Be warned right now - I did not agree with the changes that Senate Bill 1857 started (http://www.dads.state.tx.us/providers/nschanges/icf/index.html) a few years ago.
Senate Bill 1857 from 2011, pushed through by the well meaning Texas Board of Nursing, did little to help propel the ICF/IID program forward. In fact, it actually pushed the program in a backwards direction making it more akin to a nursing home than to a community based home. At a time when budgets were tight, funding was being cut, and programs were unable to pay staff decent wages, the 82nd Legislature initiated a change that turned ICF's upside down. Suddenly, ICF programs had to have Registered Nurses (R.N.) do many of the functions that the Licensed Vocational Nurses (LVN) had been doing for years including taking "on-call". Most facilities had an R.N. as a consultant to follow up on issues or provide training as needed or even do some simple reviews, but few R.N.'s had any major role in the small ICF settings (10 bed or under). With Senate Bill 1857 the state of Texas enacted stricter guidelines on the ICF programs than even the federal standards impose, and they did it without providing a single penny of extra financial support.
Regardless of what anyone says, I know for a fact that several LVN's lost their positions because of the changes. Programs either had to obtain a full-time R.N. (at R.N. pay by the way) or get an R.N. and participate in the LVN Pilot Program. The pilot program was designed into Senate Bill 1857 to study how the LVN function would do being on-call in the ICF programs, the HCS programs and others. The change required almost complete R.N. supervision for the providers that participated. Many of the providers who did not participate basically let their LVN's go and replaced them with an R.N. Without the funds needed to pay for the R.N. salary, some of them were even forced to cut the number of nursing hours provided to people living in the programs. The programs that did participate in the pilot program had to put information into the CARE system online for several years. In fact the program only recently ended and required a great deal of training and understanding to participate in the program (http://www.dads.state.tx.us/business/CBT/lvnocpp/firefox3/index.html?dhtmlActivation=fullscreen), and naturally the state had to fund all this training.
The information from the pilot program is still being studied and reviewed since it only recently ended. Without contacting many of the providers who participated in the program, I would assume they have kept their LVN's in place and continued much the way they have through the program. Ultimately, I'm looking forward to the report that DADS will review and release to providers and to the legislature. As with all statistics, it can be viewed in almost any manner.
So, in summary, an LVN On-Call Pilot Program was recently completed. It has been going on since the implementation of changes found in Senate Bill 1857 for over three years now. It consisted of the following areas where Texas tax dollars were spent:
1. Setting up an online computer reporting system
2. Training those who participated in the reporting system
3. Providers hiring R.N.'s to over see the LVN's still employed
4. Someone in Austin to compile the computer date regularly
5. Someone in Austin to analyze the data
6. Someone in Austin to prepare the reports
7. Someone to present the reports
It would be interesting to know how much money total in Texas was spent on the LVN On-Call Pilot Program that could have been poured back into services. What would be even more interesting to note is that many of the ICF programs in Texas have been in place since the late 1980's - let's just say 1988 for a starting figure. Given that the Senate Bill did not initiate the pilot program until 2011 we can know that these ICF programs have been using LVN's for on-call needs over 23 years. With over 800 (800 as an estimate) ICF programs in Texas having at least one annual survey each year, we know that the State of Texas had more around 18,400 annual surveys (and that's only annual not follow ups or investigations) to use as a review for how effective the LVN as an on-call nurse really is daily. So, was there really a need for an LVN On-Call Pilot Program? Did 18,400+ surveys and over 23 years of the program not provide enough data to avoid doing an LVN On-Call Pilot Program at the expense of the Texas Tax Payer?
Friday, May 29, 2015
Wednesday, March 25, 2015
When you have to Restrain....
The issue of restraining individuals in ICF programs is a touchy one to discuss, plan for or to deal with especially when a surveyor is questioning you about your methods. Many states, like Texas, do not have a standardized restraint or restraint training for facilities, so most are left up to their own devices to develop a program, seek out one offered by another provider, or just take the chance they will never have to do a restraint. If you are lucky, you will have a good solid program that you rarely have to use. Some places are not that lucky.
As some of you know I run a consulting company (My QIDP). Naturally, I am usually hired when things are going bad. I rarely get a call that says, "Hey, things are great, survey just left and didn't write any tags, but we were just wondering if you'd like to contract with us?" No, I get the calls like, "State is in the building now! We don't have a QIDP!" or "We're in major trouble, these tags are too long and our Q just left!" Yes, that's when I'm called to try to help. Recently I went into a program that had a restraint policy and even program they had adopted from another provider. I wasn't too worried until the provider informed me of the number of "Take Downs" they were doing daily.
Please understand that when I say a "Take Down," I am actually talking about staff members having to physically take a person down to the ground and hold them there for a period of time. I was surprised to see so many being used. To further complicate things, the provider's administrator explained to me that he had watched some of these "Take Downs" and felt they were wrong for their facility. I reviewed the training material, talked with staff, had staff demonstrate some of the maneuvers and returned to the administrator with a grim assessment. To me it appeared many of these "Take Downs" were actually a form of modified Judo. They seemed like they could easily become aggressive, and were obviously habit-forming.
After hearing my assessment, the provider asked me to develop a program. I informed him that I had some information, training, and that I'd be happy to provide a program, but once it was developed I wanted to use it with other providers. He immediately agreed that it sounded like a good idea so My QIDP set out to develop a program.
The first thing that I had to keep in mind was that complete a "Take Downs" should be the last resort. This should happen close to the time you're calling 911 in other words. There is a lot that can be done between the initial confrontation and a total "Take Down".
Because I had worked with several good organizations, served as the staff training coordinator for one, and taught their version of restraints as well as attended several different provider trainings on restraints, coupled with the fact that I have a black belt in Karate, I felt qualified to develop the program. The goal became to keep restraints to a minimum and take downs to the last resort.
