeforthemonitoringtool.

Inaddition,byaggregatingdatafromboththeSelf‐AssessmentandProvisionActionInformation,theMonitoringTeamfoundsomeveryvaluableandrelevantdataregardingproblematicconcernsfoundduringMedicationObservations

Noncompliance


# Provision AssessmentofStatus Complianceregardingthefollowingareas,nursesreviewingthePhysicalNutritionalManagementPlans(PMNPs)duringmedicationadministration,givinginstructionstothedirectsupportprofessionalsregardingpositioningandsymptomstowatchforaftermedicationadministrationaccordingtothePMNP,cleaningofthepillcrushersbetweenindividualsreceivingmedications,identifyingspecificassistiveandpositioningequipmentbeingpresentandutilized,verbalizingtherationalebetweenthemedicaldiagnosesandtheinformationcontainedinthePMNPs,givingwaterasorderedduringmedicationpass,checkingG‐Tubeplacementpriortoadministrationofmedications,countingthecontrolleddrugspriortoandafterremoval,storingmedicationproperly,ensuringthatindividualswereintheproperposition,andimplementingindividuals’programsforSelfAdministrationofMedication(SAMs)duringmedicationpass.Appropriately,theFacilityindicatedthatanyitemfoundbelow90%complianceontheMedicationObservationToolweretobeaddressedinthemonthlyMedicationAdministrationmeetings.AdequatesupportingdocumentationwasincludedinthePresentationBookforSectionM.6addressingasystemforconsistentlyimplementingtheSAMs,andminutesdated4/17/2012and4/27/2012clearlyaddressedmethodstothickenmedications.However,itwouldhavebeenextremelyhelpfultotheMonitoringTeamhadtheminutesoftheMedicationAdministrationmeetingsaddressingtheproblematicissueslistedabovebeenincludedinthePresentationBooktoeasilyidentifywhatactionswerebeingtakeninresponsetotheFacilitymonitoringfindings.

TheSelf‐AssessmentcontainedadditionalpositivedatageneratedfromtheNurseEducators’unannouncedreviewsconductedoftheMedicationAdministrationRecords(MARs)todetermineifallmedicationvarianceswerebeingcapturedthroughnurses’selfreport.TheFacility’sdataindicatedthatfromJanuarythroughJune2012,327,190,266,334,220,and100MARblankswerefoundfromthereviews,respectively.AlthoughtherewasnotedtobeapositivesignificantdecreaseinthenumberofMARblanksfoundovertime,therewasnoadditionalinformationexplainingifthedecreasewasaresultoftheunannouncedreviews,orifadditionalinterventionshadbeenimplementedcontributingtothedecreaseinblanksontheMARs.

AlthoughthedatagraphregardingPharmacyRefillsheetsandmedicationreconciliationcontainedintheFacility’sSelf‐Assessmentcouldnotaccuratelybeinterpreted,informationfromthePharmacistandCNEindicatedthattheFacilityhadreinitiatedastructuredsystemusingthePharmacyRefillSheetstotrackthemedicationsbeingbroughttothebuildingsinanattempttoreconcilethenumberofmedicationsthatwerebeingreturnedtothepharmacywithoutexplanation.Atthetimeofthereview,thePharmacistreportedthatthis


# Provision AssessmentofStatus Complianceprocedurehadalwaysbeeninplace,however,ithadnotbeenconsistentlyenforcedormonitoreduntilrecently.AnupdatedProtocolforMedicationCartExchange,dated2/15/12,wasdevelopedandtrainingrostersprovidedindicatedthat99%ofallnursesreceivedtrainingregardingtheprotocolbyMarch2012.AlthoughthePharmacistreportedthathedidhavesomedataregardingthenumberofunexplainedreturnedmedications,healsonotedthatthesenumberswerenotreliableacrosscampusasofyet.

Inanotherpositivestepforward,theFacilityindicatedthatsincethelastreview,thePharmacyDirector,HabilitationsDirector,andMedicalandNursingDepartmentshadbeenworkingtoensurethattheMARsandthePhysicians’Ordersincludedconsistentinstructionsregardingalteredtextureddietsinalignmentwiththeproperconsistenciesformedicationadministration.

RegardingtheFacility’scompliancerating,theyindicatedthat:“Basedonthefindingsfromthisself‐assessment,thisprovisionisnotinsubstantialcompliancebecausethereviewoftheMedicationHMTs,MARsreviews,andMedicationErrorreportsdatashowsthatCCSSLCneedstocontinuetotrainasconcernsareidentifiedanddevelopcorrectiveactionplans.”AlthoughthereweresomeindicationsfromtheminutesofthemeetingsreviewedthattheFacilitywasmakingattemptstomoveforwardregardingthemedicationadministrationsystem,theoverallformatofthePharmacy&TherapeuticsCommitteeMeetingminuteslackedspecificcontentinordertodeterminepreciselywhatissueswerediscussed.Inaddition,itwasnotclearfromtheminuteswhatspecificactionswerebeingtaken,whentheywereimplemented,andhoweffectivetheywereinaddressingtheproblematicissues.Includingthesecomponentsintheminuteswouldsignificantlyenhancethecontent,closethelooponissuesthatactuallyhavebeenresolved,andindicatewhatissuescontinuetoneedinterventions.Sincethepreviousreview,theCCSSLCcontinuedtohavesignificantproblematicissuesregardingitsoverallmedicationadministrationsystem.FromreviewoftheMedicationVarianceCommitteemeetingminutes,thePharmacyandTherapeuticsCommitteemeetingminutes,themedicationvariancedata,anddiscussionswithNursingDepartmentstaffandtheClinicalPharmacist,thefollowingweresomeoftheproblematicissuesidentified:

TheFacilitycontinuedtohaveproblematicissuesregardinganumberofunexplainedmedicationsthatwerebeingreturnedtothePharmacyeachmonth.Thesecouldbereflectiveofmedicationvariances.Althoughatthetimeofthereview,theprocedureforexchangingthemedicationcartwasbeingenforcedandtracked,theFacilitycandidlyreportedthatthedataregardingthisissue


# Provision AssessmentofStatus Complianceremainedunreliable.

Medicationvariancesregardingthepharmacyandthepharmacytechnicianvariancesaddressingthewrongdose,wrongdrug,wrongquantity,missingmedication,andwrongpersonhadnotyetbeguntobetracked,despiteinitialattemptsmadebythepharmacy.

Medicationvariancesregardingprescribervariancesaddressingmedicationprescribedinthepresenceofanestablishedallergy,wrongdose,andmedicationprescribedinthepresenceofcurrentdrugswiththesametherapeuticpurposehadnotyetbeentracked.

AreviewoftherawdatafortheMedicationAdministrationObservationtoolsthatwerecompletedsincethelastreviewfoundthatalthoughtherewereanumberofproblematicissuesfoundasnotedabove,thesereviewsessentiallyfoundnoissuesregardingthedocumentationofmedicationadministration.ThesefindingsweredifficulttoexplaingiventhattheunannouncedMARreviewsaswellasthenumberofknownomissionsreportedbytheFacilityinthevariancedataindicatedthatdocumentationissuesclearlyexisted.

TheminutesoftheMedicationCommittee,dated1/5/12,indicatedthatthePharmacyandNursingDepartmentscountedomissionsdifferently.Therewasnoindicationifthisissuehadbeenreconciledtoensureconsistentmedicationvarianceinformation.

AreviewoftheminutesoftheMedicationCommitteeindicatedthatthereweremedicationvariancesinvolvingthewrongtime,wrongdose,andthewrongindividualthatwerenotreportedinthemedicationvariancereportprovidedbytheFacility.Consequently,allthemedicationvariancedataprovidedbytheFacilitywasunreliable.ThisalsoindicatedthattheFacilitywastotallyunawareoftheactualvariancesthatwereoccurringatthetimeofthereview,whichhadthepotentialtoaffectthehealthandsafetyoftheindividualsatCCSSLC.

FromdiscussionswiththePharmacistandreviewoftheMedicationCommitteeMeetingminutes,theFacilityhaddiscoveredthatdosesofCalcitoninhadnotbeenadministeredasorderedpromptingthepharmacytocreateadispensinglogtotrackitsuseandonlydispenseenoughfor35daystotrackreorders.

AreviewofthemedicationvariancesreportedbytheFacilityindicatedthefollowing:

January2012‐289omissions; February‐190omissions; March‐334omissions; April‐220omissions;and May‐220omissions.

However,itwasunclearfromtheMedicationErrorsMonthSummaryreportwhat


# Provision AssessmentofStatus Complianceexactlythesenumbersrepresentedsincetheywereallmarkedasomissions.Thus,theMonitoringTeamcouldnotdetermineifMARblanksand/orunexplainedreturnedmedicationswereincludedinthevariancesnumbers.Fromthenumberofomissionsrecorded,andthediscrepanciesregardingactualmedicationvariancesreportedintheminutesoftheMedicationCommitteeMeetings,thefactthattherewerenovarianceslistedforthewrongmedication,wrongdose,wrongindividual,wrongtime,orwrongform/routeindicatedasnotedinpastreports,thatCCSSLCcontinuedtohaveasignificantproblemregardingtheunder‐reportingofmedicationvariancesaswellasunreliablevariancedata.BasedonobservationsofmedicationadministrationattheInfirmary,thefollowingproblematicissueswerefound:

TheFacilityhadimplementedaverypromisingprocedureofhavingthemedicationnursereadthePNMPinstructionstotheindividualsreceivingmedicationstoensuretheindividualwasprovidedinformationabouttheprocedureandthenursewasawareoftheprocedure.However,whilereadingthePNMPinstructionsaboutadministeringmedicationtoanindividualinawheelchairtoanindividualwhohadsustainedarecentfractureandthus,wasnotabletogetintoherwheelchair,theInfirmarynurseproceededtoadministerthemedicationswithoutrecognizingthatthePNMPinstructionsnolongerwereapplicabletotheindividual.ThePNMTshouldhavebeencalledtoreassesspositionsforsafemedicationadministration.Unfortunately,thisverypromisingprocedureimplementedinMay21012quicklybecamemoretask‐orientedratherthanclinicallyoriented;

Thenursedidnotprovideeducationtotheindividualsregardingthemedicationsthattheywerereceiving;and

Thenursedidnotperformanassessmentforpaininresponsetoanindividual’srequestforpainmedication.

BasedontheproblematicissuesobservedduringmedicationadministrationatCCSSLC,theFacilityshouldcontinuetodevelopandimplementasystemtoensurethatpriortonursesprovidingcaretoindividualswithaPNMP,andthattheyareprovidedcompetency‐basedtrainingregardingthePNMPs,andunderstandtheclinicalrationalefortheinstructionscontainedonthePNMPs.Inaddition,trainingshouldbeprovidedtoallnursesthataredesignatedasauditorsformedicationadministrationobservationsregardinghowtoappropriatelyassesscomplianceregardingpositioningandothermedicationadministrationinterventions,includingfollowingtheinstructionsinthePNMPs.AlthoughtheFacilityhadinitiatedsomepositivestepstoreviewsomeoftheelementsof


# Provision AssessmentofStatus Compliancethemedicationadministrationsystem,therecontinuedtobeanumberofsignificantproblematicissuesregardingthemedicationadministrationsystemsatCCSSLC.TheFacilityshouldaggressivelycontinueitseffortstocriticallyreviewallaspectsofthemedicationadministrationsysteminordertoaccuratelyidentifyproblematicareas,andimplementplansofactionsaimedatlong‐termresolutions.TheFacilityalsoshouldcontinuetodevelopandimplementstrategiestoincreasethereliabilityofthemedicationvariancedata,andreconcilediscrepanciesregardingtheactualvariancesthathaveoccurred.Inaddition,furthercollaborationshouldoccurbetweenthePharmacy,Nursing,andtheMedicalDepartmentsinconstructingasolidprocessthatresultsinacriticalreviewoftheoverallmedicationsystem.TheFacilityindicatedthatitwasnotincompliancewiththeelementsofthisrequirement.ThiswasconsistentwiththeMonitoringTeam’sfindings.


1. TheFacilityshouldconsideradoptingastandardizedformatforpresentingdatainameaningfulwaythatfacilitatesitsinterpretationandanalysis,andprovidetrainingtothedisciplinesregardinghowtoanalyzetheirdatatoidentifyproblematictrends.(SectionM.1)

2. AsCCSSLCpoliciesarereviewedand/orrevised,theFacilityshouldensurethatpolicies,procedures,orprotocolsaddresstheintegrationofanynewpositions,suchastheNursingAdministrationCoordinatorpositionandtheNurseCaseManagerSupervisorposition.(SectionM.1)

3. TheFacilityshouldcontinuetoimplementandexpandtheuseofnursingprotocolstoguidenursingpractices.Inordertoensurethisoccurs,mentoringofnursesshouldbeofferedinconjunctionwiththeadequatecompetency‐basednursingskillstrainingbeingprovidedbytheStateOfficeNursePractitionerGroup.DuetothenumberofindividualswithcomplexmedicalneedsatCCSSLC,thisareashouldbeconsideredapriorityforFacilityreview,andthedevelopmentandimplementationofactionplansaddressingthesignificantdeficitsthatexistinthenursingcare.(SectionM.1)

4. TheFacilityshouldensurethatdocumentsareavailable,andfiledinatimelymannerintheindividuals’records,sothatpertinentclinicalinformationisreadilyavailabletocliniciansneedingthisinformationwhenmakingdecisionsregardingtreatmentsandhealthcareservices.(SectionM.1)

5. Competency‐basedtrainingshouldbeexpandedanddocumentedforthenewAssistantInfectionControlNurseinordertoensurecompetencyinthisspecificclinicalarea.(SectionM.1)

6. TheFacilityshoulddevelopawrittenprocedurethatoutlinesCCSSLC’sprocesstoensuretheICdataarereliable,anditshouldbeincludedintheFacility’sInfectionControlManual.(SectionM.1)

7. TheFacilityshouldconsiderformalizingregularreviewsoftheInfectionControlDiscrepancyReportswiththeCaseManagersregardingpertinentmissingICinformationfoundontheweeklyInfectionControlReports.(SectionM.1)

8. TheFacilityshouldanalyzeallmonitoringdataaddressingInfectionControlinordertobetteridentifysystematicand/orstaff–relatedproblematictrendsthatmightbeimpactingtheratesofinfectionsattheFacility.(SectionM.1)

9. Aformalizedscheduleshouldbedevelopedclearlyindicatingwhichindividuals’immunizationstatusandimmunizationshavebeenresearchedandconfirmedorupdatedtoensureallindividualshavereceivedalltherequiredimmunizationsasoutlinedintheHealthCareGuidelines.(SectionM.1)

10. ThefindingsoftheInfectionControlEnvironmentalChecklistsshouldbetrendedandanalyzedinconjunctionwithotherInfectionControldata


todetermineifacorrelationbetweentheproblematicenvironmentalissuesandratesofinfectionsexist,andthisinformationshouldbeincludedintheminutesoftheInfectionControlCommitteemeetings.(SectionM.1)

11. Asrecommendedinpastreports,additionalexpertiseinInfectionControlisneededtoassistinimplementingsystemstoeffectivelyoperationalizetheInfectionControlprograminalignmentwithICstandardsofpractice,asdefinedintheHealthCareGuidelinesandtheSettlementAgreement.SuchexpertisealsoshouldbeusedtoobtainprofessionalfeedbackregardingthequalityandcompletenessoftheInfectionControlProgram.(SectionM.1)

12. TheFacilityinconjunctionwiththeStateOfficeshouldclarifytheroleofRiskManagementandtheroleoftheclinicalstaffregardingthereviewofEmergencyMockCodeDrilldataanddataaddressingtheactualmedicalemergenciesthathaveoccurred.(SectionM.1)

13. RegardingthedataaddressingEmergencyMockDrills,theFacilityshouldconductanalysesandgenerateassociatedplansofcorrection,especiallyinlightofsomeofthelowpasspercentagesofthedrillsconductedfromJanuarythroughJune2012.(SectionM.1)

14. Aspreviouslyrecommended,theFacilityshouldexpanditsemergencydrillstoincludeavarietyofscenariossothattheemergencydrillsaremorereflectiveofemergenciesthatwarrantactionsinadditiontoCPR.(SectionM.1)

15. TheFacilityshouldprovideappropriatecompetency‐basedtrainingregardingtheQuarterly/AnnualComprehensiveNursingAssessmentsfromacompetentsourcetoensurethatthenursingassessmentsincludeanadequateclinicalanalysisoftheindividuals’progress.(SectionM.2)

16. CCSSLCshouldreviewandreviseitscurrentnursingdischarge/transitionproceduresanddocumentationrequirementstoensurethatuponanindividual’stransitionfromtheFacilitytothecommunity,thenursingdocumentationisspecificanddetailedenoughtomaintaincontinuityofcare.(SectionM.2)

17. TheFacilityshouldconsiderexpandingthesystemfortrackingthedateswhenanacutenursingcareplanwasdevelopedandplacedintheActiveRecordandwhenitwasresolvedtoincludeaformatformonitoringtheactualimplementationofnursinginterventionsinalignmentwiththenursingprotocolscontainedintheacutecareplans.(SectionM.3)

18. RegardingtheFacility’stransitiontotheuseofanIntegratedHealthCarePlan,theFacilityshoulddevelopandimplementaplanaddressinghownursinginterventionsforcertainchronicconditionsthatdonotrisetothelevelofahighormediumriskorarenotacuteissueswouldbeaccountedforinaplanofcare.(SectionM.3)

19. TheFacilityshoulddevelopandimplementappropriatecareplansbasedonpriority,andriskforallindividualsatCCSSLC,especiallywhiletheFacilityisinprocessoftransitioningtoanIntegratedHealthCarePlan.(SectionM.3)

20. Nursing,inconjunctionwiththeInfectionControlNurseshoulddevelopandimplementasystemtoensurethatthecareplansaddressinginfectiousandcommunicablediseasesareclinicallyadequate,individualized,andarebeingimplementedconsistently.(SectionM.3)

21. TheFacilityshouldgivethoughtfulandseriousconsiderationtohowtoincorporateanindividual’shealthrisksintooneplanwithoutcompromisingtheAt‐Risksystemortheclinicalneedsoftheindividual.(SectionM.3)

22. AlthoughthedraftrevisionstotheAt‐RiskIndividualsPolicyandtherecentpilotprojectinitiatedregardingtheAt‐Riskprocessispromising,thesignificantexistingdeficitsinthecurrentAt‐Risksystem,especiallyregardingthenursingcomponentsofthesystem,suchastheComprehensiveNursingAssessments,theindividual‐specificinformationcontainedintheIntegratedRiskRatingFormsfromnursing,andthequalityoftheinterventionscontainedintheRiskActionPlansshouldbeaddressedregardlessofthechangestotheprocess.(SectionM.5)

23. TheFacility,inconjunctionwiththeState,shouldspecificallydefinethenursingassessmentprocessregardingat‐riskindividualsandprovidetrainingandmentoringaddressingthisarea.(SectionM.5)

24. TheFacilityshouldexpanditseffortstoensurethatpriortonursesprovidingcaretoindividualswithaPhysicalNutritionalManagementPlans,theyareprovidedcompetency‐basedtrainingregardingthePhysicalNutritionalManagementPlans,andunderstandtheclinicalrationalefortheinstructionscontainedonthePhysicalNutritionalManagementPlans.(SectionM.6)

25. Trainingshouldbeprovidedtoallnursesthataredesignatedasauditorsformedicationadministrationobservationsregardinghowtoappropriatelyassesscomplianceregardingpositioningandothermedicationadministrationinterventions,includingfollowingtheinstructionsinthePhysicalNutritionalManagementPlans.(SectionM.6)


26. TheFacilityshouldexpanditseffortstocriticallyreviewallaspectsofthemedicationadministrationsysteminordertoaccuratelyidentifyproblematicareas,andimplementplansofactionsaimedatlong‐termresolutions.(SectionM.6)

27. TheFacilityshouldalsoexpanditsstrategiestoincreasethereliabilityofthemedicationvariancedata,andreconcilediscrepanciesregardingtheactualvariancesthathaveoccurred.(SectionM.6)

28. FurthercollaborationshouldoccurbetweenthePharmacy,Nursing,andtheMedicalDepartmentsinconstructingasolidprocessthatresultsinacriticalreviewoftheoverallmedicationsystem.(SectionM.6)


SECTIONN:PharmacyServicesandSafeMedicationPracticesEachFacilityshalldevelopandimplementpoliciesandproceduresprovidingforadequateandappropriatepharmacyservices,consistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow:


o Policies,andproceduresaddressingtheprovisionofpharmacyservices;o Pharmacysurveyscompletedwithinthelastyear,plansofcorrectionand/orinternal

auditingproceduresandreportsrelatedtopharmacyservices;o AllDrugUtilizationEvaluation(DUE)reportscompletedsincetheMonitoringTeam’slast

review(includingbackgroundinformation,datacollectionformsutilized,results,anyminutesreflectingactionstepsbasedontheresults);

o Anyfollow–upstudiescompletedforanypriorDUEreports;o MinutesofPharmacyandTherapeutics(P&T)Committeemeetingsandanyattachments

sincetheMonitoringTeam’slastvisit;o Minutesofanycommitteeaddressingpolypharmacyfornon‐psychotropicmedications;o Minutesofanycommitteeaddressingmedicationerror/variancesincetheMonitoring

Team’slastvisit;o Minutesofthecommitteeaddressingseizureswithanyattachments,sincetheMonitoring

Team’slastvisit;o DUEcalendarfornext12months;o ForQuarterlyDrugRegimenReviews,forallindividualstheFacilityservices,alistingof

theindividuals,theirreviewperiods,thedatesinwhichreviewsmustbecompleted,andthedatesonwhichreviewsareactuallycompletedforthelastoneyearperiod(beginning1/1/12);

o ForQuarterlyDrugRegimenReviews,thetwomostrecentperresidentialhomethathavebeencompletedwithphysiciansignaturesanddate,includingthosefor:Individual#26,dated3/22/12;Individual#15,dated5/14/12;Individual#334,dated5/2/12;Individual#182,dated4/12/12;Individual#184,dated4/4/12;Individual#76,dated4/20/12;Individual#260,dated5/14/12;Individual#168,dated4/26/12;Individual#296,dated3/21/12;Individual#311,dated4/4/12;Individual#218,dated3/7/12;Individual#340,dated5/14/12;Individual#21,dated5/14/12;Individual#194,dated3/5/12;Individual#9,dated4/25/12;Individual#174,dated3/9/12;Individual#8,dated4/9/12;Individual#369,dated3/23/12;Individual#264,dated3/1/12;Individual#348,dated3/22/12;Individual#367,dated4/23/12;Individual#328,dated5/9/12;Individual#34,dated4/16/12;Individual#112,dated3/23/12;Individual#293,dated5/9/12;Individual#187,dated4/3/12;Individual#290,dated5/9/12;andIndividual#156,dated4/13/12;

o For10mostrecentQDRRsinwhichrecommendationsweremadeandaccepted,copiesofphysicianorders;for10mostrecentQDRRsinwhichrecommendationsweremadeandnotaccepted,copyofIPNorotherentryindicatingreasonfornon‐agreement,includingthosefor:Individual#48,dated1/27/12;Individual#182,dated2/9/12;Individual#184,dated1/20/12;Individual#186,dated1/10/12;Individual#343,dated2/6/12;


Individual#341,dated3/7/12;Individual#174,dated3/9/12;Individual#246,dated3/8/12;Individual#62,dated3/5/12;Individual#280,dated2/23/12;Individual#20,dated3/9/12;Individual#335,dated1/12/12;Individual#307,dated2/17/12;Individual#28,dated2/17/12;Individual#46,dated1/27/12;Individual#88,dated3/1/12;Individual#34,dated2/6/12;Individual#291,dated1/31/12;andIndividual#195,dated2/23/12;

o All“singlepatientinterventionreports”inWORxsystemsincetheMonitoringTeam’slastreview;

o Sincethelastreview,copyofanyinternalPharmacyDepartmentaudits/monitoringdatatoreviewSectionNoftheSettlementAgreement(i.e.,pharmacistreviewandplacementofnewordersinWORxsystem);

o Copyofall“notesextracts”associatedwith“singlepatientinterventionreports;”o Forthepastsixmonths,anyadversedrugreactionreports(ADR)completed;o Policiesand/orproceduresregardingmedicationerror/variance,includingprescription,

dispensing,administration,documentationandpotentialerrors;o Numberofmedicationerrorsvariancespermonthforprior12monthsbyerrortype,

nurse,home,shift,unit,individual,categoryofseverity,errormode,aswellasanalysisreports,includingcorrectiveactionplans,androotcauseanalysissummaries;

o Last10medicationerrorformscompletedandanyplansofcorrectionarisingfromreviewofthemedicationerrors;

o CommunicationbetweenpharmacyandNursingDepartmentconcerningmedicationerrors/variance(emails,memos,etc.)sincetheMonitoringTeam’slastvisit;

o Forthepasttwomonths,reportsand/orsummariesofanymedicationadministrationobservationsconducted;

o Policies,proceduresand/orotherdocumentsaddressingmedicationadministration;o ListofAntibiogramspermonthsforlastsixmonthsbybuilding;o MedicationhistoryforindividualswithJ‐orGastrostomy/Jejunostomy(G/J)tubes;o AscheduleofwhenQuarterlyDrugRegimenReviewsareconductedbyhome/unit;o Polypharmacyriskassessmentformsforpastsixmonthsforfiveindividualsmostrecently

ratedasbeingathighriskforpolypharmacy,andfiveindividualsratesasbeingatmediumriskforpolypharmacy;

o Alldocumentationforeachemergencychemicalrestraint,includingrestraintchecklistfor:Individual#58on1/5/120306hr;Individual#144on3/11/122300hr;Individual#246on4/14/122150hr,and4/14/122315hr;Individual#7on1/7/120350hr,and1/7/120450hr;andIndividual#253on3/4/121720hr,4/10/121209hr,and5/17/121240hr;

o Trendanalysisofchemicalrestraintuse(graphs,etc.);o Foreachdatabasemaintainedonuseofchemicalrestraints,summarylist(s)ofall

chemicalrestraintsadministeredoverthelastsixmonths;o For10ordersinvolvingdrug‐druginteractions,copiesofserialcomputerscreenshotsfor

eachstep;o Forfiveordersinvolvingpotentialallergicreactionsforneworders,copiesofserial

computerscreenshotsforeachstep;


o Forfiveordersinvolvingdrugdosagesbeloworexceedingnormallyprescribeddosageregimens,copiesofcomputerscreenshotsforeachstep;

o Forfivenewordersinwhichlabsarereviewed/monitored,copiesofserialcomputerscreenshotsforeachstep;

o Forfivenewordersforwhichtherewaspotentialforsignificantsideeffects,copiesofserialcomputerscreenshotsforeachstep.Copyofwrittendocumentation/informationprovidedtoPCPandresponseofPCP;and

o PresentationBookNforSectionN. Interviewswith:

o DonaldKocian,RPH,PharmacyDirector;ando SandySuri,RPH.

Observationsof:o PharmacyandTherapeuticsCommitteemeeting,on7/9/12.

FacilitySelf‐Assessment:Ingeneral,theFacilityhadengagedinsomereasonableactivitiestoconductitsself‐assessmentofSectionN.Forexample,thePharmacyDepartmentmonitorednewordersbysampling20permonthfortherequirementsoftheSettlementAgreement.TheFacilityincludedareviewofwhetherornotsignificantinteractionsandsideeffectswereaddressed,allergieswerechecked,labmonitoringwasaddressed,anddose,duration,andfrequencywerereviewed.However,thePharmacyDepartment’sanalysisofthedatafornewordersaddressingsuchareasasdrugdruginteractions,allergies,etc.didnotagreewiththefindingsoftheMonitoringTeam.ThismightindicatealackofsensitivityofthemonitoringtooldevelopedbythePharmacyDepartment,butalsothelackofcompletenessofthesubmittedinformation,asthePharmacyDepartmentappearedtohaveadditionalinformationforanalysisthatwasnotsubmittedaspartofthedatareview.TheFacilityreviewedQDDRsforanumberofparameters,includingtimelycompletion,laboratoryreviewwithinQDRRs,andmonitoringofatypicalantipsychotics,benzodiazepines,anticholinergics,polypharmacy,metabolicandendocrinerisks,andforlaboratorymonitoringandtherapeuticdruglevels.ReviewbytheMonitoringTeamfoundthatdifferentcomplianceratesformostoftheseindicatorsthantheFacility.TheMonitoringTeam’sfindingsagreedwiththelaboratoryreview,butdisagreedinmostotherareasofQDRRmonitoring.Ingeneral,thereweresomeproblemswiththeaccuracyoftheFacility’sfindings.TheinternalmonitoringtoolsdidnotappeartocapturetheconcernstheMonitoringTeamidentifiedwithregardtoSectionsN.1throughN.4.Inconductingitsself‐assessmentprocess,thePharmacyDepartmentutilizedthedraftofarevised“TexasHealthMonitoringInstrument:PharmacyServicesandSafeMedicationPractices.”ThisincorporatedaspectsoftheHealthCareGuidelinesandtheSettlementAgreementforneworders(SectionN.1),QDRRs(SectionsN.2,N.3,N.4),tardivedyskinesiamonitoringifappropriate(SectionN.5),reviewofADRs(SectionN.6),interpretationofDUEdatabyP&TCommittee(SectionN.7),andsystematictracking,analysis,andactionstepsformedicationvariances(SectionN.8).Fromthesubmittedinformation,twoactiverecords


werereviewed,dated3/29/12,completedbythePharmacyDirector.On4/29/12,boththePharmacyDirectorandtheQARNreviewedonerecord.AnadditionalrecordwasreviewedbythePharmacyDirectoron4/29/12,butnotreviewedbytheQARN.ThePharmacyDirectoron5/17/12revieweda4threcord.FortheonerecordreviewedbyboththePharmacyDirectorandtheQARN,inter‐raterreliabilityinformationwassummarized.Thenewmonitoringtoolincluded19questions,ofwhichtherewasagreementon11oftheanswers,forapercentagreementof58%.Eachquestionforwhichtherewasadiscrepancyintheanswerwasalsoprovided.ThisbreakdownofdiscrepancybyquestionshouldbeusedbythePharmacyDepartmentindevelopingguidelines/instructionsforinterpretationofthemonitoringtool,oridentificationofwheretofindtherequiredinformationinansweringthequestion,inordertoimprovetheinter‐raterreliability.AsQAstaffonlyreviewedonerecord,itisrecommendedthatseveralmorerecordsbereviewedtodetermineareasofcontinuednon‐agreementthatwouldpotentiallyrequirefurtherwrittenguidanceortrainingbeforefinalizingtheformalprocess.Compliancebyauditor(pharmacist,QARN)wasalsosubmittedingraphform.Thisappearedtobeapilotingoftheprocess.Thepharmacywillneedtodeterminethesamplingmethodandsamplesizetobereviewedeachmonthinordertomaketheresultsmeaningful.Thisisdiscussedinfurtherdetailinsomeofthesubsectionsbelow.ThePharmacyDepartmentcompletedtwoFacilitySupportServices,HHSCdocuments:“FacilitySupportPerformanceIndicator:PharmacyControls1stQuarterFY2012,”and“FacilitySupportPerformanceIndicator:MedicationRoomControls1stQuarter,FY2012.”Theinformationreviewedindicatedtherewerenodeficienciesorconditionsidentified,andnoplansofcorrectionwereimplementedbasedontheself‐reviews.InitsSelf‐Assessment,theFacilitydetermineditwascompliantwithSectionsN.1(perthenarrative),N.2,N.5,andN.7.TheMonitoringTeam’sfindingsshowedtheFacilitywascompliantwithSectionsN.5andN.7.SummaryofMonitor’sAssessment: ThePharmacyDepartmenthadmadeconsiderableprogressinprovidingstructureandimplementinginternalmonitoringprocesses.Forexample,ensuringanindividual’sallergiesareconsistentinalldocumentsacrosscampuswasanimportantendeavor.ImprovementsinscreeningformedicationthatshouldnotbegivenbyJ‐tubealsohadbeenimplemented.TheDUEprogramwasstrong,andthefollow‐upreviewsindicatedapositiveimpactonthepracticepatternsofthePCPsandonthequalityofcareoftheindividuals.However,considerablechallengesremained.TimelinessofcompletionoftheQDRRremainedproblematic,andaresubmissionof“corrected”dataremainedincomplete.ItdidappeartimelinessofQDRRshadimproved,butlackofadequatestatisticaldatabecameanobstacleinverifyingthis.Patientinterventionswerecategorized,butthechoiceofcategoriesappearedtorequireadecisiontreeorotherstructuretoprovideconsistentchoiceamongpharmacists.ChemicalrestraintreviewremainedachallengeinbothobtainingthereviewforminatimelymannerandinensuringtheBehaviorServicesDepartment’slistofchemicalrestraintsagreedwiththePharmacist’slistofchemicalrestraints.Inaddition,adequatecompletionofthechemicalrestraintformwasacontinuingproblem.


Althoughanumberofstepshadbeentakentoreducemedicationerrorsofadministrativeomissions[i.e.,blanksinthemedicationadministrationrecord(MAR)forwhichthemedicationwasadministered]andtrueadmissions,muchworkwasneededonthenumbersandreasonsofreturnedmedication.Therewasapaucityofstatisticalreviewformedicationvariancesforpharmacy,nursing,andmedical.AquarterlyreportofmedicationvarianceswouldbeimportanttoprovideguidancetothePharmacyDepartmentinrelationtofollow‐upinterventions,aswellasineducatingtheFacilityAdministrationconcerningthechallengesofthisarea.Concerningadversedrugreaction(ADRs),nurseshadbeentrainedaswellasthetwodentistsandfourPCPs.Asof6/25/12,noADRshadgonethroughtheprotocol/process.Morerecently,threepotentialADRswereidentified,buttheFacilitywasinprocessofdeterminingiftheymetthecriteriaofADRs.

# Provision AssessmentofStatus ComplianceN1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithin18months,upontheprescriptionofanewmedication,apharmacistshallconductreviewsofeachindividual’smedicationregimenand,asclinicallyindicated,makerecommendationstotheprescribinghealthcareprovideraboutsignificantinteractionswiththeindividual’scurrentmedicationregimen;sideeffects;allergies;andtheneedforlaboratoryresults,additionallaboratorytestingregardingrisksassociatedwiththeuseofthemedication,anddoseadjustmentsiftheprescribeddosageisnotconsistentwithFacilitypolicyorcurrentdrugliterature.

ThePharmacyDepartmentstaffingincludedthefollowing:aPharmacyDirector,twoadditionalregisteredpharmacists,andtwopharmacytechnicians.AlistofthosecompletingCPRcertificationwassubmitted,dated4/1/12.ThreeofthreepharmacistswerecurrentinCPRcertificationatthetimethelistwassubmitted.TheMonitoringTeamprovidesthisinformationfortheFacility’sinformation,butisnotrelatedtocompliance.ThePharmacyDepartmentsubmittedacopyofthecurrentdepartmentalpolicies/procedures/protocols.Theseincluded:

DADSSSLCPolicy:PharmacyServices#011,includingExhibitA:Procedures,ExhibitB:RequiredFacilityProcedures,ExhibitC:IdentifyingUnusableDrugs,effective9/26/11;

PharmacyServicesandSafeMediationPractices:o N.1.PharmacistReviewofNewMedicationOrders,implemented

11/23/09;o N.2.QuarterlyDrugRegimenReview,implementedwithQDRRform

4/7/11;o N.3.PrescriberMedicationOrderPolicy,implemented4/6/11;o N.4.Poly‐pharmacyDefinitionNon‐PsychotropicMedications,

implemented7/22/09;o N.5.Poly‐pharmacyDefinition–PsychotropicMedications,

implemented7/22/09;o N.6.AdverseDrugReactionPolicy,implemented5/1/11,withreporting

form,andpresentation“AdverseDrugReaction(ADR)”;o N.7.DrugUtilizationEvaluationPolicy,implemented4/6/11;o N.8.PharmacyMedicationErrorReportingPolicy,implemented6/2/10;

Noncompliance


# Provision AssessmentofStatus Complianceo N.9.PrescriberNotificationDocumentation,implemented3/3/10;ando N.10.PurchaseofAfterHoursEmergencyMedications,implemented

3/1/09,withcopyofletterofagreement.Itwasnotedthatnoneofthepolicieswerenewlycreatedorimplemented.However,theMonitoringTeamhadnotpreviouslyreviewedtheADRPowerPoint,andorPolicyN.10.“Patientintervention”entriesfornewordersenteredintotheWORxsoftwareprogramweresubmittedforreview,including96entries.Thefollowingliststhenumberofpatientinterventionentriesgeneratedpermonth.ForJune2012,theavailableinformationwastabulatedfromtheoriginalsubmittedinformation,anddidnotrepresenttheentiremonth:January2012–13,February2012–34,March2012–18,April2012–13,May2012‐16,andJune2012–twotodate.Interventionswerebrokendownintoseveraldifferentcategories.Thereappearedtobealargenumberofcategoriesfromwhichtochoosewithpotentialoverlap,andtheremighthavebeeninconsistencyinhowthecategorywaschosen.Thefollowingsummarizesthecategoriesandnumbersofpatientinterventionsforeachcategory:Adversedrugreaction–12;Interaction/CompatibilityIntervention‐24,OrderClarification/Confirmation‐11,PatientCare–one,PharmacokineticConsultation‐one,TherapeuticConsultation–four,Activities–five,Allergy/DiseaseStateContraindication‐nine,AntibioticRegimenChange–four,DrugInformation–five,Duplicate/UnnecessaryTherapy‐eight,uncategorized–two,andinsufficientinformationforcategorization‐10.Itwasnotclearthepurposeofthecategorization.Itisrecommendedthatthisaspectofthedataentryfornewordersbereviewedforconsistency.ThePharmacyDepartmentmightneedtodeterminetheusefulnessofthevariouscategoriesindeterminingpotentialimpactonsystemsimprovement.AspartofthePresentationBookforSectionN,thepharmacysubmitted“DrugInteractionAlerts,”whichoccurredpermonth,accordingtoindividual.ItisrecommendedthatthistoolbeconsideredasaQAreviewforthePCPsandasalearningtoolfortheMedicalDepartment.ThiswouldprovideinformationtothePCPonthedrugalertsforeachindividualbasedontheirmedicationregimen,allergies,etc.Italsowouldhavethepotentialtoprovidefeedbacktothepharmacyconcerningwhichalertsarenotclinicallyimportantforthatindividualandwhichcontinuetobeavaluablecommunication.ThepharmacyalsoprovidedasystemofalertsformedicationsthatshouldnotbeadministeredthroughaJ‐tube.Thisincludedbrightmulti‐coloredwarningstickers,additionofthephrase“seeJtubeinstructions”ontheMARofthosewithJtubes,andanotealertintheWORxsoftwareprogramforneworders.TheFacilitysubmittedacopyofmedicationhistoriesforthoseindividualswithJorG/J


# Provision AssessmentofStatus Compliancetubes.Fiveindividuals’recordsweresubmittedwithrecentmedicationhistories.NonehadmedicationsprescribedandadministeredwhichwereinappropriateviaaJ‐tube.Thispreliminaryinformationindicatedthesystemappearedtobeworkingandwouldprovideavaluablesafeguardinthenewordersystem.ThePharmacyhadcontinuedtoreviewallallergiesthatwerelistedonalldocumentsoftheindividuals,sothattherewasconsistencyacrossthesystem.Forimportantinformationthatwasnotanallergy,thePharmacyalsohadaddedthisinformationtothephysicianordersforthatindividual.OnesuchinstancewasforIndividual#296,inwhichtheallergieslistedonthephysicianordersheetincludethefollowingimportantdetails:“Allergies:NKDA[noknowndrugallergies].DentalrecordsshowcannotbegivenHydroxyzinewithLorazepamduetoparadoxicalreaction.ToleratesLorazepamwithoutincident.”Asampleofnewprescriptionswasreviewed.Thefollowingsummarizetheresults:

Elevennewordersweresubmittedinwhichthepharmacyfoundconcernswithdrug–druginteractionswiththecurrentdrugregimen.For10outof11(91%),therewasdocumentationsubmittedofcommunicationbetweenthePharmacyandPCP(eighthandwrittenentries,andtwopatientinterventions).AhandoutwasprovidedtothePCPinsevenof11(64%).Achangeintheorderoccurredinfourorders,nochangeinsixorders(noevidenceofchangewassubmittedinfour,andtheorderdidnotappeartoindicatetheneedforfurtherinterventionintwo),andincompleteinformationwassubmittedforone.

Fivenewordersweresubmittedinwhichallergieswerereviewedanddeterminedbypharmacytobeaconcern.Acomputerscreenshotoftheorderwassubmittedforthreeoutoffive(60%).Acopyofthepatientinterventionwassubmittedinnone(0%).AsaresultofthePharmacyreview,therewasadocumentedchangeinorderfornoneofthefiveorders.Therewasconfirmatorydocumentationofnochangeforthreeorders.Therewasinsufficientinformationprovidedtodeterminewhetheranorderchangeoccurredintwoorders.Forone,thesubmitteddocumentappearedtoindicateitwasnotanorder,butanupdateofcampusdocuments.Foroneinwhichnochangewasmade,thePCPdisagreedandincludedaresponsethattherewasnoallergytotheorderedmedication,buttherewasnodocumentationoftheevidenceforthisconclusion.Forone,thesubmittedevidencewasconfusing,becausetheinformationalsoindicated“NKDA.”Basedonthisinformation,adequatedocumentationoftheneworderprocessforallergiesoccurredin0%ofsubmittedcases.

FivenewordersweresubmittedinwhichsideeffectswerereviewedbyPharmacyanddeterminedtobeaconcern.Ascreenshotwassubmittedintwooutoffive(40%).Labresultswerereferencedinfourorders,andlabswere


# Provision AssessmentofStatus Compliancesubmittedforthesefourorders(100%).Labswerenotapplicableforoneorder.PrintedinformationwassenttothePCPandsubmittedforreviewinfouroutoffive(80%)oforders.Apatientinterventionnotewassubmittedfortwooutoffive(40%).Evidenceofanorderchangewassubmittedinthree(60%).Insummary,forthesefiveorderssubmitted,none(0%)hadevidenceofallthecomponentsofadequatedocumentation(i.e.,screenshot,printedinformation,patientinterventionnote,etc.)concerningsideeffectreview/collaborationwiththePCP.

Fivenewordersweresubmittedinwhich,currentlaboratoryresultsandpotentialneedforfurthertestingwereidentifiedbypharmacyduringinitialreview.NeworderswerewrittenfortwoofthemedicationsbasedonthecommunicationwiththePCP,andthreeordershadnochange.Labdatawassubmittedinfive(100%).Documentationwasadequateinfive(100%).

Sixnewordersweresubmittedinwhichpharmacyhadconcernsaboutthepotentialneedfordosageadjustments.Forfiveofsix,therewasacopyofthescreenshotordersubmitted.Forthreeorders,therewasdocumentationthePCPwascontacted.Foroneorder,thePCPwasnotcontacted,andfortwoorders,itcouldnotbedeterminedbasedontheinformationprovidedwhetherthePCPwascontacted.Therewasapatientinterventionformprovidedforoneofsix(17%).AchangeoforderbasedonpharmacyreviewandPCPcontactoccurredinone(17%).Insummary,therewasadequatedocumentationoftheprocessinone(17%).

ThePharmacyDepartmentcompletedaninternalQAreviewofneworders.AcopyoftheApril2012andMay2012reviewsweresubmittedinthePresentationBookforSectionN.Themethodofsamplingusedinthereviewwasnotidentified.Themonitoringtoolwasentitled“ChecklistforReviewofNewMedicationOrders.”Thereviewincludedvalidationthattheorderwasplacedwiththecorrectindividual;documentedthecorrectPCPorderedthemedication;reviewedforpotentialallergies;reviewedtheappropriatenessofthedrug,includingtheindication,dose,dosageform,durationoftherapy,administrationtimeandfrequency,andotherinstructionsforadministrationandinstructionsformonitoring;reviewedcompatibilitywithcurrentmedicationregimenforsignificantinteractions,therapeuticduplication,diseaseandcontraindications;andnotificationofPCPifindicated.Therewereseveraldocumentsattachedtoeachreview,basedontheinformationsourceneededtoverifysafedispensingpractices.Forthoseprescribedamedicationforwhichtherewasahistoryofallergytoamedicationinthesameclass,therewasdocumentationofpriorusewithoutsequelae,withdatesofuseforverification.TheFacilityhadcalculatedcompliancefornewordersas95%foreachmonth(January2012throughApril2012)and100%forMay2012.ItisessentialtonotethattheMonitoringTeamwouldhavebenefitedfromhavingbeenprovidedwiththesameinformationusedbythepharmacyindetermining


# Provision AssessmentofStatus Compliancecompliancewithneworderdispensing.Therationalewasnotclearfornotprovidingthesesamedocumentsfortherequestsforneworderswithallergyconcerns,sideeffectconcerns,etc.Atleastinpart,theMonitoringTeam’sfindingofnoncomplianceforthissectionappearedtobeaffectedbytheFacilitynotsubmittingtheneededdocuments.

N2 WithinsixmonthsoftheEffectiveDatehereof,inQuarterlyDrugRegimenReviews,apharmacistshallconsider,noteandaddress,asappropriate,laboratoryresults,andidentifyabnormalorsub‐therapeuticmedicationvalues.

AschedulewassubmittedconcerningthecompletionofQDRRsperresidence/unit.Duedateswereprovidedforthehomesofeachunit.Thiswasfurtherbrokendownintothetimeperiodofsevendayspriortotheduedateand14daysaftertheduedate.TheentirecalendaryearintoMarch2013wasprovided,listingtheindividualandthefour90‐daytimeperiodsforeachQDRRforthatindividual.InpreparationfortheMonitoringTeam’svisit,ascheduleofcompletedQDRRswassubmittedforJanuary2012throughJune2012.EachofthepriorQDRRswasreviewedfordateofcompletionandcomparedtothecurrentQDRR’sdateofcompletion.FortheJanuarythroughMarch2012quarter,132of262(50%)QDRRswerecompletedinatimelymanner.FortheAprilthroughJune2012quarter,162of262(62%)currentQDRRswerecompletedwithintheagreedupontimeperiodbaseduponaduedateof90daysafterthepriorQDRR,withadditionalparametersestablishedasatimeperiodofsevendayspriortotheduedateto14daysaftertheduedate.DuringtheMonitoringTeam’svisit,themostrecentquarterwasreviewedandtheinformationtheFacilityprovidedoriginallywasdeterminedtoincludemisleadinginformation.AnupdatedlistwassubmittedaspartofthePresentationBookforSectionN.Therewere264individualsonthelist,butthesecondpageofelevenpageswasmissing,providinginformationfor238ofthe264individuals.Duetothelackofcompletenessinthere‐submitteddata,afullrecalculationforcompliancecouldnotbedone.However,basedonareviewoftheincompleteinformation,compliancedidappeartobemuchimprovedfromthefirstquarterof2012.Toavoidproblemssuchasthisinthefuture,itisrecommendedthatthePharmacyDepartmentandQA/QIDepartmentreviewfinaldatapriortosubmissionforcompletenessandaccuracy.Asampleof28QDRRswasreviewed.Thesearelistedaboveinthedocumentsreviewedsection.Thefollowingsummarizestheresultsofthisreview:

Sixteen(57%)werecompletedinatimelymanner(i.e.,withinthewindowestablishedfortimeliness).

Laboratoryinformationwassubmittedaspartof27outof28QDRRs(96%).These27hadlabvaluesrecorded.

ThelabresultsdidincludeexactvaluesorindicationofnormalrangeforVitaminDlevels,completebloodcounts(CBC),electrolytes,glucose,Hemoglobin(Hgb)A1C,lipidpanel,hepaticfunction,ammonialevel,thyroidfunction,aswellasbloodlevelsofspecificmedications(mostcommonlynotedwereantiepileptic

Noncompliance


# Provision AssessmentofStatus Compliancedruglevelswiththerapeuticranges).

Twenty‐sevenoutof27QDRRswithlabs(100%)hadthedatethelabwasdrawn.

Abnormalvalueswerelistedunderthenotes/commentssectionlineforthatparticularlaborintherecommendationssection.

AlthoughbasedonincompletedatatheFacilitysubmitted,itappearedthattheQDRRswerebeingcompletedinamoretimelymannertowardstheendofthereviewperiod,recordreviewsshowedthisremainedaproblem.Asaresult,theFacilityremainedoutofcompliancewiththisprovision.

N3 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithin18months,prescribingmedicalpractitionersandthepharmacistshallcollaborate:inmonitoringtheuseof“Stat”(i.e.,emergency)medicationsandchemicalrestraintstoensurethatmedicationsareusedinaclinicallyjustifiablemanner,andnotasasubstituteforlong‐termtreatment;inmonitoringtheuseofbenzodiazepines,anticholinergics,andpoly‐pharmacy,toensureclinicaljustificationsandattentiontoassociatedrisks;andinmonitoringmetabolicandendocrinerisksassociatedwiththeuseofnewgenerationantipsychoticmedications.

ThisprovisionoftheSettlementAgreementencompassesanumberofrequirements.Eachofthemisdiscussedbelow,includingthePharmacyandMedicalDepartments’rolesinaddressingtheuseof“Stat”medicationsandchemicalrestraints,aswellasbenzodiazepines,anticholinergics,polypharmacy,andmonitoringthemetabolicandendocrinerisksassociatedwithsecondgenerationantipsychotics.ThePharmacyDepartmenthaddevelopedaninternalQAQDRRassessmentthatincludedthecomponentsofSectionN.3.EachmonththePharmacyDepartmentreviewedapproximately20completedQDRRs.ItwasnotedthatthescoresappearedtoindicatecomplianceinmostareasoftheQDRR,whichwasdifferentthantheMonitoringTeam’sreview.ThemonitoringtoolusedinternallydidnotidentifytheevidenceusedforverificationofthevariousaspectsoftheQDRR.Thissuggestedthatthereviewwasbroad,butdidnotguidethereviewertopursuetheneededdetailedinformation/documentstoverifycompliancewitheachaspectofSectionN.3.“Stat”EmergencyMedications/ChemicalRestraintUseTheFacilitysubmittedcompletedRestraintChecklistandFace‐to‐FaceAssessment,Debriefing,andReviewsforCrisisInterventionRestraintformsforninechemicalrestraintsusedfrom1/5/12to5/17/12.Thesearelistedaboveinthedocumentsreviewedsection.ThechemicalrestraintdocumentationindicatedthatfiveindividualshadninechemicalrestraintsfromJanuary2012throughMay2012.Fortheninechemicalrestraints,thepharmacysectionswerereviewedforadequacyofcompletionandcompliance.Thefollowingsummarizesthereviewofthesedocuments:

Oftheninechemicalrestraintforms,fiveforms(56%)includedinformationconcerningthejustificationofuseduetothebehavior.

Effectivenessofthechemicalrestraintwasdocumentedineightoutoftheninechemicalrestraintformscompleted(89%).Oftheninechemicalrestraints,five

Noncompliance


# Provision AssessmentofStatus Compliancewereconsideredeffectiveandfourwereconsideredineffective.

Adiscussionofsideeffectsandadverseeffectswerenotedinsevenofnineofthecompletedchemicalrestraintforms(78%).

Adiscussionofdrug/druginteractionswasnotedinsevenofnine(78%)ofthecompletedchemicalrestraintforms.

Thereweretwostatementsbypharmacythatwereconsideredrecommendations.Bothinvolvedchangesinmedication.

Therangeoftimeforcompletionoftheformsbythepharmacistwasfromoneto17days.Allbuttwowerecompletedwithinsixdays.

Therouteofmedicationwasnotedtobemissinginoneofthecompletedchemicalrestraintforms.Itisrecommendedthatdosageandrouteofmedicationbeclearlyindicatedontheseforms.ThepsychiatristalsohadadesignatedspaceforcompletionontheFace‐to‐FaceAssessment,Debriefing,andReviewsforCrisisInterventionRestraint.Reviewofthesedocumentedshowed:

Oftheninecompleted,therewerethreeforms(33%)onwhichthepsychiatrycommentsectionwascompleted.

Fornoneofthechemicalrestraintsused(0%),wasthereadescriptionofthebehaviorsandpriorstepstakenbytheIDT/psychologist.

Foroneoftheninechemicalrestraints,clinicaljustificationwasrecorded. Sideeffectswerementionedinnoneofthereviews(0%). Effectivenesswasdocumentedinnoneofthecases(0%). Informationdiscussingtherisksofdrug‐druginteractions,orotherriskswas

addressedinnone(0%). Thereweretworecommendationsdocumented.

ItisrecommendedthattheStateOfficeprovideguidanceregardingthecontentthatpsychiatristsareexpectedtodocumentontherestraintform.Separately,trendingofchemicalrestraintswasprovidedingraphform.DatabasesofthePsychologyDepartmentandthePharmacyDepartmentwerecomparedmonthlyfromJanuary2012throughMay2012.Thereappearedtobeacontinuedchallengeindatabasemanagement,becausethetwodepartmentshadsomewhatdifferentnumbersofchemicalrestraintsforMarchthroughMay2012.ForthemonthofApril2012,thePharmacyDepartmenthadrecordedonemorechemicalrestraintthanthePsychologyDepartment,andforMarch2012andMay2012,thePharmacyDepartmentrecordedonelesschemicalrestraintthandocumentedinthePsychologyDepartmentdatabase.Thetwodepartmentsareencouragedtocontinuetoresolvediscrepanciesininformationobtainedforchemicalrestraints.Polypharmacy


# Provision AssessmentofStatus ComplianceOfthe28QDRRsreviewed,polypharmacywasnotedin14reviews.

Justificationbydiagnosisofeachofthemedicationslistedinthepolypharmacyregimenwasdocumentedin14of14(100%).

Clinicaljustificationfortheuseofpolypharmacywasaddressedineightof14(57%).Examplesofjustificationcouldincludethefollowing:formultipleseizuremedications,neurologyclinicnoteswithdateofvisitconfirmingthecontinuedneedforthepolypharmacy,orreferencetopolypharmacycommitteeminuteswithaspecificdate,withcommentbythepharmacythattherewassufficientinformationtojustifypolypharmacy(forinstance,apriorreductionhadresultedinincreasedseizures).Suchbriefentrieswouldprovideevidenceforjustification,andindicatethatthepharmacistagreedthattheevidencewassufficientforjustification.

Potentialinteractionswithotherdrugsorfoodwasreviewedineightof14(57%)

Forsevenof14(50%),theQDRRsreviewedwhethermonitoring/evaluationhadoccurredforeffectivenessandappropriatenessofthedrugregimen.

BenzodiazepineUseBenzodiazepineusewasnotedinfourofthe28QDRRs.

Ofthesefour,four(100%)documentedjustificationwithappropriatediagnoses;and

OneQDRR(25%)indicatedwhethersideeffectsorotheradverseriskswerepresent.

AnticholinergicMonitoringOfthe28QDRRs,17(61%)werescreenedformedicationsassociatedwithpotentialsignificantanticholinergicsideeffectsand/orwereidentifiedasanticholinergicmedications.TheresultsofthereviewoftheQDRRsareasfollows:

Tenof17(59%)documentedclinicaljustificationoftheuseofeachofthemedicationscontributingtoanticholinergicload/effect(i.e.,theclinicalburdenofthesideeffectswaslessthanthebenefit).

Fourof17(24%)QDRRslisted/addressedsideeffects/significantrisks.NewGenerationAntipsychoticEndocrineandMetabolicSideEffectsOutofthe28QDRRsreviewed,13(46%)listedatypicalantipsychoticmedication.Ofthese,12of13(92%)includedlabvaluesthatreviewedendocrineandmetabolicrisks(i.e.,basicmetabolicprofile,glucoselevel,HgbA1C,and/orlipidpanelasappropriate).TheFacilityremainedoutofcompliancewiththisprovision.Asnotedabove,improvementwasneededinanumberofareas.


# Provision AssessmentofStatus ComplianceN4 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithin18months,treatingmedicalpractitionersshallconsiderthepharmacist’srecommendationsand,foranyrecommendationsnotfollowed,documentintheindividual’smedicalrecordaclinicaljustificationwhytherecommendationisnotfollowed.

ThePharmacyDepartmentcreatedadatabasetomonitortimelyresponsebyPCPsandpsychiatrytotheQDRRrecommendations.ThePresentationBookforSectionNincludedcopiesoftherawdata,buttheinformationwasdifficulttointerpret.SeveralpageswerehandwrittennotesfromthePharmacy.ThePharmacyisencouragedtoformalizethisdatabaseandprovidequarterlyanalysisthatcanbeusedtotrackprogressandidentifyopportunitiesforfurtherimprovement.Reviewof28QDRRsshowedthefollowing:

Ofthe28,28QDRRs(100%)hadthePCPsignature. Ofthe28,28(100%)hadthedatethePCPreviewedthedocument. Therewere35recommendationsfromthe28QDRRs. For10oftheseQDRRs,therewerenocomments/recommendationsthatneeded

furtheraction.Therewere25recommendationsthatneededfurtheraction. EvidenceofPCPreviewofrecommendationsandagreementordisagreement

withjustificationandplanwasdocumentedin21outof25(84%).o TherewasdisagreementbythePCPforfiveQDRRsofthe25.Forfiveof

five(100%),anoteofjustificationandplan(ifindicated)wasrecordedontheQDRR.

o Forfourrecommendations/comments,thePCPdeferredtopsychiatry,o ThePCPrespondedwithin14daysoftheQDRRbeingcompletedby

pharmacyin12ofthe28(43%)QDRRs. PsychiatryreviewedtheQDRRwhentherewaspolypharmacydueto

psychotropicmedication.Apsychiatristreviewed16QDRRsof28QDRRs,andagreementwasdocumentedinsixof16(38%).

Disagreementwithjustificationandplanwasdocumentedinoneoutof16(6%). Norecommendationwasmadeandnoresponsewasdocumentedinthreeof16. ThepsychiatristdeferredtothePCPinsixof16. Therewasnocheckboxofagreementornotforthreeof16. Thepsychiatristrespondedwithin14daysoftheQDRRbeingcompletedby

pharmacyinthreeof16(19%)QDRRs.Todetermineiftherecommendationsthatwereagreeduponwereactuallyactedupon,theFacilitysubmitted10examplesofQDRRrecommendationsforwhichtherewasagreementbythePCPwithsubsequentorders.Thesearelistedaboveinthedocumentsreviewedsection.Inthesampleof10,nine(90%)demonstratedthatthePCP/psychiatristactedupontherecommendationwithanorder.TheFacilitysubmittednineexamplesofQDRRrecommendationsthatwerenotfollowed,whicharelistedinthedocumentsreviewedsection.Inninecases(100%),theresponse/rationalewaswrittenontheQDRR.

Noncompliance


# Provision AssessmentofStatus ComplianceTheFacilityremainedoutofcompliancewithSectionN.4.AdditionalworkwasneededtoensurethatPCPsaswellaspsychiatristscompletedtimelyreviewsofQDRRs.

N5 WithinsixmonthsoftheEffectiveDatehereof,theFacilityshallensurequarterlymonitoring,andmoreoftenasclinicallyindicatedusingavalidatedratinginstrument(suchasMOSESorDISCUS),oftardivedyskinesia.

ThisprovisionoftheSettlementAgreementmandatessystemic,quarterlymonitoringfortheemergenceofmotorsideeffectsrelatedtotheutilizationofantipsychoticmedicationwith,forexample,theDyskinesiaIdentificationSystem:CondensedUserScale,andthemonitoringofmoregeneralsystemicsideeffectsrelatedtopsychotropicmedicationwiththeMonitoringofSideEffectsScaleeverysixmonths.Animportantcomponentofthissideeffectmonitoringalsoincludesthelatencybetweenthetimethatthenursecompletedtheexamandthedocumentationwasreviewedandsignedbytheprescribingphysician.Thereviewofthesampleoftherecordsof20individualsprescribedpsychotropicmedicationindicatedthatthedocumentationthattheMOSESevaluationwascurrent(completedwithinthelastsixmonths)andhadbeenperformedatleasteverysixmonths,waspresentforalloftheindividualsinthissample(100%).Therecordsofthe20individualsinthesamplecontaineddocumentationthattheprescribingphysicianhadreviewedtheMOSESevaluationinatimelymannerfor18ofthe20individuals(90%).ThetwoindividualsforwhomthedocumentationofthereviewwasinadequatewereIndividual#40(missingsecondpagewithphysiciansignaturefor4/12/12evaluation),andIndividual#359(missingsecondpagewithphysiciansignaturefor3/26/12).Thus,therewasinsufficientdocumentationtoconfirmthattheMOSESevaluationswerereviewedinatimelymannerforthesetwoindividuals.ThepurposeoftheDISCUSwastodetecttheemergenceofmotorsideeffectsrelatedtotheuseofantipsychoticmedication.Thereviewoftherecordsofthesampleof20individualsindicatedthattheDISCUShadbeencompletedasspecifiedforalloftheseindividuals(100%).ThoseindividualswhoserecordsshowedasignificantdelaybetweenthedatethenursecompletedtheDISCUSevaluation,andtheprescribingphysicianreviewedandsigneditwereasfollows:Individual#279(5/11/11),nophysician’ssignature);andIndividual#359(3/26/12),alsomissingphysician’ssignature.Thus,theseevaluationshadbeenreviewedandsignedinatimelymannerfortheremaining18individuals(90%).Theseresultsindicatedsignificantprogress,ascomparedtopriorreviews.ThedatetheMOSESandDISCUSevaluationswereperformedwasrecordedinthePsychiatricQuarterlyReviewdocumentation,includingtheresultsforeachadministrationandwhetherornotanyadditionalactionwasrequired.Thepresenceofanysignificantsideeffects,aswellasanyactionrequired,wouldbediscussedinthesectionofthisdocumentthatrepresentedthePsychiatrist’snarrativesummary.Each



# Provision AssessmentofStatus ComplianceQuarterlyReviewdocumentcontainedthehistoricalinformationfortheprioryearandwascontinuouslyupdated.TheDISCUSandMOSESalsoarenecessarytomonitorforthesideeffectsofReglan,whichalthoughprescribedforgastroesophagealrefluxdisease(GERD),haspharmacologicalpropertiesthataresimilartothoseofantipsychoticagents.OneofthePsychiatricNursesperformedtheDISCUSforthoseindividualswhowerereceivingantipsychoticmedication.Thus,aPsychiatricNursewouldmonitoranindividualforsideeffectsiftheywerereceivingReglan,aswellasanantipsychoticmedication.Accordingly,alistwasobtainedfromthePharmacyofallindividualsreceivingReglantodevelopthesampleforthisanalysis.Thislistwasthencross‐referencedwiththeFacility‐widelistofindividualsreceivingpsychotropicmedicationinanefforttogeneratealistofindividualsreceivingReglan,butnotalsoprescribedpsychotropicmedication.Therationaleforthisdistinctionwasthatthenursesontheindividuals’residentialunitsadministertheevaluationsfortheseindividuals,ratherthanthePsychiatricNurses.Thisprocessindicatedthat,asof7/10/12,14individualswerereceivingReglan,butwerenotprescribedmedicationforapsychiatricdisorder.Thefollowingsampleoffiveindividuals(36%)whofittheabovecriteriawasselected,including:Individual#43,Individual#205,Individual#252,Individual#113,andIndividual#239.ThereviewoftherecordsrelatedtotheMOSESevaluationsindicatedthattheexaminationhadbeenperformedeverysixmonthsasrequiredforalloftheindividualsinthissample(100%).AlloftheseMOSESevaluationshadbeenreviewedandsignedbytheprescribingphysicianinatimelymanner.ThesamesampleofindividualsreceivingReglanwasusedtoevaluatethecompletionoftheDISCUS.TheresultsofthisreviewindicatedthattheDISCUSevaluationswerecompletedeverythreemonthsasrequiredforallofthefiveindividuals(100%).Thedocumentationindicatedthattheprescribingphysicianhadreviewedfourofthefiveevaluationsinatimelymanner(80%).TheresultsforIndividual#239indicatedthatthe3/7/12DISCUShadnotbeenreviewedandsignedbytheprescribingphysicianuntil3/20/12.Duringtheonsitereview,amemberoftheMonitoringTeamalsoinquiredaboutthedegreeoftrainingthattheUnitNursesreceivewithregardtoperformingtheDISCUSevaluation.ThePsychiatryTeamindicatedthatallofthenursesreceivebothinitialtraining,aswellasannualupdates.Thistrainingwasquiteextensiveandincludedboththereviewofavideotape,aswellasarequiredpost‐trainingcompetencytesttoassessforskillacquisition.TheFacility’sPsychiatryNursesweretheinstructorsforthetraining.Inordertoverifythatthetrainingwastakingplace,theattendancefortheprioryearwasreviewed.ThePsychiatricNursesalsosuppliedtheresultsofpost‐trainingtest


# Provision AssessmentofStatus ComplianceandtheDISCUSevaluationstheNursesconductedafterviewingthevideotapestoillustratetheywereabletoutilizethecorrectmethodsforperformingtheevaluations.Thecontentofthetrainingmaterials,thedocumentationofattendance,andtheproductionofthetestingmaterials/resultsindicatedthattheUnitNurseswerereceivingadequatetrainingonhowtocompetentlycompletetheDISCUSevaluationsforthoseindividualsprescribedReglan.TheMOSESevaluationmaterialhaddetailedinstructionsonhowtoconducttheevaluationembeddedintotheactualtestingmaterial.Thisevaluationwasdesignedtobecompletedbyindividualswithanursingdegree.ThefindingofsubstantialcomplianceforthisprovisionisbasedonthecontinuedhighratesofcompletionoftheMOSESandDISCUSevaluations,andthesubstantialimprovementsintheprescribingphysicians’timelyreviewoftheseevaluations.

N6 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,theFacilityshallensurethetimelyidentification,reporting,andfollowupremedialactionregardingallsignificantorunexpectedadversedrugreactions.

ThePharmacyDepartmentsubmittedpolicyN.6.AdverseDrugReactionPolicy(developed11/12/10,approved4/6/11,implemented5/1/11).ItincludedaPowerPointpresentationforADRs.Thepolicyalsoincludedan“Adversedrugreactionreportingform,”andan“allergy/ADRreportingformforindividualsdischargedfromthehospital.”Additionally,signagewascreatedinbrightcolorsthatprovidedadescriptionofcommonmedicationsideeffectsandadversedrugreactionswithguidancetonotifyanurseimmediatelyshouldstaffobserve/identifythesesigns/symptoms.AccordingtotheActionPlan,facility‐widetrainingonADRswastobecompletedby9/1/12.Trainingdocumentsweresubmittedforthefollowingdates:4/11/12‐10staff,4/12/12‐11staff,andanundatedroster–45staff.ThePharmacyDepartmentwillneedtocollaboratewiththeemployeetrainingdepartmenttoensurealldirectsupportprofessionalsaretrainedanddemonstratethatnewemployeesaretrainedaswellascurrentemployees.ThenumberofADRsreportedinthepriorsixmonthswaszero.ThenumberofADRreportsthatwerecompletedandawaitingP&TCommitteereviewwerezero.ThenumberofADRreportsthatwerediscussedattheP&TCommitteewaszero.ThislackofanyADRsmightindicatetheneedformoretrainingofdirectsupportprofessionalsandnursesaswellasotherdepartments,suchashabilitationservices.

Noncompliance

N7 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithin18months,theFacilityshallensuretheperformanceofregulardrug

Forthecalendaryear2012,informationwassubmittedthatdocumentedthemedicationstobeincludedindrugutilizationreviews.Theseincluded:firstquarter2012–Benzodiazepines,presented4/2/12;secondquarter2012–Keppra,scheduledtobepresented7/9/12;thirdquarter2012‐Latuda,tobepresentedOctober2012;andfourthquarter2012–VitaminD,tobepresentedJanuary2013.



# Provision AssessmentofStatus Complianceutilizationevaluationsinaccordancewithcurrent,generallyacceptedprofessionalstandardsofcare.ThePartiesshalljointlyidentifytheapplicablestandardstobeusedbytheMonitorinassessingcompliancewithcurrent,generallyacceptedprofessionalstandardsofcarewithregardtothisprovisioninaseparatemonitoringplan.

Duringthepriorsixmonths,twoDUEstudieswerecompleted: OneDUEfocusedonbenzodiazepineuse.Thisincludedallmedicationsinthat

drugclass.Specificallytrackedwerethenameofthemedication,thedrugdosage,theindication,andthedurationofuse.Byrandomsample,33activerecordswerereviewed.Resultsindicatedthatforfiveofthecases,theindicationneededtobereviewed.Thirtypercentoftheindividualshadbeenonabenzodiazepineforgreaterthanfiveyears.Thisreviewwaspresentedatthe4/2/12P&Tmeeting.Asaresult,thePCPsrequestedalistofindividualsneedingdiagnosesreviewedforuseofbenzodiazepine.ThePharmacyDirectorprovidedfurtherfollow‐up.Ofthefivecasesinwhichtheindicationneededtobereviewed,threewerediscontinued,onewasonataperwithplansforeventualdiscontinuation,andonewasbeingreviewedbythepsychiatristforindications.

Therewasalsoafollow‐upDUEatthe4/2/12P&Tmeeting,inwhichReclastwasthefocus.ThisinitialDUEwaspresentedattheP&TCommitteeinJune2011.RecommendationsfromthattimeincludeduseofTylenolattimeofinfusionandeverysixhoursfor24hourstominimizeflulikesymptoms,administrationofadequatecalcium,andadministrationofadequateVitaminD.Asafollow‐up,allthoseadministeredReclastfrom7/1/11through3/29/12werereviewed,whichincluded22individuals,butthecomputerrecordwasnotavailableforoneastheindividualwasnolongeratCCSSLC,leavingapopulationof21individualsforreview.ItwasfoundthatTylenolwasorderedforallcases,which“virtuallyeliminated100%ofpotentialflulikesymptoms.”All21hadadequatecalciumsupplementorhadmedicalreasonsforareductionindosage.VitaminDadministrationwasalsoreviewed,withadministrationofVitaminDandmonitoringofVitaminDlevels.NinetypercenthadtherapeuticVitaminDlevels,andthetwowithlowVitaminDlevelshadfeedingtubesandhadadjustmentsindosages.Thefollow‐upoftheinitialDUEappearedtoshowpositiveclinicalimpact.Atthisfollow‐updiscussion,theclinicalpharmacistalsosuggestedthatReclastinfusionbeprecededbydocumentationofarecentGlomerularFiltrationRate(GFR)value.TheCommitteedecidedtorequirethataGFRbeobtainedwithinthemonthpriortoadministrationofthismedication.

Atthe7/9/12P&TCommitteemeeting,follow‐upoftheReclastDUEwasfurtherdiscussedforclarification.ItwasclarifiedthatthePCPswouldorderaBloodUreaNitrogen(BUN)andcreatininewithinthemonthpriortotheadministrationofReclast,andthatthePharmacyDepartmentwouldcalculatetheGFR.

Alsoatthe7/9/12P&TCommitteemeeting,therewasafollow‐upDUEforReglan.On12/30/11,therewere20individualsonReglaneitherintermittentlyorforaperiodgreaterthan60months.FromJanuary2012throughJune2012,


# Provision AssessmentofStatus Complianceforsixindividuals,Reglanwasdiscontinued.

Atthe7/9/12P&TCommitteemeeting,aDUEonKepprawaspresented.Asampleof32individualswasreviewedretrospectively.ThefocuswasthereviewoftheeffectonCBCs.ConclusionwasthatKeppradoesaffecttheneutrophilcount.Theresponsewasnotconstantinthatthevaluefluctuatedduringtherapyandoftenreturnedtonormal.TheresponseofthebonemarrowtoKeppraappearedtonotbedoserelated,butthedurationoftherapymightplayaroleintheeffectonformationofbloodcomponents.

TheDUEprogramwasstrong.Thefollow‐upreviewsindicatedapositiveimpactonthepracticepatternsofthePCPsandonthequalityofcareoftheindividuals.TheFacilitywasfoundtobeincompliancewiththisprovision.

N8 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinoneyear,theFacilityshallensuretheregulardocumentation,reporting,dataanalyses,andfollowupremedialactionregardingactualandpotentialmedicationvariances.

PharmacyReviewofCategorizationofErrorsThePharmacyDepartmentwasnotactiveinverifyingthattheNursingDepartment’scategorizationofmedicationerrorswasconsistentwiththePharmacy’sinterpretationofthemedicationerrorcategorization.Therewasnosubmissionofanyinformationconcerningrandomsamplingofcompletedmedicationerrorformsthatwerereviewedbypharmacytoensurethecategorizationoferrorwasaccurate.CommitteeMonitoringofMedicationErrors/VariancesThedevelopment,progress,andtrackingofamedicationerrorprocessandtrendanalysiswerereflectedintheminutesoftheMedicationErrorCommitteemeetings,whichtheclinicalpharmacistchaired.Thefollowingdescribessomeofthefindingsofthiscommittee:

TheminutesoftheMedicationCommitteeweresubmittedfor12/19/11,1/5/12,2/21/12,3/28/12,4/16/12,and5/30/12.Fromtheminutes,themedicationerrorscategorizedastrueerrorswereasfollows:October2011‐11,November2011‐five,December2011–three,January2012‐two,February2012‐eight,March2012‐44,andApril2012–three.Additionally,theP&TCommitteeof7/9/12documentedthattherewerefivetrueerrorsinMay2012.FromtheMedicationCommitteeminutes,themedicationerrorscategorizedasomissionswereasfollows:October2011–200,November2011‐148,December2011–215,January2012‐327,February2012‐190,March2012‐334,andApril2012‐220.TheP&TCommitteemeetingof7/9/12documentedthatforMay2012,theomissionstotaled129.

The12/19/11MedicationCommitteeminutesdocumentedadiscrepancyinthenumberoftrueerrorsbetweentheNursingDepartmentandPharmacyDepartment(nursingdocumentedsevenerrorsinOctober2011andpharmacydocumented11errorsinOctober2011).Therewasthebeliefthatlate

Noncompliance


# Provision AssessmentofStatus Compliancemedicationpasseswereunderreportedasmedicationvariances.Atotalof29medicationpassassessmentswerecompleted,and41%didnotneedprompting.Additionalconcernsincludedinstructingthedirectsupportprofessionalstokeepindividualsupright,andfollowingthePNMP.

The1/5/12MedicationCommitteeminutesdocumentedthatthereasonforthedocumentationerrorswasassignmentofanursetoanunfamiliarareaortheassignmentofcoveringanadditionalarea.Asthisadministrativeassignmentofnursesoccurredthreemonthsprior,thisreasonwasnotconsideredvalid,becausethenurseswouldhavehadthreemonthstogettoknowtheindividuals.ItwasalsonotedthattheNursingDepartmentandthePharmacyDepartmentcountedomissionsdifferently.TheNursingDepartmentcountedeachblankseparately.ThePharmacyDepartmentcountedtheevent/incidentastheomissionerror,whichmighthavemorethanonetypeofmedicationtobeadministeredatatime.Atotalof23medicationpassassessmentswerecompleted,and70%didnotneedprompting.AdditionalconcernsthatwerenotedincludedfollowingthePNMP,instructingdirectsupportprofessionalstokeepindividualupright,anddocumentingthatmedicationsweregiven.Itwasnotedthatnurseeducatorscontinuedtodospotchecks,andprovidedonsiteeducationandtrainingwhenconcernswereobserved.Itisrecommendedthatthepharmacysummarizeinformationandincludetotalspermonthofthenumberofdoseswhichweremedicationerrors(blanksontheMAR),aswellasseparatelythenumberofincidentssothatthereisnotmisinterpretationofinformation.

The2/21/12MedicationCommitteeminutesdocumentedthetwotrueerrorsinJanuary2012wereadministrationatthewrongtime.Therewasneedforincreasedcoordinationbetweenthenurseanddirectsupportprofessionals,becausetheindividualswerenotreadytoreceivetheirmedication.Itwasbelievedthiswasself‐correcting,becausethedirectsupportprofessionals’rolewouldbeimportantingettingtheindividualstothemedicationpassinatimelymanner.Anerroroccurredon2/5/12inwhichmedicationwasgiventothewrongperson.ItwasdeterminedtherewasalsoaneedforupdatingthephotosoftheindividualsforplacementontheMAR,andthattheyshouldbeincoloronwhitecardstock.ItwasnotedthatthePNMPscontinuedtonotbefollowed.

The3/28/12MedicationCommitteeminutesdocumentedthatmedicationpassassessmentsdidnotneedpromptingin83%ofcases.Itwasnotedthatdirectsupportprofessionalswerenotalwayspresentduringmedicationadministration,andthereappearedtobesomelackofcooperation.

The4/16/12MedicationCommitteeminutesdocumentedthattherewereanumberofmedicationerrorsinvolvingCalcitonin.ThiswascorrectedinthePharmacybycreatingalogtotrackdispensingofthismedication.Atotalof13


# Provision AssessmentofStatus Compliancemedicationpassassessmentswerecompleted,withallneedingprompting.Forimprovedaccountabilityofomissionsanderrors,andtodeterminereasonforoverages(returnedmedication),thepharmacywastocheckthecartexchangesonaweeklybasisandforwardinformationtotheNursingDepartmenttoreconcileandenterintothemedicationvariancedatabase.

The5/30/12MedicationCommitteeminutesdocumentedthatforall20medicationpassassessments,promptingwasneeded.

Attheendofeachofthemeetingminutesatablewasincludedoutliningactionsteps,evidence,staffresponsible,targetdate,etc.Thismethodensuredmanyconcernsweretrackedbasedonthediscussionintheminutes.Someareaswerefurtherdiscussedintheminutes,suchasthefindingsofthemedicationpassassessments.Theconcernofreconciliationofomissionswithoveragesbypharmacywaslesswelldocumentedintheminutes,andonlybrieflyintheactionsteps.Thiswouldbenefitfromprogressupdates,includingdescriptionsofsystemprotocolsthatwereimplemented,orfindingsbasedonthepharmacyweeklyreviewofcartexchanges.Amonthly/quarterlysummary/analysisofprogresstowardreconcilingoverageswouldbebeneficial,alongwithcorrectiveactionstakenbythePharmacybasedonthedata.ItisrecommendedthatthisbeapriorityareaforthePharmacyDepartment.

