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!

Thursday, December 3, 2015

Dealing with Serious Threats at the ICF/IID Level

Inland Regional Center from
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


Armed Threat, Terrorist Threat or Violence Policy and Procedure

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.


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.

Saturday, November 21, 2015

Missing Resident or Out Walking

ICF/IID programs in Texas have dealt with the question of when to report a missing resident for years.  I was recently visiting with a program when a staff person reported, "This person is missing!  We think they ran off."  A management staff sitting nearby quickly pointed out, "No, they are not missing, they are out for a walk!"  While it was a serious moment, the comic relief provided is a view that many facilities have to deal with daily.  We live in a world where residents are encouraged to exercise their rights and one of the many rights they often exercise is the right to move freely on and off the facility site.  The question the facility has to face, is when does that right become a reportable incident. 

The Texas Administrative code offers some insight into this issue (Texas Code).  In this code we read that "a resident whose location has been unknown by the facility for more than eight hours or less than eight hours if there are circumstances that place the resident's health or safety at risk."  This standard would appear to be clear, but sadly it is not.  It leaves itself wide open for interpretation.   The first half is fairly clear - if the resident has been missing from the facility for more than eight hours.  That's easy enough in that you check the last known time the resident was in the facility against the current time.  If it is less than eight hours, the resident is not missing - they are simply out for a walk.  If it is over eight hours, then they are considered missing. 

The second part of the code presents issues that are open for interpretation.  In the second part, we suddenly find it stating "or less than eight hours if there are circumstances that place the resident's health or safety at risk."  Who decides what those circumstances are?  If the resident has a guardian, does the guardian determine them?  If there is no guardian, does the IDTeam determine them?  Does the QIDP determine them?  Does the nurse determine if risk are present?  Or, does the surveyor who arrives and reviews the incident determine that the individual was at risk?  The fact is, the level of risk for the individual is usually not determined by anyone until the incident occurs.  

The standard routine for most facilities is rounds are made and the staff find that a resident is missing.  This may be the first time the resident has ever gone missing.  The staff calls administration, or the QIDP.  They discuss it.  The administration and others may go out and start looking around the area.  They go to local stores, parks, schools, and even check with neighbors.  In the end, the resident is usually found safe or even brought back to the facility by local law enforcement.  Most facilities let out a sigh of relief because the person was found within eight hours and they never look further at the standard.  Later, a surveyor shows up and reads about the incident in an exam report, or even a QIDP note.  The surveyor goes and looks further and finds no assessments for the resident's ability to move around the community.  The surveyor then goes and talks to the resident and determines that the resident was in an unsafe situation and that the facility failed to call in the allegation.  Boom!  There's your first tag on your 2567!  

So how can a facility prepare for the day a resident decides to take a walk?  There are actually several things a facility can do:
1.  If a guardian is involved, have them indicate what they desire for the resident.  In other words does the guardian know any reason the person would be unsafe going to a store alone should they leave the facility. 
2.  Develop a community based assessment- does the resident know about looking for traffic before crossing a street, does the resident know about red lights and crosswalks, what type of community do you live in - rural with few traffic issues, or next to an interstate with major traffic?  
3.  Have the IDTeam review and if necessary develop a plan to deal with "walks" or "elopements".
4.  Have facility policies specifically stating what the facilities view is on residents leaving.  

If the facility is completely honest, there will likely be a list of residents who can go out and easily come back on their own with no concerns.  There will also be a list of residents who should not be out on their own without supervision.  There may even be a list of residents that can do well in known areas, but not in unknown areas.  If you have a list, assessments, and IDTeam's reviews  and find that you face a surveyor who decides an individual can not be out safely from the facility, then you can present that information to the surveyor and be prepared if necessary to do an IDR for any tags cited. 