Out of this project was born "ARC". ARC stands for "Assess," "Restrain" and finally "Contain". The program is now offered through our website if someone would like to become a certified instructor (My QIDP). The program breaks down on the three levels as follows:
A - Assess the situation. Spend time talking to the individual, trying to determine what the problem is, and calming the person down through verbal cues without touching them. Sometimes the person is mad and just wants to talk to someone. There's no reason to restrain for that. You have to talk to the person and try to learn what is bothering them to the point that they may require restraining.
R-Restrain next - If you do have to restrain a person this area should combine talking to the person and gentle restraining. Several techniques are discussed in the class and demonstrated.
C- Containing a person is the last resort. You should be close to calling 911 at this point. A containment requires a full, and safe, take down of the person. This is usually reserved for the most violent situations.
After we provided training to an initial set of trainers and they in turn trained their fellow staff, the facility saw a 95% drop in containment's in the first month! Needless to say the administrator was very happy. The staff were happy too because there were fewer incidents of restraining or containing the people served.
Bottom line, examine your form of restraints that your facility uses. If they are harsh or you are using them too often, then assess them and determine where the problem is located. It could be you need new behavior plans or approaches or it may be that you just need to wipe the slate clean and develop a new program that is less aggressive. You could also contact us (My QIDP) for assistance or training in the ARC Program. Whatever you decide to do, just remember that restraining someone or even containing someone on the floor should be the last thing you do before calling 911. If restraints and containment's are use often, sooner or later a staff or individual served will end up hurt.
As some of you know I run a consulting company (My QIDP). Naturally, I am usually hired when things are going bad. I rarely get a call that says, "Hey, things are great, survey just left and didn't write any tags, but we were just wondering if you'd like to contract with us?" No, I get the calls like, "State is in the building now! We don't have a QIDP!" or "We're in major trouble, these tags are too long and our Q just left!" Yes, that's when I'm called to try to help. Recently I went into a program that had a restraint policy and even program they had adopted from another provider. I wasn't too worried until the provider informed me of the number of "Take Downs" they were doing daily.
Please understand that when I say a "Take Down," I am actually talking about staff members having to physically take a person down to the ground and hold them there for a period of time. I was surprised to see so many being used. To further complicate things, the provider's administrator explained to me that he had watched some of these "Take Downs" and felt they were wrong for their facility. I reviewed the training material, talked with staff, had staff demonstrate some of the maneuvers and returned to the administrator with a grim assessment. To me it appeared many of these "Take Downs" were actually a form of modified Judo. They seemed like they could easily become aggressive, and were obviously habit-forming.
After hearing my assessment, the provider asked me to develop a program. I informed him that I had some information, training, and that I'd be happy to provide a program, but once it was developed I wanted to use it with other providers. He immediately agreed that it sounded like a good idea so My QIDP set out to develop a program.
The first thing that I had to keep in mind was that complete a "Take Downs" should be the last resort. This should happen close to the time you're calling 911 in other words. There is a lot that can be done between the initial confrontation and a total "Take Down".
Because I had worked with several good organizations, served as the staff training coordinator for one, and taught their version of restraints as well as attended several different provider trainings on restraints, coupled with the fact that I have a black belt in Karate, I felt qualified to develop the program. The goal became to keep restraints to a minimum and take downs to the last resort.
Out of this project was born "ARC". ARC stands for "Assess," "Restrain" and finally "Contain". The program is now offered through our website if someone would like to become a certified instructor (My QIDP). The program breaks down on the three levels as follows:
A - Assess the situation. Spend time talking to the individual, trying to determine what the problem is, and calming the person down through verbal cues without touching them. Sometimes the person is mad and just wants to talk to someone. There's no reason to restrain for that. You have to talk to the person and try to learn what is bothering them to the point that they may require restraining.
R-Restrain next - If you do have to restrain a person this area should combine talking to the person and gentle restraining. Several techniques are discussed in the class and demonstrated.
C- Containing a person is the last resort. You should be close to calling 911 at this point. A containment requires a full, and safe, take down of the person. This is usually reserved for the most violent situations.
After we provided training to an initial set of trainers and they in turn trained their fellow staff, the facility saw a 95% drop in containment's in the first month! Needless to say the administrator was very happy. The staff were happy too because there were fewer incidents of restraining or containing the people served.
Bottom line, examine your form of restraints that your facility uses. If they are harsh or you are using them too often, then assess them and determine where the problem is located. It could be you need new behavior plans or approaches or it may be that you just need to wipe the slate clean and develop a new program that is less aggressive. You could also contact us (My QIDP) for assistance or training in the ARC Program. Whatever you decide to do, just remember that restraining someone or even containing someone on the floor should be the last thing you do before calling 911. If restraints and containment's are use often, sooner or later a staff or individual served will end up hurt.
Sunday, March 22, 2015
Disaster Plans and Buckets
I was recently reading through some articles on survival tips and ran across one about buckets. Specifically, the article was talking about 5 gallon buckets, the kind you can find for around $5 with the lids at Lowes or Home Depot. The idea was to use this bucket for anything from rice and beans, to transporting needed water. The article really gave some good ideas and I began to consider how a 5 gallon bucket could be used in a 6 to 10 bed ICF/IID.
The first thing to know, and hopefully you do, is that most ICF programs are required to have disaster plans. These plans, in Texas for example, require that you not only have a plan for what you are going to do if you have to stay at the facility, but also what you are going to do if you have to leave the facility and travel somewhere else. The basic requirements (and certainly not all of them) is a 72 hour supply of food, water, and medications. In addition you need clothing, hygiene products and other items for each individual in the facility. With the individual is where I began to consider how a bucket could be used. In fact, I realized that the bucket could be prepared easily, stacked in storage, and ready to go at a moment's notice. A prepared bucket for an individual could save you several minutes or longer in an evacuation. Not to mention, given time you could add items to the bucket that you know you'll need, but may not think about during the disaster (If you think of some others let me know).