MedicationErrorReportsCopiesofthelast10medicationerrorsformscompletedweresubmittedforreview.TherewerenoClassAmedicationerrors,threeClassBmedicationerrors,fiveClassCmedicationerrors,andtwoClassDmedicationerrors.Follow‐upoftheerrorswasdocumentedinnineof10errors.However,threeofthefollow‐upsprovidedinformationconcerninghowthemedicationerroroccurred,butdidnotprovidenextstepsoraproceduretopreventarecurrenceofthemedicationerror.NursingandPharmacywereeachresponsibleforfiveofthe10medicationvariances.Thenodeofvarianceincludedseveralcategories:transcription,administration,dispensing,anddocumentation.Onemedicationerrorincludedthreenodesofvariance.Itwasnotedthatoneerrorrepresented20misseddosesofmedication.Anothererrorinvolvedthediscoveryofamedicationnotrefilledfor37individualsoverthepriortwoyears.ThelattererrorgeneratedacorrectiveactionplanfromthePharmacyDepartment.Asystemicapproachfollowed,withimprovedmonitoringinthePharmacywhenrenewalsofthespecificlong‐termmedicationarerequested.Thiscouldtheoreticallypreventarecurrenceoftheerror.MedicationObservationMonitoringMonthlymedicationpassassessmentswerediscussedattheMedicationCommittee


# Provision AssessmentofStatus Compliancemeeting,andlistedthenumberofassessmentsforthemonthandthenumberofthoseinwhichpromptswereneeded.Themonitoringtoolusedwasa61‐pointlist.Thepharmacyprovideda“summaryobservedmedicationpasses–2012forFebruarythroughMay.”Forthemostrecentmonth,areasthatremainedachallengeincludedthefollowingareas:“DoesthenurserefertothecurrentPNMPpriortobeginningadministrationofmedications?”Compliancewas68%.“Pillcrusheriscleanedpermedicationadministrationpolicy.”Compliancewas64%.“MastersignaturelistinitialsmatchtheinitialsontheMAR.”Compliancewas59%.“DSPinstructedperPNMP.”Compliancewas82%.“NurseidentifiesthatspecificassistiveandpositioningequipmentispresentandbeingutilizedaccordingtothePNMP.”Compliancewas82%.“Privacywasaffordedduringmedicationpass.”Compliancewas86%.Interventions/stepstakenbythePharmacytoreducethenumbersofmedicationerrorsincludedthefollowing:

ForerrorsoriginatinginthePharmacyDepartment:o On2/15/12,a“ProtocolforMedicationCartExchange”was

implementedtoensurethePharmacyprovidedthecorrectmedicationandthecorrectcountforeachmedication.Thereceivingnursewastocompletethe“FillList”thepharmacysystemprovided,andthisdocumentwastobereturnedtothepharmacywithin24hours.Detailedinstructionswereprovidedfordiscrepanciesfound.TheFacilitysubmittedadocumententitled:“MedicationCartExchange”listingdates2/12/12through2/17/12,2/23/12,2/29/12,3/7/12,and3/9/12.Itappearedtobeatrainingrosterinwhich99of103nursesweretrainedonthisnewprocess.

ForerrorsoriginatingintheNursingDepartment:o Aspartofthe“ProtocolforMedicationCartExchange,”detailed

instructionsalsowereprovidedfordocumentationoffurloughmedicationreturned,andshortageofmedicationduetowaste,spilling,etc.Whenamedicationwasnotadministered,thenursewastoremovethemedicationfromtheindividual’sdrawerandstoreitseparatelyinalockedbox,withthereasonforthemissedmedication.Theseinstructionsprovidedasystemtodocumentthereasonforshortagesandoveragesofmedication,inanattempttoreducemedicationvariancesacrossthecampus.

o ThepharmacyalsoincludedinstructionsontheMARwhenmedicationsneededtobecrushed,accordingtothe“AdaptiveDiningTexturesReport,”whichincluded125individuals.Additionally,thephysicianorderform(theStateformPOR‐MR‐31)includedastatement:“PharmacyAlert:Pleaseensuremedicationsaredispensedinaform


# Provision AssessmentofStatus Compliancethatallowsforadministrationinaccordancewithtextureorliquidconsistencyrequirements.”

o Pharmacycollaboratedwithnursingindevelopingthecorrectthickeningofliquidsforadministrationofmedicationinthoseneedingthickenedliquids.Therewasdiscussionalsowithnursingconcerningthemedicationsthatshouldbecrushed.Thepharmacywastodeterminewhichmedicationsshouldnotbecrushed,accordingtominutesofameetingentitled:“ThickeningLiquidMedication–Minutes/Notes4/27/12.”TheplanwasfortheNursing,Pharmacy,andMedicalDepartmentstocollaborateindeterminingthebest/safestformofmedicationsfortheindividuals.

Therewasnoinformationconcerningreturnedmedicationsthatwerenotconsideredomissions.Thisaspectofmonitoring(unexplainedreturnedmedications)wasinthedevelopmentstage.TheFacilitysubmittedachartentitled“MedicationErrors12monthsummary,”whichappearedtoprovidethe“true”errorrateaccordingtohome,category,andtypeorerror.ThereweresomediscrepanciesinthemonthlytotalsandthenumbersprovidedintheMedicationCommittee.Itisrecommendedthatthesedifferencesbereviewedtodeterminethereason,andprovidecorrectiveactiontoensurethedifferentdatabasesanddatasourceshavethesameinformation.Overall,therewerethreequartersoffiscalyear2012available.Forthe1stQuarter(September2011throughNovember2011),therewere17reportedtrueerrors.Forthe2ndquarter(December2011throughFebruary2012),thereweresevenerrors.Forthe3rdquarter(March2012throughMay2012),therewere46errors.Forthecategoryoferror,therewerethreeClassAerrors,42ClassBerrors,20ClassCerrors,fiveClassDerrors,andoneClassEerror.Theerrorswerealsoreviewedaccordingtotypeoferror.Twowerethewrongmedication,eightwerethewrongdose,43wereconsideredtrueomissions,twowerethewrongpatient,and15werethewrongtime.TheFacilityalsosubmittedachartwiththesametitleasthechartdiscussedinthepriorparagraph:“MedicationErrors12monthsummary,”butthisappearedtoreflecttheadministrativeerrorofincompleteMARdocumentation.Forthethreequartersofthecurrentfiscalyear,therewereatotalof1929omissionsreportedinonesectionofthetable,2000errorsreportedinanotherpartofthetable,and2020errorsinathirdareaofthetable.ThePharmacyDepartmentshouldreviewinformationpriortosubmissiontoensureconsistencyacrossthetablesandchartssubmitted.TheseerrorsappearedtobealladministrativeerrorsinwhichtheMARwasnotcompleted,butthemedicationwaspresumedadministered.However,noinformationwassubmittedthatexplainedhow


# Provision AssessmentofStatus CompliancethePharmacyDepartmentcametothatconclusion.Thereremainednoinformationconcerningreturnedmedicationsandthereasonsforthese.FromSeptember2011throughMay2012,thereappearedtobenotrend,andnoimprovementinadministrativeomissions(categorizedasClassA).TheFacilityremainedoutofcompliancewiththisprovision.Althoughsomeactivitieshadoccurredtocorrectsomeoftheareasinneedofimprovement,theFacilitydidnotyethaveasystemtoaccuratelyidentifythefullscopeofmedicationsvariances,analyzetheinformation,anddevelopappropriateactionstocorrectdeficiencies.


1. Theprocessandcriteriaforchoosingthecategoryforthepatientinterventionshouldbereviewedandrevisedasneededtoreducevariabilityininterpretationbypharmacistsandnarrowtheselectionifapplicable.(SectionN.1)

2. The“druginteractionalerts”logshouldbeusedasaQAreviewforthePCPs.(SectionN.1)3. ThePharmacyDepartmentshouldreviewdatasubmittedtotheMonitoringTeamtoensurecompletenessandaccuracypriortosigningoffon

thecompletedrequest.(SectionsN.1andN.2)4. Forthepharmacyrecommendationsectionofthechemicalrestraintform,thedosageandrouteofmedicationshouldbeclearlyindicatedon

theseforms.(SectionN.3)5. TheStateOfficeshouldprovideguidanceregardingtheexpectationsforpsychiatristsregardingtheircontributiontothecontentofthe

chemicalrestraintform.(SectionN.3)6. ThePharmacyDepartmentshouldcollaboratewiththePsychologyDepartmentinreducingthetimefromtheuseofthechemicalrestraintto

reviewbypharmacy.(SectionN.3)7. ThePharmacyandPsychologyDepartmentsshouldresolvediscrepanciesininformationobtainedforchemicalrestraints.(SectionN.3)8. ThePharmacyDepartmentshouldcontinuetotrackthereviewoftheQDRRbythePCP,andprovideperiodicsummaryoftheresultstothe

medicalstaff.Thisshouldincludetrackingtimelinessofreview.(SectionN.4)9. ThePharmacyDepartmentshouldcollaboratewiththeTrainingDepartmenttoensurealldirectsupportprofessionalsaretrainedontheADR

identificationandreportingsystem,includingallnewemployeesaswellascurrentemployees.(SectionN.6)10. Allofthedepartmentsinvolvedinthemedicationorderingandadministrationprocessshouldworkcloselyinprovidinginformationrelatedto

medicationvariances,andcooperateininvestigatingmedicationerrors.(SectionN.8)11. ThePharmacyDepartmentshouldsamplethemedicationerrorsandindependentlycategorizetheerrorstodetermineagreementornon‐

agreementwiththenursescompletingtheforms.(SectionN.8)12. ThePharmacyDepartmentshouldsummarizeinformationformedicationerrorsandincludetotalspermonthofthenumberofdosesforwhich

thereweremedicationerrors(blanksontheMAR,forexample),aswellasseparately,thenumberofincidents.Aquarterlyreportshouldbegeneratedthattrackserrorsfromalldepartments(i.e.,pharmacy,nursing,medical).(SectionN.8)

13. Thereappearedtobedifferentdatabaseswithdifferentstatisticsformedicationerrors.Thesedifferencesshouldbereviewedtodeterminethereason,andprovidecorrectiveactiontoensurethedifferentdatabasesanddatasourceshavethesameinformation.(SectionN.8)

14. Trackshouldoccurofunexplainedreturnedmedications,thedateofreturn,theresidence,andthereasonforthereturn.(SectionN.8)15. TheQADepartmentshouldreviewadditionalrecordsinconjunctionwiththePharmacyDepartmenttoestablishinter‐raterreliability.This

shouldincludecontinuedreviewofthetoolwithdevelopmentofguidelinesorinstructions,aswellasthetrainingforthoseresponsiblefor


implementingthepharmacymonitoringtooluntilresultsareconsistentlyreplicated.Thepharmacyshouldalsodeterminethesamplingmethodandsamplesizetobereviewedeachmonth.(FacilitySelf‐Assessment)

16. Theinternalpharmacyreviewtoolshouldincorporateevidenceofverification/sourceoftheinformationforjustification,reviewofsideeffects,etc.(FacilitySelf‐Assessment)


SECTIONO:MinimumCommonElementsofPhysicalandNutritionalManagement StepsTakentoAssessCompliance: Thefollowingactivitiesoccurredtoassesscompliance:

ReviewofFollowingDocuments:o PresentationBookforSectionO;o Thefollowingdocumentsfor11individualsinSample#1thatincludedindividuals

identifiedwithPNMconcerns;whohadreceivedenteralnourishment;and/orhadexperiencedachangeofstatusasevidencedbyadmissiontotheFacilityInfirmary,emergencyroom(ER),and/orhospital,includingIndividual#340,Individual#274,Individual#68,Individual#126,Individual#124,Individual#142,Individual#266,Individual#122,Individual#269,Individual#273,andIndividual#176:OccupationalTherapy/PhysicalTherapy(OT/PT)comprehensiveassessment,assessmentofstatus,updateinindividualrecord,Nutritionassessments,AspirationPneumonia/EnteralNutrition(APEN)assessment,SpeechLanguagePathology(SLP)comprehensiveassessment,assessmentofstatus,updateinindividualrecord,HeadofBedElevation(HOBE)assessment,annualIndividualSupportPlanandIndividualSupportPlanAddendums(ISPAs)forpastyear,IntegratedRiskActionform,InterdisciplinaryTeamRiskActionPlan/IntegratedCarePlan,IntegratedProgressNotesforpastsixmonths,OT/PT/SLP/RegisteredDietician(RD)consultationsforpastyear,AspirationTriggerSheetsforpastsixmonths,PhysicalNutritionalManagementPlan(PNMP)anddiningplanswithsupportingwrittenandpictorialinstructions,forindividualshospitalizedwithinthissampletheHospitalLiaisonNursereportsacrossthepastsixmonths,therapeutic/pleasurefeedingplan,individual‐specificmonitoringforthepastsixmonths,PNMTPostHospitalizationassessment,documentationofstaffsuccessfullycompletingPhysicalNutritionalManagement(PNM)foundationaltraining,documentationofstaffsuccessfullycompletingindividual‐specifictraining,supportingdocumentationtosubstantiateanindividual’sprogresswithPNMdifficulties,incidentreportsandFacilityinvestigationsforchokingincidents,PNMPClinicminutes,monthlyreviewofOT/PTdirectintervention,quarterlyreviewofOT/PTprograms,supportingdocumentationforimplementationofOT/PTdirectinterventions,andsupportingdocumentationforimplementationofOT/PTprograms;

o ThefollowingdocumentsforsevenindividualsonthecurrentPhysicalandNutritionalManagementTeam(PNMT)caseloadwhowereassessedorreviewedinthelastsixmonths,includingIndividual#278,Individual#144,Individual#89,Individual#43,Individual#117,Individual#239,andIndividual#378,andthreeindividualswhohadbeendischargedfromthePNMTinthepastsixmonths,includingIndividual#86,Individual#113,andIndividual#10:PNMTassessment,PNMTactionplanandsupportingdocumentation,HeadofBedElevationassessment,AspirationPneumonia/EnteralNutritionassessment,annualIndividualSupportPlanandIndividualSupportPlanAddendumsforpastyear,IntegratedRiskRatingformpriortoreferraltoPNMT,


IntegratedRiskActionformcompletedbyPNMTandIDTuponreferral,IntegratedProgressNotesforpastsixmonths,AspirationTriggerSheetsforpastsixmonths,PhysicalNutritionalManagementPlananddiningplanswithsupportingwrittenandpictorialinstructions,forindividualshospitalizedwithinthissampletheHospitalLiaisonNursereportsacrossthepastsixmonths,therapeutic/pleasurefeedingplan,individual‐specificmonitoringforthepastsixmonths,PNMTPostHospitalizationassessment,NursingCarePlan/IntegratedCarePlan,documentationofstaffsuccessfullycompletingPhysicalNutritionalManagementfoundationaltraining,documentationofstaffsuccessfullycompletingindividual‐specifictraining,supportingdocumentationtosubstantiateanindividual’sprogressrelatedtoPNMdifficulties,andPNMTDischargeandsupportingdocumentation;

o ListofPhysicalandNutritionalManagementTeammembersandcurriculumvita,revised5/18/12;

o ListofallindividualsseenbythePNMTandcorrespondingcaseload,dated6/4/12;o ListofallindividualsassessedbythePNMTandthedateofassessment,from1/12

through4/12;o ListofallindividualsdischargedbythePMNT,from12/11through5/12;o PhysicalNutritionalManagementPolicyandProcedure,revised5/25/12;o ListofcontinuingeducationsessionsparticipatedinbyPNMTmembers,from1/12

through5/12;o Agenda,curriculum,attendancerosters,andcertificatesofcompletionforPNMTstaff,

from2/12through6/12;o MinutesanddocumentationofattendanceforPNMTmeetings,from1/12through5/12;o ListofchangesinPNMTevaluationforms,dated5/12;o PolicyandproceduresaddressingidentificationofPNMhealthrisklevels,including

criteriaforestablishmentofrisklevels,dated5/24/12and5/25/12;o ListofindividualswithPNMneeds,dated5/22/12;o ListofindividualswithoutPNMneeds,undated;o Wheelchair/Mobility/AssistiveEquipmentWorkOrders,from4/12through5/12;o CompletedPNMPsandDiningPlans,from10/11through5/12;o ListoftoolsPNMPCoordinatorsusetomonitorstaffcompliance,revised2/15/12;o ListofindividualsforwhomPNMmonitoringtoolswerecompletedduringlastquarter,

from3/12through5/12;o ToolsutilizedforvalidationofstaffresponsibleforPNMmonitoring,revised5/3/12;o Inter‐RaterReliabilityScores,from2/12through4/12;o DiningPlan(template)withchanges,undated;o PNMandPNMTrelateddatabasereports,andspreadsheetsgeneratedbyFacilityduring

pastsixmonths,dated5/22/12;o Listofindividualsonmodified/thickenedliquids,dated5/30/12;o Listofindividualswhorequiremealtimeassistance,dated5/30/12;o Listofindividualswhoreceivenutritionthroughnon‐oralmethods,dated5/22/12;o Listofindividualswhosedietshavebeendowngradedorchangedtoamodifiedtextureor


consistency,from3/12through5/12;o ListofindividualswithBodyMassIndex(BMI)equaltoorgreaterthan30,dated5/12;o ListofindividualswithBMIequaltoorlessthan20,dated5/12;o Listofindividualswhohavehadanunplannedweightlossof10%orgreateroverasix

monthsperiod,from12/11through5/12;o Listofindividualswhohavehadachokingincidentduringthepastsixmonths,dated

6/3/12;o Listofindividualswhohavehadanaspirationand/orpneumoniaincidentduringpastsix

months,dated6/1/12;o Listofindividualswhohavehadafallduringthepastsixmonths,dated6/4/12o Listofindividualswhohavehadadecubitus/pressureulcerduringthepastsixmonths,

from9/11through2/12;o Listofindividualswhohaveexperiencedafractureduringthepastsixmonths,dated

6/3/12;o Listofindividualswhohavehadafecalimpactionduringthepastsixmonths,undated;o Listofindividualswhoarenon‐ambulatoryorrequireassistedambulation,dated6/1/12;o Listofindividualswithpoororalhygiene,dated6/5/12;o Listofindividualswhoreceivedafeedingtubesincethelastreview,dated6/6/12;o Listofindividualswhoareatriskofreceivingafeedingtube,undated;o ListofindividualswhohavereceivedaModifiedBariumSwallowStudy(MBSS)orother

diagnosticswallowingevaluationduringthepastyear,from6/11through5/12;o Scheduleofmealsbyhome,undated;o ScheduleofallPNM‐relatedmeetingsoccurringduringtheweekoftheonsitereview,from

7/9/12through7/13/12;o CurriculaonPNMusedtotrainnewstaffresponsiblefordirectlyassistingindividuals,

variousdatesfrom4/11through10/11;o Agendaandcurriculumforcompetency‐basedannualrefreshertrainingrelatedtoPNM,

variousdatesfrom6/11through11/11;o Inter‐RaterReliabilityScores,from2/12through4/12;o FacilitySelf‐AssessmentandProvisionActioninformation,dated3/12/12,4/7/12,and

5/8/12;o ListofcompletedPNMTNursingPostHospitalizationAssessment/Evaluations,from2/12

through5/12;o ThefollowingdocumentsforIndividuals#117andIndividual#239weresubmittedprior

totheon‐sitereview:PNMTMinutes,PNMTAssessments,IntegratedRiskRatingforms,APENAssessments,HOBEAssessments,PNMTActionPlans,StaffCompetency‐basedCheck‐offs,PNMTMonitoringForms,individualPNMPs,PNMTNursingPostHospitalizationAssessments,andISPAmeetingdocumentationrelatedtointegrationofPNMTassessmentsandActionPlans,from1/12through6/12;

o QualityAssurance/QualityImprovement(QA/QI)meetingminutesrelatedtoPNM,PNMT,andtheHabilitationTherapy(HT)Department,from1/12through5/12;

o MinutesfromtheHTDepartmentmeetingsforthepastsixmonths,from1/12through


6/12;o ExternalPNMconsultantreportssincelastreview,dated3/16/12and3/22/12;o ChangestoPhysicalNutritionalManagementPlantemplatessincelastreview,dated

5/25/12;o RawdataforSectionOmonitoringforMay2012;o QA/QIQuarterlySectionReviewforSectionOforlasttwoquarters;o ContinuingeducationforPNMTcoreandalternatemembersforJune2012;o DraftPNMPtemplateforIndividual#340;o Actionplansforenvironmentalsurvey,receivingenteralnutrition,andweeklyweights

relatedtoPNMTsystemicissues;o DocumentationdevelopedbyPNMTNursefortimelinenotificationofneeded

environmentalsurveys,trackingofenteralnutrition(i.e.,“countingcans”)andweeklyweights;

o AlldocumentationforresolutionofsystemicissuesidentifiedbyPNMT;o HTDepartmentmeetingminutesforJune2012;o Competencyperformancecheck‐offsforNewEmployeeOrientation(NEO)PNM

instructors;o NumberofstaffwhosuccessfullycompletedNEOPNMfoundationalperformancecheck‐

offsoverthepastsixmonths;ando FacilityContinuingEducationpolicy.

Interviewswith:o Dr.AngelaRoberts,HabilitationTherapyDirector;o MaryWilcox,PNMTRN,DedicatedCoreMember;o RosieCortez,PNMTOT,DedicatedCoreMember;o MariaI.Garcia,AlternatePNMTPTMember;o LindaMerryman‐Scrifes,AlternateSLPMember;ando SallySchultz,StateConsultant.

Observationsof:o Infirmary,residencesanddiningroomsinCoralSea,Pacific,andAtlanticforfive

individualsonthePNMTcaseload;o PNMTPre‐Conferencemeetingon7/9/12;ando PNMTReviewson7/10/12.

FacilitySelf‐Assessment:BasedonareviewoftheFacility’sSelf‐Assessment,withregardtoSectionOoftheSettlementAgreement,theFacilityfounditwasinnoncompliancewithallofthesubsectionsofSectionO.ThiswasconsistentwiththeMonitoringTeam’sfindings.TheFacilitysubmittedthreedocuments,including:CCSSLCSelf‐Assessment,ActionPlans,andProvisionActionInformation.TheCCSSLCSelf‐AssessmentlistedthestepstheFacilitystaffcompletedtoconducttheself‐assessmentandthesubsequentresultsforthecompletionofthesetasks.TheActionPlansdocumentedthestatusofactionstepsthathadbeencompleted,wereinprocess,and/orhadnotbeenstarted.TheCCSSLCProvisionActionInformationlistedactionscompletedsincetheMonitoringTeam’s


previousvisit.TheFacilitySelf‐AssessmentpresentedtheresultsofauditingactivitiestheHTDirectorandProgramComplianceMonitor(PCM)completedusingtheSectionOMonitoringtoolforeachmonth.Oneindividualwasmonitoredeachmonthforatotalofthreeindividualsperquarter.MonthlyreportsweredevelopedforeachmonththatincludedaseparatecompliancescoreforeachindicatorfortheSectionLead(i.e.,HTDirector)andthePCM.Aninter‐ratercompliancescorewasgeneratedforeachindicatoraswellasacompliancepercentage.ThiswasapositivedevelopmentandprovidedtheHTDirectorwithvaluableinformationtoassessthecompliancestatusforeachindicator.Furthermore,theHTDirectorandPCMreportedtheycontinuedtoreviseinstructionsfortheformtoenhancetheirinter‐rateragreement.TheHTDirectorandPCMgeneratedamonthlySectionOAnalysisreport.Thereportdefinedhowinter‐rateragreementwasachievedanddiscussedhowthesamplewaschosen.TheanalysisreportdiscussedthecomplianceforeachoftheeightsectionsinSectionOandpresentedplanstoaddressareasofnon‐compliance.TheMonitoringTeamdiscussestheFacilitySelf‐Assessmentresultsatthebeginningofeachsection.SummaryofMonitor’s Assessment: AlthoughalistofPNMteammembersincludedaRegisteredNurse(RN),PhysicalTherapist,OccupationalTherapist,RegisteredDietician,andSpeechLanguagePathologist,priortotheMonitoringTeam’svisit,thePNMTSLPandPTresigned.BasedoninterviewwiththeHTDirector,thePNMTalternateSLPandPTassumedthevacantPNMTSLPandPTcorepositionsuntilthevacantpositionswerefilledand/orcurrenttherapistswereassignedtoaPNMTcoreposition.Attendancebycoreand/oranalternatePNMTmembersfor46meetingsconductedduringthetimeframefrom1/10/12to5/29/12rangedfrom65%fortheRDto85%fortheRN.ThePNMTmemberattendancewasnotadequate,becausethePNMTwasmeetingwithouttherequiredmembershipasoutlinedintheSettlementAgreement.AreviewofindividualswhohadbeenhospitalizedsincethelastreviewrevealedtheFacilityIDTswerenotconsistentlyreferringindividualstothePNMTand/orthePNMTwasnotconsistentlyinitiatinganassessmentwithinfiveworkingdays.Basedoninterview,theHTDirectorreportedtheIDTswouldnotbeprovidedtrainingonthedraftPNMTReferralpolicyuntiltherevisedISPandriskprocesshadbeenimplemented.AreviewofPNMTassessmentsandactionsplansidentifiedmultiplemissingcomponents.Inaddition,individualsthePNMTdischargeddidnothaveadequatedischargeplansasmultiplecomponentsweremissing.ListspresentedbytheFacilitytoidentifyindividualshavingphysicalandnutritionalmanagementproblemswerenotaccurate.WhencomparingliststheFacilityprovidedofindividualswithPNMneeds


with alistofindividuals’riskratings, someindividualswithPNMneedsasevidencedbyahighand/ormediumriskrankinginchoking,aspiration,falls,fractures,skinintegrityand/orweightwerenotonthelistofindividualshavingPNMneeds.Consequently,theMonitoringTeamdidnothaveconfidenceintheaccuracyofthislist.TheFacilityhadupdateditsPNMPDirectionstoaddresstheplacementofmedicationadministrationinstructionsonthePNMP,addamorecomprehensivelistofadaptiveequipmenttothePNMP,andclarifythatrevisionofaPNMPrequiredthecompletionofanAssessmentofCurrentStatus,andcompletionofanin‐servicebythetherapistwiththePNMPCoordinatorontherevisedPNMP.TheseadditionstothePNMPdirectionswereapositiveaddition.However,areviewofPNMPsforindividualsrevealedPNMPsweremissingcomponentssuchasstaffinstructionstoachievesafeelevationrangesinwheelchairandalternatepositioning,bathing/showering,oralanddentalcare,andpersonalcare.TheMonitoringTeamandthePNMTNursecompleteddirectobservationsoftheimplementationofPNMPstrategiesintheInfirmaryandresidencesforfiveindividualsonthePNMTcaseload.ThePNMTnursehadtointervenewithstaffduringeveryobservationtocorrectstaff’sapproachforwheelchairpositioning,alternatepositioning,mealtimefluidconsistencyandpresentationtechniques,andtransfers.Theseobservationsrevealedthatstaffwerenotcompetentinimplementingindividuals’PNMPs.However,inreviewingmonitoringdataforthesesameindividuals,itdidnotidentifysimilarproblems.Newstaffcontinuedtoberesponsibleforcompleting22PNMfoundationalperformancecheck‐offs.BasedoninformationprovidedbytheFacility,192newemployeeshadsuccessfullycompletedthePNMcorecompetenciesperformancecheck‐offssincethelaston‐sitereview.Basedoninterview,theFacilityannualrefreshertrainingwastobeexpanded.Currentstaffwillberesponsibleforsuccessfullycompletingperformancecheck‐offsfortransferlifts,two‐personmanuallift,bedpositioning,mechanicallift,stand‐pivottransfer,wheelchairpositioning,adaptivediningequipment,thickeningliquids,andmealtimesafety.TheFacilityhadnotimplementedaneffectivenessmonitoringsystemtoassesstheprogressofindividualswithPNMdifficultiesorprovideevidencethatinterventionsweremodifiedifanindividualwasnotmakingprogress.Morespecifically,individuals’RiskActionPlansdidnotgenerateindividual‐specificclinicaldatatosubstantiateanindividualprogressortoassessiftheindividualwasbetterorworse;monthlyprogressnoteswerenotcompletedtoreportontheeffectivenessofanindividual’ssupportsandservices;individualsathighriskforaspirationhadmultiplemonthsthataspirationpneumoniatriggerdatasheetshadnotbeencompleted;andindividuals’whoexperiencedongoingweightlossdidnothavetheirplansrevised.APENassessmentsforindividualswhoreceivedenteralnutritionwerenot:followingtheFacility‐establishedtemplateandcontentguidelines;completedwithina12‐monthperiodfor12ofthe16individuals;includingtheparticipationofrecommendeddisciplines;and/orprovidingjustificationthatthecontinueduseofthetubewasmedicallynecessaryorassessingtheindividual’spotentialtoreceivealessrestrictiveformofenteralnutritionortransitiontooralintake,ifappropriate.


# Provision AssessmentofStatus ComplianceO1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshallprovideeachindividualwhorequiresphysicalornutritionalmanagementserviceswithaPhysicalandNutritionalManagementPlan(“PNMP”)ofcareconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare.ThePartiesshalljointlyidentifytheapplicablestandardstobeusedbytheMonitorinassessingcompliancewithcurrent,generallyacceptedprofessionalstandardsofcarewithregardtothisprovisioninaseparatemonitoringplan.ThePNMPwillbereviewedattheindividual’sannualsupportplanmeeting,andasoftenasnecessary,approvedbytheIDT,andincludedaspartoftheindividual’sISP.ThePNMPshallbedevelopedbasedoninputfromtheIDT,homestaff,medicalandnursingstaff,andthephysicalandnutritionalmanagementteam.TheFacilityshallmaintainaphysicalandnutritionalmanagementteamtoaddressindividuals’physicalandnutritionalmanagementneeds.Thephysicalandnutritionalmanagementteamshallconsistofaregisterednurse,physicaltherapist,occupationaltherapist,dietician,andaspeechpathologistwithdemonstratedcompetenceinswallowingdisorders.Asneeded,

FacilitySelf‐AssessmentAreviewoftheFacility’sSelf‐Assessmentindicatedthefollowing:

ReviewofSectionOmonitoringtoolsindicatedthatthreeoutofthree(100%)hadcompliancescoresanalyzed,trendedandaggregated.

ThePNMTmembershipindicatedthatfouroutoffive(i.e.,OT,PT,SLPandRN)(80%)werededicated.However,thededicatedSLPandPThadrecentlyresigned.ThePNMTdidnothaveadieticianandtheFacilitywasrecruitingadietician.ThePNMT“willconsultwithamedicaldoctoronasneededbasis.”

PNMTmembershadcompletedcontinuingeducationinspecializedareas. AreviewofPNMTminutesindicatedzerooutofthreeindividuals(0%)hadIDT

membersrepresented;forzerooutofthree(0%)individual‐specificmonitoringwasconducted;andthreeoutofthree(100%)werere‐assessedafteradmissiontotheInfirmary,emergencyroomand/orhospital.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonfindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausewedonothaveallrequiredmembersonthePhysicalNutritionalManagementTeam(PNMT).AlthoughallindividualswhoareseenbythePNMNTreceiveaPhysicalNutritionalManagementPlan(PNMP)andappropriaterecommendationsaremade,oftentimestheserecommendationsarenotconsistentlyimplementedand/orcompleted.”Asnotedabovewithregardtothedocumentsreviewedsection,twosampleswereselectedforthereviewofSectionO.Theseincluded:

Sample#1(IDTCaseload)‐elevenindividualsidentifiedwithPNMconcernswhoreceivedenteralnourishment,andsomeofwhomhadexperiencedachangeofstatusrelatedtoPNMdifficultiesasevidencedbyanadmissiontotheFacilityInfirmary,ER,and/orhospital,including:Individual#340,Individual#274,Individual#68,Individual#126,Individual#124,Individual#142,Individual#266,Individual#122,Individual#269,Individual#273,andIndividual#176.

Sample#2(onactivePNMTCaseload)‐sevenindividualsonthecurrentPNMTcaseloadwhowereassessedorreviewedinthelastsixmonths,including:Individual#278,Individual#144,Individual#89,Individual#43,Individual#117,Individual#239,andIndividual#378.ThissamplealsoincludedthreeindividualswhohadbeendischargedfromthePNMTinthepastsixmonths,including:Individual#86,Individual#113,andIndividual#10.

DuetothemultiplerequirementsincludedinthisprovisionoftheSettlementAgreement,aswellastherequirementsofthisoverarchingprovisionoftheSettlementAgreementbeingfurtherdetailedinothercomponentsofSectionO,thefollowingsummarizesthe

Noncompliance


# Provision AssessmentofStatus Compliancetheteamshallconsultwithamedicaldoctor,nursepractitioner,orphysician’sassistant.Allmembersoftheteamshouldhavespecializedtrainingorexperiencedemonstratingcompetenceinworkingwithindividualswithcomplexphysicalandnutritionalmanagementneeds.

reviewoftherequirementsrelatedtothePNMT,includingthecompositionoftheteam,thequalificationsofteammembers,andtheoperationoftheteam.TheevaluationsandplanningprocessesinwhichthePNMTisrequiredtoengagearediscussedbelowinthesectionsofthereportthataddressSectionsO.2throughO.7oftheSettlementAgreement.Inaddition,thisprovisionspecificallyrequiresthat“theFacilityshallprovideeachindividualwhorequiresphysicalornutritionalmanagementserviceswithaPhysicalandNutritionalManagementPlan(“PNMP”)ofcareconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare…ThePNMPwillbereviewedattheindividual’sannualsupportplanmeeting,andasoftenasnecessary,approvedbytheIDT,andincludedaspartoftheindividual’sISP.ThePNMPshallbedevelopedbasedoninputfromtheIDT,homestaff,medicalandnursingstaff,andthephysicalandnutritionalmanagementteam.”ThestatusoftheserequirementsisdiscussedwithregardtoSectionO.3.PNMTMembershipAlistofPNMteammembersincludedaRegisteredNurse,PhysicalTherapist,OccupationalTherapist,RegisteredDietician,andSpeechLanguagePathologist.However,priortotheMonitoringTeam’svisit,thePNMTSLPandPTresigned.PNMTalternatemembersincludedaRegisteredNurse,PhysicalTherapist,OccupationalTherapist,andSpeechPathologist.BasedoninterviewwiththeHTDirector,thePNMTalternateSLPandPTassumedthevacantPNMTSLPandPTcorepositionsuntilthevacantpositionswerefilledand/orcurrenttherapistswereassignedtoaPNMTcoreposition.ThealternatePNMTRDpositionwasvacant.TherewerethreeallocatedRDpositions,buttwoofthesethreepositionswerevacant.Basedoninterviewandsubmitteddocumentation,thebasesalaryforRDshadimpactedtheFacilityinhiringRDs.TheHTDirectorwasworkingwithadministration,incollaborationwiththeState,toexploreincreasingthesalarybaseforRDsto,hopefully,assistinrecruitment.ThefollowingchartprovidesthecaseloadofcorePNMTmembersatthetimeofthereview:CorePNMTMembers CurrentCaseloadsOccupationalTherapist Dedicatedmemberandsupported18

individualsonthePNMTcaseloadSpeechLanguagePathologist

Supported94individualsinAtlanticand18individualsonthePNMTcaseload

RegisteredDietician Supported241individualsand18individualsonthePNMTcaseload

RegisteredNurse DedicatedmemberPhysicalTherapist Supported80individualsinPacificand18

individualsonthePNMTcaseload



Asnotedinthechartabove,thealternateSLPandPThadextensivecaseloadsbeyondtheirresponsibilitiesforindividualsonthePNMTcaseload.AncillaryPNMTMembersWithregardtoPNMancillarymembers,theFacility’s“PhysicalandNutritionalManagement(PNM)PNMTMembership”PolicyO.1stated:“asneeded,theteamconsultswithamedicaldoctor,nursepractitioner,physician’sassistantandIDTofindividualtobeseeninthemeeting.”AlthoughnotrequiredbytheSettlementAgreement,intheabsenceofaMedicalDirector,theFacilityhadnotappointedamedicalliaisontothePNMT.ContinuingEducationTheHabilitationTherapiesContinuingEducationUnit(CEU)draftpolicydefined:

ThedisciplinesresponsibleforcompletingCEUs; MinimumrequirementsforyearlyCEUs; SpecializedareasforcompletionofCEUs; CEUtrackingsystem;and “LunchandLearn”whichprovidedverificationofintegrationofknowledge

obtainedinCEcourses.ThedraftFacilitypolicywasapositivedevelopmentindefiningtheexpectationsforthecompletionofcontinuingeducationrequirementsforclinicians.FourofthefivecorePNMTmembers(80%)attendedcommunitycontinuingeducationcourses.Attendancerosters,coursecertificatesofcompletion,andagendasweresubmitted.ThecontinuingeducationcoursesthePNMTstaffattendedprovidedrelevantandappropriateclinicalinstructionforPNMTmembers.WithregardtoCorePNMTMembers:

FormerPTattended:AutismandSensoryProcessingDisorders;BedsideEvaluationoftheDysphagiaPatient;TheDysphagiaPatient:ModifiedBariumSwallowandTherapeuticIntervention;andNeurorehabilitationConference2012;

FormerSLPattended:AutismandSensoryProcessingDisorders;BedsideEvaluationoftheDysphagiaPatient;TheDysphagiaPatient:ModifiedBariumSwallowandTherapeuticIntervention;andNeurorehabilitationConference2012;

OTattended:AutismandSensoryProcessingDisorders;BedsideEvaluationoftheDysphagiaPatient;TheDysphagiaPatient:ModifiedBariumSwallowandTherapeuticIntervention;andNeurorehabilitationConference2012;

RDattended:Nonesubmitted; RNattended:AutismandSensoryProcessingDisorders;BedsideEvaluationof


# Provision AssessmentofStatus CompliancetheDysphagiaPatient;TheDysphagiaPatient:ModifiedBariumSwallowandTherapeuticIntervention;NeurorehabilitationConference2012;NorthAmericanMenopauseSocietyGuidelinesBackHormoneTherapyUseforMenopausalSymptoms;NewDietaryGuidelineonIrritableBowelSyndrome;andGumChewingQuickensBowelRecoveryAfterLiverResection.

ThreeofthefouralternatePNMTmembers(75%)attendedcommunitycontinuingeducationcourses.WithregardtoalternatePNMTMembers:

PTattended:NeurorehabilitationConference2012; SLPattended:AutismandSensoryProcessingDisorders; OTattended:AutismandSensoryProcessingDisorders;BedsideEvaluationof

theDysphagiaPatient;TheDysphagiaPatient:ModifiedBariumSwallowandTherapeuticIntervention;NeurorehabilitationConference2012;andManagingDysphagia2012;and

RNattended:Nonesubmitted;and RDattended:Vacant.

Thesecontinuingeducationscourseswereappropriateinstructioninworkingwithindividualswithcomplexphysicalandnutritionalmanagementneeds.PNMTMeetingMinutesTheFacilityPNMTminutesformatandFacilityPNMTpolicystatedmeetingsweretobeheldtwiceaweek,butcouldalsooccur:whenfeeding/healthproblemsarise,afteresophagrams/medicaldiagnostictestswereperformed,toperformfollow‐upactivities,andatanyphaseinthePNMprocedure.AreviewofthePNMTminutesfor46meetingsfrom1/10/12to5/29/12representedfourdifferenttypesofPNMTmeetings,including:

PNMTpre‐assessmentmeetingstoassignassessment/monitoringresponsibilitiestobegintheassessmentprocess;

PNMT/IDTmeetingtopresentPNMTassessmentfindingstotheindividual’sIDT;

PNMTfollow‐upmeetingstoreviewandrevise,asneeded,multipleindividuals’PNMTactionplan;and

PNMTadministrativemeetings.Attendancebycoreand/oranalternatePNMTmembersfor46meetingsconductedduringthetimeframefrom1/10/12to5/29/12was:

RN:85%; PT:69%; OT:83%;


# Provision AssessmentofStatus Compliance SLP:78%;and RD:65%,

TheattendanceofPNMTmembersatmeetingswasnotadequate,becausethePNMTwasmeetingwithouttherequiredmembershipinattendanceasoutlinedintheSettlementAgreement.AttendancebyancillaryPNMTmembersforPNMT/IDTandfollow‐upmeetingsconductedduringthetimeframefrom1/10/12to5/29/12was:

AFacilityphysicianattendedthePNMTmeetingon2/17/12;and AFacilityNursePractitionerattendedthePNMTmeetingon3/7/12.

Asstatedinthelastreport,intheabsenceofaMedicalDirector,thePNMTdidnothaveamedicalliaisonappointedtoprovidearesourceformedicalconsultationtoPNMTmembers.PNMTSystemicIssuesAPNMTadministrativemeetingwasheldon4/16/12toaddressresolutionofsystemicissuesidentifiedbythePNMT.TheFacilityDirector,AssistantDirectorofPrograms,ChiefNurseExecutive,HTDirector,PNMTPT,PNMTSLP,PNMTOT,andProgramComplianceMonitorattendedthemeeting.Thesystemicissuesraisedwere:

Weights; IDTattendanceatPNMTfollow‐upmeetings;and Environmentalissues.

WeightsMembersofthePNMTexplainedthey“arestill”notgettingweightsfromacrosscampusespeciallyforindividualsathighriskforweight.Theplanofactiondetailedthefollowing:theChiefNurseExecutivewouldreviewtheweightspolicyanddiscusswheretodocumentweightswithnursesduringanursingmeetingon4/20/12;andPNMTmemberswouldemailtheNurseManagerfortheunitandcopytheNurseOperationsOfficerwhentheydiscoveredmissingweights.Thiswouldbeaddressedonacase‐by‐casebasisunlessitbecameapparentthatitwasmoreofasystemicissue.Ifthiswereasystemicissue,itwouldbereaddressedwiththeChiefNurseExecutive.However,althoughitappearedtoremainproblematic,theHabilitationTherapyDepartmentdidnotsubmitanydocumentationtoshowthattheissuehadagainraisedtheissuewiththeChiefNurseExecutiveorothermembersoftheFacility’sAdministration.Forexample,thePNMTFollow‐Upmeetingon7/10/12continuedtodiscussthechallengeofreceivingweeklyweights.Forexample,Individual#58’sweightcontinuedtonotimprove.Basedoninformationpresentedduringthefollow‐upmeeting,thePNMTmemberswere“countingcans”toensurecaloriesweregiven.DocumentationthePNMTNursesubmitted,notdated,indicated“countingofcans”forIndividual#58hadbeeninitiatedthreeweekspriortothe7/10/12PNMTmeeting.Thiswasanunacceptablesolutiontoa


# Provision AssessmentofStatus Compliancesystemicissuethathadbeenraisedapproximatelythreemonthspreviously.ThePNMThadtheresponsibilitytoproceedwithurgencytoaddressthesystemicissuethatimpactedsevenindividualsontheircaseload(i.e.,Individual#58,Individual#278,Individual#311,Individual#144,Individual#89,Individual#179,andIndividual#117)whowereathighriskforweight.ThisissuewasdiscussedwiththeMonitoringTeamduringtheonsitereview.TheMonitoringTeamrequestedcopiesofanyactionplansorotherdocumentationtoshowwhatstepsthePNMT,HabilitationTherapyDepartment,orFacilityhadtakentoaddresstheissue.AttheconclusionoftheExitMeeting,theAssistantDirectorofProgramsinformedtheMonitoringTeamthattheFacilitywasintheprocessofdevelopinganactionplan.TheactionplanwassubmittedtotheMonitoringTeamon7/20/12.Theactionplanidentified11stepstosupportindividualsreceivingprescribednourishment/formulaandfluids,andtohaveweightsrecordedasordered.Althoughitwaspositivethatanactionplanwasdeveloped,developmentofthismorecomprehensiveplanshouldhaveoccurredassoonasthePNMTidentifiedthattheinitialplanputinplaceinAprilwasnothavingthenecessaryimpact.ThenecessarycommunicationabouttheongoingnatureofthesystemicconcernsanddevelopmentofanactionplantoaddressresolutionoftheseissuesshouldnothaverequiredthepresenceoftheMonitoringTeam.Inthefuture,thePNMTshouldbeaggressiveinnotonlyraisingsystemicissuesinatimelymanner,butalsoactingwithurgencytoensuretheissuesareresolved.TheMonitoringTeamwashopefultheactionplanstepforthepresentationofsystemicissuesbythePNMTintheIntegratedClinicalServicesMeetingwouldsupporttimelyresolutionofidentifiedissues.Ifconcernsarenotresolvedthroughthisforum,thePNMTandHabilitationTherapyDepartmentshouldusetheQA/QICounciland/orotheradministrativeinterventionsasadditionalpathwaysforthePNMTtopresentongoingconcernsandworktowardaspeedyresolutionforthoseindividualsathighestrisk.IDTAttendanceatPNMTFollow‐UpMeetingsFacilityPolicyO.2specified“amemberoftheindividual’sIDTwillattendeachsubsequentfollow‐upmeetingtoreviewprogresswiththePNMTrecommendationsuntiltheindividualisdischargedfromthePNMTcaseload.TheIDTmemberwillactastheliaisonbetweenthePNMTandtheIDT.Thepurposeoftheirattendanceatthesemeetingsistoshareinformation,updatestatusandprogressofplans.”AtthePNMTadministrativemeetingon4/16/12,thePNMTmembersreportedthatIDTmemberswereattendingtheinitialmeetinganddischargemeeting,butdidnotconsistentlyattendthePNMTfollow‐upmeetings.TheplanofactiondevelopedspecifiedthePNMTwouldhaveaflexiblescheduleduringthefollow‐upmeetingstoaccommodateIDTmembersthatwerepresent.Inaddition,thePNMTadministrativeassistantwouldassignaspecific


# Provision AssessmentofStatus Compliancepersontoattendthenextfollow‐upmeetingandwouldsendanappointmentreminder.However,nofollow‐updocumentationwassubmittedand/ordiscussionrecordedinPNMTminutesregardingthesuccessand/orlackofsuccesswiththisactionplan.AreviewofPNMTFollow‐Upmeetingattendancesheetsafter4/16/12didnotsignalthattheproblemhadbeenresolved.Forexample,atthefollow‐upmeetingon5/29/12,thegroupreviewed12individualsonthePNMTcaseload.ThePNMTsignaturepagedenotedattendancebyaQDDPforKingFish4,QDDPforRibbonFish1,aswellasanotherQDDPandRNbutthesestaffdidnotidentifytheresidencetheyrepresented.TherewasnoIDTrepresentationfromCoralSeaand/ortheInfirmary.ThePNMTshouldconsiderarevisiontotheirfollow‐upmeetingattendancesheettorequiretheIDTmembertoidentifywhichindividualtheyaresupporting.Furthermore,thePNMTshouldcontinuetodocumentwhenanIDTmemberdoesnotattendafollow‐upmeetingasrequiredbyFacilitypolicy.ThePNMTshouldrequesttimelymeetingswithFacilityAdministrationtoreportonprogressand/orlackofprogresswithactionplansrelatedtosystemicissues.EnvironmentalIssuesThePNMTindicatedtherehadbeenanincreaseinrespiratoryissuesforindividualsinCoralSea.Theplanofactionthatthegroupdecideduponatthe4/16/12meetinginvolvedtheHTDirectorcontactingtheSupportServicesDirector.AmeetingwastobesetupwithHousekeeping,InfectionControl,thePNMTand,possibly,theSafetyManagertodiscussissuesofcrosscontaminationwithcleaningsupplies,protocolstobefollowedafterfloorstripping(datarevealedanincreaseinrespiratoryissues),ascheduleforventcleaning,andscheduleforcleaningrespiratoryequipment.However,theHTDirectordidnotcontacttheSupportServicesDirectorviaemailuntil5/23/12,whichwasnotadequatetoaddresstheseenvironmentalconcernsthathadbeendescribedasurgent.Furthermore,thePNMTNurseindicatedtheroomwhereIndividual#239,Individual#247andIndividual#270residedhadreceivedpoorenvironmentalcheckspriorto8/31/10,closetoayearago.Again,thePNMTshouldhavenotifiedFacilityAdministrationoftheirconcernspriortothe4/16/12meeting.TheFacility’sactionplandevelopedatthetimeoftheMonitoringTeam’sonsitereviewtosupportindividualsresidinginrespiratorysafeenvironmentsidentifiedfouractionsteps.TheMonitoringTeamwouldrecommendajointmeetingbetweenthePNMT,SupportServicesDirector,InfectionControlNurse,andRespiratoryTherapisttofurtherexpandandimplementaninterdisciplinaryapproachtosupportingasafeenvironmentnotonlyforthesethreeindividuals,butindividualsacrossthecampus.Duringthenextonsitevisit,membersoftheMonitoringTeamwillreviewtheimplementationofthisactionplan.TheFacility’sSelf‐Assessmentindicatedthatitwasnotincompliancewiththis


# Provision AssessmentofStatus CompliancerequirementoftheSettlementAgreement.ThiswasconsistentwiththeMonitoringTeam’sfindings.

O2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshallidentifyeachindividualwhocannotfeedhimselforherself,whorequirespositioningassistanceassociatedwithswallowingactivities,whohasdifficultyswallowing,orwhoisatriskofchokingoraspiration(collectively,“individualshavingphysicalornutritionalmanagementproblems”),andprovidesuchindividualswithphysicalandnutritionalinterventionsandsupportssufficienttomeettheindividual’sneeds.Thephysicalandnutritionalmanagementteamshallassesseachindividualhavingphysicalandnutritionalmanagementproblemstoidentifythecausesofsuchproblems.


BasedontheFacility’sreviewofitsPNMTpolicy,itconcludedthatanadequatereferralprocesswasinplace,whichincludedaformalreviewprocess.However,basedontheMonitoringTeam’sreview,theFacility’sIDTshadnotreceivedtrainingonthePNMTreferralpolicy.BasedoninterviewwiththeHTDirector,theIDTswouldreceivetrainingaftertherevisedISPandriskprocesshadbeenimplemented.Inaddition,theMonitoringTeam’sreviewoftheadequacyofIDTreferraland/orPNMTself‐referralforindividualsinSample#1andSample#2isdiscussedinfurtherdetailinthissection.

BasedontheFacility’sreviewofthreePNMTassessments,twooutofthree(67%)hadacomprehensivereviewofidentifiedhighandmediumrisks;oneoutofthree(33%)hadanadequateactionplandevelopedandstrategiestominimizeriskindicators;andnone(0%)didhadindividual‐specificclinicalbaselinedataestablished,adequateanalysistoproviderationalefordevelopmentofrecommendations,adequatedocumentationorre‐assessmentofindividuals’PNMPstrategies,definedclinicalindicators,criteriaforreferralbacktoPNMTfromnursinguponhealthstatuschange,ordischargesummaries.

AreviewMedicalMorningmeetingsign‐insheetsthelastsixmonthsdemonstratedtheHospitalLiaisonand/orthePNMTNursewerepresentat105outof120(88%)meetings.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausethePNMTassessmentsandsubsequentactionplanscontinuetolacktheessentialcomponentsnecessarytoprovidesupportssufficienttomeettheindividuals’needs.TheMonitoringTeam’sfindingsalsoshowedtheFacilitywasinnoncomplianceasillustratedinthecomplianceindicatordatainthissection.Facility’sListsofIndividualswithPNMProblemsTheFacilityproducedthefollowinglistswhichidentifiedindividualswithPNMconcerns:

Fifty‐twoindividuals(20%ofthecensus)werefoundasrequiringmealtimeassistance.Thelist,dated5/30/12,wasgeneratedfromtheHTdatabase.

Twenty‐eightindividuals(11%ofthecensus)wereidentifiedathighriskand125(48%ofcensus)wereidentifiedatmediumriskforaspiration.TheIntegratedRiskRatingbyHome,dated5/31/12,categorizedriskratingsFacility‐wide,byhome,andindividualspecific.TheStaterecentlyhadrevisedthecriteriaforhighriskofaspirationtoincludeallindividualswhoreceived

Noncompliance


# Provision AssessmentofStatus Complianceenteralnutrition.Asaresultofthischange,IDTswillneedtorevisetheriskratingforaspirationforindividualswhoreceiveenteralnutrition.

Twenty‐twoindividuals(8%ofthecensus)wererecognizedathighriskand132(51%ofthecensus)atmediumriskforchoking.However,Individual#42whoexperiencedachokingincidenton3/11/12wasrankedincorrectlyatmediumrisk.Consequently,itdidnotappearthattheFacilityhadanaccuratelisttoidentifyindividualswhowereathighriskofchoking.

AlistdevelopedbytheHTDepartmentnoted31individuals(12%ofthecensus)hadadiagnosisofdysphagia(i.e.,difficultyswallowing).AsecondlistofIndividualsdiagnosedwithdysphagiafromICD‐9codes,dated6/5/12,identified38individuals(15%ofthecensus).ThedisparitybetweenthesetwolistsillustratedtheFacilitydidnothaveanaccuratelisttoidentifyindividuals,whohaddifficultyswallowing.

Onehundredandthirtyindividuals(53%ofthecensus)utilizedawheelchairasprimarymobility.Thelist,dated5/21/12,wasgeneratedfromtheHTdatabase.However,anindividualonthewheelchairprioritylist(i.e.,Individual#350)wasnotidentifiedonthelistofindividualswhoutilizedawheelchair.Consequently,itdidnotappearthattheFacilityhadanaccuratelisttoidentifyindividualswhousedawheelchair.

TheFacilitydidnothavealisttospecificallyidentifyindividualswhorequiredpositioningassistanceassociatedwithswallowingactivities.

Asnotedabove,thelistspresentedbytheFacilitytoidentifyindividualshavingphysicalandnutritionalmanagementproblemswerenotaccurate.TheFacilityshoulddevelopasustainablesystemtomaintainandupdatetheselistsontheHTdatabasetoensuretheirvalidity.AbasiccomponentofcompliancewiththisprovisionistheaccurateidentificationofindividualswithPNMconcerns.Withoutanaccuratelist(s),itwouldbedifficultfortheFacilitytoensurethatitprovidessuchindividualswithadequatephysicalandnutritionalinterventions.PNMTReferralProcessandInitiationofAssessmentAdraftFacilityPolicyO.3,PhysicalandNutritionalManagement:ReferraltothePNMThadbeendeveloped.Basedoninterview,trainingwouldnotbeprovidedtoIDTmembersuntilafterthenewISPandRiskProcesswererolledout.TheIDT,PCP(primarycarephysician),orPNMTcouldreferindividualstothePNMTforwhomtheteamneededadditionalassistanceinformulatingaplan.IndividualsweretobereferredtothePNMTwhen:

Anindividual’srisklevelwasdeterminedtobeinthehighestrangeofoneormorecategoriesandtheIDThadnotbeenabletoimproveoutcomesusingactionplans;

Anindividual’shealthorriskstatuschangedordeteriorated,eventhoughanIDT


# Provision AssessmentofStatus Complianceactionplanhadbeendevelopedandimplemented;

AnindividualhadcontinuedhospitalizationseventhoughanIDTactionplanwasinplace;and

ThePNMTcouldalsoself‐referanindividualbasedonevaluationsconsults,ordatafromtheFacility’smonitoringsystems.

ThepolicyalsoindicatedthePNMTwastobeginanassessmentwithinfiveworkingdaysofthereferralorsoonerto“determinepossiblecausesforchangeinstatus,analyzeassessmentfindings,integraterecommendations,andproposeaplanwithgoalsanddesirableoutcomes.”TheFacilitypresentedalist,dated7/2/12,identifyingwhohadbeenreferredtothePNMTasaresultofanIntegratedRiskRatingmeeting.SincetheMonitoringTeam’slastreview,16individualshadbeenreferredtothePNMT.AreviewofthePNMT’scaseloadoverthepastfivemonths(JanuarythroughMay,2012)showedthattheIDTshadreferredindividualstothePNMTthatwerecurrentlyonthePNMTcaseload,individualshadbeendischargedfromthePNMTbuttheIDTreferredtheseindividualstothePNMTagain,and/orthePNMThadnotcompletedareview.ThefollowingsummarizesthestatusoftheindividualsreferredtothePNMT:

Individual

IRRMeetingDateresultinginPNMTReferral

PNMTReferralStatus

Individual#79 1/17/12 PNMTassessmenton10/20/11and1/24/12,butnotonPNMTcaseload

Individual#223 Referralon3/7/12,butalreadyonPNMTcaseload

PNMTcaseload JanuarytoMay,2012


PNMTcaseloadfromJanuarytoMay,pendingdischarge

Individual#177 1/25/12 NotassessedbyPNMTIndividual#43 Referralon4/9/12,

butalreadyonPNMTcaseload

PNMTcaseloadJanuarytoMay,2012

Individual#194 2/21/12 DischargedfromPNMTon2/23/12Individual#9 6/1/12 NotassessedbyPNMTIndividual#179 Referralon2/2/12,

butalreadyonPNMTcaseload

PNMTcaseloadfromJanuarytoMay2012

Individual#153 2/17/12 DischargedfromPNMTon1/18/11,but


# Provision AssessmentofStatus CompliancethePNMTdidnotreassess


PNMTcaseloadfromJanuarytoMay2012;pendingreleasefromPNMTcaseloadmeetingwithIDTon5/11/12

Individual#117 Referredon6/14/12butalreadyonPNMTcaseload

10/6/11‐ willnotbereferredtoPNMT‐actionsinplace;addedtoactivePNMTcaseloadon4/27/12

Individual#348 2/23/12 DischargedfromPNMTon5/10/11;notreassessedbyPNMT

Individual#274 4/13/12 PerreportofHTDirectoraccidentallycheckedforPNMTreferralonIRRform

Individual#166 4/9/12 PNMTassessmentwithIDTon9/22/11;notreassessedbyPNMT


PNMTcaseloadfromJanuarytoMay2012

Individual#141 1/6/12 NotassessedbyPNMTTheprecedingresultsshowedtheFacilityshouldreviewthePNMTreferraldatabasetoassesstheaccuracyofinformationcontainedwithinthedatabase.TheFacility’sdatabaseshouldnotonlyreflectwhenareferralwasmadetothePNMT,butalsoidentifythestatusofthePNMTreferral.Inaddition,theFacilityshouldauditcompliancewiththeFacilityPNMTreferralpolicy.FourindividualsfromSample#1whohadbeenhospitalizedwithPNM‐relatedissueswerereviewedtodetermineifareferralhadbeenmadetothePNMT.SevenindividualsfromSample#2werereviewedtodetermineifthePNMThadinitiatedanassessmentwithinfiveworkingdays.Thereviewoftheseindividuals’recordsfound:

InnoneofthefourrecordsinSample#1ofindividualswhohadahospitalizationindicatingachangeinstatusthatshouldhaveinitiatedareferraltothePNMT(i.e.,Individual#340,Individual#273,Individual#176,andIndividual#124)(0%)wasevidencefoundofanIDTreferraltothePNMTand/oraPNMTself‐referralwithinfiveworkingdaysoftheISPAmeeting.Forexample,Individual#340hadbeenhospitalizedwithpneumoniaandhadexperiencedtworespiratoryinfectionswithinthepastsixmonths;Individual#273hadbeenhospitalizedtwotimeswithpneumonia;Individual#176hadbeenhospitalizedthreetimesandhadanunplannedweightlossof20.4%withinthepastsix


# Provision AssessmentofStatus Compliancemonths;andIndividual#124hadbeendischargedfromthePNMTbutwashospitalizedwithadiagnosisofaspirationpneumonia.

InoneofsevenindividualrecordsreviewedinSample#2(i.e.,Individual#278)(14%),thePNMTself‐referraland/orIDTreferralmetthetimelinecriteriafortheinitiationofanassessment(i.e.,fiveworkingdays)establishedbytheFacilityPNMTreferralpolicyandasestablishedintheStateAt‐RiskIndividualspolicy.Fortheremainingindividuals,thePNMTdidnotbeginanassessmentwithinfiveworkingdaysand/ortherewasnoreferraldateprovidedtodetermineifanassessmenthadbeeninitiatedwithinfiveworkingdays.Forexample,Individual#89’sPNMTassessmentdidnotnoteareferraldate;Individual#239wasreferredbytheIDTinFebruary2012,althoughthePNMTdidnotinitiateanassessmentuntil4/13/12;Individual#144’sIDTreferraldatewas2/23/12,althoughthePNMTassessmentdatewas3/8/12;Individual#89andIndividual#43’sreferraldatescouldnotbedetermined;andIndividual#117’sreferraldatewas3/20/12,butthePNMTassessmentdateof4/27/12exceededthefiveworkingdays.

TheseexamplesshowedtheFacilityIDTswerenotconsistentlyreferringindividualstothePNMTandthePNMTwasnotconsistentlyinitiatinganassessmentwithinfiveworkingdays.Basedoninterview,asnotedpreviously,theHTDirectorreportedtheIDTswouldnotbeprovidedtrainingonthedraftPNMTReferralpolicyuntiltherevisedISPandriskprocesshadbeenimplemented.PNMTAssessmentAtthetimeofthereview,thecurrentPNMTcaseloadwas18individuals.Sincethelastreview,threeindividualsthePNMTsupportedhaddied(i.e.,Individual#316,Individual#175,andIndividual#117).Individual#117diedduringtheweekoftheonsitereview.SevenindividualshadbeendischargedfromthePNMT(i.e.,Individual#79,Individual#10,Individual#194,Individual#56,Individual#113,Individual#244,andIndividual#86).TheFacilityPNMTpolicyindicatedthePNMTwasresponsibleforcompletingacomprehensiveassessmentandactionplan,aswellasmonitoringtheefficacyoftheinterventions.Thepolicyfurtherdefinedthecontentoftheassessmentandactionplan.TheMonitoringTeamreviewedthecontentofPNMTassessmentsandactionplansforthesevenindividualsinSample#2andfound:

NoneofthesevenindividualPNMTassessmentsreviewed(0%)wereadequatetoidentifythephysicalandnutritionalinterventionsandsupportssufficienttomeettheindividual’sneeds.Forexample:

o NoneofthesevenindividualPNMTassessmentsreviewed(0%)followedtheFacility‐establishedPNMTassessmenttemplate.PNMT


# Provision AssessmentofStatus Complianceassessmentsreviewedweremissingcomponentsfrom theFacilityPNMTassessmentformat.

o InnoneofsevenindividualPNMTassessmentsreviewed(0%),theassessmentidentifiedthecauseoftheindividual’sphysicalandnutritionalmanagementproblems.PNMTassessmentsdidnotprovideanadequateanalysistoidentifythecauseoftheindividual’sPNMconcerns.

o InfiveofthesevenindividualPNMTassessmentsreviewed(71%),aPNMTself‐referraland/orIDTreferraldatewasnoted.Individual#89andIndividual#43’sPNMTassessmentsdidnothavereferraldates.

o InnoneofthesevenindividualPNMTassessmentsreviewed(0%),theassessmentreviewedandupdatedtheindividual’sriskrating(s),asappropriate.

o InnoneofsevenindividualPNMTassessmentsreviewed(0%),therewasdocumentationofadequatePNMTassessmentofanindividual’sPNMhighandrelatedmediumrisklevels.IndividualsathighriskforPNMconcernswerenotadequatelyassessed(i.e.,weight,aspiration).Forexample,thePNMTassessmentsdidnotprovideanassessmentthatidentifiedthecomprehensivesupportsthatwouldbenecessarytomitigatetheriskindicators.Inaddition,theassessmentdidnotidentifytheclinicalindicatorsthatwouldsignalahealthyand/orunhealthystatusfortheindividual.

o InthreeofthesevenindividualPNMTassessmentsreviewed(i.e.,Individual#89,Individual#239,andIndividual#117)(43%),aHOBEassessmenthadbeencompletedfollowingtheState‐establishedassessmenttemplate.However,theHOBEassessmentformatdidnotincludeanassessmentofarecommendedsaferangefordentalprocedures.Atherapisthastheclinicalexpertisetoestablishasafeelevationrangewhileanindividualispositioned.Thetherapistshouldworkincollaborationwiththedentisttoachievethegoalofasafeelevationrangeduringdentalprocedures.

o InnoneofthesevenindividualPNMTassessmentsreviewed(0%)wereindividual‐specificclinicalbaselinedataestablishedtoassistteamsinrecognizingchangesinhealthstatus.

o Innoneofthesevenindividuals’PNMTassessment(0%),individualizedclinicalcriteriadefinedwhennursingstaffshouldcontactthePNMT.

Giventhatmultiplecomponentsasidentifiedabovewerenotpresent,PNMTassessmentswerenotadequate.


# Provision AssessmentofStatus CompliancePNMTActionPlanTheFacilityPNMTpolicystatedactionplanswouldincludeactionsteps:whichreportedassessmentresultsandprovidedmeasurableobjectivestobeincorporatedintheISP,includedclinicalindicatorsandtimelinesforreassessmenttodetermineiftheplanwassuccessfuland/orrequiredamendment,addressedthedevelopmentandimplementationofdirectinterventionsandsupportstolowertheindividual’srisklevelandpromotestablehealth,andrecommendedcompetency‐basedtrainingtosupporttheimplementationofactionsteps.Actionsplansweretominimallyincludemeasurableobjectives,actionsteps,frequencyofmonitoringorreporting,personresponsible,scheduleforfollow‐up,outcomes,timelines,andotherinformation,asapplicable.TheMonitoringTeamreviewedindividuals’PNMTactionplansandfound:

Innoneofthesevenindividuals’PNMTactionplansreviewed(0%),theplanadequatelyaddressedtheindividual’sidentifiedPNMproblemsaspresentedinthePNMTassessment.

Inthreeofthesevenindividuals’PNMTactionplansreviewed(i.e.,Individual#89,Individual#239,andIndividual#117)(43%)theHOBErecommendationswereintegratedintoPNMTactionplan.

Innoneofthesevenindividuals’PNMTactionplansreviewed(0%),preventativeinterventionswereincludedintheplantominimizetheconditionsofidentifiedriskindicators.Forexample,theactionplansforindividualswhoexperiencedsignificantweightlossdidnotprovideaggressiveinterventionstominimizetheircontinuedweightloss.

Innoneofthesevenindividuals’PNMTactionplansreviewed(0%),therewereappropriate,functional,andmeasurableobjectivestoallowthePNMTtomeasuretheindividual’sprogressandefficacyoftheplan.

Innoneofthesevenindividuals’PNMTactionplansreviewed(0%),theplansincludedthespecificclinicalindicatorstobemonitored.Forexample,actionplansdidnotidentifyclinicalindicatorstobemonitoredbynursingand/orthePNMTmembersthatwouldindicatetheindividualwasexperiencingachangeofstatus.

Innoneofthesevenindividuals’PNMTactionplansreviewed(0%),thefrequencyofmonitoringwasincludedintheplans.Actionplanswouldidentifyfrequencyofmonitoringforsomesteps,butidentificationofmonitoringfrequencywasnotconsistentintheplans.

Innoneofthesevenindividuals’PNMTactionplansreviewed(0%),theactionplanwasintegratedintotheISP.

Forsevenofthesevenindividualsreviewed(100%),aPNMT/IDTmeetinghadbeenconductedtodiscusstheIntegratedRiskRatingForm,PNMTassessment,andactionplan.

Innoneofsevenindividuals’documentationreviewed(0%),supportingdocumentationwaspresenttoconfirmimplementationofPNMTactionplan


# Provision AssessmentofStatus Compliancewithin14daysoftheplan’sfinalization.

Giventhatmultiplecomponentsasidentifiedabovewerenotpresent,individuals’PNMTactionplanswerenotadequate.PNMTFollow‐upandProblemResolutionAreviewofPNMTfollow‐upmeetingsforindividualsinSample#2showed:

Insevenofthesevenindividuals’PNMTactionplansreviewed(100%),actionplanstepshadestablishedtimelines.

Innoneofthesevenindividuals’PNMTactionplansreviewed(0%),actionplanstepshadbeencompletedwithinestablishedtimeframes.UnmetactionstepswerereportedfromPNMPfollow‐upmeetingtomeetingthatexceededthetimeframesestablishedbythePNMTmembers.Forexample,weightsforindividualswhorequiredweeklyweightstoassesstheirweightstatuswouldnotbeprovidedfromweektoweek.

Innoneofthesevenindividuals’PNMTactionplansreviewed(0%),whenrisktotheindividualwaswarranted,thePNMTtookimmediateaction.Forexample,multipleindividuals’weightstatusthatplacedthematriskwasnotaddressedclinicallywithinanadequatetimeframe.

Innoneofthesevenindividualrecordsreviewed(0%),documentationwaspresentforadequateclosureofPNMTactionplansteps.

Thefollowingconcernswerenotedduringthereviewofindividuals’PNMTactionplans:

PNMTmembersdidnotattendISPApost‐hospitalizationmeetingstoreviewthePNMTactionplansforrevisions,ifappropriate.

PNMTFollow‐Upmeetingsreportedactionplanstepsnotbeingmetbyduedateand/orwerebeingfollowedfrommonthtomonthwithoutresolution.

PNMTFollow‐Upmeetingsstatedarecommendationwascompleted,buttherewasnoanalysisprovidedtoassesstheefficacyoftheinterventionorreportiftheindividual’shealthstatuswasbetterand/orworse.

Aspirationtriggersheetshadnotbeenconsistentlycompletedonamonthlybasis.

IndividualsDischargedbythePNMTTheFacility’sPNMTpolicydidnotaddresstheprocedurestobefollowedbythePNMTandtheIDTfordischarginganindividualfromthePNMT.However,theFacilityhaddevelopedadraftPNMTDischargetemplatethathadnotbeenimplemented.Thetemplatesectionsincludedgeneralinformation,riskfactors,activeproblemlist,behavioralchallenges,medicationsideeffects,physicalclinicalindicators,nutritionalindicators,diagnostictests,hospitalization/Infirmaryadmissions,treatments,PNMP,HealthManagementPlan,PNMTanalysis/summary,PNMTrecommendationscompleted


# Provision AssessmentofStatus Complianceandpending. ThePNMTdraftDischargetemplatewasapositivestepforwardtoformalizethedischargeprocess.Sincethelastreview,thePNMThaddischargedsevenindividuals.TheMonitoringTeamreviewedtherecordsofthreeofthesesevenindividuals:Individual#86,Individual#113,andIndividual#10.Areviewofthethreeindividuals’recordsindicatedtheFacilityshouldexpandthePNMTpolicytodefinePNMTdischargeprotocols.FacilityrecordssubmittedindicatedIndividual#10hadbeendischargedbythePNMTon2/10/12.However,areviewofIndividual#10’srequesteddocumentationnotedhewas“currentlystillon[the]PNMT.”However,hisPNMTassessmentstated:“theteamandthePNMTagreethatfortheaccomplishmentof[Individual#10’s]goalsthereisnoneedforthePNMTtocontinuetofollowhiscase,”andtherewasnoadditionaldocumentation(i.e.,PNMTactionplan,IPNs)tosubstantiatePNMTinvolvement.However,forreviewpurposes,Individual#10wasremovedfromthesample,leavingtwoindividualsinthesample.Findingregardingtheseindividualswereasfollows:

Innoneofthetwoindividuals’recordsreviewed(0%)forindividualsdischargedbythePNMT,anISPAmeetingoccurred.

Innoneofthetwoindividuals’recordsreviewed(0%)forindividualsdischargedbythePNMT,theISPAmeetingprovidedobjectiveclinicaldatatojustifythedischarge.

Innoneofthetwoindividuals’recordsreviewed(0%)forindividualsdischargedbythePNMT,thePNMTrecommendationswereintegratedintotheISPoranISPA.

Innoneofthetwoindividuals’recordsreviewed(0%)forindividualsdischargedbythePNMT,therewascriteriaforreferralbacktothePNMT.

IndividualsdischargedbythePNMTdidnothaveadequatedischargeplansasmultiplecomponentsweremissingfromaPNMTdischargesummary.TheFacilityshouldprovideadditionalguidancethroughthedevelopmentofprocedurestofurtherdefinethePNMTdischargeprocesstoinclude,ataminimum:statusofefficacyofimplementedPNMTrecommendations,justificationforanindividualtobedischargedfromthePNMTthroughtheprovisionofobjectiveclinicaldatatodocumentstableorimprovedhealth,integrationofthePNMTrecommendationsintotheISP,andobjectiveclinicaldataforreferralbacktothePNMT.

O3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshallmaintainandimplementadequatemealtime,


TheFacility’sreviewofthreePNMPsindicated100%(threeoutofthree)compliancescoreforadequateinstructionsforamountoftimetoremainuprightafterameal,medicationadministrationspecificallypositioning,andpositioning

Noncompliance


# Provision AssessmentofStatus Complianceoralhygiene,andoralmedicationadministrationplans(“mealtimeandpositioningplans”)forindividualshavingphysicalornutritionalmanagementproblems.Theseplansshalladdressfeedingandmealtimetechniques,andpositioningoftheindividualduringmealtimesandotheractivitiesthatarelikelytoprovokeswallowingdifficulties.

whilereceivingoralhygiene.A67%compliancescore(twooutofthree)wasachievedforadequateinstructionsforpositioningandalternatepositioning,andpositioningwhileperformingpersonalcare.

Threediningplanswereauditedandthefollowingdatawaspresented:100%hadadaptiveequipment,67%hadtriggersthatwouldpromptreview;33%hadbehavioralconcernsrelatedtointake,and0%hadpresentationtechniques.

TheFacility’sreviewoftheindividuals’ISPsnotedthatPNMPswereintegratedin33%oftheISPs.

TheFacility’sreviewofindividuals’ISP/ISPAsdatarevealed0%PNMPswerereviewedand/orchangedwhentheindividualwasadmittedtotheInfirmary,emergencyroomand/orhospital.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughPNMPsprescribeadequatemealtime,oralhygieneandoralmedicationplansforindividuals,diningplanscontinuetolackadequatefeedingandmealtimetechniquesandpositioningoftheindividualduringpersonalcareandduringotheractivitiesthatarelikelytoprovokeswallowingdifficulties.Whentheydocontainthenecessarycomponents,theplansarenotconsistentlyintegratedintotheISP.WhentheyareintegratedintotheISPtheyarenotconsistentlyreviewedand/orchangeduponchangeinstatusorsetting.”TheMonitoringTeam’sfindingsalsoshowedthattheFacilitywasnotcompliantwiththisprovision.PNMPswerereviewedforindividualsinSample#1andSample#2,andtheresultsofthisreviewarediscussedinthissection.IdentificationofIndividualsRequiringaPNMPTheFacilityprovidedanadditionallistthatidentifiedindividualswithPNMneeds,dated5/18/12.Thelistnotedthat237of260(91%)individualshadPNMneedsandhadaPNMP.Twenty‐threeof260(9%)individualsdidnothavePNMneedsoraPNMP.Areviewofthese23individualsriskrankingspresentedintheCCSSLCIntegratedRiskRatings‐byHome,dated5/31/12,showedthatsomeoftheseindividualshadPNMneedsasevidencedbyahighand/ormediumriskrankinginchoking,aspiration,falls,fractures,skinintegrity,and/orweight.However,theseindividualswereidentifiedwith“noPNMneeds.”Inaddition,oneofthe23individuals(i.e.,Individual#61)hadbeenadmittedtotheFacilityon5/15/12,andherriskrankingswerenotprovided.Thefollowingconcernswerenotedforindividualswhoreceivedahighand/ormediumPNMriskranking,butdidnothaveaPNMP:

Anindividual’shighand/ormediumriskratingforaspirationindicatestheneedforaPNMP.Individual#7’sIDTrankedherathighriskforaspiration,butshewasnotonthelistofindividualswithPNMneeds.

IndividualsathighriskforchokinghaveaneedforaPNMP.Individual#7wasrankedathighriskforchoking,butwasnotonthelistofindividualswithPNM


# Provision AssessmentofStatus Complianceneeds.

Individualsathighand/ormediumriskforfallshadaneedforaPNMP.However,individualswereidentifiedasnothavingPNMneeds,butwererankedathighand/ormediumriskforfalls(i.e.,Individual#193andIndividual#353).

Individualsathighand/ormediumriskforskinintegrityrequiredaPNMP.However,individualswereidentifiedwith“noPNMneeds,”butwererankedathighand/ormediumriskforskinintegrity(i.e.,Individual#255andIndividual#353).

Individualsathighand/ormediumriskforweightindicatedtheneedforaPNMP.However,individualsrankedathighand/ormediumriskforweightdidnothaveaPNMP(i.e.,Individual#48,Individual#238,Individual#5,Individual#46,Individual#88,Individual#255,Individual#325,Individual#174,Individual#318,Individual#109,Individual#312,andIndividual#353).

Basedontheexamplesabove,individualswhohadbeenidentifiedwith“noPNMneeds”did,infact,havePNMneeds.Consequently,theMonitoringTeamdidnothaveconfidenceintheaccuracyofthislist.TheHTDepartmentshouldfollowtheStateOfficepolicythatdefinedthePNMcriteriaforindividualswhorequireaPNMP.TheStateOfficepolicyPNMcriteriashouldbeutilizedtoreviewthelistof23individualswith“noPNMneeds”todeterminewhichoftheseindividualsmeetthePNMcriteriaandshouldbeprovidedwithaPNMPsufficienttomeettheirneeds.PNMPFormatandContentOn5/30/12,theFacilityPNMPDirectionshadbeenrevised.Thedirectionshadbeenupdatedtoaddresstheplacementofmedicationadministrationinstructions;addadaptiveequipmentsuchasacontinuouspositiveairwaypressure(C‐Pap)devices,glasses,denturestothePNMPiftheindividualrequiredstaffassistanceforplacementoftheequipment;andspecifythatrevisionofaPNMPrequiredthecompletionofanAssessmentofCurrentStatus,andcompletionofanin‐servicebythetherapistforthePNMPCoordinatorontherevisedPNMP.TheseadditionstothePNMPdirectionswerepositivechanges.ThePNMPCoordinatorSupervisorwasresponsibleformaintainingtheHTDatabasetoensurecurrentinformationwasenteredwhenanindividual’sPNMPwasrevised.TheserevisionscouldoccurduringanannualISPmeetingand/orwhenanindividualexperiencedachangeinstatus.BasedoninterviewwiththePNMPCoordinatorSupervisor,thecontentoftherevisedPNMPwasreviewedtoensurecompliancewiththeFacilityPNMPdirections.Ifnot,thePNMPwouldbereturnedtothetherapistforcorrection.ThePNMPCoordinatorhadtheabilitytorunindividual‐specificPNMPreportsandPNMPsbyhome.


