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.

https://www.facebook.com/groups/1453874194921388/

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:  http://www.dads.state.tx.us/services/crs/surrogate/index.html 

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 (MYQIDP.com) and we can provide support or the QIDP function to meet your needs.