So, as I sat thinking about this during some disaster television show such as The Walking Dead (AMC), I came up with a small list of things that I would think a bucket survival package would need. I would put the heavier stuff toward the bottom of the bucket with clothing items last on the top. Here's my considered list:
1. Hygiene packet - these can be purchased at Wal Mart and other stores for about $3-$5 each. They contain deodorant, shaving cream, toothpaste, a razor, a toothbrush and often some other minor items such as hand sanitizer. Naturally, you would want to decide what items are needed per individuals and abilities.
2. Hand Sanitizer - although mentioned above, not all packets have this item and you simply can not have too much of this during a disaster. A small alcohol based sanitizer could have other uses as well should things get bad.
3. Clothing - Don't worry at this point about the winter clothing, but instead consider the needed items such as underwear, socks, T Shirts and then put anything like jeans, shirts, etc. There are several good sites that can teach you how to pack clothing tightly (Example) It's likely that if the disaster is during the winter, the individual will wear his or her coat for the trip - at least they should!
4. Information Sheet - on the top of the clothing put the person's information sheet. This should have diagnosis, medications, allergies, emergency contact numbers, etc.
After you have put the items above in the bucket, put the lid on and snap it tight. The bucket will keep water out of the items, serve as a seat if needed somewhere and has many other uses in really bad situations. Regardless of the situation though, you now have 6 (if you are a six bed facility) buckets prepared to go. Finally, write the person's first name only on the outside of the bucket and stack them in the storage area.
By using a bucket, you will reduce your evacuation time tremendously. You can have the individuals put their buckets on the van or transport while your staff focusses on the food, water, medical and medications supplies - most of which should already be ready to go as well.
Finally, if you like the bucket idea, you can expand other ways to use them. A bucket might present a smaller and easier way to manage the food supplies, toilet paper, or even emergency charts during the transportation. Buckets can keep electronics such as cell phones, radios, chargers, and even a small solar charger ready and dry to be used as needed. So the next time you head out to Lowes or Home Depot for supplies, be sure your buckets are on the list.
The first thing to know, and hopefully you do, is that most ICF programs are required to have disaster plans. These plans, in Texas for example, require that you not only have a plan for what you are going to do if you have to stay at the facility, but also what you are going to do if you have to leave the facility and travel somewhere else. The basic requirements (and certainly not all of them) is a 72 hour supply of food, water, and medications. In addition you need clothing, hygiene products and other items for each individual in the facility. With the individual is where I began to consider how a bucket could be used. In fact, I realized that the bucket could be prepared easily, stacked in storage, and ready to go at a moment's notice. A prepared bucket for an individual could save you several minutes or longer in an evacuation. Not to mention, given time you could add items to the bucket that you know you'll need, but may not think about during the disaster (If you think of some others let me know).
So, as I sat thinking about this during some disaster television show such as The Walking Dead (AMC), I came up with a small list of things that I would think a bucket survival package would need. I would put the heavier stuff toward the bottom of the bucket with clothing items last on the top. Here's my considered list:
1. Hygiene packet - these can be purchased at Wal Mart and other stores for about $3-$5 each. They contain deodorant, shaving cream, toothpaste, a razor, a toothbrush and often some other minor items such as hand sanitizer. Naturally, you would want to decide what items are needed per individuals and abilities.
2. Hand Sanitizer - although mentioned above, not all packets have this item and you simply can not have too much of this during a disaster. A small alcohol based sanitizer could have other uses as well should things get bad.
3. Clothing - Don't worry at this point about the winter clothing, but instead consider the needed items such as underwear, socks, T Shirts and then put anything like jeans, shirts, etc. There are several good sites that can teach you how to pack clothing tightly (Example) It's likely that if the disaster is during the winter, the individual will wear his or her coat for the trip - at least they should!
4. Information Sheet - on the top of the clothing put the person's information sheet. This should have diagnosis, medications, allergies, emergency contact numbers, etc.
After you have put the items above in the bucket, put the lid on and snap it tight. The bucket will keep water out of the items, serve as a seat if needed somewhere and has many other uses in really bad situations. Regardless of the situation though, you now have 6 (if you are a six bed facility) buckets prepared to go. Finally, write the person's first name only on the outside of the bucket and stack them in the storage area.
By using a bucket, you will reduce your evacuation time tremendously. You can have the individuals put their buckets on the van or transport while your staff focusses on the food, water, medical and medications supplies - most of which should already be ready to go as well.
Finally, if you like the bucket idea, you can expand other ways to use them. A bucket might present a smaller and easier way to manage the food supplies, toilet paper, or even emergency charts during the transportation. Buckets can keep electronics such as cell phones, radios, chargers, and even a small solar charger ready and dry to be used as needed. So the next time you head out to Lowes or Home Depot for supplies, be sure your buckets are on the list.
Thursday, March 5, 2015
Avoiding the "Duck Syndrome"
Several years ago I first used the phrase "Duck Syndrome" to describe a large group of people with developmental disabilities accompanied by one or two staff going to an event or a store together. The thought came to me after I watched a group of six people enter a store with a staff member at the front of the group and a staff member at the back of the group. The group walked through the store, picked up the one item they needed, walked back to the counter, paid for it and walked out in single file. It seemed to me that it looked like a group ducks walking together. The thought and phrase wasn't to belittle anyone, it's just a fact. That fact is they all looked like little ducks following the mother duck through an area. It was a syndrome I hated seeing for two reasons. First, it draws attention to the group. Everyone looks and notices the group walking through the store. It's bad enough they all road the van with the handicapped plates to the store together, but now they had to all walk through the store for one item. Second, it served absolutely no purpose whatsoever. What were the people with disabilities learning? How to walk through a store, pick up an item and let the staff pay for it. That was about it. There was no training from the staff on what they needed, why they needed it, how much it would cost, how to pay for it and count the change....nothing. The entire "parade" through the store only served to pick up a needed item and walk people in and out of a store.