# Provision AssessmentofStatus ComplianceAreviewof11individuals’PNMPswhoreceivedenteralnutrition(i.e.,Individual#122,Individual#126,Individual#142,Individual#340,Individual#273,Individual#176,Individual#124,Individual#266,Individual#274,Individual#269,andIndividual#68)inSample#1found:

Elevenofthe11individuals(100%)hadaPNMP. Elevenofthe11individuals’PNMPs(100%)werecurrentwithinthelast12

months. Noneofthe11individuals’annualISPs(0%)notedthattheappropriate

disciplineswerepresenttoapproveandintegratethePNMPintheISP.TheSettlementAgreementrequiresthatPNMPsbedevelopedbasedoninputfromtheIDT,homestaff,medicalandnursingstaff,andthephysicalandnutritionalmanagementteam.

o Medicalstaffwerepresentin9of11annualISPmeetings(82%);o Nursingstaffwerepresentin10of11annualISPmeetings(91%);o RegisteredDieticianstaffwerepresentinnoneof11annualISP

meetings(0%);o Physicaltherapistswerepresentintwoof11annualISPmeetings

(18%);o Occupationaltherapistswerepresentin1of11annualISPmeetings

(COTAattended)(9%);o Speechlanguagepathologistswerepresentintwoof11meetings

(18%);o Psychologistswerepresentinfiveof11annualISPmeetings(45%);ando Directsupportprofessionalswerepresentineightof11meetings

(73%). Noneofthe11individuals’PNMPs(0%)wereintegratedintotheISP(e.g.,PNMP

strategiesintegratedintonursingcareplans,skillacquisitionprograms,BSPs). Elevenof11,individuals’PNMPs(100%)notedindividual‐specificrisksand

relatedtriggers. Innoneof11individuals’PNMPs(0%)wereadequatepositioninginstructions

includedforwheelchairpositioning,includingwrittenandpictorialinstructionsandsafeelevationranges.Morespecifically,thewheelchairpositioninginstructionsdidnotprovideadequateinstructionsforstafftoachieveasafeelevationrange.

Inthreeof11individuals’PNMPs(i.e.,Individual#274,Individual#126,andIndividual#269)(27%),therewereadequatealternatepositioninginstructionsincludingwrittenandpictorialinstructionsandsafeelevationranges.

In10of11individuals’PNMPs(i.e.,Individual#266,Individual#176,Individual#340,Individual#273,Individual#124,Individual#126,Individual#68,Individual#122,Individual#142,andIndividual#274)(91%),bedtimepositioningoptionswerenoted.Individual#269’sPNMPstated:“requires


# Provision AssessmentofStatus Complianceassistancewithall bedmobility.”However,herPNMPdidnotprovidestaffinstructionsforalternatebedpositions.

In11of11individuals’PNMPs(100%),thereweretransferinstructions(i.e.,mechanicallift,two‐person,pivot).

Individual#269ateorallyandreceivedenteralnourishment.Thefollowingrelatedfindingsweremadewithregardtothisindividual’sPNMP:

o Innoneofoneindividual’sPNMPs/diningplansforindividualswhoateorally(0%),mealtimeplansincludedwrittenand/orpictorialinstructionsforpositioning.

o Inoneofoneindividual’sPNMPs/diningplansforindividualswhoateorally(100%),mealtimeplansincludedwrittenand/orpictorialinstructionsforfoodtexture.

o Inoneofoneindividual’sPNMPs/diningplansforindividualswhoateorally(100%),mealtimeplansincludedwrittenand/orpictorialinstructionsforfluidconsistency.

o Inoneofoneindividual’sPNMPs/diningplansforindividualswhoateorally(100%),mealtimeplansincludedstaffpresentationtechniques.

Noneof11individuals’PNMPs(0%)notedsafepositioningelevationrangestobeutilizedduringdentalappointments.

Elevenof11individuals’PNMPs(100%)statedthetimeanindividualneededtoremainuprightaftereatingand/orreceivingenteralnutrition.

Innoneof11individuals’PNMPs(0%),medicationadministrationstrategiesincludedpositioningoptionswithsafeelevationranges.

Individual#269receivedmedicationbymouth.Thefollowingrelatedfindingsweremadewithregardtothisindividual’sPNMP:

o Inoneofoneindividual’sPNMPs(100%),themedicationadministrationstrategiesforindividualsthatreceivedmedicationbymouthincludedinstructionsfordiettextureandfluidconsistency.

o Inoneofoneindividual’sPNMPs(100%),themedicationadministrationstrategiesforindividualswhoreceivedmedicationbymouthincludedinstructionsformealtimeadaptiveequipment.

o Innoneofoneindividual’sPNMPs(0%),medicationadministrationstrategiesforindividualswhoreceivedmedicationbymouthincludedinstructionsforpresentationtechniques.

Innoneof11individuals’PNMPs(0%)includedadequatestrategiesfororalhygiene,includingpositioningwithsafeelevationranges.Specifically,thesafeelevationrangesweremissing.

Sevenof11individuals’PNMPs(i.e.,Individual#340,Individual#274,Individual#68,Individual#142,Individual#266,Individual#269,andIndividual#273)(64%)includedthereasonsforanindividual’sprescribedadaptiveequipment.


# Provision AssessmentofStatus Compliance Fiveof11individuals’PNMPs(i.e.,Individual#340,Individual#126,Individual

#124,Individual#266,andIndividual#176)(45%)includedbathing/showeringpositioninginstructionstoachieveasafeelevationrange.

Oneof11individuals’PNMPs(i.e.,Individual#274)(9%)includedadequatepersonalcareinstructions,withelevationstrategiesduringcheckingandchanging.

Elevenof11individuals’PNMPs(100%)statedhowanindividualwouldcommunicatewithstaff.

Areviewofsevenindividuals’PNMPsonthePNMTcaseloadinSample#2found:

Sevenofthesevenindividuals(100%)hadaPNMP. Sevenofthesevenindividuals’PNMPs(100%)werecurrentwithinthelast12

months. Noneofthesevenindividuals’annualISPs(0%)notedthattheappropriate

disciplineswerepresenttoapproveandintegratethePNMPintheISP.o MedicalstaffwerepresentinoneofsevenannualISPmeetings(14%);o NursingstaffwerepresentinfourofsevenannualISPmeetings(57%);o RegistereddieticianstaffwerepresentinnoneofsevenannualISP

meetings(0%);o PhysicaltherapistswerepresentinoneofsevenannualISPmeetings

(14%);o OccupationaltherapistswerepresentinoneofsevenannualISP

meetings(14%);o Speechlanguagepathologistswerepresentinnoneofsevenmeetings

(0%);o PsychologistswerepresentintwoofsevenannualISPmeetings(29%);

ando Directsupportprofessionalswerepresentinfourofsevenmeetings

(57%). Noneofthesevenindividuals’PNMPs(0%)wereintegratedintotheISP(e.g.,

PNMPstrategiesintegratedintonursingcareplans,skillacquisitionprograms,BSPs).

Sevenofsevenindividuals’PNMPs(100%)notedindividual‐specificrisksandrelatedtriggers.

Intwoofsevenindividuals’PNMPs(i.e.,Individual#89andIndividual#144)(29%),therewereadequatepositioninginstructionsforwheelchairpositioning,includingwrittenandpictorialinstructionsandsafeelevationranges.

Intwoofsevenindividuals’PNMPs(i.e.,Individual#89andIndividual#144)(29%),therewereadequatealternatepositioninginstructionsincludingwrittenandpictorialinstructionsandsafeelevationranges.

Infourofsevenindividuals’PNMPs(Individual#89,Individual#144,Individual


# Provision AssessmentofStatus Compliance#278,andIndividual#43)(57%),bedtimepositioningoptionswerenoted.

Insevenofsevenindividuals’PNMPs(100%),thereweretransferinstructions(i.e.,mechanicallift,two‐person,pivot).

ThreeindividualsateorallywithinSample#2:Individual#144,Individual#278andIndividual#378.Thefollowingrelatedfindingsweremadewithregardtotheseindividuals’PNMPs:

o Inoneofthreeindividuals’PNMPs/diningplans(i.e.,Individual#144)forindividualswhoateorally(33%),mealtimeplansincludedwrittenand/orpictorialinstructionsforpositioning.

o Inthreeofthreeindividuals’PNMPs/diningplansforindividualswhoateorally(100%),mealtimeplansincludedwrittenand/orpictorialinstructionsforfoodtexture.

o Inthreeofthreeindividuals’PNMPs/diningplansforindividualswhoateorally(100%),mealtimeplansincludedwrittenand/orpictorialinstructionsforfluidconsistency.

o Intwoofthreeindividuals’PNMPs/diningplans(Individual#278andIndividual#378)forindividualswhoateorally(66%),mealtimeplansincludedstaffpresentationtechniques.

Noneofsevenindividuals’PNMPs(0%)notedsafepositioningelevationrangestobeutilizedduringdentalappointments.

Fourofsevenindividuals’PNMPs(i.e.,Individual#278,Individual#378,Individual#239,andIndividual#117)(57%)statedthetimeanindividualneededtoremainuprightaftereatingand/orreceivingenteralnutrition.

Inthreeofsevenindividuals’PNMPs(i.e.,Individual#144,Individual#278,andIndividual#117)(43%),medicationadministrationstrategiesincludedpositioningoptionswithsafeelevationranges.

ThreeindividualsreceivedmedicationorallywithinSample#2:Individual#144,Individual#278andIndividual#378.Thefollowingrelatedfindingsweremadewithregardtotheseindividuals’PNMPs:

o Inthreeofthreeindividuals’PNMPs(100%),medicationadministrationstrategiesforindividualsthatreceivedmedicationbymouthincludedinstructionsfordiettextureandfluidconsistency.

o Inthreeofthreeindividuals’PNMPs(100%),medicationadministrationstrategiesforindividualswhoreceivedmedicationbymouthincludedinstructionsformealtimeadaptiveequipment.

o Innoneofthreeindividuals’PNMPs(0%),medicationadministrationstrategiesforindividualswhoreceivedmedicationbymouthincludedinstructionsforpresentationtechniques.

Noneofsevenindividuals’PNMPs(0%)includedstrategiesfororalhygiene,includingpositioningwithsafeelevationranges.

Noneofsevenindividuals’PNMPs(0%)includedthereasonsforanindividual’s


# Provision AssessmentofStatus Complianceprescribed adaptiveequipment.

Fiveofsevenindividuals’PNMPs(i.e.,Individual#144,Individual#278,Individual#378,Individual#239,andIndividual#43)(71%)includedbathing/showeringpositioninginstructionstoachieveasafeelevationrange.

Threeofsevenindividuals’PNMPs(i.e.,Individual#144,Individual#278,andIndividual#378)(43%)includedadequatepersonalcareinstructions,withelevationstrategiesduringcheckingandchanging.

Sevenofsevenindividuals’PNMPs(100%)includedstrategiesforhowstaffwastocommunicatewithanindividual.

Sevenofsevenindividuals’PNMPs(100%)statedhowanindividualwouldcommunicatewithstaff.

AreasofnoncomplianceinPNMPstrategieswerenotsignificantlydifferentfromindividualsinSample#1orSample#2.Thefollowingconcernswerenoted:

HOBEassessmentshadnotbeencompletedtoestablishsafeelevationrangesinwheelchairandalternatepositions,bathing/showering,personalcare,oralcare,dentalappointments,orotheractivitiesthatwerelikelytoprovokeswallowingdifficulties.HTDepartmentmeetingminutes,dated5/18/12,indicated“accordingtoStatepolicywemusthaveHOBEsonfileforthefollowingcategoriesaspartofstandardassessment:requiringventilation,enteralfeedings,andhavehadaspirationpneumoniainthepastyear.”TheHTDirectorwastoschedulerefreshertrainingonHOBEassessments.Individuals’PNMPswillneedtohaveHOBEassessmentdataintegratedtoprovidestaffinstructionsforsafeelevationrangesindailyactivities.

Wheelchairpositioninginstructionsinstructedstafftoplaceanindividualinthemost“uprightposition.”BasedoninterviewwithstaffduringanobservationandthePNMTnurse,the“uprightposition”onthePNMPreferredtotheindividualbeinguprightnotthetiltofthewheelchairbase.Forexample,individuals’wheelchairsweredesignedtobetiltedwithinarangeofdegrees.However,thePNMPdidnotprovideinstructionsforstafftoachievethesafeelevationrangeand/orrangesforanindividualinthewheelchair.DuringaninterviewwiththePTDirector,adraftPNMPwassharedwiththeMonitoringTeamtoaddressthisconcern.ThepositioninginstructionsonIndividual#340’sPNMPhadbeenrevisedtostate:“usemostallowedrangesoftheWC45‐75degreespositioninwheelchairwhenreceivingnutritionormedicationviaG‐tube.75[degrees]ispreferablebutifhisheadisflexingforwardhemaybereclinedto45degrees.”Theseinstructionswereanimprovement.Theseinstructionsprovideddirectionforplacementofthewheelchairbasewithinrecommendeddegreesofelevationtosupportsafetyfortheindividual.

Theabsenceofclinicians(i.e.,OT,PT,SLP,andRD)duringtheannualISPmeetingsnegativelyimpactedthediscussionrelatedtotheintegrationofPNMP


# Provision AssessmentofStatus ComplianceanddiningplansintotheISP,riskassessment,andmultiplesupportplans. ThesecliniciansweretheauthorsofthePNMPsandtheircontributionwascriticaltotheteamunderstandingthepurposeoftheindividual’sPNMP.

AccordingtoFacilitydocumentation,aPNMPaudittoolhadbeendevelopedbuthadnotbeenimplemented.TheFacilityshouldreviewtheFacilityPNMPaudittooltodetermineifthetoolincludesthePNMPcomplianceindicatorspresentedinthissection.ImplementationofIndividuals’PNMPOff‐Campus(i.e.,communityouting,hospitalization)TherewasnoFacilitypolicythatspecificallyaddressedtheimplementationofindividuals’PNMPoff‐campus(i.e.,hospitalization,communityouting).Nineindividuals’(i.e.,Individual#126,Individual#124,Individual#176,Individual#273,Individual#340,Individual#304,Individual#156,Individual#266andIndividual#198)inSample#1andfourindividuals(i.e.,Individual#239,Individual#117,Individual#144andIndividual#239)inSample#2werehospitalizedsincethelastreview.AreviewofHospitalLiaisonreportsfortheseindividualsnotedthefollowingconcerns:

HospitalLiaisonReportsnotedthepresenceofanindividual’sPNMP,butdidnotdiscussifthePNMPstrategieswerebeingimplementedasprescribed.

IPNscompletedbyHospitalLiaisonNursenotedthepresenceofacopyofthePNMPandthepositionoftheindividual(e.g.,Individual#176,Individual#124,Individual#340,Individual#304,Individual#156,andIndividual#198).TheIPNsaddressedthepositionoftheindividual(s),however,thenotesdidnotindicateifthepositionandtheelevationrangewereinalignmentwiththePNMPstrategies.

TheStateOfficepolicy012.2stated:“theplan[PNMP]isdesignedtospana24‐hourday,sevendaysperweek,andisdesignedtomeettheneedsofaspecificindividual.”TheFacilityshoulddeveloplocalprocedurestoaddresstheimplementationofPNMPsoff‐campus.ChangeinStatusUpdateforIndividuals’PNMPsConductedbytheIDTand/orIndividualsonthePNMTCaseloadIndividuals’revisedPNMPwerereviewedtodetermineifanISPAmeetinghadbeenconductedtoaddresstheproposedrevisionsandthefollowingwasfound:FortheindividualsinSample#1,fourofthe11individuals’PNMPshadbeenrevisedaftertheirannualISPmeeting(i.e.,Individual#340,Individual#126,Individual#142,andIndividual#176).

Noneofthefourindividuals(0%)hadanISPAmeetingconductedtoaddressthe


# Provision AssessmentofStatus CompliancePNMPrevisions.

Noneofthefourindividuals’records(0%)hadsupportingdocumentationtoshowthattheindividuals’revisedPNMPshadbeenimplemented(i.e.,IPNnotes,individual‐specificmonitoring).

FortheindividualsinSample#2,sevenofthesevenindividuals’PNMPshadbeenrevisedaftertheirannualISPmeeting.

Oneofsevenindividuals’ISPAmeeting(s)(i.e.,Individual#278)(14%)notedthePNMPhadbeenreviewedandrevised,asappropriate,basedontheindividual’schangeinstatus.

Oneofthesevenindividuals’records(i.e.,Individual#278)(14%)hadsupportingdocumentationtoshowthattheindividuals’revisedPNMPshadbeenimplemented(i.e.,IPNnotes,individual‐specificmonitoring).

TheFacilityPNMPDirections,revised5/30/12,includedasectionrelatedtoPNMPrevisions,anddiscontinuingand/orplacingstrategiesonhold.However,thissectiondidnotinstructclinicianstorequestanISPAmeetingtopresentPNMPrevisions.TheFacilityPNMPDirectionsshoulddiscussrequestinganISPAmeetingtoensurethataninterdisciplinarydiscussionoftheproposedrevisionsoccursandtheIDTmembersprovideapprovaloftherevisedPNMP.

O4 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,eachFacilityshallensurestaffengageinmealtimepracticesthatdonotposeanundueriskofharmtoanyindividual.Individualsshallbeinproperalignmentduringandaftermealsorsnacks,andduringenteralfeedings,medicationadministration,oralhygienecare,andotheractivitiesthatarelikelytoprovokeswallowingdifficulties.


TheFacilityhadcompletedcompetency‐basedtrainingfor48outof82diningroommonitors(59%).

TheFacility’sSelf‐Assessmentindicatedthat:“Basedonfindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughthesystemisinplace,notallrequiredemployeeshavebeentrained.Thesystemhasproduceddata;however,ithasnotbeeninplacelongenoughtoanalyzethatdataortomakenecessarycorrectivechanges.”TheMonitoringTeamdiscussesthisinitiativewithinthissection.MonitoringTeam’sObservationofStaffImplementationofIndividuals’PNMPsTheMonitoringTeamandthePNMTnursecompleteddirectobservationsintheInfirmaryandresidences,includingthediningroomsforfiveindividualsonthePNMTcaseload,including:Individual#43,Individual#239,Individual#89,Individual#378,andIndividual#278.

Innoneofthreeobservationsduringmealtimesofindividuals(0%),stafffollowedmealtimeplaninstructionsforpositioning(Individual#278,Individual#378,andIndividual#89).

Inoneoftwoobservationsduringmealtimesofindividualswhoateorally

Noncompliance


# Provision AssessmentofStatus Compliance(50%),staffpresentedthecorrectfoodtexture.TheincorrectfoodtexturewaspresentedtoIndividual#378.

Inoneoftwoobservationsduringmealtimesofindividualswhoateorally(50%),staffpresentedthecorrectfluidconsistency.Individual#378’sprescribedfluidconsistencywasnectar,butshewaspresentedaregularfluid.

Intwooftwoobservationsduringmealtimesofindividualswhoateorally(100%),theindividualand/orstaffusedtheprescribedadaptiveequipment.(Individual#278andIndividual#378).

Innoneoftwoobservationsduringmealtimesofindividualswhoateorally(0%),stafffollowedmealtimepresentationtechniques(i.e.,Individual#378andIndividual278).

Innoneofoneobservation(0%),staffcompletedatransfer(i.e.,mechanicallift,pivot,two‐personmanual)asinstructedinthePNMP(i.e.,Individual#378).

Innoneofoneobservation(0%)stafffollowedalternatepositioninginstructions(i.e.,Individual#43).

Innoneoftwoobservations(0%)wastheindividualpositionedcorrectlyinawheelchair(i.e.,Individual#239andIndividual#89).

Thefollowingconcernswerenoted:

ThePNMPprovidesthefoundationforhealthandsafety.ObservationsofthesefiveindividualsbytheMonitoringTeamandthePNMTnurserevealedthatPNMPshadbeenbreached.ThePNMTnursehadtointervenewithstaffduringeveryobservationtocorrectstaff’sapproachforwheelchairpositioning,alternatepositioning,mealtimefluidconsistencyandpresentationtechniques,andtransfers.

ApulledstaffmemberintheInfirmarystatedthatadditionaltrainingwouldbehelpful.AnotherpulledstaffinRibbonfishwasnotfamiliarwiththecorrectprocedureforapivottransfer.Pulled/reliefstaffrequiredadditionalsupporttoimplementindividuals’PNMPscorrectly.

Theseobservationssubstantiatedthatstaffwerenotcompetentinimplementingfoundationaland/orindividual‐specificPNMPstrategies.ThePNMTandIDTmembersshouldprovideadditionalsupporttostafftoenhancetheircompetencyintheimplementationofPNMPs,particularlyforthoseindividualsathighestrisk.FacilityInitiativesSincethelastreview,theFacilitycontinuedtoworkonimprovingtheirmealtimedeliverysystemtoensurestaffdidnotengageinunsafemealtimepractices.DiningRoomMonitorshadbeenaddedtoprovideanadditionallevelofoversightinthediningrooms.FacilityPolicyP.5,EnsuringSafePracticesDuringMeals,definedtheroleofaDiningRoomMonitor(DRM).TheDRMwasresponsibleformonitoringtheoverall


# Provision AssessmentofStatus Compliancefunctionofthediningroom.ADRMwasaTeamLeaderorResidentialCoordinator.Therewere82DiningRoomMonitors.TheDRMdidnotdirectlyassistindividuals.TheDRMwasresponsibleforcompletingoneDiningRoomObservationReportpermealwhichincludedthefollowingsectionswithmultipleindicatorsundereachsection:

Environmental; PresenceanduseofPNMP/DiningPlanandDietCard; Presenceanduseofmaterials/equipment; Implementationofdiningplantechniques;and Individualsassistedbystaff.

BasedoninterviewwiththeHTDirector,theseindicatorswerepulledfromavarietyofsources:ICF/IDsurvey,MockSurvey,IndependentMonitor’sReports,andFacilitystaff.DiningRoomMonitoringTrainingrostersweresubmittedwhichreported49DRMs(i.e.,TeamLeadersandResidentialCoordinators)completedathree‐hourtrainingconductedbytheHTDirector.ThetrainingincludedareviewofFacilityPolicyP.5,EnsuringSafePracticesDuringMeals,SafeMealtimePracticesProtocol,DiningRoomObservationReportandInstructions,MealtimeSafetyObjective,andvisitsforcompetencyinthediningroom.TheFacilityself‐assessmentresultsforSectionO.4indicated48outof82DRMs(58%)hadcompletedthistraining.Thefinalcomponentofthecompetency‐basedtrainingrequiredajointobservationwithatherapistinthediningroomwithouttheDiningRoomObservationReport,thesecondobservationrequiredthecompletionofoneformbytheDRMinconjunctionwiththetherapist,andthefinalrequiremententailedtheindependentcompletionofareportforminthediningroombytheDRMandthetherapist.Aninter‐raterreliabilityagreementscoreof80%hadtobeachievedtocompletecompetencyfordiningroomsupervision/monitoring.Thisinitiativewasinthebeginningstages.TheMonitoringTeamwillobserveDRMsduringthenexton‐sitereviewaswellasreviewtheFacility’strackingandtrendingofdatafromthesereports.

O5 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,eachFacilityshallensurethatalldirectcarestaffresponsibleforindividualswithphysicalornutritionalmanagementproblemshavesuccessfullycompletedcompetency‐basedtraininginhowtoimplementthemealtimeandpositioningplansthattheyareresponsibleforimplementing.


TheFacilitydidnothavedataavailabletosubstantiatethatcompetency‐basedtrainingforstaffhadbeencompletedforindividualsthatrequiredindividual‐specificPNMPtraining.TheFacilityreporteditwasintheprocessofdevelopingasystemtodocument“individual‐specific”training.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthough100%ofthestaffhascompletedcompetency‐basedtrainingforfoundationalskills,theycontinuetoneedsupportwithimplementinganddocumentingtheimplementationof‘individual‐specific’training.”TheMonitoringTeamconcurswiththeseself‐assessmentfindings.

Noncompliance


# Provision AssessmentofStatus ComplianceNEOOrientationSincethelastreview,theNEOtrainingscheduleandcurriculumhadnotbeenrevised.NewstaffwereresponsibleforcompletingthefollowingPNMfoundationalperformancecheck‐offs:mechanicallifting;transfers,includingstandpivottransfer,andtwopersonmanualtransfer;bedpositioning/positioner;wheelchairpositioning;bathtrolleys;rollingshower;toiletchair;stationaryshowerchair;hearing;speech‐languagecommunicationobjectives;adaptivediningequipment;mealtimesafety;SimplyThick;heelprotectorandsoftshoes;hosieryandcompressionsstockings;elbowpad;palmprotectors;wristandhandsplints;anklefootorthotics;helmets;gaitbelts;andwalking/program/walking.Thecontentoftheperformancecheck‐offswererelevantandappropriatetoteststaffcompetencieswithfoundationalPNMskills.BasedoninformationprovidedbytheFacility,192newemployeeshadsuccessfullycompletedthePNMcorecompetenciesperformancecheck‐offssincethelaston‐sitereview.TheFacilityshouldprovidethetotalnumberofnewemployeeswhorequiredtraining(N)andthenumberofnewemployeeswhohavecompletedfoundationalPNMtraining(n)toyieldapercentoftrainingcompliance.PNMCoreCompetenciesforCurrentStaffTheFacilityreportedthat323currentstaffhadsuccessfullycompletedtheperformancecheck‐offsforPNMfoundationalskillsinthepastsixmonths.TheFacilityshouldprovidethetotalnumberofcurrentstaffwhorequiredtraining(N)andthenumberofcurrentstaffwhohavecompletedfoundationalPNMtraining(n)toyieldapercentoftrainingcompliance.AnnualRefresherTrainingBasedoninterview,theFacility’sannualrefreshertrainingwastobeexpanded.Currentstaffwouldberesponsibleforsuccessfullycompletingperformancecheck‐offsfortransferlifts,two‐personmanuallift,bedpositioning,mechanicallift,stand‐pivottransfer,wheelchairpositioning,adaptivediningequipment,thickeningliquids,andmealtimesafety.Again,theFacilityshouldprovidethetotalnumberofcurrentstaffwhorequiredannualrefreshertraining(N)andthenumberofcurrentstaffwhohavecompletedfoundationalPNMtraining(n)toyieldapercentoftrainingcompliance.Individual‐specificPNMPTrainingTheFacilityreportedtheprocessfortheprovisionofindividual‐specificcompetency‐basedtrainingforPNMPs,diningplansandotherinterventionplanswas“stillunderdevelopment.”TrainingofRelief/PulledStaffAsstatedabove,theFacilityacknowledgedcurrentstaffhadcompletedPNM


# Provision AssessmentofStatus Compliancefoundationalcompetency‐basedtrainingandperformancecheck‐offs.However,observationsofrelief/pulledstaffintheInfirmaryandRibbonfishshowedthatthesestaffdidnotimplementindividuals’PNMPasprescribed.Theseobservationssubstantiatedthatrelief/pulledstaffthatprovidedsupportstoindividualsonthePNMTcaseloadrequiredadditionalsupporttoimplementPNMPscorrectly.TrainerCompetenciesAtthetimeofthereview,PNMPCoordinatorsweretheprimarytrainersforNEOandannualrefreshertraining.PNMPCoordinatorshadsuccessfullycompletedthePNMfoundationalperformancecheck‐offs.Basedoninterview,theFacilityhadnotformalizedatrain‐the‐trainerprocessforthePNMPCoordinators.TheFacilityshoulddevelopandimplementtrain‐the‐trainercompetencycheck‐offsforPNMPCoordinatorstosubstantiatetheircompetencyastrainers.

O6 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,eachFacilityshallmonitortheimplementationofmealtimeandpositioningplanstoensurethatthestaffdemonstratescompetenceinsafelyandappropriatelyimplementingsuchplans.


TheFacilityhaddevelopedandimplementedaDiningRoomMonitortrainingcurriculum.Inaddition,anidentification,training,andvalidationprocesswasdevelopedformonitorstoachieveaccuratescoring.Anauditingprocesswasusedformonitoringformswithanalysisofindividual‐specificconcernsandsystemicissuesandtheestablishmentofathresholdforstafftraining.Thisinitiativewillbediscussedbelowwithinthissection.

TheFacility’sauditoffourPNMTactionplansindicatedfouroutoffour(100%)identifiedthefrequencyofmonitoringinmeasurabletermsandnoneofthefourincludedmonitoringresults.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughthereisapolicywhichclearlyoutlinesthemonitoringsystemtoensureimplementationofmealtimeandpositioningplans,thesystemhasnotbeeninplacelongenoughtodetermineeffectiveness.Additionally,asystemisinplacetoensurethatthestaffdemonstratedcompetencyinsafelyandappropriatelyimplementingsuchplans,however,staffcontinuetoneedsupportwithdocumentingtheimplementation.PNMTactionplans,althoughoftenadequate,continuetolackproperdocumentationofcompletion.”However,notrendanalysisofcompliancemonitoringdatawaspresentedtosubstantiatethatstaffdemonstratedcompetencyinimplementingPNMPplans.Furthermore,areviewofFacilitymonitoringresultsforindividualswithinSample#2showedthattheFacility’smonitorshadfound90to100%compliance.ThesemonitoringresultswerenotconsistentwiththeMonitoringTeam’sandthePNMTnurse’sobservationsasdescribedindetailwithregardtoSectionO.4.

Noncompliance


# Provision AssessmentofStatus ComplianceFacilityMonitoringofStaffCompetencywithPNMPsOn1/9/12,theComplianceMonitoringformwasinitiated.Thisformreplacedtheindividual‐specificmealmonitoringandPNMTpre‐assessmentmonitoringforms.Sincethelastreview,norevisionshadbeenmadetotheComplianceMonitoringforminstructions.StaffresponsibleforcompletingthisformincludedthePT,PTA,OT,COTA,SLP,andPNMPCoordinators.TheFacilityPolicyP.4,DocumentingMealMonitoring,statedtheComplianceMonitoringformcouldbeusedtomonitorcompliancewithpositioning,snackadministration,medicationadministration,oralcare,bathing,lifting/transferring,andcommunication.However,thecurrentfocusfortheuseofthisformwasrelatedtostaffcompliancewithmeals.Thepolicyindicatednursingwastoconductmealmonitoringquarterly.Therapistswereresponsibleformealmonitoringforindividualsathighand/ormediumriskforaspiration,respiratorycompromise,andchoking.Individualsatmediumriskwithinthesecategoriesweremonitoredoncepermonth.HTstaffmonitoredindividualsathighrisktwiceamonth.ThePNMTusedthistoolpriortoevaluatinganindividual,withnosetschedule.TheresultsoftheseformswereenteredintotheComplianceMonitoringdatabase.Asof6/1/12,reportswereavailable.TheFacilitydidnotprovidethesereportsand/orananalysisofthemonitoringresults.TheMonitoringTeamreviewedthemonitoringresultsforthefiveindividuals(i.e.,Individual#43,Individual#239,Individual#89,Individual#378,andIndividual#278)inSample#2whotheMonitoringTeamandthePNMTnurseobserved.VariousFacilitystaffmonitoredtheseindividuals’staffwhiletheyimplementedthePNMPs.However,theFacilitymonitoringresultswerenotcongruentwithobservationsconductedduringtheonsitereview.TheMonitoringTeamreviewedindividual‐specificmonitoringforthepastsixmonthsandfound:

Individual#89’sstaffwasmonitoredatotaloffivetimes,includingbyaPNMPCoordinatorthreetimes,aPNMTNurse,andaRNCaseManager.Eachindividual‐specificmonitoringconductedwasscoredat100%compliance.Nomonitoringwasconductedfororalcare,bathing,transfers,oralternatepositioning.

Individual#278’sstaffwasmonitoredeighttimesusingtheComplianceMonitoringform.ThemonitorsincludedthePNMTNurse,PNMPCoordinator,SLP,Nurse,andCertifiedOccupationalTherapyAssistant(COTA).Sevenmonitoringsessionswerescoredat100%complianceandonewasscoredat90%duetothePNMPnotbeingavailable.Nocompliancemonitoringwasconductedforalternatepositioning,medicationadministration,oralcare,bathing,andlifting/transfer.

Individual43’sstaffwasmonitoredeighttimes.ThemonitorsincludedthePNMTNurse(fourtimes),PNMTPT(twotimes),Nurse(onetime),Physical


# Provision AssessmentofStatus ComplianceTherapyAssistant(onetime).Sevenmonitoringresultswerescoredat100%compliance.Theremainingmonitoringresultsscoredat90%complianceasaresultofstaffacknowledgmentofnothavingreceivedtraining.Nocompliancemonitoringwasconductedforalternatepositioning,medicationadministration,oralcare,bathing,andlifting/transfer.

EightComplianceMonitoringformsforIndividual#378werecompleted,includingbyaPNMPCoordinator(threetimes),PNMTNurse(twotimes),SLP(twotimes),andRNCaseManager(onetime).Thecompliancescorewas100%forsevenand90%duetostaffnotbeingtrained.Nocompliancemonitoringwasperformedforalternatepositioning,oralcare,bathing,andlifting/transfer.

SeventeenComplianceMonitoringformswerecompletedforIndividual#239byPNMPCoordinators(fourtimes),COTA(fivetimes),RTTechIII(twotimes),PNMTPT(threetimes),RN(twotimes),PNMTNurse(onetime).Thecompliancescoresforeachofthese17individual‐specificmonitoringwas100%.Nocompliancemonitoringwasdoneforalternatepositioning,oralcare,andlifting/transfer.

Themonitoringdatafortheseindividualsreflected90to100%staffcompliancewithPNMPs.TheFacility’smonitoringresultswerenotinalignmentwiththeMonitoringTeam’sobservations.Consequently,theMonitoringTeamdidnothaveconfidenceintheindividual‐specificmonitoringdatapresented.ThesemonitoringresultswouldleadtheFacilitytotheconclusiontherewerenoproblemswithstaffcomplianceofPNMPs.However,theMonitoringTeamandPNMTnursewitnessedmultiplebreachesintheimplementationofindividuals’PNMPsforthefiveindividualsobserved.Thesemonitoringresultswouldnotbeusefulinidentifyingproblematictrendsthatneededtobeaddressed.TheFacilityshouldhaveconfidenceinmonitoringdatatoallowittosubstantiateidentifiedproblematictrendsand,asaresult,developcorrectiveactionplanstoaddressthetrends.Inaddition,noevidencewaspresentedtoconfirminter‐raterreliabilitybetweenmonitors.Inter‐raterreliabilityshouldbeestablishedforthemonitoringtoolstoensurethatallauditors/monitorswereconsistentlydeterminingcomplianceusingthesameprocessandcriteria.

O7 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshalldevelopandimplementasystemtomonitortheprogressofindividualswithphysicalornutritionalmanagement


TheHTDirectorandthePCMauditedtherecordsoffourindividualsonthePNMTcaseload.Theirfindingsindicatednone(0%)oftheindividualrecordsprovided“consistentcompletionofadequateindividuals‐specificmonitoringtoaddressimplementationstatusofriskactionplansteps”and“didnotdetermineifPNMPswereeffectiveasevidencedbyimprovedclinicalindicators.”The

Noncompliance


# Provision AssessmentofStatus Compliancedifficulties,andreviseinterventionsasappropriate.

MonitoringTeam’sfindingsalsoshowedsimilarproblems.Thecurrentmonitoringsystemprovideddataonstaffcompliancewithindividual’sPNMPs.However,theMonitoringTeamquestionedthevalidityofmonitoringresultsforindividualsobservedduringtheon‐sitereview.However,theprovisionlanguageinthissectionrequirestheFacilitytodevelopandimplementaneffectivemonitoringsystemtoassesstheprogressofindividualswithphysicalornutritionalmanagementdifficulties.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughasystemhasbeendevelopedandimplementedtomonitortheprogressofindividualswithphysicalornutritionalmanagementdifficulties,itstilllacksthespecificityneededinordertodetermineeffectiveness.Additionally,becausenobaselineisestablishedusingspecificclinicalindicators,itisunclearwhetherinterventionsareeffectiveandsubsequentlyrevisedappropriately.”TheMonitoringTeam’sfindingsalsoshowedthattheFacility’scurrentmonitoringsystemdidnotassessand/ormonitortheeffectivenessofindividual‐specificriskactionplanssupportsandservicestominimizeand/orremediatephysicalornutritionalmanagementconcerns.EffectivenessofMonitoringtoAssesstheProgressofIndividualswithPhysicalorNutritionalManagementDifficultiesTheStateAtRiskIndividualspolicyintheRiskReviewsectionindicated:“eachdisciplineorprogramstaffidentifiedasresponsibleintheplanmustreviewthesupportplansthataddressidentifiedrisktoassesstheeffectivenessofthesupportforwhichtheyareresponsible.Thisreviewmustbecompletedasindicatedbyanindividual’sriskseverityorstatuschange,inordertoassesseffectiveness.DocumentationofthereviewwillberecordedintheIntegratedProgressNotes.”Areviewofindividuals’RiskActionPlansandIPNsinSample#1found:

Noneofthe11individuals’records(0%)containedevidenceofeffectivenessmonitoringbytherapiststoassesstheefficacyofriskactionplaninterventionsforindividualswithPNMdifficulties.

Noneofthe11individuals’records(0%)containedevidencethatinterventionswerechangedduetoalackofanindividual’sprogress.


Therapistshadnotconductedeffectivenessmonitoringtoassesstheprogressofanindividual’sriskactionplaninterventions.

Individuals’RiskActionPlansdidnotgenerateindividual‐specificclinicaldata,whichshouldbeusedtosubstantiateanindividualprogressandtoassessiftheindividualwasbetterorworse.


# Provision AssessmentofStatus Compliance Individuals’IPNsdidnotincludeanassessmentanindividual’sclinical

indicatorstoprovideanupdateonhealthstabilityand/orinstability. Monthlyprogressnoteswerenotcompletedtoreportontheeffectivenessofan

individual’ssupportsandservicesasidentifiedinariskactionplan.

PNMTMonitoringtoAssessIndividual’sProgressTheFacilityPNMTpolicydiscussedmonitoringanindividual’sPNMP.ThemonitoringofPNMPswasonecomponentthatshouldhavebeenevaluatedtoassessanindividual’sprogress.However,thepolicydidnotspecificallyaddresstheimplementationofeffectivenessmonitoringforindividualswithPNMTinterventionsasoutlinedinactionplans.BasedontheMonitoringTeam’sreviewoftherecordsforindividualsinSample#2:

Noneofthesevenindividuals’records(0%)containedevidencethattheprogressofindividualswithPNMdifficultieswasmonitoredtoassesstheefficacyoftheriskplaninterventions.

Noneofthesevenindividuals’records(0%)containedevidencethatinterventionswerechangedduetoalackofprogress.


IndividualsathighriskforaspirationdidnothaveAspirationTriggerDataSheet(s)implemented,and/orthereweremultiplemonthsduringwhichdatasheetshadnotbeencompleted.

Individuals’whoexperiencedongoingweightlossdidnothavetheirplansrevised.

Individuals’PNMTactionplansdidnotconsistentlyspecifyindividual‐specificclinicalindicatorstodefineanindividual’sstableand/orunstablehealthstatus.

Individualsdidnotreceiveindividual‐specificeffectivenessmonitoring. IPNsdidnotincludeareportontheeffectivenessofanindividual’ssupportsand

servicesasidentifiedinariskactionplan.

TheFacilityshouldimplementaneffectivenessmonitoringsystemtoreportontheprogressofindividual’sriskactionplanssupportsandservices,andreviseinterventionsasappropriate.

O8 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithin18monthsorwithin30daysofanindividual’sadmission,eachFacilityshallevaluateeachindividualfedby

FacilitySelf‐AssessmentAreviewoftheFacility’sSelf‐Assessmentresultsindicatedthefollowing:

TheHTDirectorandPCMauditedthreeindividuals’APENdatacollectiontools.Noneofthethree(0%)APENs“containedinformationsupportingthemedicalnecessityofthetube”and“potentialtransitiontoalessrestrictiveformofenteralnutritionand/ororaleating.”

Noncompliance


# Provision AssessmentofStatus Complianceatubetoensurethatthecontinueduseofthetubeismedicallynecessary.Whereappropriate,theFacilityshallimplementaplantoreturntheindividualtooralfeeding.

TheFacilityPNMTpolicywasreviewedandtheFacilityfoundthepolicydidnotdefinethefrequencyanddepthofassessmenttobecompletedbythefollowingdisciplines:nursing,medical,SLP,andOT.TheFacilityPNMpolicyindicatedindividuals“whoeatbytubeareevaluatedtodeterminewhetheratubeismedicallynecessaryandplansaremadetoreturntotheleastrestrictivemethodofeatingasappropriate.”TheFacilityPNMpolicyhadnotbeenrevisedtodefinethePNMTandIDTmembers’responsibilitiesduringtheinitialPNMT/IDTmeetingtoassesstherationaleforthecontinuedneedforenteralnutrition,ifappropriate.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughindividualswhoareenterallynourishedareevaluatedtheAspirationPneumoniaEnteralNutritional(APEN),datacollectiontoolsdonotconsistentlydocumentthecontinueduseofthetubeasmedicallynecessary.Subsequently,itisunclearfromthedocumentationwhetheraplantoreturntheindividualtooralfeedinghasbeenconsidered.”TheMonitoringTeam’sreviewofAPENdatacollectiontoolsforindividualsinSample#1andSample#2alsofoundtheFacilitywasnotincompliancewiththisprovision.IndividualsWhoReceiveEnteralNourishmentBasedoninterviewwiththeHTDirector,onaregularbasis,theHospitalLiaisonNursewastoupdatethelistofindividualswhoreceivedenteralnutrition.ASectionO.8actionplanindicatedaprotocolhadbeencompletedforthemaintenanceofthislist.However,theprotocolwasnotprovidedtotheMonitoringTeam.Twolistsweresubmittedthatidentifiedindividualswhoreceivedenteralnutrition:

CCSSLC:Individualswhoreceivenutritionthroughnon‐oralmethods,dated5/22/12,identified81individuals.Thelistpresentedthenameoftheindividual,theirhome,diningmethod,typeoftube,datetubeplaced,methodofdelivery,andiftheyreceivedpleasurefoods.

EnteralDiningReport,dated7/3/12,identified80individuals.Thelistpresentedthenameoftheindividual,homeandresidentialunit,typeoftube,anddeliverymethod.Thislistreflectedonelessindividual,becauseoneindividualwithafeedingtubehaddied.

Individual(s)WhoReceivedaFeedingTubeSincetheMonitoringTeam’slastreview,on4/14/12,oneindividual(i.e.,Individual#117)receivedagastrostomytube.On3/12/12,aFacilityphysicianreferredIndividual#117tothePNMTforahistoryoffalls.ThePNMTassessment,dated4/27/12,exceededthefiveworkingdaystimelinetoinitiateanassessment.Inaddition,thePNMThadnot


# Provision AssessmentofStatus Compliancecompletedanassessmentpriortotheplacementofhisgastrostomytube.TheFacilityshouldrevisethedraftFacilityPNMTReferralpolicytostateanindividualshouldbereferredtothePNMTpriortoplacementofafeedingtubeand/orafteranemergencytubeplacement.APENAssessmentsSincetheMonitoringTeam’slastreview,thedraftStateAt‐RiskIndividualspolicyandprocedures,dated5/24/12,presentedarevisedprocessforcompletinganAPENassessment.TheAspirationPneumonia/EnteralNutrition(APEN)wasidentifiedasadatacollectiontoolthatshouldbecompletedatleastannuallyiftheindividual:

Hadaspirationpneumoniaduringthepastyear;and/or Receivedenteralnutritionormedication.

TheAPENDataSheetinstructions,dated6/13/12,indicated:“forindividualswhoreceiveenteralnutrition,theAPENshouldbeusedtohelpidentifypotentialforreturntooraleatingandestablishmedicalnecessityofcontinuingenteralnutrition.”Theanalysisandrelatedrationalewastobedocumentedintheindividual’sIntegratedRiskRating(IRR)form.ThepurposeoftheAPENwasto“provideavehicleforrecordingthedataneededtoguidetheteamindetermineappropriateriskassignment.”MultipledisciplinesweretocontributeAPENdata.TheNurseCaseManagerwasresponsibleforbringingthecompletedformtotheISPmeeting.TheIDTwouldutilizetheAPENdatafora“comprehensivediscussionofenteralnutrition,aspirationandotherrelatedriskfactors.”TheIDTwasto“formulateplansbasedonthediscussionandanalysistodeterminethebestcourseoftreatmentoractionforindividualswhohavehadaspirationpneumoniaandtoassessindividualsforpossiblereturntooraleating.”However,theserevisionshadnotbeenformallyimplemented.TheMonitoringTeamwillreviewtheimplementationoftherevisedAPENprocessduringthenextreview.TheFacilitylist(s)ofindividualswhoreceivedenteralnutritiondidnotindicatethedateofthemostcurrentAPENassessment.TheFacilitylist(s)shouldincludethedateoftheAPENassessmenttotrackiftheseassessmentswerecompletedatleastannuallyforindividualswhoreceivedenteralnutrition.ElevenindividualsinSample#1,whoseIDTsweresupportingthem,receivedenteralnourishment:Individual#122,Individual#126,Individual#142,Individual#340,Individual#273,Individual#176,Individual#124,Individual#266,Individual#274,Individual#269,andIndividual#68.Areviewoftheseindividuals’APENassessments,actionplans,andISPsfound:

Noneofthe11individuals’APENassessments(0%)followedtheFacility‐establishedtemplateandcontentguidelines.

Threeofthe11individuals’APENassessments(i.e.,Individual#122,Individual


# Provision AssessmentofStatus Compliance#340,andIndividual#124)(27%)werecompletedwithina12‐monthperiod.

Noneofthe11individuals’APENassessments(0%)indicatedthattherewasinputfromappropriateIDTmembersasoutlinedintheFacility‐establishedAPENassessmentformat.APENassessmentsrevieweddidnothaveasignaturesheetand/orrequireddisciplineswerenotinattendance.

Noneofthe11individuals’APENassessments(0%)providedjustificationthatthecontinueduseofthetubewasmedicallynecessary.Theassessmentshouldprovideclinicaljustificationandananalysisofwhythetuberemainsamedicalnecessity.APENassessmentsresultsaddressedtheindividual’sriskforaspirationpneumonia.Theassessmentdidnotassessthemedicalnecessityofatubeorassesstheindividual’spotentialtoreceivealessrestrictiveformofenteralnutritionortransitiontooralintake,ifappropriate.

Noneofthe11individuals’APENactionplans(0%)wereintegratedintheISPand/oranISPA.

Noneofthe11individuals’APENrecommendationsandactionplans(0%)wereimplemented.

Noneofthe11individuals’APENassessments(0%)recommendedtheimplementationofaplantoreturntheindividualtooralfeeding,ifappropriate.

FiveofthesevenindividualsinSample#2,whoweresupportedbythePNMT,receivedenteralnourishment:Individual#89,Individual#239,Individual#117,Individual#43,andIndividual#278.Areviewoftheseindividuals’APENassessments,actionplans,andISPsfound:

Noneofthefiveindividuals’APENassessments(0%)followedtheFacility‐establishedtemplateandcontentguidelines.

Oneofthefiveindividuals’APENassessments(i.e.,Individual#89)(20%)werecompletedwithina12‐monthperiod.

Noneofthefiveindividuals’APENassessments(0%)indicatedthattherewasinputfromappropriateIDTmembersasoutlinedintheFacility‐establishedAPENassessmentformat.

Noneofthefiveindividuals’APENassessments(0%)providedjustificationthatthecontinueduseofthetubewasmedicallynecessary.Theassessmentshouldprovideclinicaljustificationandananalysisofwhythetuberemainsamedicalnecessity.

Noneofthefiveindividuals’APENactionplans(0%)wereintegratedintheISPand/oranISPA.

Noneofthefiveindividuals’APENrecommendationsandactionplans(0%)wereimplemented.

Noneofthefiveindividuals’APENassessments(0%)recommendedtheimplementationofaplantoreturntheindividualtooralfeeding,ifappropriate.


# Provision AssessmentofStatus ComplianceAsdocumentedabove,therewasnodiscernibledifferencebetweenthecontentofAPENassessmentsandactionplansfortheindividualsinSample#1orSample#2.TheseassessmentsandactionplansdidnotmeettherequirementsoftheSettlementAgreementto:“evaluateeachindividualfedbyatubetoensurethatthecontinueduseofthetubeismedicallynecessary”and“whereappropriate,theFacilityshallimplementaplantoreturntheindividualtooralfeeding.”PathwaytoReturntoOralIntakeand/orReceiveaLessRestrictiveApproachtoEnteralNutritionTheFacilitydidnothavewrittenproceduresforreturninganindividualtooraleating.TheFacilitylistCCSSLC:Individualswhoreceivenutritionthroughnon‐oralmethods,dated5/22/12,identifiedoneindividualinSample#1(i.e.,Individual#68)whoreceivedpleasurefeedings.NoneoftheindividualsinSample#2participatedinaformaltherapeutic/pleasurefeedingprogram.AreviewofIndividual#68’srecordsfound:

Noneoftheoneindividualwhohadreturnedtooralintake(0%)hadaplantoreturntooralfeeding.

Becausenoplanhadbeendeveloped,itsimplementationcouldnotbeassessed. Noneoftheoneindividualwhoreturnedtooralintake(0%)hadreceiveda

mealtimeassessment. Becausenoplanexisted,noneoftheoneindividual’splans(0%)identified

individual‐specifictriggersforwhentheplanshouldbestopped. Becausenoplanexisted,noneoftheoneindividual’splan(0%)identified

monitoringoversightforstaffcompliancewithplan. Becausenoplanexisted,noneoftheoneindividual’splans(0%)weremonitored

asoutlinedintheplan. Becausenoplanexisted,noneoftheoneindividual’splans(0%)weremodified,

ifappropriate.TheFacilityshouldestablishproceduresforIDTsand/orPNMTmemberstofollowforindividualswhowererecommendedtoreceivealessrestrictivemethodofenteralnutritionand/orreturntooralintake.


1. TheFacilityshouldidentifyaphysiciantoprovidePNMTmembersaresourceformedicalconsultation.(SectionO.1)2. TheFacilityshouldimplementtheactionplandevelopedtoprovideresolutionforidentifiedPNMTsystemicissues.(SectionO.1)3. ListstheFacilitymaintainstoidentifyindividualshavingphysicalandnutritionalmanagementproblemsshouldbeaccurate.TheFacility

shoulddevelopasustainablesystemtomaintainandupdatetheselistsontheHTdatabasetoensuretheirvalidity.(SectionO.2)4. TheFacilityshouldimproveitsPNMTreferraldatabase.TheFacility’sdatabaseshouldnotonlyreflectwhenareferralwasmadetothePNMT,

butalsoidentifythestatusofthePNMTreferral.Inaddition,theFacilityshouldauditcompliancewiththePNMTreferralprocess.(Section


O.2)5. PNMTassessmentsshouldbesufficienttoidentifyphysicalandnutritionalinterventionsandsupportstomeettheindividual’sneeds.They

shouldfollowtheFacility‐establishedPNMTassessmenttemplate;provideanadequateanalysistoidentifythecauseoftheindividual’sPNMconcerns;includeaPNMTself‐referraland/orIDTreferraldate;updatetheindividual’sriskrating(s),asappropriate;addressHOBEassessmentdata;establishindividual‐specificclinicalbaselinedatatoassistteamsinrecognizingchangesinhealthstatus;andidentifyindividual‐specificclinicalcriteriatoalertnursingstafftocontactthePNMT.(SectionO.2)

6. PNMTactionplansshouldinclude:theindividual’sidentifiedPNMproblemsaspresentedinthePNMTassessment;integrationofHOBEassessmentdata;preventativeinterventionstominimizetheconditionsofidentifiedriskindicators;appropriate,functional,andmeasurableobjectivestoallowthePNMTtomeasuretheindividual’sprogressandefficacyoftheplan;andspecificclinicalindicatorstobemonitored.(SectionO.2)

7. TheFacilityshouldprovideadditionalguidancethroughthedevelopmentofprocedurestofurtherdefinethePNMTdischargeprocesstoinclude,ataminimum:statusofefficacyofimplementedPNMTrecommendations,justificationforanindividualtobedischargedfromthePNMTthroughtheprovisionofobjectiveclinicaldatatodocumentstableorimprovedhealth,integrationofthePNMTrecommendationsintotheISP,andobjectiveclinicaldataforreferralbacktothePNMT.(SectionO.2)

8. TheHTDepartmentshouldfollowtheStateOfficepolicyforindividualswhorequireaPNMP.TheStateOfficepolicyshouldbeutilizedtoreviewtheFacility’slistof23individualswith“noPNMneeds”todeterminewhichoftheseindividualsmeetthePNMcriteriaandshouldbeprovidedwithaPNMPsufficienttomeettheirneeds.(SectionO.3)

9. TheFacilityshoulddevelopprocedurestofurtherdefinetheimplementationofPNMPsoff‐campus.(SectionO.3)10. TheFacilityshouldreviewitsPNMPaudittooltodetermineifthetoolincludesacomprehensivesetofPNMPcomplianceindicators.(Section

O.3)11. TheFacilityPNMPDirectionsshoulddiscussrequestinganISPAmeetingtoensureaninterdisciplinarydiscussionoccursofproposedrevisions

toPNMPsandtheIDTmembersapprovetherevisedPNMP.(SectionO.3)12. ThePNMTandIDTmembersshouldprovideadditionaltrainingand/orsupporttostafftoenhancetheircompetencyintheimplementationof

PNMPsforthoseindividualsathighestrisk.(SectionO.4)13. Whenprovidingdataontraining,theFacilityshouldprovidethetotalnumberofemployeeswhorequiredtraining(N)andthenumberof

employeeswhohavecompletedtraining(n)toyieldapercentoftrainingcompliance.(SectionO.5)14. TheFacilityshouldprovideadditionaltrainingand/orsupporttorelief/pulledstafftoensurePNMPsareimplementedasprescribed.(Section

O.5)15. TheFacilityshoulddevelopandimplementtrain‐the‐trainercompetencycheck‐offsforPNMPCoordinatorstosubstantiatetheircompetency

astrainers.(SectionO.5)16. Inter‐raterreliabilityshouldbeestablishedfortheFacilitymonitoringtoolstoensurethatallauditors/monitorsareconsistentlydetermining

complianceusingthesameprocessandcriteria.(SectionO.6)17. TheFacilityshouldimplementaneffectivenessmonitoringsystemtoreportontheprogressofindividual’sriskactionplanssupportsand

services,andreviseinterventionsasappropriate.(SectionO.7)18. TheFacilityshouldmaintainaccuratelist(s)ofindividualswhoreceiveenteralnutrition.(SectionO.8)19. TheFacilityshouldrevisethedraftFacilityPNMTReferralpolicytostatethatanindividualshouldbereferredtothePNMTpriortoplacement

ofafeedingtubeand/orafteranemergencytubeplacement.(SectionO.8)20. TheFacilitylist(s)identifyingindividualswhoreceiveenteralnutritionshouldincludethedateoftheAPENdatacollectiontoolandIRRFto

trackifassessmentshavebeencompletedannuallytodeterminewhetherornotthecontinueduseofthetubeismedicallynecessary,asrequiredbytheSettlementAgreement.(SectionO.8)

21. TheFacilityshouldestablishproceduresforIDTsand/orPNMTmemberstofollowforindividualswhowererecommendedtoreceivealessrestrictivemethodofenteralnutritionand/orreturntooralintake.(SectionO.8)


SECTIONP:PhysicalandOccupationalTherapyEachFacilityshallprovideindividualsinneedofphysicaltherapyandoccupationaltherapywithservicesthatareconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,toenhancetheirfunctionalabilities,assetforthbelow:


o PresentationBookforSectionP;o CCSSLCSelf‐Assessment,ActionPlans,andProvisionActionInformation;o Forthefollowing15individualsinSample#1,whichincludedindividualsidentifiedwith

PNMconcernsand/orhadexperiencedachangeofstatusasevidencedbyadmissiontotheFacilityInfirmary(ifapplicable),emergencyroom,and/orhospital:Individual#47Individual#251,Individual#97,Individual#304,Individual#159,Individual#246,Individual#7,Individual#198,Individual#181,Individual#350,Individual#332,Individual#42,Individual#156,Individual#243,andIndividual#46,thefollowingdocuments:OccupationalTherapy/PhysicalTherapycomprehensiveassessment,assessmentofstatus,updateinindividualrecord,Nutritionassessments,AspirationPneumonia/EnteralNutritionassessment,SpeechLanguagePathologycomprehensiveassessment,assessmentofstatus,updateinindividualrecord,HeadofBedElevationassessment,annualIndividualSupportPlanandIndividualSupportPlanAddendumsforpastyear,IntegratedRiskActionform,InterdisciplinaryTeamRiskActionPlan/IntegratedCarePlan,IntegratedProgressNotesforpastsixmonths,OT/PT/SLP/RDconsultationsforpastyear,AspirationTriggerSheetsforpastsixmonths,PhysicalNutritionalManagementPlan,diningplanswithsupportingwrittenandpictorialinstructions,forindividualshospitalizedwithinthissampletheHospitalLiaisonNursereportsacrossthepastsixmonths,therapeutic/pleasurefeedingplan,individual‐specificmonitoringforthepastsixmonths,PNMTPostHospitalizationassessment,documentationofstaffsuccessfullycompletingPhysicalNutritionalManagementfoundationaltraining,documentationofstaffsuccessfullycompletingindividual‐specifictraining,supportingdocumentationtosubstantiateanindividual’sprogresswithPNMdifficulties,incidentreportsandFacilityinvestigationsforchokingincidents,PNMPClinicminutes,monthlyreviewofOT/PTdirectintervention,quarterlyreviewofOT/PTprograms,supportingdocumentationforimplementationofOT/PTdirectinterventions,andsupportingdocumentationforimplementationofOT/PTprograms;

o FacilityPoliciesandProceduresrelatedtotheprovisionofOT/PTsupportsandservicesimplementedsincelastmonitoringvisit,revised4/23/12and5/25/12;

o OrganizationalchartofHabilitationTherapyDepartment,dated5/14/12;o CurrentOT,CertifiedOccupationalTherapyAssistant(COTA),PT,PhysicalTherapy

Assistant(PTA),andAssistiveTechnology(AT)staff,correspondingcaseloads,andcurriculavitafornewhires,revised5/17/12;

o ContinuingeducationcompletedbyOTsandPTssincelastonsitevisit,from1/12through6/12;

o Listofindividualswhousewheelchairasprimarymobility,dated5/21/12;o Listofindividualswithtransportwheelchairs,dated5/21/12;


o Listofindividualswithotherambulationassistivedevices,dated5/21/12;o Listofindividualswithorthoticsand/orbraces,dated6/5/12;o PhysicalNutritionalManagementMaintenanceLog,dated6/4/12;o OT/PTAssessmentsandUpdates(templates)withchangesmadesincelastreview,

revised5/10/12;o CompletedOT/PTAssessmentsfornewlyadmittedindividualssincelastreview,dated

12/20/11and2/27/12;o TrackingLogofcompletedindividualassessmentssincelastreview,from1/12through

7/12;o WheelchairseatingandPNMclinicassessment(templates),revised5/30/12;o Individual‐specificmealtimemonitoringschedule,undated;o Monthlyindividual‐specificPNMPchecksheet,revised2/15/12;o MonthlyHomeEquipmentchecksheet,revised2/15/12;o ComplianceMonitoring,revised2/2/12;o PNMPClinicminutes,revised5/30/12;o Competency‐basedperformancecheck‐offsheetsforPNMcorecompetenciesand

individual‐specificPNMPsalongwithdiningplansandotherinterventionplans,variousdates;

o SummaryreportsandmonitoringresultsrelatedtoOT/PT,from12/11through5/12;o ListofindividualsreceivingdirectOTand/orPTservicesandfocusofintervention,dated

5/21/12;o CompletedauditsofOT/PTdocumentation,from1/12through4/12;o Habilitation,Training,EducationandSkillAcquisitionStatePolicy#017,effectivedate

5/10/12;o UseofProtectiveDevicesPolicy#05,undated;o ISPMeetingGuide(Preparation/Facilitation/DocumentationTool),revised2/16/12;ando MostcurrentFacilitySectionPpolicies,multipledates.

Interviewswith:o Dr.AngelaRoberts,HabilitationTherapyDirector;o PaulOsborne,PTDirector;ando RosalindaCortez,OTDirector.

Observationsof:o Infirmary,residencesanddiningroomsinCoralSea,Pacific,andAtlantic.

FacilitySelf‐Assessment:BasedonareviewoftheFacility’sSelf‐Assessment,withregardtoSectionP oftheSettlementAgreement,theFacilityfounditwasinnoncompliancewithallofthesubsectionsofSectionR.ThiswasconsistentwiththeMonitoringTeam’sfindings.TheFacilitysubmittedthreedocuments,including:CCSSLCSelf‐Assessment,ActionPlans,andProvisionActionInformation.TheCCSSLCSelf‐AssessmentlistedthestepstheFacilitystaffcompletedtoconducttheself‐assessmentandthesubsequentresultsforthecompletionofthesetasks.TheActionPlansdocumentedthestatusofactionstepsthathadbeencompleted,wereinprocessand/orhadnotbeen


started.TheCCSSLCProvisionActionInformationlistedactionscompletedsincetheMonitoringTeam’spreviousvisit.TheFacilitySelf‐AssessmentpresentedtheresultsofauditingactivitiescompletedbytheHTDirectorandProgramComplianceMonitorusingtheSectionPMonitoringtoolforeachmonth.Oneindividualwasmonitoredeachmonthforatotalofthreeindividualsperquarter.MonthlyreportsweredevelopedforeachmonththatpresentedaseparatecompliancescoreforeachindicatorfortheSectionLead(i.e.,HTDirector)andthePCM.Aninter‐ratercompliancescorewasgeneratedforeachindicatoraswellasacompliancepercentage.ThiswasapositivedevelopmentandprovidedtheHTDirectorwithvaluableinformationtoassessthecompliancestatusforeachindicator.Furthermore,theHTDirectorandPCMreportedtheycontinuedtoreviseinstructionsfortheformtoenhancetheirinter‐rateragreement.TheHTDirectorandPCMgeneratedamonthlySectionPAnalysisreport.Thereportdefinedhowinter‐rateragreementwasachievedanddiscussedhowthesamplewaschosen.TheanalysisreportdiscussedthecomplianceforeachofthefoursectionsinSectionPandpresentedplanstoaddressareasofnon‐compliance.TheMonitoringTeamdiscussestheFacilityself‐assessmentresultsatthebeginningofeachsection.Summaryof Monitor’sAssessment:TheOTDirectorsupervisedtwofull‐timeOTsandtwopart‐timeOTs,whofilledonefull‐timeequivalentposition.ThereweretwoCertifiedOccupationalTherapyAssistants(COTAs)onstaff.ThePTDirectorsupervisedtwofull‐timePTs,twocontractPTs,twophysicaltherapyassistants(PTAs),andfourorthopedicequipmenttechnicians.OnecontractPTprovided10hoursofserviceperweekandthesecond15hoursperweek.TherewasonePTvacancyatthetimeofthereview.Therewere11PNMPCoordinatorsandaPNMPSupervisor.Fiveoffiveindividualsnewlyadmitted(100%)receivedanOT/PTassessmentwithin30daysofadmissionorreadmission.Basedonareviewofindividuals’OT/PTassessments,theyweremissingimportantelementsand,consequently,werenotconsideredadequateOT/PTassessments.OT/PTdirectinterventionsand/orprogramswerenotintegratedintoindividuals’ISPs.Inaddition,monthlyand/orquarterlyprogressnoteswerenotcompletedtoprovidetheresultsofeffectivenessreview/monitoringoftheindividual’sprogresswithdirectand/orindirectOT/PTsupports.Noevidenceofindividual‐specificcompetency‐basedtrainingfortheimplementationofindirectOT/PTprogramswasprovided.BasedoninterviewwiththeHTDirector,theFacilitywascurrentlyintheprocessofdevelopingobjectivesandperformancecheck‐offstodocumentthisprocess.TheMonitoringTeamwillreviewthisprocessduringthenextreview.


TheFacilityOT/PTMaintainingAdaptive‐ AssistiveEquipmentPolicy#P.3includedsomeimportantcomponents.However,itwasmissingtheprocessforidentification,training,andvalidationformonitors;theprocessofinter‐raterreliability;andaprocessfordatatrendanalysisandutilizationoffindingstodrivetrainingandproblemresolution(individualandsystemic).Individuals’Physical/NutritionalManagementDatasheetsfordirectand/orindirectOT/PTprogramswerenotcompletedonamonthlybasis.Consequently,thedatapresentedwasunreliabletotracktheimplementationofOT/PTprograms.

# Provision AssessmentofStatus ComplianceP1 Bythelateroftwoyearsofthe

EffectiveDatehereofor30daysfromanindividual’sadmission,theFacilityshallconductoccupationalandphysicaltherapyscreeningofeachindividualresidingattheFacility.TheFacilityshallensurethatindividualsidentifiedwiththerapyneeds,includingfunctionalmobility,receiveacomprehensiveintegratedoccupationalandphysicaltherapyassessment,within30daysoftheneed’sidentification,includingwheelchairmobilityassessmentasneeded,thatshallconsidersignificantmedicalissuesandhealthriskindicatorsinaclinicallyjustifiedmanner.


TheFacility’sreviewof100%ofSectionPmonitoringtoolsindicatedthat12outof12(100%)hadcompliancescoresanalyzed,trended,andaggregated.4

AnFacility’sauditofOT/PTassessmentsindicatedthatfouroutoffour(100%)includedhealthriskfactors;threeoutoffour(75%)containedarationaleforservices/supportsandassessmentdatatojustifyanOT/PTprogram;twooutoffour(50%)includedindividual‐specifictriggerstoalertstaffofchangeinstatus,indicatedefficacyofservicesandsupports,andincludedananalysisofdata.Twoofthree(67%)hadadequateserviceandsupportsformediumandhigh‐riskindicators;oneoutofthree(33%)includedfunctionaloutcomesforOT/PTprogramsandhadmeasurableobjectivesincludingskillacquisitionplansasappropriate.Theself‐assessmentdidnotdescribethesampleand/orwhythesamplesizedecreasedfromfourtothreeforcertainindicators.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthougheachindividualresidingattheSSLCreceivesacomprehensiveoccupationalandphysicaltherapyassessmentwhichincludesfunctionalmobility,wheelchairmobility(asneeded),considerationofsignificantmedicalissuesandhealthriskindicators,thedocumentationdoesnotconsistentlyshowspecifictriggers,efficacyofcurrentsupportsorfunctionaloutcomesinaclinicallyjustifiedmanner.”TheMonitoringTeamcompletedareviewoftenindividuals’OT/PTassessmentstodetermineiftheywereadequate.Theresultsofthisreviewarereportedinthissection.AsdescribedabovewithregardtoSectionO.1,theMonitoringTeamselectedSample#1.Itincluded15individualswithPNMconcernsand/orwhohadexperiencedachangeofstatus(i.e.,admissiontotheFacilityInfirmary,emergencyroom,and/orhospital).ThesampleconsistedofIndividual#47,Individual#251,Individual#97,Individual#304,Individual#159,Individual#246,Individual#7,Individual#198,

Noncompliance


# Provision AssessmentofStatus ComplianceIndividual#181,Individual#350,Individual#332,Individual#42,Individual#156,Individual#243,andIndividual#46.Thissectionaddressescurrentstaffing,andcontinuingeducationasfactorsthathavetheabilitytoaffectcompliance.Thediscussionrelatedtonewadmissions,andOT/PTassessmentsaddressthespecificrequirementsofthisparagraph.CurrentStaffingTheOTDirectorsupervisedtwofull‐timeOTsandtwopart‐timeOTs,whofilledonefull‐timeequivalentposition.ThereweretwoCertifiedOccupationalTherapyAssistants(COTAs)onstaff.ThePTDirectorsupervisedtwofull‐timePTs,twocontractPTs,twophysicaltherapyassistants(PTAs),andfourorthopedicequipmenttechnicians.OnecontractPTprovided10hoursofserviceperweek,andthesecondprovided15hoursperweek.TherewasonePTvacancyatthetimeofthereview.EachofthesetherapistsheldalicensetopracticeinthestateofTexas.Therewere11PNMPCoordinatorsandaPNMPSupervisor.ContinuingEducationDocumentationofcontinuingeducationcoursestheOTsandPTscompletedwassubmitted.Basedondocumentationsubmitted,inthepastsixmonths,noState‐sponsoredwebinarshadoccurred.Thecontinuingeducationthecliniciansattendedincludedthefollowingtopicareas:

AutismandSensoryProcessingDisorders; BedsideEvaluationoftheDysphagiaPatient; TheDysphagiaPatient:ModifiedBariumSwallowandTherapeutic

Intervention; EthicsandProfessionalResponsibilityPart1:PT; IntroductiontoBenignParoxysmalPositionalVertigo;and IntroductiontoPediatricMedicalScreening;andManagementofCerebral‐

OriginSpasticity.Attendancesheetsandcontinuingeducationcertificatesofcompletiondocumentationweresubmittedfortheprecedingcourses.TheOTsandPTsattendedappropriatecontinuingeducationcourses.NewAdmissionsSincethelastreview,fiveindividuals(i.e.,Individual#5,Individual#40,Individual#61,Individual#63,andIndividual#97)hadbeenadmittedtoCCSSLC.AnexaminationoftheiradmissionandOT/PTassessmentdatesestablished:

Fiveoffiveindividualsnewlyadmitted(100%)receivedanOT/PTassessmentwithin30daysofadmissionorreadmission.



OT/PTAssessmentsAnOT/PTassessmentshouldincludethefollowing:

Signatureanddatebytheclinicianuponcompletionofthewrittenreport; Dateshowingitwascompleted10dayspriortotheannualISPmeeting; Diagnosesandrelevancetofunctionalstatus; Individualpreferences,strengths,andneeds; Medicalhistoryandrelevancetofunctionalstatus; Healthstatusoverthelastyear; Medicationsandpotentialsideeffectsrelevanttofunctionalstatus; Documentationofhowtheindividual’srisklevelsimpacttheirperformanceof

functionalskills; Functionaldescriptionofmotorskillsandactivitiesofdailylivingwith

examplesofhowtheseskillsareutilizedthroughouttheday; EvidenceofobservationsbyOTsandPTsintheindividual’snatural

environments(e.g.,dayprogram,home,work) Discussionofthecurrentsupportsandservicesprovidedthroughoutthelast

yearandeffectiveness,includingmonitoringfindings; Discussionoftheexpansionoftheindividual’scurrentabilities; Discussionoftheindividual’spotentialtodevelopnewfunctionalskills; Comparativeanalysisofhealthandimpactonfunctionalstatusoverthelast

year; Comparativeanalysisofcurrentfunctionalmotorandactivitiesofdailyliving

skillswithpreviousassessments; IdentificationofneedfordirectorindirectOTand/orPTservices,as

appropriate; Reassessmentschedule; Monitoringschedule; Recommendationsfordirectinterventionsand/orskillacquisitionprogramsas

indicatedforindividualswithidentifiedneeds; Arecommendationregardingtheindividual’sappropriatenessforcommunity

placement; Mannerinwhichstrategies,interventions,andprogramsshouldbeutilized

throughouttheday.Tenindividuals’OT/PTcomprehensiveassessments(i.e.,Individual#159,Individual#304,Individual#7,Individual#251,Individual#47,Individual#246,Individual#46,Individual#198,Individual#97,andIndividual#156)inSample#1wereevaluatedforthepresenceofthefollowing:

Tenof10individuals’OT/PTassessments(100%)weresignedanddatedbytheclinicianuponcompletionofthewrittenreport;


# Provision AssessmentofStatus Compliance Fiveof10individuals’OT/PTassessments(i.e.,Individual#304,Individual#7,

Individual#251,Individual#198,andIndividual#97)(50%)weredatedashavingbeencompleted10dayspriortotheannualISP;

Twoof10individuals’OT/PTassessments(i.e.,Individual#7andIndividual#97)(20%)includeddiagnosesandrelevancetofunctionalstatus;

Fourof10individuals’OT/PTassessments(i.e.,Individual#7,Individual#46,Individual#198,andIndividual#97)(40%)introducedindividualpreferences,strengths,andneeds;

Noneof10individuals’OT/PTassessments(0%)includedmedicalhistoryandrelevancetofunctionalstatus.Multipleindividuals’OT/PTassessmentshadnotbeenupdatedtoreflectachangeinstatus.Forexample,Individual#246’sOT/PTassessmenthadnotbeenupdatedtoreflecthiscurrentmedicalhistoryandhealthstatusrelatedtohisModifiedBariumSwallowstudy(MBSS)on5/30/12.Inaddition,Individual#251’sOT/PTassessmenthadnotbeenupdatedtoaddresstheresultsofhisMBSSon12/21/11orhisISPAmeetingon11/28/11,atwhichtheteamdiscussedfourfallswithin30days.Individual#304’sOT/PTassessment,dated8/3/11,didnotdiscussmedicalhistoryandrelevancetofunctionalstatusandhealthstatusoverthelastyear.Forexample,hisassessmentdidnotdiscusshisdiagnosisofgastroesophagealrefluxdisease(GERD)andtheimpactonhisfunctionalstatus;

Noneof10individuals’OT/PTassessments(0%)adequatelyaddressedhealthstatusoverthelastyear.Individuals’OT/PTassessmentshadnotbeenupdatedtoprovideanaccuratehealthstatusoverthepastyear.Forexample,Individual#159’sassessmentdidnotaddressachokingincidenton5/4/11orherPICAbehavior.Individual#7’sOT/PTassessment,dated3/20/12,didnotdiscussheroverweightstatusandtheimpactonherhealthandfunctionalstatus(i.e.,BodyMassIndex30).Individual#47’sOT/PTassessment,dated10/11/11,didnotdiscusshishistoryoffallswithinthepastyear(i.e.,IRRform,dated9/20/11,documented10fallswithinthepastyear);

Threeof10individuals’OT/PTassessments(i.e.,Individual#7,Individual#97,andIndividual#156)(30%)listedmedicationsanddiscussedthepotentialsideeffectsrelevanttofunctionalstatus.Threeindividual’sOT/PTassessmentsdidnotaddressmedications(i.e.,Individual#251,Individual#304,andIndividual#47).Fourindividual’sOT/PTassessmentspresentedmedicationsandsideeffects,butdidnotadequatelyaddresstheimpactonanindividual’sfunctionalstatus;

Oneof10individuals’OT/PTassessments(Individual#97)(10%)provideddocumentationofhowtheindividuals’risklevelsimpactedtheirperformanceoffunctionalskills;

Threeof10individuals’OT/PTassessments(i.e.,Individual#7,Individual#251,andIndividual#97)(30%)includedafunctionaldescriptionofmotor


# Provision AssessmentofStatus Complianceskillsandactivitiesofdailylivingwithexamplesofhowtheseskillswereutilizedthroughouttheday;

Threeof10individuals’OT/PTassessments(i.e.,Individual#7,Individual#46,andIndividual#97)(30%)providedevidenceofobservationsbyOTsandPTsintheindividuals’naturalenvironments(e.g.,dayprogram,home,work);

Noneofnineindividuals’OT/PTassessments(0%)reviewedthecurrentsupportsandservicesprovidedthroughoutthelastyearandeffectiveness,includingmonitoringfindings(Note:Individual#97wasnewlyadmitted);

Oneof10individuals’OT/PTassessments(i.e.,Individual#46)(10%)discussedtheexpansionoftheindividual’scurrentabilities;

Oneof10individuals’OT/PTassessments(i.e.,Individual#46)(10%)presentedtheindividual’spotentialtodevelopnewfunctionalskills;

Oneof10individuals’OT/PTassessments(i.e.,Individual#46)(10%)gaveacomparativeanalysisofhealthandimpactonfunctionalstatusoverthelastyear;

Oneof10individuals’OT/PTassessments(i.e.,Individual#46)(10%)offeredacomparativeanalysisofcurrentfunctionalmotorandactivitiesofdailylivingskillswithpreviousassessments;

Sixof10individuals’OT/PTassessments(i.e.,Individual#159,Individual#304,Individual#251,Individual#46,Individual#97,andIndividual#156)(60%)identifiedtheneedfordirectorindirectOTand/orPTservices,asappropriate;

Nineof10individuals’OT/PTassessments(i.e.,Individual#159,Individual#304,Individual#7,Individual#251,Individual#47,Individual#246,Individual#46,Individual#198,andIndividual#156)(90%)hadareassessmentschedule;

Sevenof10individuals’OT/PTassessments(i.e.,Individual#159,Individual#304,Individual#7,Individual#251,Individual#47,Individual#246,andIndividual#156)(70%)suppliedamonitoringschedule;

Fourof10individuals’OT/PTassessments(i.e.,Individual#159,Individual#304,Individual#97,andIndividual#156)(40%)hadrecommendationsfordirectinterventionsand/orskillacquisitionprograms;

Eightof10individuals’OT/PTassessments(i.e.,Individual#159,Individual#304,Individual#251,Individual#47,Individual#246,Individual#46,Individual#198,andIndividual#156)(80%)madearecommendationabouttheappropriatenessforcommunitytransition;

Noneof10individuals’OT/PTassessments(0%)definedthemannerinwhichstrategies,interventions,andprogramsshouldbeutilizedthroughouttheday.

These10individuals’OT/PTassessmentsweremissingessentialcomponentsand,consequently,werenotadequatecomprehensiveOT/PTassessments.TheFacility


# Provision AssessmentofStatus ComplianceshouldreviewtherevisedOT/PT assessmenttemplateandcontentguidelinestoensuretheseessentialelementsareaddressed.TheOTsandPTsshouldconsidereachoftheseelementsastheycompleteassessmentstoensureassessmentswerecomprehensiveasrequiredbytheSettlementAgreement.Inaddition,theOT/PTauditshouldincludetheseelements.

P2 Within30daysoftheintegratedoccupationalandphysicaltherapyassessmenttheFacilityshalldevelop,aspartoftheISP,aplantoaddresstherecommendationsoftheintegratedoccupationaltherapyandphysicaltherapyassessmentandshallimplementtheplanwithin30daysoftheplan’screation,orsoonerasrequiredbytheindividual’shealthorsafety.Asindicatedbytheindividual’sneeds,theplansshallinclude:individualizedinterventionsaimedatminimizingregressionandenhancingmovementandmobility,rangeofmotion,andindependentmovement;objective,measurableoutcomes;positioningdevicesand/orotheradaptiveequipment;and,forindividualswhohaveregressed,interventionstominimizefurtherregression.