I recently had a resident in a facility who would walk to the store at the end of the block.  He would do this daily, especially when he had spending money.  He would go into the living room, announce to the staff that he was going to the store, and he would walk to the store.  Within about twenty to thirty minutes he would come back.  Assessments indicated he had the ability to safely move through the neighborhood, the IDTeam had reviewed it, and he had a service goal indicating that he could walk to the store.  The goal also indicated that he was usually only gone for about thirty to forty-five minutes.  During the time this individual lived in the home, survey arrived.  The surveyor questioned me about the individual and I provided the information.  She reviewed it and moved on to the next concern.  We received no deficient practice; however, I feel strongly that if we had not had the assessment and the IDTeam review, there would have been greater concerns expressed and to be honest there would be good reason for those concerns. 

Sunday, September 13, 2015

Email Provides a Simple Documentation Method

In the world of ICF/IID settings documentation is often critical not only to remind others of what has been completed or set in motion, but also to prove something happened.  There's a good chance that most people reading this post has at least some level of familiarity with documentation.  We usually call it "Q Notes" or "QIDP Notes".  It could also be that documentation is maintained in the form of an Interim staffing or a "Mini-Staffing".  Naturally we all know that documentation is also present in the IPP, Data, Annual CFA, Assessments, Referrals, and Reviews.  Q Notes are often meant to cover small items that do not occur during the annual staffing, may not be a big enough event for an IPP or staffing, and may only be needed to prove you did address something.

How many times have you found yourself in front of a surveyor who asked, "So, what did you do about this situation when you were notified?"  You stand there for a moment thinking to yourself, "Yeah, right, that was six months, two weeks, a day, and four hours ago right before I went to lunch and had a cheeseburger....Yes, I told everyone at 11 am, that we would....." Yeah, right.  It's more likely that that you stood there with a "Deer in the headlight" look on your face and said, "Yes, we addressed that and talked about it as a team."  You know the next question coming: "So, do you have any notes about that?"  This is when panic sets in.  You run through your mind quickly and think, "Did I do a Q Note, have a Interim, anything?"  You quickly tell the surveyor you have to go check.  Now you're in the chart digging and looking for an event that happened six months ago that you may or may not have completed any documentation on at that time.  Worse, you may be at your desk digging through stacks of paper and trying to find that one sticky note where you placed the documentation.    Worse yet, you may be thinking that the event occurred when you were not even at the your note may be on your home desk or anywhere in your car for that matter.

Now, let's face the facts....most likely you did not do the note.  You may not have been at the office, you talked on the phone, made a decision, moved forward and forgot about it.  But what if it is something that you really need some sort of documentation for?  Let's say it's something that you know, beyond any doubt, that a surveyor is very likely to ask you about or it may come up.  This is where you need to consider modern documentation and how simple it can be.

Most QIDPs have email now.  If you do not, get an account and change your calendar from 1995.  You can open a Gmail account for free and it will hold all your emails - up to a gigabyte or so- at no charge.  You can also search your email by keywords, email addresses, etc.  Once you have your email account, put it on your smart phone, tablet, or simply your computer.  Now use it.  The next time you have a situation that may need to be documented, send yourself a note or send it to a member of the IDTeam or even your Director.  You may want to let them know in advance that you're going send it so it is not confusing.

Let's consider this example for a moment.  Johnny lives at ICF -A.  Johnny had a bad day and broke a window.  The IDTeam has already approved Johnny paying for the window.  You get a call on Sunday afternoon telling you about the event.  You tell staff that Johnny will need to know he is paying for the window and you talk with Johnny.  Johnny agrees (he is calm now) and says he will pay.  You are at the park with your family - no notepad, no computer, just your trusty cell phone.  You send the following email to your manager:

Manager - Johnny broke a window today about 2:00pm.  We talked about it on the phone and he is calm now.  He knows he needs to pay for this and has agreed to pay for the window.  Please implement this Monday morning as soon as possible.  I would like a report indicating the status on this by Wednesday.  If you need more time, please let me know and have staff reminded to follow current behavior plans.

The above note has covered what happened, the intervention you did, and the fact that Johnny understands he is to pay for the window.  You also have the opportunity to send the email not only to your manager, but you might send it to your supervisor, other members of Johnny's team, his parent or guardian, and even if possible to Johnny's own email account.  The note also has valuable information.  It will be date stamped for Sunday afternoon and will have a time on it as well.  It will also show a list of people you notified.    It is now part of your email record.