Since that time I have hated the idea of mass groups going somewhere for one event or one need. I've seen it with physician appointments (one person has an appointment, but ten go!). I've seen it with shopping trips, trips to the zoo, trips to the mall, trips to parades and even trips to events like Special Olympics. It's degrading and wrong, but supporters (of the Duck Syndrome if you will) have some valid points of concern. They say that if they don't line everyone up and walk through a store or event, someone will get lost and they (the staff will get in trouble for it). I also hear the excuse of they simply do not have enough funds to have staff for "individualised outings" There is actually merit to both of these arguments. In the ICF setting, the regulations and funding cuts have made it tough to ensure individual outings. But there is ways to try to avoid the problem.
Consider the following solutions if you find yourself working in a facility where the "Duck Syndrome" is used frequently:
1. Asses your staffing ratios - can you increase it so that everyone is not forced to go on a march?
2. Consider bringing in staff for special events - can you bring in an extra staff during a scheduled appointment time, or for a special event? Sometimes that person could be a part-time person or a staff flexing a schedule a little.
3. If you have to go somewhere together consider the staff dropping off one staff and the person(s) who needs to go to the event or appointment and then taking others somewhere else.
4. Consider breaking the group up - if you have six to ten people, can a staff go with four or five and another staff go with the others? If you're in a restaurant, nothing says you have to all sit at the same table, ask for and even have a few tables around the restaurant for two or three individuals only. Have your staff monitor the room. In the movie theater, you don't all have to sit on the same row.
5. Look at the schedules - does everyone go to bed at eight, but yet you have two people or more working until ten or later? If so, flex those schedules to where those people can help out during the special events.
Ultimately, whatever you decide to do as the QIDP, always put yourself in the place of a person with disabilities. It could easily be you walking in that line through the store to pick up one item. How would you feel if you knew other people in the store were looking at your, even staring at you? How would you feel to walk through a store with ten other people just to pick up one item? Would you want to be in the "Duck Syndrome"? I'm betting the answer to most of those questions is "No" or "Not really feeling good about this." If that's what you're thinking, then you need to work to find a way to avoid this syndrome. The people you serve have been singled out and handed a rough hand in life already. It's your job to take that rough hand dealt and make it better. As the QIDP you have a unique opportunity to make a difference and to make that difference in someones life......don't let that opportunity slide by you for the convenience of something like the "Duck Syndrome".
Since that time I have hated the idea of mass groups going somewhere for one event or one need. I've seen it with physician appointments (one person has an appointment, but ten go!). I've seen it with shopping trips, trips to the zoo, trips to the mall, trips to parades and even trips to events like Special Olympics. It's degrading and wrong, but supporters (of the Duck Syndrome if you will) have some valid points of concern. They say that if they don't line everyone up and walk through a store or event, someone will get lost and they (the staff will get in trouble for it). I also hear the excuse of they simply do not have enough funds to have staff for "individualised outings" There is actually merit to both of these arguments. In the ICF setting, the regulations and funding cuts have made it tough to ensure individual outings. But there is ways to try to avoid the problem.
Consider the following solutions if you find yourself working in a facility where the "Duck Syndrome" is used frequently:
1. Asses your staffing ratios - can you increase it so that everyone is not forced to go on a march?
2. Consider bringing in staff for special events - can you bring in an extra staff during a scheduled appointment time, or for a special event? Sometimes that person could be a part-time person or a staff flexing a schedule a little.
3. If you have to go somewhere together consider the staff dropping off one staff and the person(s) who needs to go to the event or appointment and then taking others somewhere else.
4. Consider breaking the group up - if you have six to ten people, can a staff go with four or five and another staff go with the others? If you're in a restaurant, nothing says you have to all sit at the same table, ask for and even have a few tables around the restaurant for two or three individuals only. Have your staff monitor the room. In the movie theater, you don't all have to sit on the same row.
5. Look at the schedules - does everyone go to bed at eight, but yet you have two people or more working until ten or later? If so, flex those schedules to where those people can help out during the special events.
Ultimately, whatever you decide to do as the QIDP, always put yourself in the place of a person with disabilities. It could easily be you walking in that line through the store to pick up one item. How would you feel if you knew other people in the store were looking at your, even staring at you? How would you feel to walk through a store with ten other people just to pick up one item? Would you want to be in the "Duck Syndrome"? I'm betting the answer to most of those questions is "No" or "Not really feeling good about this." If that's what you're thinking, then you need to work to find a way to avoid this syndrome. The people you serve have been singled out and handed a rough hand in life already. It's your job to take that rough hand dealt and make it better. As the QIDP you have a unique opportunity to make a difference and to make that difference in someones life......don't let that opportunity slide by you for the convenience of something like the "Duck Syndrome".
Monday, February 16, 2015
Vision, Hearing and W323
W323 specifically deals with Vision and Hearing screenings. These screenings are required annually and to date have been completed by a variety of screeners. Audiologist, optometrist, and even physicians have completed these assessments to comply with the federal standards.
In Texas it has been generally accepted that if your physician checks hearing and vision and notes that it is "Okay" or "Within normal limits" etc, surveyors have stayed away from writing W323. Often this has been completed by simply a "check" next to "Hearing," and/or "Vision". These "checks" or "checkmarks" have been accepted in most survey regions of Texas for upward of twenty years now. That has recently changed apparently.
At a recent survey a surveyor noted that a "check" was not sufficient to indicate what sort of hearing and vision screening a physician had completed. It did not seem to matter that the choices for the check were "Normal," "Abnormal," and "Unable to determine". For the survey in question, "Normal" was checked for each individual questioned; however, that did not seem to meet the needs. The surveyor stated, "CMS has indicated that a checkmark is no longer acceptable and that we have to cite deficient practice for a checkmark." That statement was repeated again in the exit survey.
Interestingly, the standard did not change and neither did the information found in the federal tag regarding practices and probes. Apparently, someone working at CMS changed his or her opinion about what is and is not acceptable and issued some sort of memo to the states, or at least the state of Texas.