TheFacility’sauditoffourOT/PTprogramsindicatednoneoftheplans(0%)weredevelopedwithin30daysoftheISP,individualizedbasedonobjectivefindings,hadeffectiveanalysistojustifyidentifiedstrategies,andhadobjective,measurableandfunctionaloutcomes.Progressnoteswerenotcompletedtoidentifyimplementationofplans,statusofprogress,orjustificationoftheinitiation,continuationordiscontinuationoftheplan.ProgramswerenotembeddedintheISPincludingskillacquisitionprograms,asappropriate.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonfindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughtheintegratedoccupationalandphysicaltherapyassessmentsareconsistentlycompletedwithin30daysoftheISP,theyarenotconsistentlyintegratedaspartoftheIndividualSupportPlan(ISP).Subsequently,thedocumentationdoesnotsupportthataplantoaddresstherecommendationsoftheintegratedoccupationaltherapyandphysicaltherapyassessmentareimplementedwithin30daysoftheplan’screation.Theplansinclude:individualizedinterventionsaimedatminimizingregressionandenhancingmovementandmobility,rangeofmotion,andindependentmovement,however,theystilllackobjective,measurableoutcomesandjustificationforthecontinuationordiscontinuationoftheplans.”TheMonitoringTeam’sfindingsweresimilartotheFacility’sfindings,andthestatusofdirectandindirectOTinterventionsisdiscussedindetailbelow.IntegrationofOT/PTDirectIntervention(s)andIndirectOT/PTProgram(s)intheISPTheprimaryOT/PTinterventionprovidedtoindividualswasthePhysicalNutritionalManagementPlan.CompliancedatarelatedtoPNMPsisdiscussedabovewithregardtoSectionO.3.DirectOT/PTtherapywasprovidedtooneindividual(i.e.Individual#243).PNMPCoordinatorsprovidedindirectOT/PTprogramsto10individualsinAtlantic,36individualsinPacific,and33individualsinCoralSea.ResidentialstaffimplementedOT/PTprogramsforthreeindividualsinAtlantic,42individualsinPacific,and62individualsinCoralSea.Oneofthe15individualsinSample#1(i.e.,Individual#243)wasreportedtoreceive

Noncompliance


# Provision AssessmentofStatus CompliancedirectOT/PTinterventions.Threeofthe15individualswereprovidedindirectOT/PTprograms.Ofthesethree,oneindividual(i.e.,Individual#42)hadanOT/PTprogramimplementedbyaPNMPCoordinator,andtwoindividuals(i.e.,Individual#181andIndividual#350)hadindirectOT/PTprogramsimplementedbyresidentialstaff.Areviewoftheseindividuals’recordsfound:

ForoneofthefourISPsreviewed(i.e.,Individual#181)(25%),anOTand/orPTattendedtheannualmeeting.

InnoneofthefourISPsreviewed(0%),theOT/PTinterventionand/orprogramwasidentified.

InnoneofthefourISPsreviewed(0%)wereskillacquisitionprogramsrecommendedtopromoteskillslearnedindirecttherapyinterventionand/orOT/PTprograms.

InnoneofthefourISPsreviewed(0%)wereskillslearnedintegratedintotheindividual’sdailyroutine.

ForadequateintegrationofOT/PTdirectinterventionsand/orindirecttherapyprograms,theindividuals’ISPsshouldinclude:attendancebyanOTand/orPT;identificationofthedirectinterventionand/orOT/PTprogram;asappropriate,skillacquisitionprogramstopromotereinforcementofnewskillslearned;andasappropriate,integrationofskillslearnedfromthedirectinterventionsand/orOT/PTprogramsintotheindividual’sdailyroutine.DirectOT/PTInterventionsThedirectOT/PTinterventionplanforoneindividual(i.e.,Individual#243)wasreviewed.ComprehensiveprogressnotesrelatedtoOT/PTinterventionsshouldinclude:

Informationregardingwhethertheindividualshowedprogresswiththestatedgoal;

Descriptionofthebenefitofthegoaltotheindividual; Areportontheconsistencyofimplementation;and Recommendations/revisionstotheOT/PTinterventionplanasindicated

relatedtotheindividual’sprogressorlackofprogress.DocumentationofOT/PTreviewfornoneoftheoneindividual(0%)wascomprehensive.Theprogressnotesdidnotincorporatetheelementsoutlinedabove.IndirectOT/PTProgramsBasedondocumentationsubmitted:“CCSSLCdoesnotcurrentlyhaveanydocumentationregardingthequarterlyreviewofOT/PTprograms.”


# Provision AssessmentofStatus ComplianceForindividualswhoreceiveindirectOTand/orPTprograms, monthlydocumentationfromtheOT/PTshouldinclude:

Informationregardingwhethertheindividualshowedprogresswiththestatedgoal(s);

Adescriptionofthebenefitofdeviceand/orgoal(s); Identificationoftheconsistencyofimplementation;and Recommendations/revisionstothedirectinterventionand/orprogramas

indicatedinreferencetotheindividual’sprogressorlackofprogress.Thecompletionofmonthlyprogressnotesshouldprovideeffectivenessreview/monitoringoftheindividual’sprogresswithdirectand/orindirectOT/PTsupports.

P3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,theFacilityshallensurethatstaffresponsibleforimplementingtheplansidentifiedinSectionP.2havesuccessfullycompletedcompetency‐basedtraininginimplementingsuchplans.


TheFacility’sauditofOT/PTprogramsfoundfouroffourstaff(100%)implementedtheprogram;noneoffour(0%)programsindicatedthatstaffhadreceivedindividual‐specificcompetency‐basedtraining.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughstaffimplementOT/PTplansatthefoundationallevel,documentationdoesnotsupporttheyhavesuccessfullycompletedcompetency‐basedtraininginimplementing‘individual‐specific’plans(plansrequiringskillthatdeviatedfromthestandardfoundationaltraining).”TheMonitoringTeam’sreviewresultedinsimilarfindings.Individual‐specificcompetency‐basedperformancecheck‐offshadnotbeencompletedbyPNMPCoordinatorsand/orstafftotesttheircompetencyfortheimplementationofindividuals’OT/PTprograms.Competency‐BasedTrainingThestatusofFacilitycompliancewithcompetency‐basedtrainingandmonitoringforcontinuedstaffcompetencyandcomplianceofdirectsupportprofessionalswasaddressedinSectionO.4,O.5,andO.6.Noevidenceofindividual‐specificcompetency‐basedtrainingfortheimplementationofindirectOT/PTprogramswasprovided.BasedoninterviewwiththeHTDirector,theFacilitywascurrentlyintheprocessofdevelopingobjectivesandperformancecheck‐offstodocumentthisprocess.TheMonitoringTeamwillreviewthisprocessduringthenextreview.

Noncompliance

P4 CommencingwithinsixmonthsoftheEffectiveDatehereofandwith


Noncompliance


# Provision AssessmentofStatus Compliancefullimplementationwithintwoyears,theFacilityshalldevelopandimplementasystemtomonitorandaddress:thestatusofindividualswithidentifiedoccupationalandphysicaltherapyneeds;thecondition,availability,andeffectivenessofphysicalsupportsandadaptiveequipment;thetreatmentinterventionsthataddresstheoccupationaltherapy,physicaltherapy,andphysicalandnutritionalmanagementneedsofeachindividual;andtheimplementationbydirectcarestaffoftheseinterventions.

AreviewoftheHTdatabase reportforfourindividuals found oneindividual’smonitoringresults(25%)includedthecondition,availability,andeffectivenessofsupports.

AreviewofPNMPClinicminutesindicatedthatoneindividual’stherapists(25%)reviewedequipmentannually.

Areviewoftrainingrostersforthosewithindividual‐specificPNMPprogramsindicatedthatoneoutoffour(25%)individual’sstaffhadsuccessfullycompletedcompetency‐basedtraining.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughasystemtomonitorphysicalsupportsandadaptiveequipmenthasbeendevelopedandimplementeditdoesnotconsistentlyaddresstheeffectivenessofthosesupports.Additionally,staffcontinuestoneedsupportindocumentingtheimplementationoftheseinterventions.”TheMonitoringTeam’sfindingsweresimilar.Theseandadditionalfindingsarediscussedbelow.MonitoringSystemTheOccupational/PhysicalTherapyServicesPolicy#014stated:“theStateCentershallimplementasystemtomonitorandaddress:

Thestatusofindividualswithidentifiedoccupationalandphysicaltherapyneeds;

Thecondition,availabilityandappropriatenessofphysicalsupportsandassistiveequipment;

Theeffectivenessoftreatmentinterventionsthataddresstheoccupationaltherapy,physicaltherapy,andphysicalandnutritionalmanagementneedsofeachindividual;and

Theimplementationofprogramscarriedoutbydirectsupportstaff.”However,asacknowledgedbytheFacility’sself‐assessmentfindingsandtheMonitoringTeam’sfindingspresentedbelow,theFacility’scurrentmonitoringsystemsdidnotadequatelyaddressthesepolicycomponents.TheFacility’sOT/PTMaintainingAdaptive‐AssistiveEquipmentPolicy#P.3includedthefollowinginformationonthemonitoringofadaptive/assistiveequipment:

MonthlymonitoringbythePNMPCoordinatorsforthepresenceofadaptive/assistiveequipmentusingtheMonthlyPerson‐SpecificPNMPCheckSheet;and

Therapists’monitoringoftheadaptive‐assistiveequipmentandconditionbydocumentingonthePNMPClinicMinutesannuallypriortotheannualISPmeeting.


# Provision AssessmentofStatus ComplianceHowever,this policydidnotincludethefollowingkeyelements:

Theprocessforidentification,training,andvalidationformonitors; Theprocessofinter‐raterreliability;and Aprocessfordatatrendanalysisandutilizationoffindingstodrivetraining

andproblemresolution(individualandsystemic).Areviewwasconductedofthefourindividuals’monitoringresults(i.e.,Individual#243,Individual#181,Individual#350,andIndividual#42)whoreceiveddirecttherapyinterventionand/orindirectOT/PTprograms

Fourofthefourindividuals(100%)weremonitoredattherecommendedfrequencyusingtheMonthlyPerson‐SpecificPNMPCheckSheet.

Fourofthefourindividuals(100%)weremonitoredfortheconditionandavailabilityoftheirequipmentusingtheMonthlyPersonSpecificPNMPCheckSheet.

Noneofthesefourindividuals(0%)weremonitoredforthestatusoftheiridentifiedoccupationalandphysicaltherapyneeds.

Noneofthefourindividuals(0%)weremonitoredfortheeffectivenessoftheirtherapyOT/PTprograms.

Oneoffourindividuals’PNMPClinicMinutesdocumentation(25%)indicatedacomprehensiveannualreviewofanindividual’sprescribedadaptive/assistiveequipmentforcondition,availability,andeffectiveness.

Basedondocumentationsubmitted,“currently,CCSSLCisrevisingtheprocessofmonthlyreviewsofOT/PTprograms.”Datasheetsforthefourindividualsreceivingdirecttherapyinterventionand/orindirectOT/PTprogramsweresubmittedindicatingiftheprogramwascompletedand/ornotcompleted.Thedatasheetcontainedasectionatthebottomoftheformthatindicatedareviewbythetherapist.Thedatasheetswerebeingrevisedtobemorecomprehensiveandcapturedataregardingeffectiveness.However,areviewofPhysical/NutritionalManagementDatasheetsforthefourindividualsfound:

Noneofthefourindividuals’Physical/NutritionalManagementDatasheetsfordirectand/orindirectOT/PTprograms(0%)werecompletedonamonthlybasis.

Noneofthefourindividuals’Physical/NutritionalManagementDatasheets(0%)monitoredthestatusofidentifiedoccupationalandphysicaltherapyneeds.

Consequently,thedatapresentedwasunreliabletotracktheimplementationofOT/PTprograms.


Recommendations:ThefollowingrecommendationsareofferedforconsiderationbytheStateandtheFacility:1. TheFacilityshouldreviewtherevisedOT/PTassessmenttemplateandcontentguidelinestoensureessentialelementsareaddressed.TheOTs

andPTsshouldconsidereachoftheseelementsastheycompleteassessmentstoensureassessmentsarecomprehensiveasrequiredbytheSettlementAgreement.Inaddition,theOT/PTauditshouldincludetheseelements.(SectionP.1)

2. ForadequateintegrationofOT/PTdirectinterventionsand/orindirecttherapyprograms,theindividuals’ISPsshouldinclude:attendancebyanOTand/orPT;identificationofthedirectinterventionand/orOT/PTprogram;asappropriate,skillacquisitionprogramstopromotereinforcementofnewskillslearned;andasappropriate,integrationofskillslearnedfromthedirectinterventionsand/orOT/PTprogramsintotheindividual’sdailyroutine.(SectionP.2)

3. TheFacilityshouldensurecomprehensiveprogressnotesrelatedtoOT/PTdirectinterventionsandindirectprogramsinclude:a. Informationregardingwhethertheindividualshowedprogresswiththestatedgoal;b. Adescriptionofthebenefitofthegoaltotheindividual;c. Areportontheconsistencyofimplementation;andd. Recommendations/revisionstothedirectinterventionorOT/PTprogramasindicatedrelatedtotheindividual’sprogressorlackof

progress.(SectionP.2)4. TheFacilityshoulddevelopandimplementindividual‐specificcompetency‐basedtrainingandperformancecheck‐offsforPNMPCoordinators

andstaff.(SectionP.3)5. TheFacilityOT/PTMaintainingAdaptive‐AssistiveEquipmentPolicy#P.3shouldinclude:

a. Theprocessforidentification,training,andvalidationformonitors;b. Theprocessofinter‐raterreliability;andc. Aprocessfordatatrendanalysisandutilizationoffindingstodrivetrainingandproblemresolution(individualandsystemic).

(SectionP.4)6. IndividualswhoreceiveOT/PTdirectinterventionsand/orprogramsshouldbemonitoredforthefollowing:

a. Thestatusoftheiridentifiedoccupationalandphysicaltherapyneeds;andb. TheeffectivenessoftheirOT/PTtherapyprograms.(SectionP.4)


SECTIONQ:DentalServices StepsTakentoAssessCompliance:Thefollowingactivitiesoccurredtoassesscompliance:

ReviewofFollowingDocuments:o Policies,andproceduresaddressingtheprovisionofdentalcare;o Forthepastsixmonths,minutesfromthestatewideDentalCommittee;o Listsofindividualswhowithinthepastsixmonths:

Fornewlyadmittedindividuals,wereseenfordentalservices,includingdateofadmission,anddateofinitialevaluation;

Wereseenfordentalservicesduringthepastsixmonthsotherthanfortheannualexam,dateofvisit,andreasonortypeofvisit;

Haverefuseddentalservices; Havemissedanappointment(otherthanrefusals),thedateofthemissed

appointment,thereasonforthemissedappointment,andthedateofthecompletedmake‐upappointment;

Havehadatooth/teethextraction,includingname,dateofextraction,andnumberofteethextracted;

Havebeenseenfordentalemergencies(e.g.,abscesstooth,complications,etc.),includingname,dateofemergencyvisitandreason,whetherindividualcomplainedofpain,documentsconfirmedpain,andtreatmentdocumented;

Havehadpreventativedentalcare; Havehadrestorativedentalcareincludingname,dateofcompletedrestorative

work,andforeachappointmentcompleted,typeofrestorativework,and Weredueforannualdentalexams,whethertheyhavehadexams,andwhether

thedentistwasabletocompletethoseexams,includingname,anddateofcompletedannualexam;

o Mostrecentcomprehensiveexamsforoneindividualfromeachresidence–copyfromdentaloffice’srecordofvisitandcopyfromactiverecordofsamevisitfor:Individual#26,Individual#238,Individual#341,Individual#339,Individual#305,Individual#183,Individual#13,Individual#371,Individual#198,Individual#228,Individual#368,Individual#127,Individual#209,andIndividual#314;

o Fivemostrecentoffsiteoralsurgeryconsultsandprogressnotespastsixmonthsfor:Individual#376,Individual#50,Individual#60,Individual#111,andIndividual#231;

o Listofabbreviationsusedinalldentalrecords/reports;o Forthepastsixmonths,datasummariesusedbytheFacilityrelatedtodentalservices,

and/orqualityassurance/enhancementreports,includingsubsequentcorrectiveactionplans;

o Attendancetrackingsheetfordentalappointmentsforthepastsixmonths;o Listofrefusalsforthepastsixmonthsperdateofrefusal,includingreasonfor

appointment(e.g.,prophylaxis,annual,etc.);o Listofthosewhohavenotseendentistinoneyearandreason;o Listofthosewhohaveoutstandingneedfordentalx‐rays,accordingtocurrent


professionalstandards,andtypeofx‐raythatisneededtofulfillrequirement/recommendations,includingdateoflastfullmouthx‐rays;

o Listofthosewhowereedentulousattimeofthelastonsitevisit,andthosewhohavebecomeedentuloussincethattime;

o Listofotherreasonsformissedappointmentsperdateforpastsixmonths,includingreasonforappointment(e.g.,prophylaxis,annual,etc.);

o Listofnoshows/missedappointmentperbuildingpermonthforthelastsixmonthso Listofrefusalsperbuildingpermonthforthelastsixmonths;o Listofinterventionsperindividualformissedappointments(i.e.,follow‐upappointment

scheduled,whetherfollow‐upcompleted,anycorrespondencetoQDDP,homemanager,team,etc.);

o QDDP,IDTminutesthatreview,assess,develop,andimplementstrategiesfordentalvisitrefusalsandnoshowsduringthelastsixmonths,includingISPAsthatdocumenteddiscussion/actionplansconcerningdentalrefusals;

o Forfivemostrecentemergencyexams,integratedprogressnotesfromstartofemergencytoclosure,andcopyofDentalDepartmentevaluationandtreatmentfor:Individual#168,Individual#144,Individual#62,Individual#117,andIndividual#7;

o Appointmentscheduleforthoseundergoinggeneralanesthesia/conscioussedation,includingindividualsforwhomgeneralanesthesiawasscheduledbuttheappointmentwasnotcompleted,andthereason;

o Forsixindividualsundergoinggeneralanesthesia/conscioussedation,completecopyofdentalrecordfromstartofconcerntoclosure,includingcopyofanyoperativereports,copyofanymonitoringtapes,consents,secondopinions,consultreports,pre‐operativechecklistorevaluation,andpost‐operativechecklistormonitoringforms,etc.for:Individual#38,Individual#169,Individual#369,Individual#225,Individual#113,andIndividual#69;

o Forthepastsixmonths,copiesofcorrespondenceconcerningrestraintandsedationuseofofficevisit(toQDDP,team,psychologist,etc.);

o CompletedentalrecordsforpriorthreeyearsatSSLC(i.e.,alldocumentationincludingprogressnotes,prophylactic,annual,emergency,restorativeformscompleted,x‐rayconsultreports,restraintchecklist,oralsurgeonconsults,etc.),foroneindividualmostrecentlyseenfromeachresidentialunit.Alsotablewithname,datesofannualexams,prophylacticexams,anddatesofothertreatmentfor:Individual#215,Individual#137,Individual#169,Individual#176,Individual#57,Individual#109,Individual#158,Individual#250,Individual#300,Individual#321,Individual#269,Individual#209,Individual#234,andIndividual#77;

o For10individualsgivendentalpre‐treatmentsedation,copiesofprogressnotes/vitalsignlogs,otherpre‐appointmentassessmentsfromactiverecordanddentalofficefromstartofsedationinresidence(ifapplicable)toreleasefrommonitoring,includingpre‐treatmentsedationsheetsfor:Individual#145,Individual#379,Individual#334,Individual#218,Individual#212,Individual#210,Individual#321,Individual#187,Individual#42,andIndividual#136;


o CurrentlistofHRCapproveddentalmedicalrestraintswithsedation,includingtypeofsedation,suchasbymouth(PO)sedation,intravenous(IV)orgeneralanesthesia;

o Restraintandsedationtrackinglist/systemusedbytheDentalDepartment(i.e.,typeofrestraint,reason,sedationplan,drugusedanddosage,effectivenessofrestraint,trialoflessrestrictiveapproach);

o Inpastsixmonths,permonth,percentageofindividualsutilizinggeneralanesthesia/IVsedationfordentalexamandtreatment;

o Inpastsixmonths,permonth,percentageofindividualsutilizingoralsedationfordentalvisits;

o Inpastsixmonths,permonth,percentageofindividualsutilizingmechanicalrestraintsfordentalvisits;

o Formostrecentfiveextractionsinpastsixmonths,initialevaluationforthis,secondopinion,andsubsequentdocumentationuntilclosurefor:Individual#169,Individual#250,Individual#308,Individual#69,andIndividual#191;

o Forthosecompletingannualexamsinpastsixmonths,oralhygieneratingineachexamlistedperindividualanddateofexam;

o Listofthosewhoreceivesuctiontooth‐brushingtreatment;o Listofthosewhohavebeenidentifiedasbenefitingfromsuctiontooth‐brushing

treatment,butwhoarenotreceivingsuctiontoothbrushing(e.g.,waitingforequipment,training,careplanrevision,etc.);

o Tenannualdentalassessmentscompletedinlast30daysandfortheprioryearofthesesameindividualsfor:Individual#218,Individual#323,Individual#205,Individual#304,Individual#355,Individual#3,Individual#157,Individual#239,Individual#13,andIndividual#211;

o Listofdentalrecordannualexaminations/assessmentsandtreatmentplanrecordcompletedinlastsixmonths,andthedateofpreviousdentalrecordannualexamination/assessmentandtreatmentplanrecordforallindividuals;

o MostrecentannualdentalsummariesprovidedfortheISPfor:Individual#244,Individual#78,Individual#71,Individual#287,Individual#305,Individual#46,Individual#371,Individual#198,Individual#367,andIndividual#332,Individual#195;

o Mostrecent/currentFacilityoralhygienedata(numbersandpercentagegood,fair,poorratings),withdateofdata;

o Forthoseindividualsforwhichcareplans/ISPindicatetheybrushtheirownteeth,themostrecenttwooralhygienescores,withdatesofthescores;

o Listofthoseindividualsthatflosstheirownteeth;o Listofindividualsprovidedinstructionsonflossing,withdatesoftraining;o Forthosethatareedentulous,listofthosewithdentures;o Forthoseedentulouswithoutdentures,listofreasonswithdocumentationasindicated;o SummaryinformationondesensitizationplanssincetheMonitoringTeam’slastvisit;o Forthoseundergoingtotalintravenousanesthesia(TIVA),anyincidentofinjuryin24

hoursfollowingTIVAadministrationinpriorsixmonths;o Forthosewithdocumentedpneumonia,foreachindividual,datepneumoniadocumented,


dateoflastdentalvisit,typeofprocedure/visitcompleted,andtypeofanesthesia(TIVA,oral,local,none,etc.)inpastsixmonths;and

o PresentationBookforSectionQ. Interviewswith:

o EnriqueVenegas,DMD,DentalDirector;ando KathyRoach,RDH.

FacilitySelf‐Assessment:TheDentalDepartmentreviewedanumberofreports/logs/databasestoassessitscompliancewithcomprehensivedentalcare.Forexample,thetimelinessofannualexamsandinitialdentalexamsfornewlyadmittedindividualswasassessed.Oralhygieneratingsweretracked.Tooth‐brushinginstructiontoindividualsand/orsupportstaffalsowastracked.Thenumberofindividualsthatinthepastyearreceivedpreventivecare,completionofdentalappointments,aswellasthetimelinessofresponsetodentalemergencies,andtheclosureofemergencieswereassessed.TheFacilityreviewedtherateofclassroomtrainingfordirectsupportprofessionals.TheFacilityassessedwhetherISPshadthemostcurrentdentalassessmentavailable.TheFacilityalsotrackedwhetherdesensitizationnomineesfromtheDentalDepartmentcompletedbehavioralevaluations.Generally,thesewerereasonablecomponentsofaself‐assessmentforSectionQ.InterraterreliabilitywasavailablefromtheMarchmonitoring.Interrateragreementrangedfrom91to96%.TheFacilityassesseditremainednoncompliantinbothsubsectionsofSectionQ,althoughconsiderableprogresshadbeenmadeinapproachingthresholdlevelsofcomplianceinseveralareas.ThiswasconsistentwiththeMonitoringTeam’sfindings.SummaryofMonitor’sAssessment:TheDentalDepartment had madeconsiderablestridestowardcompliance.AlthoughtheFacilityhadnotachievedcompliancewitheitherofthesubsectionsofSectionQ,severalspecificaspectsofdentalcarehadreachedthelevelnecessaryforcompliance,suchascompletionofannualexamsandtooth‐brushinginstruction.Oralhygienescoreshadcontinuedtoimprove.ItwillbeimportantfortheDentalDepartmenttosustaintheseeffortswhileitfocusesonareasthatremaininneedofimprovement.Thequalityofself‐toothbrushingrequiredreviewandinterventionforthoseindividualsthatstillhadpoororalhygienescores.Dentaldesensitizationandotherprocedurestoreducetheuseofsedationremainedunderdevelopedafterthreeyears.Thosethatwouldbenefitfromdesensitizationhadbeenmethodicallychosen,andrecently,asmallsampleofthesehadbeenselectedtobeginthedesensitizationprocess.QuarterlyreportsreflectingtheactivityandprogressoftheDentalDepartmentwouldbebeneficialtotheDentalDepartmentandFacilityAdministration,butperiodicreportswerenotpartoftheinternalQAprogramoftheDentalDepartment.Ofconcern,thecurrentsoftwareprogramhadallowedthedepartmenttoadvanceandmakeimprovement.Thereweretwotothreeyearsofdataavailableandtrendanalysiswasavailable.Itappeareduser‐friendlyandmuchinformationcouldbequicklyqueriedfromit.Thenew


statewidesystemappearedtobereplacingit,butthechallengesofimplementationweresignificantandthebenefitstotheDentalDepartmentneededclarity.Itwillbeimperativetobeabletousethepriordataandincorporatethepriordataintothenewsystemtocontinuetoprovidetrendanalysis.

# Provision AssessmentofStatus ComplianceQ1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithin30months,eachFacilityshallprovideindividualswithadequateandtimelyroutineandemergencydentalcareandtreatment,consistentwithcurrent,generallyacceptedprofessionalstandardsofcare.ForpurposesofthisAgreement,thedentalcareguidelinespromulgatedbytheAmericanDentalAssociationforpersonswithdevelopmentaldisabilitiesshallsatisfythesestandards.

TheDentalDepartmentincludedthefollowing:DentalDirector,oneadditionalstaffdentist,threedentalhygienists,andtwodentalmedicationaides.Threeotherconsultantdentistswerelistedthatwerenotonstaff.AlistofdentalstaffcertifiedinCPRwassubmitted,dated4/1/12.Ofthedentalstaff,sevenofseven(100%)werecurrentinCPRcertification.TherewasanunusualentryintheCPRstatusofoneofthedentists.CPRcertification,fromtherosterprovided,extendedtwoyearsuntilthenextrenewal.ForonedentisttheCPRcompletiondatewas5/18/10,withanexpirationdateof5/17/14.Acopyofthecertificationwasverified.ItisrecommendedtheDentalDepartmentreviewthedatesofsubmittedentriesforCPRcertificationwiththeSSLCtrainingdepartmentortraininginstructortoverifythatthecertificationwasintendedforafour‐yearperiod.AnnualAssessmentsAlistofthoseindividualshavingannualexaminationappointmentswassubmittedforthetimeperiodfrom12/1/11through5/31/12.Ofthese,154werelistedwithapriorannualexaminationdates.Ofthese,151hadanannualexaminationdatecompletedwithin365daysofthepriorannualexam.Thiswasacompliancerateof98%.TheDentalDepartmentdocumentedthattherewasnoindividualresidingatCCSSLCwhohadnotseenadentistduringthetimeperiodbetween5/31/11and5/31/12.Separately,copiesoftheannualdentalassessmentthatwerecompletedintheprior30daystotheMonitoringTeamvisitalongwiththeprioryear’scompletedassessmentweresubmitted.Forthetimeperiodfrom5/29/12through6/13/12,atotalof10annualassessmentsweresubmitted.For10outof10(100%)oftheseindividuals,anannualdentalassessmenthadbeencompletedwithin365days.Copiesofthecompletedannualassessmentsfor14individualsweresubmitted,onefromeachresidence.Eachincludedtheannualassessmentfromthedentalofficerecordandacopyfromtheactiverecordforthesamevisit.Thefollowingfindingsweremadewithregardtothedentalofficerecorddocumentsandtheactiverecorddocumentsrelatedtotheannualassessments:

Fourteenofthe14individualannualassessmentshadidenticalinformationinboththedentalofficerecordandactiverecord(100%).

Noncompliance


# Provision AssessmentofStatus Compliance Fourteenofthe14submittedassessments(100%)had anentryconcerning

cooperation,behavioralissues,andneedforsedation/restraintuse. Fourteenofthe14assessments(100%)hadentriesfororalhygienerating,teeth

restorations,andperiodontalcondition. Intra‐oralandextra‐oralexamscreeningwasdocumentedin14outof14

(100%). Thedentaltreatmentplanwasdocumentedin100%ofthecases. Oralhygienerecommendationsweredocumentedin14assessments(100%). Riskratingwasdocumentedin14outof14(100%)assessments. Communitytransitionpreparednesswasdocumentedin14outof14(100%)

assessments.

Additionally,duringthetimeperiodfrom12/1/11through5/31/12,therewerefiveindividualsnewlyadmittedtotheFacility.Fiveoutoffive(100%)hadcompletedaninitialdentalexaminthefirstmonth(fromsixto26days).DentalRecordsTheFacilitysubmittedthecompletedentalrecordsforthepriorthreeyearsforoneindividualfromeachresidence,asaseparatemeasureofcompletenessandtimelinessindentaldocumentation.Fourteenrecordsweresubmitted,andthefollowingfindingswerebasedonthereviewofthismaterial:

For13outof14(93%),themostrecentannualdentalassessmentwaswithin365daysofthepriorassessment.

Aperiodontalchartwascompleted/documentedinthreeof14(21%)records.Noneofthe14wasedentulous.

Apermanentdentitionchartwassubmittedfor14individuals(100%). Thedentaltreatmentplanwasdocumentedin14of14(100%)records. Asedationplanwassubmittedforsixof14,butwasoutdatedinfiveofsix.A

currentsedationplanwasinplaceforoneindividual. Fourindividualshadundergoneoralsurgeryconsultation. TenhadaTIVAanesthesiarecord. Fourteenof14(100%)hadacurrentannualdentalsummary. Eightof14hadinformationsubmittedconcerningmissedappointmentsinthe

prioryear. Thirteenof14hadinformationsubmittedconcerningthecompletionofdentalx‐

rays.AchartwassubmittedfordentalexamscompletedfromFY2010(startinginJune2010)andendinginFY2012(May2012).ForthetimeperiodDecember2011throughFebruary2012,therewere493appointmentslisted.Ofthese,421haddocumentationashavingbeencompleted(85%completionrate).Therewere27appointmentscancelled.


# Provision AssessmentofStatus ComplianceTherewere43missedappointments(noshowsandrefusals),whichwas9%oftheappointmentsscheduled.Fortwoappointments,attendancewasnotdocumented.ForthetimeperiodMarch2012throughMay2012,therewere580appointmentslisted.Ofthese,497haddocumentationashavingbeencompleted(86%).Therewere41cancellations.Therewere40missedappointments(noshowsandrefusals),whichwas7%oftheappointmentsscheduled.Fortwoappointments,attendancewasnotdocumented.OralHygieneAnoralhygieneratingwascompletedoneachindividualatthetimeoftheannualexam.Themostcurrentratingsforeachindividualwereusedindeterminingthepercentageofthecampuswithgood/fair/poororalhygiene.For260individuals,currentoralhygieneratingsindicated42%hadagoodoralhygienerating,40%hadafairoralhygienerating,and18%hadapoororalhygienerating.Asacomparison,thepriororalhygieneratingsfromNovember2011for271individualswereprovided.Atthattime,100outof271(37%)hadagoodoralhygienerating,98(36%)hadafairoralhygienerating,and73(27%)hadapoororalhygienerating.TheDentalDepartmentalsohadcumulativedataindicatingtrendingoforalhygieneratingineachresidentialunit.Thisallowedformorefocusedinterventionsandinterdisciplinarystrategizinginunitsinwhichoralhygieneratingswerestillachallenge.AccordingtotheProvisionActionInformation,updated6/29/12,theDentalDepartmenttrackedoralhygieneratingsmonthlyforallresidentialunits.Trendlinescouldthenbecreatedreflectingthemonthlydata.Throughemailcommunication,theDentalDepartmentprovidedeachunitamonthlyprogressreportofthetrendofgood/fair/poororalhygiene,aswellasarequesttotheunitstoidentifyindividualsneedingadditionalfocus.Twoofthestaffalsoprovideddentalhygienehands‐oninstructionintheresidences.Therewasalsovideotrainingoforalhygienecare.Formorerecentdata,anoralhygieneratingwascompletedoneachindividualatthetimeoftheannualexamforthepriorsixmonths.Themostrecentoralhygienescoresweresubmitted.Accordingtothisdocument,forthese154individuals,37%hadagoodoralhygienescore,46%hadafairoralhygienescore,and17%hadapoororalhygienescore.OralHygieneRatingsforPreviousSixmonths‐%

Rating 1/1/12to6/30/12

7/1/11to12/31/11

1/1/11to6/30/11



Thetrendindicatedplateauingofthosewithgoodoralhygiene,continuedincreaseinthosewithfairoralhygieneandacontinueddecreaseinthosewithpoororalhygiene.Fromaseparatedocumententitled“DentalServicesDepartment‐monthlytrendingreport,”forthemostrecentquarter(MarchthroughMay2012),therewere280appointmentsforwhichoralhygieneratingswererecorded.Ofthese,106outof280(38%)hadanoralhygieneratingofgood,115(41%)hadanoralhygieneratingoffair,and59(21%)hadascoreofpoor.Thismorerecentlist,comparedtothepriorsix‐monthtrend,indicatedanormalvariabilityfromquartertoquarter,basedonsmallnumbers.Atotalof81individualshadcareplans/ISPsthatincludedbrushingone’sownteeth.Theoralhygienescoresofthese81individualsweresubmittedforthepriortworatings.Theseratingsoccurredfromafewdaystoapproximatelyfivemonthsapart.Forthemostrecentscores,36individuals(44%)hadagoodoralhygienerating,37individuals(46%)hadafairoralhygienerating,andeight(10%)hadapoororalhygienerating.Thepriorscoreindicated37individuals(46%)hadagoodoralhygienerating,32individuals(40%)hadafairoralhygienerating,and10(12%)hadapoororalhygienerating.Twoindividualswerenewadmissionsanddidnothavepriorscores.Assomeoftheratingswereonlydaysapart,itwasnotpossibletodetermineiforalhygienewasimprovingorstableinthosethatbrushedtheirownteeth.Forthosewithcontinuedpoororalhygieneratingthatbrushedtheirownteeth,itisrecommendedthatadditionalassistancebeconsidered,andthattheDentalDepartmentparticipateinIDTmeetingstodiscussadditionalstepstobetaken.Aspartofpreventiveoralcare,suctiontoothbrushingwasprovidedtothosewithdysphagiaandotherindicationsforthisprocedure.Alistsubmittedindicated41individualsreceivedsuctiontoothbrushing,whichwas41outof261(16%)ofthepopulation.Therewasoneindividualidentifiedthatwouldbenefitfromsuctiontoothbrushing,butwasnotreceivingsuctiontoothbrushing.Thereasonprovidedwasthattheindividualhadfragilehealth.Asmanyofthosethatreceivesuctiontoothbrushinghavefragilehealth,thereasondocumenteddidnotprovideadequatedetailfornotprovidingsuctiontoothbrushing.Forinstance,iftherewasaprolongedhospitalizationthatpreventedthisprocedure,thatwouldhavebeenimportanttodocument.On12/20/11,theDentalDepartmentparticipatedinaDentalDepartmentalconference

Good 37% 39% 26%

Fair 46% 35% 43%

Poor 17% 26% 31%


# Provision AssessmentofStatus CompliancecallwithotherSSLCDentalDepartments.Therewasapresentationonthepreferredsuctiontoothbrushsystem.TheDentalDepartmentimplemented/trackedotheractionstepstoimproveoralhygieneacrossthecampus.Theseincluded:

TheDentalDepartment,aspartofitsself‐assessment,trackedtooth‐brushinginstructionfortheindividualand/orstaff.TheDentalDepartmentsubmittedatableof262names,includingthosewhowereedentulous,entitled:“SummaryforTooth‐brushingInstructionforIndividualand/orStaff.”Thetableindicatedthatallthosewithteethhadbeenprovidedtooth‐brushinginstruction(100%).However,thetimeperiodofthedatawasnotincluded(i.e.,whetheritwas12months,sixmonths,onequarter,etc.).

Additionally,theDentalDepartmentsubmittedarosterofdirectsupportprofessionalsthathadcompleteddentaltrainingontoothbrushing,andthosedirectsupportprofessionalsthatremainedtobetrained.ThedifficultiesofthistaskwereevidentbasedonthesubmittedcolorcodedchartinwhichemployeesthatnolongerworkedatCCSSLCwerelisted,alongwithnewhires,aswellasallotherdirectsupportprofessionalsfromallresidentialunits,includingtheInfirmary.Thereappearedtobeconsiderableturnoverinthedirectsupportprofessionalstaffing,whichwasanaddedchallengefortheDentalDepartmenttoensureadequatetraininginthisoralhygienetask.TheDentalDepartmentindicatedthat447of492(91%)ofdirectsupportprofessionalsthatwerecurrentlyemployedhadreceivedtrainingintoothbrushing,althoughthedateofthedatatowhichthiscalculationreferredwasnotindicated.However,theextensivetablesubmittedwasupdatedasof6/12/12,indicatingtheinformationwascurrent.Additionally,thelistofthosetobetrainedincludedtwoadministrativestaff,habilitationtherapystaff,threepsychiatrydepartmentstaff,twoQDDPs,onestaffdescribedas“ortho,”andseveralactivetreatmentstaff.Itwasnotindicatediftheseotherdepartmentnumberswerepartofthetabulationofthe447outof492staff.

Flossingwasdiscouragedreportedlyduetoinjuriesofthemouthandfingers,aswellasflossbeingusedasaweapon.Therefore,notrainingwasconductedonuseoffloss.Flossingwasallowedduringdentalproceduresforonly61individuals.ItisrecommendedthattheStateOffice/FacilityAdministrationreviewcurrentandpriorguidanceconcerningallowingindividualstofloss.Withadequatesupervisionandappropriatestorage,opportunitiestoincludeflossingaspartofdentalhygieneshouldbeconsidered.X‐raysTheFacilitysubmittedalistofthosewhohadoutstandingneedfordentalx‐rays.These


# Provision AssessmentofStatus Compliancewerecategorizedbypriority.Inthehighestprioritycategorywerethosewithpoororalhygiene,observeddecay,mobilityofteeth,andimminentneedfordentalrestorationsand/orextractions.Therewasnooneidentifiedinthiscategory.The“mediumpriority”groupincludedthosewithfairtopoororalhygiene,thosethatexhibitedpsychoticorirrationalbehavior,werecombative,andfrequentlyrefuseddentalservices.Threeindividualswerelistedinthiscategory.Inthe“lowpriority”categorywerethosewithgoodtofairoralhygiene,novisibledecay,hadseverebruxism,wereunabletobestillforx‐rays,hadlimiteddentition,and/orhadsafetyconcernssuchaspicaorself‐injuriousbehavior.Thisgrouphad23names.Therewasanadditionalcategoryinwhichtherewasnoabilitytotakedentalx‐raysbecauseofanatomicanomaliesofthemouth,medicallycompromisedstate,therewerecontraindicationsforTIVA,hadfixationofthetemporomandibularjoint,hadaterminalcondition,and/orhadacompromisedairway.Thisincluded20names.Preventive,Restorative,EmergencyDentalServicesInformationsubmittedindicated20individualsresidingatCCSSLCwereedentulous,forarateof20outof261(8%).Itwasnotedthatindividuals’transitionstothecommunityplayedaroleinmakingdatabasesappeartobeinnon‐agreement,becausethelistidentifying20individualsasedentulousalsoincludedtwoindividualsthathadmovedtothecommunity.Aseparatedatabaseindicatedthattherewere21individualswithoutteeth.Fiveindividualshaddentures.Sixteenindividualswereedentulousanddidnothavedentures.Reasonsgivenwerethatallsixteenhadinabilitytocomprehend/cooperatewithdentalproceduresoffabrication.Additionally,sixofthe16hadaninadequateridgeneededforadentalprosthesis.Oneofthe16hadananatomiccontraindication.TheDentalDepartmentdidprovidethebreadthofservicesrequiredtocarefortheindividualsatCCSSLC.SinceSeptember2011(thebeginningofFY2012)throughMay2012,fromatablelabeled“TypeofServicesProvided,”194annualswerecompleted,87annualswithcleanings,14annualswithedentulousindividuals,57appointmentsforcleaning,389appointmentsforcleaningwithfluoridetreatment,21dentalvisitsfordenturecare,31emergencydentalexams,175appointmentsforextractions,94appointmentsforrestoration,and116visitsforx‐rays.Separately,tablesofamonthlytrendingreportentitled“routineoremergencyappointments”indicatedtherewere47emergenciesfortheSeptember2011–throughMay2012timeperiod,not31asmentionedinthepriorparagraph.Fromatablesubmittedfor“DentalServicesDepartment–monthlytrendingreportfor


# Provision AssessmentofStatus ComplianceFY2012,”inthemostrecentsixmonthsfromDecember2011throughMay2012,therewere400appointmentsforprophylacticcare(includedannual/cleaning,cleaning,cleaning/fluoridetreatment,cleaning/periodicexam,fluoridetreatment).Atotalof17individualsunderwent51restorativecareprocedures.Therewere16appointmentsfordentalemergencies.SeparateinformationsubmittedbytheDentalDepartmententitled“Self‐Assessment:SummaryforPreventiveServices”listed262individuals,includingthosethatwereedentulous.Oftheindividualslistedwithteeth,all(100%)hadbeenprovidedpreventiveservices.However,thedocumentdidnotincludethetimeperiodduringwhichthepreventiveservicesoccurred(e.g.,yearly,quarterly,etc.),orifthiswascurrentinformation(2012)orprioryearinformation.OralSedationMonitoringandevaluationofuseoforalsedationwasreviewed.Tenactiverecordsweresubmittedforindividualswhounderwentoralsedation.Thefollowingsummarizestheresultsofthisreview:

Oneoutofnine(11%)confirmednothingbymouth(NPO)statusornothingperG‐tube.OneindividualwasdocumentedtonotneedNPOstatus.

Ten(100%)listedthemedicationadministered,thedose,andtheroute. Ten(100%)listedpre‐procedurevitalsigns. Three(30%)documentedintra‐procedurevitalsigns. Ten(100%)documentedpost‐procedurevitalsigns. Adequatedocumentationregardingeffectivenesswasfoundineightofthe10

(80%)oftheactiverecords. None(0%)documentedapostdentalprocedureIPNnote. Ten(100%)includeddocumentationofcurrentsedationconsent. Ten(100%)includedarestraintchecklist.

TheProvisionActionInformation,updated6/29/12,documentedthattheDentalDepartmenthadconcernsaboutthenumberofindividualsarrivingfordentalappointmentswithoutbeingsedatedduetonosedationorders.Thiswasabusinessagendaitematthe3/26/12NursingQualityAssurancemeeting.ThisalsowastobediscussedattheMorningMedicalMeeting.AnemaildirectivefromtheCNEdated4/4/12wenttonursesandtheDentalDepartment.Thisprovidedclearguidanceregardingthedocumentstosendafteradministrationofasedativefordentalclinic,althoughitdidnotaddresstheissuerelatedtoalackofsedationorders.Nursesweretoforwardtheoriginalrestraintchecklistandthevitalsignflowsheet(butnottobeconfusedwithTIVAdocuments).Asabaselinepriortosedation,thenursingstaffwasinstructedtoobtainafullsetofvitalsignswithpulseoximetry,documentgait/balance/coordination,andmentalstatus.Thisinformationwastobeobtained


# Provision AssessmentofStatus Complianceevery30minutesoncesedationwasadministereduntiltheindividualwassenttothedentalclinic.TheDentalDepartmentwastocontinuetotakevitalsignsattheappointment,andnursesweretoresumevitalsignsoncetheindividualreturnedtothehome.Nursesweretoobtainthesamepre‐dentalvisitinformationaswellasadditionalinformation(i.e.,lungsounds,skincolor,signs/reportsofnausea/vomiting,reviewofrecordfortimeofsedationadministrationandtimeofdentalprocedure),withascheduleofdecreasingfrequencyofmonitoringuntiltheindividualhadrecoveredfromthesedation.Therewasanadditional4/30/12NursingQualityAssurancemeetingthatnotedimprovementinthepre‐treatmentsedation,butdidnotdescribefurtherifthisreflectedimprovementinorderingofthesedationorinmonitoringofthesedation,orsomeotheraspectofcare.The5/14/12DentalTeamMeetingdocumentedthattheSedationCarePlanlogswereincreasinglyincomplete,withlackofvitalsigndocumentation.Therewasalsoaconcernaboutthefilinglocationintheactiverecord.Thenursingcoordinator,aswellascasemanagerswereemailedconcerningthisinformation.GeneralAnesthesia/TIVATheactiverecordwassubmittedforsixindividualswhohadundergonegeneralanesthesiain2012.OneindividualunderwentTIVAtwiceduringthistime.Thedaterangeoftheseprocedureswasfrom4/16/12through6/12/12.Theproceduresundergeneralanesthesiaincludedoneormoreaspectsofdentalcare.Thelistvariedineachcase,andincludedthefollowing:annualexam,prophylaxis,extractions,andrestorativecare.Reviewoftheserecordsrevealedthefollowing:

Consentforthedentalprocedures/anesthesiawasup‐to‐dateinsevenofseven(100%)procedures.

Apre‐operativeanesthesiaclearancewascompletedandsubmittedinsevenofsevencases(100%).

Apre‐operativemedicalclearancewascompletedandsubmittedinsevenofsevencases(100%).

Theoperativeanesthesiarecordwascompletedinsevenofsevencases(100%). Thepostanesthesiacare“Respiration,Energy,Alertness,Circulation,and

Temperature(REACT)”scorewasdocumentedinsevenofsevencases(100%)oftheactiverecords.

Arecoverynotewasdocumentedforsevenofsevencases(100%).Thisconsistedofaphonecalltothehomethefollowingdayinsevenofsevencases.Afollow‐upvisitoccurredinthreeofsevencases(43%).

Pre‐operativevitalsignswererecordedinsevenofsevencases(100%). Post‐operativevitalsignswererecordedinsevenofsevencases.(100%).


# Provision AssessmentofStatus Compliance Aperiodontalchartwassubmittedforfiveofseven(71%)cases/six

(83%)individuals.ForoneindividualthatrequiredextensivedentalworkunderTIVA,hypoxiadevelopedtowardtheendoftheprocedure.ItwasnotclearwhethertheperiodontalchartwasnotcompletedatthefirstTIVAappointmentbecauseofthehypoxia(anesthesiologistsuggestedlimitinganesthesiatimetolessthantwohours).TheperiodontalchartwascompletedatthesecondTIVAappointment.

Atreatmentplanwassubmittedforsixofsevencases(86%)/six(100%)individuals.Fortheoneindividual,whorequiredtwoTIVAappointments,theStateassertedinitscommentsonthedraftreportthatthetreatmentplanforthefirstTIVAappointmentappliedtothesecondTIVAappointment.However,atthetimeofthesecondTIVAappointment,theplandidnotappeartobeupdatedtoincludecurrentinformation.Thetreatmentplanof4/16/12indicatedthathewasacandidatefordesensitization,buttheDentalProgressNoteof6/11/12indicatedBehavioralServicesdeterminedtheindividualwasnotappropriatefordesensitization.

Painmedicationwasprescribedintwooftwocasesinwhichextractionsoccurred(100%).

From1/10/12through5/16/12,35individualsunderwentdentalproceduresusingTIVA.TheQA/QIQuarterlySectionReviewofSettlementAgreementProgress,dated3/22/12,identifiedoneoftheDentalDepartmentchallengeswastoreducethetimeinobtainingtherequiredconsents,medicalclearances,etc.,forTIVAprocedures.TheminutesofthesubsequentQA/QICouncildidnotprovideanyprogressonthisconcern,andtheDentalDepartmentdidnotprovidefurtherinformationonthisidentifiedchallenge.Thequalityofthesedationandthetypeofsedationweretrackedviatwodatabases.A“SedationUsageReport”trackedsedationuseperchronologicaldate.Foranydaterequested,theuseofsedation(individual,medication,dosage,effectiveness)waslogged.Additionally,toaidthedentistandIDTindeterminingsedationneeds,alogofallsedationswerelistedperindividual,alongwithlevelofeffectiveness.Thisprovidedhistoricalinformationandguidanceinorderingtheappropriateamountofsedationforthenextdentalvisit.TheFacilitywasaskedtosubmitinformationconcerninganyinjurytoanindividualwhohadbeenadministeredTIVAinthefollowing24hours(e.g.,fallswithinjury,etc.).Alistof35individualswassubmittedwhohadundergoneTIVAfromJanuary10,2012through5/16/12.Allwereconsideredtohave“normalrecovery,”andtherewerenoadversereactionsdocumented.



TheFacilitywasaskedtosubmitthedateofthemostrecentdentalvisitforthoseindividualsthatwerediagnosedwithpneumoniafrom12/1/11through5/31/12.Thiswastoincludethetypeofdentalprocedurecompleted,andthetypeofanesthesiaorsedationprovided.Alistof26individualswassubmittedwhohaddocumentedpneumonia.Notrendwasidentifiedinwhichdentalprocedures/sedationthatwasprovidedprecededthedevelopmentofpneumonias.Therewasonlyoneindividualidentifiedthatdevelopedaviralpneumoniathreedaysafteradentalvisitthatinvolvedaphysicalevaluationandfluoridetreatmentwithoutsedation.ThereweretwootherindividualsatCCSSLCthatalsohadviralpneumoniaatthesametime,suggestingalocalspreadofviralinfectionunrelatedtodentalcare.ExtractionsTheDentalDepartmentsubmittedadocumententitled“ExtractionChartreviewedSummary”forthetimeperiod12/1/11through5/31/12.Thislogincludedtheindividual’sname,thenumberofteethextracted,andthereasonfortheextraction.All31individualswithtoothextractionswerelisted.Tenindividualshadonetoothextracted,eightindividualshadtwoteethextracted,sevenindividualshadthreeteethextracted,oneindividualhadfourteethextracted,oneindividualhadfiveteethextracted,twoindividualshadeightteethextracted,oneindividualhad12teethextracted,andoneindividualhad22teethextracted.Forclinicaljustificationoftheextraction,thereasonfortheextractionofeachtoothwaslisted.Thelistofreasonsincludeddecaynon‐restorable,impactedwisdomtooth,impactedwisdomtoothwithdiscomfort,pulpitiswithdiscomfort,abscessednon‐restorable,rootfragmentnon‐restorable,brokennon‐restorable,androotfracturenon‐restorable.Forfiveindividualsthatunderwentextractionsoncampus,thedentalrecordwassubmitted.Thefollowingfindingsweremade:

Consentwasobtainedinfiveoffive(100%). ApriordentalIPN/DPNindicatingtheneedforextractionswasdocumentedin

fiveoffive(100%). Forfourofthefivecases,IVsedationwasused.Foroneofthefivecases,oral

pre‐treatmentsedationwasusedinpreparationforTIVA.Onehadalocalanesthetic.

Fromonetothreeteethwereextractedatavisit. Painmedicationwasprovidedinfiveoffivecases. Afollow‐upphonecallwasdocumentedinfourcases. Afollow‐upvisitwasdocumentedinfivecases.

Forfiveindividualsthatunderwentextractionsoffcampusattheoralsurgeryconsultant’soffice,thedentalrecordwassubmitted.Thefollowingfindingsweremade:


# Provision AssessmentofStatus Compliance Noneofthefivehadpriorrefusalsfordentalappointmentsorunsuccessfully

completedappointments,accordingtothesubmittedinformation. Fiveoffive(100%)hadcompletedIPNs/DPNsintherecordpriortoreferralto

theoralsurgeonindicatingtheneedfortheextractionorotherprocedure.Fourcaseswerereferredfornon‐restorabledecay.Onewasreferredforapartiallyavulsedtooth.

Onetothreeteethwereextractedforthefourcasesneedingextraction. Five(100%)includedanoralsurgeryconsultreport. Five(100%)submittedacopyoftheanesthesiareport. Acopyoftheconsentwassubmittedforfiveoftheseoralsurgeries(100%). Therewasoneormorepost‐operativeIPN/DPNnotesfromtheSSLCDental

Departmentsubmittedforfiveoff‐sitedentalprocedures(100%).EmergencyTreatmentTheDentalDepartmentprovideda“DentalEmergencyLog”forthemonthsDecember2011throughMay2012.Theselogsreflected16emergencies.Apriordocumentreferredto31to47emergenciesoveralongertimeperiod,butthesmallcurrentnumbersuggestedinconsistencyindatabasemanagement.Forthese16recentemergencieslistedinthe“DentalEmergencyLog,”15outof16(94%)wereseenthesamedayastheemergencycontactwiththeDentalDepartment,andallwereseenwithinonebusinessday.The“DentalEmergencyLog”alsotrackedtheseemergenciestocompletion.Fourteenoutof16(88%)weretrackedtoclosure.Tworemainedoutstanding,awaitingconsultationwiththeoralsurgeon.Emergencytreatmentwasreviewedforfiveindividuals.Thereasonsfortheemergencywereasfollows:postTIVAtreatment,partiallydissolvedcapsulecausingirritationinmouth,cheekbite,fall,andanon‐emergency(individualwantingbraces).Thefollowingfindingsaremadebasedonthisreview:

Fourrecords(80%)documentedthepresenceornotofpain. Painwasdocumentedintwocases.Painwastreatedinthesetwocases. Allfivecases(100%)wereseenonthesamedaythecomplaintwasmadeknown

totheDentalDepartment. Follow‐upoccurredforfouroffourcasesconsideredanemergency(100%).

Becauseofthescopeanddetailoftheaboveinformation,thefollowingsummaryofthissectionisprovidedtofocustheDentalDepartmentonareasnecessaryforsubstantialcompliancetobeachieved.Therearemanyareasoutlinedabovewith90%orgreatercompliance.Maintenanceoftheseareaswillberequired.However,afewareasneedfurtherrefinement.Theroleofindividualsinflossingtheirteethwasinneedofreview.DeterminingthepreviousFacilityorStateOfficedocumentsorpoliciesthatdidnotallow


# Provision AssessmentofStatus Complianceitwouldbetheinitialstep,andthendecisionsmadeaboutwhatiscurrentlynecessaryandappropriateforadequatedentalcare.Inaddition,reviewofthoseindividualswhobrushtheirownteeth,buthavepoororalhygienescoresisneeded,andasappropriate,newplansimplementedandresultstracked.Intra‐visitrecordingofvitalsignswhenoralsedationisadministeredshouldbeprovidedanddocumented,whereapplicable.ItalsowouldbeimportanttodocumentwhetheranindividualwasmadeNPOwhenanorder/expectationforNPOisincludedinthedentalvisitrecord,priortoinitiatingthedentalprocedure.TheseareallareasthatappeartobechallengesthattheDentalDepartmentcanbemetinthenearfuture.

Q2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshalldevelopandimplementpoliciesandproceduresthatrequire:comprehensive,timelyprovisionofassessmentsanddentalservices;provisiontotheIDTofcurrentdentalrecordssufficienttoinformtheIDTofthespecificconditionoftheresident’steethandnecessarydentalsupportsandinterventions;useofinterventions,suchasdesensitizationprograms,tominimizeuseofsedatingmedicationsandrestraints;interdisciplinaryteamstoreview,assess,develop,andimplementstrategiestoovercomeindividuals’refusalstoparticipateindentalappointments;andtrackingandassessmentoftheuseofsedatingmedicationsanddentalrestraints.

Thissectionofthereportincludesanumberofsub‐sectionsthataddressthevariousrequirementsofthisprovisionoftheSettlementAgreement.Theseincludethedevelopmentofdentalpoliciesandprocedures,provisionofdentalrecordstoIDTs,refusalsandmissedappointments,trackingofuseofsedatingmedicationsandrestraints,andinterventionstominimizetheuseofsedatingmedications.PoliciesandProceduresTheDentalDepartmentsubmittedonerevisedpolicythatwasimplementedduringthepriorsixmonths.ThiswasDentalServices:AnnualDentalExamination–DentalQ.16,revised4/12/12andimplemented4/19/12.Changes/revisionswerehighlighted.Thefollowingstatementshadoneormorechanges:

“AllnoteswillbewrittenintheIntegratedProgressNotesoftheindividual’sActiveRecordwithcopiesmadefortheDentalSectionoftheActiveRecordandtheDentalClinicalRecord.”

“Acompleteextraandintra‐oralexaminationwillbecompletedwithin365daysofthepreviousannualexaminationbutnomorethan31daysprior.”

“10dayspriortoISP’sAnnualsthemostcurrentDentalAssessmentwillbefiledintheClientInformationRecordfolder.IfDentalAssessmentisdatedmorethan60dayspriortoISPAnnualdate,anupdatedandrevisedassessmentwillbeplacedintheClientInformationRecord.”

Acopyofthein‐servicetrainingrosterwassubmittedfor“RevisionofDentalPolicyQ.16–AnnualDentalExamination–In‐servicechangesinschedulingofAnnualExamination(elevenmonthrecalls).”Thisoccurredon4/19/12.Fivedentalstaffattended.ThispolicywaspartofDentalServicesmanualthatincluded21policiesandprocedures.ProvisionofDentalRecordstoIDTsTheDentalDepartmentprovidedanannualdentalsummarytotheIDT,aportionofwhichwasalsocopieddirectlyintothe“Rationale”sectionoftheIntegratedRiskRating

Noncompliance


# Provision AssessmentofStatus ComplianceForm,withdentalriskdetermined.Contentofthedocumentincludeddentaltreatmentperformedintheprioryear,oralhygieneratings,presentconditionoftheteeth,periodontalcondition,mobility,missingteeth,intra‐oralandextra‐oralassessment,behaviorassessmentwhileunderdentaltreatment,sedationutilized,effectivenessofsedation,communitytransitionrequirements,andwhetheradesensitizationprogramwasinplace.ThetenmostrecentannualdentalsummariesprovidedfortheISPprocessweresubmitted.Eachwascompletedaccordingtotheabovedescription.TheannualdentalsummarywascompletedfromthreetofiveweekspriortothedateoftheIntegratedRiskRatingForm,indicatingup‐to‐dateinformationwasprovidedbytheDentalDepartment.TheDentalDepartmentsubmittedseveraltablesinwhichtheISPdateoftheindividualwaslisted,thedatetheannualassessmentwasdue(10dayspriortotheISP),alongwiththedateoftheannualdentalsummary.Forthe15ISPsthatoccurredinDecember2011,all15hadreceivedtheannualdentalsummarybytheduedate.Forthe27ISPsthatoccurredinJanuary2012,all27hadreceivedtheannualdentalsummarybytheduedate.Forthe29ISPsthatoccurredinFebruary2012,all29hadreceivedtheannualdentalsummarybytheduedate.Forthe25ISPsthatoccurredinMarch2012,all25hadreceivedtheannualdentalsummarybytheduedate.Forthe24ISPsthatoccurredinApril2012,all24hadreceivedtheannualdentalsummarybytheduedate.Forthe26ISPsthatoccurredinMay2012,all26hadreceivedtheannualdentalsummarybytheduedate.Additionally,accordingtotheSelf‐Assessment,amemberoftheDentalDepartmentattended95outof146ISPs(annuals)fromDecember2011throughMay2012,whichwasa65%attendancerate.However,the3/22/12QA/QIQuarterlySectionReviewofSettlementAgreementProgressindicatedthattheDentalDepartmentneededtoreviewaccuracyoftheattendancedatafortheISPmeetings.Thesubsequent4/19/12QA/QICouncilminutesdidnotprovideanupdate,andtheDentalDepartmentdidnotsubmitfurtherupdatesconcerningthisissue.AspartoftheprocesstodiscussdentalconcernswiththeIDT,theDentalDepartmenttrackeditsattendanceatISPs/ISPAs.ForNovember2011,twooutof22(9%)wereattended.ForDecember2011,DentalDepartmentalattendancewassevenoutof15(47%).ForJanuary2012,DentalDepartmentalattendancewas12outof27(44%).ForFebruary2012,DentalDepartmentalattendancewas17outof29(59%).ForMarch2012,DentalDepartmentattendancewas13outof24(54%).ForApril2012,DentalDepartmentattendancewas21outof24(88%).ForMay2012,DentalDepartmentalattendancewasfouroutof25(16%).


# Provision AssessmentofStatus ComplianceRefusals/MissedAppointmentsAreviewofinformationfromachartentitled“Listofrefusalsforthepastsixmonthsperdateofrefusal(listreasonforappointment)”fordentalappointmentsforthepriorsixmonths(12/1/11to5/31/12)indicatedthat28individualsrefusedappointments.Oneindividualrefusedfourtimes,andtwoindividualsrefusedtwotimes.Ofthese,21ofthe28subsequentlycompletedadentalvisit,andsixremainedincompleteasofthedateofthedocumentsubmitted.Oneindividualreferredforadentalemergencysubsequentlyhadresolutionofthesignsandsymptoms,anddidnotrequireadditionalfollow‐up.Reasonsforthescheduledappointmentsthatwererefusedincludedcleaning(17appointments),extraction(oneappointment),annualexam(sevenappointments),andrestoration(twoappointments).Separately,alistentitled“IndividualsIdentifiedtohaverefusedDentalTreatmentbetween12/1/11and5/31/12”listed26individuals.Additionally,oneindividualthathadrefusednolongerresidedatCCSSLC.Althoughnotinexactagreement,thetwodatabasesweresimilar.ForthetimeperiodDecember2011throughMay2012,therewere108missed/noshowappointmentsthatwerenotcategorizedasrefusals.Reasonsforthescheduledappointmentsthatweremissedincludedcleaning(74appointments),annualexams(15appointments),andrestorations(fourappointments).Fromsubmittedgraphsentitled“CCSSLCDentalServicesDepartmentmonthlytrendreportfrom12/1/11through5/31/12,”moreinformationwasprovidedconcerningmissedappointments.ThenumberofcancelledappointmentswasgreateronShift1thanShift2,butthenumberof“noshows”wasaboutequalbetweenthetwoshifts.Themajorreasonsidentifiedformissedappointmentsincludedmedicalillness,dentalclinicissues,refusals,andstaffingissues.Informationwasalsoprovidedconcerningappointmentattendanceperunit.AtlanticUnithadthehighestnumbersof“cameasscheduled,”“noshow”andrefusedtreatment,comparedtotheotherunits.Specificresidenceshadthehighestrateofcancelling(Residence#515and#516),hadthehighestrateof“noshow”(Residences#518,#522A,and#522B),andthehighestrateofrefusal(Residence#522A).Separately,adocumententitled“Havemissedanappointment(otherthanrefusals),thedateofthemissedappointment,thereasonforthemissedappointment,andthedateofthecompletedmake‐upappointmentforthetimeperiod12/1/11through5/31/12”identified83individualsthatmissed116appointments.Thereasonsfortheappointmentsthatweremissedincludedcleaning(82),restorations(seven),postopcare


# Provision AssessmentofStatus Compliance(three),denturecare(six),annualexams(eight),TIVA(two),exam(two),andother(two).Thereasonslistedforthemissedappointmentsincludedbehaviors(six),medicalreasons(34),staffingconcerns(11),dentalclinicreasons(16),weather(four),conflictintheindividual’sschedule(five),refused(17),homeissues(six),administrativeissues(one),nursing(eight),furlough(six),andreasonnotsubmitted(two).Itwasunclearwhythisinformationincludedrefusalsdespitethereportheadingindicatingitwasdatathathadseparatedrefusalsfromallothermissedappointments.ItisrecommendedthattheDentalDepartmentreviewthereasonsforrefusalstoremainaspartofthemissed(non‐refusal)data.Forreschedulingofthemissedappointmentsforthe83individuals,therewasoneindividualthatmovedfromCCSSLC,sixthatremainedtobecompleted,andonethatdidnotneedtoberescheduledastheconcernresolved.Theother75individualscompletedappointments(90%).Ofthese75,itwasnotedthat13individualscompletedtheappointmentmorethan60daysafterthedateoftheoriginalmissedappointment.Atotalof62completedanappointmentwithin60days(83%).ItisrecommendedtheDentalDepartmentcontinuetodecreasethetimebetweenmissedappointmentsandcompletedappointments.TheDentalDepartmentsubmittedatableentitled“MissedDentalAppointmentswithoutISPA2/1/11‐6/1/12.”Duringthistime,therewere149missedappointments.Thisincludedbothappointmentsthathadbeenrefused,aswellasallother“noshows.”TherewerethreecategoriesofmissedappointmentsthatdidnotrequireanISPA,includingDentalDepartmentissues(16missedappointments),illness(29missedappointments),andweather(4missedappointments).Thesetotaled49missedappointmentsnotneedingafollowupISPA.Theothercategoriesofreasonfor“noshow”wereidentifiedasbehaviorsathome,staffingissues,schedulingconflicts,furloughandnursingissuesandtotaled100missedappointmentswithoutanISPAasof6/1/12.Subsequenttothisinformation,14ofthe100individualshadanISPAcompleted.Therewasnoevidencesubmittedthattheother86individualshadISPAscreatedandimplementedtoaddressthe“noshow”appointments.TheDentalTeamMeetingof5/14/12documentedthattheDentalDepartmentwouldmaintainalistofmissedappointmentsaswellasISPAsreceived.Acopywastobefiledfollowingthemissedappointmentlogkeptinthedentalchart.ThisallowedtheDentalDepartmenttodeterminewhethertherewasclosurebytheIDTinfollow‐uptocommunicationofamissedappointment.InterventionstoMinimizetheUseofSedatingMedicationsand/orRestraints


# Provision AssessmentofStatus ComplianceInformationwassubmittedconcerninguseofrestraintsfordentalprocedures.Forthepriorsixmonths,thedentalofficedidnotusemechanicalrestraints.Fororalsedation,fromDecember2011throughMay2012,accordingtothedataprovided,903appointmentswerekept.Ofthese,therewere41appointmentsinwhichoralsedationwasgiven(4.5%),and32(3.5%)forwhichIVsedationwasadministered.Separately,alistofHRC‐approveddentalandmedicalrestraintswassubmitted,includingtheuseofsedation,dated9/1/11through5/31/12.Atotalof81individualswerelistedthatrequireddentalsedation.Ofthese,35hadapprovalforTIVA,33hadapprovalfororalsedation,and13hadapprovalforbothoralsedationandTIVA.DesensitizationTheDentalDepartmentcollaboratedwiththePsychologyDepartment,PCPs,Pharmacy,andPsychiatryDepartmentinadvancingthedentaldesensitizationprogramatCCSSLC.TheDentalDepartmentalsoreferredindividualstotheIDTiftherewastheneedtoconsiderdentaldesensitization.Anoutline/timelineofprogresswassubmittedbytheDentalDepartmentfordesensitization.TheDentalDepartmenthadnominated174individualsforbehaviorevaluations.Reportedly,thePsychologyDepartmenthadupdatedandimplemented110newdesensitizationplansasof12/9/11.AllHRCapprovalshadbeenobtainedsince9/7/11.BeginninginFebruary2012,theAnnualPre‐TreatmentSedationPsychiatricClinic,aninterdisciplinaryteam,reviewedthepre‐treatmentsedationneedsforindividualsbyUnit.AccordingtotheProvisionActionInformation,PacificUnitwasdiscussedon2/7/12,Kingfish3and4on3/7/12,CoralSeaUniton3/21/12,DolphinandPorpoiseUnitson3/23/12,Kingfish1and2on3/28/12,andDolphinandPorpoiseUnitson4/11/12.Thisseriesofdatescompletedtheyearlypre‐treatmentsedationreviewsbythiscommittee.WhencomparingemailcorrespondencefromtheDentalDepartmenttoconfirmtheaccuracyoftheabovemeetingcontent,therewasonemeetingforwhichinformationwasinconflict.AnemailindicatedthatRibbonfishwasreviewedon2/7/12.Thereasonforthediscrepancywasnotdetermined.ThePre‐TreatmentSedationPsychiatricClinicstartedwithareviewofpre‐treatmentsedationswithpharmacy,dental,andpsychiatryparticipation.Approvalswereprovidedatthatmeeting,basedoneffectivenessofpriorusageanddosage.Forordersexceedingoroutsideofpriorcommitteeapproval,priorinterdepartmentalreviewandapprovalwerenecessary.Beginningon2/15/12,aDesensitizationPlanWorkgroupdiscussedthedecisiontreeevaluationprocess,baselineinformation,thepotentialfortwomockclinicsfordesensitization,trialsofappropriatereplacementbehavior,anddatacollection.


# Provision AssessmentofStatus ComplianceSeparately,on2/28/12,aDesensitizationCommitteereviewedthenominationlistsoftheDentalDepartment,andcomparedthislisttothePsychologyDepartmentnominations.Therewerefurthermeetingsofthiscommitteeon3/21/12and4/19/12,whichtrackedprogressofthemockclinics,theestablishmentofdentalnominations,andthecreationofalistofthoseconsideredinappropriateforadesensitizationprogram.Accordingtothe“SectionLeadMonthlyReport–Dental,”dated5/30/12,theDesensitizationCommitteehadidentifiedaninitialgroupofindividualsfordesensitizationplandevelopment.Adocumententitled“CCSSLCDentalTentativeListofIndividualsforInitialDesensitizationTrialProgram,”withahandwrittendateof4/19/12,listedeightindividuals,whowereamong23individualswhoreceivedStridentTreatment(suctiontooth‐brushing)andhadbeenapprovedforadesensitizationprogram.ARestrictivePracticeCommitteemetatfrequentintervalsfromMarchtoMay2012(starting3/21/12)toreviewtherestrictivepracticesofdentalpre‐treatmentsedationutilizedinthepriorweek.Apolicywascreated,BehavioralServices:RestrictivePracticesCommittee,K.19,dated3/22/12,toprovideguidancetothisprocess.Toprovideefficiencyinthesystem,dentalpre‐treatmentsedationswerediscussedattheWednesdaymeetings(personal,mechanical,andchemicalrestraintswerediscussedatMondaymeetings,andmedicalpre‐treatmentsedationwasdiscussedatFridaymeetings).Restraintreviewincludeddeterminingwhetherthedatasupportedtheneedfortherestraintandwhetherdocumentationwascorrect.Aspreparationforthediscussion,theDentalDepartmentprovidedalistofindividualsthathadreceivedsedationthepriorweek,alongwithahistoricalsedationlogofmedicationandeffectiveness.Atthe3/21/12RestrictivePracticesCommitteeMeeting,therewasdiscussionconcerningtheneedtodifferentiatethoserequiringdesensitizationduetofearfromthoseneedingreinforcementprogramsduetonon‐complianceandoppositionalbehavior.AdditionalmeetingsoftheRestrictivePracticesCommitteeoccurredon:3/28/12,4/4/12,4/18/12,4/25/12,5/2/12,5/9/12,5/16/12,6/6/12(?),6/13/12,6/20/12,and6/27/12.ADesensitizationCommitteemeetingof3/21/12identified65individualsforwhomthePsychologyDepartmentandDentalDepartmentdisagreedconcerningtheneedandroleofdesensitization.Aseparatedocumententitled“CCSSLC:IndividualswithDesensitizationPlans”wassubmittedaspartofthe3/21/12DesensitizationCommitteemeeting,althoughthedocumentwasundated.Atotalof179individualswerelisted,ofwhich157hadlistedthedatesofthedecisiontreediscussion,and118hadadateunderthecolumnofbaselinedata(possiblyrepresentingthedateofcompletionofthedataforthat


# Provision AssessmentofStatus Complianceindividual).Therewere61determinedtobe“NA,”anditwasnotclearthereasonforthe“NA”categoryofbaselinedata.Atotalof94ofthe179individualshadthebaselinestepdefined(derivedfromadentaltaskanalysisof12steps).Atotalof154individualshadISPAs,andninehadimplementationdatesdocumentedfordesensitizationplans.Aspartofthe4/19/12DesensitizationCommitteeagenda,alistofthosenotconsideredappropriatefordesensitizationplanswasdistributedwithrationale.Atotalof59nameswerelisted.Mainreasonsfornotofferingadesensitizationprogramwere“physiological”for19individuals,“physiologicalspasticity”for16individuals,andedentulousstateforthreeindividuals.Forseven,therationalelisted“nosedation,”whichdidnotprovidearationale.Therewere12otherswithnorationalelisted.On4/22/12,theDentalDepartmentprovidedfeedbacktothislist.Atotalof16ofthe59werenotedtobeindividualsneedingdesensitizationformedicalreasonsandwerenotreferredfordentalneeds.Thislistappearedtobeincomplete,butdidindicateprogressinreviewingtheneedsoftheindividuals.Theresultofthesedeliberationswasdocumentedinasummarystatementon5/31/12.Reportedly,atthattime99ofthe174dentalnomineeshadadesensitizationplan,37dentalnomineeshadoutstandingbehaviorevaluations,and38dentalnomineeswereconsideredinappropriatefordentaldesensitizationplans.Thisinformationderivedfroma“DentalDesensitizationNomineesRosterList,”whichwasundated.Therewasnodataindicatingimplementationandprogressofdesensitizationplans.QualityAssurance/ImprovementInitiativesTheStateOfficehaddevelopedanewdentaldatabase,butaccordingtothe12/20/11dentalconferencecall,thesoftwaredidnotappeartobereliableduetomultiple“crashes.”Fromnotestakenduringadentalscancallof3/27/12,allSSLCswereprovidedthisnewdatabase.Oneoftheinitiallimitingstepswasdatainputintothesystem.TherewaslackofpersonnelsupporttoenterdataatsomeSSLCs.DatabaseinputcouldoccurattheSSLClevel,butdatacouldnotbedeletedattheSSLCsite.DuringdiscussionswiththeDentalDepartmentduringtheMonitoringTeam’svisit,itwaslearnedthattherecontinuedtobedelaysinimplementingthesystem,asthemedicaldatabasehadtobecompletedbeforethedentaldatabasecouldbedevelopedand/orimplemented.Thesoftwareprogramwasextensive,andcreatingasimplequerywasperceivedaspotentiallydifficultgiventhecomplexityofthesoftwareprogram.Therewasalsotheproblemthatolderdatacouldnotbetransferredintothenewdatabasesystem.Notesfroma4/17/12dentalscancallindicatedthenewdatabasecontinuedtohave


# Provision AssessmentofStatus Compliancechallenges,andthatdifferentSSLCswereatdifferentstagesofimplementation.ItisrecommendedthattheDentalDepartmentkeepacopyofalldatafromthepriorsoftwareprogram.Additionally,theStateOfficeisencouragedtoreviewtheperceivedobstaclesinimplementationandutilizationofthenewsoftwaredatabaseprogram.AlthoughithasbeenprovidedtoallSSLCsforimplementation,pilotingoneSSLCwouldhelptoidentifythedegreetowhichtheseconcerns/perceptionsareaccurate,andprovidetheopportunityforearlyprogram/systemchangestominimizedisruptionindatabaseentryandmanagement.Amajorconcernwasthattheolderdatacouldnotbetransferredintothenewsoftwareprogram.Theabilitytodemonstrateprogressrequirestrendingoverseveralquarters/years.Ifthesoftwareprogramistobechanged,oneofthemajorrequirementsshouldbeitsabilitytoincorporatethehistoricaldataforcomparisonwiththenew.Ifthenewsoftwareprogramisunabletoincorporatepastinformation,thentheStateOfficeshouldprovideanalternativeroutetotheSSLCstocreatecharts,graphs,andtrendlines.TheQA/QIDepartmentusedthefollowingmonitoringtoolstoreviewthequalityandcompletenessofdentalcare:

FortoolsusedbothbytheQADepartmentandtheDentalDepartment,therewasinformationconcerninginter‐raterreliabilityprovided.AnewDentalDepartmentmonitoringtoolwasimplementedfortheMarch2012review.Inter‐raterreliabilityfortheDentalDepartmentandQADepartmentwasassessedforthecompositescore.Therewasnointer‐raterreliabilityscoreforeachofthesubsections.Asaresult,thisinformationwasnotveryhelpful.ForthemonthsofMarch2012,April2012,andMay2012,thescorewasover90%eachmonth.Itisrecommendedthattheanalysisbereviewed,andreviewbebasedoneachquestion.Thiswouldallowforpracticalreviewofwheretherewasadditionalneedforinstructions/guidelines,developmentofmonitoringcriteria,and/ortrainingforauditors.