Fast forward by four months, and the financial auditor is reviewing Johnny's records.  She sees where Johnny signed a check and paid for something to "XWY Glass" in the amount of $250.  She comes to you and says, "I see the consent and that Johnny agreed.  What is this about though?"  You can easily give her Johnny's approved behavior plan that shows that he has to pay for broken items.  You can then do a search in your email and pull the email by date, Johnny's name, or possibly even the keywords "broken glass".  You show the email as to where you addressed this initially to coincide with the behavior plan.   The surveyor then returns to the financial audit satisfied.  You have your plan, your documentation, and your manager followed your directives and obtained correct consents.
As a further precaution, should you feel compelled, you can "CC" yourself the email as well.  Once you get it, you can print it out and put it with all the time stamps and date stamps in Johnny's chart.   You could also print out a copy of the sent email if you would prefer.   The email will then essentially serve as a "Q Note".  This is always a good idea in case you get that outstanding job offer and decide to leave Johnny's organization for that much higher paying QIDP job!

The bottom line is that documentation is needed, but don't hesitate to utilize the email factor for documentation.  It can save you time and provide a digital, date, and time stamped record of the event.  You can then have it on your email server or even have a printed hard copy on file.   It's a simple documentation method that is often overlooked in the ICF/IID field and other fields as well.

Monday, August 24, 2015

New Group on Facebook

I have created a new group on Facebook called "QDDP/QIDP Discussion Group".  This group is open to anyone, but it especially focusses on QIDPs or QDDPs working across the nation.  Hopefully we will have people join in the discussions, share assessments, ideas, and experiences which can help other "Q's," staff, families, and individuals.

Tuesday, August 18, 2015

Surrogate Decision Making and Texas

From SDM Home Page Click for Page
Several years ago the legislators in Texas initiated a program called "Surrogate Decision Making".  The program has a focus on individuals living in the ICF/IID setting without the ability to consent to certain issues, without a guardian, and without an involved family member.   The program has been in place for several years now and has seen ups and downs during that period.

The first thing to note about the Surrogate Decision Making (SDM) Program is that it is designed with the intention of being helpful for those individuals who need assistance making decisions.  Before this program nobody was certain who would give consent for example for a psychotropic medication if the person needing it did not have the ability to give informed consent and did not have a guardian.  The responsibility often fell to family members, ministers, or even the physician in an emergency setting.   The IDTeam would meet, review and pretty much agree with whatever was being ordered.  While I do not know specifically of any cases where this lead to abuse of a person, I can certainly see how it could for the convenience possibly be abused.

The SDM Program was put in place and the responsibility, as it is today, to determine whether a person living in an ICF/IID could give consent usually fell to the IDTeam.  The steps to proceed are simple:
1.  The IDTeam is notified of any needing consent.
2.  The IDTeam meets and assigns an assessment to be completed (Surrogate provides them here)
3.  Once the assessment is completed the IDTeam reviews it and makes a decision.
4.  If the person is able to give consent, then he or she does and the process continues per regulations (usually to the Speciality Constituted Committed or the Human Rights Committee)
5. If the person can not give informed consent, did not have a legal guardian, then the process of the program started for psychotropic medications.

The Up side of the program is obvious.  There are volunteers, many from the ICF/IID field, who meet together with no interest in the facility where the person lives.  If you are interested in becoming a volunteer, see the website (Website)   They review the paperwork, meet the person, ask questions, record the meeting, and make a determination.  Once the determination to give consent is made, they then decide how long the consent will be given for on an individual basis.  The consent time frame can range from a few months (such as six months) to several years depending on the situation and questions members may have or concerns.  Most seem to give about a year to two years for psychotropic medications.  This is the up side because it removes the decision from the facility, helps ensure that medications are not used in an abusive manner.

