Saturday, January 7, 2017

The Second Part of a POC for The ICF/IID Program

In the first part of these installments, we discussed the fact that a POC must establish that in your plan you are going to fix the problem and who is going to address it and how they are going to address it.  Since the first part of the POC describes the individuals directly affected, who is going to set the corrective action in motion and how that person will do it, it is time to move on to the next part.

The second component of a POC requires the facility to identify everyone who may be affected by the deficient practice and how the facility will ensure that the deficient practice does not occur to someone else.  In simple terms, the survey team has usually looked at a sample of people.  Let's say you have a six-bed facility and they look at three people.  There are three other people who could have the same problem - even if surveyors only identified the problem for "One of three sampled individuals" this does not mean that individual number four might not have the same concerns or problems.  All this means is that the survey team did not look at individual number four and he or she may have the same issues.  To ensure that no individuals in the facility have the same issue or problem, the facility must identify how it is going to ensure the deficient practice does not affect others.

Thinking back to the last post, you will remember that the tag written was for failing to follow up on a physician's recommendation.   The POC has set forth that the IDTeam will meet, make recommendations and the QIDP will implement those recommendations.  The question at this point that must be considered is "Has the facility overlooked any other physician recommendations for anyone else residing in the facility?"  To answer the question, the ICF must address how it is going to ensure that anyone potentially affected has been reviewed.

At this point the POC may state something like the following:

The QIDP will review physician recommendations for individuals #2-6 (assuming it is a six bed facility) and ensure that no physician recommendations have been overlooked.  In the event that a recommendations has been overlooked, the QIDP will refer the recommendation to the IDTeam for review and direction per the guardian, surrogate, or individual as appropriate.

Based on the above statement, the POC now clearly indicates that the QIDP will be responsible to check and ensure that there are no other individuals in the home being affected by the deficient practice.  Further, if an  individual is being affected, the the plan indicates how it will be corrected.

For the third part of this series we will look at what must be done to ensure that the problem does not occur again.  This part is usually considered the "monitoring" to ensure the problem is caught or does not happen again section of the POC.  For our purposes it is the third part of a POC.



Sunday, December 4, 2016

The First Part of a POC for The ICF/IID Program


If you are familiar with the ICF world, then you know exactly what the title of this article means.  It means you have to write a POC or Plan of Correction for the program where you provide services.  No program wants to see a set of deficient practice tags, but the fact is you're going to seem them more often than not.  State surveyors are going to arrive, monitor your program and write tags from time-to-time.  Those tags are going to show up on a form 2567 and you're going to have to write a POC to address each one.

Writing a POC is not always as easy as it looks.  Most of us would like to simply write, "We made a mistake, we fixed it, we won't do it again," and be done with it.   Unfortunately, the state, especially Texas, will not accept this time of POC.  In fact, it can help to know that they are looking for specific things when you write your POC.  There is no way this blog can address all the potential deficient practice you may face, but we can look at the specific criteria that, if met, should help you get your POC approved and your program moving along in the right direction.

The first thing your POC must do is establish that you are going to fix the problem and explain how and who is going to fix the problem.  The state of Texas often views this as wanting to know how the corrections will be completed for the people identified as being immediately affected.   You can not, for example, simply say the facility is going to fix the problem.  You must be specific.  Let's say, for consideration, that you received a deficient practice tag for failing to do review a physician's recommendation for client #1.  In this case, your POC might start out something like below:

The QIDP will conduct an interim staffing for individual #1 to review the physician's recommendation for.....

With the above you have started the POC off with who, the QIDP, will do what, an interim staffing.  This may or may not be enough to satisfy the need of the POC.  It all depends on what the physician's recommendation was and when it was made.  For example, the physician might recommend an optional surgery.  At that point the IDTeam would simply need to review the recommendation as stated and perhaps have the following statement:

.....an optional surgery and determine the client and his guardian's decision.

On the other hand the recommendation may be specific such as a referral for a specialist.  That POC would be written as such:

....a specialist to see the client.  The QIDP will ensure the follow up appointment is scheduled and coordinated with the IDT.

With the opening of your POC and the first rule is you must determine who is going to fix the problem and how it is going to be addressed for the individual or individuals affected by the deficient issue.  Once you have made this decision and documented it in your plan, you can move on to the second part of correcting the deficient practice for your POC.

Next article will cover the second part of POC criteria. 

It should also be noted that the State of Texas presents an excellent training on the POC process at Texas POC Process

Friday, October 21, 2016

The IPP: A Changing Document

from: http://www.abbreviations.com/term/273975

The IPP (Individual Program Plan) is the core of active treatment, both formal and informal, for any Intermediate Care Facility (ICF).   For the most part the IPP, developed at the annual staffing, details the needs of the person as projected over the next year.  The goal of the IDTeam (Interdisciplinary Team) is to help the person develop an IPP that meets his or her needs and helps advance the person toward greater independence.  In a perfect world that IPP would be reviewed and updated at the next annual staffing.  Unfortunately, we do not live in a perfect world.