The particular facility in question had about five years worth of physicals on file at the home. I looked back through them and each had the same use of a "checkmark" for a review of vision and hearing. It appeared to support what I hear from many QIDP's and Administrators and that is that "Surveyors will find something no matter how good your program is doing." Ironically, none of the individuals with checkmarks have hearing devices or glasses. The individuals who have glasses in that home see an optometrist on a regular basis.
In the end the facility will have one of three choices. It can naturally appeal the decision of the surveyor in an attempt to find out if this was simple surveyor bias or if it has a foundation in the CMS oversight. The facility could simply start having everyone see an optometrist and audiologist regardless of needs and thus spend further Medicaid tax dollars. Finally, the facility could request additional information from the physician regarding specific test used to determine that everything "checks" out for an individual, and that could simply cause the physician to refer the individual to someone else. Whatever choice the facility makes, one thing is clear and that is that standards continue to be open to interruption whether its by an individual surveyor, a region, or even the federal government.
In Texas it has been generally accepted that if your physician checks hearing and vision and notes that it is "Okay" or "Within normal limits" etc, surveyors have stayed away from writing W323. Often this has been completed by simply a "check" next to "Hearing," and/or "Vision". These "checks" or "checkmarks" have been accepted in most survey regions of Texas for upward of twenty years now. That has recently changed apparently.
At a recent survey a surveyor noted that a "check" was not sufficient to indicate what sort of hearing and vision screening a physician had completed. It did not seem to matter that the choices for the check were "Normal," "Abnormal," and "Unable to determine". For the survey in question, "Normal" was checked for each individual questioned; however, that did not seem to meet the needs. The surveyor stated, "CMS has indicated that a checkmark is no longer acceptable and that we have to cite deficient practice for a checkmark." That statement was repeated again in the exit survey.
Interestingly, the standard did not change and neither did the information found in the federal tag regarding practices and probes. Apparently, someone working at CMS changed his or her opinion about what is and is not acceptable and issued some sort of memo to the states, or at least the state of Texas.
The particular facility in question had about five years worth of physicals on file at the home. I looked back through them and each had the same use of a "checkmark" for a review of vision and hearing. It appeared to support what I hear from many QIDP's and Administrators and that is that "Surveyors will find something no matter how good your program is doing." Ironically, none of the individuals with checkmarks have hearing devices or glasses. The individuals who have glasses in that home see an optometrist on a regular basis.
In the end the facility will have one of three choices. It can naturally appeal the decision of the surveyor in an attempt to find out if this was simple surveyor bias or if it has a foundation in the CMS oversight. The facility could simply start having everyone see an optometrist and audiologist regardless of needs and thus spend further Medicaid tax dollars. Finally, the facility could request additional information from the physician regarding specific test used to determine that everything "checks" out for an individual, and that could simply cause the physician to refer the individual to someone else. Whatever choice the facility makes, one thing is clear and that is that standards continue to be open to interruption whether its by an individual surveyor, a region, or even the federal government.
Sunday, February 1, 2015
Where does the QIDP Role Stop?
The QIDP is often given multiple task within the ICF/IID organization and the line between QIDP work and "Other" can sometimes become blurred together. The question then becomes "Where does the QIDP's role stop?" Most QIDP's reading this post will say it never stops, or it stops after I leave the organization. Sadly, this approach to QIDP work is making it harder and harder to find people willing to become QIDPs.
Consider the basic responsibilities of most QIDP's listed below:
1. Obtain Consents
2. Write CFA reports
3. Implement IPPs and Objectives
4. Maintain IPPs and Objectives
5. Coordinate services
6. Write Plans of Correction
7. Train Staff and monitor staff
8. Write Interim staffings between annual CFA meetings
9. Obtain and coordinate Specially Constituted Committee people, minutes and meetings
This short list is only the basic QIDP responsibility list. We could extend it further and likely give each item listed above sub-categories. Anyone looking at this would think initially, "That's not too much," and it might not be if a QIDP was assigned to only four to six individuals. However, the fact is most QIDP's have a caseload of somewhere between eighteen and twenty-four individuals. This means the QIDP has to do the above nine items for upward of twenty-four individuals.
This is twenty-four individuals with unique wants and needs, unique family dynamics, unique behaviors, and unique problems. Basically the QIDP is responsible for all nine areas presented and to be the counselor for the individual person.
This is where the lines often blur together and would-be QIDP's spend a brief amount of time working in the field before deciding that a teaching job or a job in a department store might present fewer headaches and fewer hours. When the line blurs together the QIDP might end up hiring new staff, training all the new staff, completing background checks on new staff, handling individuals money, accounting for property of the individuals, grocery shopping, shopping for clothing for the individual, minor repairs at the home, coordinating major repairs and on-and-on. The list of QIDP "Responsibilities" can rapidly grow to a point to where the QIDP is the Human Resource Manager, the Accountant, the Home Manager, the on-call staff person, etc. It can actually become overwhelming just to think about it.
All this being said though, the reader must still keep in mind that the caseload is the key to the QIDP's responsibilities. My QIDP (MY QIDP) started to meet the needs of small facilities. The fact is a six-bed facility owned by one person or even a small group, does not need a full-time QIDP. If they do have a full-time QIDP, there's a good chance that QIDP will have to have some other duties and responsibilities pertaining to the operation; however, the larger groups where a QIDP has a large caseload (18-24), you may want to consider giving a Home Manager responsibilities for home related items, a payroll or human resource department the responsibilities related to employees, and allow the QIDP to function as a QIDP and not the manager, book-keeper, director, staff training coordinator, etc. Once we reach a point where QIDP's can do the job they sought, we'll have happier QIDP's who decide to stay in the field rather than seek something different.