The down side is the length of time it takes.  The process, from start to finish with a consent in hand, can take anywhere from one to two months up to six months or longer.  This is because the people working the program in Austin must ensure they have accurate and complete information to present to the volunteers who make the decisions.  A facility can send in an application and supporting documentation and then receive a letter with one or two questions or as many as fifty or more questions depending on what the reviewer in Austin feels is needed.  Once that additional set of questions is received, the facility must obtain the information, answer the questions, and send the information back either by fax or by mail.  Emails with information, as of this writing, are not permitted due to the potential for the information being lost.  During this process, the facility has, in the case of a psychotropic medication, to follow the standards which require a physician's order to be followed.  Needless to say, without a valid consent, the facility is basically giving the medications to meet one standard (follow physician orders and meeting the needs of the person) while ignoring another standard (requirement to have consent prior to giving the medication).

The general rule in Texas has been to allow the facility to complete the paperwork, send it in, and implement the psychiatric medication with the IDTeam and the Specially Constituted Committee's oversight until consent is received- a process that breaks at least two federal standards when being implemented.  In the area of other needs such as special dental surgeries, etc, the person has usually had to wait on the surgery.  While there is an emergency process that can be implemented, it is not generally used for psychotropic medications or non-lifesaving surgeries.  Texas surveyors usually look over the paperwork that has been submitted and allow the facility to slide on the standards since there is no way to meet both the Texas Surrogate Rules and the Federal ICF/IID standards.  However, there have been some surveyors in the past who would not allow this standard to slide and have instead written a significant amount of deficient practices for the facility while the facility has no choice but to work through and wait for a SDM meeting (or hearing) date.

The Texas SDM Program only handles certain cases as listed on their website at SDM.   On the positive side, an involved family member  as defined by the link can make many decisions for their loved one.  The only decisions that a family member can not make concerns the use of psychotropic medications or to implement a highly restrictive behavior procedure.

Ultimately the program is a lot of work to implement and use as it should be used when needed.  The other positive side of it though is you have a great staff to contact (Contact)  who will help you each step of the way.  Dennis Tomlinson, M.Ed has been with the program for many years.  Cathy Albaugh, R.N., and Marti Granger, R.N. work closely with Dennis and are always happy to help and answer questions.  The program is always looking for volunteers and is always willing to work with facilities as needed across Texas.   Don't hesitate to contact them, and if you have time and would love to help people with disabilities live better and informed lives then contact the program at their website: 

Saturday, August 1, 2015

Has The Time of the QIDPD Ended?

Last year CMS modified and updated the ICF/IID regulations which included changes to the QIDP tag, W159.  In the guidelines section a specific line has drawn attention across the nation, including Texas, " The QIDP function may not be delegated to other employees even though the QIDP cosigns their work." (CMS Regulations)

Texas was quick to note this change in Provider Letter 15-12 (April 29) to the CMS (Letter).  Texas specifically noted the following:

W159 (42 CFR §483.430(a)) states that each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional.  The new W159 Guidance states, “The QIDP function may not be delegated to other employees even though the QIDP co-signs their work.”

With the new modification several states will have to consider what to do about their QIDP - Designees (QIDPD).  Several states have used non-degreed persons to serve the function of the QIDP and have done so for well over twenty-thirty years.  Although different states have had different guidelines (here is Indiana's from 2010 page 12: Link for example) the basic rule has been the QIDPD has experience with people who have developmental disabilities much like the QIDP; however, they do not have the four year degree required.  In state's like Texas, a QIDP would simply sign off on the work of the QIDPD and surveyors were happy as long as the needs of the individuals were being met.  As you can imagine, with budget cutbacks and a shortage of QIDP's (one of the reasons for My QIDP) several facilities will have to address the new rule.

Surveyors in Texas are already informing agencies about the changes, and agencies are scrambling to find solutions.  The rule indicates that the QIDP can not simply sign off on the work anymore.  This means that the QIDP essentially has to do the work even with the QIDPD there.   The problem goes further in that the rules give guidelines that a facility must have the right number of QIDP's to meet the needs of the people served.  The standards does not indicate what that ratio is, and that alone may be the saving grace for the QIDPD.  Because of this wording, agencies have a couple of options.  First, make no mistake, a QIDP function will have to be in place.  However, here are some options to keep the QIDPD involved:

1.  Keep the QIDP involved in staffings and other requirements as required, but have the QIDPD type the staffings, reports, data, and other information.