As you might imagine there is a lot that can go into an IPP.  Depending on the abilities of the person served an IPP might cover basic areas such as getting up in the morning and getting dressed to taking a bus to work at a local job placement.  The most important aspect of the IPP is that it has to be considered a "Changing Document".  That is to say that it must be flexible, or alive, for the IDTeam and for the person it is designed to serve.

When I have said that an IPP must be a "Changing Document" to staff and others, I have sometimes seen a blank stare returned to me.  It's the stare that says, "What?"  I have had people ask me if this means we must change it monthly, or weekly.  I have had others ask if we musth change it quarterly.  The changing of an IPP is naturally dependent on several issues. Those issues that make the document a "Changing Document" are as follows:

1.  The changing abilities of the person served - you may design an IPP to teach a person how to use a washing machine.  The person may have an IPP designed to spend a year learning the washing machine; however, he or she masters the use of the washing machine in six months.  At this point the IDTeam must consider that the individual's abilities have changed and that he or she now needs to progress to something else.  It may be a move to the dryer, ironing, or even hanging up clothing.  Whatever the IPP changes to will depend on the IDTeam's review and assessment of the person's abilities.

2.  The changing of the person's environment - perhaps the individual has a job at a local restaurant.  The IPP may address this with a service goal that says something like, "Johnny will attend to his part time job at the local restaurant each assigned day that he is on shift."  Maybe for some unforeseen reason Johnny has a change in jobs.  Maybe he stops working at the restaurant, maybe he gets a different job with a lawn company, or maybe he is fired.  Whatever has happened, Johnny will need to have his IPP changed or modified to meet the changing environment that he has now found himself living in with regards to his IPP.

3.  The changing of a person's needs - This could happen in several ways.  Maybe the individual has never needed glasses, or hearing devices, or a walker before in his life.  Suddenly, a change in his needs means that he now needs - just for example - glasses.  Although the IPP has never addressed adaptive equipment before and the staffing may still be four months away, the change in the person's needs now supports a change in the IPP.  Assessments must be completed and the IDTeam must determine how the IPP will address the new adaptive equipment.

5.  A change in the person's behavior management needs - the fact of the matter is we all have "behaviors".  Some behaviors are good, some are bad.  Sometimes we may have no negative, or bad, behaviors at all and then for some reason we start having negative behaviors.  When this happens, the IDTeam should follow a strict review process and implement the least, intrusive, corrective measure possible.  For example, the individual might start being physically aggressive.  The IPP would need to be modified to address those changes.  This modification could include new informal goals, new formal goals, a behavior intervention plan of some sort, additional supervision or possibly psychiatric medications.  Whatever intervention may come, the IPP should be modified to handle the changes and needs of the individual.

Now if you are paying close attention, you may have noticed that I skipped number four above.  Number four is that mysterious factor - just as mysteriously it is missing in the list.  It's what I like to refer to as the following:

4.  Anything else mysterious, unforeseen or unexpected that the IDTeam may encounter - there are any number of possible factors here that can affect the unexpected or unforeseen.  Maybe the person served suffers a loss of a parent - the IPP might need to be modified to incorporate counseling for the person.  Maybe the person has some other life-changing event that the IDTeam has not considered.  Whatever that unexpected or unforeseen "Anything Else" might be, the IPP should address it in some way.    Hopefully, the unforeseen will be something as simple as a need to brush teeth better and not something major of life altering.   However, if the unknown or unexpected happens, the IDTeam has a responsibility to remember that the IPP stands ready as a "Changing Document" to meet the person's new needs.

Monday, July 18, 2016

Surveyors Who Interpret Standards


You read the headline and thought to yourself, "A surveyor would never interpret the standards would they?"  The federal and state standards are clearly written, state exactly what they mean, and really should have no room for interpretation right?  You would think that it would be clear and cut, but unfortunately that is not always the case.  

Imagine you have been faced with an issue and had to take some action either as the QIDP or the Administrator.  It really does not matter what the issue is, we can just assume it is any issue that could be considered a minor or major issue depending on how you look at it.  You read the standards and it clearly says "If this happens, then you should do this."  You look at the guidelines and decide what your organization is going to put in place to fix the problem.  Done right?  Well, maybe....

Two weeks later your annual survey shows up so naturally the action you have taken to correct a problem comes into the surveyor's sight.  They ask the routine questions such as "What happened," "What action did you take?" "What was the result?" "Did notify XYZ?"  You're able to answer all the surveyor's questions in order and with a reasonable answer....then it happens....out of the wild blue yonder the surveyor says, "Well did you do this?"  You answer honestly and say, "Well no, I did not consider that and did not do that."  .....Bam, the next thing you know the surveyor makes that statement, "Well, you know this is deficient practice and I'm going to have to cite this....."

If that has never happened to you, then congratulations!  If on the other hand, you have faced the human surveyors, many who have been QIDPs before with their own ideas of what is right and what is wrong to do, then you have likely been subject to that area you did not consider.   Whatever the case may be, many of us have found ourselves sitting there and thinking, "Well that's not in the tags...."