Consider the basic responsibilities of most QIDP's listed below:
1. Obtain Consents
2. Write CFA reports
3. Implement IPPs and Objectives
4. Maintain IPPs and Objectives
5. Coordinate services
6. Write Plans of Correction
7. Train Staff and monitor staff
8. Write Interim staffings between annual CFA meetings
9. Obtain and coordinate Specially Constituted Committee people, minutes and meetings
This short list is only the basic QIDP responsibility list. We could extend it further and likely give each item listed above sub-categories. Anyone looking at this would think initially, "That's not too much," and it might not be if a QIDP was assigned to only four to six individuals. However, the fact is most QIDP's have a caseload of somewhere between eighteen and twenty-four individuals. This means the QIDP has to do the above nine items for upward of twenty-four individuals.
This is twenty-four individuals with unique wants and needs, unique family dynamics, unique behaviors, and unique problems. Basically the QIDP is responsible for all nine areas presented and to be the counselor for the individual person.
This is where the lines often blur together and would-be QIDP's spend a brief amount of time working in the field before deciding that a teaching job or a job in a department store might present fewer headaches and fewer hours. When the line blurs together the QIDP might end up hiring new staff, training all the new staff, completing background checks on new staff, handling individuals money, accounting for property of the individuals, grocery shopping, shopping for clothing for the individual, minor repairs at the home, coordinating major repairs and on-and-on. The list of QIDP "Responsibilities" can rapidly grow to a point to where the QIDP is the Human Resource Manager, the Accountant, the Home Manager, the on-call staff person, etc. It can actually become overwhelming just to think about it.
All this being said though, the reader must still keep in mind that the caseload is the key to the QIDP's responsibilities. My QIDP (MY QIDP) started to meet the needs of small facilities. The fact is a six-bed facility owned by one person or even a small group, does not need a full-time QIDP. If they do have a full-time QIDP, there's a good chance that QIDP will have to have some other duties and responsibilities pertaining to the operation; however, the larger groups where a QIDP has a large caseload (18-24), you may want to consider giving a Home Manager responsibilities for home related items, a payroll or human resource department the responsibilities related to employees, and allow the QIDP to function as a QIDP and not the manager, book-keeper, director, staff training coordinator, etc. Once we reach a point where QIDP's can do the job they sought, we'll have happier QIDP's who decide to stay in the field rather than seek something different.
Tuesday, December 30, 2014
Blame The QIDP
"The QIDP is responsible for everything." You have likely heard that phrase spoken by administrators, owners, staff, surveyors, and you may have even spoken it yourself from time-to-time. It is the quick out and the quick way to blame someone for all the problems. In most cases, if you questioned the statement, you were quickly pointed to the federal standards and tag number W159, or as some know it, "The QIDP Tag!" W159 is taken to mean that everything happening at the facility is the responsibility of the QIDP. While each state is different in interpretations, and in some cases each surveyor is different in interpretations, most would agree that W159 focuses most of the blame squarely on the QIDP. If we take the meaning at exactly the way it has been expressed then we can conclude that the QIDP is responsible for the following things:
1. Billing
2. What the physician does or does not do.
3. What the nurse does or does not do.
4. Data input to the state.
5. Renewing the license for the facility.
6. Setting up all the diets.
7. Doing all the psychological
8. Prescribing psychotropics as needed.
9. Training staff on everything- OSHA, CPR, etc.
10. etc.
You may be looking at the list and thinking to yourself, "It's impossible for the QIDP to be responsible for all that stuff. The QIDP doesn't even do our billing!" You would be right in your assumption, it is impossible for the QIDP to be responsible for all that stuff. In fact, there is a good chance that the use of W159 should not be the foundation to say the QIDP is responsible for everything, but instead it should be the foundation to say, "The QIDP should coordinate everything." In other words, you can not be responsible for all those items listed above and you simply can not be "responsible for everything." If that statement, used so often, that says, "The QIDP is responsible for everything," was true, then you'd have no need for most of the other federal tags. Why would you need a dietician? The QIDP can do it! Why would you need someone in billing? The QIDP can do it! Why would you need an Administrator? The QIDP can do it! The fact is saying the QIDP is responsible for everything is simply wrong. It's wrong to place this burden on a QIDP and it's wrong to express this saying. However, QIDP's reading this, do not think you'll get off the hook that easily.
The fact is, as stated before, the correct expression should be, "The QIDP should coordinate everything". A closer look at what W159 says will clearly show that the position of the QIDP is not to be responsible for everything, but instead it is to coordinate everything.
W159 says "Each client's active treatment program must be integrated, coordinated, and monitored by a qualified intellectual disabilities professional." That is the entire standard, and if you look closely you will notice the words "responsible for everything" can not be found. In fact, the more appropriate wording that says the QIDP should ensure the program for each individual is "integrated, coordinated, and monitored" comes to light. More simply put, the QIDP should "coordinate" everything related to the client's programming needs (and those can be many as you know!).
As you know, W159 continues with questions and guidelines for the surveyor. Without going into too much more detail, it is easy to read and see that the QIDP's function really centers on coordinating all the services for the people served, or the client. That responsibility will require a lot of knowledge about what is going on with the person, what is happening around the person, and even the day-to-day basic functions of the home where the person lives.....it will not, however, mean that the QIDP is responsible for everything. Should the QIDP have a working knowledge of everything that is going on? Yes. Should the QIDP be responsible to do everything? No.
The function of the QIDP is to coordinate and ensure that services meet the needs of the individual served or the client. So, blaming the QIDP for everything based on W159 or any other assessment of the facility is simply wrong. The QIDP should do his or her job and coordinate, but others in the facility program must do their jobs as well. If you find you are in a facility where problems are constant, do not simply assume the QIDP is responsible. Look at your administrative structure and deal with the appropriate person(s) for the problem. Let's take a little time to stop blaming the QIDP for everything and start addressing the area of need.
Monday, December 8, 2014
Dealing With Negative Surveys
The fact is if you are a QIDP long enough, you're going to have a negative survey experience. It's going to be based on one of three potential reasons that you face a negative experience in all likelihood. Here are the three most likely reasons for a negative survey:
1. Either you or someone within your organization fails to do the work required in an important area - an example might be the QIDP fails to type an annual staffing, the nurse does not do annual assessments, staff do not document data or goals, or the organization fails to get some required appointments or needs met per standards.