2.  Designate the QIDPD to handle a lot of staff training issues.

3.  Consider looking into the QIDPD obtaining a degree.  Many degrees can be obtained online and some have rapid programs now.

4.  Pair your QIDP and your QIDPD as a team.  If your QIDP has been handling a caseload of six, for example, and your QIDPD has been handling a caseload of six, give all twelve to the QIDP, but have the QIDPD work directly with the QIDP.

5.  Look at other options for your QIDPD to do.  Can the QIDPD help with finance, computer inputs, monthly state reports, etc?  If so, redistribute some duties to the QIDPD to balance the work load.

With the right modifications the time of the QIDPD will not be over.  Whatever your organization decides to do, two things are apparent.  First, you will have to address these changes and you'll have to address most likely without any additional funding.  Second, if you find yourself stuck in a bind, you can always contact My QIDP ( and we can provide support or the QIDP function to meet your needs.

Wednesday, July 29, 2015

Concerns For HB 2789 (84th Legislature 2015) and the New 90.44 Trauma-Informed Care Training

For those who may not know Texas has modified required training for the ICF/IID program with the new requirement of Trauma-Informed Care Training.  Before everyone starts to cry and moan, it should be noted that this training is currently in an online form for DFPS ( It should also be noted that the new bill allows the training to be conducted online.  It's very likely that DADS will offer the training at some regional training sites, but that it will also be offered in an online format considering the content of the bill, now a law.

The law (Link to Final Bill) requires all "new employees to complete the training before working with individuals with intellectual and developmental disabilities."  Because of the requirement that the training be completed before a potential employee works with an individual, it is very likely that DADS will provide the resources online.  Most facilities will simply add this to their new employee orientation and perhaps complain a little about further training requirements without further compensation from the state- that's just the way it is always going to be as it appears now.

DADS has also offered providers the opportunity to give feedback and input on the proposed 90.44 Texas Administrative Code.  I can not stress enough that providers need to take this opportunity to provide feedback.  Information about the feedback and the new 90.44 can be found here on DADS website.  For the sake of review, I have some concerns that I would like everyone to consider.  Below is the full proposed 90.44 from the noted website: 

A license holder must ensure that an employee, contractor, or subcontractor who is hired by the license holder to work at a facility on or after XXX, and whose duties will require the employee, contractor, or subcontractor to work directly with a resident completes trauma-informed care training provided by DADS before the employee, contractor, or subcontractor works with a resident. For purposes of this section, “to work directly with a resident” means to serve on a resident’s interdisciplinary team, or to provide active treatment, health care services, or clinical services to a resident.

DADS has raised some serious questions and concerns with the proposed tag.  Consider the two closely related issues below as your write your concerns and provide your input:

1.  The law calls for "employees who work directly with..." individuals to have the training; however, the DADS rule goes further and requires the following to also have the training:  "Contractor, subcontractor".  Initially, that may not sound too bad, but consider this:  Is your physician going to be willing to take time out of his or her schedule to complete this online training and provide you the certificate?  Physicians are already pressed for time and we all know how hard it is to find Medicaid and Medicare physicians, so once you find them are you willing to risk them leaving your service over training requirements?  This Contractor and Subcontractor will include your physicians, R.N.s, dietitians, dentist and any other person who may work directly with the resident.  Solution: DADS needs to consider keeping this to "Employees Only" as it is written by the law and not read additional information into and put additional hardships on the ICF/IID programs.

2.  The new 90.44 also goes further and clarifies who "to work directly with a resident" means by stating that it is the person who serves "on the resident's interdisciplinary team, or to provide active treatment, health care services, or clinical services to a resident."  Once again this is very strict language written here.  This means that should your regular physician agree and complete the training, you'll be fine in that area, but consider further issues:  What if a specialist is called in to see a resident such as a Neurologist - that person will provide care and input for the IDTeam and by this rule it means that person will also have to take the training.  In addition, this could be stretched to include vocational sites.  Active Treatment is not defined as "formal" or "informal" by this proposed rule. As we all know informal active treatment may occur on a person's outside job site.  The resident goes to work and has a supervisor who will provide training and feedback - that is informal active treatment - so, based on this rule will the supervisor, let's say the grocery store manager, also have to take DADS training and provide a certificate to the facility?  If the supervisor does, how many of your employed people are likely to keep their jobs?  As for those individuals in the school systems, will your district require their special education teachers to take this training?  What about other teachers who may have contact with your resident?  What about teacher aides?  What about substitute teachers the district hires as you may not know when they will call them or who they will be?