So, how can you handle these situations?  I have on a few occasions been faced with this difficult situation.  Now, do not misunderstand me, I completely understand where the surveyor is coming from and often agree that the question makes sense and it is something that the organization should have or might have considered doing, but ultimately it simply is not part of the standards.  I have found it best to handle these situations in a couple of ways.

The first way I have handled them is to confront the surveyor directly.  I might say, "Well, I see what you are saying, but we did not consider that because it was not in the standards and we did not feel we need to exceed standard requirements on this issue."  That goes over well sometimes, and sometimes it goes over like a lead weight.  If it does the later, then I usually indicate that I would like to talk to the program manager about the issue and do that.

The second way to handle these issues is to simply express your disagreement, or not, and wait for the tags to arrive.  You can then assess the tags, discuss possible responses to the tags, and even consider arguing the tags through your state's dispute.  Remember, in most cases the surveyors understand if you decide to follow your state's dispute route - that's what it's there for - disputes. 

The final thing to consider is that after you've talked with the surveyor and expressed your views simply drop it.  It's entirely possible that the surveyor will go back to the office, reconsider, or even be told by supervisors that they should not cite the particular situation.  In those cases, and I have seen some, you will receive deficiencies that never mention the item the surveyor brought up.  When this happens, it just confirms my faith that the surveyors are just as human and subject to errors as we are in the field. 

Thursday, May 19, 2016

ICF/IID: Privacy During Medication Pass and W130

From
It several parts of Texas privacy during medication pass has become a focus issue in the ICF/IID homes during surveys.  Recently one home was cited for giving medications at the dinging room table and the tag used was W130.

W130 does deal with privacy and specifically states "ensure privacy during treatment and care of personal needs".  That seems straight forward enough, but if someone wants additional clarification, the guidelines for surveyors provides the following:
"Clients must be provided privacy during personal hygiene activities (e.g., toileting, bathing, dressing) and during medical/nursing treatments that require exposure of one's body.

People not involved in the care of the client should not be present without their consent while they are being examined or treated.

Whenever possible, the facility should be sensitive to clients’ preferences for same sex care in private situations. "

The above clarifies that privacy during certain activities is required.  However, some facilities are receiving citations for giving oral medications in front of others.  W130 was written because the medications were provided in front of others.   It could be argued that the section of the guideline stating that "People not involved in the care of the client should not be present without their consent while they are being examined or treated" means that a privacy should be maintained during oral medication pass as well.  However, it would be more likely that this statement is referring to an examine or treatment with a physician or nurse that requires "exposure of one's body" in some specific way such as removing a shirt, pants, etc.  It could also be assumed that the "treated" part of this guideline also refers to when there is "exposure of one's body" as stated in the previous sentence.  The case could be made that treated also refers to an oral medication pass, but I think this point could be argued on the basis that there was no "exposure of one's body".

Looking at the guidelines, it is hard to equate taking a pill with "medical/nursing treatments that require exposure of one's body".  The only example noted in the deficient practice was that the individual took his medications in front of others.  It was not noted whether he objected or wanted the other people around or not.

Had the facility been prepared for an Informal Dispute Resolution (IDR) in Texas, it might have been the time to move forward with one.  The use of W130 for an oral medication seems to be a stretch at best, but had it been connected to a discussion of the medications, then it might have been clear what the problem was in this instance.  For example, if the individual took a specific medication for cancer treatment, then his privacy would have been violated had staff discussed what the medication was used for in front of others at the table.    The final result was that the facility administration really had no idea what was done wrong, but wrote a Plan of Correction (POC) all the same and submitted it for review.  The facility will likely clear a follow up visit and move forward.  It would be logical to assume that if this trend continues, private providers are going to be forced to strongly consider the IDR process.

Source: Page 53:   ICF/IID Standards




Friday, April 29, 2016

Texas Supportive Decision Making Act and the ICF/IID Programs

from
Provider letter 16-13 (  Information Letter No. 16-13 — Supported Decision-MakingAgreement Act ) introduced the Supported Decision Maker to just about every program in the state of Texas as an alternative to guardianship.  Unfortunately, for the ICF/IID programs, it ultimately presents more concerns than it does supports and may really be a problem for ICF/IID use.

The act presents a “Supported Decision Maker” into the equation for ICF/IID, or a SDM.  It should not be confused with a “Surrogate Decision Maker” from the Surrogate Program that is also known as an “SDM”.  This act is entirely separate from the surrogate program.  It does present some potential concerns when dealing with the surrogate program for individuals who have always depended on that program.

A quick read through the role of an SDM will indicate that the SDM is to gather information and to communicate the individual’s “life decisions”.  This is all done after the individual (the client in the ICF/IID) signs a supported decision-making agreement with the person who will serve as the SDM.   The SDM does not make the decisions, but only helps the person make the decisions and then communicates the person’s decision to the appropriate person(s).  It sounds all straight forward in a basic reading.