2. A negative surveyor acting out of line - let's face it, nobody wants to say it, but the truth is some surveyors act differently than others. While they should all hold the facility to the standards, there are simply some of them that have their own interpretations of what those standards mean. In other words, they may "see something that's not in the standards," or "hold the facility to different level of the standards" (quotes I have heard from providers). A surveyor that comes in with a negative attitude from the start can cause a difficult survey process to follow. They tend to look deeper and longer, they tend to complain about everything, and often they make statements about right and wrong that simply are not part of the standards, but instead opinion based. Surveyors will tell you that this doesn't happen; however, that would be to admit that surveyors are not human and subject to influences that can cause them to have a bad day. Sorry, the fact is, some surveyors act negatively during the survey process. Sorry - truth hurts.
3. The final reason for a negative survey is usually a combination of the above two. For example, you may have a really bad dietician who does not do his or her job. As a result all the diets are wrong or there is a lack of training on some special diets needed. Along comes a surveyor already in a "negative" mood and suddenly this issues is a major problem. The surveyor becomes visibly upset and then starts to, as many people have stated, "dig for more bad stuff". Often this process becomes extremely hard on the surveyor and the facility because it continues to grow.
So, with the above three potential situations in mind, what can the QIDP do to ensure a positive survey? There are actually several things the QIDP can do:
1. Try to ensure that all areas have been addressed prior to the annual survey. Do a mock survey, find your weak spots (yes, you have them, we all do) and work on correcting them.
2. Make the survey process positive by being honest. I'm not saying to go tell the surveyor something like, "Well, look over here on John's annual hearing test....we didn't get it finished for fourteen months instead within the twelve..." No, there is no reason to hand the surveyor the deficient tag, let them look, but when they ask you about it, be honest. This is your time to build a reputation and you want to have a reputation of being honest even in light of negative findings. In other words, it's better to simply say, "I see what you're looking at and agree, we did not get the vision test completed in a timely manner. We will correct that." Don't lie - it's your reputation and the reputation of the facility that you need to maintain.
3. If a surveyor becomes aggressive when seeking answers or is being negative, try to remain positive. We have all seen surveyors that appear to attempt to make everything that has gone wrong a terrible thing! I have heard QIDPs, staff, managers and even owners say things like, "Wow, we know it's a mistake and we need to correct it, but that surveyor is just hounding us over it," or "If that surveyor acts like that, I'm not coming back in the morning." Simply remain as positive as you can and answer the questions directly. I once had a negative acting surveyor asking me direct questions that to be honest I did not agree with the findings that were being presented. I could tell the surveyor was going to "jump" on anything I said in a negative manner based on the fact that they just had over two things I already answered. I simply changed my form of answers to "Yes" or "No". When the surveyor prompted me further on a question I had answered "No" to by saying, "So are you telling me that you did not do this?" I responded, "Yes, I am telling you we did not address that." Naturally, the 2567 had a statement that said, "QIDP A stated that he agreed and the facility did not address X".
4. Get the deficiencies, write the POC and address them. Simple.
5. If you truly feel that the survey was negative and it was not yours or the facilities fault, first complete the comment option (online in Texas), consider talking with the surveyor's supervisor, and finally if needed file a formal complaint following your state's guidelines. However, remember that you may have to deal with the same surveyor again, the surveyor may have just had a bad day, or maybe....just maybe, you did have a negative survey because of issues within your facility or you were having a bad day....
Ultimately, regardless of the outcome of any survey, you need to remember that surveyors are not there to "Pat you on the back" and tell you what a great job you and your staff are doing. They are there to ensure compliance with a minimal set of standards. They look for the negative things in the facility and that is their job. While they may like things you are doing that are positive, there is always a good chance they can find something wrong. They are human and just like you they can make mistakes or misunderstand something you have been working on for the facility. Just because one set of surveyors finds something wrong, it does not mean the next set will find the same issues. It's just part of the nature of the business. The bottom line though is that a survey process, the corrective action taken after the process, and the continued work between surveyors and facilities should have an end result of one thing: Improving the lives of people with Developmental Disabilities, and if that can happen in the end, that's all that really matters.
Sunday, December 7, 2014
QIDP, QDDP, ICF - What Does It All Mean?
One of the major questions that I am asked all the time is "What do you do?" When I respond, "I'm a QIDP," you can imagine the blank stares I get. People look at me with the old "Deer in the headlight" look as they ponder their next question. The next question comes quickly, "What's a Q...?" They naturally trail off because they did not hear exactly what I said or they did not understand.
At this point in the conversation, I usually respond, "I am a consultant for homes serving people with disabilities. I write programs and goals for the individuals living in those homes." Guess what? I'm suddenly classified as a "Computer Programer" and everyone is excited because they think I'll be able to write them a neat little app for their cell phones. While writing apps, and other work is a nice attachment hobby, it is not what a "Q" does or even what it means to be a "Q".
For those aware of the terminology, the next part is going to be a little boring. The old term "QMRP" stood for Qualified Mental Retardation Professional. The term basically means that the person is "qualified" to write goals and to serve in a certain capacity to help people who have a diagnosis of Mental Retardation. There are specific federal standards, and in some cases state standards, around the country that address what a Q does and his or her role (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_j_intermcare.pdf).
With the changes of terminology brought about by Rosa's Law (http://myqidp.com/Rosa%27s%20Law%20and%20changes.pdf) the use of the term "Mental Retardation" was removed from use in the United States. Naturally, when that change was made, the acronym "QMRP" was no longer appropriate. Some states elected to change the term to "QDDP" or Qualified Developmental Disabilities Professional, while others went with the federal change to "QIDP" or Qualified Intellectual Disabilities Professional.