CCSSLCprovidedatrainingworkshopfordentalandotherclinicaldepartmentson12/13/11to12/14/2011,focusingontheQualityAssuranceDataProjectbeingdevelopedwiththeassistanceofoutsideconsultants.TheDentalDirectorattendedthisworkshop.TheDentalDepartmentforwardedacopyofmonitoringdatabasesutilizedfortheSettlementAgreementtotheQA/QIDepartmenton3/30/12,alongwith“additionalreports”generatedbythedepartment.On4/27/12,theDentalDirectormetwiththeQA/QIDirectorandstafftoreviewthislistofdatabasesandreports.ItwillbeimportantmovingforwardthatthiscollaborationcontinueandthatkeyindicatorsbeidentifiedtoassisttheFacilityinmeasuringitseffectivenessinprovidingdentalservicestothe


# Provision AssessmentofStatus Complianceindividualsitsupports.


1. Foronedentalstaffmember,theDentalDepartmentshouldreviewthedatesofsubmittedCPRcertificationwiththetrainingdepartmentortraininginstructortoverifythatthecertificationwasintendedforafour‐yearperiod.(SectionQ.1)

2. Forthosewithcontinuedpoororalhygieneratingsthatbrushtheirownteeth,additionalassistanceshouldbeconsidered.TheDentalDepartmentshouldparticipateintheirIDTmeetingstodiscussadditionalstepstobetaken.(SectionQ.1)

3. IncollaborationwiththeQADepartment,theDentalDepartmentshouldreviewandcomparethefindingsinthedifferentdatabases,anddeterminethereasonsfortheapparentdifferencesinthefinaldata,andcorrectionsshouldbemadepriortodistributionoftheinformation.(SectionQ.1)

4. TheDentalDepartmentshouldreviewtheStateOfficepolicy/communicationprovidingguidanceconcerningflossingatSSLCs,andmeetwiththeStateOfficetodetermineifcurrentinterpretationprohibitsindividualsfromusingfloss.Withadequatesupervisionandappropriatesafestorage,opportunitiesforusingflossaspartofdentalhygieneshouldnotbedeniedcampus‐wideandshouldbeconsideredforthosewhobrushtheirownteeth,similartoanyotherpersonalhygieneskill.(SectionQ.1)

5. TheMedicalandDentalDepartmentsshouldreviewthecurrentsystemtominimizedelaysinobtainingtherequiredconsents,medicalclearances,etc.,forTIVAprocedures.Thisshouldbedemonstratedintheformofapolicyorprotocol.Atrackinglogfortheconsentprocessisrecommended..(SectionsQ.1andQ.2)

6. TheDentalDepartmentshouldreviewthereasonforrefusaldatatobelocatedinthenon‐refusaldatabase.(SectionQ.2)7. TheDentalDepartmentshouldcontinuetodecreasethetimebetweenmissedappointmentsandcompletedappointments.(SectionQ.2)8. Whilebeginningtousethenewdatabase,theDentalDepartmentshouldmaintainacopyofalldatafromthepriorsoftwareprogram.The

StateOfficeisencouragedtoreviewtheperceivedobstaclesinutilizationofthenewsoftware.Additionally,ifthenewsoftwareprogramisunabletoincorporatepastinformation,thentheStateOfficeshouldprovideanalternativeroutetotheSSLCstoassimilatethisinformationsocharts,graphs,andtrendlineswillincludedatafromthepastthreeyearsandanynewdatamovingforward.(SectionQ.2)

9. FortheQAtools,compositescoresshouldnotbeused,butscoresbasedonindividualquestionsorsubsetsofquestionsthatfocusonspecificclinicalareas.(SectionQ.2)

10. TheDentalDepartmentisencouragedtodevelopquarterlyreports,includingabriefsynopsisandseriesofchartstoreflecttheactivitiesofthedepartment(oralhygiene,numberofvisitsforrestorative,prophylaxis,etc.permonth/quarter,numbersandpercentageofrefusedappointments,numberusingsedation,progressindentaldesensitization,etc.).SuchinformationshouldbeusedasaguidefordevelopingfutureQIendeavors,orotherdentalplansorprograms.(SectionQ.2)


SECTIONR:CommunicationEachFacilityshallprovideadequateandtimelyspeechandcommunicationtherapyservices,consistentwithcurrent,generallyacceptedprofessionalstandardsofcare,toindividualswhorequiresuchservices,assetforthbelow:

StepsTakentoAssessCompliance: Thefollowingactivitiesoccurredtoassesscompliance: ReviewofFollowingDocuments:

o PresentationBookforSectionR;o CCSSLCSelf‐Assessment,ActionPlans,andProvisionofInformation;o Forthefollowing24individualswhohadcommunicationdeficits,AACsystem(s),and/or

receiveddirectand/orindirectcommunicationsupports:Individual#238,Individual#297,Individual#235,Individual#278,Individual#325,Individual#137,Individual#339,Individual#154,Individual#119,Individual#251,Individual#176,Individual#110,Individual#221,Individual#268,Individual#229,Individual#307,Individual#69,Individual#191,Individual#141,Individual#145,Individual#343,Individual#367,Individual#91,andIndividual#99inSample#3,thefollowingdocuments:CommunicationComprehensiveassessment,UpdateandAssessmentofCurrentStatusfromindividualrecord,ISPandISPAsforpastyear,PositiveBehaviorSupportPlan,skillacquisitionprogramsrelatedtocommunicationandsupportingdocumentationforimplementation(indirectsupports),directSLPtherapyinterventionplansandsupportingdocumentationsuchasIPNs,monthlyreviewsbySLP,AACprogramsandsupportingdocumentationforimplementationofindirectsupports,individual‐specificcommunicationmonitoringforpastsixmonths,evidenceofeffectivenessmonitoringforSLPinterventions(direct)andprograms(indirect);

o SpeechassessmentsforfiveindividualsnewlyadmittedtoCCSSLC,including:Individual#5,Individual#40,Individual#61,Individual#63,andIndividual#97,variousdates;

o Policyandproceduresaddressingtheprovisionofspeechand/orcommunicationservicesandsupportsincludingchangessincelastmonitoringvisit,revised5/25/12;

o ContinuingeducationandothertrainingcompletedbySLPssincelastmonitoringvisitwithcertificatesofcompletion,from1/12through6/12;

o ListofcurrentSLPandaudiologystaffalongwithcorrespondingcaseloadsandcurriculumvitasfornewlyhiredSLPs,revised5/17/12;

o ListofindividualswithAACdevices,dated5/22/12;o CommunicationMasterPlanList,dated5/31/12;o AACScreeningforms,variousdates;o Speechlanguage(SL)comprehensiveassessmentsandupdates(templates)usedbySLPs

alongwithanychanges,dated5/10/12;o TrackingLogofSLPassessmentscompletedsincelastreview,from1/12through7/12;o MonitoringformsusedbySLPs,SpeechLanguagePathologyAssistants(SLPAs),and

PNMPCoordinators,variousdates;o Copiesofblankcommunicationcompetency‐basedperformancecheck‐offsheetsfornew

employees,undated;o Inter‐RaterReliabilityComplianceScoresandcorrespondingAudits,from12/11through

4/12;o Listofindividualsreceivingdirectspeechservicesandfocusofintervention,undated;


o Listofindividualswithbehavioralissuesandcoexistingseverelanguagedeficitsandrisklevel/statusforchallengingbehavior,dated6/5/12;

o ListofindividualswithPBSPsandreplacementbehaviorsrelatedtocommunication,dated6/5/12;

o MinutesforCommunicationcommitteemeetingsheldsincelastreview,dated3/22/12;o MinutesforSpeechDepartmentmeetingsheldsincelastreview,variousdatesbetween

2/12and5/12;o Listofallgeneralcommonareadevices,undated;o OT/PTAssessments,ISPs,andPNMPsforfourindividualsmostrecentlyassessedbyan

SLPforwhomAACdevicewasrecommended,from1/12through5/12;o Copiesofblankcommunicationcompetency‐basedperformancecheck‐offforindividual‐

specificcommunicationprograms,undated;o Copiesofexternalconsultantreportssincelastreview,dated3/22/12;o CopiesofcompletedauditsofSLPdocumentation,from1/12through4/12;o BehaviorSupportCommitteeminutesandattendancesign‐insheetsformeetingsheld

sincelastreview,from1/12through5/12;o CopiesofAmericanSpeechHearingAssociation(ASHA)certificationforSLPs;o IndividualsSupportPlanProcesspolicy#0045.1,effectivedate6/1/12;ando RawdataforSLPauditsforApril2012.

Interviewswith:o Dr.AngelaRoberts,HabilitationTherapyDirector;o LindaMerryman‐Scrifes,SLPDirectorandalternatePNMTSLPmember;o MelissaGrothe,CCC‐SLP;ando BryannaGutierrez,CCC‐SLP.

Observationsof:o IndividualswithAACdevicesinresidencesofRibbonfish,Atlantic,andtheInfirmary.

FacilitySelf‐Assessment: BasedonareviewoftheFacility’sSelf‐Assessment,theFacilityfounditwasinnoncompliancewithallofthesubsectionsofSectionR.ThiswasconsistentwiththeMonitoringTeam’sfindings.TheFacilitysubmittedthreedocuments,including:CCSSLCSelf‐Assessment,ActionPlans,andProvisionActionInformation.TheCCSSLCSelf‐AssessmentlistedthestepstheFacilitystaffcompletedtoconducttheself‐assessmentandthesubsequentresultsforthecompletionofthesetasks.TheActionPlansdocumentedthestatusofactionstepsthathadbeencompleted,wereinprocessand/orhadnotbeenstarted.TheCCSSLCProvisionActionInformationlistedactionscompletedsincetheMonitoringTeam’spreviousvisit.TheFacilitySelf‐AssessmentpresentedtheresultsofauditingactivitiescompletedbytheHTDirectorandProgramComplianceMonitorusingtheSectionRMonitoringtoolforeachmonth.MonthlyreportsweredevelopedforeachmonththatpresentedaseparatecompliancescoreforeachindicatorfortheSection


Lead(i.e.,HTDirector)andthePCM.Aninter‐ratercompliancescorewasgeneratedforeachindicatoraswellasacompliancepercentage.ThiswasapositivedevelopmentandprovidedtheHTDirectorwithvaluableinformationtoassessthecompliancestatusforeachindicator.Furthermore,theHTDirectorandPCMreportedtheycontinuedtoreviseinstructionsfortheformtoenhancetheirinter‐rateragreement.TheHTDirectorandPCMgeneratedamonthlySectionRAnalysisreport.Thereportdefinedhowinter‐rateragreementwasachievedanddiscussedhowthesamplewaschosen.TheanalysisreportdiscussedthecomplianceforeachofthefoursectionsinSectionRandpresentedplanstoaddressareasofnon‐compliance.TheMonitoringTeamdiscussestheFacilityself‐assessmentresultsatthebeginningofeachsection.SummaryofMonitor’sAssessment: TheFacilityhadfourfull‐timeSLPpositionsallocated.TherewasonevacantSLPposition.Inaddition,thereweretwocontractSLPswhoprovidedservices15hoursperweekforeachcontracttherapist.TheFacilitydocumentedappropriatequalificationsforlicensedSLPs.AFacilitypolicyentitledCCSSLC–CommunicationServices,dated10/7/09existed.However,theFacilitypolicydidnotprovideclearoperationalizedguidelinesforthedeliveryofcommunicationsupportsandservices.Priortothepreviousreview,theSpeechDepartmenthadestablishedaMasterCommunicationPlanscheduletore‐assesseachindividualusingaprioritysystemandtherevisedSLPassessmentformat.However,thecompletionofthisschedulewasnotinalignmentwiththeFacility’sannualISPschedule.Consequently,teamsdidnothavethemostcurrentassessmentandrecommendedsupportsandservicesavailableduringtheannualISPmeeting.Duetothefactthateveryindividualneededtobere‐assessedwithanupdatedSLPassessmentformatandcontent,theSpeechDepartmentmadethedecisiontoabandontheprioritylistandfollowtheFacilityISPcalendar.Basedondocumentationsubmitted,thisdecisionenabledSLPstobecontributingmembersoftheIDTandsupporttheindividual.ItwaspositivethatIDTmembersandtheindividualwouldbeprovidedwithacurrentassessmentpriortotheannualISPmeetingtoassistinannualplanning.Unfortunately,individualsidentifiedthroughtheprioritysysteminneedofcommunicationsupportswouldhavetowaitfortheseservicesuntiltheirannualISPmeeting.Asof5/31/12,152ofthe271(56%)individualshadreceivedanSLPassessmentusingtherevisedformat.Tenoftheseindividualshadtransitionedtothecommunityorhaddied.Anevaluationofindividuals’SLcomprehensiveassessmentsrevealedtheseassessmentsweremissingsomekeycomponents.BasedoninterviewwiththeHTDirector,thedecisionhadbeenmadetonothaveaSLPattendtheFacilityPositiveBehaviorSupportCommitteemeetings,becausetheirattendancewasnotproductiveinsupportingopportunitiesforcollaborationbetweenaSLPandpsychologist.TheSLPsreportedthatitwasmoreproductivetoworkone‐on‐onewithapsychologistinachievingimplementationofsharedfunctionalcommunicationrecommendations.However,documentationofthiscollaborationwasnotconsistently


presentedintheSLPassessmentsandPBSPsreviewed.ObservationsbytheMonitoringTeamandtwoFacilitySLPsofindividualswithAACsystemsdidnotrevealthepresenceand/oruseoftheAACsystem.Inaddition,individuals’skillacquisitionprogramsdidnotsupporttheuseofanAACsystem.Staffalsohadnotbeenprovidedwithindividual‐specificcompetencytrainingandperformancecheck‐offstodemonstratetheircompetencyinsupportingindividualsintheuseoftheirAACsysteminvariousenvironmentsanddailyactivities.AlthoughtheFacility’sCommunicationServicespolicyincludedsomeimportantcomponents,anumberweremissing.Itdidnotincludethefollowingkeyelements:thefrequencyofmonitoring;theprocessforidentification,training,andvalidationformonitors;theprocessofachievinginter‐raterreliability;andaprocessfordatatrendanalysisandutilizationoffindingstodrivetrainingandproblemresolution(individualandsystemic).

# Provision AssessmentofStatus ComplianceR1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithin30months,theFacilityshallprovideanadequatenumberofspeechlanguagepathologists,orotherprofessionals,withspecializedtrainingorexperiencedemonstratingcompetenceinaugmentativeandalternativecommunication,toconductassessments,developandimplementprograms,providestafftraining,andmonitortheimplementationofprograms.


TheFacility’sreviewof100%ofSectionRmonitoringtoolsindicatedthat12outof12(100%)hadcompliancescoresanalyzed,trendedandaggregated.

TheFacility’sauditoffourspeech‐languageassessmentsindicatedthatfouroutoffour(100%)hadanassessmentoftheindividual’sneedforanAACsystem,andhadadescriptionofsignificanthealthcareissuesand/orriskindicators.Threeoffourassessments(75%)hadananalysisofassessmentdatatoidentifystrengthsandpotentialforfunctionalcommunication,strategiesforcommunicatingandjustification[forrecommendations.Oneoffourassessments(25%)hadmeasurable,functionaloutcomesfordirectspeechtherapy.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausethedepartmentisstillintheprocessofprovidingtheassessmentstotheentireCCSSLCpopulation.Additionally,theassessmentsarebeingauditedtoensuretheyincludethenecessarycomponents.”InordertoreviewspeechlanguagesupportsprovidedtoindividualsattheFacility,asampleorindividualswasdrawn.ItisreferredtoasSample#3.Itincluded24individualsidentifiedwithsevereexpressiveorreceptivelanguagedisorders,receivingdirectspeechinterventions,havingaPositiveBehaviorSupportPlan(PBSP),havinganAACsystem,and/orreceivingindirectcommunicationsupports.Theindividualsincludedinthesamplewere:Individual#238,Individual#297,Individual#235,Individual#278,Individual#325,Individual#137,Individual#339,Individual#154,

Noncompliance


# Provision AssessmentofStatus ComplianceIndividual#119,Individual#251,Individual#176,Individual#110,Individual#221,Individual#268,Individual#229,Individual#307,Individual#69,Individual#191,Individual#141,Individual#145,Individual#343,Individual#367,Individual#91,andIndividual#99.ThisparagraphoftheSettlementAgreementincludesanumberofrequirementsthatareaddressedinsubsequentsectionswithinSectionR.Thissectionwilladdresscompliancewithcurrentstaffing,staffqualifications,adequatenumbersofspeechlanguagepathologists,continuingeducation,andFacilitypolicy.TheSLPassessmentprocessandthedevelopmentandimplementationofprogramsarediscussedwithregardtoSectionR.2.StafftrainingisaddressedwithregardtoSectionR.3,andtheFacility’smonitoringsystemisdiscussedwithregardtoSectionR.4.StaffingTheFacilityhadfourfull‐timeSLPpositionsallocated.TherewasonevacantSLPposition.Inaddition,thereweretwocontractSLPs,whoeachprovidedservices15hoursperweek.TheProvisionActionInformationstated:“Speech‐LanguagePathologistsarenolongerassignedtoaspecificunit.Instead,assessmentsarecompletedaccordingtotheISPcalendarandevenlydistributedbetweentherapists,regardlessoftheirunit.”TheFacilitydidnotindicatewhatanadequatecaseloadforSLPsatCorpusChristiwouldbe.TheFacilityshouldcompleteananalysis,includingconsiderationofthevariousrequirementsofthejob,aswellastheacuityoftheindividualsinrelationtoSLPneeds.QualificationsTheFacilityhaddocumentationtoshowappropriatequalificationsforlicensedSLPs.

Threeofthreefull‐timeSLPstaff(100%)werelicensedtopracticeinthestateofTexas.

TwooftwocontractSLPstaff(100%)werelicensedtopracticeinthestateofTexas.

Twooftwofull‐timeSLPstaff(100%)hadevidenceofAmericanSpeechandHearingAssociationcertification.ThethirdSLPdidnotholdtheCompetencyofClinicalCertification(CCC)issuedbyASHA,becauseshewas“grandfathered”intotheprofessionofSpeechLanguagePathologyinJanuary1986.

OneoftwocontractSLPstaff(50%)hadevidenceofASHAcertification.ThesecondcontractSLPdidnothaveacopyofherASHAcertificationtoprovideforthedocumentrequest.TheFacilityreporteditwouldbeavailableduringthenextreview.


# Provision AssessmentofStatus ComplianceContinuingEducationDocumentationofcontinuingeducationcoursescompletedbytheSLPswassubmitted.Basedondocumentationsubmitted,noState‐sponsoredwebinarswereofferedinthepastsixmonths.Thecontinuingeducationattendedbythecliniciansincludedthefollowingtopics:

AutismandSensoryProcessingDisorders; InteractiveTrainingonAACDevices; BedsideEvaluationoftheDysphagiaPatient; TheDysphagiaPatient:ModifiedBariumSwallowandTherapeuticIntervention; NeurorehabilitationConference2012; TexasAssistiveTechnologyNetworkStatewideConference;and ManagementDysphagia2012.

Basedonareviewofcontinuingeducationcompletedinthelast12months: Threeofthreefull‐timeSLPstaff(100%)hadcompletedcontinuingeducation

relevanttocommunicationandtransferrabletothepopulationserved.FacilityPolicyAFacilitypolicynumber016,CCSSLC–CommunicationServices,dated10/7/09,existed.However,theFacilitypolicydidnotprovideclearoperationalizedguidelinesforthedeliveryofcommunicationsupportsandservices.Thefollowingcomponentswereincludedinthispolicy:

Timelinesforcompletionofnewadmissionassessments(within30daysofadmissionorreadmission).

Thefollowingcomponentswerenotincludedinthispolicy: RolesandresponsibilitiesoftheSLPs(e.g.,meetingattendance,stafftraining

etc.); Outlineofassessmentschedule; Frequencyofassessments/updates; Timelinesforcompletionofcomprehensiveassessments(i.e.,within30daysof

identificationviascreening); TimelinesforcompletionofComprehensiveAssessment/AssessmentofCurrent

Statusforindividualswithachangeinhealthstatuspotentiallyaffectingcommunication(i.e.,withinfivedaysofidentificationasindicatedbytheIDT);

DescriptionofaprocessforeffectivenessmonitoringbytheSLP; Criteriaforprovidinganupdate(AssessmentofCurrentStatus)versusa

ComprehensiveAssessment; Methodsoftrackingprogressanddocumentationstandardsrelatedto


# Provision AssessmentofStatus Complianceinterventionplans;and

Monitoringofstaffcompliancewithimplementationofcommunicationplans/programs,includingfrequency,dataandtrendanalysis,aswellas,problemresolution.

TheFacilityshouldexpandtheCommunicationServicespolicytoincorporatetheprecedingcontent.Asnotedabove,initsSelf‐Assessment,theFacilityindicatedthatitwasnotincompliancewiththisprovision.ThiswasconsistentwiththeMonitoringTeam’sfindings.

R2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,theFacilityshalldevelopandimplementascreeningandassessmentprocessdesignedtoidentifyindividualswhowouldbenefitfromtheuseofalternativeoraugmentativecommunicationsystems,includingsystemsinvolvingbehavioralsupportsorinterventions.


TheFacility’sauditoffourspeech‐languageassessmentsfoundnone(0%)hadcollaborationwithspeechandpsychology,andjointlydevelopedskillacquisitionplans,ifnecessary.Threeoffourassessments(75%)indicatedtrainingonindividualcommunicationsystemswasprovided.

AreviewoftheFacility’spolicynotedspeech‐languagepathologist’sresponsibilitieswerenotdefined.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausealthoughindividualsarereceivingspeech‐languageassessments,theycontinuetolackdocumentationofcollaborationwithpsychology.Additionally,therearenopolicies/protocolsclearlydefiningtheroleoftheSpeech‐LanguagePathologists.”ThefindingsoftheMonitoringTeamrelatedtocollaborationbetweentheSLPandpsychologistarediscussedwithinthissection.TheMonitoringTeamfindingsalsoshowedtheFacilitywasinnoncompliancewiththisprovision.AlthoughpolicyisdiscussedwithregardtoSectionR.1,theMonitoringTeamreviewedadditionalindicatorsinrelationtotheFacility’scompliancewithSectionR.2.AssessmentPlanPriortothepreviousreview,theSpeechDepartmenthadestablishedaMasterCommunicationPlanscheduletore‐assesseachindividualusingaprioritysystemandtherevisedSLPassessmentformat.However,thecompletionofthisschedulewasnotinalignmentwiththeFacility’sannualISPschedule.Asaresult,theimplementationofthepriorityscheduleplacedIDTmembersandtheindividualsatadisadvantageattheannualISPmeeting.TheteamdidnothaveaccesstothemostcurrentassessmentandrecommendedsupportsandservicesduringtheannualISPmeeting.Sincethelastreview,theFacilityhaddevelopedarevisedISPschedule.Assessmentswouldbe

Noncompliance


# Provision AssessmentofStatus CompliancecompletedthroughouttheyearatarateofapproximatelysixISPsperweek(i.e.,twoperdayonTuesday,Wednesday,andThursday).Duetothefactthateveryindividualneededtobere‐assessedwithanupdatedSLPassessmentformatandcontent,theSpeechDepartmentmadethedecisiontoabandontheprioritylistandfollowtheFacilityISPcalendar.Basedondocumentationsubmitted,thisdecisionenabledSLPstobecontributingmembersoftheIDTandsupporttheindividual.ItwaspositivethatIDTmembersandtheindividualwouldbeprovidedwithacurrentassessmentpriortotheannualISPmeetingtoassistinannualplanning.Unfortunately,individualsidentifiedthroughtheprioritysysteminneedofcommunicationsupportswouldhavetowaitfortheseservicesuntiltheirannualISPmeeting.Asof5/31/12,152ofthe271(56%)individualshadreceivedanSLPassessmentusingtherevisedformat.Tenoftheseindividualshadtransitionedtothecommunityorhaddied.NewAdmissionsSincethelastreview,fiveindividuals(i.e.,Individual#5,Individual#40,Individual#61,Individual#63,andIndividual#97)hadbeenadmittedtoCCSSLC.AnexaminationoftheiradmissionandSLPsassessmentdatesestablished:

Fiveoffiveindividuals(100%)receivedacommunicationscreeningorassessmentwithin30daysofadmissionorreadmission.

CommunicationAssessmentASpeechLanguage(SL)comprehensiveassessmentshouldincludethefollowing:

Signatureanddatebytheclinicianuponcompletionofthewrittenreport; Dateshowingitwascompleted10workingdayspriortotheannualISP; Diagnosesandrelevanceofimpactoncommunication; Individualpreferences,strengths,andneeds; Medicalhistoryandrelevancetocommunication; Medicationsandsideeffectsrelevanttocommunication; Documentationofhowtheindividual’scommunicationabilitiesimpacttheirrisk

levels; Descriptionofverbalandnonverbalskillswithexamplesofhowtheindividual

utilizestheseskillsinafunctionalmannerthroughouttheday; EvidenceofobservationsbySLPsintheindividual’snaturalenvironments(e.g.,

dayprogram,home,work); EvidenceofdiscussionoftheuseofaCommunicationDictionary,asappropriate,

aswellastheeffectivenessofthecurrentversionofthedictionarywithnecessarychangesasrequiredforindividualswhodonotcommunicateverbally;

Discussionoftheexpansionoftheindividual’scurrentabilities; Discussionoftheindividual’spotentialtodevelopnewcommunicationskills;


# Provision AssessmentofStatus Compliance Effectivenessofcurrentsupports,includingmonitoringfindings; Adescriptionoftheindividual’sAACneeds,includingclearclinicaljustification

andrationaleastowhethertheindividualwouldbenefitfromAAC; Comparativeanalysisofhealthandfunctionalstatusfromthepreviousyear; Comparativeanalysisofcurrentcommunicationfunctionwithprevious

assessments; Identificationoftheneedfordirectorindirectspeechlanguageservices,as

appropriate; Specificandindividualizedstrategiestoensureconsistencyofimplementation

amongvariousstaff; Reassessmentschedule; Monitoringschedule; Recommendationsfordirectinterventionsand/orskillacquisitionprograms,as

appropriate,includingtheuseofAACasindicatedforindividualswithidentifiedcommunicationdeficits;

Arecommendationregardingtheindividual’sappropriatenessforcommunityplacement;and

Mannerinwhichstrategies,interventions,andprogramsshouldbeutilizedthroughouttheday.

Eightindividuals’SpeechLanguagecomprehensiveassessments(i.e.,Individual#367,Individual#99,Individual#145,Individual#91,Individual#343,Individual#191,Individual#339,andIndividual#268)inSample#3wereevaluatedforthepresenceofthefollowing:

Eightofeightindividuals’SLassessments(100%)weresignedanddatedbytheclinicianuponcompletionofthewrittenreport;

Threeofeightindividuals’SLassessments(i.e.,Individual#367,Individual#145,andIndividual#339)(38%)weredatedascompleted10workingdayspriortotheannualISP;

Sevenofeightindividuals’SLassessments(88%)includeddiagnosesandrelevanceofimpactoncommunication(i.e.,Individual#91’sassessmentdidnot);

Fourofeightindividuals’SLassessments(i.e.,Individual#367,Individual#99,Individual#339,andIndividual#268)(50%)introducedindividualpreferences,strengths,andneeds;

Sevenofeightindividuals’SLassessments(88%)includedmedicalhistoryandrelevancetocommunication(i.e.,Individual#91’sassessmentdidnot);

Eightofeightindividuals’SLassessments(100%)listedmedicationsanddiscussedsideeffectsrelevanttocommunication;

Sevenofeightindividuals’SLassessments(88%)provideddocumentationof


# Provision AssessmentofStatus Compliancehowtheindividual’scommunicationabilitiesimpacted his/her risklevels (i.e.,Individual#91’sassessmentdidnotaddressthiselement);

Eightofeightindividuals’SLassessments(100%)incorporatedadescriptionofverbalandnonverbalskillswithexamplesofhowtheseskillswereutilizedinafunctionalmannerthroughouttheday;

Twoofeightindividuals’SLassessments(i.e.,Individual#367andIndividual#268)(25%)providedevidenceofobservationsbytheSLsintheindividuals’naturalenvironments(e.g.,dayprogram,home,work);

Oneofsevenindividuals’SLassessments(i.e.,Individual#367)(14%)containedevidenceofdiscussionoftheuseofaCommunicationDictionary,asappropriate,aswellastheeffectivenessofthecurrentversionofthedictionarywithnecessarychangesasrequiredforindividualswhodidnotcommunicateverbally(Individual#191communicatedverbally);

Fiveofeightindividuals’SLassessments(i.e.,Individual#367,Individual#145,Individual#191,Individual#339,andIndividual#268)(63%)includeddiscussionoftheexpansionoftheindividuals’currentabilities;

Threeofeightindividuals’SLassessments(i.e.,Individual#145,Individual#191,andIndividual#268)(38%)providedadiscussionoftheindividuals’potentialtodevelopnewcommunicationskills;

Noneofeightindividuals’SLassessments(0%)includedtheeffectivenessofcurrentsupports,includingmonitoringfindings;

Noneofeightindividuals’SLassessments(0%)offeredacomparativeanalysisofhealthandfunctionalstatusfromthepreviousyear;

Eightofeightindividuals’SLassessments(100%)gaveacomparativeanalysisofcurrentcommunicationfunctionwithpreviousassessments;

Threeofeightindividuals’SLassessments(i.e.,Individual#145,Individual#191,andIndividual#339)(38%)identifiedtheneedfordirectorindirectspeechlanguageservices;

Twoofeightindividuals’SLassessment(i.e.,Individual#99andIndividual#339)(25%)hadspecificandindividualizedstrategiesoutlinedtoensureconsistencyofimplementationamongvariousstaff;

Sevenofeightindividuals’SLassessments(88%)hadareassessmentschedule(i.e.,Individual#91’sassessmentdidnothavethiselement);

Fiveofeightindividuals’SLassessments(i.e.,Individual#367,Individual#99,Individual#343,Individual#191,andIndividual#268)(63%)suppliedamonitoringschedule;

Eightofeightindividuals’SLassessments(100%)hadrecommendationsfordirectinterventionsand/orskillacquisitionprograms,includingtheuseofAACasindicatedforindividualswithidentifiedcommunicationdeficits.Thisincludedthreeindividuals(i.e.,Individual#145,Individual#191,andIndividual#339),forwhomdirecttherapywasrecommended.Theremainingfivewere


# Provision AssessmentofStatus Complianceidentifiedasrequiringskillacquisitionprograms;

Eightofeightindividuals’SLassessments(100%)madearecommendationabouttheappropriatenessforcommunitytransition;and

Twoofeightindividuals’SLassessments(i.e.,Individual#339andIndividual#268)(25%)definedthemannerinwhichstrategies,interventions,andprogramsshouldbeutilizedthroughouttheday.

Theseeightindividuals’SLcomprehensiveassessmentsweremissingimportantelementsandwerenotconsideredcomprehensiveSLassessments.TheSLPsshouldconsidereachoftheseelementswhencompletingassessmentstoensureassessmentsarecomprehensiveasrequiredbytheSettlementAgreement.Inaddition,theSLauditshouldincludetheseelements.SLPandPsychologyCollaborationBasedonreviewof13of24recordsforindividualsinSample#3withPositiveBehaviorSupportPlans(i.e.,Individual#325,Individual#367,Individual#343,Individual#145,Individual#141,Individual#191,Individual#69,Individual#307,Individual#268,Individual#176,Individual#251,Individual#119,andIndividual#297),thefollowingwasnoted:

Inoneof13communicationassessmentsandPBSPsreviewed(i.e.,Individual#367)(8%),thesedocumentsaddressedtheconnectionbetweenthePBSPandtherecommendationscontainedinthecommunicationassessment.

Infourof13communicationassessmentsreviewed(i.e.,Individual#367,Individual#343,Individual#141,andIndividual#191)(31%)containedevidenceofreviewofthePBSPbytheSLP.However,onlyasummaryoftheindividual’sPBSPwasprovidedintheassessment.TheassessmentshouldofferinformationoncollaborationbetweentheSLPandthepsychologistrelatedtofunctionalcommunicationandbehavioralconcerns.TheSLPassessmentandPBSPshoulddiscusshowrelatedrecommendationswillbemadetotheteamtoimproveandenhancefunctionalcommunicationskills.

BasedonreviewofthePositiveBehaviorSupportCommitteemeetingminutesfrom1/10/12to5/25/12,participationbytheSLPwasnotedinnoneofthe31meetings(0%).BasedoninterviewwiththeHTDirector,thedecisionhadbeenmadetonothaveaSLPattendtheFacilityPositiveBehaviorSupportCommitteemeetings,becausetheirattendancewasnotproductiveinsupportingopportunitiesforcollaborationbetweenaSLPandpsychologist.TheSLPsreportedthatitwasmoreproductivetoworkone‐on‐onewithapsychologistinachievingimplementationofsharedfunctionalcommunicationrecommendations.However,documentationofthiscollaborationwasnotconsistentlypresentedintheSLPassessmentsandPBSPsreviewed.


# Provision AssessmentofStatus ComplianceTheFacilityremainedoutofcompliancewiththisprovision.Inadditiontoimprovingthecontentandqualityofassessments,theFacilityalsoneededtocompleteupdatedassessmentsforindividualsattheFacility,finalizeandimplementanassessmentreviewschedule,andimprovethecollaborationbetweenSLPsandpsychologistsforindividualswithPBSPs.

R3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,forallindividualswhowouldbenefitfromtheuseofalternativeoraugmentativecommunicationsystems,theFacilityshallspecifyintheISPhowtheindividualcommunicates,anddevelopandimplementassistivecommunicationinterventionsthatarefunctionalandadaptabletoavarietyofsettings.

FacilitySelf‐AssessmentTheFacility’sSelf‐AssessmentfindingswereindistinguishablefromthefindingsforSectionR.2.IntegrationofCommunicationintheISPBasedonreviewoftheISPsfor10ofthe24individualsinSample#3(i.e.Individual#235,Individual#278,Individual#339,Individual#137,Individual#154,Individual#110,Individual#221,Individual#229,Individual#91,andIndividual#99),thefollowingwasnoted:

Infourof10ISPsreviewedforindividualswithcommunicationneeds(i.e.,Individual#235,Individual#154,Individual#110,Individual#229)(40%),aSLPattendedtheannualmeeting.

Inoneof10ISPsreviewed(i.e.,Individual#110)(10%),thetypeofAACand/orcommunicationsupports(mightinclude,butnotbelimitedto,theCommunicationDictionaryandstrategiesforstaffuse)wasidentified.

CommunicationDictionariesfornoneofthe10individuals(0%)werereviewedatleastannuallybytheIDTasevidencedintheISP.

Oneof10ISPsreviewed(Individual#110)(10%)includedadescriptionofhowtheindividualcommunicated,includingtheAACsystemiftheyhadone.

Oneof10ISPsreviewed(i.e.,Individual#110)(10%)includedhowcommunicationinterventionsweretobeintegratedintotheindividuals’dailyroutines.

Oneof10ISPsreviewed(Individual#110)(10%)containedskillacquisitionprogramstopromotefunctionalcommunication.

Noneof10ISPsreviewed(0%)includedhowcommunicationinterventionsweretobeintegratedintotheindividuals’dailyroutines.

Theindividuals’ISPsshouldinclude:attendancebyaSLPforindividualswithcommunicationneeds;thetypeofAACand/orcommunicationsupportsprovidedandtheireffectiveness;reviewoftheeffectivenessofthecurrentversionofcommunicationdictionaryanddescriptionofnecessarychanges,asappropriate;adescriptionofhowtheindividualcommunicatesincludingtheAACsystem,iftheyhaveone;andhowcommunicationinterventionswillbeintegratedintotheindividual’sdailyroutine.

Noncompliance


# Provision AssessmentofStatus ComplianceIndividual‐SpecificAACSystemsTheFacilityprovidedalistofindividualswithAlternativeandAugmentativeCommunicationdevices(highandlowtech).Twenty‐threeofthe258individuals(9%)atCCSSLChadanAACdevice.Duringthelastreview,24of271individuals(9%)hadanAACsystem.TherewasnodiscernibleincreaseinthenumberofindividualswhohadbeenprescribedanAACsystemsincethelastreview.TheMonitoringTeamandtwoFacilitySLPsconductedobservationsintheresidencesofAtlanticandRibbonfish,andtheVocationalAnnexforsevenindividualsidentifiedbytheFacilitywithAACsystems(i.e.,Individual#339,Individual#268,Individual#251,Individual#221,Individual#141,Individual#69,andIndividual#137)inSample#3.TheMonitoringTeamcompletedanadditionalindividual‐specificobservationintheInfirmary(i.e.,Individual#137).Observationfindingsincludedthefollowing:

AACsystemsfornoneofsevenindividuals(0%)werepresent. AACsystemsfornoneofsevenindividuals(0%)werenotedtobeinuse. FornoneofsevenindividualswithAACsystems(0%),staffinstructions/skill

acquisitionplansrelatedtotheAACsystemwereavailable.IndividualswithAACsystemsshouldbepresent,inuse,portable,andfunctional.Inaddition,anindividual’suseofanAACsystemshouldbeenhancedthroughtheimplementationofskillacquisitionprograms,asappropriate.Staffshouldbeprovidedwithindividual‐specificcompetencytrainingandperformancecheck‐offstodemonstratetheircompetencyinsupportingtheindividualintheuseoftheindividual’sAACsysteminvariousenvironmentsanddailyactivities.General‐UseAACDevicesTheFacilityprovidedaListofGeneralCommonAreaDevicesthatidentifiedthelocation,typeofdevice,andintentofdevice.Observationsofgeneral‐useAACdevicesbytheMonitoringTeamandtwoFacilitySLPswerecompletedinRibbonfish,Atlantic,andtheVocationalAnnextodeterminethepresenceanduseofgeneralAACdevices.Findingsincludedthefollowing:

Twoofthetworesidences(100%)hadgeneraluseAACdevicespresentinthecommonareas.

NoneofthegeneraluseAACdevices(0%)observedcontainedcleardirectivesonhowstaffshouldusethesedevices.

OneofthemultiplegeneraluseAACdevicesobservedhadaclearfunctionwithinthatsetting/situation.TheVocationalAnnexhadageneralAACdevicethatprovidedphotographsofvariousactivitiestoenableindividualstochooseanactivity.ThesephotoswereattachedtoaboardwithVelcro.

DuringtheMonitoringTeam’sobservations,noneoftheindividualsusedanyof


# Provision AssessmentofStatus Compliancethe generaluseAACdevices.

TheFacilityshouldre‐assessthefunctionalityofgeneral‐useAACdevicesinresidencesandotherenvironments.DirectCommunicationInterventionsDirectcommunication‐relatedinterventionplansforeightindividualsintheSample#3whoreceiveddirectspeechservices(i.e.,Individual#297,Individual#251,Individual#69,Individual#154,Individual#307,Individual#110,Individual#229,andIndividual#191)werereviewed.Comprehensiveprogressnotesrelatedtocommunicationinterventionsshouldinclude:

Informationregardingwhethertheindividualshowedprogresswiththestatedgoal.

Adescriptionofthebenefitofdeviceand/orgoaltotheindividual. Areportregardingtheconsistencyofimplementation. Recommendations/revisionstothecommunicationinterventionplanas

indicatedrelatedtotheindividual’sprogressorlackofprogress.Fornoneofeightindividuals(0%),documentationoftheSLP’sreviewofcommunicationinterventionswascomprehensive.Theprogressnotesdidnotincorporatetheelementsoutlinedabove.IndirectCommunicationSupportsIndividualswithAACdevicesdidnothaveindirectcommunicationsupports/programsdesignedtoassisttheindividualsand/orstaffinusingtheAACdeviceortoenhancetheirskillsinutilizingtheAACsystem.Forsuchindirectsupports,theSLPsmonthlydocumentationshould:

Provideinformationregardingwhethertheindividualshowedprogresswiththestatedgoal(s);

Describethebenefitofdeviceand/orprogramfortheindividual(s); Identifywhetherornotimplementationisconsistent;and Identifyrecommendations/revisionstotheprogramasindicatedinreferenceto

theindividual’sprogressorlackofprogress.Thecompletionofmonthlyprogressnotesshouldprovideeffectivenessreview/monitoringoftheindividual’sprogresswithdirectand/orindirectSLsupports.

R4 CommencingwithinsixmonthsoftheEffectiveDatehereofandwith


Noncompliance


# Provision AssessmentofStatus Compliancefullimplementationwithinthreeyears,theFacilityshalldevelopandimplementamonitoringsystemtoensurethatthecommunicationprovisionsoftheISPforindividualswhowouldbenefitfromalternativeand/oraugmentativecommunicationsystemsaddresstheircommunicationneedsinamannerthatisfunctionalandadaptabletoavarietyofsettingsandthatsuchsystemsarereadilyavailabletothem.ThecommunicationprovisionsoftheISPshallbereviewedandrevised,asneeded,butatleastannually.

BasedontheFacility’sreviewoffourISPs,two(50%)indicatedhowtheindividualcommunicatesandnone(0%)indicatedhowtheAACsystemwasindividualized,meaningfulandfunctional,andadaptabletoavarietyofsettings.

Threeoutoffourtrainingrosters(75%)indicatedstaffworkingwitheachindividualwhousesanAACsystemreceivedindividual‐specificcompetency‐basedtrainingontheindividuals’AACsystem.However,theMonitoringTeam’sobservationofsevenindividualswithprescribedAACsystemsdidnotprovideevidenceofindividual‐specificcompetency‐basedtrainingfortheirAACdevices.

TheFacility’sSelf‐Assessmentindicatedthat:“basedonthefindingsfromthisself‐assessment,thisprovisionisnotincompliancebecausetheInter‐DisciplinaryTeamscontinuetoneedsupportincludingthenecessarycomponentsofSpeech‐Languageassessments.”Basedonitreview,theMonitoringTeamalsofoundthattheFacilitywasnotincompliance.However,thisprovisionrequirestheFacilitytodevelopandimplementamonitoringsystemtomonitorcompliancewithanindividual’scommunicationsupports.Inaddition,theFacility’sSLPsshouldconducteffectivenessmonitoringtoassesstheefficacyofdirectandindirectcommunicationsupports.MonitoringSystemTheFacilityCommunicationServicespolicy#016,effectivedateof10/7/09,includedthefollowinginformationonthemonitoringofcommunicationsupports:

MonitoringforthepresenceofcommunicationadaptiveequipmentorotherAACsupports/materials;

Monitoringfortheuseofcommunicationadaptiveequipmentinmultipleenvironments(home,dayprogram,work);and

Monitoringfortheworkingconditionofcommunicationadaptiveequipment.Thispolicydidnotincludethefollowingkeyelements:

Thefrequencyofmonitoring; Theprocessforidentification,training,andvalidationformonitors; Theprocessofinter‐raterreliability;and Aprocessfordatatrendanalysisandutilizationoffindingstodrivetrainingand

problemresolution(individualandsystemic).Basedondocumentationsubmitted,theFacilityHTDepartmentstaff(i.e.,SLPs,SLPAssistants,andPNMPCoordinators)implementedthefollowingformstomonitorindividuals’communicationequipment:

MonthlyPerson‐SpecificPNMPCheckSheetwithinstructions; MonthlyHomeEquipmentCheckSheetwithinstructionslocatedonform;and ComplianceMonitoringFormwithinstructions;and TherapistsusedthePNMPClinicMinutesformtoannuallymonitoran


# Provision AssessmentofStatus Complianceindividual’sadaptiveequipment.

TheFacilityreportedthefollowinginformationforeachform:datemonitoringform(s)usewasinitiated,presenceofmonitoringforminstructions,staffpositionsresponsibleformonitoring,processusedtoconfirmmonitors’competencywiththeuseoftheforms,monitoringschedule,monitoringscheduleforindividualsathighrisk,howmonitoringformswereanalyzedandbywhom,andFacilityprotocolsforthemonitoringforms.ThisinformationfurtherdefinedtheFacility’sprotocolsfortheimplementationoftheseforms.However,additionalworkneedstobedonetoestablishinter‐rateragreementbetweentherapistsandPNMPCoordinatorstoconfirmPNMPCoordinatorscompetencyforthecompletionoftheseforms.TheFacilitydidnotprovidemonitoringreportsanalyzingandtrendingresultsfromtheMonthlyPerson‐SpecificPNMPCheckSheet,MonthlyHomeEquipmentCheckSheet,andComplianceMonitoringFormrelatedtocommunication.Thesereportsshouldaddressataminimumthefollowingindicators:

Compliancewithestablishedmonitoringfrequency; Equipmentpresence; Equipmentinworkingorder; Equipmentusedinvariousenvironments;and Inthecaseaproblemwasidentified,therewasevidenceofresolution.

Sevenindividuals’(i.e.,Individual#339,Individual#268,Individual#251,Individual#221,Individual#141,Individual#69,andIndividual#137)forthelastsixmonthswerereviewed.TheMonthlyPerson‐SpecificPNMPCheckSheetwascompletedfortheseindividuals.

Twoofsevenindividuals(i.e.,Individual#221andIndividual#137)(29%)weremonitoredattherecommendedfrequency.

Fourofsevenindividuals(57%)weremonitoredforthepresenceoftheircommunicationsystem.

Monitoringforfourofsevenindividuals(57%)includedreviewofwhetherornottheircommunicationsystemwasinworkingorder.

Fourofsevenindividuals(57%)weremonitoredforuseinavarietyofenvironments.

Problematicareasneedingfocusorimprovementincluded:

IndividualswithAACdeviceswerenotmonitored(i.e.,Individual#141,Individual#339,andIndividual#268).

Monitoringformsconsistentlyreportedthecommunicationdevicewasbeingused.However,thesefindingswerenotcongruentwiththeMonitoringTeam’sobservationsofthesesevenindividuals.



1. TheFacilityshouldcompleteananalysis,includingconsiderationofthevariousrequirementsofthejob,aswellastheacuityoftheindividualsinrelationtoSLPneeds.(SectionR.1)

2. TheFacilityshouldexpandandimplementtheCommunicationServicespolicytoincorporatethefollowing:a. RolesandresponsibilitiesoftheSLPs(e.g.,meetingattendance,stafftrainingetc.);b. Outlineofassessmentschedule;c. Frequencyofassessments/updates;d. Timelinesforcompletionofcomprehensiveassessments(i.e.,within30daysofidentificationviascreening);e. TimelinesforcompletionofComprehensiveAssessment/AssessmentofCurrentStatusforindividualswithachangeinhealthstatus

potentiallyaffectingcommunication(i.e.,withinfivedaysofidentificationasindicatedbytheIDT);f. DescriptionofaprocessforeffectivenessmonitoringbytheSLP;g. Criteriaforprovidinganupdate(AssessmentofCurrentStatus)versusaComprehensiveAssessment;h. Methodsoftrackingprogressanddocumentationstandardsrelatedtointerventionplans;andi. Monitoringofstaffcompliancewithimplementationofcommunicationplans/programs,includingfrequency,dataandtrendanalysis,

aswellas,problemresolution.(SectionR.1)3. TheFacilityshouldreviewtherevisedSLassessmenttemplateandcontentguidelinestoensuretheminimumelementsforcomprehensive

assessmentsareaddressed.TheSLPsshouldconsidereachoftheseelementsastheycompleteassessmentstoensureassessmentsarecomprehensiveasrequiredbytheSettlementAgreement.Inaddition,theSLauditshouldincludetheseelements.(SectionR.2)

4. Individuals’ISPshouldinclude:attendancebyaSLPforindividualswithcommunicationneeds;thetypeofAACand/orcommunicationsupportsprovidedandtheireffectiveness;reviewoftheeffectivenessofthecurrentversionofcommunicationdictionary,andidentificationofnecessarychangesasappropriate;adescriptionofhowtheindividualcommunicates,includingtheAACsystem,iftheyhaveone;andhowcommunicationinterventionswillbeintegratedintotheindividual’sdailyroutine.(SectionR.3)

5. AACsystemsshouldbepresent,inuse,portable,andfunctional.Inaddition,asappropriate,anindividual’suseofanAACsystemshouldbeenhancedthroughtheimplementationofskillacquisitionprograms.Staffshouldbeprovidedwithindividual‐specificcompetency‐basedtrainingandperformancecheck‐offstodemonstratetheircompetencyinsupportingtheindividualinthefunctionalimplementationoftheAACsysteminvariousenvironmentsanddailyactivities.(SectionR.3)

6. TheFacilityshouldre‐assessthefunctionalityofgeneral‐useAACdevicesinresidencesandotherenvironments.(SectionR.3)7. TheFacilityshouldensurecomprehensiveprogressnotesrelatedtocommunicationinterventionsfordirectandindirectsupports:

a. Containinformationregardingwhethertheindividualshowedprogresswiththestatedgoal;b. Describethebenefitofdeviceand/orgoaltotheindividual;c. Reportonwhetherthereisconsistencyinimplementation;andd. Identifyrecommendations/revisionstothecommunicationinterventionplanasindicatedrelatedtotheindividual’sprogressorlackof

progress.(SectionR.3)8. ThemonitoringsectionsoftheFacilityCommunicationServicesPolicy#016shouldinclude:

a. Thefrequencyofmonitoring;b. Theprocessforidentification,training,andvalidationformonitors;c. Theprocessofinter‐raterreliability;andd. Aprocessfordatatrendanalysisandutilizationoffindingstodrivetrainingandproblemresolution(individualandsystemic).

(SectionR.4)9. TheFacility’smonitoringreportsfortheMonthlyPerson‐SpecificPNMPCheckSheet,MonthlyHomeEquipmentCheckSheet,andCompliance

MonitoringFormrelatedtocommunicationshouldbecompletedattheestablishedmonitoringfrequency.Inaddition,theyshouldaddress,at


aminimum,thefollowingindicators:a. Equipmentpresence;b. Equipmentinworkingorder;c. Equipmentusedinvariousenvironments;andd. Inthecaseaproblemisidentified,evidenceofresolution.(SectionR.4)


SECTIONS:Habilitation,Training,Education,andSkillAcquisitionProgramsEachfacilityshallprovidehabilitation,training,education,andskillacquisitionprogramsconsistentwithcurrent,generallyacceptedprofessionalstandardsofcare,assetforthbelow.


o SectionSPresentationBookcompletedbyKimberlyBenedict,DirectorofDayPrograms;o SectionS–Habilitation,Training,Education,andSkillAcquisitionProgramsBi‐Annual

Report(December2011toMay2012)completedbyKimberlyBenedict,DirectorofDayPrograms;

o ForSectionS.1,IndividualSupportPlans,ISPMonthlyReviews(forlastthreemonths),FunctionalSkillsAssessments,PersonalFocusAssessments(PFAs),asprovided,aswellasselectedSkillAcquisitionPlans(SAPs)for:Individual#295(familyvisitSAP,datedJuly2012);Individual#167(privacySAP,datedJuly2012),Individual#236(sensoryexperienceSAP,datedJune2012),Individual#272(activateswitchSAP,datedJune2012),Individual#95(moneymanagementSAP,datedJuly2012),Individual#172(angermanagementSAP,datedJuly2012);Individual#275(busSAP,datedJuly2012),Individual#65(papershreddingSAP,datedJuly2012),Individual#184(firedrillSAP,datedJune2012),Individual#315(choiceofoutfitSAP,datedJuly2012),Individual#58(sensoryactivitySAP,datedJuly2012),andIndividual#153(communityaccessSAP,datedJune2012);

o ForSectionS.2,PersonalFocusAssessment,FunctionalSkillsAssessment(FSA),VocationalAssessment,andIndividualSupportPlan,asavailable,for:Individual#295,Individual#167,Individual#236,Individual#272,Individual#95,Individual#172,Individual#275,Individual#65,Individual#184,Individual#315,Individual#58,andIndividual#153;and

o ForSectionS.3,SelectedSkillAcquisitionPlansandISPMonthlyReviews(forlastthreemonths),asavailable,for:Individual#295,Individual#167,Individual#236,Individual#272,Individual#95,Individual#172,Individual#275,Individual#65,Individual#184,Individual#315,Individual#58,andIndividual#153.

InterviewsandMeetingswith:o SectionKreviewwithJudySutton,M.S.,LPC,BCBA,ChiefPsychologiston7/9/12and

7/10/12;o SectionSreviewwithKimberlyBenedict,DayProgramDirector,on7/10/12;o SectionFreviewwithRachelMartinez,QDDPCoordinator,on7/11/12;o SectionCmeetingwithJudySutton,M.S.,LPC,BCBA,ChiefPsychologist,andGeorge

Zukotynski,StateOfficeCoordinatorforPsychology/BehavioralServices,on7/11/12;o PsychologistsandAssistantPsychologists,includingDanielRivera,ShesheiaNeal,Tiffany

Carranza,MelinaPineda,LloydHalliburton,LindaCardwell,RobertMeza,ChristinaMautinez,EdithCahlik,LaurieRoberts,RobertCramer,GinaHawkins,AndySpear,SamanthaMendoza,JohnGuerra,GildaMontelegro,EverettBush,KarenHernandez,andTabithaAnastasi,on7/11/12;


o MeetingwithQA/QIandSectionKandSProgramComplianceMonitors,includingJudySutton,M.S.,LPC,BCBA,ChiefPsychologist;AraceliMatehala,ProgramComplianceMonitor;CynthiaVelasquez,QADirector;PearlQuintanilla,QAAdministrativeAssistant;SharonDavis,QAAdministrativeAssistant;KarenRyder,QA/ProgramComplianceMonitor;andTabithaAnastasi,on7/12/12;and,

o CoordinatorsandSupervisorsofDayTreatment,Habilitation,Vocational,andEducationalStaff,includingJanieMartinez,DeniseAguilar,MalindaValdemar,LucyTigeria,DavidMcKinney,SofiaFores,JoseSoto,BrigetteEscamilla,PatriciaZagorski,MaryClauss,ErinWillis,andKimberlyBenedict,on7/12/12.

Observations:o ObservationanddiscussionwithstaffmembersattheSkillPlanReviewCommittee

meeting,on7/10/12;o Observationanddiscussionwithstaffmembersandindividualsatthe“TopChefo Competition,”on7/10/12;o ObservationanddiscussionwithstaffmembersattheRestrictivePracticesCommittee,on

7/11/12;o ObservationofSkillPlanIntegritychecksatApartment524‐Aand522‐D,on7/11/12,and

SandDollar,on7/12/12;o Onsitedirectobservations,includinginteractionwithdirectsupportprofessionals,and

otherstaffandprofessionals,wereconductedthroughoutthedayand/oreveninghoursatthefollowingresidentialanddayprogramming,andhabilitationsites:

Apartment522A(Kingfish1),on7/9/12; Apartment522C(Kingfish3),on7/9/12; Apartment522D(Kingfish4),on7/9/12and7/11/12; Horizons/ALSBuildingon7/10/12; Apartment524A(Ribbonfish1),on7/11/12; Apartment524B(Ribbonfish2),on7/11/12; Apartment518(Porpoise),on7/11/12; Gymnasium,on7/11/12; SandDollar,on7/12/12; OuterReef,on7/12/12; Apartment514(Dolphin),on7/12/12;and AngelFish(Building517)‐KaleidoscopeDayProgramandComfortZone,on

7/13/12.

FacilitySelf‐Assessment:TheFacilitydevelopedaSelf‐AssessmentwithregardtoSectionSoftheSettlementAgreement.AccordingtothecurrentSelf‐Assessment,theFacilityfoundthatitwasoutofcompliancewithallofthesubsectionswithinHabilitation,Training,Education,andSkillAcquisitionPlans(SectionsS.1toS.3).ThisfindingwasconsistentwiththeMonitoringTeam’sreview.TheSelf‐Assessmentidentified:1)activitiesengagedintoconducttheself‐assessment;2)theresultsoftheself‐assessment;and3)aself‐ratingbasedonfindingsoftheself‐assessment.Althoughthisformat


appearedhelpfulinmonitoringtheFacility’sprogresstowardcompliance,anumberofconcernswerenoted:

Additionalspecificitywithinsomeassessmentareasappearednecessary.Forexample,inSectionS.1,SAPswerereviewedtodetermineiftheycontained“ABAcomponents.”TherearemanycriticalABAcomponentsandtheseneedtobespecifiedhere.Inaddition,forSectionS.2,vocationalassessmentswerereviewedtoassesswhetherornotcommunity‐basedsituationalassessmentswerecompleted“whenappropriate.”Criteriafor“appropriate”needstobedefined.Inaddition,thesewereexaminedand“100%…containedtherequiredelements.”Theseelementsneedtobespecified.Considerationshouldbegiventoexaminingthequalityoftheelementscontainedinthesereportsaswell.

Moredetailwasnecessarytoadequatelyinterpretscoresinsomeareas.Forexample,althoughengagementrateswereprovidedinSectionS.1,detailedinformationonthenumberofobservationsmade,whichresidentialprogramsweretargeted,etc.,wasnotavailable.Forexample,reviewofSAPcompetencyrostersreflectedascoreof91%ofsuccessfulcompletionwasvague.Howmanyindividualsorprogramswererelatedtothisscore?DidthisjustincludeNEOorongoingintegritychecks?

Itwasunclearwhysamplingwasnotutilized.Thatis,insomecases,all(100%)ofcertaindocumentswerereviewed.Forexample,96vocationalassessmentswerereportedlyreviewed.Thisseemsexcessiveandunnecessary.Asmaller,moredetailedandcomprehensivereviewappearedpreferable.

AlthoughevidenceindicatedongoinguseofthepreviousmonitoringtoolbyactivetreatmentandQAstaff,itwasunclearhowtheQADepartmentwasonlyinvolvedindevelopingorfacilitatingtheuseofthisnewSelf‐Assessment.

Inter‐raterreliabilityscoreswerenotprovidedonmeasuresusedtoassesscompliance.Inter‐raterreliabilityneedstobeestablishedacrossauditorstoensuretheaccuracyofthedata,aswellastheconsistencyacrossraters.

Attimes,itwasunclearhowtheFacilityselecteditssample.Forexample,“areviewoftheengagementdatabaseandunitbasedactivetreatmentcommitteemeetings”wascompletedforSectionS.1,buttheparametersofthissamplewerenotdescribed.FoursetsofISPdisciplineassessmentswereselectedforSectionS.2,and39treatmentintegritychecklistswerereviewedforSectionS.3.However,itwasunclearhowthesewereselected(i.e.,iftheywererandomlyselectedorsampledacrossunits,etc.).

Overall,theFacilitydemonstratedongoingprogressinthecollectionofdatathatappearedhelpfulinmonitoringcompliance.WiththeassistanceoftheQualityAssuranceDepartment,theself‐assessmentshouldcontinuetobeimprovedandexpandedtoaddresstherequirementsoftheSettlementAgreement,whileensuringvalidityandreliabilityofthedata.SummaryofMonitor’sAssessment:ProgresswasnotedinmanyareasofSectionSoftheSettlementAgreement.However,concernsremainedthroughoutallareas.Continuedeffortandrelatedprogresswerenotedintheareaofhabilitationtrainingandservices,in


particularwithregardtothedevelopmentofskillacquisitionplans(SAPs).However,itwasevidentthatmorerobustsupportandexpertisewereneededtoimprovethequalityoftheSAPsaswellastoeffectivelymonitortheirimplementation(i.e.,usingintegritychecks)andindividualprogress(i.e.,usingISPmonthlyprogressnotes)overtime.Lowerthanexpectedestimatesofengagementwerenotedduringthecurrentreview.Progressinsupportingindividualsinoff‐campusvocationalpositionswasevident.Thisincludedactiveeffortsatinformaljobexplorationandtheslow,butincreasingtrendinsuccessfullyplacingindividualsinmeaningfulemploymentpositionsinthecommunity.Thistrendmightbeenhancedbyincreasedcompletionofformalsituationalassessmentwithinoff‐campussettings.

# SummaryofProvision AssessmentofStatus ComplianceS1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshallprovideindividualswithadequatehabilitationservices,includingbutnotlimitedtoindividualizedtraining,education,andskillacquisitionprogramsdevelopedandimplementedbyIDTstopromotethegrowth,development,andindependenceofallindividuals,tominimizeregressionandlossofskills,andtoensurereasonablesafety,security,andfreedomfromundueuseofrestraint.

Continuedeffortandprogresswasnotedintheareaofhabilitationtrainingandservices,inparticularthedevelopmentofskillacquisitionplans.However,itwasevidentthatmorerobustsupportandexpertisewasneededtoimprovethequalityoftheSAPsreviewed.TheMonitoringTeam’spreviousreportsdocumentedimprovementovertimeinthenumberofplansdevelopedaswellasthequalityofSAPsatCCSSLC.However,intheMonitoringTeam’slastreport,baseduponcontinualobservationsofinadequacieswithinSAPs,theMonitoringTeamstronglyencouragedtheFacilityto:1)reviewpreviouslyreportedfindingsandrecommendationsregardingSAPs(becausethemajorityofconcernswerestillapplicable);2)identifywaystowriteSAPstoallowmoreflexibilityinmovingthroughthestepsofthetaskanalysis,and,ultimately,towardmasteryoftheentireskillwithouthavingtore‐writetheentireprogram;and3)mostimportantly,providefrequentandrobustclinicalandtechnicalsupporttothestaffwritingandreviewingtheseprograms.BasedonthecurrentMonitoringreview,itappearedthattheserecommendationswerestillvalidand,asaresult,theycontinuetoremaininplace.Tobeclear,theMonitoringTeamstronglybelievesthatrobusttechnicalsupporthasbeenneededforsometimeandtheprovisionofthatsupport,ifprovided,hasbeeninadequatetodate.ThisisanareawhereadditionalandsignificantsupportattheStatelevelappearsnecessary.ItshouldbenotedthatitwasobvioustotheMonitoringTeamthatFacilitystaffmemberswhoaredeveloping,implementing,andmonitoringtheseSAPsappearedwellmeaningandcommittedtoproducingwell‐designedSAPs.Indeed,thereappearedtobenolackofeffortintherevisionoftheSAPformataswellasrelatedtrainings.Thatis,sincetheMonitoringTeam’slastreview,documentationsuggestedatleastthreerevisions(dated2/23/12,3/20/12,and5/15/12)anddozensoftrainings,includingadministrative,professional,clinical,anddirectcarestaff.However,theseauthorscontinuedtolacktheexpertiseandtechnicalsupportinwritingSAPs.Specific

Noncompliance


# SummaryofProvision AssessmentofStatus CompliancefindingsrelatedtoreviewofSAPsarereportedbelow.InanefforttoreviewtheadequacyofthemostrecentlydevelopedSAPs,asampleof12SAPswasselectedfromindividualswithISPsheldsincetheMonitoringTeam’slastvisit.Thatis,onerecentlycompletedSAPwasrandomlyselectedfromeachofthe12individualsidentifiedforreview.Inaddition,effortswereemployedtoensurearepresentativesampleacrossresidentialprograms.Indeed,thesampleincludedindividualsfrom12differentresidentialprogramsandalloftheSAPswereimplementedinJuneorJuly.Thissamplereflectedapproximately5%ofthetotalnumberofindividualswithISPsandapproximately10%ofthoseindividualswithISPsheldsincetheMonitoringTeam’slastvisit.ThefollowingquantifiestheresultsoftheMonitoringTeam’smostrecentreview:

Ingeneral,rationalesfordevelopmentwerefoundinall12(100%)ofthesampledSAPs.However,oneappearedincomplete(i.e.,Individual#58).Onerationalewasverydetailedandcitedthespecificneedandassessment(i.e.,Individual#275).

SeveralSAPshadstatedrationalesthattargetedaspecificneed(asidentifiedbytheFSA)that,uponreview,didnotappearconsistentwithand/orconspicuouslyidentifiedwithintheFSA.Forexample,anidentifiedneedastherationalefortheprivacySAPforIndividual#167wasnotfound,asstated,intheFSA.OtherexamplesincludedthelackofevidencewithinFSAsasidentifiedforIndividual#272,Individual#95,andIndividual#65.

OfthecurrentlysampledSAPs,11(92%)wereidentifiedinthemostrecentISP.ReferencetothesampledSAPwithintheISPforIndividual#167wasnotevident.

All12(100%)oftheplansreviewedhadanidentifiedtaskanalysissection.However,onlythetaskanalysisfoundinone(8%)ofthesampledSAPswasfoundtobeadequate(i.e.,switchactivationSAPforIndividual#272).

One(8%)ofthesampledSAPsofferedanadequateoperationaldefinition.Thatis,almostallplanscombinedtheoperationaldefinitionsectionwithinthebehaviorobjectivesection,whichinmostcasesoverlookeddefiningtheactualtarget.Thesearedistinctandshouldbeseparated.

Thebehavioralobjectiveinonly40%(fiveSAPs)includedanydescriptionoftheactualskillbeingtargeted.

Ten(83%)oftheSAPsprescribedspecificimplementationschedules.However,ofthese,plansprescribeddaily(50%),weekly(20%),ormonthly(30%)implementationschedules.Formanyindividuals,thisscheduleappearedinsufficienttoprovidethefrequentopportunitiestorespondthatarenecessarytopromotelearning.Inmostcases(60%),opportunitiestorespondwereeitherunclearorataratejudgedinsufficient(onceaweekorless).


# SummaryofProvision AssessmentofStatus Compliance Thelisteddiscriminativestimuli(SD)appearedadequateineight(67%)ofthe

SAPssampled.Insomecases,itappearedthatthiscuecontainedadditionalorunnecessaryverbalprompts(e.g.,Individual#167),inappropriatelyincludedexplanationsorrationales(e.g.,Individual#172),orcouldnotbeeasilyidentified(e.g.,Individual#58).ConsiderationshouldbegiventothefactthatanSDcanbethelastcompletedstepofataskanalysis,andthepotentialnegativeoutcomesassociatedwithutilizingallverbalprompts.

Theinstructionsectionsinnone(0%)oftheSAPsreviewedappearedadequate.Manyofthesesectionseitherrepeatedthetaskanalysis(e.g.,Individual#72andIndividual#65),includedexplanationsorrationales(e.g.,Individual#58),weretoocomplexorconvoluted(e.g.,Individual#236),orintroducedadditionalunnecessaryandpotentiallycounter‐therapeuticverbalprompts(e.g.,Individual#272,Individual#95,individual#275,Individual#184,andIndividual#315).

Itwasunclearwhydatacollectionappearedthesameacrossdifferentformsofinstruction(i.e.,wholetaskversusforwardchaining).Thatis,forsomecaseswherewholetaskpresentationwasprescribed,datawascollectedforonlyonestep(e.g.,Individual#295).Inthiscase,thedescriptionof“whole[total]taskpresentation”wasnotaccurate(i.e.,thetaskanalysisappeareddesignedasaforwardchainingprocedure).

Correctrespondingand/orerrorcorrectionprocedureswerejudgedadequatefornone(0%)oftheSAPsreviewed.Theseproceduresinmostcasesfocusedmoreonhowstaffshoulddocumentcorrectorincorrectrespondingratherthanhowstaffshouldreinforceornotreinforcecorrectorincorrectresponding,respectively.Inaddition,directionsforincorrectrespondingoftenincludeda“2ndchance,”ratherthanfollowingtheprompthierarchy.

GeneralizationandmaintenanceprocedureswerecombinedinallSAPsandwereviewedasadequateinnone(0%)plans.Itappearedthatafundamentalmisunderstandingregardinggeneralizationandmaintenancestrategiescontinued,asevidencedinthecurrentlyreviewedsample.

Individualizedreinforcerswerenotedinnone(0%)oftheSAPs,withallrelyingontheuseofverbalpraise.

Itwasunclearwhymasterycriteria(whentochangesteplevels)wasincludedinbehavioralobjectives,aswellaswhythecriteriawasinconsistentacrossplans.

ItwasunclearwhygraphswereincludedinthemajorityofSAPs.Thatis,progresswasnotedinthemoreconsistentuseofISPmonthlyprogressnotesforall(100%)oftheindividualssampled.However,concernswerenotedwithregardtodatacollectionofSAPs(forspecificinformation,thisisdiscussedwithregardtoSectionS.3oftheSettlementAgreement).

Overall,thecurrentreviewevidenced:1)difficultyinwritingobjective,measureable,meaningful,and,insomecases,attainablebehavioralobjectives;2)incomplete,


# SummaryofProvision AssessmentofStatus Compliancesubjective,toocomplex,orinsufficientlydetailedtaskanalysis;3)teachingconditionsthatdidnotconspicuouslyidentifyrelevantelementsandprecisetrainingschedules;4)acontinuedmisunderstandingofchainingmethodologies;5)inappropriateand/orinsufficientdatacollection;6)insufficientuseofrobustandindividualizedreinforcers;7)thelackofadherencetotypicalpromptingmethodology,orinotherwords,misuseofexcessiveverbalpromptingatthebeginningandtheendofbehavioralresponding;8)thelackofprogrammeddifferentialreinforcement;9)attimes,overlycomplex,redundantand/ordisorganizedcontent;and,10)thecontinuedmisunderstandingofstrategiesrelatedtomaintenanceandgeneralizationaswellastheirapplication.ThepreviousreportnotedthattheFacilityhadstartedprobingtheaccuracyoftaskanalyseswithindividualspriortothedevelopment,training,andimplementationofskillacquisitionplans.ThispracticeappearedthoughtfulaswellaslikelytopromotetheefficientandeffectivedevelopmentofmeaningfulSAPs.BasedonverbalreportsduringtheMonitoringTeam’scurrentvisit,thispracticehadcontinuedandcontinuedtobebeneficialtostaff.Itshouldbenotedthatthemorecomplete,precise,andindividualized(accurate)thetaskanalysis,themorelikelythatskillwellbeacquiredefficiently.Staffshouldcontinuetoexpectthatvalidationofthetaskanalysiswillconfirmadequateconstruction,butperhapsmightprompttheneedforfurtheradjustment.ConsistentwiththeMonitoringTeam’spreviousvisits,observationsduringtheJuly2012onsitevisitattemptedtoestimatelevelsofengagementinrecreational,leisure,and/orotheractivitiesacrossresidentialprograms.TheMonitoringTeammeasuredengagementacrossmanysitesatmultipletimesacrossdaysandtimesofday.Engagementwasmeasuredbybrieflyobservingtheindividualswhowereengagedatthemomentandthenumberofstaffavailableatthattime.Aspreviouslynoted,thedefinitionofengagementwasveryliberal,andincludedactive(e.g.,blowingbubbles,coloring,paintingnails,etc.)andpassiveforms(e.g.,listeningtotheradio,watchingTV,etc.)ofengagement.Thetablebelowprovidesspecificinformationonobservedlevelsofengagement(i.e.,individualsengaged:totalnumberofindividuals)inrelationtostaff‐to‐individualratiosacrossresidentialprograms.EngagementObservationsLocation Engaged Staff‐to‐individualratio522A 0:1 2:1522A 2:2 2:2522C 2:2 1:2522C 4:4 2:4522D 3:3 2:3


# SummaryofProvision AssessmentofStatus Compliance524A 2:6 1:6524A 1:2 0:2524A 0:4 0:4522D 2:9 2:9524D 3:6 5:6524B 2:7 3:7524B 0:2 0:2524B 2:2 2:2516 2:4 1:4510(Outerreef) 0:8 0:8510(Outerreef) 1:5 1:5517(Kaleidoscope) 3:4 3:4517(ComfortZone) 1:1 1:1Overallengagementwas42%.Anengagementlevelofatleast75%wouldbeatypicaltargetforafacilitylikeCCSSLC.Aspreviouslyobserved,poorstaff‐to‐individualratiosinsomeprogramsappearedrelatedtopoorengagement.TheFacilitycontinuedtoactivelymonitorengagementusing5‐MinuteEngagementToolsand,asnotedinthepreviousreport,adatabasehadbeendevelopedtomanageengagementdata,andallowexaminationofcurrentestimatesandtrendsovertime,includingmonthlyreviewbyprogramstaff.Althoughreportsattimesindicatedpotentialover‐estimationofengagementscoresaswellasinconsistenciesinthenumberofprogramsauditedpermonth,thismonitoringsystemcontinuedtoappearfunctionalandprovidemeaningfuldata.Currently,itappearedthattheFacilitywasresponsivetoMonitoringTeamdataandgraphingrecommendations,andhadcreatedgraphsdisplayingthenumberofengagementtoolscompletedeachmonth(i.e.,betweenDecember2011andMay2012)acrossprograms.Inaddition,estimatedengagementbasedonthesecompletedtoolswasalsosimilarlygraphed.TheMonitoringTeamviewedthisasprogress.Basedondataprovided,itappearedthatthenumberoftoolscompletedeachmonthacrossresidentialprogramsrangedfromzeroto16,withsomeprogramsnotcompletinganytoolsincertainmonthsfromDecemberthroughFebruary(i.e.,SandDollarandSeaHorse).Inaddition,itappearedthatthenumberoftoolscompletedeachmonthacrossvocationalanddayprogramsrangedfromzerotoeightwithsomeprogramsnotcompletinganytoolsincertainmonthsfromDecemberthroughFebruary(i.e.,HorizonsandKaleidoscope).Someprogramsduringthistimeperiodhadnotcompletedanyengagementtools(i.e.,OuterReef).Indeed,thismightberelatedtothelowengagementratesobservedattheOuterReefduringtheMonitoringTeam’scurrentonsitevisit.TheFacilityreportedarangeofengagementratesbetween46.5%and100%.Noaveragescoreacrossprogramswasprovided.Itshouldbenotedthat


# SummaryofProvision AssessmentofStatus Complianceapproximately36%ofthemonthlyengagementrateswerebasedonthecompletionofthreeorlessengagementtoolspermonth.Consequently,cautionshouldbeusedwheninterpretingengagementestimatesbasedonassessmentsthatoccurredlessthanonceaweek.TheFacilitymightwanttoconsideronlyreportedengagementratesforamonthifacertaincriteriahasbeenmet(e.g.,atleasttwoperweek).Overall,activeeffortsaimedatimprovingengagementwerenoted.Theseincluded:1)clearexpectationsappearedtobeset(i.e.,eightperresidenceeachmonth–twoperweekacrossthe6‐2and2‐10shift;and,eightpervocational/dayprogrameachmonth–twoperweekacrossthemorningandafternoon);2)trainingsonconductingthesemonitoringsessionsaswellastherevisionoftheform;and3)ongoingformalreviewandsubsequentactionplanswhenlevelswerelowerthanexpected(e.g.,atDolphinandSandDollar).TheMonitoringTeam’spreviousreportsevidencedprogressovertimeindevelopingnewvocational,dayprogram,and“retirement”settingsoncampusinanefforttosupportindividualsofftheirresidentialprograms.Inaddition,targetedprogrammingforindividualswithAutismalsohadbeenindevelopment.PreviousreportsalsohighlightedevidencethattheFacilitycontinuedtoexaminereasonswhyindividualsdidnotparticipateinday,vocational,oreducationprograms.Previousrecommendationsincludedthecollectionofdataonworkrefusalsand/orpercentageoftimeatdayorvocationalprogrammingtoensureadequatemonitoringovertime.Inresponse,asevidencedduringtheMonitoringTeam’spreviousvisit,theFacilityhadstartedcollectinganddisplayingdataonthenumberofavailableworkandclassroomopportunitiesrefused.Currently,theFacilityhadenhancedthisdatacollectionandmonitoringsystemtoincludegraphicdisplaysofdayprogramandvocationalattendanceforeachresidenceovertime(bymonth).Overall,increasingtrends(basedontheaverageofresidentialprograms)werenotedwithineachdayprogramaswellasforworkattendanceacrossresidentialprograms.Thecollectionofthisdataandgraphicdisplayreflectedprogressandappearedlikelytoprovideimportantdataandeffectiveongoingmonitoring.TheMonitoringTeamlooksforwardtoexamininghowthisdataisusedtoimproveattendance,perhapsforthoseresidencesand/orprogramswiththelowestattendanceratesorwithdecliningorvariablerates.However,asdiscussedinmoredetailwithregardtoSectionF,thisneedstobeanindividualizedprocess.ISPsthattheMonitoringTeamreviewedcontinuedtoprovidelittle,ifany,justificationforindividualsnotparticipatinginfull‐dayoffsiteprogramming,orexpandingindividuals’opportunitiesforappropriate,individualizeddayandvocationalsupports.Consequently,datatargetingattendanceovertimeforoneormoreresidentscouldbemorecloselymonitoredtoassessthesuccessofindividualizedinterventions.Indeed,documentationrevealedthatthisdatawasalreadybeingcollected.Infact,documentationevidencedaprogram(incentiveprogram)whereindividualswerepraisedforexcelledattendance.Oneofthesesettings,forexample,theHorizonsprogram,verballypraisedindividualswithattendanceof80%orbetter(permonth).Thisappearedtobeaninformalprogramthat


# SummaryofProvision AssessmentofStatus Compliancehadnotbeenformallyevaluated.TheFacilityshouldconsidermonitoringattendancedataonanindividualbasisforselectindividualswhoarethemostresistanttoattendingvocationalordayprogramming.Thiswouldestablishabaselinetoexaminetheeffectivenessoffutureinterventions(similartotheincentiveprogram)developedtoenhanceattendance.TheMonitoringTeam’spreviousreviewshadnotedconcernswiththelimitedopportunitiesforindividualstoworkoffcampusincompetitiveemploymentpositions.Overtime,thenumbersofindividualsinsupportedcommunity‐basedemploymentpositionshadslowly,butgraduallygrownfromapproximatelyseven(atbaseline)to19(January2012).Currently,accordingtosummarydocumentation,20individualswereworkinginsupportedemploymentpositionswithin15community‐basedsites.Overall,thedatareflectedaslow,butincreasingtrendinsupportingindividualsinmeaningfulemploymentpositionsinthecommunity.Duetothecontinuedinadequacyandconcernsasnotedabove,theFacilityremainedoutofcompliancewiththisprovisionoftheSettlementAgreement.

S2 WithintwoyearsoftheEffectiveDatehereof,eachFacilityshallconductannualassessmentsofindividuals’preferences,strengths,skills,needs,andbarrierstocommunityintegration,intheareasofliving,working,andengaginginleisureactivities.