After reading over the entire act, the sample agreement, and the responsibilities of the SDM, there are several concerns that may need to be addressed by the next legislative session:

1.  This act does nothing to resolve the “waiting” period faced by ICF/IID providers when it comes to the Surrogate Decision Making Program.  The program often can take months to complete and obtain a legal consent for things needed immediately such as psychotropic medications.  The facility and IDTeam usually has no choice except to give the medications while consent through the Surrogate Program is being sought.  A better use for the SDM would have been to have this person make a decision pending a Surrogate Decision Making Committee’s review of the decision, but that application would only apply to ICF/IID programs that use the Surrogate Program.

2.  This act allows 14 year olds to sign the agreement as a witness.  Since a 14 year old is not a legal adult, there can and will likely be problems with those signatures being considered “legal” witnesses to the agreement.

3.  The act assumes the person with the disability requires assistance with making decisions without any assessment to determine if that individual needs assistance.  Further, if the individual needs assistance in making decisions, then who decides the individual with disabilities has the ability to understand and sign the agreement to obtain an SDM?

4.  Some providers may see this as an avenue to avoid the Surrogate Decision Making Program’s long, and often paperwork intensive, procedures.  If a facility does decide to use the SDM and avoids the Surrogate program, what grounds will a surveyor have to cite the facility regarding consents?  Will the surveyor refer to prior Surrogate use?  The new law creates some confusion here since the SDM presents information and communicates the person’s decision.  If the decision is “I want to take Risperdal,” and that is communicated, then in theory the IDTeam could accept this as consent without using the Surrogate Program.  Again, this is going to create issues for the surveyor and the provider as to how to defend their cases for or against deficient practice.

5.  The act also gives no consideration to the level of disability.  It simply “assumes” that a few questions can be presented to anyone with disabilities and he or she will decide they “want” an SDM.  Based on the wording, a person with Profound Intellectual Disabilities who simply nods his or her head at the right time during questions, could sign the agreement.  The SDM could then present that individual’s “decision” to the rest of the IDTeam based on whatever efficient level of communication the SDM has with the individual.   There would be no way of telling if the person really wanted the SDM or really made the decision as presented.   

6.  The act does not give any consideration to other assessments.  For example, if a person has been using the Surrogate Program for consent for psychotropic medications – does the assessment from the previous Surrogate Application mean the person can not obtain a Supportive Decision Maker?  If the person does obtain a SDM, what grounds does that leave for surveyors who believe the person can not give consent?

7.  Since anyone can be an SDM in this program, it means that Administrators, QIDPs, Managers and even direct care staff could sign the agreement.  For that matter, a person’s physician could sign the agreement, present the information to the person, and then communicate that person’s decision to the facility regarding surgery, medications, etc.  This would then mean that consent is assumed by the person’s decision.

Overall, the Supportive Decision Making Act can likely be a benefit to many programs in the state.  It has been applied to the ICF/IID programs, but probably should not have been.  It will create confusion and in some cases such as situation when a surveyor writes deficient practice pertaining to consents, the SDM may be the fall back defense in an Informal Dispute Resolution (IDR) or even a lawsuit presented by the provider or the SDM.  In theory, the provider could present that the SDM provided the individual’s decision regarding an issue and that the decision was then accepted as consent.    In such a case as this, should it reach a legal level, it would be up to a court to determine if the person had ever been “deemed incompetent in a court of law,” and usually if they have not, then the court considers that person competent to make his or her own decisions. 





Tuesday, April 19, 2016

The Most Overlooked Disaster Item in the ICF/IID

The state and federal standards are the minimum requirements needed to operate an ICF/IID program and those standards are often low in all areas including disaster plans.  In Texas, a disaster plan has a good deal of items and information required.  You must have food, clothing, medications, etc. as a norm.  There is one important issue that the state requirements overlook when it comes to disasters.

Consider the potential for a disaster at your facility.  You have made preparations.  You have all your required supplies, you have a disaster plan, and you have staff willing to work during the disaster.  The day comes and disaster strikes.  You are not required to evacuate, but your facility is without power, without water, and without phone service.  You expect it is going to be three to four days before these items are restored.  Your staff use flashlights at night, all the medications you need are on-site, you have water, you have food, and things are going along just fine.  You can not see any potential problems, until someone has to go to the restroom.  Because your facility is in the middle of town, it's not like you can go out into the woods.  No, you are stuck with two options.  You could use your three day supply of toilet paper, because you know you have those standards supplies on hand as all ICF/IID programs should.  Once you use your bathroom though you are faced with a major problem.  You could use some of your drinking water to flush the toilet, and hope that the sewer lines are not part of the services that have been cut, or you could have everyone use the toilet and simply leave it until the utilities are back.  The problem with leaving it is that it becomes smelly, it promotes a potential health hazard, and depending on how long the crisis last, it could be a major issue to flush the toilet once utilities do come back.   That's your first option in a nutshell, or you could be prepared.

The second option that you could have in place is to purchase five gallon buckets - the kind you find at hardware stores - and go to a sporting goods store and purchase a toilet seat made for the five gallon buckets - yes, they make a special seat to attach.  Now the people you serve can use the toilet with dignity and still within the bathroom.  Once finished, the bucket can be emptied into a trash bag or cleaned through another approved method.  Between bathroom usage, the bucket can be put outside.  This will help avoid the smell, the health hazard, and the potential for a really bad clogged toilet once the power and utilities do come back.  You may want to consider a few of these buckets so that rotations can be maintained.