For lack of a better way to explain the position a QIDP or QDDP is simply a person who works and writes goals and data to help individuals with Intellectual Disabilities learn to live more independently. The Q may be found on a state level working for organizations such as large or small institutions, or on a smaller level working for ICF (Intermediate Care Facilities) in settings with six to twelve people being served. Ultimately, the Q is essentially a "Case Manager" and has duties much like those of any human service case manager. While there are many different views of how a QIDP should work, there is a national organization that bonds these Q's together and even provides formal training (http://www.qddp.org/). Other organizations offer training and consulting services such as my own organization (http://myqidp.com).
QMRP = Qualified Mental Retardation Professional (outdated now)
QDDP = Qualified Developmental Disabilities Professional
QIDP = Qualified Intellectual Disabilities Professional
ICF/MR = Intermediate Care Facility for people with Mental Retardation (outdated now)
ICF/IID = Intermediate Care Facility for Individuals with Intellectual Disabilities
Within the world of ICF settings, there are several other acronyms you may encounter. Some can be found on my site at: http://myqidp.com/ICFMR.htm
At this point in the conversation, I usually respond, "I am a consultant for homes serving people with disabilities. I write programs and goals for the individuals living in those homes." Guess what? I'm suddenly classified as a "Computer Programer" and everyone is excited because they think I'll be able to write them a neat little app for their cell phones. While writing apps, and other work is a nice attachment hobby, it is not what a "Q" does or even what it means to be a "Q".
For those aware of the terminology, the next part is going to be a little boring. The old term "QMRP" stood for Qualified Mental Retardation Professional. The term basically means that the person is "qualified" to write goals and to serve in a certain capacity to help people who have a diagnosis of Mental Retardation. There are specific federal standards, and in some cases state standards, around the country that address what a Q does and his or her role (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_j_intermcare.pdf).
With the changes of terminology brought about by Rosa's Law (http://myqidp.com/Rosa%27s%20Law%20and%20changes.pdf) the use of the term "Mental Retardation" was removed from use in the United States. Naturally, when that change was made, the acronym "QMRP" was no longer appropriate. Some states elected to change the term to "QDDP" or Qualified Developmental Disabilities Professional, while others went with the federal change to "QIDP" or Qualified Intellectual Disabilities Professional.
For lack of a better way to explain the position a QIDP or QDDP is simply a person who works and writes goals and data to help individuals with Intellectual Disabilities learn to live more independently. The Q may be found on a state level working for organizations such as large or small institutions, or on a smaller level working for ICF (Intermediate Care Facilities) in settings with six to twelve people being served. Ultimately, the Q is essentially a "Case Manager" and has duties much like those of any human service case manager. While there are many different views of how a QIDP should work, there is a national organization that bonds these Q's together and even provides formal training (http://www.qddp.org/). Other organizations offer training and consulting services such as my own organization (http://myqidp.com).
QMRP = Qualified Mental Retardation Professional (outdated now)
QDDP = Qualified Developmental Disabilities Professional
QIDP = Qualified Intellectual Disabilities Professional
ICF/MR = Intermediate Care Facility for people with Mental Retardation (outdated now)
ICF/IID = Intermediate Care Facility for Individuals with Intellectual Disabilities
Within the world of ICF settings, there are several other acronyms you may encounter. Some can be found on my site at: http://myqidp.com/ICFMR.htm
Saturday, November 29, 2014
Welcome To QIDP
Welcome to QIDP. It wasn't difficult for me to come up with a title for this blog since I am a QIDP; however, I wanted to be able to transcend the boundaries often placed by individual states. Once I began searching I found names for our former "QMRP" such as "QDDP," "QIDP," or simply "Case Manager" being used frequently. The new federal standards created for the ICF/IID world in 2013 used the term QIDP. Since I run a company, originally called My QMRP, called My QIDP I thought it was appropriate to simply call this QIDP.
While this blog will focus on issues facing QIDP's in Texas and other states, it can also lend expertise and guidance to others working in the field of Developmental Disabilities, or Intellectual Disabilities. You may even find information blending over to mental health issues, and other disabilities. I would like to reach out to QDDP's, QIDP's, Case Managers, and other titles I may not have considered and ask for your input. If you have an article, experience, story, or anything along those lines you'd like to share, then contact me at myqidp@gmail.com The rules are simple:
1. This must be your original work.
2. No real names concerning clients, consumers, individuals, patients, residents, etc.
3. Avoid names of facilities if it might harm your provider or others.
4. Your article will give credit to you. You may include contact information, etc to be placed in the article.
5. QIDP Blog is not required to post any submissions, but will consider all.
6. QIDP Blog is not a place to name-call, bad mouth, or point out specific surveyors - you may talk about incidents, but do not name the surveyor - remember they have jobs, families, and lives too and we will not adversely affect them. Even their 2567's only say "QIDP A...."
I look forward to hearing from you all soon!
Thanks,
Clinton S. Thomas, Th.D.
While this blog will focus on issues facing QIDP's in Texas and other states, it can also lend expertise and guidance to others working in the field of Developmental Disabilities, or Intellectual Disabilities. You may even find information blending over to mental health issues, and other disabilities. I would like to reach out to QDDP's, QIDP's, Case Managers, and other titles I may not have considered and ask for your input. If you have an article, experience, story, or anything along those lines you'd like to share, then contact me at myqidp@gmail.com The rules are simple:
1. This must be your original work.
2. No real names concerning clients, consumers, individuals, patients, residents, etc.
3. Avoid names of facilities if it might harm your provider or others.
4. Your article will give credit to you. You may include contact information, etc to be placed in the article.
5. QIDP Blog is not required to post any submissions, but will consider all.
6. QIDP Blog is not a place to name-call, bad mouth, or point out specific surveyors - you may talk about incidents, but do not name the surveyor - remember they have jobs, families, and lives too and we will not adversely affect them. Even their 2567's only say "QIDP A...."
I look forward to hearing from you all soon!
Thanks,
Clinton S. Thomas, Th.D.
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