Progresshadbeennotedinthecompletionofassessmentsthatexamineindividuals’preferences,strengths,skills,needs,andbarrierstocommunityintegrationaswellasintheareasofliving,working,andleisureactivities.AspreviouslydescribedintheMonitoringTeam’spreviousreports,thePersonalFocusAssessmentwasexpectedtobecompletedpriortotheISPtohelpteamsidentifyanindividual’sgoals,interests,likes/dislikes,achievements,andlifestylepreferencesacrossawiderangeofareas.Aspreviouslyreported,althoughPFAsappearedtobecompletedforthemajorityofindividualssampled(i.e.,93%inJuly2011and94%inJanuary2012),onlyaminorityoftheseassessmentsappearedtobeadequatelycompleted(i.e.,31%inJuly2011and53%inJanuary2012).InanefforttoreviewtheadequacyofthemostrecentlycompletedPFAs,asampleof12individualswhohadISPsheldsincetheMonitoringTeam’slastvisitwasselected.Thesamplingwascontrolledtoensureadequaterepresentationacrossresidentialprograms.Indeed,thesampleincludedindividualsfrom12differentresidentialprograms.Thissamplereflectedapproximately5%ofthetotalnumberofindividualswithISPsandapproximately10%ofthoseindividualswithISPsheldsincetheMonitoringTeam’slastvisit.Currently,ofthe12individualssampled,10(83%)hadPFAsthatappearedtobeadequatelycompleted.TheexceptionsweretwoPFAsthatweremissingorincompleteforIndividual#295andIndividual#272.Ofthe11availablePFAs,10(91%)weredatedpriortotheISP.TheoneexceptionwasaPFAthatwasnotdated(i.e.,Individual#95).Consequently,itappearedthatmostPFAswereavailablepriortotheISP.Achangein

Noncompliance


# SummaryofProvision AssessmentofStatus Complianceformatwasnotedas10ofthe11availablePFAswerethemostrecentformat,dated9/15/11.Thisformatdifferedfrompreviousformats,becauseitnolongerincludedacomprehensivelistofassessmentsthattheIDTrecommendedforcompletionpriortotheISP.Lastly,onlysixofthe11PFAsweresigned.ItshouldalsobenotedthattheMonitoringTeamrecognizesthattheFacilitywasintheprocessofinitialimplementationofthenewPreferencesandSkillsInventory(PSI)thatwillreplacethePFA.ThesamesampleasdescribedabovewasutilizedtoexaminethecompletionoftheFunctionalSkillsAssessment.TheMonitoringTeam’spreviousreportindicatedthat91%oftheindividualssampledhadFSAsthatappearedfullycompletedandadequatelysummarized.However,atthattime,severaloftheseFSAwerecompletedaftertheISPmeetingand,asaresult,wereunlikelytoadequatelyinformtheIDTasintended.Currently,oftwelveindividualssampled,12(100%)hadcompletedFSAs.However,uponcloserexamination,only11(92%)appearedtobesummarizedandofferrecommendations.TheexceptionwastheFSAforIndividual#58thatappearedcompleted(alltheitemswerescored),buttheassessmentwasnotsummarizedandrecommendationswerenotprovided.Inaddition,threeindividualsappearedtohaveFSAscompletedusingthenewsummaryandrecommendationformat(i.e.,Individual#236,Individual#272,andIndividual#184).ItappearedthatthisnewformatwasimplementedinFebruary2012.However,itwasunclearwhyIDTsforthreeotherindividuals(withISPscompletedinMarch2012)didnotutilizethisnewformat(i.e.,Individual#95,Individual#275,andIndividual#65).Overall,thechangetothenewformatappearedpotentiallymorehelpful,becauseitprovidedanopportunityfortheIDTtoexamineadditionalassessmentinformation,including1)barrierstocommunityintegrationinlivingandleisure;2)supportsneededtoovercomebarriers;3)skilltrainingrecommendations;and4)ideasforthefuture.However,thischangedidnotnecessarilyprovideanymoredetailinsomeoftheinformationprovided.Thatis,reviewofsampledFSAsevidencedrecommendationsthatappearedquitebriefandnon‐specific.Morespecifically,mostoftheFSAsreviewedcontainedthreetofiverecommendationsthateachincludedonlyoneword(orjustafewwords)describingacommonlabelorcategoryofskills/activitiesofdailyliving(e.g.,“Community,”“Leisure,”or“MoneyManagement”).ItwasuncleartotheMonitoringTeamwhysuchaverycomprehensiveassessment(47ormorepages),thatrequiressignificantresourcestobecompleted,wouldproducesuchbriefandoftencrypticrecommendations.Indeed,thepointoftheassessmentwastoinformtheIDTprocessbyidentifyingtheneedsoftheindividual.TheMonitoringTeamencouragestheFacilitytocloselyreviewtherecommendationsproducedbythecompletionoftheFSAandexaminewhetherornottherecommendations:1)areconsistentwithfindingswithintheassessment;2)offernew(orquestionpreviously)identifiedneeds;3)offerutilityinthedevelopmentofnewSAPsorotherprogramming;and4)areviewedashelpfultotheIDT.


# SummaryofProvision AssessmentofStatus ComplianceAsnotedintheMonitoringTeam’spreviousreports,slowprogresshadbeennotedintheareaofvocationalassessments,includingtheuseofsituationalassessmentopportunities.However,concernswerenoted,includinginconsistenciesinformat,lackofindividualization,recommendationsthatdidnotreflectfuturevocationalvisions,useofgraphicdisplaysthatweredifficulttointerpret,andtheuseofunstructuredandon‐campussituationalassessments.Ingeneral,theprimaryfindingwasthatpreviousvocationalassessmentswerelimitedinnatureduetotheprimarycompletionofon‐campussituationalassessments.Thatis,forindividualsalreadyworkingon‐campus,theuseofassessmentstargetingthesameorsimilarjobexperiencesappearedtolimittherangeanddiversityofpotentialemploymentvisions.Indeed,evenforindividualswhohavenotworked,theFacilitywascurrentlylimitedinthediversityofworkithadtooffer.Inanefforttoreviewtheadequacyofvocationalassessments,12individualswithISPmeetingsheldsincetheMonitoringTeam’spreviousvisitwereselectedandtheirvocationalassessmentswerereviewed.Thissamplewasthesamesampleasdescribedabove.Currently,onlyseven(58%)vocationalassessmentswereavailableforthe12individualssampled.ItwasuncleartotheMonitoringTeamwhythesemissingassessmentswerenotprovidedasrequested.Thatis,verbalreportswhileonsiteindicatedthatallindividualswithISPswithinthepastsixmonthswouldhavecompletedvocationalassessments.Ofthesevenavailablevocationalassessments,all(100%)werecompletedwithinthelast12monthsandall(100%)werecompletedpriortothemostrecentISP.Inaddition,althoughin‐textsummariesdescribedanumberofpreviousvocationalexplorationsandjobintroductions,formostindividualssampled,documentationevidencedsupplementalassessmentsforonlyfive(71%).Ofthesefiveindividuals,four(80%)appearedtohaveoneormoresituationalassessmentsand/orjobexplorationscompletedwithinthelastyear.Morespecifically,four(57%)ofthesevenevidencedsituationalassessment(s)withinthelast12months;andtwo(29%)ofthesevenevidencedjobexplorationassessments.TheexceptionwasIndividual#315whohada“jobintroduction”inSeptember2010.Thevocationalassessmentsfortwoofthesampledindividualsindicatedthatsituationalassessmentswerenotconductedduetothepreference,contentment,and/orinsistenceoftheindividual(i.e.,Individual#295andIndividual#167).ThisisdespitethefactthatthevocationalassessmentforIndividual#167acknowledgedthat“…[individual]’svocationalgoalmaybelimitedduetolimitedexposuretocommunityjobs.”Overall,none(0%)ofthemoreformalsituationalassessmentwereconductinginthecommunity.ItwasuncleartotheMonitoringTeamwhycriteriaforrevisionincludedyearlyupdatesforthoseactivelyemployedinvocationalprogrammingandrevisioneverythreeyearsforthosenotactivelyworking.Itwouldappearthatmorerobustandongoingassessmentwouldbenecessaryforthoseindividualsnotworking.


# SummaryofProvision AssessmentofStatus ComplianceConsistentwithfindingsreportedintheMonitoringTeam’spreviousreports,allofthereportedsituationalassessmentswereconductedoncampustargetingexistingemploymentactivities.Attimes,thesituationalassessmentsappearedtoberelatedtothecurrentlyidentifiedvision(e.g.,Individual#184andIndividual#172),andforothers,thesituationalassessmentsdidnotappearconsistentwiththeidentifiedvision(e.g.,Individual#275andIndividual#95).Overall,situationalassessmentsmighthavebeenmoremeaningfulandfunctional,atleastforsomeoftheindividuals,iftheyhadbeencompletedincommunity‐basedsettings.Thatis,becausesituationalassessmentsprimarilyappearedtobecompletedoncampus,therangeanddiversityofemploymentvisionscontinuedtobepotentiallylimited.Jobexplorationassessments,however,wereallconductedoff‐campusandreflectedprogressinexploringadditionalcommunity‐basedsettingsthatwerelikelytooffermorediverseopportunitiesand,hopefully,awiderrangeofmeaningfulemploymentpositions,aswell.TheFacilityshouldconsideraddingmorespecificationtotheSituationalAssessmentSummaryaswellaswithinthevocationalexplorationsectionofthevocationalassessment.Morespecifically,itwouldappearhelpfultoIDTmemberswhoreadtheassessmentif,ontheform,thespecificsite/settinginwhichtheassessmentwasconductedaswellasthespecificdatewasidentified.Thisshouldincludeconspicuouslyhighlightingwhetherornotthesettingwasonoroffcampus.Inaddition,theformshouldrequiretheratertoidentifythecurrentvocationalvisionanddeterminewhetherornotitisconsistentwiththeactualexperiencetargetedbythesituationalassessment.Iftheywereconsistent,theraterwouldneedtobrieflyofferhowtheexperienceisdifferentfrompastorcurrentvocational(likelyon‐campuswork)experiences,aswellastheuniqueorpotentialbenefits.Iftheyareinconsistent,theratershouldberequiredtoexplainhowtheyaredifferentandofferarationaleastowhytheexperiencewasofferedtotheindividual.Thisextrastepmightfacilitatebetterunderstandingofthedirectionpursuedbyvocationalstaff,aswellasdemonstrateeffortsatprovidingindividualswithnewexperiencesoutsidetheir“comfortzone”orbeyondthattypicallyofferedoncampus.Inaddition,allassessmentsshouldclearlyprovidespecificdatesonwhichsituationalassessmentswerecompleted.Lastly,insomecases,individualsappearedresistantoruninterestedinexploringnewoptionsthroughsituationalassessments.Inthesecases,theFacilityshouldconsiderclearlydocumentingthedetailedeffortsmadeinencouragingthesenextexperiences.Theseeffortsshoulddemonstratestrategiesbeyondverbalencouragement,andincludedocumentedrationalesbeyond,forexample,theindividual’spreferenceorresistancetochange.Vocationalstaffshouldbevigilantwithregardtooldadage“youdon’tknowwhatyoudon’tknow”which,insomecases,canbeaccuratelyappliedtoindividualswithrestrictedvocationalexperiences.Datadisplayedwithincurrentlyprovidedsummarydocumentationappearedtoreflectadecreaseinthenumberofon‐campusandoff‐campussituationalassessmentsoverthe


# SummaryofProvision AssessmentofStatus Compliancepastfourandthreemonths,respectively.ItappearedthathigherratescompletedinFebruaryandMarchcouldnotbesustained.However,theoverallratesofJobExplorationsappearedtoreflectanincreasingtrendoverthepastsixmonths(withtheexceptionofMarch).TheMonitoringTeamstronglyencouragestheFacilitytocontinuewiththeseassessments,andlooksforwardtoagreateremphasisonthecompletionofcommunity‐basedsituationalassessments.AsnotedinmanyoftheMonitoringTeam’spreviousreports,theutilityofthevocationalassessmentwillcontinuetoimproveasitsfindingsarebasedonmeaningfulsituationalassessments,includingagreaterdiversityofexperiencespotentiallyavailableincommunity‐basedoff‐campussettings.Theirvaluealsowillimproveastheresultsarelinkeddirectlytofunctionalskillacquisitionprogramsrelatedtoachievingindividualizedemploymentvisions.TheMonitoringTeamrecognizedtheeffortsatutilizing(oratpreparingtoutilize)otherstandardizedandstructuredassessments(e.g.,theEducationalandTrainingAssessment,theABLLS‐R,etc.)inanattempttobettersupportindividualsineducationalsettings.Indeed,initialeffortstomorebroadlyutilizemoreevidence‐basedassessmentsandskilltrainingcurriculaappearedpromising(asdiscussedwithregardtoSectionK.8).TheMonitoringTeamlooksforwardtocontinuedreviewoftheseinitialandongoingeffortsoftheFacility.Duetothecontinuedinadequacyandconcernsasnotedabove,theFacilityremainedoutofcompliancewiththisprovisionoftheSettlementAgreement.

S3 WithinthreeyearsoftheEffectiveDatehereof,eachFacilityshallusetheinformationgainedfromtheassessmentandreviewprocesstodevelop,integrate,andreviseprogramsoftraining,education,andskillacquisitiontoaddresseachindividual’sneeds.Suchprogramsshall:

(a) Includeinterventions,strategiesandsupportsthat:(1)effectivelyaddresstheindividual’sneedsforservicesandsupports;and(2)arepracticalandfunctionalinthemostintegratedsettingconsistentwiththeindividual’sneeds,and

Someprogresswasnotedregardingthedevelopment,training, andmonitoringofindividualized,practicalandfunctionalskillacquisitionplans.However,seriousconcernsremainedregardingthequalityofthesedevelopedSAPs,theirproceduralintegrity,andtheirongoingmonitoringandreview.TheMonitoringTeam’spreviousreportsnotedthataweeklypeerreviewprocess,entitledtheSkillAcquisitionReviewCommittee,hadbeeninitiatedtoexaminedevelopedskillplansandtoprovidefeedbackandongoingcoaching,andrefinement.Accordingtoverbalreportsandonsiteobservation,thiscommitteecontinuedtomeetweeklyto

Noncompliance


# SummaryofProvision AssessmentofStatus Compliancereviewdevelopedplans.Overtime,thiscommitteehadreceivedtechnicalsupportfromoneofthecontractedBCBAs,theClinicalPsychologist,andChiefPsychologist.Basedonfindingsfromthecurrentreview(asdiscussedwithregardtoSectionS.1),robustclinicalandtechnicalsupportcontinuedtobenecessary.Indeed,basedonverbalreportsduringtheMonitoringTeam’smostrecentvisit,itappearedevidentthatavailableon‐campusresources,includingthosecitedabove,wereinsufficientorunavailabletoprovidethesupportnecessarytomaketheneededqualitativechangestothedevelopment,implementation,andmonitoringofSAPs.InanefforttoexaminewhetherornotSAPseffectivelyaddressedtheindividuals’needsforservicesandsupports,randomlyselectedSAPswereexaminedinasampleofindividualswithISPmeetingsheldsincetheMonitoringTeam’slastvisit(thiswasthesamesampleasdescribedwithregardtoSectionS.1oftheSettlementAgreement).Morespecifically,SAPswerereviewedtodetermineiftargetedneedswereidentifiedbycurrentlycompletedassessments.AspreviouslyreportedwithregardtoSectionS.1,althoughrationaleswerefoundforall12(100%)oftheindividuals,concernswerenotedwithregardtotheassessmentscitedwithintheserationales.Overall,therationalelistedinone(8%)ofthesampledSAPsappearedincomplete(i.e.,Individual#58).Therationaleofapproximatelyeight(67%)sampledSAPsincludedreferencestospecificneedsasidentifiedwithincompletedassessments(e.g.,FSA,ISPA,PsychologicalEvaluation),and10(83%)citeddiscussionattheISPastherationalefortheneed(although,technically,theMonitoringTeamdidnotviewthisasaformalassessment).TheMonitoringTeamcouldonlyconfirmagreementintwo(29%)ofthesevenSAPsthatcitedaspecificassessmentasthebasisoftheidentifiedneed(i.e.,Individual#295andIndividual#275).Thatis,inthemajorityofcases,theMonitoringTeamcouldnotidentifythetargetedneedwithintheassessmentcitedwiththeSAP.Infact,inseveralcases,theneedidentifiedwithintheSAPappearedcountertoinformationfoundwithinthecitedassessment(e.g.,thePFAforIndividual#236andIndividual#95).Inaddition,theneedsaddressedbytheSAPscouldonlybeconfirmedin10(83%)oftheISPs.Lastly,someidentifiedassessmentswerenotavailabletotheMonitoringTeam(i.e.,thePALSforIndividual#236andtheISPAforIndividual#315).InanefforttoexaminewhetherornotSAPswerepracticalandfunctionalinthemostintegratedsetting,theprescribedsettingsofcurrentSAPswereexamined.AsdescribedinSectionS.3.boftheSettlementAgreement,all(100%)oftheindividualscurrentlysampledhadatleastoneSAPidentifiedforcompletioninaresidentialsetting.Indeed,themajorityofSAPsreviewedacrossallsampledindividualsweresetwithintheresidentialsetting.However,all(100%)oftheindividualssampledhadatleastoneSAPidentifiedforcompletioninacommunitysetting,and10(83%)hadSAPsidentifiedforeithervocational/worksettingsand/orclassroom/dayprogramsettings.UponreviewofthetwelvesampledSAPs,itappearedthateight(67%)clearlyhadSAPsthatwere


# SummaryofProvision AssessmentofStatus Compliancepracticalandfunctional.Morespecifically,itwasunclearwhetherornotfourofthesampledSAPswouldeverbeeffectiveorpromoteasuccessfulskillinthemostintegratedsettingorultimatelyeffectivelyserveapurpose.Thesefindingsaredescribedbelow:

TheSAPforIndividual#236targetedteachingtwosignsofbeinghappyandcontentinacommunitysetting.Itwasunclearhowstaffwouldultimatelyknowwhetherornotshewastrulyhappyorcontent.And,althoughstaffcouldbringhertoaplacewheresheislikelytobehappyorcontent,theseselectedresponsesofemotioncannotnecessarilybepromptedoraccuratelymeasured.

TheSAPforIndividual#275didnotappearpractical,becauseherlevelofsupervisionandcommunityrestrictionslimitedheraccesstothecommunitysignificantly.Thatis,shehadnotbeenabletoworkonthisobjectiveforthepastthree(ormore)monthsduetocommunityrestrictionscontingentuponmaladaptivebehavior.

TheSAPforIndividual#58targetedtheskillofchoosingandengaginginasensoryactivity.Itwasunclearhowstaffmighteffectivelyidentifyormeasurewhetherornothe“engaged”inasensoryactivity(anythingthatstimulatesthesenses).Althoughexperiencingsunonyourfaceorthesmellofoceanaircanbeapleasurableandrewardingactivity,itwasuncleartotheMonitoringTeamhowtheFacilitywouldteachthisasaskill(i.e.,usingobjectiveandmeasureableresponses).

TheSAPforIndividual#153targetedimprovinghisexposurebyteachinghimthe“Abilitytorideinthevanoffcampus.”Althoughincreasingthediversityofexperiencesforindividualsislaudable,itwasunclearhowtheFacilitymightdetermineifridinginthevan“enricheshislifeexperiences,”orservedameasurablepurpose.

SincetheMonitoringTeam’slastreview,substantialeffortstoprovidecompetency‐basedtraining(CBT)onskillacquisitionplans(SAP)toCCSSLCstaffwereevident.Thatis,accordingtosummarydocumentation,theActiveTreatmentDepartmentconductedCBTtargetingSAPstoover560CCSSLCprofessionalanddirectsupportprofessionalsinAprilandMay2012.Inaddition,verbalreportsaswellasdocumentationindicatedthatskillacquisitiontrainingcurriculumhadbeenintegratedintotheNewEmployeeOrientation(NEO).However,itwasdifficultfortheMonitoringTeamtodetermineifthiscontentwassignificantlydifferentfromcontentfoundinprevioustrainingcurriculum.Thatis,theformatsusedwithinNEOcontinuedtoappearoutdatedcomparedtoexpectationsbasedonverbalreportsregardingchangestoSAPformats,includingchangestooperationaldefinitionsaswellaschangestothemaintenanceandgeneralizationsections.Currently,basedontheNEOmaterialsprovided,itappearedthatthecurriculumcontinuedtobeinadequate.Morespecifically,materialsidentifiedanoperationaldefinitionsection,butoperationaldefinitionswererarelyfoundinreviewed


# SummaryofProvision AssessmentofStatus ComplianceSAPs(asdiscussedwithregardtoSectionS.1).Inaddition,thematerialsdidnotadequatelyaddresschaining(includingthedifferenttypes),differentialreinforcement,ortheuseoftheprompthierarchy.Thetrainingneededtobemorerobustwithregardtodetermininghowtoidentifythepromptleveltargeted,whentouseamoreintrusivelevelofprompt,howtolimittheuseofprompts(i.e.,fadingtoavoidpromptdependency),masterycriteriainvolvedinchangingpromptlevels,etc.TheFacilitystilldidnotsubmitanytrainingcontentondifferentialreinforcement(e.g.,how/whentousereinforcersfollowingcorrecting/incorrectresponding)ortypesofchaining.TheSAPexampleincludedinthetrainingwasofa“whole”task,butitwasonlyonestep,whichisnottypicallyseenasanadequatetaskanalysis.TheFacilityappearedtoutilizedataobtainedthrough“IntegrityTreatmentChecklists”asonemethodtoassessstaffcompetencyinimplementingSAPs.Thatis,summarydocumentationreportedthattheeffectivenessoftheCBT(inimplementingSAPs)wouldbeassessedthroughtheuseofIntegrityTreatmentChecklists(ITC).ItwasuncleartotheMonitoringTeamwhyscoresobtainedduringtheactualtrainingwerenotutilized(orprovidedforreview).However,summarydocumentationsuggestedthathighratesofcompetencywereobtainedinApril(89.4%)andMay(95.5%).Theseestimatesshouldbereviewedwithcaution,becausetheyappearedtobebasedoninsufficientdata.Morespecifically,thescoreforAprilwasonlybasedondatacollectedacrossseven(58%)oftheprograms,and,onaverage,approximatelyfourchecksperresidence.Inaddition,similarconcernswerenotedforMaydata.AlthoughthescoreforMaywasbasedondatacollectedacross12(100%)oftheprograms,thisestimatewasbased,onaverage,ononlyfourchecksperresidenceaswell.Consequently,theFacilityshouldensurethatanadequatesampleofintegritycheckshadbeencompleted(withsufficientIOAbetweenraters)priortoreportingintegrityestimates.AsreportedinpreviousMonitoringreports,reportedintegrityscores,insomecases,hadlikelyoverestimatedthelevelofactualimplementationintegrity.And,asfoundduringtheMonitoringTeam’sreview,concernsregardingtheadequacyofintegritycheckswerenotedduringdirectobservationofintegritychecks.Morespecifically,theMonitoringTeam’spreviousreportdescribedinadequaciesfollowingdirectobservationoftwoactivetreatmentstaffconductingSAPintegritytreatmentchecks.Atthattime,severalconcernswerenotedregardingtheadequacyoftheseintegritychecks,anditwasrecommendedthatactivetreatmentstaffreceivemoretrainingandsupportinaccuratelycompletingthesechecksaswellascompletingIOAestimatesacrossraters.DuringtheMonitoringTeam’smostrecentvisit,similarconcernswerenotedfollowingdirectobservationofseveralintegritycheckscompleted.Thatis,duringtheintegritytreatmentchecks,directsupportprofessionalsappearedtobecoachedorpromptedattimesbytheraters,ratersoftendiscussedtheSAPand/orrelatedscoringduringtheintegritycheck,andratersoftenhaddifficultycorrectlyscoringtherubricduringthesessions.Attimes,


# SummaryofProvision AssessmentofStatus ComplianceratersalsohaddifficultyaccuratelydescribingtheSAP,includinghowtoappropriatelypromptincorrectrespondingandexplaininggeneralization.Indeed,onseveraloccasions,ratersfailedtodemonstrateindependentscoring.Reviewoftheactualintegritychecksrevealedthatratersdidnotfullyscoretherubric.Overall,concernsremainedregardingtheactualintegrityoftheintegritychecks.Consistentwithpreviousobservations,currentlyreviewedintegritychecksessionsreflectedtheneedforongoingsupportandtrainingforactivetreatmentstaffwhoconductthesesessions.TheMonitoringTeamrecognizesthatcompletingintegritycheckswithahighdegreeoffidelityandreliabilityischallengingand,likeotherchallengingskills,requiressufficientsupporttomaster.ItwasevidentthattheFacilityrecentlyhadre‐trainedthoseindividualscompletingthesechecks(dated6/5/12).Theseeffortsshouldcontinue.Inaddition,documentationrevealedongoingrevisionoftherubric(mostrecentlyon4/10/12)utilizedduringthesechecks.TheFacilityshouldconsiderfurtherrevisionovertime,whennecessary.Forexample,thecurrentreviewnotedconcernwithusingadequatetaskanalysesandspecificcriteriatargetingtaskanalyseswerenotincludedwithintherubric.Inaddition,currentfindingsdemonstratedcontinuedconfusionwiththemethodofchaining,butthiswasnotconspicuouslyincludedintherubric.Also,itwasnotalwaysclearwhentrainingwasprescribed.PerhapsclearerinstructionsonItem5(ofthecurrentrubric)wouldfacilitatemoreconspicuousidentificationoftheprescribedtrainingschedule.Inaddition,operationaldefinitionsandbehavioralobjectiveswerealmostalwayscombinedinSAPs(basedonthesample),andyeteachcomponenthaditsownsectiononthisrubric.Perhapshighlightingthatthesewerediscretecomponentswouldbehelpful.Relatedly,attemptstomoreclearlydiscriminatebetweengeneralizationandmaintenanceproceduresmightbeeffectiveifthesewereclearlydiscretewithintherubric.Lastly,therubricappearedtobemissingreferencetootherimportantcomponents(i.e.,promptinghierarchyandmethods,methodofinstruction,andmasterycriteria).Consistentwithpreviousreviews,mixedfindingswereobservedduringonsitevisitswhendirectsupportprofessionalswereaskedsimplequestionsaboutbehavioralandskillacquisitionprogramming.Thatis,asdiscussedwithregardtoSectionK.11oftheSettlementAgreement,inconsistentfindingswithregardtostaffknowledgeofPBSPsandSkillAcquisitionPlanscontinuedtobeobservedduringonsitevisits.Asmallsampleofstaffmemberswasinterviewedaboutselectedindividualsandtheirprogramminginanefforttoestimatestaffknowledgeaboutindividuals.Overall,althoughmanystaffappearedknowledgeableofplansandskillprogramsofrandomlyselectedindividuals,manystaffstillwereunabletoanswerbasicquestionsaboutbehavioralorskillprogrammingforsomeindividuals.Forexample,adirectsupportprofessionalwasabletoprovideaccurateinformationinresponsetoquestionsaboutIndividual#167,butwasunabletolocatetheIndividualNotebooktodescribedatacollection.Staffcorrectlyansweredquestionsregardingtargetbehaviorsandprescribedconsequence‐based


# SummaryofProvision AssessmentofStatus ComplianceinterventionsforIndividual#58andwasabletogenerallydescribetheplanforIndividual#22.However,whenasked,staffneededtoconfirmwhetherornotsomeindividualshadaPBSP(e.g.,Individual#310).Insomecases,staffreportedthatanindividual(Individual#254)hadaPBSPwhenthatwasnotthecase.Inonecase,staffdescribedatargetbehaviorofPICAandrelatedpreventativestrategiesthatwerenotlistedinIndividual#315’sPBSP.Briefonsitereviewsalsoevidencedsomewhatmixedfindingswithregardtotheadequacyofdatacollection.Inmostcases,however,datacollectionwasnotadequate.Briefrecordreviewsexaminingthecollectionofbehavioraldataindicatedthat91%,29%,63%,and70%ofthedataappearedadequatelycollectedforIndividual#275,Individual#353,Individual#315,andIndividual#254,respectively.Briefreviewsofskillacquisitionplandataindicatedthat53%,46%,67%,and40%ofthedataappearedadequatelycollectedforIndividual#7,Individual#353,Individual#310,andindividual#254,respectively.TheseestimateswereconsistentwithverbalreportsattheSkillPlanReviewCommitteethatsuggestedthatthebiggestobstaclewasensuringadequateproceduralintegrityofskillplanimplementationanddatacollection.DuringtheMonitoringTeam’spreviousreview,itwasnotedthattheFacilityhadimplementedweeklychecksexaminingthequalityofdatacollectionforSAPs.Thatis,achecklistwascreatedtoassesstheadequacyofdatacollectionforeachskillplanacrossallindividualsinaresidence.Thisongoingevaluationofdatacollectionappearedtoofferaneffectivealthoughindirectwaytomoreregularlyandsystematicallymonitortheadequacyofdatacollection,aswellaspromptfeedbackorinitiatefurtherexaminationwheninadequatedatacollectionwasobserved.DirectobservationsbytheMonitoringTeamduringthemostrecentonsitevisitevidencedthecontinueduseofthesechecks.Indeed,accordingtosummarydocumentation,onJuly1,2012,arevisedstandardizedweeklySAPchecklistwasimplemented.Likethepreviousrubric,thischecklistwasusedtoexamineanddocumentthepercentageofdatacollectedperweek.Reviewofdocumentationdidnotevidenceasummaryofthedatacollectedduringthesechecks.Aspreviouslyrecommended,theFacilityshouldconsiderrevisiontothechecklisttodetermineanoverallscore(perpersonorperresidence)thatwouldallowmonitoringofadequatedatacollectionovertime.Atthepreviousreview,datacollectionproceduresassociatedwithSAPs,includingISPMonthlyReviews,werenotexaminedbecauseatthattimeitwasanticipatedthatthesemethodswerelikelytochangewiththeinclusionoftheMurdochskillprogramlibraryanddatacollectionsystem.Accordingtoverbalreportsanddocumentationprovidedatthattime,theMurdochlibrary(acommerciallyavailableskillteachingandmonitoringformat)wasbeingpilotedatthePacificandCoralSeaHomes.Unfortunately,accordingtoverbalreportsattheMonitoringTeam’smostrecentonsitevisit,theMurdochdata


# SummaryofProvision AssessmentofStatus Compliancecollectionsystemhadbeendiscontinued.Indeed,verbalreportsanddiscussionduringtherecentlyobservedSkillPlanReviewCommitteemeeting,on7/10/12,revealedapreviousconsensusanddecisionnottoimplementthisformofdatacollection,buttoutilizearevisedversioninitsplace.Inaddition,verbalreportsvoicedduringthemeetingindicatedsupportofthisdecisionbytheStateConsultantduringarecentreviewofskillprogramming.Thatis,thefeedbackindicatedthatthecurrentFacility’sformatwasacloseenoughapproximationtotheformatlikelytobesupportedbytheStateOffice.TheMonitoringTeambelievedthattheMurdochdatacollectionsystemofferedmanyadvantagesoverthepreviousandcurrentmonitoringapproachreviewedhere.Thecurrentfindingsarereportedbelow.ReviewofbothselectedSAPsaswellasISPmonthlyreviews(forthelastthreemonthsasrequested)evidencedconcerns.Itshouldbenotedthatthesamesampleofindividuals(includingthesameselectedSAPsandrelatedISPmonthlyprogressnotes)describedinSectionS.1wasutilizedhere.Overall,thecurrentreviewfoundnone(0%)oftheISPmonthlyreviewsforselectedSAPsadequate.ThefollowingquantifiestheresultsofthemostrecentMonitoringTeam’sreviewandclarifiesreasonswhythesewerefoundtobeinadequate:

Noneofthe12(0%)ofthosesampledutilizedgraphicdisplaysthatwereadequateand/orinterpretable;

Ofthosesampled,four(33%)hadcompletedataandhaddatathatwasclearlyaccurateforthemonthreviewed.AnexampleofproblemsnotedwasthatJunedatawasdisplayedinaMaymonthlynoteforIndividual#236;

Ofthosesampled,nine(75%)hadbehavioralobjectivesthatmatchedtheobjectiveontheSAP.TheremainingthreelistedbehavioralobjectivesthatdidnotmatchtheobjectiveontheSAP(Individual295,Individual#58andIndividual#236);

Ofthosesampled,nine(75%)weresignedanddated.ThosethatwerenotincludedIndividual#236,Individual#95,andIndividual#315.Forthese,theMonitoringTeamcouldnotdeterminewhetherornotthereviewswerecompletedinatimelyfashion.

Ofthosesampled,twowereclearlynotreviewedinatimelymanner.Thatis,someappearedtobeupdatedconcurrentwiththeMonitoringTeam’scurrentonsitereview(i.e.,Individual#275andIndividual#58).

Overall,theMonitoringTeamfoundthegraphicdisplaysdifficulttounderstandandinterpret.Inaddition,theMonitoringTeamfoundthedatacollectionsystem,attimes,redundantandnotinformative.Also,itwasunclearwhygraphicdisplayswerefoundinboththeSAPandISPmonthlyreviews.Thatis,thedisplaydidnotappeartoprovidenecessaryorhelpfulinformationrelativetotheimplementationoftheSAP.Inallcases,graphsdidnotincludemeaningfultitlesand/orlabels(ontheYaxis).Themetricused


# SummaryofProvision AssessmentofStatus ComplianceontheY‐axis aswellastheinformationfoundintablesattachedtographs wasoftenmeaningless.Thepointofusinggraphicdisplayistofacilitateefficientandeffectivemonitoringofdata.Itwasachallengetoefficientlyunderstandoreffectivelyinterpretanyofthesampledgraphsgivetheinsufficientinformationprovided.TheinterpretationandusefulnessofSAPdatawaslimitedinanumberofways.First,promptinglevelswerenotalwaysconsistentlyrecordedinreviewedSAPsorISPmonthlyreviews.Relatedly,thenatureofprompting(i.e.,ifitwasusedand,ifitwas,whatlevelofpromptingwasrequired)couldnotbedeterminedfromcurrentgraphicdisplays.Secondly,graphicdisplayspresenteddataacrossmonths(ontheXaxis).Thismonthlydatapointwasprimarilytheaverageoffour(orless)trialsor,asfoundinmanycases(i.e.,25%inthecurrentsample),wasbasedonasingletrial.Thisisclearlyinsufficienttomonitorandadjustskillacquisitionprogrammingovertime.Inaddition,thereweremultipledatacodes,inadditionto“+”correctand“‐“incorrect,thatdirectsupportprofessionalscouldutilizetodescribeperformance.Theseincluded“A”(absent)and“R”(refusal)inadditiontopromptlevel,insomecases.Reviewofdocumentationreflectedthefrequentuseoftheseadditionaldatacodes.However,thesewerenotreflectedinmonthlygraphicdisplays.Consequently,graphicdisplaysdidnotadequatelyreflectperformance.Thatis,threedatapointsofzeroscouldreflectthreeincorrecttrials,oneincorrecttrialandtworefusals,ortwoincorrecttrialsandonerefusal.Itbecamemorecomplicatedwiththeinclusionofmoredatacodes(oneormoreabsences,forexample),aswellasmorethanonetrialasthebasisofthemonthlydatapoint(i.e.,somemonthlydatapointswereaveragedacrossfourtrials).TheFacilitycontinuedtoneedanongoingdatacollectionandmonitoringsystemthataddressedtheaboveconcerns.TheFacilityshouldreviewalloftheMonitoringTeam’spreviousandcurrentfindingsandrecommendationsrelatedtodatacollection,datadisplay(i.e.,includingstandardsofgraphicdisplay)andongoingperformancemonitoring.ThefindingsandrecommendationsrelatedtoPBSPsarejustasrelevanttoSAPs.Lastly,emphasisshouldbeplacedonimplementingadatacollectionsystemthatwouldefficientlyidentifythetypeofchainingstrategyutilized,whichstep(s)ofthetaskanalysisiscurrentlytargeted,andwhatpromptingleveliscurrentlybeingutilized.Thiswouldallowstafftomoreefficientlyruntrialsaswellasdetermineifmasterycriteriahadbeenmet.Inaddition,thissystemshouldsupporttheimplementationofmorefrequentteachingtrialsandrelatedongoingdatacollection(i.e.,promptlevel,correct/incorrectresponding),aswellaseasilyaccommodatedatacollectiononsignificantlymoretrialsovertime.Seriousconsiderationshouldbegiventocollectingdataoneveryteachingtrialconducted.Giventheaboveconcernsregardingthedevelopment,training,andmonitoringofSAPs,theFacilityremainedinnoncompliancewiththisprovisionoftheSettlementAgreement.


# SummaryofProvision AssessmentofStatus Compliance

(b) Includetothedegreepracticabletrainingopportunitiesincommunitysettings.

Continuedprogresswasnotedinsupportingskillacquisitionprogrammingwithinthecommunity,includingtheprocurementofoff‐campusemployment.TheMonitoringTeam’spreviousreportsnotedprogressinthenumberofindividualswithformalopportunitiestoengageinskillacquisitionprogramswithinthecommunity.DocumentationfromtheMonitoringTeam’spreviousreviewsindicatedanincreasingprogressionofapproximately8%,30%,68%,and95%ofindividualsatCCSSLCwithSAPsdesignedforimplementationincommunitysettingsasofJuly2010,January2011,July2011andJanuary2012,respectively.BasedupontheMonitoringTeam’scurrentreviewofsampledSAPs,itappearedthatindividualshadapproximatelyfivetoeightSAPsacrossanarrayofindividualizedcontentareas.However,generalthemesofSAPsemergedasall(100%)individualssampledhadSAPstargetingmoneymanagementandmedicationskills(oridentifiedpre‐requisiteskillsformedication).Inaddition,occasionalSPOswereevidentaswell.Thesewerefoundtobeinplaceforfive(42%)ofindividualssampled.ItwasuncleartotheMonitoringTeamwhytheseSPOscontinuedtobeutilized.Thatis,verbalreportsduringtheMonitoringTeam’spreviousvisitsindicatedthattheSPOswouldbephasedoutandreplacedbySAPs.Inaddition,all(100%)oftheindividualssampledhadaSAPidentifiedforcompletioninacommunitysettingand10(83%)hadSAPsidentifiedforeithervocational/worksettingsand/orclassroomordayprogramsettings.ConcernswithregardtothequalityofthesegoalsarediscussedinfurtherdetailwithregardtoSectionS.1andF.2.a.1.Oneoftheconsistentlyreportedchallengestocommunityintegrationidentifiedduringpreviousvisitswasthelimitedavailabilityoftransportation.Inresponse,threenewvanswerepurchasedandavailable(inNovember2010)tosupportcommunityintegrationandsupportedemployment.AttheMonitoringTeam’slastreview,verbalreportsaswellasdocumentationindicatedthatsixnewvansweretobepurchasedinJuly2011.AtthetimeoftheMonitoringTeam’spreviousandcurrentonsitereview,thesevanshavenotyetbeenpurchased.Duetothecontinuedinadequacyandconcernsrelatedtothequalityoftheplansdevelopedtosupportcommunitytrainingopportunities,theFacilityremainedoutofcompliancewiththisprovisionoftheSettlementAgreement.

Noncompliance


1. TheStateOfficeshouldassisttheFacilityinidentifyingorprovidingstaffwithexpertiseinskillacquisitionaswellaswritingandmonitoringskillacquisitionprogramming.ThislikelywillrequireinvolvementofBehavioralServicesand/orSpecialEducationstaffthathavecompetencyintheseareas.Usingsuchresources,robustcompetency‐basedtrainingandre‐trainingshouldbeprovidedtothestaffcurrentlydeveloping,


monitoringandtrainingtheimplementationofSAPs.Thisshouldincludedevelopingmultipleexemplars(e.g.,SAPs,datacollectionmethods,monthlymonitoring/reviewnotes)thatcouldbeusedbystafftoaddressneedstypicaltoindividualsinresidentialsettings.StaffshouldthenusetheseexemplarsasafoundationtoindividualizesubsequentSAPs.Ongoingon‐sitecriticalreview,training,andsupportbyexpertstaffshouldoccuronaweeklyormonthlybasis.(SectionS.1andS.2)

2. TheFacilityshouldensurethatassessmentslistedaspartoftherationaleprovideclearevidenceofthelinkbetweentheidentifiedneedandtheskilltargetedwithintheskillplan.Ensuringspecificcitationofitemsand/orsectionsofassessmentswithinrationalesmightimprovetheaccuracywithwhichtheserationalesareidentified.(SectionS.1)

3. TheFacilityshouldensurethatSAPsarebasedonidentifiedneedsasfoundinassessments.Thatis,needsshouldnotbeidentifiedthroughtaskanalyses.(SectionS.1)

4. AprocessshouldbedevelopedandimplementedtodescribehowpreferencesthatareidentifiedwithinthePFAorCFAareincorporatedintoskillprograms.(SectionS.1)

5. TheFacilityshouldexpanditsuseofthe“testtrial”fordeveloped(orselected)taskanalysisthroughdirectobservation(i.e.,observetheindividualtryingthenewskillwhensupportedbystaff)andindividualize,asappropriate.Thisshouldbecompletedpriortoimplementing(training)theskillprogram.Theplanningandvalidatingofeachtaskanalysisshouldoccurpriortotrainingandstaffshouldexpectthatadjustmentslikelywillbenecessary.(SectionS.1)

6. Aspreviouslyrecommended,theidentificationofspecificpromptlevelsshouldbeeliminatedwithinbehavioralobjectives,becausethisappearstonecessitatemorefrequentrevisionsoftheprogramor,ifincludingreferencetoapromptlevelisdesired,an“independentlevel”ofrespondingcouldbestated(followingtheinitialinstruction)whenwritingmostbehavioralobjectives.Inaddition,criteriaformastery(movingupastepinthetaskanalysis)shouldnotbeincludedinthebehavioralobjective,butratherintheinstructionssection.Considerationshouldbegiventostandardizingthemasterycriteria,whenappropriate(SectionS.1)

7. SkillPlansshouldutilizeamoregeneralizeddiscriminativestimulusthatdoesnotincludespecificstepsofthetaskanalysis.Thisinstructionshouldcuecompletionoftheentiretaskanalysisandshouldreducetheamountofnecessaryrevisionastheindividualmakesprogress.(SectionS.1)

8. Redundancyofinformationacrosssectionsintheskillacquisitionplansshouldbeavoided.Instructions,discriminativestimuli,errorcorrection,reinforcementprocedures,anddatacollectionprocedures,forexample,arenotnecessaryunderthemethodologysection,iftheyaresufficientlydescribedinothersections.(SectionS.1)

9. Effortsshouldbemadetoensurethateachtaskanalysisisadequate,thatis,notsubjectiveoroverlycomprehensiveorcomplex(i.e.,nottryingtodotoomuch),ordoesnothavesufficientdetailtoensureidentificationofacorrectresponse(s).Theyshouldbecomplete,detailed,andaccurate.(SectionS.1)

10. Moretrainingshouldbeprovidedonbehaviorchains,includingtaskanalysis,discriminativestimuli,differentialreinforcement,andthecollectionofdataappropriatetothetypeofchainingprocedureprescribed.Thatis,total(whole)taskpresentationprovidestrainingtotheindividualoneachstepofthetaskanalysisduringeverysession.(SectionS.1)

11. Programmingforgeneralizationshouldincludemorespecificationregardingtheproceduresusedtopromotegeneralization.Itisnotsufficienttomerelysuggestthattheskillsarelikelytogeneralizetoanyindependentlivingsituationorsetting.(SectionS.1)

12. Programmingformaintenanceshouldincludemorespecification,includingwhenmaintenanceprobeswouldbeconductedoncetheentireskillislearned,andbedistinctofgeneralizationstrategies.(SectionS.1)

13. Wheneverappropriate,a“least‐to‐most”fadingsequence(prompthierarchy)shouldbeusedinsteadofa“most‐to‐least.”If“most‐to‐least”isused,arationaleshouldbeprovided.(SectionS.1)

14. Planauthorsshouldensurethepromptsequencesinskillplansareappropriate,especiallywhenprimarilytargetingverbalresponses.(SectionS.1)

15. Whenappropriate,morefrequentteachingopportunitiesshouldbeprescribedforskillacquisitionprograms.Frequencyofimplementationshouldbedailyormultipletimesperweek.Exceptionsmightincludeskillsthatindividualsperformincommunity‐basedsettings,whichmight


bedifficulttoaccessonadailyschedule.(SectionS.1)16. Theerrorcorrectionproceduresshouldbestandardizedacrossallskillacquisitionplans,whenappropriate.Thisshouldnotincludedata

collectionprocedures,butratherdescriptionsofhowstaffrespondtoerrors(i.e.,avoidprovisionofreinforcers).Additionalstaffinstructions(e.g.,explanations,secondchances,specificpromptingsequences)shouldbeavoidedandnotincludedinthissection.(SectionS.1)

17. ConsiderationshouldbegiventostandardizingwhenstaffmembersevaluateperformanceonaSAP.Thatis,theauthorsofSAPsshouldconsiderdeterminingperformance(correctorincorrectresponding)onthefirsttrial.SomeSAPsprovideasecondchance(togetthetrialcorrect),whichleadstoinconsistencyandperhapslessefficientlearning.(SectionS.1)

18. Staffinstructionsshouldincludespecificationonthemethodofprompting(most‐to‐leastorleast‐to‐most),determinationoftheinitialpromptlevel,descriptionofhow/whenstaffprovideapromptedtrial,andproceduresforreinforcementfollowingapromptedcorrectresponse.Staffinstructionsshouldavoidtheuseofsupplementalverbalresponsesfromstaff,becausethisislikelycounterproductiveandinconsistentwiththepromptinghierarchy(SectionS.1)

19. Differentialreinforcementshouldbeusedwhenimplementingskillacquisitionplans.Highlypreferredreinforcersshouldimmediatelyconsequentcorrectrespondingfollowinganinstructionordiscriminativestimulus.Reinforcers(perhapslesspreferredreinforcers)shouldalsoimmediatelyconsequentcorrectrespondingfollowingapromptedtrial.Reinforcersshouldnotfollowincorrectresponding.Thesedifferencesinprovisionofreinforcementshouldbeobviousandeasyforstafftoimplement.(SectionS.1)

20. Reinforcementproceduresshouldbepartofeveryskillacquisitionplanandreinforcersshouldbeindividualized,whenappropriate.(SectionS.1)

21. Preferenceassessmentsshouldberegularlycompletedwithallindividuals,andtheresultsshouldbeconspicuouslynotedinskillacquisitionplans,PBSPs,etc.(SectionS.1)

22. TheFacilityshouldexaminetheusefulnessofthecurrentdatasheetusedforSAPsandconsideradoptingadataformthatallowsthecollectionofdataduringeachlearningtrial.Thiscouldincludetheidentifiedstepofthetaskanalysisandpromptlevel.Thistypeofsystemwouldberesponsivetoindividualswhoproceedquicklythroughataskanalysis.(SectionS.1)

23. TheIDTsofindividualscurrentlynotattendingadayorvocationalprogramawayfromtheirresidentialunitshouldcontinuetomeettoidentifythebarrierstotheirparticipationandproblem‐solvetoassist,asappropriate,individualsinovercomingsuchobstacles.IDTsshouldreviewsuchreasonsandjustificationsregularlyanddocumenttheseintheISP,aswellasprogressmadeinassistingindividualstoovercomesuchobstacles.(SectionS.1)

24. Asappropriate,behavioralsupportsshouldbedevelopedforindividualstosupporttheirparticipationinmeaningfuldayandvocationalprograms.(SectionS.1)

25. Althoughsomedataiscollectedtotrackprogramattendance(e.g.,vocational,work,class,etc.),ifnotalreadyavailable,datashouldbedisplayedtomonitorongoingperformanceofindividualsorprogramsovertime.Thiswouldfacilitatetheidentificationofindividualimprovementordecline,andallowcloserexaminationoftheeffectivenessofcurrentsupports.(SectionS.1)

26. Generallyacceptedgraphingconventionsstillshouldbeusedwhendisplayingdataacrossallassessmentandmonthlyreview(specificrecommendationsregardinggraphingareofferedwithregardtoSectionK).(SectionS.1)

27. Collaborativeeffortsacrossdisciplines(e.g.,psychologyandactivetreatmentservices)shouldcontinuetoensurethateachdiscipline’sstrengthsareutilizedtoimprovecurrentsupportsandservices.Specialconsiderationshouldbegiventopromotingtheeffectivecollaborationbetweenpsychologyandactivetreatmentasteamsworktodevelopskillacquisitionprograms.(SectionS.1)

28. TheFacilityshouldensurethatallassessmentsareadequatelycompleted,includingsummaryandrecommendationsectionsofthePFAandFSA,priortotheISPmeeting.(SectionS.2)

29. Whenmonitoringvocationaldata,theFacilityshouldclearlyindicatewhetherornotsituationalassessmentswerecompletedinon‐oroff‐campussettingsforeachindividuallisted.(SectionS.2)

30. Situationalassessmentson‐campusshouldcontinue,butwiththeunderstandingthatthesestillpotentiallylimitthevocationalvisionsofsomeindividuals.Community‐basedvocationalassessmentsshouldbepursuedaswell,becausethesemightofferedmorediversevocational


opportunities.(SectionS.2)31. TheSkillAcquisitionReviewCommitteeshouldpursueconsistentandongoingcollaborationwiththeStateLevelConsultantsandthe

PsychologyDepartmentfortechnicalsupportwhendeveloping,implementing,andmonitoringskillacquisitionprograms.(SectionS.3.a).32. Furthertrainingofactivetreatmentstaffoncompletingskillplanintegritychecksshouldbecompleted.Thisincludestrainingoncompleting

IOAprobes.(SectionS.3.a)33. Datashouldcontinuetobecollectedandsummarizedtoallowmonthlyexaminationofintegritychecksofskillplansacrossprograms.(Section

S.3.a)34. TheFacilityshouldexamine,develop,andmonitorsystemsnecessarytoprovideeffectivecompetency‐basedtrainingfordirectsupport

professionalsontheimplementationofskillacquisitionplans.(SectionS.3.a)35. Necessaryequipment(e.g.,vans)shouldbepurchasedtosupporttheintegrationofindividualsintothecommunity.(SectionS.3.b)36. Communityoutingdatashouldincludemonthlysummariesandgraphicdisplaythatallowmonitoringovertime.Thismightincludetheaverage

numberofoutingsperweek(ormonth)foreachindividualandresidence.Individualswhodonotgooutshouldbeincludedwhensummarizingthedata.Thequalityofthecommunityoutingalsoshouldberatedintermsofmeetingindividuals’preferencesandofferingopportunitiesforcommunityintegration.(SectionS.3.b)

ThefollowingisofferedasanadditionalsuggestiontotheStateandFacility:

1. Asrecommendedpreviously,aspreadsheetshouldbecreatedthattrackscommunity‐basedsupportedemploymentandthatwouldallowongoingassessmentoftrendsovertime.Thisshouldidentifyeachindividual,thesetting(s)inwhichtheywork,thenumberofhoursworkedperweek(averageandrange)persite,andthedatesofemploymentpersite.Newpositionseachmonth(orquarter)shouldbehighlighted.(SectionS.1)


SECTIONT:ServingInstitutionalizedPersonsintheMostIntegratedSettingAppropriatetoTheirNeeds StepsTakentoAssessCompliance:Thefollowingactivitiesoccurredtoassesscompliance:

ReviewofFollowingDocuments:o InresponsetorequestfordescriptionofhowtheFacilityassessesindividualsfor

communitytransition,acopyoftheLivingOptionsDiscussionRecordtemplate,undated;o CommunityPlacementReportforperiodbetween11/16/11and5/31/12,dated6/5/12;o Listofindividualsassessedforplacementbetween6/1/11and5/31/12,dated6/5/12;o Listofindividualscurrentlyreferredforcommunityplacement,dated6/1/12;o ListofindividualswhohavehadaCommunityLivingDischargePlan(CLDP)developed

sincethelastreview,undated;o Listofindividualswhohaverequestedcommunityplacement,buthavenotbeenreferred,

dated6/1/12;o ListofthoseindividualswhowouldbereferredbytheIDTexceptfortheobjectionofthe

LAR,whetherornottheindividualhimselforherselfhasexpressed,oriscapableofexpressing,apreferenceforreferral,undated;

o Listofindividualsthatprefercommunitytransition,butnotreferredduetoLARpreference,dated6/4/12;

o AnnualReport:“ObstaclestoTransitionStatewideSummary,FiscalYear2011,dataasof8/31/11;

o Listofindividualstransitionedtocommunitysettings,from12/1/11through5/31/12;o Listoftraining/educationalopportunitiesprovidedtoindividuals,families,andLARsto

enablethemtomakeinformedchoicesrelatedtocommunitytransitionforpast12months,includingtosign‐insheets;

o Listofalltrainingandeducationalopportunitiesthataddresscommunityliving,includingbutnotlimitedtoproviderfairs,communitylivingoptionin‐services,and/oronsitevisitstocommunityhomesandresourcesprovidedtoFacilitystaff,undated;

o FacilityandLocalAuthoritystafftrainingcurricularelatedtocommunityliving,transitionanddischarge,includinganytrainingmaterials;

o CorpusStateSupportedLivingCenterTourActivity,dated6/13/12;o Listofstaffattendingcommunitytours,from8/5/11through5/18/12;o LivingOptionsDiscussionforthePSP,undated;o LivingOptionsAddendumtemplate,undated;o InclusionoftheDesignatedLocalAuthorityduringLivingOptionsDiscussions;o CommunityLivingDischargePlans(CLDPs),includingindividuals’mostrecentISPand

relatedassessmentsforIndividual#30,Individual#338,Individual#151,Individual#114,Individual#41,Individual#277,andIndividual#364;

o BlanktemplateforEssential/NonessentialSupports,andSupportSpreadsheet;o InresponsetorequestforStateOfficereviewofCLDPs,thestatement:“NoEvidence;”o PostMoveMonitoringSchedule,dated6/1/12;


o Listofalternatedischarges,dated6/1/12;o ListofindividualstransferredtootherSSLCs,dated6/1/12;o Listofallegedoffenders,dated6/1/12;o DischargePacketforIndividual#264forwhomanalternatedischargewascompleted;o ObstaclestoMovingtoaCommunitySetting:ObstacleCollectionForm,dated8/2/11;o ObstaclestoCommunitySettingReportingPeriodmonthlyreports,forthemonthsof

December2011throughMay2012;o ObstaclestoCommunitySettingReportingperiod12/1/11through2/29/11;o ObstaclestoCommunitySettingReportingperiod3/1/12through5/31/12;o Forthelastone‐yearperiod,alistofindividualswhohavetransitionedtothecommunity

indicatingwhetherornotsincetheirtransition,1)hadpolicecontact,andifsothereasonwhy,thedate,andanindicationofwhetherornottheywerearrestedorotherwisedetained;2)hadapsychiatrichospitalization,includingthedateonwhichtheywerehospitalizedandthelengthofstay;3)hadanERvisitorunexpectedmedicalhospitalization,includingthereason;4)hadanunauthorizeddeparture,includingthedateandlengthofdeparture;5)beentransferredtodifferentsettingfromwhichhe/sheoriginallytransitioned,includingbothaddressesandreasonfortransfer;6)died,includingthedateofdeathandcause;and/or7)returnedtotheFacility,includingthedateofindividual’stransitiontothecommunity,dateofreturn,andreason,undated;

o IndividualSupportPlans,Sign‐inSheets,andAssessmentsforthefollowing:Individual#290,Individual#363,Individual#184,Individual#268,Individual#282,Individual#336,Individual#26,Individual#250,Individual#228,andIndividual#63;

o Pre‐MoveandPost‐MoveMonitoringdocumentationforthefollowing:Individual#151,Individual#30,Individual#114,Individual#277,Individual#364,Individual#41,andIndividual#338;

o Inter‐RaterReliabilityforT–SubSectionI:PlanningforMovement,Transition,andDischarge,for3/12through5/12;

o Last10monitoringtoolscompletedby:a)AdmissionsPlacementCoordinator;andb)QualityAssuranceDepartmentstaff,variousdates;

o SettlementAgreementComplianceReportforSectionT–SubSectionI:PlanningforMovement,Transition,andDischargefor3/12through5/12;

o CCSSLCSelf‐Assessment,updated6/25/12;o CCSSLCActionPlans,updated6/25/12;o CCSSLCProvisionActionInformation,undated;ando PresentationBookforSectionT.

Interviewswith:o DoraFlores,formerAdmissionsDirector,andcurrentTransitionSpecialist;o EsmereldaVogt,AdmissionsDirector;o SandraVera,Post‐MoveMonitor(PMM);o NeldaGonzalez,ProgramComplianceMonitor;ando RachelMartinez,QDDPCoordinator.


Observationsof:o ISPmeetingforIndividual#341;ando Post‐MoveMonitoringvisitforIndividual#30.

FacilitySelf‐Assessment:BasedonareviewoftheFacility’sSelf‐AssessmentwithregardtoSectionToftheSettlementAgreement,theFacilityfoundthatitwasincompliancewiththefollowingsubsections:T.1.c,whichisanoverarchingprovisionencompassinganumberofdifferentprovisions;T.1.c.3,whichrequiresteamstoreviewCLDPswithindividualsandtheirLARs;T.1.d,whichrequirestheFacilitytoprovideindividualstransitioningtothecommunitywith“currentcomprehensiveassessmentofneedsadsupportswithin45dayspriortotheindividual’sleaving;T.1.e,whichrequiresthedevelopmentofaCLDPthatincludesadequateessentialandnonessentialsupports,andthattheessentialsupportsareconfirmedtobeinplacepriortotheindividual’stransition;T.1.g,whichrequiresthecollectionandanalysisofdataregardingobstaclestoplacement,aswellaseffortsonDADSparttoovercomesuchobstacles;T.1.h,whichrequirestheFacilitytoprovideaCommunityPlacementReport;andT.2.a,relatedtopost‐movemonitoring.NotallofthesefindingswereconsistentwiththeMonitoringTeam’sfindings.Specifically,theMonitoringTeamdidnotfindtheFacilityincompliancewithT.1.c,T.1.d,T.1.e,T.1.g,orT.2.aforthereasonsdiscussedinthesectionsofthereportthatfollow.TheMonitoringTeamdidfindtheFacilityincompliancewithT.1.c.2(withwhichtheFacilitydidnotfinditselftobeincompliance),T.1.c.3,andT.1.h.InitsSelf‐Assessment,theFacilityhadidentified:1)activitiesengagedintoconducttheself‐assessment;2)theresultsoftheself‐assessment;and3)aself‐ratingusingtheinformationcitedinthesectiononresults.AlthoughanumberofconcernscontinuedtoexistwiththeFacility’sselfassessmentprocess,overtime,thisformatshouldbehelpfulinsubstantiatingtheFacility’sfindingswithregardtocompliance.Sincethelastreview,anumberofnewindicatorshadbeenaddedtotheSelf‐Assessment.ManyoftheseappearedtohavemeritinassistingtheFacilitytoidentifywhereitwasdoingwell,andwhereitneededtofocusitsimprovementefforts.However,anumberofconcernswerenoted,including,forexample:

TheFacility’sSelf‐Assessmentdidnotdefinehowthesampleswereselected,orgiveasenseofwhethertheywererepresentativesamples.

ItwasoftenunclearwhatcriteriatheFacilityhadusedinitsassessments,and,attimesappearedthatthepresenceofanitemversusitsqualitywasassessed.Forexample,thequalityofassessmentsusedindevelopingCLDPsisessentialtocompliancewithSectionT.1.d,butinfindingitselfincompliance,theFacilitydidnotappeartotakequalityintoconsideration,justtimeliness.

Inaddition,notallrequirementsoftheSettlementAgreementhadbeenreviewed.Forexample,nowhereintheSelf‐AssessmentdiditappearthattheFacilityhadassessedthequalityoftheessentialandnon‐essentialsupportsintheCLDPs.

Attimes,theSelf‐Assessmentincludedpotentialkeyindicatorsoroutcomemeasures.Forexample,forSectionT.1.b,whichaddresseseducationaboutcommunityoptions,theFacilityhadincludednumbersofindividualsthatparticipatedincommunitytours,numbersofindividualsandfamiliesparticipatingintheProviderFair,etc.Thiswasvaluableinformation.However,inorderforittobemeaningful,itneededtobeputintothecontextofameasurableoutcomeindicator.Thiswouldneedtobeaccomplishedbyidentifyingbaselines,andthensettingagoalforwhatwouldbeconsideredanacceptableordesirablelevelofparticipation.


Attime,itemsthatwerebeingmeasureddidnotequatetocompliance.Forexample,forSectionT.1.b.3,theStateOfficerequirementforassessmentforappropriatenessforplacementrequiredanumberofstepsasdetailedintheMonitoringTeam’sreport.However,theSelf‐Assessmentdidnotaddressthesesteps,butratherbroadlyreferencedtheLivingOptionsdiscussion.

Forthevariousmonitoring/audittools,inter‐raterreliabilityneededtobeestablishedwiththeQAandprogrammaticstaff(e.g.,QDDPCoordinator)responsibleforconductingaudits.

Asdiscussedduringthelastreview,theneedstillexistedtoaddorrevisetheguidelines/instructionsfortheaudittools.Thiswillbeessentialtoimprovetheaccuracyofthemonitoringresults(validity),aswellasthecongruencebetweenvariousauditors(reliability).


Initslastreport,theMonitoringTeamrecommendedthattheFacilitySelf‐Assessmentpresentthefindingsastherateofcomplianceversusnoncompliance.Thischangehadbeenmade,anditfacilitatedthereader’sunderstandingofthefindings.Overall,theFacilityhaddemonstratedincreasinguseofthedataithadcollected.Effortstoensurethevalidityandreliabilityofthedatawillbeimportantnextsteps,aswillusingthedatatoidentifyareasinwhichfocusedattentionisneeded.ParticularlygiventhenumberofdiscrepanciesbetweentheFacility’sfindingsandtheMonitoringTeam’sfindings,theFacilityshouldcarefullyreviewthedifferencestodeterminefactorsthatmightbeleadingtofindingsofsubstantialcompliancewhentheFacilityisnotyetincompliance.TheFacility’sprogressindevelopingaqualityassuranceprocessforSectionTisdiscussedinfurtherdetailbelowwithregardtoSectionT.1.f.SummaryofMonitor’sAssessment:Individuals’ISPscontinuedtonotconsistentlyidentifyalloftheprotections,services,andsupportsthatneedtobeprovidedtoensuresafetyandtheprovisionofadequatehabilitation.Itisessential,asteamsplanforindividualstomovetocommunitysettings,thatISPsprovideacomprehensivedescriptionofindividuals’preferencesandstrengths,aswellastheirneedsforprotections,supports,andservices,andthat,asappropriate,thesebetransitionedtothecommunitythroughthecommunitylivingdischargeplans.Asnotedinpreviousreports,oneissuethatappearedtodelayindividuals’referraltothecommunityattimeswasaLocalAuthorityrepresentativenotbeingatameetingatwhichtheteamdecidedareferralshouldbemade.Newruleshadbeenputinplacetoresolvethisissue.TherulessetforththeparametersforensuringLArepresentativeswereinvitedtomeetings,notificationsoftheAdmissions/PlacementCoordinatorofreferralsmadeduringmeetings,informingtheLAofreferralsmadeintheirabsence,andholdinganadditionalmeetingshouldtheLAhaveanyquestionsorconcernsaboutthereferral.Itwaspositivethatwiththesenewrules,anLArepresentative’sinabilitytoattendameetingwouldnotdelayapotentialreferral.


AnincreasingnumberofassessmentspreparedforannualISPmeetingshadbegunto includetheassessor’srecommendationregardingtransitiontothecommunity.However,individuals’ISPsgenerallystilldidnotincludeasummaryorconclusionoftheprofessionalteammembers’determinationwithregardtowhetherornotcommunityplacementwasappropriate.Suchrecommendationsshouldbepresentedtotheentireteam,includingtheindividualandLAR,forconsideration.Basedonteamdiscussion,includinganyoppositionfromtheindividualorhis/herLAR,theentireteamthenshouldmakeadecisionregardinganypotentialreferralforcommunitytransition.TheFacilitysubmittedmonthlyandquarterlyaggregatetotalsoftheobstaclecategoriesStateOfficehadidentified.Basedoninterview,Facilitystaffindicatedthateducationofindividualsandtheirguardianshadbeenidentifiedasanareaofneed.However,theystatedthatformalanalysisofallofthedatawasstillinprocess.TheFacilitywouldsoonbesubmittingitssecondannualreporttotheState,whichshouldincludeananalysisofdatacollectedthusfar.AlthoughtheFacilityhadmadesomeprogress,CommunityLivingDischargePlanscontinuedtoinadequatelydefinethenecessaryprotections,support,andservicestoensuretheindividual’shealthandsafety.ManyoftheissuesidentifiedintheMonitoringTeam’spreviousreportsregardingdeficiencieswiththeCLDPshadnotyetbeenrectified.Asaresult,individualstransitioningtothecommunitywerepotentiallyatriskduetothelackofadequatelyplannedandimplementedprotections,services,andsupports.Post‐movemonitoringhadbeencompletedinatimelymannerforalloftheindividualswhohadtransitionedtothecommunity.ThePostMoveMonitor’scommentsgenerallyprovidedathoroughdescriptionofthemethodsusedtoevaluatetheitemandthefindings(e.g.,interviews,documentreviewsandobservations).Thiswasfurtherconfirmedthroughanobservationofapost‐movemonitoringreview.Duringthecourseofthereview,thePost‐MoveMonitoridentifiedsomeseriousissues.ThePost‐MoveMonitorhandledtheseissuesprofessionallywithcommunityproviderstaff,andtookappropriatestepstoensurethesafetyoftheindividual.Thepost‐movemonitoringactivitiesidentifiedsomeissueswithregardtotheprovisionofservicesatthecommunitysites.Inaddition,oneoftheindividualswhohadtransitionedtothecommunityhadexperiencedseriousevents,suchaspolicecontact.However,IDTsatCCSSLCdidnotdocumentthoroughfollow‐uporattemptstoensurethattheindividualshadtheprotections,services,andsupportstheyneeded.

# Provision AssessmentofStatus ComplianceT1 PlanningforMovement,

Transition,andDischargeT1a Subjecttothelimitationsofcourt‐

orderedconfinementsforAsreportedinpreviousreports,on3/31/10,DADSissuedarevisedpolicyentitled“MostIntegratedSettingPractices.”ThisStatepolicyaccuratelyreflectedtheprovisions

Noncompliance


# Provision AssessmentofStatus Complianceindividualsdeterminedincompetenttostandtrialinacriminalcourtproceedingorunfittoproceedinajuvenilecourtproceeding,theStateshalltakeactiontoencourageandassistindividualstomovetothemostintegratedsettingsconsistentwiththedeterminationsofprofessionalsthatcommunityplacementisappropriate,thatthetransferisnotopposedbytheindividualortheindividual’sLAR,thatthetransferisconsistentwiththeindividual’sISP,andtheplacementcanbereasonablyaccommodated,takingintoaccountthestatutoryauthorityoftheState,theresourcesavailabletotheState,andtheneedsofotherswithdevelopmentaldisabilities.

containedinSectionToftheSettlementAgreement.Thepolicy’sstatedpurposewasto“prescribeproceduresforencouragingandassistingindividualstomovetothemostintegratedsettinginaccordancewiththeAmericanswithDisabilitiesActandtheUntiedStatesSupremeCourt’sdecisioninOlmsteadv.L.C.;identificationofneededsupportsandservicestoensuresuccessfultransitioninthenewlivingenvironment;identificationofobstaclesformovementtoamoreintegratedsetting;and,post‐movemonitoring.”Thepolicyincludedcomponentstoensurethatanymoveofanindividualtothemostintegratedsettingwasconsistentwiththedeterminationsofprofessionalsthatcommunityplacementwasappropriate,thatthetransferwasnotopposedbytheindividualortheindividual’sLAR,andthatthetransferwasconsistentwiththeindividual’sISP.Duringfuturereviews,theMonitoringTeamwillcontinuetoevaluatetheStateandtheFacility’simplementationofthispolicy.WithregardtotheavailabilityforfundingcommunitytransitionofindividualsfromCCSSLC,fundingavailabilitywasnotcitedasabarriertoindividualsmovingtothecommunity.Nooneappearedtobeonawaitinglist,andtransitionswereoccurringatareasonablepace.Infact,theState’sexpectationwasthatonceareferralwasmade,thetransitiontothecommunityshouldoccurwithin180days.Permissionneededtobesoughtforanytransitionsthatwereanticipatedtotakelongerthanthe180‐daytimeframe.Atthetimeofthereview,atCCSSLC,11individualshadbeenreferredforcommunitytransition.Sixofthese11individualshadexceededthe180‐daytimeframe.Generally,theseindividualshadsignificantbehavioralconcernsand/ormedicalconcernsthatrequiredcarefulplanning,andidentificationofacommunityproviderwhocouldoffersupportstoensuretheindividuals’healthandsafety,aswellastheirgrowthanddevelopment.Foroneindividualthathadbeenonthelistforalittleoverayear(i.e.,Individual#213),hehadexperiencedmedicalissuesrequiringhospitalizationandongoingrevisionstohismedicalplanofcare.Althoughhisreferralhadnotbeenrescinded,histeamwantedhimtobemoremedicallystablebeforeatransitionoccurred.Foranotherindividualthathadbeenonthelistforapproximatelyayear(i.e.,Individual#26),althoughattimesitwasunclearwhetherornotshewantedtotransitiontothecommunity,herteamcontinuedtomeetandattempttoidentifyoptionsthatwouldsupportherbehavioralandmentalhealthneeds.AsisdiscussedinfurtherdetailwithregardtoSectionT.1.g,althoughobstaclestoindividuals’transitiontocommunitysettingshadnotbeenfullyidentifiedandanalyzedonasystemiclevel,anecdotally,theavailabilityofcommunityproviderswhocouldsupportindividualswithcomplexbehavioraland/ormedicalneedsappearedtobeanissue.TheMonitoringTeamagreeswholeheartedlywiththeteams’decisionsnottotransitionindividualsuntilanappropriateconfigurationofsupportsandserviceswas


# Provision AssessmentofStatus Complianceidentified.However,thislikelyisanareainwhichmoresystemicattentionisneededfromDADSStateOffice.Asnotedinpreviousreports,oneissuethatappearedtodelayindividuals’referraltothecommunityattimeswasaLocalAuthorityrepresentativenotbeingatameetingatwhichtheteamdecidedareferralshouldbemade.BasedondocumentationtheFacilityprovided(i.e.,theCommunityPlacementReport),twoindividualshadnotbeenreferredtothecommunityduetotheLAnotbeingpresentattheirannualmeeting.Ofthese,oneindividualhadsincebeenreferredtothecommunity.ItwasunclearwhetherornotameetinghadbeenheldfortheremainingindividualwhoseoriginalmeetingwasheldinMay2012.However,asdiscussedwithregardtoSectionF,newruleshadbeenputinplacetoresolvethisissue.Therulesweresummarizedinadocumententitled:“InclusionoftheDesignatedLocalAuthorityduringLivingOptionsDiscussions.”Morespecifically,theruleshadbeenmodifiedtoallowareferraltobemadewithouttheLApresent.TherulesalsosetforththeparametersforensuringLArepresentativeswereinvitedtomeetings,notificationsoftheAdmissions/PlacementCoordinatorofreferralsmadeduringmeetings,informingtheLAofreferralsmadeintheirabsence,andholdinganadditionalmeetingshouldtheLAhaveanyquestionsorconcernsaboutthereferral.Itwaspositivethatwiththesenewrules,anLArepresentative’sinabilitytoattendameetingwouldnotdelayapotentialreferral.Atthetimeofthereview,assessmentspreparedforannualISPmeetingsincreasinglyincludedtheassessor’srecommendationregardingtransitiontothecommunity.Ofthe10ISPsreviewed,alloftheassessmentsforoneindividual(10%)(i.e.,Individual#228)includedtheapplicablestatement/recommendation.Forfourofindividualsmostoftheassessmentsincludedsuchastatement(i.e.,Individual#63,Individual#250,Individual#336,andIndividual#290).However,individuals’ISPsstilloftendidnotincludeasummaryorconclusionoftheprofessionalteammembers’determinationwithregardtowhetherornotcommunityplacementwasappropriate.Ofthe10ISPsreviewed,oneindividual(i.e.,Individual#26)hadbeenreferredfortransitiontothecommunityafewmonthspreviously,andtheteamagreedtocontinuethereferral.Fortheremainingnineindividuals,twoindividuals’ISPs(22%)includedanindependentrecommendationfromtheprofessionalsontheteamtotheindividualandLAR(i.e.,Individual#184,andIndividual#282).Suchrecommendationsshouldbepresentedtotheentireteam,includingtheindividualandLAR,forconsideration.Basedonteamdiscussion,includinganyoppositionfromtheindividualorhis/herLAR,theentireteamthenshouldmakeadecisionregardinganypotentialreferralforcommunitytransition.Thisisdiscussedinfurtherdetailwith


# Provision AssessmentofStatus ComplianceregardtoSectionT.1.b.3.InreviewingCLDPsandISPsofthoseindividualsthatwerereferred,noneofthemhadopposedtransitiontothecommunity.TheFacilityremainedoutofcompliancewiththisoverarchingprovisionofSectionToftheSettlementAgreement.

T1b CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshallreview,revise,ordevelop,andimplementpolicies,procedures,andpracticesrelatedtotransitionanddischargeprocesses.Suchpolicies,procedures,andpracticesshallrequirethat:

SincetheMonitoringTeam’spreviousreview,theFacilityhadmaintaineditssetofpoliciesrelatedtoSectionToftheSettlementAgreement.However,itwasanticipatedthattheStateOfficewasgoingtoissueanupdatedpolicyrelatedtoMostIntegratedSettingthatlikelywouldrequiremodificationstobemadetoFacilitypolicies.Asnotedinpreviousreports,thethreeMonitoringTeamshadanumberofconcernsrelatedtotheDADSdraftpolicy,andon5/16/11,hadsubmittedcommentsfortheState’sconsideration.ItwasanticipatedthattheStatewouldaddresstheMonitoringTeams’concernsintherevisedversionofthepolicy.Atparties’meetingsinJuly2012,thepartiesagreedthattheMonitorswouldrateT.1.basjustthedevelopmentofanadequatepolicy.ThesectionsT.1.b.1throughT.1.b.3wouldbeconsideredstand‐aloneprovisionsthatrequireimplementationindependentofT.1.boranyoftheothercellsunderT.1.b.DuetothefactthattheStateandFacilityhadnotyetfinalizedanadequatepolicyrelatedtotransitionanddischargeprocesses,theFacilityremainedoutofcompliancewiththisprovision.

Noncompliance

1. TheIDTwillidentifyineachindividual’sISPtheprotections,services,andsupportsthatneedtobeprovidedtoensuresafetyandtheprovisionofadequatehabilitationinthemostintegratedappropriatesettingbasedontheindividual’sneeds.TheIDTwillidentifythemajorobstaclestotheindividual’smovementtothemostintegratedsettingconsistentwiththeindividual’sneeds

AsnotedabovewithregardtoSectionFoftheSettlementAgreement,CCSSLChadcontinuedtomakeeffortstoimproveISPs.TheISPformatwasintheprocessofchanging,buttheISPsreviewedforthisreviewincludedasectionfordiscussionabouttheindividual’slivingoptions.Thissectionincludeddiscussionregardingtheindividual’sandhis/herLAR’sawarenessofcommunityoptions,theirpreferencesforaspecificlivingoption,andteammembers’recommendationsrelatedtotheindividual’stransitiontothecommunity.Asectionoftheplanalsocapturedtheteam’sLivingOptionRecommendation,andanyreasons/obstaclesfornotreferringanindividualtothecommunity.ThedraftDADSPolicy004.1–IndividualSupportPlanProcessstated:“ThepurposeofthispolicyistoestablishprocedurestodevelopanintegratedIndividualSupportPlan(ISP)thatisbothbeneficialandeffectiveforindividualsregardlessofthesettinginwhichservicesareprovided”(emphasisadded).TheothersectionsoftherevisedISPMeetingGuideweredesignedtoelicitfromtheteamacomprehensivesetofprotections,services,andsupports.

Noncompliance


# Provision AssessmentofStatus Complianceandpreferencesatleastannually,andshallidentify,andimplement,strategiesintendedtoovercomesuchobstacles.

Areviewwasconductedofasampleof10ISPs.Thefindingsrelatedtothisreviewarediscussedbelowwithregardtothetworequirementsincludedinthisprovision,including:1)theidentificationintheISPoftheprotections,services,andsupportsthatneedtobeprovidedtoensuresafetyandtheprovisionofadequatehabilitationinthemostintegratedappropriatesettingbasedontheindividual’sneeds;and2)identificationofthemajorobstaclestotheindividual’smovementtothemostintegratedsetting,andidentificationandimplementationofstrategiestoovercomesuchobstacles.IdentificationinISPsofNeededProtections,Services,andSupportsAswasdiscussedwithregardtoSectionFoftheSettlementAgreement,individuals’ISPsdidnotidentifyalloftheprotections,services,andsupportsthatneededtobeprovidedtoensuresafetyandtheprovisionofadequatehabilitation.Someoftheseissuesrelatedtothoroughandadequateassessmentsnotbeingcompleted,servicesandsupportsnotbeingadequatelyintegratedwithoneanother,and/oradequateplansnotbeingdevelopedtoaddressindividuals’preferences,strengthsandneeds.Ashasbeenreiteratedsincethebaselinereview,itisessential,asteamsplanforindividualstomovetocommunitysettings,thatISPsprovideacomprehensivedescriptionofindividuals’preferencesandstrengths,aswellastheirneedsforprotections,supports,andservices.Thisisimportantforthreereasons,including:1)asindividualsandtheirguardiansareconsideringdifferentoptionsinthecommunity,itisimportantforthem,aswellaspotentialproviders,tohaveaclearideaaboutwhatprotections,supports,andservicestheindividualneedstoensurethatperspectiveprovideragenciesareabletosupporttheindividualappropriately;2)giventheextensivehistoriesofmanyindividualsservedbyCCSSLC,itisimportanttohaveonedocumentthatsummarizesthemostrelevanthistoricalandcurrentinformationaboutanindividualtoensurethatnoneoftheimportantcomponentsoftreatmentarelostinthetransitionprocess;and3)astheprocessprogresses,theISPwillbethekeydocumentthatisusedtoensurethatessentialsupportsareidentifiedandinplacepriortoanindividual’smove,andnon‐essentialsupportsareprovidedinatimelyandcompletemanner.Whenallofthenecessaryprotections,supports,andservicesarenotoutlinedintheISP,itismuchmoredifficulttoensuretheindividual’ssafetransition.Basedonareviewof10ISPs,noneoftheplansreviewed(0%)includedacomprehensivelistoftheprotections,supports,andservicesneededtosupporttheindividual.Ashasbeenstatedinpreviousreports,oftenthisappearedtobeduetostaff’sassumptionsthatsupportswerebeingprovidedattheSSLC,andthattheydidnotneedtobespelledoutindetail.Inotherinstances,thecontinuingdeficitsinassessmentsfromvariousdisciplinesappearedtostymietheteams’abilitytocreateacomprehensivelist.Inotherinstances,thelackofintegrationacrossdisciplinesandlackofincorporationofthevariousplans(e.g.PBSPs,PNMTs,healthcareplans,psychiatrictreatmentplans,communicationplans,


# Provision AssessmentofStatus Complianceetc.)continuedtoresultinincompleteISPs.PreviousreportshaveprovideddetailedexamplesofconcernsrelatedtoISPs.TheFacilityisencouragedtoreviewtheMonitoringTeam’spreviousreportsinrelationtoSectionsFandToftheSettlementAgreement,aswellastocriticallyanalyzerecenttransitionstothecommunity,andidentifysupportsthatweremissingfromISPsandCLDPs.IdentificationofandPlanstoOvercomeObstaclestoTransitiontoCommunityAsnotedabove,theISPformatincludedasectiononobstaclestheIDTidentified.ThenewformatincorporatedtheStateOffice’sstandardizedlistofobstacles/barrierstocommunitytransitiontoassistintheanalysisofinformationcollectedfromIDTsthroughouttheSSLCsystem.Thesewereobstaclesteamswouldpotentiallyidentifyduringtheconsiderationforreferralprocess.Reportedly,amoredetailedlistofobstacleswouldbemaintainedshouldissuesariseasteamsmadeeffortstotransitionindividualstothecommunity.Inreviewingthesampleof10ISPs,teamsgenerallyhadidentifiedsomeobstacles.Ofthe10ISPsreviewed,nineshouldhavehadobstaclesdefined.Theremainingindividualhadbeenreferredfortransitiontothecommunity(i.e.,Individual#26).Ofthenineremainingplans,none(0%)includedanadequatelistofobstacles.Theproblemsassociatedwiththeremaininglistsofobstaclesincludedthefollowing:

Whenguardiansorindividualsobjected,adequateinquirydidnotoccurwithregardtospecificallywhattheirconcernswere(e.g.,Individual#63,althoughthenarrativeincludedsomeinformation,noneoftheboxeswerecheckedtoidentifytheguardian’sspecificconcerns;Individual#184;Individual#282;Individual#336;andIndividual#268,althoughthenarrativeindicatedtheguardianwasconcernedabouttheindividual’sbehavioralneedsbeingmet);

Attimes,theteamdidnotidentifyanyobstacles,buttheindividualwasnotreferredfortransition(e.g.,Individual#290,althoughthenarrativeindicated“preferencesforahomesitehavenotbeendetermined;”andIndividual#363);and

Somewerenotadequatelyjustified(e.g.,Individual#228forwhomtheteamidentifiedthatlackofunderstandingoflivingoptions.However,herPSIindicatedinresponsetothequestionaboutwhereshewouldwanttolive:“Sheisnonverbalandtherefore,unabletogiveusthisinformation.”Inaddition,herreactionsontwocommunityhometoursweredescribedas“alert,lookingaroundwithinterest,andsmiling.”Moreover,theteamindicatedshecouldnotmakedecisionsonherown,makingtheteamthebodythatwouldmakereferraldecisions,absentaguardian.Similarly,forIndividual#250,althoughthestandardlistofobstacleswasnotincludedintheISP,thenarrativeindicatedtheobstaclewasthattheindividual’spreferencehadnotbeendetermined.However,duetothedifficultytheindividualhadincommunicatingher


# Provision AssessmentofStatus Compliancepreferences,itappearedthatthemother’sconcernsaboutplacementweremoreatissue,eventhoughshewasnottheguardian).