The bottom line is the state's directives for a disaster plan and supplies is good, but it does not cover everything.  Consider bathroom needs and the preparation that can go into getting ready for a disaster to ensure you face no problems.

I am not trying to promote anyone's website, but here is a link to a potential toilet bucket - just remember, you can get your own going easily through places like Lowes and Home Depot, and there are several other organizations selling complete kits as well: Bucket Toilet Example 

Saturday, April 2, 2016

"Real" Money for Training in the ICF/IID Program

Source
If you are in Texas, if you go through annual surveys, and if you have individuals living in the ICF training on money management skills (you better have) then you may have faced the "Fake Money" issue.  There are several ICF programs in Texas that have received deficient practice for failing to use "Real" money in their training programs.  Often these programs note several reasons for not using real money such as "The clients will take it," "The staff will take it," or "Real money simply disappears."  By most people's standards, those are all good reasons to make fake money.  The fact is a small purchase of "Fake" money can cover bills and coins ranging from pennies up to hundred dollar bills for training.  If they are lost, torn up, or even thrown away there is usually plenty more in the set to be used (see picture above).  The argument sounds solid until the surveyor walks through the door.

If you have gone through a survey and had "Fake" money, then there is a good chance that it was an area of concern at the least, and possibly written into deficient practice at the most.  Several sets of deficient practice I have seen have listed it as an example under Active Treatment or the famous "W159" or as some call it "The QIDP Tag".  There has always been the possibility of filing an Informal Dispute Resolution (IDR) in Texas over the issue, but the fact is the example of the "Fake" money is usually worked into a tag with several other issues.  In the end you might get the example removed, but in most cases you would still have the tag to contend with for your plan of correction (POC).

After a home recently received the "Fake" money as an example under a tag, I decided to read the specific tag that was written.  This, as warned above, was a situation where several examples were listed to support the tag and planning an IDR simply was not as feasible as correcting the tag.  ONce you start looking at the Federal Standards, you can find the word "Money" mentioned 19 times.  Since "Fake" and "Real" "money" was the issue, there was no reason to search anything else.  Out of the 19 times money is mentioned, the tie to training only falls under tag W126.

W126 deals with encouraging and allowing the individuals (clients) to manage their financial affairs and for the facility to teach them how to manage their money if they do not know how to do it.  It is not until you read into the guidelines that you find the mention of money brought up.  Remember, these guidelines are the guide for surveyors to use when they are in the facility.  In the third full paragraph we find the following statement:

"Money management includes a broad spectrum of programs with varying levels of participation by the client ranging from the use of choice in money expenditures, to an understanding of the concept of money, and ultimately to actual money handling and budgeting. The IDT must not conclude that a money management program is inappropriate based solely upon the level of intellectual or physical disability of the client."

The first thing the reader will notice is that money management "includes a broad spectrum of programs and varying levels of participation".  This statement supports the IDTeam's efforts for some people to manage checkbooks, others to take care of banking needs, and still others to study the meaning and use of something as small as a penny.  In other words, through assessments the IDTeam has to determine at what level and what training the individual needs for money management.   The next interesting thing to note is that the guide states "...ultimately to actual money handling".  This statement would seem to support a facilities use of "Fake" money and even the use of pictures, or references of some kind to something other than actual money.  So, with this in mind, how can the facility use fake money in a world where the surveyors seem to insist on "Real" money for training only?

You basically have two choices.  You could simply use real money and avoid all confrontation.  That would be the simple method.  The second method you could use is documentation.  Documentation would need to be very strong for your case.  For example, what are the reasons you can not use "Real" money?  Maybe it's a case where the person you are training eats the money, throws it away, tears it up during training, etc.  Is there a plan to work toward "Real" money eventually?  You would clearly need to demonstrate the pattern.  For example, a person might use "Fake" money because he tears it up, but part of his training is to not tear the money up.  So, at some point, "Real" money could be used - remember the guidelines state your goal is "ultimately to actual money handling."

There are multiple ways that an IDT could address the issue and justify the use of "Fake" money for training.  However, the bottom line is that you must have solid documentation, justification, and a goal in place to work toward the eventual use of "Real" money.  If you put these in place, it is doubtful that most surveyors would write an example of "Fake" money into deficient practice- and while doubtful that they would write the "Fake" money into deficient practice, it is almost a certainty that they would not write it under W126.   Remember, the surveyor writes the 2567 in such a way that it can stand alone as evidence.  This is done to protect the survey process, the individual's we serve, and to ensure that should the 2567 be called into question through an IDR or another avenue of review, it can stand as evidence alone of the deficient practice.

One final thought before you go out and buy up ton's of "Fake" money to use.  Do your documentation as discussed above, and consider contacting your program manager for the region you operate in (if in Texas).  Talk with the Program Manager about your reason for wanting to use "Fake" money.  If you do that, then odds are the Program Manager will talk with surveyors before they come to your facility.  You may be able to avoid having "Fake" money as an example in the 2567, and you will not have to waste time and resources with an IDR for what will likely be an example in a tag only.