The bottom line is that DADS has taken the basic law and for whatever reason expanded it to include everyone who has some influence or input into the resident's life.  On the surface this looks good and I certainly understand and appreciate DADS protective nature toward the residents; however, as it is currently written, it could include even a remote specialist, such as an gastrointestinal specialist, who might be a referral for an individual.  Before that specialist could see the individual and provide any services the facility will have to contact them and require that they take the training and send the certificate to the facility.  There will be some specialist out there who will do it I'm sure, but I'd be willing to wager that there will be a lot more who will thank you for your time and suggest you take the resident to someone else.  The current proposed rule for Trauma-Informed Care Training is a good and needed rule, but it simply needs some modification to ensure that it does not place the resident in jeopardy of not receiving needed services and the facility in jeopardy of non-compliance.  You need to write DADSA through as quickly as possible.  Be direct and point out concerns.  

Monday, July 27, 2015

Social Media Consents in the ICF/IID

Most ICF/IID programs have a huge pile of "Consents" that must be signed each year, and one of those consents usually deals exclusively with newspaper or news postings.  You basically seek consent to allow the individual's picture to appear in the newspaper or on a news show.  This happens when individuals participate in Special Olympics, attend special events in their towns, or perform some sort of community work as a group or as individuals.  Sometimes the individual ends ups in the spotlight because he or she has worked in the community and the news source wants to show how people with disabilities can work.   Whatever the case may be, you likely have a consent that covers basic news coverage, but do you have one that covers the new arena of "Social Media"?

Social Media is a new and rapidly growing area that may or may not replace our newspapers and magazines in the future.  Most people have seen social media, even if they do not recognize it.   Social Media can come in many formats.  It can be movies or clips, articles or webpages, tweets on Twitter, or postings on Facebook.  There are too many outlets for social media to list them all here, but something as simple as your companies webpage could be considered a form of social media.  Below is a list of links for social media that this author has been involved in during the past year:

Four States News:
A facility website:

Anyone of the above outlets could (and some do) result in the people you serve in your ICF/IID program being featured.  Maybe they end up featured in pictures, or maybe in a full printed article.  Whatever the case may be, you have to ask yourself, because you know the surveyors will at some point, do you have consent to share the person's information or picture on social media?

In some cases, people believe that because they have a consent to share information with the news or newspaper, that the consent should also cover social media, or digital media.  While that might be true from a legal point-of-view (note: I am not a lawyer and this is not legal advice only my opinion as a QIDP) I would personally doubt that the family and the individual completely understands the social media concepts.

I would suggest that all facilities consider two things:

First, consider the need for a social media policy.  How will you deal when one of your staff post pictures on Twitter of the local dance with the people from your facility?  How will the facility deal with a news station having a YouTube page where they post news stories?  How will you develop your own website with pictures of the individuals?  There is a lot of questions that need to be addressed in a policy.

Second, make a consent.  Ensure that your consent notes not only newspapers and local media, but also social media.  While you can give some examples of social media there is no way you can give all of them, or cover all the new ones that may develop.  I would write something like this "gives permission to appear on social media such as Facebook, Twitter, Tumbler, YouTube and other social media outlets that may be used for positive promotions or to spotlight individual accomplishments or events."

In closing keep in mind that you can never go wrong by obtaining consent from the Individual, the IDTeam, or the Individual's guardian or Surrogate Decision Maker (Texas).  Also keep in mind is that I am not a lawyer and I am not giving legal advice here - If you are concerned and want to go further with your consent to ensure it is completely legal, then I recommend that you consult a licensed lawyer in your state who deals with consent or guardianship issues.   Just remember that social media is likely going to be around for a long time and sooner or later you will deal with it on some level.