Moreover,actionplanstoovercometheobstaclesidentifiedgenerallywerenotadequate.OfthenineISPs,six(67%)includedanactionplantoovercomeobstaclesidentified(i.e.,Individual#363,Individual#184,Individual#336,Individual#228,Individual#63,andIndividual#250).Oftheseseven,none(0%)wereadequate.Theplanswerenotadequatelyindividualizedormeasurable(e.g.,manyindicatedthattheindividualwouldparticipateincommunitytours,butthenumberortours,thetypesofprogramsthatwouldbevisited,orthespecifictimeframesinwhichthiswouldoccurwerenotstated),andanumberonlyaddressedtheindividual,whentheobstaclerelatedtoaguardian’sorfamilymember’sreluctance.Ashasbeennotedpreviously,whenaguardianisreluctant,totheextentpossible,therelatedactionplansshouldaddressthespecificissuesaboutwhichtheguardianisconcerned.Forexample,iftheguardianwereconcernedaboutthebehavioralsupportsavailableinthecommunity,thenmoreeducationorresearchabouttheindividual’soptionsforbeingproperlysupportedwouldbeappropriatetopicsforanactionplan.Sometimes,theactionplanswillinvolvestaffactionasopposedtoguardianaction.Basedoninterviews,Facilitystaffrecognizedthatthiswasanareathatcontinuedtoneedimprovement.TheMonitoringTeamhasprovidednumerousexamplesinpreviousreportsregardingtheconcernsrelatedtotheidentificationofobstacles,andthelackofplanstoovercomethem.TheFacilityisencouragedtoreviewthepreviousreports.Althoughsomelimitedprogresshadbeenmadeinteams’awarenessoftheneedtoidentifyobstacles,CCSSLCremainedatthebeginningstagesofadequatelyidentifyingobstaclestocommunitytransition,anddevelopingplanstoovercomesuchobstacles.Thisdeficiency,inadditiontoISPsthatdidnotadequatelyidentifyindividuals’needsforprotections,supports,andservices,resultedinafindingofnoncompliancewiththisprovisionoftheSettlementAgreement.

2. TheFacilityshallensuretheprovisionofadequateeducationaboutavailablecommunityplacementstoindividualsandtheirfamiliesorguardianstoenablethemtomakeinformedchoices.

Asdescribedinpreviousreports,CCSSLChadengagedinanumberofactivitiestoprovideeducationaboutcommunityplacementstoindividualsandtheirfamiliesorguardianstoenablethemtomakeinformeddecisions.Basedondocumentationprovided,thishadtakenanumberofforms,including:

Annualproviderfair:OnNovember9,2011,theAdmissionsandPlacementDepartmenthostedaHome‐andCommunity‐BasedServices(HCS)providerfair.Theprovidersrepresentedofferedservicesinavarietyofcounties.Aquestionnairehadbeenusedtoassistindividualsandthestaffaccompanyingthemtoaskrelevantquestionsofcommunityproviders.Datahadbeencollectedregardingattendanceofindividuals,familiesandstaff.Satisfactionsurveysalso

Noncompliance


# Provision AssessmentofStatus Compliancehadbeendistributedto:a)providersthatparticipated;andb)individuals,families,andstaffthatattended.TheFacilityprovidedasummaryoftheinformation.Reportedly,someofthisinformationwasbeingusedtomakechangesforfuturefairs.Planswereunderwayforthenextproviderfair.OneofthenewTransitionSpecialistswashadbeguntocontactprovidersandwasworkingwiththeSelf‐Advocacygrouptodesignfliers.

CommunityLivingOptionsInformationProcess(CLOIP):IndividualsandtheirguardiansalsowereprovidedinformationthroughtheLocalAuthorityCLOIPprocess.Basedontrackingsheetsprovided,itappearedthatthisoccurredregularlyaspartoftheindividualplanningprocess.However,itdidnotappearthatoutcomes/measureshadbeendeterminedand/ordatacollectedregardingthenumberofindividuals,andfamilies/LARswhoagreetotakeneworadditionalactionsregardingexploringcommunityoptions,orthenumberofindividualsandfamilies/LARswhorefusetoparticipateintheCLOIPprocess.CollectionandreviewofsuchdatawouldallowtheStatetoevaluatetheeffectsoftheprocessandmakechangesmadetofutureCLOIPactivities.

Toursofcommunityproviders:SinceJanuary2011throughthepresent,visitstocommunitygrouphomesanddayprogramscontinuedtooccureveryFridaywithassistancefromtheActiveTreatmentDepartmentandNuecesCountyLocalAuthority.Thesewereopentoindividuals,families/guardians,orstaffwhowantedtoattend.Suchvisitsofferedindividualsandtheirfamiliestheopportunitytoobtainfirst‐handknowledgeofwhatcommunitysupportsareavailable,tomeetproviderstaff,andpotentiallyotherpeoplewithwhomtheycouldhavetheopportunitytoliveorwork.Facilitystaffreportedthattheyattemptedtogiveeveryoneachancetoparticipateinthesevisits.SomeIDTshadmadespecificreferralsforindividualstoattend.However,itwasunclearifdatahadbeenanalyzedtoensurethat:a)allindividualshavetheopportunitytogoonatour(exceptthoseindividualsand/ortheirLARswhostatethattheydonotwanttoparticipateintours);b)placeschosentovisitarebasedonindividual’sspecificpreferences,needs,etc.;and3)theindividual’sresponsetothetourisassessed.Asnotedinpreviousreports,apositiveenhancementtothisprocessincludedthedevelopmentofalistofquestionsthatindividualsmightwanttoaskcommunityproviders.Thelistofferedsomebasicquestionsaddressingleisureactivities,supportsprovided,numbersofpeoplelivinginthehome,andtheprovider’sexperience.Itwasagoodstart,andcouldbeexpandeduponbasedonexperiencewithitsuse.

Aplanforstafftolearnmoreaboutcommunityoptions:AlthoughCCSSLC


# Provision AssessmentofStatus Compliancehadnot providedaformalplantoaddresseducationoncommunitylivingoptionstomanagementstaff,clinicalstaff,anddirectsupportprofessionals,theyhadcontinuedtotakeanumberofstepstoprovideeducationalopportunities.However,thisshouldbeformalizedinaplan.Asnotedinthepreviousreport,theyhadpartneredwiththeLocalAuthoritytoprovidetrainingtoeachteamoncampus.Thishadcontinued,andonJuly12,2012,theLocalAuthority’sAnnualHCSEducationalPresentationwasoffered.Inaddition,theFacilitywastrackingthestaff,includingtheirtitlesthatparticipatedinthecommunitytours,aswellastheproviderfair.Basedonreviewofthelist,thestaffthatattendedcommunitytourswerelargelydirectsupportprofessionals,QDDPs,andactivetreatmentstaff.

ThefollowingwereareasthattheFacilityhadnotyetaddressedfully:o Providingopportunitiesforindividualstovisitfriendswholivein

community;o Ifaggregatedata,whichwasnotyetbeinganalyzed,showedthat

familiesandguardianshadsimilarconcerns,thenusingmechanismstoprovideinformationonspecifictopicscouldbeused.Forexample,includingarticlesinnewslettersorofferingspecificeducationalseminarsmightbeuseful.TheFacilityhadnotyetengagedinthesetypesofactivities.

o Providingeducationat:Self‐advocacymeetings,asofferedandinvited;housemeetingsfortheindividuals;andfamilyassociationmeetings.

ThemostchallengingareawithregardtoeducationofindividualsandLARs/familiesisindividualizingthisprocess,anddocumentingthatindividualsandtheirguardiansaremakinginformeddecisions.Inreviewing10recentlycompletedISPs,oneindividualhadbeenreferredforplacement(i.e.,Individual#26).Fortheremainingnine,seven(78%)hadaplanthataddressededucationaboutcommunityoptions.However,noneofthese(0%)wereadequate.Thefollowingconcernswerenoted:

Noneoftheplanswereindividualizedtoaddresstheindividualand/ortheLAR’sparticularneedsorconcerns.Theplansforthefollowingindividualswerenotindividualized:Individual#290,Individual#363,Individual#184,Individual#336,Individual#228,Individual#63,andIndividual#250.Forexample,someindividualshadspecificneedsthatacommunityproviderwouldhavetoaddressandtheyortheirfamiliesexpressedconcernsabouttheabilityofcommunityproviderstoaddresstheseneeds(e.g.,behavioralormedicalsupports).However,theactionplansdevelopeddidnot,forexample,targetspecifictypesofprovidersforcommunitytours,identifyresearchthattheteamwoulddotoanswertheindividualsortheirguardians’questions,includevisitstopeerswithsimilarneedsthathadmovedtothecommunity,etc.

Noneoftheplansweremeasurable,orprovidedfortheteam’sfollow‐upto


# Provision AssessmentofStatus Compliancedeterminetheindividual’sreactiontotheactivitiesoffered.Manyoftheplansinvolvedparticipationincommunitytours,butdidnotsayhowmanyorwhenthesewouldoccur.Nomethodologieswereincludedtoensurethattheindividualand/orguardian’squestionswereanswered(e.g.,helpingthemwritealistofquestionsspecifictothem,orastaffpersonassistingwithaskingquestions).Theactionplansgenerallyprovidedfortheteamtoprovide“ongoing”monitoring,butnospecificstrategieswereincludedtoobtaintheindividual’sreactionatthetimeorshortlyafteraneducationalopportunity.Often,whentheindividual’sLARorfamilywasreluctant,nospecificstrategieswereincludedintheactionplantoaddressthefamilyorguardian’sconcernsorquestions.Rather,theactionplansweretargetedtowardstheindividual(e.g.,Individual#363,Individual#63,andIndividual#250).AstheMonitoringTeamdiscussedwithstaffduringtheonsitereview,itisessentialthatthesebeindividualizedusingtheinformationthattheteamisabletogatheraboutthereasonsforthefamilymemberorLAR’sreluctance.Forexample,ifhe/shehasquestionsaboutthespecificsupportsavailableinthecommunity,identifyingproviderswithexpertiseinprovidingsuchsupportsandintroducingtheLARorfamilymembertosuchproviderswouldbeimportant.Forsome,talkingtoanotherguardianorfamilythathasexperiencedatransitiontothecommunitymightbehelpful.Atthetimeofthereview,thishadnotyetoccurred.CreativeideasandbrainstormingwithinCCSSLCandwithotherSSLCswillbenecessarytoidentifythebestwaystoprovideeffectiveeducationalopportunities.

Noneoftheplansindicatedwhetherornottherewasaplanthepreviousyearand/orifitwascompleted.

Thefollowingindividualshadnoplan:Individual#268,Individual#282.AlthoughtheFacilitywascontinuingtocompletesomeofthebasicactivitiesrelatedtoeducationandsomeprogresshadbeenmadeinexpandingtheseopportunities,minimalprogresshadbeenmadesincethelastreviewinindividualizingtheprocess.AlthoughmoreindividualshadaplanintheirISP,theplanswerenotindividualizedormeasurable.Theindividualizationofthisprocessiskeytoensuringthatindividualsandtheirguardiansareprovidededucationthatallowsthemtomakeaninformedchoice,asrequiredbytheSettlementAgreement.

3. WithineighteenmonthsoftheEffectiveDate,eachFacilityshallassessatleastfiftypercent(50%)ofindividualsforplacementpursuanttoitsneworrevisedpolicies,procedures,

AsisdiscussedabovewithregardtoSectionT.1.aoftheSettlementAgreement,theindividuals’ISPsrevieweddidnotconsistentlydocumentanindependentassessmentordeterminationbytheprofessionalsontheteamoftheindividuals’appropriatenessfortransitiontothemostintegratedsettingappropriatetomeettheirneeds.TheFacilityhadbeguntoimplementtheStateOffice’splantohaveeachprofessionalmemberoftheIDTdocumenthis/herrecommendationregardingtheindividual’sability

Noncompliance


# Provision AssessmentofStatus Complianceandpracticesrelatedtotransitionanddischargeprocesses.WithintwoyearsoftheEffectiveDate,eachFacilityshallassessallremainingindividualsforplacementpursuanttosuchpolicies,procedures,andpractices.

totransitiontothecommunityintheassessmentscompletedpriortoannualISPmeetings.Theseassessmentsalsoweretoidentifysupportsthattheindividualwouldneedinacommunitysetting.Inaddition,attheISPmeeting,theprofessionalmembersoftheteamneededtomakearecommendationtotheindividual/guardian.Basedonthereviewof10ISPs:

Someassessmentsincludedtherequiredstatements/recommendation,andothersdidnot.However,thiswasanareainwhichimprovementwasseen.Ofthe10ISPsreviewed,alloftheassessmentsforoneindividual(10%)(i.e.,Individual#228)includedtheapplicablestatement/recommendation.Forfourofindividualsmostoftheassessmentsincludedsuchastatement(i.e.,Individual#63,Individual#250,Individual#336,andIndividual#290).

Ofthe10ISPsreviewed,oneindividual(i.e.,Individual#26)hadbeenreferredfortransitiontothecommunityafewmonthspreviously,andtheteamagreedtocontinuethereferral.Fortheremainingnineindividuals,twoindividuals’ISPs(22%)includedanindependentrecommendationfromtheprofessionalsontheteamtotheindividualandLAR(i.e.,Individual#184,andIndividual#282).Thefollowingproblemswerenotedfortheotherindividuals:

o Fortwoindividuals(22%),theassessmentsand/orISPnarrativeincludedstatementsshowingdisagreementamongsttheteamregardingtheindividual’sappropriatenessforcommunitytransition(i.e.,Individual#290,andIndividual#63).Forbothoftheseindividuals,theteamrecommendationwasthattheindividualremainattheFacility.However,itwasnotclearhowtheteamdisagreementaboutthishadbeenresolved.

o Foroneindividual(11%)(i.e.,Individual#228),allteammembershadincludedstatementsintheirassessmentsindicatingtheindividualcouldbesupportedinalessrestrictivesetting.IntheISPnarrative,theteamindicated:"Allthedisciplineswhoworkwith[Individual#228]agreedintheirassessmentsthatcommunityplacementwouldbeappropriateifthepropersupportswereinplacetomeetherspecialneeds.Sheisingoodhealthandadaptswelltonewsituations."Individual#228didnothaveaguardianoractivefamilyinvolvement.InotherportionsoftheISP,theteamconcludedthatsherequiredaguardianforallaspectsofdecision‐making.However,theteam"determinedthat[theIndividual]wouldnotbenefitfrommovingtoalessrestrictiveenvironmentatthistime."Thereasongivenwasthat:"Sheneedsadditionaleducationaboutcommunitylivingoptions."Theteamdidnotprovideadequatejustificationforitsconclusion.Inadditiontothefactthattheteamindicatedtheindividualcouldnotmakeherowndecisions,shealsohadbeenontwocommunitytoursthepreviousyear,andappearedtobe"alert,lookingaroundwithinterest,andsmiling."Moreover,herPSI


# Provision AssessmentofStatus Complianceindicatedinresponsetothequestionaboutwhereshewouldwanttolive:"Sheisnonverbalandtherefore,unabletogiveusthisinformation."Itwasuncleariftheteamdidnothaveenoughinformationaboutcommunityoptions(giventhatinlieuofaguardian,theteamwasresponsibleforthisdecision),oriftheteambelievedtherewasanotherobstacletotransitionthattheydidnotidentify.

o Forfourindividuals(44%),basedontheassessmentsandsometimesthenarrativesintheISPs,theteammembersstatedthattheindividualcouldbesupportedinalessrestrictivesetting.However,aspecificrecommendationtotheindividualand/orLARwasnotmade(i.e.,Individual#363,Individual#268,Individual#336,andIndividual#250).

TheFacilityremainedoutofcompliancewiththisprovision.Althoughprogresswasnotedwithregardtotheinclusionofrecommendationsinindividuals’assessmentsrelatedtotheirappropriatenessfortransitiontothecommunity,thiswasnotconsistentlyseeninallassessments.Inaddition,frequently,professionalmembersoftheteamwerenotmakingand/ordocumentingintheISPaconsensusrecommendationtotheindividualand/orhis/herguardian.

T1c WhentheIDTidentifiesamoreintegratedcommunitysettingtomeetanindividual’sneedsandtheindividualisacceptedfor,andtheindividualorLARagreestoservicein,thatsetting,thentheIDT,incoordinationwiththeMentalRetardationAuthority(“MRA”),shalldevelopandimplementacommunitylivingdischargeplaninatimelymanner.Suchaplanshall:

Sincethelastreview,someprogresshadbeenmadewithregardtoCCSSLCteams’developmentofCLDPs.Teamshadexpandedthescopeoftheessentialandnon‐essentialsupportsincludedintheplans.However,unfortunately,noneoftheCLDPswereyetadequatetoensureindividualshadappropriateprotections,supports,andservicestomeettheirneedsoncetheytransitionedtothecommunity.TheCLDPscontinuedtoneedimprovement.CommunityLivingDischargePlanswerereviewedforsixofthesevenindividualswhohadtransitionedfromtheFacilitytothecommunitysincetheMonitoringTeam’slastonsitereview,representing86%ofthisgroupofindividuals.TheseincludedtheCLDPsplansforIndividual#277,Individual#114,Individual#364,Individual#151,Individual#338andIndividual#30.WithregardtothetimelinessoftheCommunityLivingDischargePlans,fiveofthesix(83%)includeddocumentationtoshowthattheyweredevelopedsufficientlypriortotheindividual’stransition.Theplanthatdidnotincludesuchdocumentation(Individual#151)appearedtohavebeendevelopedonlytwoweekspriortotheindividual’stransition.However,thedocumentationinthebodyoftheCLDPindicatedthatsomeplanning,includingvisitstoprovidershadoccurredoverfourmonthspriortotheCLDPmeetingdate.Itwasunclear,though,whathadhappenedintheinterveningmonths.TheFacilityhadaddedinformationtothefacesheetoftheCLDPtoidentifywhenthe

Noncompliance


# Provision AssessmentofStatus Complianceplanfirstwasinitiated,andeachdateonwhichitwasrevised.Datesdocumentedonthetopofthefirstpageforthisindividualdidnotshowmuchpriorplanning.Fortheremainingplans,theinitiationdatesweregenerallyclosetothereferraldate,andmanyrevisiondateswerenoted.Thiswasapositivedevelopment.TheFacilitycontinuedtomakeprogressinthisarea,butremainedoutofcompliance.

1. SpecifytheactionsthatneedtobetakenbytheFacility,includingrequestingassistanceasnecessarytoimplementthecommunitylivingdischargeplanandcoordinatingthecommunitylivingdischargeplanwithproviderstaff.

TheCommunityLivingDischargePlansreviewedincludedanumberofactionstepsrelatedtothetransitionoftheindividualstothecommunity.However,noneofthesixplansreviewed(0%)clearlyidentifiedacomprehensivesetofspecificstepsthatFacilitystaffwouldtaketoensureasmoothandsafetransition,andwhensuchstepswereidentified,theyoftenwerenotsufficientlydetailedormeasurable.Verysimilarlytothelastreview,someexamplesofthegeneralconcernsnotedacrossallplansincluded:

Manyoftheplansidentifiedtheneedfortrainingforcommunityproviderstaff.However,noneofthemadequatelydefinedwhichcommunityproviderstaffneededtocompletethetraining(e.g.,directsupportprofessionals,managementstaff,clinicians,dayandvocationalstaff,etc.),and/orwhatlevelofmasteryoftheinformationwasrequired(e.g.,demonstrationofcompetence).Insomecases(e.g.,Individual#364,andIndividual#277),thestaffrequiringtrainingweredefinedingeneraltermssuchasresidentialanddaystaff.Thiswasinsufficienttoensurethattheindividualreceivedthesupportsherequired.

Plansalsodidnotspecifythemethodoftraining,forexample,ifitwouldbenecessaryforcommunityproviderstafftoshadowCCSSLCstaff,and/orshowcompetencyinactuallyimplementingaplan,suchasaBSP.Forsomeindividuals,specificcomponentsoftheirISPsshouldbetargetedformoreintensivetrainingofcommunityproviderstaff,or,ataminimum,evidencethatthecommunityproviderstaffhavethecompetenciesnecessarytosafelysupporttheindividual.

MissingfrommostoftheplanswasanyrequirementthatcollaborationoccurbetweentheFacilityclinicianscurrentlyworkingwiththeindividualandthecommunityclinicianswhowouldassumeresponsibilityforsupportingtheindividual(e.g.,medicalstaff,nurses,therapists,psychologists,etc.).Formanyindividuals,thiswouldbenecessarytoensureongoingcoordinationofcare.Inacoupleoftheplansreviewed,actionstepswereincludedfortheCCSSLCnursetomeetwiththecommunityprovidernurse.Thiswaspositive,however,notnecessarilywelldefined.However,forotherclinicians,suchasthepsychologist/behavioranalyst,psychiatrist,physician,habilitationtherapists,etc.,nosuchactionstepswereincluded.

Similarly,nocoordinationwasspecifiedasneedingtooccurbetweencurrentandfutureresidentialorday/vocationalstaff.

Noncompliance


# Provision AssessmentofStatus Compliance NoneoftheplansdescribedCCSSLC’sstaff’sinvolvementinevaluatingpotential

sitesatwhichindividualswouldbeserved(e.g.,HabilitationTherapiesstafftoensureadequateaccessibilityand/orequipment,PsychologyDepartmentstafftodetermineifsafetyissuescouldbeaddressedinspecificsettings,and/orifmodificationsneededtobemadetoexistingplanstoaddresschangesinenvironment).

NoneoftheplansaddressedanyrolethatCCSSLCstafforcommunityproviderstaffmightplayinassistingtheindividualtomakethetransition.Forexample,thereappearedtobenoconsiderationabouttheneedforCCSSLCstafftofollowtheindividualintothecommunityforanyperiodoftime(e.g.,thefirstdayorlonger),ortocheckinbytelephoneonoccasion.Likewise,noactionstepswereprovidedinanyoftheCLDPsforcommunityproviderstafftovisittheindividualatCCSSLC.Differentindividualshavedifferentreactionstotransitions.However,teamsshouldbecognizantofthestressthattransitioncancause,andshouldbuildmechanismsintoCLDPstoreducethistotheextentpossible.

ThemonitoringactivitieswereidentifiedintheCLDPs,includingtheroleoftheIDDLocalAuthority,aswellastheroleofFacilitystaffinthepost‐movemonitoringandfollow‐upprocess.However,noactionstepsweredesignedtoensurethatthePost‐MoveMonitorworkedtogetherwiththeLocalAuthorityServiceCoordinatortopassonimportantinformationorensuremonitoringcontinuedtooccurofessentialandnon‐essentialsupports.

AsisdescribedinfurtherdetailinthesectionofthisreportthataddressesSectionT.1.eoftheSettlementAgreement,theCLDPsalsodidnotconsistentlyidentifytheessentialsupportsrequiredbytheindividuals.TheFacilityremainedoutofcompliancewiththisprovision.

2. SpecifytheFacilitystaffresponsiblefortheseactions,andthetimeframesinwhichsuchactionsaretobecompleted.

Basedonthesamplereviewed,teamsgenerallyidentifiedtargetdatesforthecompletionofactionsstepsincludedinCLDPs.Teamsalsohadcontinuedtoconsistentlyidentifythespecificperson(s)responsiblebynameand/orpositionforactionstepsincludedinCLDPsforwhichFacilitystafforotherswereresponsible.Suchdetailswerefoundinallsixoftheplansreviewed(100%).TheFacilitywasfoundtobeinsubstantialcompliancewiththisprovision.Asnotedinthelastreport,inordertoremainincompliance,theFacilityiscautionedtoensurethatasthesupportsincludedinCLDPsexpandthatadequatetimeframesandpersonsresponsibleareassigned.Forexample,implementationofplans,suchasPNMPs,healthcareplans,andPBSPs,willrequireastartdate,andthenafrequencytobestatedforanumberofdifferentaspectsofplanimplementation(e.g.,dailyimplementationanddocumentation,monthlyreviewbyaclinician,atleastannualrevieworasneededmodificationstotheplan,etc.).Thiswillrequirealotmoredetailregardingboth



# Provision AssessmentofStatus Compliancetimeframesandpersonsresponsible.

3. Bereviewedwiththeindividualand,asappropriate,theLAR,tofacilitatetheirdecision‐makingregardingthesupportsandservicestobeprovidedatthenewsetting.

BasedonreviewofsixCLDPs,allsix(100%)includeddocumentationthattheplanshadbeenreviewedwiththeindividualand/ortheLAR.


T1d EachFacilityshallensurethateachindividualleavingtheFacilitytoliveinacommunitysettingshallhaveacurrentcomprehensiveassessmentofneedsandsupportswithin45dayspriortotheindividual’sleaving.

AstheMonitoringTeamhasnotedinpreviousreports,issuesexistedwithregardtoboththeavailabilityofassessments,aswellastheirquality.Invariousothersectionsofthisreport,theMonitoringTeamincludedtransitionassessmentsintheirsampleofassessmentsreviewed.Consistently,theMonitoringTeamfoundthemtobeinadequatetoprovidetheIDTswithadequateinformationwithwhichtodevelopanappropriateCLDPortooffercommunityproviderstheinformationnecessarytoensureasafeandsuccessfultransitionfortheindividual.CommentarywithregardtotheadequacyofassessmentsforthesepurposescanbefoundwithregardtoSectionsL.1,andM.2oftheSettlementAgreement.ThefollowinginformationisrepeatedherefromSectionMandexemplifiestheissuesrelatedtoinadequateassessmentprocessesforindividualstransitioningtothecommunity.Regardingthenursingdocumentationfordischarges/individualstransitioningtothecommunity,areviewoftheNursingDischargeSummariesforsixindividualsincluding:Individual#41,Individual#364,Individual#277,Individual#151,Individual#30,andIndividual#114foundthefollowing:

None(0%)oftheNursingDischargeSummariesadequatelyaddressedthehealth/mentalissuesoftheindividuals.

Therewasadequateinformationcontainedinnone(0%)oftheNursingDischargeSummariesthatwouldguidethecommunitystaffinprovidingtheneedednursingcaretotheindividual.

Acurrentnursingassessmentwasconductedfornone(0%)oftheindividualspriortodischarge/transferringtheindividualtothecommunity.

Therewasadequatedocumentationidentifyingspecificnursinginterventionsneededforallhealth/mentalissuesinnone(0%)ofthecasesreviewed.

Withregardtotrackingtheavailability,timeliness,andqualityofassessments:

FornoneofthesixCLDPsreviewed(0%)wereallassessmentsprovidedinatimelymanner.Timelinesswasanareawheresomeimprovementswereseen.MoreassessmentswereupdatedandsubmittedtoallowforreviewbyboththeIDTdevelopingtheCLDPandthecommunityproviderstaff.However,forallsixindividuals,oneormoreassessmentwassubmittedafterthefinalcommunity

Noncompliance


# Provision AssessmentofStatus Compliancelivingdischargeplanwasdeveloped.Someweredatedthedayoftheindividual’stransitiontothecommunity.Itwasunclearwhat,ifanythinghappenedtoupdatetheCLDPwiththeassessmentinformation,ormakeneededchangestoessentialornonessentialsupports.TheFacilityhadbeguntotrackthetimelinessofassessments,andprovidedtheMonitoringTeamwithaprintoutofthegridshowingthedateseachassessmentwassubmittedforeachoftheindividualsthathadtransitioned.However,thedatawasveryconfusing.Itincludedasummarydate,whichappearedtobethedatedeachassessmentsummarywascompleted;a“Calculated45day”date,whichwasdifferentformostassessments,andappearedtobethedatethatresultedwhen45dayswasaddedtotheassessmentdate;andthetransitiondate.Thepurposeoftheassessmentsbeingupdatedpriortotheindividualleavingistoensurethattheindividual’sCLDPaccuratelyreflectstheindividual’scurrentstrengths,needs,andpreferences.Therefore,thedateshouldbecalculatedsoitisnomorethan45priortowhentheindividualtransitionstothecommunity,butalsoisavailablefortheteam’sreviewatthe“final”CLDPmeeting.

Inaddition,thequalityoftheseassessmentswaslacking.NoneofthesixCLDPsreviewed(0%)werebasedonadequateassessments.Inparticular:

o Mostoftheassessmentformatswerenotdesignedtoprovideasummaryofrelevantfactsrelatedtoindividuals’staysattheFacility.Althoughitisunderstandablethatanindividual’sfullhistorycannotbeincludedinadischargesummary,itisimportantthattheFacilityprovidecommunityproviderswithasummaryof,forexample,treatmentsorplansthathaveparticularlysuccessfulorunsuccessful,andimportantmilestonesduringtheindividual’sstayattheFacility.Suchasummaryshouldcontainananalysisofinformation,notmerelyalistingofdates,times,occurrences/labresults,etc.

o Inaddition,assessmentsfrequentlywereinadequatetoassistteamsindevelopingacomprehensivelistofprotections,supports,andservicesinacommunitysetting.Theydidnotdescribeorrecommendtheprotections,treatments,andsupportsthatneededtobeprovided(e.g.,implementationofplans,staffingsupports,trainingforstaff,specificstaffqualifications,etc.),and/orthespecificclinicalsupportsrequired(i.e.,qualificationsofclinicalstaff,thefrequencyandleveloftheirinvolvement,etc.).

o Moreover,assessmentsdidnotidentifysupportsthatmightneedtobeprovideddifferentlyormodifiedinacommunitysetting,and/ormakespecificrecommendationsabouthowtoaccountforthesedifferences.Forexample,nursingassessmentsforindividualswhohadnursing


# Provision AssessmentofStatus Compliancecare/healthmanagementplansattheFacilityshouldincluderecommendationsabouttheircontinuationand/oranymodificationsthatneedtobemadetoaccommodatecommunitysettingsthatmightnothavenursesavailableatalltimes.Similarly,psychology/behavioralassessmentsshouldidentifydifferences(e.g.,environmental,staffing,trainingofstaffonprotectiveholds,etc.)thatcouldimpacttheimplementationofthePBSPinplaceattheFacility,and/ormakerecommendationsaboutneededmodifications.

o Inadditiontospecificissuesrelatedtotransition,asisdiscussedinothersectionsofthisreport,theunderlyingassessmentswerenotofadequatequality.

o Finally,ashasbeenrecommendedinpreviousreports,aprocessshouldbeconsidered,particularlywithregardtothetransitionofmedicalandotherclinicalinformation,forasummarytobedeveloped,includingbutnotlimitedtotheindividual’scurrentstatus,anyoutstandingissues(e.g.,testsdue,issuesforwhichresolutionhasnotbeenreached),aswellasanycriticalinformationabouttheindividual’streatment(e.g.,allergies,pasthistoryofmedicationuse,etc.).Thiswouldresultinadocumentthatcouldbeprovidedtocommunitymedicalcareprovidersthatwouldfacilitatethetransitionofthisinformation.

Inadditiontosignificantqualityissuesrelatedtotheassessmentsavailable,therecontinuedtobeassessmentsthatwerenotupdated,orwereupdatedaftertheindividual’sCLDPwasfinalized.TheFacilityremainedoutofcompliancewiththisprovision.

T1e EachFacilityshallverify,throughtheMRAorbyothermeans,thatthesupportsidentifiedinthecomprehensiveassessmentthataredeterminedbyprofessionaljudgmenttobeessentialtotheindividual’shealthandsafetyshallbeinplaceatthetransitioningindividual’snewhomebeforetheindividual’sdeparturefromtheFacility.Theabsenceofthosesupportsidentifiedasnon‐essentialtohealthandsafetyshallnotbeabarriertotransition,butaplansettingforththe

TheCLDPsreviewedincludedessentialandnon‐essentialsupports.Sincethelastreview,someprogresshadbeenmadeinexpandingthescopeofprotections,supports,andservicesidentifiedintheCLDPs.However,theFacilityrecognizedthatthiswasanarearequiringfurtherdevelopment.Onapositivenote,acrosstheState,changeswerebeingmadetoISPs.Ifdonecorrectly,thisshouldgreatlyassistteamswhenitistimetoplanforanindividual’stransitiontothecommunity.Thecurrentformatofidentifyingthefullarrayofsupportsaftertheindividualwasreferredfortransitionmadeitmoredifficultduetothegenerallyshorttimeframesfromreferraltotransition.TheFacilityandStateOfficerecognizedthattheessentialandnon‐essentialsupportsrequiredimprovement.OneefforttoassistteamswiththisprocessincludedtheStateOffice’sdevelopmentofaSupportSpreadsheetandanEssential/Non‐EssentialSupportsoutline.Theoutlineprovidedsomeoftheitemsthattheteamsneededtoconsider,particularlyrelatedtotrainingforstaff,aswellasaformatforteamstousetohelpidentifythevarioussupportsandrelatedtrainingthatshouldbeprovidedasthe

Noncompliance


# Provision AssessmentofStatus ComplianceimplementationdateofsuchsupportsshallbeobtainedbytheFacilitybeforetheindividual’sdeparturefromtheFacility.

individualtransitionedtothecommunity.Italsoemphasizedtheneedtoidentifytheevidencethatwouldbeneededtodetermineimplementation.Thespreadsheetidentifiedfourareasofsupportsforteamstoconsider,includinggeneralsupports,environmentalsupports,personalsupportsor“dealbreakers,”andrestrictivepractices.Eachhadabriefdefinition.AtCCSSLC,atthetimeofthereview,twoteamshadusedthesetoolsastheyhadbeguntheprocessofdevelopingthelistsofessentialandnon‐essentialsupports.Accordingtostaff,thetoolssignificantlyassistedteamsinthinkingaboutandoutliningafullersetofprotections,supports,andservices.However,atthetimeofthecurrentreview,teamsdidnotconsistentlyidentifyalltheessentialornon‐essentialsupportsthattheindividualneededtotransitionsafelytothecommunity,nordidteamsadequatelydefinetheessentialsupportsinmeasurableways.Moreover,theplansdidnotconsistentlyidentifypreferencesoftheindividualsthatmightaffectthesuccessofthetransition.Thismadeitdifficultforthoroughandmeaningfulmonitoringtooccurpriortoandaftertheindividual’stransitiontothecommunity.Innoneofthesixplansreviewed(0%)wasacomprehensivesetofessentialandnon‐essentialsupportsidentifiedinmeasurableterms.TheMonitoringTeamhasprovidedmanyexamplesofconcernsinpreviousreports.Similarlytothelastreport,thefollowingsummarizesthegeneralconcernsnoted:

Generally,teamswerenotvisualizingtheindividualwithnosupportsatall,andthenidentifyingeachandeverysupportthatwasneededtoassisttheindividualtobesuccessfulinaparticularcommunityenvironment(s).DuetothecurrentinadequaciesoftheISPs,teamsneededtostartatthebeginning,anddescribethefullarrayofsupportstheindividualneededandwanted.Oncethesewerelisted,theCLDPneededtoidentifyhowtheywouldbeprovidedinthecommunity,bywhom,when,withwhatfrequency,andforhowlong.Thiscouldonlybeaccomplishedbyreviewingcurrentassessments,which,asnotedabove,wereinadequate,andthenaskingeachteammemberwhattheydidfortheindividualhourly,daily,weekly,monthly,quarterly,andannually.Basedonthisknowledge,thefoundationfortheCLDPcouldbebuilt.

Althoughclinicalservices(e.g.,nursing,psychology,therapy,etc.)weresometimesnowreferencedintheCLDPs,theystilloftenweremissing.Inaddition,theintensityofthesupportswasnotidentified,norwerethequalificationsortherolesclearlydefined.Supportsdefinedas“beseenbyapsychologisttomonitorBSPandbehaviors,”or“seeadieticianwithin45days”wereinadequate.TeamswerenotclearlyidentifyingwhatthesesupportsentailedfortheindividualatCCSSLC,andthendefiningintheCLDPhowfunctionallyequivalentsupportscouldbeprovidedinthecommunity.

Inaddition,clinicalsupportsthatCCSSLCwasproviding,basedonassessment


# Provision AssessmentofStatus Complianceinformation,werenotincludedintheCLDPs,andnojustificationwasprovidedfornotidentifyingafunctionallyequivalentsupport.Forexample,nursingcare/healthmanagementplansoftenwerenotreferencedintheCLDPsreviewed,orweresimplyreferencedassomethingtheCCSSLCnursewouldreviewwithcommunityproviderstaff,notasplansthatrequiredimplementation.Likewise,individualswhowerereceivinghabilitationtherapiessupportsatCCSSLCdidnothavefunctionallyequivalentsupportsidentifiedintheirCLDPs.

Ofsignificantconcern,forindividualswhohadbeenidentifiedasbeingatriskthroughtheFacility’sat‐riskscreeningprocess,theriskactionplansthattheFacilityhadbeguntodevelop,albeitstillinadequate,werenotadequatelyreflectedinactionplansincludedintheCLDPs.AsisdiscussedwithregardtoSectionIoftheSettlementAgreement,plansforindividualswhoseteamsidentifythemasbeingat‐riskshouldbeofadequateclinicalintensitytoaddressthelevelofrisk.Similarly,theactionplansincludedinCLDPsforsuchindividualsshouldincludesupportsandservicesofadequateintensitytoensuretheindividuals’wellbeingtotheextentpossible.Basedonthismostrecentreview,CLDPsincludedsomeoftheactionsteps,butnoneoftheCLDPsreflectedevenallofwhatwasintheCCSSLCinadequateriskactionplans.OftenmultiplestepsrelatedtothemultiplerisksthateachofthesixindividualshadwerenottransferredintotheCLDPs.

InremovinganysupportthattheindividualutilizedattheFacilityfromthearrayofsupportthatwouldbeprovidedinthecommunity,teamsshouldjustifywhythesupportisnotneededinthecommunity.Forexample,forindividualswithhealthmanagementplansattheFacility,theirdiscontinuationwouldneedtobejustified,oranalternatesupportprovided.Similarly,ifindividualsreceivesupportsfromHabilitationTherapiesorDietaryatCCSSLC,theseservicesshouldbeincludedintheCLDP,unlessjustificationisprovidedfornotincludingthem,oranequivalentcommunityserviceisidentified.

Teamswerenotfactoringinmodificationsthatneededtobemadetocurrentprogramsorplans,andwritingthisintotheessentialornonessentialsupports.Asoneexample,whenanindividualwhohasaBehaviorSupportPlanthatusescampusbucksasareinforcermovestothecommunity,plansneedtobeputintoplacetotransitiontheindividualtoadifferentreinforcer.

Oftenplansrequiredthatcommunitystaffbetrainedonexistingplans.Asnotedabove,concernsexistedwithregardtothelackofexpectationsforthequalityoroutcomesofthistraining,aswellasthescopeofstafftrained.

Inaddition,few,ifany,plansidentifiedanessentialornonessentialsupportforthefullsetofplansimplementedattheFacility(e.g.,nursingcareplans,healthmanagementplans,PNMPs,andPBSPs)tobeimplementedinthecommunity.Althoughthiswasimproving,mostoftheCLDPsweremissingspecific,


# Provision AssessmentofStatus Compliancemeasurableactionstepsforsomesuchplans.

Manyoftheindividualsreviewedhadspecifichealthcareindicatorsthatneededtobemonitoredandreported(e.g.,constipation,input/output,seizures,weight,mealrefusals,psychiatricsymptoms,etc.).However,few,ifanysupportswereincludedintheCLDPstoensurethatspecificstaffwereresponsibleformonitoringsuchindicators,andwhenspecificcriteriaweremet,reportingthesetohealthcarestaff.Withthemostrecentplans,moreactionstepswereseenformonitoringsomeoftheseindicators,butconsistentlynotallwereidentified,andwhentheywere,noparametersfornotificationornextstepswereidentified.

Onlyoneoftheapplicableplans(i.e.,forIndividual#30)identifiedtheneedtodevelopacrisisinterventionplans.However,evenforthisindividual,itwasunclearwhattheplanneededtoinclude,whowouldreviewit,and/orhowthecurrentmethodsfordealingwithcrisesattheFacilityneededtobemodifiedinacommunitysetting.

Directsupportstaffingratiosandrequirements(i.e.,supervisionlevel)generallywerenotspecified.Inspecifyingstaffingsupports,teamsshouldidentifyspecificallytheindividual’sstaffingneedsinrelationtootherssupportedinthehomeorday/vocationalprogram(e.g.,ifanindividualrequiresline‐of‐sightsupervision,andotherindividualsliveinthehome,theteamshouldconsiderthisindescribinganappropriateratio),aswellasindifferentsituations(e.g.,inthehome,inthecommunity,atadayorworksite,atnight,etc.),aswellasthequalificationsofstaff(e.g.,specifictrainingrequirementsforstaff,competenciesorcertificationsneeded,etc.).Forthecoupleofplansthatdidmentionstaffing,concernswerenoted.Forexample,forIndividual#364,hehadone‐to‐onesupervisionforcommunityactivitieswhileatCCSSLC.TheCLDPdowngradedthisto“eyesight”levelofsupervisionwithoutexplanationorjustification.

Inreviewingassessments,albeitincomplete,manyrecommendationswerenotspecificallyaddressedinCLDPs(e.g.,specificmedicalfollow‐up,adherencetoweightreductionprograms,etc.).

Generally,dayandvocationalsupportswerenotwelldefined. Supportsthatneededtobeprovidedacrossdayandvocationalprograms,as

wellasresidentialprograms(e.g.,nursing,psychology,therapy,etc.)generallywerenotincludedaspartoftheday/vocationalcomponent.

Issuescontinuedtobenotedwithregardtothemeasurabilityofsupportsidentified.Althoughthishadimprovedsignificantly,theissuewasnotcompletelyresolved.

Itappearedthatteamsoftenwereidentifyingduedatesforcriticalsupportsthatwerenotreflectiveofwhattheindividualneeded,butratherdependentonissuesrelatedtotheconversionofindividuals’MedicaidfrominstitutionaltocommunityMedicaid.Nothavingsuchsupportsavailableatthetimeoftransition,orshortly,thereafterpotentiallycompromisedindividuals’successful


# Provision AssessmentofStatus Compliancetransition.

Ofthesixindividualswhohadtransitionedtothecommunityin2012,twohadexperiencednegativeoutcomes.OnehadbeentotheERtwice,andeventuallyhadopenheartsurgery.TheotherhadbeentotheERtwice,includingonceasaresultofbehaviorsthatcausedaninjury,andhadpolicecontactbasedonathreattokillhimselfaswellasrelatedbehaviors.TheMonitoringTeamonlyreviewedthepost‐movemonitoringinformationforthesecondindividual,becausethefirsthadmovedtoanareaforwhichanotherFacilityprovidedthemonitoringservices.However,forthesecondindividual,concernswerenotedwithregardtothetransitionplan,aswellasthequalityofsupportscommunityprovidersofferedtotheseindividuals.TheFacilityisstronglyencouragedtoconductreviewsofanysignificantadverseoutcomeforanindividualwhotransitionstothecommunity.Suchreviewsshouldbeconductedinthespiritofidentifyingwaysinwhichimprovementscanbemadetopreventnegativeoutcomesinthefuture.AswaspreviouslydiscussedinsomedetailwhileattheFacility,goodtransitionplanningrequiresthecommitmentoftheentireIDT,aswellasthosetaskedwithprimaryresponsibilityfordevelopingtheCLDPs.Theentireteamshouldbeinvolvedincritical,butconstructivereviewsofissuesthatindividualshaveexperiencedoncetheytransitionedtothecommunity.WithregardtoMonitoringbytheLocalAuthorityorothermeanstoensureessentialsupportsareinplacepriortoanindividual’stransition,theLocalAuthority’sreviewappearedtobeageneralsafetyassessmentasopposedtoanindividualizedassessmentbasedontheessentialsupportsidentifiedbytheteam.TheonlyassurancesthattheLocalAuthoritystaffcompletingthe“Pre‐MoveSiteReviewInstrumentfortheCommunityLivingDischargePlan”hadthattheessentialsupportswereinplaceappearedbasedona“meetingwiththesiteadministrator/manager.”Theformincludedtworelatedquestions,including:1)“Didthesiteadministrator/managerhaveacopyoftheconsumer’sdraftCommunityLivingDischargePlanandknowtheoutcomesimportanttotheconsumerorlegallyauthorizedrepresentative;”and2)“Didthesiteadministrator/managerverifyservicesandsupportscouldbeprovidedthatarenecessarytoassisttheconsumerinachievingtheoutcomes?”(Emphasisadded.)ResponsestothesequestionsdidnotrepresentadequateproofthattheessentialservicesrequiredbytheCLDPswereinplace.Noneoftheseforms,forthesamplereviewed,providedanyadditionaldocumentationtoshowthattheLocalAuthorityrepresentativeshadactuallyconfirmedthattheindividualizedessentialsupportswereinplace.However,theFacilitywashavingthePost‐MoveMonitorconductapre‐movesitevisitdesignedspecificallytodetermineiftheessentialsupportswereinplace.Areviewwasconductedoffourindividuals’pre‐movesitevisitdocumentation(i.e.,Individual#30,


# Provision AssessmentofStatus ComplianceIndividual#114,Individual#277,andIndividual#151).Allthree(100%)appearedthorough,andincludedeachessentialsupportlistedintheindividual’sCLDP.Theyidentifiedtheevidencethathadbeenreviewedtodeterminethattheessentialsupportwasinplace.Theyalsoappearedtohavebeencompletedinatimelymanner,acoupleofdayspriortotheindividual’stransition.Theprocesswillbecomemorecomplicatedasmoreessentialsupportsareappropriatelyidentifiedinindividuals’CLDPs.Asnotedinthepreviousreport,thisissubstantialprogress,however,inmeetingthisrequirementoftheSettlementAgreement.Overall,afindingofnoncompliancewasmadeforthiscomponentoftheSettlementAgreement.Althoughprogresswasnotedwithregardtothepre‐moveconfirmationofessentialsupports,substantialworkwasstillneededinadequatelydelineatingtheessentialandnon‐essentialsupportsinindividuals’CLDPs.

T1f EachFacilityshalldevelopandimplementqualityassuranceprocessestoensurethatthecommunitylivingdischargeplansaredeveloped,andthattheFacilityimplementstheportionsoftheplansforwhichtheFacilityisresponsible,consistentwiththeprovisionsofthisSectionT.

AtthetimeoftheMonitoringTeam’spreviousreview,theFacilitywasusingthemonitoringtoolsthathadbeenmodifiedbasedontheMonitoringTeams’audittools.Atthetimeofthismostrecentreview,theFacilitycontinuedtoconductauditsusingthesetools.TheQADepartmentconductedreviewsofCLDPs,andthePostMoveMonitoringProcess.TheQADepartment,andthePost‐MoveMonitorconductedreviewsoftheLivingOptionscomponentofSectionT.SincetheMonitoringTeam’slastreview,littlehadchangedwithregardtomonitoring,andqualityassuranceefforts.Areasinwhichprogresshadbeensustainedincluded:

ValiditycheckswerebeingconductedbetweentheQADepartmentauditor,andthePost‐MoveMonitor.Thiswasagoodattempttoensureinter‐raterreliability.However,asisdiscussedinothersections,astandardinter‐raterreliabilitymethodologyshouldbeusedstatewide,andfocusneededtobeonensuringthatnotonlyweretheresultsofthemonitoringsimilar,butthatalsotheywereaccurate.Inotherwords,ifbothauditorswereincorrectintheirassessmentofanindicator,highinter‐raterreliabilitywouldbepresent,butthedatastillwouldnotbevalid.

TheFacilityalsohaddevelopedauser‐friendlyformatfordisplayingtheresultsofmonitoringactivities.Itprovidedaprintoutoftheresultsofeachindicator,whichcouldbeviewedoveraperiodofmonths,allowingcomparisonstobeeasilymade.

TheauditscompletedoftheLivingOptionscomponentidentifiedsignificantissuesrelatedto,forexample,theteams’identificationofadequate,individualizedsupportsandservices.Otherareasinwhichproblemswerenotedincludedtheidentificationofobstaclestotransition,anddevelopmentofstrategiestoaddressthem.ThesefindingswereconsistentwiththoseoftheMonitoringTeam.

Noncompliance


# Provision AssessmentofStatus Compliance TheFacilityhadcontinuedtoincorporatethedataintoitsself‐assessment.

Areasinwhichcontinuedeffortsneededtobemadeincluded:

Asnotedabove,inter‐raterreliabilityhadnotyetbeenestablished,norhadtheaccuracyofthemonitoringdata.

AsdetailedintheMonitoringTeam’sreportonAustinSSLC,dated7/7/11,theMonitoringTeamcontinuestohaveconcernsabouttheadequacyoftheguidelinesprovidedtoreviewers.Effortstoimprovethesearenecessarytoensureaccuracyinmonitoringaswell.Facilitystaffrecognizedthisandindicatedthattheywereworkingonnew/additionalinstructionsforthetools.

Analysisofthedata,anddevelopmentofappropriatecorrectiveactionplanshadnotyetoccurredtotheextentnecessary.

Althoughprogresscontinuedtobemadeinthisarea,theFacilityrecognizedtheneedtofullydevelopandimplementqualityassuranceprocessesnecessarytoassessitsimplementationofSectionT.TheFacilityshouldcontinuetoexpanditsmonitoringactivitiesinthisarea,includingmodifying,asappropriate,themonitoringtools,particularlytoimprovetheguidanceprovidedtoauditors;trainingstaffwhowillconductthemonitoringonthereviewtoolsandtheirimplementation;ensuringthereviewsaccuratelyevaluatequalityaswellasthepresenceorabsenceofitems;andestablishinginter‐raterreliability.Inaddition,theFacilityshouldanalyzeinformationresultingfrommonitoringactivities,and,asappropriate,develop,implement,andmonitoractionplanstoaddressconcernsidentified.Suchplansshouldincludeactionsteps,person(s)responsible,timeframesforcompletion,andanticipatedoutcomes.

T1g EachFacilityshallgatherandanalyzeinformationrelatedtoidentifiedobstaclestoindividuals’movementtomoreintegratedsettings,consistentwiththeirneedsandpreferences.Onanannualbasis,theFacilityshallusesuchinformationtoproduceacomprehensiveassessmentofobstaclesandprovidethisinformationtoDADSandotherappropriateagencies.BasedontheFacility’scomprehensiveassessment,DADSwilltakeappropriatestepstoovercomeorreduceidentifiedobstaclesto

ActivitiesattheFacility andStatelevelsdemonstratedprogresstowardssubstantialcompliancewiththisprovisionitem.TheStateissuedtheAnnualReport:ObstaclestoTransitionStatewideSummary,FiscalYear2011,withdatacurrentasof8/31/11.AsnotedintheMonitoringTeam’spreviousreport,basedonreviewoftheannualreport,theFacilitywasbeginningtogatherdataontheobstacles.However,thisremainedlimited:

Dataforfivefiscalyears,2007through2011,werereportedinthenewannualreport.Dataincludednumberindividualswhomovedtothecommunity,deaths,anddischargestootherplacements.Dataalsowasprovidedforthesetimeframesonnumbersofindividualsreferredforcommunityplacements,thenumberofrescindedreferrals,communitytransitions,andnumbersofindividualswhoreturnedfromcommunitytransitions.

Verylimiteddatawereincludedinthereportregardingthetypesofobstaclesidentified(eventhoughthedatacollectionsystemwasnotedtobeflawed),andtheconcernsofLARsandindividualsthatledtotheirpreferencetonotbe

Noncompliance


# Provision AssessmentofStatus Complianceservingindividualsinthemostintegratedsettingappropriatetotheirneeds,subjecttothestatutoryauthorityoftheState,theresourcesavailabletotheState,andtheneedsofotherswithdevelopmentaldisabilities.TotheextentthatDADSdeterminesittobenecessary,appropriate,andfeasible,DADSwillseekassistancefromotheragenciesorthelegislature.

referred. Thedatasystemonlyallowedoneobstacletoberecordedperindividual.This

confoundedthedata. Thedataonthe69individualsindicatedthat27(39%)werenotreferreddueto

LARpreference.Thedatasystem,however,didnotindicateifthiswasthesolereasonfornon‐referral,orifitwasoneofanumberofobstacles.

TheCCSSLCreportdidnotyetincludeananalysisoftheoveralldataincludedinthereport.

Asnoted,dataaccuracyandvalidityneededtobeimproved. AssistancefromtheQADepartmentandStateOfficemightbehelpfulin

analyzingdataonceitiscollected. Forexample,graphsofthedatacouldbetrendedoversuccessivemonths,and

analysiscouldbecompleted.Facilitystaff’sknowledgeoftheunderlyingissuescouldbehelpfulinidentifyingpotentialsolutionstoexistingobstacles.

TheFacility’sassessmentreportthatwasincludedintheState’soverallreportoutlinedthemajorconcerns,andtheFacility’sinitialplanstoaddresseach.Theseincluded:

QuestionsregardingthereliabilityofthedatacollectionweretobeaddressedthroughadditionaltrainingofIDTs,aswellasrevisiontothedataformtoassistinunderstanding,andfacilitatedataentry.

AhighlevelofindividualandLARreluctancewastobeaddressedthroughindividualizedactionplansisISPs,initiativestoimprovetheCLOIPprocess,andadditionaleducationalsupportstoindividuals,families,andfriends.

ThelackofLocalAuthorityparticipationinindividuals’meetingswastobeaddressedthroughfurthertrainingoftheQDDPsonhowtoaddressthisissue.

DADStookstepstoovercomeorreducetheseobstacles.

DADScreatedareportsummarizingobstaclesacrossthestate,andincludedtheFacility’sreportasanaddendum/attachmenttothereport.ThestatewidereportwasdatedOctober2011.

Thestatewidereportlistedthe13obstacleareasusedinFY11.DADSwillbeimprovingthewayitcategorizesandcollects(andthewayithastheFacilitiescollect)dataregardingobstacles.

DADSindicatedactionsthatitwouldtaketoovercomeorreducetheseobstacles:

o Elevennumbereditemswerelisted.FivewererelatedtotheIDTprocessandupcomingchangestothisprocess,threewererelatedtoworkingwithlocalauthoritiesandlocalagencies,twowererelatedtoimprovingprovidercapacityandcompetence,andtwowererelatedtofundinginitiativesregardingslotavailabilityandthenewcommunityliving


# Provision AssessmentofStatus Compliancespecialistpositions.Ingeneral,theseweredescriptionsoftheearlystepsofactivitiesrelatedtoaddressingobstaclestoeachindividuallivinginthemostintegratedsetting.

o DADSdidnot,butshould,includeadescriptionastowhetheritdeterminedittobenecessary,appropriate,andfeasibletoseekassistancefromotherstateagencies(e.g.,DARS).

Sincethelastreview,theFacilityhadcontinuedtogatherdatarelatedtoobstacles.AsdiscussedindetailwithregardtoSectionT.1.b.1,concernscontinuedtoexistwithteams’accurateidentificationofobstacles.TheFacilityhaddevelopeditsowndatacollectiontoolentitled:“ObstaclestoMovingtoaCommunitySetting.”Itsetforththevariousobstaclecategoriesandsubcategoriesinaneasy‐to‐useformat.However,basedonreviewofindividuals’ISPs,teamscontinuedtostrugglewithunderstandingthepotentialobstacles,andselectingtheappropriateones,particularlythesubcategories.Asaresult,thevalidityofthedatawasquestionable.Forexample,inreviewingaggregatedataforthequartersbetween12/1/11and2/29/11,and3/1/12and5/31/12,the“individual’slackofunderstandingofcommunitylivingoptions”wastheobstaclewiththehighestcount.Basedonareviewofalimitednumberofreviews,itappearedthatattimes,teamsidentifiedthisobstacle,evenwhenforexample,anindividual’sunderstandingoflivingoptionscouldnotbeandlikelynevercouldbeassessed.Asnotedabove,theFacilitysubmittedmonthlyandquarterlyaggregatetotalsoftheobstaclecategoriesStateOfficehadidentified.Basedoninterview,Facilitystaffindicatedthateducationofindividualsandtheirguardianshadbeenidentifiedasanareaofneed.However,theystatedthatformalanalysisofallofthedatawasstillinprocess.TheFacilitywouldsoonbesubmittingitsannualreporttotheState,whichshouldincludeananalysisofdatacollectedthusfar.Improvementsindatacollectionandanalysis,implementationofnewISPprocesses,andactualizationoftheplannedactivitiestoovercomeorreduceobstacleswillbenecessaryforsubstantialcompliancetobeobtained.

T1h CommencingsixmonthsfromtheEffectiveDateandatsix‐monthintervalsthereafterforthelifeofthisAgreement,eachFacilityshallissuetotheMonitorandDOJaCommunityPlacementReportlisting:thoseindividualswhoseIDTshavedetermined,throughthe

Inresponsetoadocumentrequest,theFacilitysubmittedtotheMonitoringTeamaCommunityPlacementReport.Forthetimeperiodbetween11/16/11and5/31/12,thereportlisted:

CurrentReferrals:Twelveindividualswereincludedonthislist,butoneoftheseindividualshadtransitionedtothecommunitysincethereportwasissued.

CommunityPlacements:Sixindividualswereincludedonthislist.Asnotedabove,andadditionalpersonhadtransitionedintheweekspriortothereview.

RescindedReferrals:Oneindividualwasincludedonthislist.Thereasonwas



# Provision AssessmentofStatus ComplianceISPprocess,thattheycanbeappropriatelyplacedinthecommunityandreceivecommunityservices;andthoseindividualswhohavebeenplacedinthecommunityduringtheprevioussixmonths.ForthepurposesoftheseCommunityPlacementReports,communityservicesreferstothefullrangeofservicesandsupportsanindividualneedstoliveindependentlyinthecommunityincluding,butnotlimitedto,medical,housing,employment,andtransportation.Communityservicesdonotincludeservicesprovidedinaprivatenursingfacility.TheFacilityneednotgenerateaseparateCommunityPlacementReportifitcomplieswiththerequirementsofthisparagraphbymeansofaFacilityReportsubmittedpursuanttoSectionIII.I.

IDTdecision:behavioral/psychiatric.DuringDecember2010,theMonitoringPanelrequestedsomeadditionalinformationregardingtransitioninordertocapturecategoriesofindividualswhohaveeitherrequestedcommunitytransition,orwhoseteamshavedeterminedtheycanbeappropriatelyplacedinthecommunity.Formeetingsoccurringbetween11/16/11and5/31/12,thereportlisted:

IndividualPrefersCommunity,NotReferred–LARChoice:Thislistincludedsevenindividuals.

IndividualPrefersCommunity,NotReferred–OtherReasons:Thislistincludednineindividuals.Oneoftheseindividualshadsincebeenreferredtothecommunity.Fortheremainingeightindividuals,forone,theLAwasnotpresent,whichisarequirementforareferralbeingmade(althoughthisrecentlyhadchangedasdiscussedwithregardtoSectionT.1.a).Inthesecases,theteamsreportedlywererequiredtoreconveneameetingatwhichtheLAcouldbepresent.Itwasunclearifthishadoccurred.Foroneotherindividual,thereasonlistedwas“exploringcommunityoptions.Foroneindividual,citizenship/fundingissuewasthereasonlisted.Forfiveindividuals,behavior/psychiatricissueswerelisted.

TheMonitoringPanelaskedthatafinalcategorybeaddedthatincludedalistofnamesofindividualswhowouldbereferredbytheteamexceptfortheobjectionoftheLARwhetherornottheindividualhimselforherselfhasexpressed,oriscapableofexpressing,apreferenceforreferral.TheFacilityprovidedaseparatelistoftwoindividualsthatfellintothiscategory.However,asnotedabovewithregardtoSectionT.1.aoftheSettlementAgreement,professionalsonindividuals’teamsneedtomakeindependentrecommendationsregardingtheappropriatenessofanindividualforcommunityplacement.Thiswasnotyethappeningconsistently.Therefore,itwasunlikelythatthisdatawasyetreliable.

T2 ServingPersonsWhoHaveMovedFromtheFacilitytoMoreIntegratedSettingsAppropriatetoTheirNeeds

T2a CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacility,oritsdesignee,shallconductpost‐movemonitoringvisits,withineachof

TimelinessoftheChecklistsPost‐movemonitoringdocumentationwasreviewedforfourindividuals(i.e.,Individual#30,Individual#114,Individual#277,andIndividual#151).Thissamplerepresentedall(100%)oftheindividualsforwhomtheCCSSLCPost‐MoveMonitorneededtocompletereviewssincethelastreview.Forthefourindividuals,10reviewsshouldhavebeencompletedsincethepreviousreview.Ofthe10requiredvisits,all(100%)hadbeen

Noncompliance


# Provision AssessmentofStatus Compliancethreeintervalsofseven,45,and90days,respectively,followingtheindividual’smovetothecommunity,toassesswhethersupportscalledforintheindividual’scommunitylivingdischargeplanareinplace,usingastandardassessmenttool,consistentwiththesampletoolattachedatAppendixC.ShouldtheFacilitymonitoringindicateadeficiencyintheprovisionofanysupport,theFacilityshalluseitsbesteffortstoensuresuchsupportisimplemented,including,ifindicated,notifyingtheappropriateMRAorregulatoryagency.

documentedashavingbeencompletedontime.Inaddition,monitoringvisitswereconductedatthevarioussitesatwhichsupportswereprovided.Asapplicable,thePost‐MoveMonitorappearedtohaveconsistentlyvisitedindividualsattheirresidentialaswellastheirday/vocationalsites.ContentofChecklists:Sincethelastreview,allofthepost‐movemonitoringreportsusedtheupdatedformat,whichwasconsistentwiththeformattheSettlementAgreementrequired.Infact,thenewformatincludedsomeadditionalitemsfromthoseincludedonthesampletoolprovidedinAppendixCoftheSettlementAgreement.ThePost‐MoveMonitorreportedandtheMonitoringTeamagreesthattheseadditionsenhancedthetool,andappearedtoassistthePost‐MoveMonitorinreviewingimportantelementsoftheprotections,supports,andservicesthecommunityprovidersofferedtoindividualsthathadtransitioned.TheFacilitycontinuedtoensurethatthemethodologybeingusedtoconfirmtheexistenceofnecessaryprotections,supports,andserviceswasstated.Thechecklistsreviewedgenerallywerecompletedverythoroughly.Attimes,issueswerenotedthatrequiredfollow‐up.Someoftheseinvolvedsupportsthathadnotbeenfullyprovidedand/orissuesthathadarisensincethetransition.Similartothelastreview,theMonitoringTeam’soverallconcernwasthelackofadequatefollow‐upbyteamsatCCSSLC.AlthoughthePost‐MoveMonitorappearedtoidentifyissuesandtakeactionwithprovideragenciestoremedyissuesfound,individuals’teamsalsoweresupposedtomeet,reviewthereports,andtakeactionormakerecommendations,asappropriate.Thispiecedidnotappeartobesolidlyinplace.Insomeinstances,seriousissueshadoccurredforindividuals(e.g.,Individual#114’scalltothepolicethreateningtokillhimself),orthepost‐movemonitoringactivitiesidentifiedpotentialmisunderstandingsonthepartofthenewhomeoftheneedtoconsistentlyprovideidentifiedsupports(e.g.,Individual#277whorequiredalarmsonthedoorsforhisandothers’safety).Aspartofitsdocumentrequest,theMonitoringTeamaskedforanyfollow‐upISPAsorCLDPfollow‐updocumentation.ForIndividual#114,theteammet,buttheteam’sresponsewasnotadequate.Itdidnotappearthattheteamreviewedinanymethodicalwaythebehaviors,theirfunctions,orwhetherornottheproviderwasimplementingtheSSLCBSP.Moreover,theproviderhadnotobtainedtherequiredpsychologyreviewoftheBSP,buttheteamdidnotappeartoemphasizewiththeprovidertheimportanceofobtainingthissupportassoonaspossible.ForIndividual#277,noevidencewassubmittedthattheteamhadmet.Certainly,theFacilityhadnotused“itsbesteffortstoensure”supportswereprovided.Althoughprogresscontinuedtobemadewithregardtothepost‐movemonitoring


# Provision AssessmentofStatus Complianceprocess,follow‐uptothemonitoringvisitsremainedthe biggestchallengefortheFacility.Thiswillrequiretheeffortsofindividuals’IDTs,aswellastheAdmissionsandPlacementOffice.TheFacilityremainedoutofcompliancewiththisprovision.

T2b TheMonitormayreviewtheaccuracyoftheFacility’smonitoringofcommunityplacementsbyaccompanyingFacilitystaffduringpost‐movemonitoringvisitsofapproximately10%oftheindividualswhohavemovedintothecommunitywithinthepreceding90‐dayperiod.TheMonitor’sreviewsshallbesolelyforthepurposeofevaluatingtheaccuracyoftheFacility’smonitoringandshalloccurbeforethe90thdayfollowingthemovedate.

Duringtheweekoftheonsitereview,amemberoftheMonitoringTeamaccompaniedthePost‐MoveMonitoronapost‐movemonitoringvisitforIndividual#30,includingtohisdayprogramandhome,aswellastoanemergencyrelocationsite.TheMonitoringTeamappreciatesthePost‐MoveMonitorfinalizingthereportfromthevisit,becausethisprovidedtheopportunitytocomparetheobservationsofthevisitwiththewrittenreport.Ashasbeennotedinthepast,thePost‐MoveMonitorsystematicallyreviewedthesupportsincludedinIndividual#30’sCLDP.Sheaskedmanygoodquestions,conductedobservations,andreviewedrelevantdocumentation.Duringthecourseofthereview,thePost‐MoveMonitoridentifiedsomeseriousissues,includingthatthewaterhadbeenturnedoffinthehomeinwhichtheindividualwaslivingduetononpaymentofthebill.Theindividualandhishousematehadtomovetemporarilytoahotel.Inordertoensurehissafety,inadditiontonotifyingtheLocalAuthority’ssupportcoordinationunitandDFPS,thePost‐MoveMonitormadeanadditionalvisittothehotelthattheprovideridentifiedastheemergencyrelocationsite.Moreover,inadditiontorequestinganemergencymeetingwiththeteamatCCSSLC,thePost‐MoveMonitormadeanadditionalvisittotheindividual’shomethefollowingdaytoconfirmthatthewaterhadbeenrestored.ThePost‐MoveMonitorhandledtheseissuesprofessionallywithcommunityproviderstaff.Theseissuesalsowerereflectedinthewrittenreport.Thereportwasthorough,andincludedacompletedescriptionoftheevidencethatthePost‐MoveMonitorhadreviewedtodrawherconclusions.Herconclusionsappearedtobesound,andshedocumentedthefollow‐upthatwouldoccurtoaddresstheoutstandingissuesidentified.Duetothethoroughandaccuratepost‐movemonitoringobserved,theFacilityhasbeenfoundinsubstantialcompliancewiththisprovision.Ashasbeendiscussed,maintainingsubstantialcompliancewillrequirethePost‐MoveMonitortokeeppacewiththeexpandedresponsibilitiesformonitoringthatwilloccuronceCLDPsareimproved.


T3 AllegedOffenders‐TheprovisionsofthisSectionTdonotapplytoindividualsadmittedtoaFacilityforcourt‐orderedevaluations:1)foramaximumperiodof180days,todetermine


# Provision AssessmentofStatus Compliancecompetencytostandtrialinacriminalcourtproceeding,or2)foramaximumperiodof90days,todeterminefitnesstoproceedinajuvenilecourtproceeding.TheprovisionsofthisSectionTdoapplytoindividualscommittedtotheFacilityfollowingthecourt‐orderedevaluations.

T4 AlternateDischarges‐

NotwithstandingtheforegoingprovisionsofthisSectionT,theFacilitywillcomplywithCMS‐requireddischargeplanningprocedures,ratherthantheprovisionsofSectionT.1(c),(d),and(e),andT.2,forthefollowingindividuals:(a) individualswhomoveoutof

state;(b) individualsdischargedatthe

expirationofanemergencyadmission;

(c) individualsdischargedattheexpirationofanorderforprotectivecustodywhennocommitmenthearingwasheldduringtherequired20‐daytimeframe;

(d) individualsreceivingrespiteservicesattheFacilityforamaximumperiodof60days;

(e) individualsdischargedbasedonadeterminationsubsequenttoadmissionthattheindividualisnottobeeligibleforadmission;

(f) individualsdischargedpursuanttoacourtorder

Ataparties’meetingonDecember2and3,2010,itwasagreedthatinadditiontothecategorieslistedintheSettlementAgreement,othercircumstancesresultinginanindividualmovingfromaSSLCmightfallunderthecategoryof“alternatedischarges.”OneofthesereasonswasanindividualtransferringtoanotherSSLC.Sincethelastreview,oneindividualhadtransferredanotherSSLCs(i.e.,Individual#264).BasedonareviewofthedischargesummarycompletedforIndividual#264,itcontainedthecategoriesconsistentwiththeCentersforMedicareandMedicaidServices(CMS)requirements.Theyincludedasummaryoftheindividual’sdevelopmental,behavioral,social,health,andnutritionalstatus.However,insomecases,thissummarydidnot“accuratelydescribetheindividual,includinghis/herstrengths,needs,requiredservices,socialrelationshipsandpreferences”asrequiredbytheCMSguidelines[42CodeofFederalRegulations(CFR)§483.440(b)(5)(i),andW203].Inaddition,thedischargeplandidnotappeartomeettheCMSrequirement[42CFR§483.440(b)(5)(ii),andW205]toprovideadischargeplan“sufficienttoallowthereceivingfacilitytoprovidetheservicesandsupportsneededbytheindividualinordertoadjusttothenewplacement.”EachoftherequirementsoftheCMS‐requireddischargeplanningprocessisdiscussedbelow:

Ifanindividualiseithertransferredordischarged,theFacilityhasdocumentationintheindividual’srecordthattheindividualwastransferredordischargedforgoodcause:Basedontheinformationprovided,inoneoutofonerecordsreviewed(100%),goodcausewasidentifiedinthedischargesummaries(i.e.,team’sagreement,includinghisguardians,thatherequiredamorestructuredenvironment,whichtheotherFacilitycouldoffer).

TheFacilityprovidedareasonabletimetopreparetheindividualandhisorherparentsorguardianforthetransferordischarge(exceptinemergencies):Basedontheinformationprovided,fornoneoutofoneindividuals(0%),reasonabletimewasgiventoprepare.Fortheoneindividual,itwasnotclearfromthe

Noncompliance


# Provision AssessmentofStatus Compliancevacatingthecommitmentorder.

informationprovidedhowmuchtimewasprovided.

Atthetimeofthedischarge,theFacilitydevelopsafinalsummaryoftheindividual’sdevelopmental,behavioral,social,healthandnutritionalstatus:Althoughthefinalsummaryincludedeachofthesecomponents,fornoneoftheoneindividuals(0%)wastheinformationadequate.Concernsincluded:

o Adequatesummarieswerenotprovidedoftheindividual’soverallstayatCCSSLC.Infact,muchoftheinformationrelatedtohispriorplacements,asopposedtoasummaryofwhathadoccurredwhilehewasattheFacility.

o Incompletehistoricalandcurrentstatusinformationwasprovided(e.g.,significantlapsesininformationwithregardtopsychiatricinformation).

o Generally,littleinformationwasprovidedaboutthesupportstheindividualwasreceiving,andlittleanalysiswasprovidedregardingwhatsupportshadassistedtheindividualversusthosethathadnotbeeneffectivetoassistthereceivingfacilitytodevelopanappropriatetreatmentplan.

o Theindividualhadsignificantpsychiatricissues.Alistwasprovidedofhiscurrentmedicationsanddiagnoses.However,thesummaryprovidedinadequateinformationaboutattemptsatCCSSLCtomodifyhismedications,reviewhisdiagnoses,etc.,and/ordetermineifthecurrentpsychiatrictreatmentwaseffective.

Withtheconsentoftheindividual,parents(iftheclientisaminor)orlegalguardian,providesacopytoauthorizedpersonsandagencies:Fornoneoftheoneindividual(0%),CCSSLCprovideddocumentationtoshowthatacopyofthedischargesummaryandrelatedassessmentshadbeenprovidedtothereceivingFacility.

TheFacilityprovidesapost‐dischargeplanofcarethatwillassisttheindividualtoadjusttothenewlivingenvironment:BasedonthenarrativesprovidedintheReferralsand/orNecessaryServicesRequiredinNewEnvironmentsection,theIDTfornoneoftheoneindividual(0%)adequatelydescribedthekeysupportsthattheindividualwouldneedinhisnewsetting.Thissectionofthesupportsimplystated:“Priortohistransferto[SSLC],[Individual]andhisGuardian’s(sic)wereprovidedwithanexplanationofhisimpendingtransferandan


# Provision AssessmentofStatus Complianceexplanationofthereasonforthetransfer.Acompletere‐assessmentofallneededsupports/serviceswillbeconductedbythe[SSLC]uponhisarrival.”Theinformationincludedintheothersectionsofthesummarywaslargelyassessmentinformationornarrativesregardingincidents.Althoughsomesupportshewasreceivingweremixedintothenarrative,aspecificandcomprehensivelistwasnotincludedanywhereinthedocument.

TheFacilitywasnotincompliancewiththisprovision.ThiswasduetothefactthatitdidnotmeettheCMSrequirementsfortransition/dischargeplanning.