Reference:
State Operations Manual. Washington: U.S. Dept. of Health, Education, and Welfare, Social Security Administration, 2015. CMS. CMS, 14 Aug. 2015. Web. 2 Apr. 2016. W126 page 48-49

Monday, February 15, 2016

The IDTeam Approach

Too often QIDP/QDDP's feel the urge to cure or come up with all the answers.  It is not entirely the QIDP's fault.  It often goes back to the organization that places everything on the shoulder's of the QIDP.  The general feeling becomes "Send it to the Q, he or she will know what to do."  While all QIDP's wish they had all the answers, the fact is nobody has all the answers.  This was recognized years ago when the federal standards for ICF/IID programs were first developed.  That is why the standards set forward the need for an IDTeam approach.

For the few reading this who may not know, IDTeam stands for Interdisciplinary Team.  Just like the word says, it means a team approach from a group of different disciplines.  Input can be taken from the QIDP, shift managers, direct care staff, nurses, administrators, physicians, dentist, and other specialist.  All this input comes together to form the IDTeam.  Generally meetings are held with the client (person served), their guardian or involved family member, the QIDP, a manager, a direct care, and a nurse at minimum.  Everyone brings input from different areas to help solve a problem.  For example, the nurse may present the physician's recommendations for a new medication, a direct care staff may point out some informal training that has worked with the client, the involved family member may know routines that helped at home, and the client may be able to tell everyone how he or she feels about something.

When the IDTeam comes together it is not the responsibility of the QIDP to have or present all the ideas.  It is the QIDP's responsibility to coordinate the ideas and implement the ones the IDTeam agrees to.

I watched this concept recently demonstrated in an ICF/IID program where the Floor Supervisor, Sarah Ostlund, presented a unique idea to help a client stop slamming the door to his bedroom into the wall.  While everyone was considering medications, one-on-one staff, and even expensive door control devices, Sarah obtained a simple pool noodle, cut it in three pieces and attached them by screws to the back of the door.  After some experimentation, she found that the client would still slam the door, but now the effect was softened by the pool noodle.  Sarah presented the idea and her results to an IDTeam that was seeking more expensive means to address the problem.

Once presented, the IDTeam adopted the swimming noodles attached to the client's door as part of the IPP.  Eventually, without the results of damaged walls and the loud noise, the facility saw a decrease in the door being slammed open by this client.

In all honesty, had the IDTeam depended solely on the QIDP to come up with an idea, it is very likely that a new behavior plan, an increase of one-on-one staff, and maybe even medication modifications would have been tried first.  Sarah ended up saving the facility and the client from a lot of undue expenses and hardships.  The swim noodle, that I now call a "Door Noodle" continues to work at this time.

Sarah Ostlund is the Floor Supervisor and Placement Coordinator for Caring Palms ICF/IID program in Brownsville, Texas.  Caring Palms   Sarah's "Door Noodles" below:

Thursday, January 21, 2016

Wanted!

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In life most people have a basic need to be "wanted," desired, sought after, or loved.  It's something that drives us to build friendships, it drives up to grow loving relationships and it pushes us to family reunions year-after-year so we can have our parents and grandparents tell us how much they miss us.  We want to be wanted.  In the field of developmental disabilities there are often few rewards.  The money is not great, the benefits are few, and the hours are long, but the opportunity to be wanted and loved is always present.

I was recently working in an office as some people with disabilities left their workshop in the room next to me.  I heard one individual talking with a staff and her question was simple.  She asked, "When are you going to work in my house again?"  The staff responded that she did not know and then asked, "Do you want me to come work at your home?"  The response was immediate, "Yes."
It was a simple interaction that I intruded on by listening to the conversation.  I happened to be at an angle where I could turn in my seat and watch the staff.  What I saw was amazing.  The staff was smiling, she hugged the person, and told her that she would see what she could do about working at the young lady's home again soon.  The staff was "wanted."

Too often we forget that the unconditional love, admiration, and even friendship that we so often seek from family members and friends outside work, can be found in the hearts and minds of the people we serve.  Jesus once said that we must approach the Kingdom of Heaven and accept it with the mind of a child.  The people we serve are often noted to have IQ levels around the age of four to five year old children.  Even though they come to us in the body of a thirty-five year old, or forty year old etc, they come with the mind of a child.  They come with an unconditional love that mimics that childlike approach Jesus discussed about the Kingdom of Heaven.  They accept us with our faults, our short-comings, and often without knowing anything about our lives outside of work.  That unconditional love pushes them to a love that is "wanting".  They "want" us in their lives.  They "want" us working with them, visiting them, and spending time with them.

You will receive a lot of gifts in your lifetime.  Friends will give you birthday presents, loved ones will give you Christmas presents, and others will give you all sorts of gifts over your lifetime.  The gift of being "wanted" though is one that is expected from your family and even your friends, but it is one that is often given freely and in love from the people we serve without any strings or any expectations.  They innocently reach out to us and they honestly want us involved in their lives, and there can be no greater gift than to be wanted unconditionally.