Friday, July 17, 2015

Texas Ranked Low For Developmentally Disabled Services

United Cerebral Palsy (UCP) completes a study each year to determine the best states for people with developmental disabilities and the worst states.  They include the District of Columbia, so the total is 51 altogether in the review (  Texas has historically ranked at the bottom, but this year it has moved up….well, slightly.  Texas is ranked number 50 near the bottom.  The only state or district to receive a worse report was Mississippi.

Being one of the largest states, most populated, and one of the best states to start businesses in – at least according to some sources – you would think that Texas would have the ability and funding to achieve a better ranking.  The sad truth is that Texas just doesn’t seem to put too much emphasis on services for people with developmental disabilities.

Consider the job outlook for people with disabilities.  In 2004, supported or competitive employment levels were at a solid 22%, but by 2011, it had dropped to 5%.  This could be an indicator that businesses are not willing to hire people with developmental disabilities.  If these business organization do not hire, then there’s a good chance that state legislators, often receiving the bulk of campaign donations from business, might not feel people with developmental disabilities rank very high on the scale of importance.    A further factor in the equation seems to be families receiving support went from a high of 27,677 to 20,156 by 2011.  That’s just over a 7,000 drop in services.  As recently as two years ago a mother of a disabled child told me that “Texas has nowhere near the services and programs that my previous state offered.”   This parent planned to seek services by moving to another state.  

One of the brighter spots on the assessment did show a drop in the number of people living in institutions from 4,996 in 2005 to 3,547 in 2013.   Another not-so-surprising statistic reported was the rise of HCS (called HCBS for Home and Community Based Services on the chart) or Texas Home Living (not mentioned in the report TxHmL) use which saw a steady rise to 28,838 while ICF (intermediate care facilities) experienced a decrease down to 9,025.  This shift is not likely due to the differences in the services as much as it is to do with the money.  The daily rate average for the state is cheaper for HCS services than it is for ICF programs.  Already providers have seen a trend of movement in the waiting list.  While some people have been on the list for years waiting for services, people in the 15-22-age range seem to come up on the list more often for HCS placement.  This appears to be regardless of how long the person has been on the waiting list.  This trend would indicate, at least to this writer,  a steady or unwritten drive by the state to “age out” the ICF programs by filling the HCS programs with the younger population.  Whether it is a conscience or unconscious move on the state’s part, it is certainly a factor of saving funds by utilizing the more cost saving programs. 

As indicated above, the fundamental problem for Texas is the same as many states running along the bottom of the list.  Money.  Without money services have a tendency to be inadequate and fall short of the needs of the people they are meant to serve.  Providers of ICF and HCS programs are faced with a “minimal” set of standards to meet from the federal guidelines and the state guidelines, but without proper funding it is difficult to exceed and sometimes meet those minimal standards. 

Another or perhaps major problem for Texas is that not everyone fits in a nice little box.  Some people need the State Supported Living Centers, while others would be better served in an ICF, and yet again others might be best served in an HCS or TxHmL.  With an HCS waiting list that seems to be dominated by the age factor, such factors as abilities, or readiness for the HCS programs, appears to be overlooked.  It should also be noted that private organizations, both ICF and HCS, depend on the local LAR (Legally Authorized Representative) for the state to provide most of the placement referrals.  Since the state operates the Supported Living Centers, and their own ICF and HCS programs, then they naturally tend to fill those openings first when someone seeks services regardless of the true need of the individual.  When all those factors are overlooked, you end up with people staying in programs that honestly do not meet their needs and thereby helping statistically to cause the state to remain at the bottom or near the bottom in services provided.

A state as large and as financially powerful as Texas should not be ranked at the bottom for services for people with developmental disabilities.  The fact is with some minor modifications Texas could have outstanding programs, but it is going to take the people of Texas pushing the legislators to do something.  There needs to be funding set aside for programs, and there needs to be a review and modification to the the way the waiting list and placement is handled.  Private providers, state providers and the individuals and families of those individuals with developmental disabilities must come together to develop strategies that ensures the appropriate services are provided regardless of the program needed.