1. TheprofessionalteamssupportingindividualsatCCSSLCshouldindependentlymakerecommendationsregardingindividuals’appropriatenessfortransitiontothemostintegratedsetting,appropriatetomeettheirneeds.Suchrecommendationsshouldbepresentedtotheentireteam,includingtheindividualandLAR,forconsideration,andclearlydocumentedinthePSP.Basedonteamdiscussion,includinganyoppositionfromtheindividualorhis/herLAR,theentireteamthenshouldmakeadecisionregardinganypotentialreferralforcommunitytransition.(SectionT.1.aandT.1.b.3)

2. Ashasbeenrecommendedinpreviousreports,withregardtopolicy:a. Statepolicy,aswellasFacilitypolicy,shouldbemodifiedtoreflectthechangesthathaveoccurredregardingtransitionproceduresso

thatexpectationsregardingpracticeareclearlydelineated.b. Inaddition,asappropriate,theFacilityshouldincludeinitslocalpoliciesanyFacility‐specificdetailsthatarerelevanttofull

implementationoftheStatepolicy.(SectionT.1.b)3. WhenanindividualorLARindicatesthattheydonotwanttoconsidertransitiontothecommunity,itisimportanttodocumentthespecific

reasonsforthis.Forexample,reasonscouldrangefromconcernsaboutqualityofcommunityservices,ratesofturnoverincommunitysettings,concernsabouttheindividualleavingcomfortablesurroundings,typesofservicesthatarenotavailable,etc.SuchinformationneedstobecollectedandanalyzedbytheFacilityandtheState.(SectionT.1.b.1)

4. Asteamsbegintobetterdefineobstaclestomovement,andbegintotalkingreaterdepthabouttheoptionsavailableincommunitysettingstomeetindividuals’specificneedsincomparisonwithservicesandsupportsavailableattheFacility,thisdiscussionshouldbememorializedintheISPtodocumentthatindividualsandtheirfamiliesaremakinginformeddecisionswithregardtoanindividual’slivingoptions.(SectionT.1.b.1)

5. Withregardtoeducationopportunities:a. FortheCLOIPprocess,outcomes/measuresshouldbedeterminedand/ordatacollectedregardingthenumberofindividuals,and

families/LARswhoagreetotakeneworadditionalactionsregardingexploringcommunityoptions,andthenumberofindividualsandfamilies/LARswhorefusetoparticipateintheCLOIPprocess.CollectionandreviewofsuchdatashouldbecompletedtoallowtheStatetoevaluatetheeffectsoftheprocessandmakechangesmadetofutureCLOIPactivities.

b. Withregardtocommunitytours,datashouldbeanalyzedtoensurethat:a)allindividualshavetheopportunitytogoonatour(exceptthoseindividualsand/ortheirLARswhostatethattheydonotwanttoparticipateintours);b)placeschosentovisitarebasedonindividual’sspecificpreferences,needs,etc.;and3)theindividual’sresponsetothetourisassessed.

c. TheFacilityshoulddevelopaformalplantoaddresseducationoncommunitylivingoptionstomanagementstaff,clinicalstaff,anddirectsupportprofessionals.


d. TheFacilityshouldprovideopportunitiesforindividualstovisitfriendswholiveincommunity;e. Iftheanalysisofaggregatedatashowedthatfamiliesandguardianshadsimilarconcerns,thenusingmechanismstoprovide

informationonspecifictopicsshouldbeused.Forexample,includingarticlesinnewslettersorofferingspecificeducationalseminarsmightbeuseful.

f. TheFacilityshouldprovideeducationat:Self‐advocacymeetings,asofferedandinvited;housemeetingsfortheindividuals;andfamilyassociationmeetings.

g. TheFacilityshouldaddcreativeandindividualizededucationalactivitiestomeettheneedsofvariousindividualsandfamilies/guardians,includingactionplansinindividuals’ISPsdesignedtomeettheirspecificneeds.(SectionT.1.b.2)

6. Giventhatfromanormalizationperspective,whenpeoplemove,oftenoneofthehardestaspectsisleavingfriendsbehind,andtypicallyplanswouldbemadetohelpstayintouchwithimportantcolleaguesorfriends,asappropriate,itwouldbeimportanttoincludesuchactivitiesinindividuals’transitionplans.(SectionT.1.c.1)

7. Essentialandnon‐essentialsupportsshouldbebetterdefinedinCommunityLivingDischargePlans.Morespecifically:a. TheroleoftheFacilityandcommunityproviderstaffinthetransitionanddischargeprocessshouldbedefinedbetter.Thisshould

include,butnotbelimitedtodefining:i. Whichcommunityproviderstaffneedtocompletewhichtraining(e.g.,directsupportprofessionals,managementstaff,

clinicians,dayandvocationalstaff,etc.),and/orforeachcomponentoftraining,whatlevelofmasteryoftheinformationisrequired(e.g.,demonstrationofcompetence);

ii. Themethodoftraining,forexample,ifitwouldbenecessaryforcommunityproviderstafftoshadowCCSSLCstaff,and/orshowcompetencyinactuallyimplementingaplan,suchasaPBSP,PNMP,etc.Forsomeindividuals,specificcomponentsoftheirISPsshouldbetargetedformoreintensivetrainingofcommunityproviderstaffpriortotheindividual’stransition(i.e.,anessentialsupport),or,ataminimum,evidencethatthecommunityproviderstaffhavethecompetenciesnecessarytosafelysupporttheindividual;

iii. CollaborationbetweentheFacilityclinicianscurrentlyworkingwiththeindividualandthecommunityclinicianswhowillassumeresponsibilityforsupportingtheindividual(e.g.,medicalstaff,nurses,therapists,psychologists,etc.);

iv. Coordinationbetweencurrentandfutureresidentialorday/vocationalstaff;v. CCSSLC’sstaff’sinvolvementinevaluatingpotentialsitesatwhichindividualswouldbeserved(e.g.,HabilitationTherapies

stafftoensureadequateaccessibilityand/orequipment,BehavioralServicesDepartmentstafftodetermineifsafetyissuescouldbeaddressedinspecificsettings,and/orifmodificationsneededtobemadetoexistingplanstoaddresschangesinenvironment);and

vi. TheroleCCSSLCstafforcommunityproviderstaffmightplayinassistingtheindividualtomakethetransition;b. DuetothecurrentinadequaciesoftheISPs,teamsshouldstartatthebeginning,anddescribethefullarrayofsupportstheindividual

needsandprefers.Oncethesearelisted,theCLDPsshouldidentifyhowthenecessarysupportswillbeprovidedinthecommunity,bywhom,when,withwhatfrequency,andforhowlong.Thiscanbeaccomplishedbyreviewingcurrentassessments,which,asnotedabove,wereinadequate,andthenaskingeachteammemberwhattheydofortheindividualhourly,daily,weekly,monthly,quarterly,andannually.Basedonthisknowledge,thefoundationfortheCLDPcouldbebuilt;

c. Withregardtoclinicalservices,theCLDPsshoulddefinetheintensityofthesupports,aswellasthequalifications,andtherolesofclinicians;

d. ClinicalsupportsthatCCSSLCisprovidingshouldbeincludedintheCLDPs,oradequatejustificationfornotidentifyingafunctionallyequivalentsupportshouldbedocumentedintheCLDP;

e. Forindividualswhoseteamsidentifythemasbeingat‐risk,CLDPsshouldbeofadequateclinicalintensitytoaddressthelevelofrisk.Specifically,theactionplansincludedinCLDPsforsuchindividualsshouldincludesupportsandservicesofadequateintensitytoensuretheindividuals’wellbeingtotheextentpossible;


f. InremovinganysupportthattheindividualutilizedattheFacilityfromthearrayofsupportsthatwillbeprovidedinthecommunity,teamsshouldjustifywhythesupportisnotneededinthecommunity;

g. Teamsshouldfactorinmodificationsthatneedtobemadetocurrentprogramsorplans,andwritesuchmodificationsintotheessentialornonessentialsupports;

h. Asappropriate,teamsshouldidentifyasanessentialornonessentialsupporttheimplementationofcurrentplans(e.g.,nursingcareplans,healthmanagementplans,PNMPs,diets,exerciseprograms,etc.).Asnecessary,modificationsmightneedtobemadetothemethodologyforprovidingthesesupports,withtheendresultbeingtheindividual’sneedforthesupportbeingmet;

i. Forindividualswhohavespecifichealthcareindicatorsthatrequiremonitoring(e.g.,seizures,weight,aspirationtriggers,etc.),teamsshouldincludesupportsintheCLDPstoensurethatspecificstaffareresponsibleformonitoringsuchindicators,andwhenspecificcriteriaweremet,reportingthesetohealthcarestaff;

j. Asappropriate,crisisinterventionplansshouldbedeveloped,and/oressentialandnon‐essentialsupportsshoulddefinehowthecurrentmethodsfordealingwithcrisesattheFacilityshouldbemodifiedinacommunitysetting;

k. Directsupportstaffingratiosandrequirementsshouldbespecified.Inspecifyingstaffingsupports,teamsshouldidentifyspecificallytheindividual’sstaffingneedsinrelationtootherssupportedinthehomeorday/vocationalprogram(e.g.,ifanindividualrequiresline‐of‐sightsupervision,andotherindividualsliveinthehome,theteamshouldconsiderthisindescribinganappropriateratio),aswellasindifferentsituations(e.g.,inthehome,inthecommunity,atadayorworksite,atnight,etc.),aswellasthequalificationsofstaff(e.g.,specifictrainingrequirementsforstaff,competenciesorcertificationsneeded,etc.);

l. RecommendationsinassessmentsshouldbeaddressedspecificallyinCLDPs(e.g.,SPL,andOT/PTtherapyrecommendations,adherencetoweightreductionprograms,etc.),andjustificationprovidedforanyrecommendationnotincludedasanessentialornon‐essentialsupport;

m. Asrecommendedpreviously,CLDPsshouldclearlyidentifyanyactionstepsthathavebeenbegunattheFacility,butneedtobecompletedonceanindividualtransitionstothecommunity;

n. Particularattentionneedstobegiventoadequatelydefiningdayandvocationalsupports.Justlikeresidentialsupports,day/vocationalsupportsshouldbedefinedwithspecificity,includingstaffingrequirements,aschedulethataddressestheneedsandpreferencesoftheindividual,thetypeoftrainingthatshouldbeprovided,identificationofanyancillarysupportsthatneedtobeprovidedattheday/vocationalsite,suchasbehavioralorothertherapysupports,etc.Supportsthatneedtobeprovidedacrossdayandvocationalprograms,aswellasresidentialprograms(e.g.,nursing,psychology,therapy,etc.)shouldincludedaspartoftheday/vocationalcomponent;

o. Forindividualswithcomplexbehavioralormedicalneeds,communitysupportsadequatetomeettheirneedsshouldbeavailableupontheirtransition(e.g.,involvementofthecommunitypsychologist,psychiatrist,neurologist,etc.),andteamsshouldincludedatesthatmeettheindividuals’needs.IftheconversionofMedicaidfrominstitutionaltocommunityisabarriertotheprovisionofsupports,teamsshouldidentifythisasanobstacle;and

p. Focusedeffortshouldbeplacedonensuringeachofthesupportsidentifiedismeasurable.(SectionsT.1.c.1andT.1.e)8. Inadditiontoaddressingrecommendationsrelatedtoassessmentsinothersectionsofthisreporttoimprovetheoverallqualityof

assessmentsusedindevelopingCLDPs,modificationsshouldbemadetoassessmentsto:a. Provideasummaryofrelevantfactsrelatedtoindividuals’staysattheFacility.Althoughitisunderstandablethatanindividual’sfull

historycannotbeincludedinadischargesummary,itisimportantthattheFacilityprovidecommunityproviderswithasummaryof,forexample,treatmentsorplansthathaveparticularlysuccessfulorunsuccessful,andimportantmilestonesduringtheindividual’sstayattheFacility;

b. Assistteamsindevelopingacomprehensivelistofprotections,supports,andservicesinacommunitysetting.Assessmentsshoulddescribeorrecommendtheprotections,treatments,andsupportsthatanindividualrequires(e.g.,implementationofplans,staffingsupports,trainingforstaff,specificstaffqualifications,etc.),aswellasthespecificclinicalsupportsrequired(i.e.,qualificationsof


clinicalstaff,thefrequencyandleveloftheirinvolvement,etc.);andc. Identifysupportsthatmightneedtobeprovideddifferentlyormodifiedinacommunitysetting,and/ormakespecific

recommendationsabouthowtoaccountforthesedifferences.(SectionT.1.d)9. Aprocessshouldbeconsidered,particularlywithregardtothetransitionofmedicalandotherclinicalinformation,forasummarytobe

developed,includingbutnotlimitedtotheindividual’scurrentstatus,anyoutstandingissues(e.g.,testsdue,issuesforwhichresolutionhasnotbeenreached),aswellasanycriticalinformationabouttheindividual’streatment(e.g.,allergies,pasthistoryofmedicationuse,etc.).Thisshouldbecomprehensive,andnotjustincludegeneralmedicalinformation,butalsospecialists’involvementwithindividuals.Thiswouldfacilitatethetransitionofthisinformationtocommunitymedicalcareproviders.(SectionT.1.d)

10. TheStateandFacilityshouldconductcriticalanalysesofthetransitionplanningandimplementationprocessesforanyindividualswhoreturntotheFacility,whorequiremorerestrictivelevelsofplacementfromtheircommunitysetting(e.g.,aretransferredtoamentalhealthhospitalaftertransitioningtothecommunity),whosecommunitytransitionsareinjeopardy,orwhoexperienceotherseriousnegativeoutcomes.(SectionT.1.candT.1.e)

11. WithregardtomonitoringactivitiesrelatedtotheFacility’sperformancewiththissectionoftheSettlementAgreement,theFacilityshould:a. Modify,asappropriate,themonitoringtools,particularlytoimprovetheguidanceprovidedtoauditors;b. Ensurethereviewsaccuratelyevaluatequalityaswellasthepresenceorabsenceofitems;c. Establishinter‐raterreliability;andd. Analyzeinformationresultingfrommonitoringactivities,and,asappropriate,develop,implement,andmonitoractionplanstoaddress

concernsidentified.Suchplansshouldincludeactionsteps,person(s)responsible,timeframesforcompletion,andanticipatedoutcomes.(SectionT.1.f)

12. CCSSLCshouldreviewthetransition/dischargesummaryprocessthatitisusingforindividualswhoundergo“alternatedischarges”toensurethattherequirementssetforthbyCMSaremet,includingaprocessthat:

a. “[A]ccuratelydescribestheindividual,includinghis/herstrengths,needs,requiredservices,socialrelationshipsandpreferences”[42CodeofFederalRegulations(CFR)§483.440(b)(5)(i),andW203];and

b. Providesadischargeplan“sufficienttoallowthereceivingfacilitytoprovidetheservicesandsupportsneededbytheindividualinordertoadjusttothenewplacement”[42CFR§483.440(b)(5)(ii),andW205].(SectionT.4)


SECTIONU:Consent StepsTakentoAssessCompliance:Thefollowingactivitiesoccurredtoassesscompliance:

ReviewofFollowingDocuments:o PresentationBookforSectionU;o Copiesofletterssenttoprimarycorrespondents,currentLegallyAuthorized

Representatives(LARs),andpreviousguardiansforwhomlettersofguardianshiphadexpired,datedMay1,2012;

o CCSSLCpolicies,including: CorpusChristiStateSupportedLivingCenter–StatewidePolicyandProcedures,

Policy#057–Self‐Advocacy,dated5/30/12; Policy#UU.9–RightsandProtectionComplaintResolution,implementationdate

3/9/12; PolicyUU.11–ReviewofRestrictiveBehaviorSupportPlansandCrisis

InterventionPlansbytheHumanRightsCommittee(HRC),implementationdate5/1/12;

PolicyUU.12–ReviewofPsychotropicMedications,Pre‐SedationandSedationsforMedicalAppointmentsbytheHRC,implementationdate5/1/12;

CorpusChristiStateSupportedLivingCenter–StatewidePolicyandProcedures,Policy#019,–Guardianship,dated3/7/12;

o ISPAddendumtemplaterelatedtoprioritizationoftheneedforaguardian,undated;o SamplecompletedISPAddendumrelatedtoprioritizationoftheneedforaguardian,

undated;o CCSSLCprioritizedlistofindividualslackingbothfunctionalcapacitytorenderadecision,

andLegallyAuthorizedRepresentative(LAR)torendersuchadecision,undated;o Listofoneindividualforwhomanadvocatehadbeenobtained;o ConsentMonthlyReportforApril2012;o ReportonMissingGuardianshipLetters,dated7/12/12;o Self‐AssessmentforSectionU;o SettlementAgreementCrossReferencedwithICF/MRStandardsSectionU–Consent

monitoringtool;o ProvisionActionInformationforSectionU;o ActionPlansforSectionU;o TexasGuardianshipStatute‐ProbateCode,ChapterXIII.Guardianship,Sections601

through700;o TexasHealthandSafetyCode,Title7.MentalHealthandMentalRetardation,SubtitleD.

PersonswithMentalRetardationAct,Chapter591.GeneralProvisions,SubchapterA.GeneralProvisions,Section591.006.Consent;

o TexasHealthandSafetyCode,Title7.MentalHealthandMentalRetardation,SubtitleB.StateFacilities,Chapter551.GeneralProvisions,SubchapterC.PowersandDutiesRelatingtoPatientCare,Section551.041.MedicalandDentalCare;and

o TexasHealthandSafetyCode,Title7.MentalHealthandMentalRetardation,SubtitleD.


PersonswithMentalRetardationAct,Chapter592.RightsofPersonswithMentalRetardation,SubchapterA.GeneralProvisions,Section592.054.DutiesofSuperintendentorDirector.

Interviewswith:o KarenForrester,HumanRightsOfficer(HRO);ando KarenRyder,ProgramComplianceMonitor.

FacilitySelf‐Assessment:In itsSelf‐Assessment,theFacilityrecognizedthatitwasnotincompliancewiththerequirementsofSectionU.Sincethelastreview,theFacilityhadincorporatedsomerecordreviewsintoitsself‐assessmentprocess.However,muchofthedataincludedintheSelf‐AssessmentrelatedtoothersectionsoftheSettlementAgreement.Forexample,someoftherequirementsrelatedtotheHumanRightsCommittee’sreviewofpsychotropicmedicationwereincludedinthissection.ThesewouldbereportedonmoreappropriatelywithregardtoSectionJoftheSettlementAgreement.OtherconcernsrelatedtotheSelf‐Assessmentincluded:

ForSectionU.1,reviewsreportedlywerebeingconductedof“263ISPAs(forallindividuals)todetermineifGuardianshipPolicywasfollowedinsofarasGuardianshipPrioritydetermination.”Althoughthisactivityhadnotyetbeencompleted,itwasunclearwhatcriteriatheassessorswouldusetodetermineifthepolicyrequirementshadbeenmet.

OnceStateOfficeissuesproceduresforformallyassessingindividualsandpursingguardianshiporotherdecision‐makingresources,thentheself‐assessmentprocesswillneedtobemodified.Forexample,itwillbeimportantfortheFacilitytoconductauditstoensurethatteamsarecorrectlyidentifyingindividualswhomightneedguardiansorotherassistanceinmakingdecisions,thatindividualsareappropriatelyprioritizedonthelist,andthatadequateeffortsarebeingmadetoidentifyneededsupports.

ForSectionU.2,theassessmentmainlyrelatedtoreviewinglettersthathadbeensentouttocurrentguardiansand/orinvolvedfamilymembers.Althoughthiswasanimportantactivity,movingforward,assessmentofSectionU.2willneedtobebroader,includingassessmentofwhetherornottheFacilityasawholeandindividuals’teamsaremaking“reasonableeffortstoobtainLARsforindividualslackingLARs.”

Basedoninterviewswithstaff,sincethelastreview,aProgramComplianceMonitorhadbeenassignedtoSectionU.TheProgramComplianceMonitorandHumanRightsOfficerhadusedtheSettlementAgreementCrossReferencedwithICF/MRmonitoringtoolforSectionUtoconductjointreviewsinFebruaryandMarch.Inter‐raterreliabilitymeasurementsinMarchandAprilwere46%and58%,respectively.Abreakdownwasprovidedbyquestion.Reportedly,thetwostaffwerenowworkingtogethertodevelopbetterguidelinesforthetooltohelptoimproveinter‐raterreliability.Thiswasapositiveeffort.Oncetheconsentpolicyisestablished,itshouldbepairedwithfurthercompetency‐basedtrainingfromStateOfficetoensurethevalidityaswellasreliabilityofmonitoringresultsacrossFacilitiesforSectionU.SummaryofMonitor’sAssessment:Atthetimeofthereview,theStateOfficeGuardianshipPolicyhadbeendisseminated,butthepolicyonconsentremainedinthedevelopmentphase.CCSSLChadadoptedthe


StateOffice policyandhad beguntoimplementportionsof thepolicy.AlthoughteamsattheFacilityhadcompletedIndividualSupportPlanAddendatoidentifyindividuals’prioritylevelforobtainingaguardian,anumberofconcernswerenotedwiththeprocess.Asathresholdissue,prioritizinganindividual’sneedforguardianshipcannotbedoneadequatelyuntilaprocessisinplacetoscreenforanindividual’sneedforaguardian.Atthetimeofthereview,theprocessforassessingindividuals’“functionalcapacitytorenderadecision”andprovideinformedconsentwasstillnotbeingcompletedusinganadequatestandardizedtool.However,itwasanticipatedthattheStateOfficepolicywouldsetforthamethodicalapproachforscreeningindividualstodetermineapossibleneedforassistanceindecision‐making,and,asappropriate,assessinginmoredetailindividuals’functioninginthisarea.AlthoughproblemswerenotedwiththeprocesstheFacilityused,CCSSLCgeneratedaprioritizedlistofindividualsneedingguardians.Itincludedatotalof263names.Ofthese,167individualswereidentifiedasadultswithnoguardians,butneedingguardians,including43athighneed,102atmediumneed,and22atlowneedforaguardian.Therewere96individualsidentifiedashavingnoneedforaguardian.Sincethelastreview,noguardianshadbeenidentifiedforindividualswhoneededthem.CCSSLChadmadeeffortstoidentifypotentialguardianshipresources.Sincethelastreview,onesucheffortincludedsendingletterstoinvolvedfamilymemberstoinquireabouttheirinterestinpursuingguardianship,aswellascurrentguardianstodetermineiftheywouldconsiderbecomingguardianforsomeoneelse.However,atthetimeofthereview,noviableresourceshadbeenidentified.Itwillbeessentialthatadequateresourcesbeidentifiedtoaddressthisneed.Onapositivenote,asnotedinthelastreport,theFacilitywasimplementinganadvocacyprogram.Thisinvolvedtherecruitmentofvolunteerstoserveasindividuals’advocates.Advocateshadbeenidentifiedfortwoindividuals.Thispotentiallyprovidedaresourcetoassistindividualsindecision‐makingthatwaslessrestrictivethanguardianship.TheFacilityshouldbecommendedforitseffortsinthisregard.CCSSLCalsocontinuedtoprovidesupporttotheSelf‐AdvocacyGroup.Someoftheiractivitiesinvolvedassistingindividualstolearnabouttheirrightsaswellasdecision‐making.

# Provision AssessmentofStatus ComplianceU1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithinoneyear,eachFacilityshallmaintain,andupdatesemiannually,alistofindividualslackingbothfunctionalcapacitytorenderadecisionregardingtheindividual’shealthorwelfareandanLARtorendersuchadecision(“individualslacking

Since theMonitoringTeam’slast review,DADSStateOfficehadissuedPolicy#019:Guardianship,dated3/7/12.BasedoninterviewwithFacilitystaffanddocumentreview,CCSSLChadadoptedtheStateOfficepolicyandhadbeguntoimplementportionsofthepolicy.Asisdiscussedinfurtherdetailbelow,althoughsomeconcernswerenoted,teamsattheFacilityhadcompletedIndividualSupportPlanAddendatoidentifyindividuals’prioritylevelforobtainingaguardian.Asecondpolicyonconsentreportedlywasindevelopment.Sincethelastreview,becauseCCSSLCwasawaitingfurtherguidancethroughStateOfficepolicy,limitedprogresshadbeenmadewithregardtoconsentandguardianship.TheStateis

Noncompliance


# Provision AssessmentofStatus ComplianceLARs”)andprioritizesuchindividualsbyfactorsincluding:thosedeterminedtobeleastabletoexpresstheirownwishesormakedeterminationsregardingtheirhealthorwelfare;thosewithcomparativelyfrequentneedfordecisionsrequiringconsent;thosewiththecomparativelymostrestrictiveprogramming,suchasthosereceivingpsychotropicmedications;andthosewithpotentialguardianshipresources.

encouragedtofinalizetheconsentpolicy,becauseitshouldassisttheFacilitiesinmovingforwardwithregardtotheimplementationoftheSectionUSettlementAgreementrequirements.Asnotedabove,sincetheissuanceoftheStateOfficepolicy,CCSSLCteamshadmettoreviewallindividualstheFacilitysupportedanddeterminetheirguardianshipprioritylevel.AworkgrouphaddevelopedanISPaddendumtemplatethatteamsusedtostructureanddocumenttheirdiscussions.ThetemplateessentiallyrepeatedinquestionformatthecriteriaincludedintheSettlementAgreementandStatepolicyinrelationtofactorsthatmightprioritizeoneindividual’sneedforaguardianoveranotherindividual’sneed.Basedonreviewofdocumentationprovided,anumberofproblemswerenotedwithregardtotheimplementationoftheprocess:

BasedonthefewcompletedISPAstheFacilityprovided,itdidnotappearthatthefullteam,includingtheindividual,wasinvolvedinthedecision‐makingreviewprocess.Forexample,forIndividual#283andIndividual#182,accordingtothesign‐insheets,onlytheQDDP,nurse,andpsychologistwerepresentatthemeetings.ForIndividual#307,thesign‐insheetwasblank.Giventhatteamsreviewed263individualsineightdays,itwasunclearhowtheappropriatemembersofindividuals’teamscouldhavebeenpresentforthediscussions.

Amissingcomponentfromthisprocesswastheadequatescreeningand/orassessmentofindividuals“functionalcapacitytorenderadecisionregardingtheindividual’shealthorwelfare.”Thefirstfactortheteamwastoconsiderifanindividualdidnothaveaguardianread:“Doesthepersonhavealimitedabilitytoexpresstheirownwishesormakedeterminationsregardingtheirownhealthandwelfare?”However,notoolwasprovidedtoassistteamsinmakingthisdetermination,andlimitedcriteriawereincludedontheform(i.e.,“considerIDDlevelofmoderate/severeorprofound,moderatetoseverecommunicationstatus”).Withoutsomefurtherguidance,teamslikelywilluseinconsistentcriteriatomaketheirdecisions.ItistheMonitoringTeam’sunderstandingthattheStateOfficepolicyonConsentwillprovidefurtherguidance.However,untilthattime,teams’abilitytoassessindividuals’functionalcapacityislimited.

Inaddition,becausethisinitialfactor(i.e.,anindividual’s“abilitytoexpresstheirownwishesormakedeterminationsregardingtheirownhealthandwelfare”)wasweightedthesameastheotherthreefactorsdiscussedbelow,itappearedthatanindividualmighthavenoabilitytocommunicatehis/herwishesandnoabilitytomakeadeterminationabouthis/herhealthorwelfare,butifnoneoftheotherfactorswerepresent,he/shewouldnotbeplacedontheprioritizedlistforguardianship.

ThenarrativesincludedintheISPAsaddressingeachofthefourquestionsusedtoassistinprioritizinganindividual’sneedforaguardianvariedconsiderablyin


# Provision AssessmentofStatus Compliancedetailandquality.Forthequestionsrelatedtorestrictiveprogramming,frequencyofdecision‐making,and“active”familyinvolvement,similartowhatisdiscussedabove,limitedcriteriaorguidelineswereincludedtoassistteamsinobjectivelyquantifyingtheirdecisions.Forexample,activefamilyinvolvementwasdefinedasinvolvementonceayear,butthequalityofsuchinvolvementwasnotdefined;someexampleofrestrictiveprogrammingwereincludedonthetemplate,butitwasnotclearifthiswasmeanttobeacomprehensivelist;andalthough“3+”wasidentifiedforthecriterionforfrequentdecision‐making,itwasunclearifthelistoftypesofdecisionstobeincludedwasmeanttobeall‐inclusive.Thislackofdetailedguidanceappearedtoconfuseteams.Forexample,“No”wasmarkedforIndividual#307forthequestionaboutfrequencyofdecisionsrequiringconsent.However,thenarrativenoted:“Diet,Finance,wheelchairwithaseatbelt,andabedwithbedrailsandbedrailpadding.”Itwasunclearifthisconstitutedfourdecisions,and/orwhetherornottheteamhadconsidereddecisionsrelatedtohealthcare,routineconsentsthathadbeensigned,etc.

DuringtheinterviewwithstaffaswellasinreviewingthesampleISPaddendumrelatedtoprioritizationoftheneedforaguardian,itwasnotedthatifanindividualhadanadvocatethroughtheProtectionandAdvocacyagency,theywerenotplacedontheprioritylistforguardianship,eveniftheymettheothercriteria.Itwasnotclearhowthisdecisionwasmade.ThispracticewasnotdescribedintheStateOfficepolicy.Inaddition,theProtectionandAdvocacyagencyhasnoauthoritytomakedecisionsonanindividual’sbehalf.Therefore,ifanindividualrequiresaguardian(i.e.,lacksfunctionaldecision‐makingcapacity),regardlessofwhetherornottheyhaveanadvocate,theyshouldbeplacedontheprioritizedlistinalignmentwiththeotherfactorstheSettlementAgreementdetails.

Basedonthisprocess,CCSSLCgeneratedaprioritizedlist.Itincludedatotalof263names.Ofthese,167individualswereidentifiedasadultswithnoguardians,butneedingguardians,including43athighneed,102atmediumneed,and22atlowneedforaguardian.Therewere96individualsidentifiedashavingnoneedforaguardianAlthoughthenewpolicysetforthaprocessforprioritizinganindividual’sneedforguardianship,thiscannotbedoneadequatelyuntilaprocessisinplacetoscreenforanindividual’sneedforaguardian.Asnotedabove,aprocesshadnotyetbeensetforthtoscreenorassessanindividual’sfunctionaldecision‐makingcapacity.OncetheStateOfficepolicyisfinalized,CCSSLCshouldreviewandrevise,asnecessary,itspoliciesaswellastheprioritizedlist.Asnotedpreviously,thiswilltakeconsiderableeffort.BasedontheMonitoringTeam’sreviewofISPs,althoughteamsoftenidentifiedthat


# Provision AssessmentofStatus Complianceindividualsdidnothaveguardiansandhaddifficultywithdecision‐making,thediscussionappearedlimited.IntheISPsreviewed,teamsmadenodelineationofanindividual’spriorityneedforasurrogatedecision‐maker,andlittleplanningappearedtooccurinrelationtoalternativestoguardianshiporidentifyingpotentialguardians.Morespecifically,inreviewing10ISPsandrelatedaddenda,whichareidentifiedinthedocumentsreviewedsection,thefollowingwasfound:

Sixof10(60%)hadaguardianappointed. Twooftheremainingfour(50%)(i.e.,Individual#250andIndividual#228)had

ISPsorISPAsthatincludedadiscussionoftheindividual’sneedforaguardian.AsFacilitystaffpointedout,althoughtheRightsAssessmentsweregenerallybeingcompleted,littleconnectionwasfoundbetweenthemandtheISPs.

Noneoffour(0%)includedanadequateassessmentoftheindividual’s“functionalcapacitytorenderadecisionregardingtheindividual’shealthorwelfare.”Itisimportanttonotethattheteams’discussionswerenotinformedthroughthecompletionofavalidscreeningorassessmentprocesstoassisttheminidentifyingindividuals’capacitytomakedecisions,includingdifferenttypesofdecisions,and/ortothinkthroughsomeofthesupportsthatmightincreaseindividuals’decision‐makingcapacity.Nodiscussionwasdocumentedofwhetherornottheteamwouldrecommendlimitedguardianship,orifothersupportscouldbeprovidedtotheindividualstoassisttheminmaintainingsomeofalloftheirabilitytomakedecisionsforthemselves.

Twooffour(50%)(i.e.,Individual#250andIndividual#228)hadISPAsthatincludedadiscussionoftheindividual’spriorityfactorsforneedingaguardian.However,evenforthesetwo,concernswerenotedwithregardtotheadequacyofthesediscussions,andparticularly,theobjectivecriteriatheteamsused.Forexample,althoughmultiplerestrictivepracticeswerenotedforIndividual#250,herteamdidnotidentifyherashavingcomparativelyfrequentneedsfordecision‐making.”

AsnotedwhiletheMonitoringTeamwasonsite,itwillbeimportantfortheFacility’smonitoringandself‐assessmentactivitiestoevaluatethequalityofteams’activitiesrelatedtoassessmentofindividuals’functionalcapacity,identificationofviableoptionstoassistindividualswithdecision‐making,andprioritizationofindividuals’needsforguardianship.Asnotedinpreviousreports,theTexasGuardianshipStatuterecognizedguardianshipasarestrictiveprocedurethatrequireddueprocess.Thestatutealsoofferedlimitedguardianshipasalessrestrictiveoptiontofullguardianship.Therefore,itisimportantthatassessmentsofanindividual’scapacitytoprovideinformedconsentdetailtheareasinwhichhe/sheisabletomakeinformeddecisionsaswellasthoseareasinwhichhe/shecannotmakesuchdecisions.Further,itisimportantforsuchassessmentsto


# Provision AssessmentofStatus Complianceidentifyiftherearesupportsorresourcesthatcouldenableanindividualtomakeinformeddecisions,orincreasetheircapacitytomakesuchdecisions.Asnotedinpreviousreports,theSocialSupportsQuestionnairetheFacilityhaddevelopedincludedquestionstobegintohaveteamsthinkaboutareasinwhichindividualsmightbeabletomakedecisions,aswellaswaysinwhichindividualswereabletocommunicatetheirchoicesordecisions.However,itappeareduseofthisformhadbeendiscontinued.AsnotedintheMonitoringTeam’spreviousreport,theDADSGuardianshipProgramhadprovidedFacilitystaffwithtrainingonthevariousguardianshipoptions,aswellasalternativestoguardianship.ThishadoccurredinDecember2011.Basedonstaffreport,thetrainingwashelpfulineducatingstaffabouttherestrictivenessofguardianship,aswellassomeofthealternatives.AsnotedintheMonitoringTeam’spreviousreport,theFacilityhadbeguntoimplementanadvocacyprogram.Thisinvolvedtherecruitmentofvolunteerstoserveasindividuals’advocates.Sincethetimetheprogramhadbeenoperational,advocateshadbeenidentifiedfortwoindividuals,andanotherpotentialmatchwasbeingconsidered.Thispotentiallyprovidedaresourcetoassistindividualsindecision‐makingthatwaslessrestrictivethanguardianship.TheFacilityshouldbecommendedforitseffortsinthisregard.TheHumanRightsOfficerwasanadvisortotheSelf‐AdvocacyGroup.Someoftheiractivitiesrelatedtoexpandingindividuals’knowledgeoftheirrights,aswellasconsent‐relatedissues.Forexample,sometopicsincludeddiscussionsofprosandconsofcertaindecisions,suchasdecisionsrelatedtodietrestrictions.Sucheffortstoprovideeducationshouldassistsomeindividualstoexpandtheirdecision‐makingcapacity.Asdiscussed,itwillbeimportanttoexpandtheseefforts,andforteamstoindividualizethem.Theseinclude,butarenotlimitedtodevelopinginformationinformatsthataremoreeasilyunderstood,includingutilizingsimplerlanguage,orformatswithpictures;expandingindividuals’knowledgeaboutoptionsavailable(e.g.,makinginformeddecisionsaboutjobsorplacestolivemightrequireindividualstoseeandexperiencethedifferentoptions,ormakingadecisionaboutinclusionofpersonalinformationinanarticleinthenewslettermightrequiresomeonetoseethenewsletterand/orsomeoftheplacestowhichitisdistributed);andidentifyingspecificstaffingsupportstoassistanindividualtointerpretinformation(e.g.,signinterpreters,someonetoreadandexplaininformationinauser‐friendlymanner,etc.).Althoughsomelimitedprogresshadbeenmade,theFacilityremainedoutofcompliancewiththiscomponentoftheSettlementAgreement.TheFacilityhadaprioritizedlist,butanadequatestandardizedprocessfordeterminingindividuals’functionalcapacitytorenderinformeddecisionsstillwasnotbeingused.Inaddition,althoughteamswere


# Provision AssessmentofStatus Compliancebecomingmoreinvolvedintheprocess,includingtheidentificationof anindividual’sprioritylevelforguardianship,sufficientcriteriawerenotinplacetostandardizetheprocessacrossteams.OncetheStateOfficepolicyonconsentisfinalized,theFacilityisencouragedtoimplementitexpeditiously.

U2 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,startingwiththoseindividualsdeterminedbytheFacilitytohavethegreatestprioritizedneed,theFacilityshallmakereasonableeffortstoobtainLARsforindividualslackingLARs,throughmeanssuchassolicitingandprovidingguidanceontheprocessofbecominganLARto:theprimarycorrespondentforindividualslackingLARs,familiesofindividualslackingLARs,currentLARsofotherindividuals,advocacyorganizations,andotherentitiesseekingtoadvancetherightsofpersonswithdisabilities.

BasedoninterviewswithFacilitystaffandreviewofdocumentation,sincethelastreview,noguardianshadbeenidentifiedforindividualswhoneededthem.AsnotedintheMonitoringTeam’spreviousreports,theHumanRightsOfficerhadengagedinsomeeffortstoidentifypotentialguardianshipresources,includingcontactingacoupleoftheotherSSLCstodiscusstheireffortsinrecruitingguardians,andsomeprivateentitiesthatmighthaveresources.However,accordingtoCCSSLCstaff,therewerenoknownguardianshipresourcesavailableinthearea.Forexample,Facilitystaffhadnotbeenabletoidentifyanyfor‐profitornonprofitguardianshipentitiestowhichreferralscouldbemade.Sincethelastreview,theFacilityalsohadsentletterstoalloftheindividuals’primarycorrespondentsand/orguardians.Forthoseindividualswithguardians,theletterinquiredabouttheirwillingnesstoconsiderbecomingguardianforsomeoneelseattheFacility.Forthoseindividualswithlapsedguardianshipletters,theletterrequestedupdateddocumentation.Forindividualswithoutguardians,butwithinvolvedfamilymembers,thelettersincludedsomeinformationabouttheimportanceofguardianship,andinquiredaboutthefamilymember’sinterestinpursuingguardianship.Althoughthelettersgeneratedanumberoftelephonecalls,atthetimeofthereview,theyhadnotresultedinanynewguardiansforindividuals.Basedonsamplesreviewed,theHumanRightsOfficerwastrackingallrelatedcontactthroughtheIntegratedProgressNotes.OtherplansincludedtheHumanRightsOfficerpresentingatanupcomingFamilyAssociationMeeting.Inaddition,theSelf‐AdvocacyGroupandHumanRightsOfficerplannedtohaveaboothattheupcomingProviderFair.Guardianshipandconsentinformationwouldbeprovidedinthesevenues.AsindicatedintheMonitoringTeam’slastreport,theHumanRightsOfficeralsohadreinitiatedherinvolvementwithavolunteersurrogatedecision‐makingprogramthatofferedsupportstoindividualslivingincommunity‐basedICFs/DDthatdidnothaveguardians.Giventhepotentialconnectionsthatsuchavolunteerpositioncouldoffer,thiswasavaluableendeavor.AlthoughitappearedfromthetrainingmaterialsthatthiswasalegislatedprocessthatspecificallyexcludedindividualsatSSLCs,itraisedthequestionofwhetherornotitwouldbeavaluableprocesstopursueforindividualsattheSSLCs.

Noncompliance



CCSSLChadnotyetimplementedtheportionoftheStateOfficeGuardianshippolicythatrequireddevelopmentandoperationofaGuardianshipCommittee.AsdiscussedwhiletheMonitoringTeamwasonsite,thiswouldbeanimportantinitiativetobegintodevelop.Suchagroup,ifproperlyconstituted,mightbehelpfulinidentifyingresourcesrelatedtoalternativestoguardianship,potentialguardians,aswellasfundingtosupportindividualsforwhomtheguardianshipfeesprohibitthemfromapplyingtobecomeaguardian.Inaddition,continuedcollaborationwiththeotherSSLCswillbeessential.Forexample,asdiscussed,anotherFacilityhadidentifiedapotentialfundingsourcethroughthe“appliedincome”optionavailableforindividualseligibleforSupplementalSecurityIncome.Asnotedabove,thecurrentlistofindividualsrequiringguardiansincluded169names.Although,asalsodiscussedabove,giventhelackofadequateassessments,itwasnotclearifthiswasanaccuratenumber,itwillbeessentialthatadequateresourcestoaddressindividuals’needforguardiansbeidentified.TexasGuardianshipStatuteidentifiedanumberofpiecesofinformationthatthecourtmayconsiderinmakingitsdecisionregardingtheneedforguardianshipand,ifneeded,thetypeofguardianshipthatwouldbeordered(i.e.,fullorlimitedguardianship).Giventheknowledgethatindividuals’teamshaveregardingtheirstrengths,needs,andpreferences,teamscouldpotentiallyprovidevaluableinformation,bothintermsofwrittenreports,aswellasverbalinformation,regardingindividualswhobecomethesubjectofguardianshipproceedings.AstheStatefinalizesitspolicyonconsentandguardianship,itshoulddefinethepotentialrolesofSSLCstaffintheprocess.


1. TheStateshouldfinalizetheStateOfficepolicyonconsent,andimplementitassoonaspossible.Indoingso,itshouldconsiderincludinginthepolicythefollowing:

a. Anassessmentprocessthatclearlyidentifiesanindividual’sspecificcapacitiesaswellasincapacitiesrelatedtodecision‐making.Suchadetailedassessmentwouldpotentiallybehelpfulinaguardianshipproceeding,inwhichdecisionsneedtobemaderegardingfullversuslimitedguardianship;

b. Anassessmentprocessthatidentifiesalternativestoguardianship,includingpotentialsupportsorresourcesthatwouldeitherallowanindividualtomakeinformeddecisions,orincreasehis/herabilitytomakeinformeddecisionsovertime(e.g.,education,informationprovidedinalternativeformats,etc.);

c. DefinitionoftheroleofStateandFacilitystaffintheguardianshipprocess,includingpotentiallycompletingassessmentsforuseinguardianshipproceedings,participatinginguardianshipproceedings,andassistingintheidentificationofpotentialguardiansfor


considerationbytheCourt.(SectionU.1)2. OncetheStatepolicyisfinalized,theStateshouldprovidekeyFacilitystaffwithtrainingonitsimplementation.(SectionU.1)3. OncetheStatepolicyisfinalized,CCSSLCshoulddevelopand/orreviseitspoliciesrelatedtoconsenttoreflecttheStatepolicy.(SectionU.1)4. OncetheStateidentifiesthetoolsandprocessestobeusedtoassessindividuals’decision‐makingcapacity,teamsshouldscreen/assessall

individualsservedbytheFacility.(SectionU.1)5. Basedonitsmonitoringactivities,theFacilityshouldidentifyareasinwhichteamsrequirefurtherguidanceregardingtheirresponsestothe

questionsrelatedtoprioritizinganindividual’sneedforaguardian.Asappropriate,additionalguidanceshouldbedevelopedandprovidedtoteamswithagoalofincreasingconsistencybetweenteams.(SectionU.1)

6. Ifanindividualrequiresaguardian(i.e.,lacksfunctionaldecision‐makingcapacity),regardlessofwhetherornottheyhaveanadvocate,theyshouldbeplacedontheprioritizedlistinalignmentwiththeotherfactorstheSettlementAgreementdetails.(SectionU.1)

7. Effortsshouldbemadetoidentifyothersupportsthatmightassistindividualstomakedecisions.Theseinclude,butarenotlimitedtodevelopinginformationinformatsthataremoreeasilyunderstood,includingutilizingsimplerlanguage,orformatswithpictures;expandingindividuals’knowledgeaboutoptionsavailable(e.g.,makinginformeddecisionsaboutjobsorplacestolivemightrequireindividualstoseeandexperiencethedifferentoptions,ormakingadecisionaboutinclusionofpersonalinformationinanarticleinthenewslettermightrequiresomeonetoseethenewsletterand/orsomeoftheplacestowhichitisdistributed);andidentifyingspecificstaffingsupportstoassistanindividualtointerpretinformation(e.g.,signinterpreters,someonetoreadandexplaininformationinauser‐friendlymanner,etc.).(SectionU.1)

8. AsStateOfficepolicyrequires,theFacilityshoulddevelopaGuardianshipCommitteetoassistitinitseffortsrelatedtodevelopingalternativestoguardianship,identifyingguardians,andsecuringfundingforguardianship.(SectionU.2)

9. TheStateshouldconsiderseekingorprovidingfundingforaguardianshipprogramintheCorpusChristiareathatwouldberesponsiblefortheidentification,training,andoversightofguardians,suchasthoseprogramsthatareavailableinotherpartsofthestate.(SectionU.2)

10. Astheprocessesforassessingindividuals’capacitiestomakedecisionsareimplemented,itwillbeimportantfortheFacilitytoconductauditstoensurethatteamsarecorrectlyidentifyingindividualswhomightneedguardiansorotherassistanceinmakingdecisions,thatindividualsareappropriatelyprioritizedonthelist,andthatadequateeffortsarebeingmadetoidentifyneededsupports.Inadditiontoprovidingstatisticsandnarrativedescriptionsofactivities,theSelf‐Assessmentshouldincludeanalysesoftheauditresults.(FacilitySelf‐Assessment)

11. InadditiontotheFacility’seffortstodevelopbetterguidelinesfortheaudittool,oncetheconsentpolicyisestablished,StateOfficeshouldprovidefurthercompetency‐basedtrainingtoensurethevalidityaswellasreliabilityofmonitoringresultsacrossFacilitiesforSectionU.(FacilitySelf‐Assessment)


SECTIONV:RecordkeepingandGeneralPlanImplementation StepsTakentoAssessCompliance:Thefollowingactivitiesoccurredtoassesscompliance:

ReviewofFollowingDocuments:o NoterelatedtoCCSSLCPolicies–SectionV,relatedtorecordkeeping,indicatingno

changessincelastreview;o CCSSLCFilingandRetentionSchedule,revised10/1/11;o ListofPersonsResponsibleforManagementofRecords;o DescriptionofQualityAssuranceProcedures,effectiveMarch2012;o Plansofcorrectionresultingfromrecordauditsforlastthreemonths:“NoEvidence;”o MasterRecordOrderandGuidelines:HistoricalRecords,revised11/19/10;o MasterRecordOrderandGuidelines:InactiveRecords,dated3/10/11;o ActiveRecordOrderandGuideline,revised12/12/11;o IndividualNotebook:GuidelinesandRetentionSchedule,revised5/21/11;o MasterTableofContentsofPolicyandProcedure,dated3/15/12;o PolicyTrackingFY2012;o QualityAssuranceChecklistscompletedforlast10recordsreviewedbyFacilitystaff;o Samplesoftrainingmaterialsanddocumentationofcompletionoftrainingonrecently

approvedpolicies;o Forthelastthreemonths,trendingreportsforSectionVreviewedatmonthlyQA

meetingswithRecordsDepartmentstaff;ando PresentationBookforSectionV.

Interviewswith:o ElenaMenchaca,UnifiedRecordsCoordinator;o LilyRodriguez,UnifiedRecordsCoordinator;o EdesiriOnovughe,MedicalRecordsCoordinator;ando BlancaGoans,AdministrativeProgramSpecialist.

FacilitySelf‐Assessment:BasedonareviewoftheFacility’sSelf‐AssessmentwithregardtoSectionVoftheSettlementAgreement,theFacilityfoundthatitwasoutofcompliancewithallofthesubsections.ThiswasconsistentwiththeMonitoringTeam’sfindings.InitsSelf‐Assessment,theFacilityhadidentified:1)activitiesengagedintoconducttheself‐assessment;2)theresultsoftheself‐assessment;and3)aself‐ratingusingtheinformationcitedinthesectiononresults.AnumberoftheindicatorsincludedintheFacilitySelf‐AssessmentforSectionVhadmerit.SincetheMonitoringTeam’slastreview,theQADepartment’sroleinauditinghadbeendefined.Thiswasapositiveaddition.AlthoughanumberofconcernscontinuedtoexistwiththeFacility’sselfassessmentprocess,overtime,thisformatshouldbehelpfulinsubstantiatingtheFacility’sfindingswithregardtocompliance.Thefollowingconcernswerenoted:


SelectedresultsoftheFacility’sregularrecordauditsshouldbe includedinSectionV.1toprovideinformationabouttheadequacyofindividuals’activeandmasterrecords,andtheirindividualnotebooks.

AstheFacilityidentified,nowthataprocessisavailablefortrackingtrainingonnewpolicies,theFacility’sSelf‐Assessmentshouldreviewthisdata.

WithregardtoSectionV.3,theFacilityshouldassessifitiscompletingtherequiredrecordreviews,butalsoifanalysesofthedataarebeingusedtoimprovethesystem.TheFacilityhadaddeddataabouttheindividualrecordfollow‐upandcorrectionprocess.Thiswasverypositive.Additionalinformationshouldbeprovidedaboutthesystemicissuesidentifiedandaddressed.

WithregardtoSectionV.4,itwillbeimportantfortheFacilitytoincorporatethetopicsthepartiesagreedupon,andarenowincorporatedintotheMonitoringTeams’reports.

Inter‐raterreliabilitywillneedtobeestablishedwiththeQAandprogrammaticstaffresponsibleforconductingaudits.


Overall,theFacilityhaddemonstratedthatitwasbeginningtoincorporatesomeofthedataithadcollectedintoitsself‐assessmentprocess.Effortstoensurethevalidityandreliabilityofthedatawillbeimportantnextsteps,aswillusingthedatatoidentifyareasinwhichfocusedattentionisneeded.TheFacility’sprogressindevelopingaqualityassuranceprocessforSectionVisdiscussedinfurtherdetailbelowwithregardtoSectionV.3.SummaryofMonitor’sAssessment:CCSSLCcontinuedtomaintainActiveRecordsaswellasIndividualNotebooks.Facilitystaffalsocontinuedtoworktoconvertindividuals’historicalfilestotheMasterRecordformatStateOfficeissued.Asignificantamountofhistoricalinformationhadbeensenttoanoutsidevendortomaintain.TheFacilitycontinuedtouseanActiveRecordsDocumentationLog.Itidentifiedtypicalitemstobefiledforeachdiscipline.Thelogallowedarecordtobemaintainedofwhendepartmentssubmitteddocuments,andwhentheywerefiled.Asisdiscussedthroughoutthisreport,policiesandproceduresnecessarytoimplementtheSettlementAgreementwereinvariousstagesofdevelopment.Atthetimeofthelastreview,theFacilityhaddevelopedsystemstotrackdraftpoliciesthroughtofinalization.Sincethelastreview,theFacilityhadbeguntousethesystemithaddesignedtotrackthetrainingofstaffonneworrevisedpolicies.Apilotprojecttomaintaincopiesofupdatedpolicymanualsinvariousprogramandadministrativelocationsalsohadbeencompletedandwasbeingrolledoutacrosscampus.CCSSLCwasconductingreviewsofmorethantherequiredfiverecordseachmonth.AProgramComplianceMonitorfromtheQADepartmentalsohadbeenassigned.Effortswerebeingmadetorevise


thetoolsanddevelop guidelinestoimprovethereliabilityandvalidityofthemonitoringresults.Theprocessesforidentifyingtrendsthatneededtobeaddressedandputtingplansinplacetoaddressproblematictrendsremainedinthebeginningstagesofdevelopment.However,theRecordsDepartmentcontinuedtouseitsknowledgeofproblemswiththerecordstoworkwithsomeoftheotherdepartmentsonareasofneed.Forexample,theDayProgramDirectorwasbeginningtoimplementaplantomonitorskillacquisitiondatatoidentifymissingdata.TheChiefNurseExecutivealsohadcreatedasystemtomonitornursingstaff’sentriesintotheIntegratedProgressNotes.

# Provision AssessmentofStatus ComplianceV1 Commencingwithinsixmonthsof

theEffectiveDatehereofandwithfullimplementationwithinfouryears,eachFacilityshallestablishandmaintainaunifiedrecordforeachindividualconsistentwiththeguidelinesinAppendixD.

AtthetimeoftheMonitoringTeam’sreview,twofileclerkswereassignedtoeachunit.Thefileclerksassistedwiththemaintenanceoftherecords.AsindicatedintheMonitoringTeam’spreviousreports,allindividuals’ActiveRecordshadbeenconvertedtothenewTableofContents.Sincethattime,theStateOfficehadissuedrevisionstotheTableofContents,andchangeshadbeenmadeintheactiverecordsacrosscampus.FileClerkscontinuedtohaveresponsibilityformaintainingtheActiveRecords,forthemostpart.However,someexceptionshadbeenmadetothis.Someofthesedistinctionsweredescribedinthepreviousreport.CCSSLChadIndividualNotebooksforindividualspriortotheconversionprocess,andreportedly,allIndividualNotebookswereinplace.ResidentialCoordinatorswereresponsibleformaintainingthenotebooks.ThefileclerksremoveddatarelatedtoindividualsskillplansandPBSPsonamonthlybasis,andfileditintheactiverecords.Thefinalphaseoftheprocessinvolvedtheconversionofindividuals’historicalfilestotheMasterRecordformatStateOfficeissued.Basedoninterviewwithstaff,sincethelastreview,progresscontinuedtobemade.TheMedicalRecordsCoordinatorwasoverseeingtheconversionofrecords.Inaddition,informationthatcouldbestoredoffsitehadbeenpreparedandsenttoasecurewarehousefromwhichretrievalwasreadilyavailableshouldtherebeaneedfortherecords.Similartothepreviousreview,fromalimitedreviewofrecordswhileonsite,itwasnotedthatveryfewdocumentsweremissingfromtherecords.Inthepast,issueshadbeennotedwithregardtoNursingQuarterlyAssessments,NursingAnnualAssessments,andNursingHealthManagementPlans,butduringthisreview,theyweregenerallyfoundintherecords.Ofnote,anumberofrecords(e.g.,restraintrecords,PBSPs,etc.)weremissingfromtheMonitoringTeam’sdocumentrequests,butitwasunclearifthiswasduetothefactthattheydidnotexist,ortheywerenotfiledproperly.Asnotedinthelastreport,oneofthemechanismsthatseemedtohavehadapositive

Noncompliance


# Provision AssessmentofStatus ComplianceeffectwastheimplementationoftheActiveRecordsDocumentlog.Itidentifiedtypicalitemstobefiledforeachdiscipline.Thelogallowedarecordtobemaintainedofwhendepartmentssubmitteddocuments,andwhentheywerefiled.Thiswasanelectronicsystem,whichallowedfunctionssuchasauto‐populatingfields,andlinkingreferencestodocumentstotheirelectronicversion.Italsoallowedtrackingandtrendingtobecompletedmoreeasily.AsnotedintheMonitoringTeam’spasttworeports,theFacilityhadanActiveRecordCheckoutprocedure.Thisprocedurewentintoeffectanytimeanindividual’sactiverecordneededtoleavetheunit,forexample,formedicalappointmentsoranISPmeeting.Thispolicyaddressedanessentialcomponentofmaintainingcontroloverthesecurityoftherecords.TheFacilitycontinuedtomakeprogressinthisarea.Inadditiontoensuringthattherecordsaremaintainedproperly,thecompletionoftheMasterRecordconversionisnecessaryforcompliancewiththiscomponentoftheSettlementAgreement.ItwillbeimportantfortheFacilitytouseitsmonitoringresultstoidentifyanyareasinwhichtherecordsmightnotmeettherequirementsofAppendixDoftheSettlementAgreement,andtakeaction,asappropriate,tocorrectthem.

V2 ExceptasotherwisespecifiedinthisAgreement,commencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithintwoyears,eachFacilityshalldevelop,reviewand/orrevise,asappropriate,andimplement,allpolicies,protocols,andproceduresasnecessarytoimplementPartIIofthisAgreement.

Asisdiscussedthroughoutthisreport,policiesandproceduresnecessarytoimplementtheSettlementAgreementwereinvariousstagesofdevelopment.AsnotedintheMonitoringTeam’slastreport,theFacilityhaddevelopedsystemstotrackdraftpoliciesthroughtofinalization.Atthattime,aprocessalsorecentlyhadbeguntotrackthetrainingofstaffonneworrevisedpolicies.Sincethen,theprocesshadbeenusedtotracktrainingonnewandrevisedpolicies.Basedonareviewofasampleofpoliciesandtherelatedtraining,thetrackingprocessseemedtocapturetheessentialelements,includedwhoneededtobetrained,whowouldprovidethetraining,whocompletedthetraining,andthecurriculumused.Basedoninterviewswithstaff,theCompetencyTrainingDepartmentwasmaintainingthedata,sothatitcouldbeeasilydeterminedwhohadcompletedthetrainingandwhostillneededtocompleteit.SincetheMonitoringTeam’slastreview,thisprocesshadbeenformalizedinpolicy.Asanattachment,PolicyA.13includedaformatforfollowinganddocumentingtheprocessdescribedabove.TheQA/QICommitteewasinvolvedindecision‐makingaboutwhichstaffrequiredtraining.TheAdministrativeProgramSpecialistwasusingtheseformstofollow‐uptoensurethattrainingidentifiedasbeingnecessarywasprovidedtoallstaffforwhomtrainingwasrequired.Plansalsowereunderwaytoimproveaccesstopoliciesforallstaff.Bycreatinghyperlinkstotheelectronicversionsofpolicies,theAdministrativeProgramSpecialist

Noncompliance


# Provision AssessmentofStatus Compliancehadmadeitpossibleforthosewithregularcomputeraccesstohaveaquickmethodtofindspecificpolicies.Aprocessalsohadbeenpilotedformakingpapercopiesavailableinprogrammaticandadministrativeareas.Thepilothadbeensuccessful,andatimelinewasprovidedforrollingthisprocessoutacrosscampus.TheFacilitywasmakingprogressinupdatingand/ordevelopingpoliciestoaddressthevariousrequirementsoftheSettlementAgreement.However,itwasnotyetincompliancewiththisprovision.InadditiontocontinuingtodevelopandrevisepoliciesinconcertwiththeissuanceofStateOfficepolicies,theFacilityalsoshouldcontinuetoensurethatstaffthatrequiretrainingonthepoliciescompletethetrainingadequatetofacilitatethepolicies’implementation.

V3 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinthreeyears,eachFacilityshallimplementadditionalqualityassuranceprocedurestoensureaunifiedrecordforeachindividualconsistentwiththeguidelinesinAppendixD.Thequalityassuranceproceduresshallincluderandomreviewoftheunifiedrecordofatleast5individualseverymonth;andtheFacilityshallmonitoralldeficienciesidentifiedineachreviewtoensurethatadequatecorrectiveactionistakentolimitpossiblereoccurrence.

Progresshadbeenmadeand/orsustainedwiththisprovisionoftheSettlementAgreement.Positivedevelopmentsincluded:

TheUnifiedRecordsCoordinatorswereconductingrecordreviews. Basedonthedocumentationprovided,itappearedthatmorethanfivereviews

werebeingconductedeachmonth.Basedoninterview,atotalof10recordauditsweredoneeachmonth.

Sincethelastreview,aProgramComplianceMonitorhadbeenassignedfromtheQADepartment.InApril2012,recordreviewswereconductedtotrytoestablishinter‐raterreliability.TheProgramComplianceMonitorandUnifiedRecordsCoordinatorshadbeguntheprocessofwritinginstructionsforthetoolstoimprovethereliabilityandvalidityofthefindings.

TheProgramComplianceMonitorhadbeguntoselecttherecordsforreview. Toconducttheaudits,themonitorswerecompletingtheActiveRecordOrder

GuidelinesAuditTool,andthentheinformationcollectedwasusedtocompletethemonitoringtoolentitled“SettlementAgreementCrossReferencedwithICF/MRStandards–SectionV:RecordkeepingandGeneralPlanImplementation,Provisions1,3,and4.”

Inaddition,anindividual’steamforonerecordrevieweachmonthswasselectedforcompletionoftheStateOffice’sinterviewtooldesignedtosolicitinformationspecificallyaboutSectionV.4,whichrequirestheFacilitytoroutinelyutilizeindividuals’recordsinmakingcare,medicaltreatmentandtrainingdecisions.

IssuesidentifiedthroughthemonitoringprocesswithregardtoindividualrecordswereaddressedwiththespecificFileClerks.Individualizedtrainingortechnicalassistancewasprovided.Inaddition,emailsweresentrequestingcorrections,ifotherdepartmentswereinvolved.SincetheMonitoringTeam’slastreview,theFacilitycontinuedtheprocessofcheckingtodetermineifcorrectionshadbeenmade.Basedoninterview,attimes,secondemailshadtobesent,becauserequestedcorrectionshadnotbeenmade.

Noncompliance



Areasinwhichimprovementsshouldbemadeinordertoachievecompliance,included: Itisimportanttonotethatbasedonknowledgegainedfrominternalauditing

andsurveys,aswellasinformationthattheMonitoringTeamprovided,theFacilityhadtakenstepstocorrectissues.Forexample,theDayProgramDirectorwasbeginningtoimplementaplantomonitorskillacquisitiondatatoidentifymissingdata.TheChiefNurseExecutivealsohadcreatedasystemtomonitornursingstaff’sentriesintotheIntegratedProgressNoteswiththeintentionofidentifyingandcorrectinganyproblematicareas.However,noevidencewaspresentedtoshowthattheauditdatahadbeenanalyzedthoroughlytoidentifytrendsanddeterminetheotherunderlyingissues,and/oractionplansdevelopedtoaddresssuchissues.TheFacilityrecognizedthatthiswasthenextstepintheprocess.Sincethelastreview,theRecordsDepartmentstaffhadbeguntomeetwiththeProgramComplianceMonitortodiscussmonitoringresults,andhadspokentotheDataAnalysttoseekassistanceinaggregatingthedataandproducingreports.AttheMonitoringTeam’srequest,theFacilitysubmittedsomereportsthatshowedthebreakdownindataforSectionV.Themosthelpfulofthisinformationwasbrokendownbyquestion,asopposedtothegraphsthatprovidedoverallcompliancescoresthatweredifficulttointerpretinanymeaningfulway.

Effortshadbeguntoensurethatthoseconductingtheauditshadbeenproperlytrained,andthattherewasadequateinter‐raterreliability.Asnotedinothersectionsofthisreport,itisessentialthatinter‐raterreliabilitybeestablishedusingastandardizedprocess.Inaddition,accuracyofmonitoringisessential.Thiswillrequirethedevelopmentofadequateinstructionsandclearcriteriaforratingitemsontheaudittools.

AlthoughtheFacilitycontinuedtocompletesomeofthetasksthatrequiredwithregardtothisprovisionoftheSettlementAgreement,CCSSLChadnotbeguntoaggregateandanalyzeresultsofmonitoringdata,and/ordevelop,andimplementactionsnecessarytocorrectdeficienciesidentifiedsystemically.TheFacilityremainedoutofcompliancewiththisprovision.TheFacilityalsowasstillintheprocessoffinalizinginstructionsformonitoringtools,andestablishinginter‐raterreliability.

V4 CommencingwithinsixmonthsoftheEffectiveDatehereofandwithfullimplementationwithinfouryears,eachFacilityshallroutinelyutilizesuchrecordsinmakingcare,medicaltreatmentandtraining

Recently,theMonitorsandthepartiesagreedtoalistofactionsthattheSSLCswouldengageintodemonstratesubstantialcompliancewiththisprovisionitem.CCSSLChadnotincorporatedthisstructureintotheirinternalmonitoring.ThefollowingrepresenttheMonitoringTeam’sfindings:

Recordsareaccessibletostaff,clinicians,andothers:AlthoughCCSSLCwasnotyetself‐assessingthis,theMonitoringTeamobservedthat:

Noncompliance


# Provision AssessmentofStatus Compliancedecisions. o Onapositivenote,inanefforttoensureaccessibilityofcertain

documentsthatteamsneededtodevelopISPsandengageinrelatedactivities,PersonalFoldersforeachindividualweremaintainedontheshareddrive.

o AsnotedintheMonitoringTeam’slastreport,toaddressissuesrelatedtothetimelyfilingofinformationneededtomakedecisions,CCSSLChaddevelopedaprocesstotrackthesubmissionandtimelyfilingofinformationintheActiveRecord.Theimpactofthispolicyandtherelatedeffortsappearedtohavebeensignificant.Thisprocessappearedtohaveimprovedtheaccountabilityforthetimelyfilingofdocumentsintherecords.However,astheFacility’smonitoringactivitiesshowed,someissuescontinuedtoexistwiththetimelyavailabilityofdocumentsinActiveRecords.Thenewsystemwashelpfulinidentifyingwhereproblemshadoccurred,increasingaccountability.However,itcouldnotbedeterminedifmissingdocumentsfromtheMonitoringTeams’documentationrequestswereduetothedocumentsnotbeingcompleted,notbeingavailableintheactiverecords,orinadvertentlynotincludedintherequestedpackets.TheFacilityshouldcontinuetoensurethatdocumentsareavailable,andfiledinatimelymannerintheindividuals’records,sothatpertinentclinicalinformationisreadilyavailabletocliniciansneedingthisinformationwhenmakingdecisionsregardingtreatmentsandhealthcareservices.

o Generally,itappearedthatrecordswereavailableintheresidences,and,asneeded,atclinicappointments,inindividuals’meetings,etc.

Dataaredocumented/recordedtimelyondataandtrackingsheets(e.g.,PBSP,seizure):TheMonitoringTeamobservedsomeproblems.Forexample:

o Recordingofdataisakeypartofrecordkeeping,andtheintegrityofsuchdatacollectioniskeytotheclinicaldecision‐makingprocess.InreviewingthecollectionofdataforPositiveBehavioralSupportPlansandskillacquisitiongoals,itwasdeterminedthatstaffmightnothavebeenaccurately,consistently,andtimelydocumentingdata,andprocesseswerenotinplacetoensuredatareliability.Similarly,theMonitoringTeamregularlyfoundthatnursingstaffwerenotadequatelydocumentingongoingassessmentsand/ortheresultsofsuchassessments.

o Asnotedabove,theRecordsDepartmentwaspartneringwiththeDirectorofDayProgramstoimplementaplantomonitorskillacquisitiondatatoidentifymissingdata.TheChiefNurseExecutivealsohadcreatedasystemtomonitornursingstaff’sentriesintothe


# Provision AssessmentofStatus ComplianceIntegratedProgressNoteswiththeintentionofidentifyingandcorrectinganyproblematicareas.ItshouldbenotedthattheNursingDepartment’sfindingsof100compliancewithdocumentationintheIntegratedProgressNoteswasnotconsistentwiththeMonitoringTeam’sfindings,asdiscussedingreaterdetailwithregardtoSectionM.

Staffsurveyed/askedindicatehowtheunifiedrecordisusedasperthisprovisionitem:TheUnifiedRecordsCoordinatorswereaskingasampleofteammemberstocompletethequestionsthatStateOfficehadsentrelatedtoSectionV.4.BasedondiscussionswithRecordDepartmentstaff,theydidnotfindthistoolmeasurable,andhadrevisedit,andjustbegunuseoftherevisedform.

Observationatmeetings,includingISPmeetings,indicatestheunifiedrecordisusedasperthisprovisionitem:TheFacilityhadnotyetdevelopedaprocessforincorporatinginformationregardingtheuseofrecordsduringrelevantmeetingsintothemonitoringordatabaseforSectionV.4.Asdiscussedinpreviousreports,thisshouldincludeobservationsofavarietyofmeetingsinwhichinformationfromtherecordsneedstobeutilized(e.g.,psychiatricreviews,ISPmeetings,etc.).TheUnifiedRecordsCoordinatorsmightnotdothis,butsuchindicatorsmightbedistributedinothermonitoringtools,andthedatafedbacktotheRecordsDepartment.BasedontheMonitoringTeam’sobservationsandrecordreviews:

o AsdiscussedwithregardtoSectionFandSectionIoftheSettlementAgreement,althoughimprovementwasseen,ISPsandintegratedhealthcareplanscontinuedtolackconsistentevidenceofteamsmakingdata‐baseddecisions.

Althoughprogresswasbeingmade,theFacilityremainedoutofcompliancewiththisprovision.Teamswerenotconsistentlyusingdatatomakedecisions,andthequalityofdataandinformationintherecordsoftenwasnotadequatetoallowteamstomakewell‐informeddecisions.


1. CCSSLCshouldfinalizeconversionoftheMasterRecordstothenewTableofContents.(SectionV.1)2. TheStateandFacilityshouldconsiderrecommendationsregardingpoliciesandproceduresthatareofferedthroughoutthisreportasthey

developand/orfinalizepoliciesandprocedures.(SectionV.2)3. Effortsshouldensurethatthestaffresponsibleforconductingrecordauditsareprovidedwithnecessarytraining,adequateguidelinesand

criteriaareincludedintheaudittools,andinter‐raterreliabilityshouldbeestablished.(SectionV.3)4. Monitoringofrecordsshouldresultinactionsteps/planstoaddressindividualaswellassystemicissuesastheyareidentified.Asappropriate

andnecessary,suchactionplansshouldincludeactionsteps,person(s)responsible,timeframesforcompletion,andanticipatedoutcomes.As


theplansareimplemented,theyshouldbemonitoredtoensurethedesiredoutcomesarebeingachieved.Ifnot,theplansshouldbemodified.(SectionV.3)

5. Documentsshouldbesubmittedandfiledinatimelymannerintheactiverecordssothatpertinentclinicalinformationisreadilyavailabletocliniciansneedingthisinformationwhenmakingdecisionsregardingtreatmentsandhealthcareservices.(SectionV.4)

6. Asisspecifiedinothersectionsofthisreport,improvementsshouldbemadewithregardtothequalityofthedataandotherinformationthatisenteredintoindividuals’records.(SectionV.4)

7. EffortsshouldbemadetoensurethatIDTmembers,aswellasotherappropriatestaff,documentinandutilizetheIntegratedProgressNotesinamannerthatresultsintheprovisionofintegrated,qualitycaretotheindividualsCCSSLCsupports.(SectionV.4)

8. AstheFacilityexpandsitsself‐assessmentprocesses,forSectionV.4,anumberofdifferentmethodologies,including,forexample,interviewingstaff,observingmeetingsinwhichinformationfromtherecordsneedstobeutilized(e.g.,psychiatricreviews,PSPmeetings,etc.),andreviewingdocumentssuchasmedicalconsultationstoensurethatkeyinformationfromtherecordhasbeenconsidered.AlloftheseindicatorsmightnotbereviewedbytheUnifiedRecordsCoordinators,butmightbedistributedinothermonitoringtools.(FacilitySelf‐Assessment,andSectionsV.3,andV.4)

9. Furtherrefinementoftheinternalauditingprocessshouldoccur,includingestablishmentofinter‐raterreliability,analysisofauditresults,anddevelopmentandimplementationofcorrectiveactionplans.(FacilitySelf‐Assessment)


ListofAcronyms

Acronym/ Symbol Meaning≥ Greaterthanorequalto≤ LessthanorequaltoAAC AlternativeorAugmentativeCommunicationABA AppliedBehaviorAnalysisABC Antecedent‐Behavior‐ConsequenceADLS Assessment‐Discussion‐SkillPlanLinkADOP AssistantDirectorofProgramsADR AdverseDrugReactionAED AntiepilepticDrugAED AutomatedExternalDefibrillatorAFO AnkleFootOrthoticALS AdultLifeSkillsA/N/E Abuse/Neglect/ExploitationAPC Admissions/PlacementCoordinatorAPEN AspirationPneumoniaEnteralNutritionAPS AdultProtectiveServicesASHA AmericanSpeechandHearingAssociationAT AssistiveTechnologyBACB BehaviorAnalystCertificationBoardBCABA BoardCertifiedAssistantBehaviorAnalystBCBA BoardCertifiedBehaviorAnalystBSC BehaviorSupportCommitteeBID TwiceaDayBiPAP BilevelPositiveAirwayPressureBM BowelMovementBMI BodyMassIndexBMP BasicMetabolicPanelBSC BehaviorSupportCommitteeBSP BehaviorSupportPlanBUN BloodUreaNitrogenc Withcc CubicCentimetersCCC CompetencyofClinicalCertificationCBC CompleteBloodCountCCSSLC CorpusChristiStateSupportedLivingCenterCD CommunicationDictionaryC‐Diff ClostridiumdifficileCDC CentersforDiseaseControl


CEU ContinuingEducationUnitsCIP CrisisInterventionPlanCIR Client’sInformationRecordCLDP CommunityLivingDischargePlanCLOIP CommunityLivingOptionsInformationProcessCME ContinuingMedicalEducationCMP ComprehensiveMetabolicPanelCMS CentersforMedicareandMedicaidServicesCNE ChiefNurseExecutiveCNS CentralNervousSystemCOPD ChronicObstructivePulmonaryDiseaseCOTA CertifiedOccupationalTherapyAideCPAP ContinuousPositiveAirwayPressureCPR CardiopulmonaryResuscitationCPE ComprehensivePsychiatricEvaluationCRIPA CivilRightsofInstitutionalizedPersonsActCT ComputedTomographyCTD CompetencyTrainingDepartmentCV CurriculaVitaeCWS CertifiedWoundSpecialistDADS TexasDepartmentofAgingandDisabilityServicesDARS DepartmentofAssistiveandRehabilitativeServicesd/c DiscontinuedDCP DirectCareProfessionalDEXA Dual‐energyx‐rayabsorptiometryDFPS DepartmentofFamilyandProtectiveServicesDISCUS DyskinesiaIdentificationSystem:CondensedUserScaleDNR DoNotResuscitateDOJ UnitedStatesDepartmentofJusticeDM‐ID DiagnosticManualofIntellectualDisabilityDPN DentalProgressNoteDRA DifferentialReinforcementofAlternativeBehaviorDRO DifferentialReinforcementofOtherBehaviorDRR DrugRegimenReviewsDRM DiningRoomMonitorDRT DiningRoomTransporterDSM‐IV‐TR DiagnosticandStatisticalManualofMentalDisorders,FourthEdition,TextRevisionDSP DirectSupportProfessionalDUE DrugUtilizationEvaluationDVT DeepVeinThrombosisECU EnvironmentalControlUnitEDO EveningDutyOfficer


EDWR EstablishedDesiredWeightRangeEEG ElectroencephalogramEGD EsophagogaastroduodenoscopiesEKG ElectrocardiogramEMS EmergencyMedicalServicesENT Ear,Nose,andThroatER EmergencyRoomFACCWS FellowofTheCollegeofCertifiedWoundSpecialistsFAST FunctionalAnalysisScreeningToolFBI FederalBureauofInvestigationFDA FederalDrugAdministrationFNP FamilyNursePractitionerFSA FunctionalSkillsAssessmentFTE Full‐timeEquivalentGERD GastroesophagealRefluxDiseaseGFR GlomerularFiltrationRateGI GastrointestinalG‐tube GastrostomytubeG/J‐tube Gastrostomy/JejunostomyortransgastricfeedingtubeHCG HealthCareGuidelinesHCS HomeandCommunity‐BasedServicesHDS HomeDiningSupervisorHgbA1C HemoglobinA1CHIV HumanImmunodeficiencyVirusHMP HealthManagementPlanHMT HealthMonitoringToolsh/o HistoryofHOBE HeadofBedElevationHRC HumanRightsCommitteehs AtnightHT HabilitationTherapiesIBWR IdealBodyWeightRangeIC InfectionControlICAP InventoryforClientandAgencyPlanningICD InternationalClassificationofDiseasesICF/MR IntermediateCareFacilitiesforpersonswithMentalRetardationID/DD IntellectualDisabilities/DevelopmentalDisabilitiesIDT InterdisciplinaryTeamIED IntermittentExplosiveDisorderIHCP IntegratedHealthCarePlanILASD InstructorLedAdvancedSkillsDevelopmentILSD InstructorLedSkillsDevelopment


IM IntramuscularIM IncidentManagementIMC IncidentManagementCoordinatorIMRT IncidentManagementReviewTeamIOA Inter‐observerAgreementIPN IntegratedProgressNotesIRRF IntegratedRiskRatingFormISP IndividualSupportPlanISPA IndividualSupportPlanAddendumIT InformationTechnologyITC IntegrityTreatmentChecklistsIV IntravenousJ‐tube JejunostomyfeedingtubeLA LocalAuthorityLAR LegallyAuthorizedRepresentativeLON LevelofNeedLOS LevelofSupervisionLVN LicensedVocationalNurseLRA LaborRelationsAlternativesMAR MedicationAdministrationRecordMAS MotivationAssessmentScaleMBS(S) ModifiedBariumSwallowStudyMD MedicalDoctormg MilligramsMH MentalHealthMHMR MentalHealthMentalRetardationml millilitersMOM MilkofMagnesiaMOSES MonitoringofSideEffectsScaleMR MentalRetardationMRI MagneticResonanceImagingMRA MentalRetardationAuthorityMRSA Methicillin‐resistantStaphylococcusaureusn SampleofthePopulationAuditedN TotalPopulationBeingReviewedNADD NationalAssociationofDualDiagnosisNM NutritionalManagementNMT NutritionalManagementTeamNOO NursingOperationalOfficerNOS NotOtherwiseSpecifiedNP NursePractitionerNPO NothingbyMouth


NSAID Non‐SteroidalAnti‐InflammatoryDrugsO2 OxygenOCD ObsessiveCompulsiveDisorderOHR OralHealthRatingOIG OfficeofInspectorGeneralORIF OpenreductioninternalfixationOT(R) OccupationalTherapistPA PhysicianAssistantPALS PositiveAdaptiveLivingSkillsPBSP PositiveBehaviorSupportPlanPCM ProgramComplianceMonitorPCN ProgramComplianceNursePCP PrimaryCarePractitionerPECS PictureExchangeCommunicationSystemPEG PercutaneousEndoscopicGastrostomyPET PerformanceEvaluationTeamPFA PersonalFocusAssessmentPIT PerformanceImprovementTeamPMAB PreventionandManagementofAggressiveBehaviorPMM PostMoveMonitorPNM PhysicalandNutritionalManagementPNMP PhysicalandNutritionalManagementPlanPNMPC PhysicalandNutritionalManagementPlanCoordinatorPNMT PhysicalandNutritionalManagementTeamPNS PhysicalandNutritionalSupportsPO BymouthPOI PlanofImplementationPPD PurifiedProteinDerivativePRN Prorenata(asneeded)PSP PersonalSupportPlanPSPA PersonalSupportPlanAddendumPSR PsychiatricServicesReviewPST PersonalSupportTeamPT PhysicalTherapistP&T PharmacyandTherapeuticsPTA PhysicalTherapistAssistantRAT ReviewAuthorityTeamRATM ReviewAuthorityTeamMeetingREACT Respiration,Energy,Alertness,Circulation,andTemperature RD RegisteredDieticianRN RegisteredNurseRO RuleOut


ROM RangeofMotionRPC RestrictivePracticesCommitteeRPH RegisteredPharmacistRRC RestraintReductionCommitteeRT RespiratoryTherapistRTT ResidentialTreatmentTechnicianq EachQA QualityAssuranceQA/QI QualityAssurance/QualityImprovementQDRR QuarterlyDrugRegimenReviewQE QualityEnhancementQI QualityImprovementQID FourtimesadayQMRP QualifiedMentalRetardationProfessionalRN RegisteredNurseSA SettlementAgreementinU.S.v.TexasSA SpeechAssistantSAC SettlementAgreementCoordinatorSAO SkillAcquisitionObjectiveSAP SkillAcquisitionPlanSAMS Self‐AdministrationofMedicationSd DiscriminativeStimuliSEPR SupplementalExternalPeerReviewSFBA StructuralFunctionalBehaviorAssessmentSIB Self‐InjuriousBehaviorSLP SpeechandLanguagePathologistSLPA SpeechLanguagePathologyAssistantSOAP Subjective,Objective,Assessment,andPlanSPCI SafetyPlansforCrisisInterventionSPO SpecificProgramObjectiveSRB SociallyResponsibleBehaviorSSLC StateSupportedLivingCenterSSO StaffServiceObjectiveStat ImmediatelySTD Sexually‐transmitteddiseaseUGI UpperGastrointestinalUI UnusualIncidentUIMRT UnitIncidentManagementReviewTeamUIR UnusualIncidentReportUNT UniversityofNorthTexasUTI UrinaryTractInfectionTID Threetimesaday


TIVA TotalIntravenousAnesthesiaTOC TableofContentsTSH ThyroidStimulatingHormoneTST TuberculinSkinTestTWR TemporaryWorkReassignmentUA UrinalysisUTI UrinaryTractInfectionVFS VideoFluoroscopyStudyVNS VagalNerveStimulatorWAIS WechslerAdultIntelligenceScaleWBC WhiteBloodCountWC WheelChair