Tuesday, January 5, 2016

New Year QIDP / QDDP Task

source
Well 2016, arrived and if you are like most people it got here way too fast.  You still have your books all set for 2015, all your plans are based in 2015 and for the next three months you will be scratching out your "5" to make it a "6" on everything you sign.  The good news though is there are some things as a QIDP that you can do now to ease the transition into the new year.  Some of these suggestions will apply to all QIDP/QDDP, and some will only apply to Texas QIDPs, but at least you will have a list to start out on the right foot for 2016.

The first thing you should do for 2016, is consider your annual dates.  You might as well make a calendar for the following at a minimum:

1.  Annual staffing dates
2.  Fire Drill schedule
3.  School start and stop dates (if you work with any people in school)
4.  EMR check schedules -required annually in Texas
5.  CPR renewal dates
6.  Annual medical appointment dates - hopefully your nurse will complete this part

Most of the above can easily be placed on a Google or Apple calendar.  You can then set the calendar to remind you of the event a few days or weeks in advance.

Since January 2016 is usually the start of the cold season - at least it usually is in Texas - you need to consider your annual inspections.  You need to have the heat unit inspected - especially gas units (a pre-season check).  You need to look at your fire extinguishers and see what month you should schedule their updates while reminding yourself to check the unit monthly.  You need to look at your alarm inspections -fire, and other alarms- and see when they are due.  Finally, if you use flame resistant treatment for curtains, you may need to check those dates and see if this is the year for updated treatment.

This time of the year may also be a good time to have maintenance, check your appliances, furniture, etc.  It could also be a good time for clothing inventory and updates.  There's a good chance that several people may have new clothing from Christmas so now is a good time to clean up closets (with consent naturally).

You can make a list and get most of these items scheduled for the entire year in just a few hours.  Unfortunately, a good number of us will look up at our calendars and realize it's already February long before we get our updates rolling.  Why don't you take a few minutes now to get it done?



Monday, December 21, 2015

Dealing With Santa

This time of year is filled with joy and anticipation of visits from Santa and his reindeer.  In North America we cling to the methodology of Santa Claus with an iron fist.  He's in commercials, he's on soda pop cans, he's at the mall, and tune in to ABC Family or just about any of the dozen's of children networks found on television and you'll see dozens of specials with Santa.  Santa is involved in saving puppies, stopping Jack Frost, and even having a day off.  He's everywhere!  Children usually from the age of about two or three until anywhere between eight and ten cling to the idea that Santa is coming.  It seems like most children around eight to ten begin to figure out that Santa can't go around the world in one night, and that it's odd how much Santa's handwriting looks like mom and dads.  It's that time when families usually sit down together and talk about the legend of Santa Claus and in our case how Santa's spirit of giving in honor of Jesus' birth has been passed from parent to parent.  It can be a sad time, or a joyful time when parents can no longer spend Christmas Eve late planting presents around the tree.  But what about the person who has Intellectual Disabilities?  The person with ID is often regulated by psychologist to an age range of 0-6 years of age for the rest of their lives.  Many of them never stop believing or arrive at the questions their peers may come to.  How do we as professionals deal with Santa Claus?

It's not an easy for professionals.  We are constantly reminded, often by surveyors and others, that we should ensure activities and events are "age appropriate."  It is not really "age appropriate" for Santa to visit a group home of say six forty-something year old men.  But, if you've even been to a Christmas party with people who have diagnosis of ID, then you've seen them respond to the arrival of Santa.  It is like the magic of childhood never leaves.  They scream, get excited, tell him what they want for Christmas and often receive presents already arranged by staff.  To be blunt, it can be a crazy time and fun time!

As professionals, we have to make decisions everyday.  Those of us who work in the ICF programs with the IDTeam to help the person we're serving make the best decisions for his or her life know how tough decisions can be.  We help people decide how much money to spend, when to get a job, if they can take college classes, how long they will be in high school, what medications they will take, what goals they will train on, and so on.  We spend a great amount of time in the ICF setting deciding people's lives all while striving to encourage their independence.  So ultimately with Santa we have a decision to make.  We can tell the person we serve that there is no Santa.  We can tell them the stories of Santa and how he was a real person.  We can tell them that the people who show up to parties are simply carrying on the spirit of Santa.  We can if the IDTeam feels that is important, but in the big scheme of things how important is truth about Santa to the well being of the person who has Intellectual Disabilities?

Maybe it's okay to sit back for one little party each year and let the person believe.  Maybe we should look to that psychological assessment and hold the psychologist to their assessments - if they say 0-6 years of age, then that's the age someone would believe in Santa.  Why not let it be?  We are usually talking about one party a year where the person gets excited, believes that Santa has arrived for the party, and wants to get a present from Santa or even talk to him!  Out of 365 days a year, will a couple of days of Santa really throw the person with an ID diagnosis into a tailspin?  It's not likely to happen.   So, unless there is some sound reason, based on the individual's needs, it's okay to let the party roll, let Santa visit, let everyone have fun and believe.  It's not going to hurt anyone.....and to tell the truth, I've been to a few of those parties where I'm pretty sure the beard was real and it makes me wonder during those moments too!
Link

Thursday, December 3, 2015

Dealing with Serious Threats at the ICF/IID Level

Inland Regional Center from
http://www.nbcnews.com/
For those of us working in the ICF/IID field, the unthinkable happened yesterday in California when a shooting took place at a facility for people with developmental disabilities.  The facility serves several thousand people and has an employee list of over five hundred.  This type of shooting could have just as easily have happened in Texas at a state supported living center, a local LAR facility in just about any county, a state run small facility, an HCS setting, or even a private ICF/IID home.  

The shooting in California at a state run facility has brought the very real threat of a potential attack here in Texas home (News Report).  This was not a shooting in a mall, movie theater, or some other large public event where a shooter decided to harm others.  This shooting took place in a facility where people work with people who have developmental disabilities.  It took place with people who could have been our co-workers.  I encourage all facilities to consider putting policies and procedures in place to deal with a threat within the facility immediately or to review your current policy and procedures for these types of events.  This threat could come in the form of a telephone call, digital threat, employee, family member, or an unknown person.  We need to be prepared.  

I am pasting a potential policy and procedure here.  If you wish to have a Word format copy, please email me at (My QIDP)  I will be happy to share this policy with any facility or organization.  If you have specific questions about the policy, do not hesitate to ask me.  If you would like for me to provide training for dealing with a potential event (threat) at your facility, we can arrange that for a small fee to cover travel and expense.  This is too important to minimize.  The shooting in California brings this close to home.  We have very comprehensive disaster plans in most ICF/IID settings in Texas, but I seriously doubt everyone's plan addresses the kind of events we saw unfold yesterday.  



Start: --------------------------------------------------------------------------------------------------------
Policy and Procedure


Date:

Armed Threat, Terrorist Threat or Violence Policy and Procedure


Policy:
It is the policy of the facility to take all precautions possible to ensure the safety and well-being of residents (clients), staff, and visitors during any potential armed threat, terrorist threat or violent threat made toward the facility, a specific individual(s), or on the property owned by the facility at all times.

Procedure:

Telephone or Electronic Threat

1.     In the event of a telephone, text, fax, electronic, or digital threat made against the facility, a specific individual(s) or toward the property owned by the facility, the facility will take immediate action and notify 911 services and the Administration.
2.     A threat against a building or property will be reason for immediate evacuation from the building or property unless otherwise directed by city, county, state or federal officials designated to respond to the threat.
3.     A threat against a specific individual(s) will result in immediate protective action as follows:
a.     Notification of local law enforcement
b.     Follow directions of local law enforcement
c.      Secure or lock down the building or property

Armed Threat / Terrorist Threat or Violence

1.     If there is an armed threat, terrorist threat, or violence event at the facility or on the property of the facility, the facility will take immediate action in response:
a.     If possible, lock the facility or property to slow or stop the event from occurring or proceeding.
b.     If the event has occurred within the property, secure residents (clients) and visitors away from the event as quickly as possible including the possibility of evacuation or lock down.
c.      Immediately notify 911 – follow directions
d.     Leave the 911 line open to allow officials to possibly monitor events as they unfold
e.     Report all known information, including descriptions, number of individuals involved, injured, locations within the facility, etc.
f.      Move residents (clients), visitors, and staff away from any known threat area as orderly and as quickly as possible if move can be accomplished safely.
g.     Care for any injured as quickly as possible
2.     If the event leads to a hostage situation follow these procedures:
a.     Remain as calm as possible
b.     Listen closely to any directions from those holding hostages
c.      Follow directions if provided
d.     In the event of a rescue, be prepared to cooperate with rescuers immediately.

Standing Rules

1.     For any potential event of an armed threat, terrorist attack, or violence, there are certain measures the facility will have in place:
a.     Evacuations routes will be clearly posted.
b.     Security and safety of all residents (clients), visitors and staff will be priority.
c.      Facility address and phone number should be placed clearly next to each phone within the facility.
d.     During non-business hours, and at all times for ICF/IID homes, the facility should be locked and secured with the obvious exception of such times as residents (clients) are using outside facilities.
e.     All staff will be trained on this policy.
f.      The facility will have one “Armed Threat / Terrorist Threat or Violence Threat” drill each calendar year.
g.     The administration will review and revise procedures pending results of the annual drill.
h.     Any part of this policy and procedure may be modified, changed or deleted at any time during the year by administration and at anytime during an actual event by city, county, state, or federal officials designated to respond with an event.
i.       Once security has been maintained, the Administrator or Designee will notify DADS of the incident and follow recommendations or outlines as directed.
j.       The facility will designate one person to act as “Spokesperson” for the facility.  The spokesperson will respond to any news or media questions or inquiries on a local, state, or national level. 
k.     Staff other than the spokesperson may only respond to any news and media questions with “No comment” unless otherwise given permission by the spokesperson or the facility Administrator or designee.