Department Response to Recent Incidents at Facilities for People with Developmental Disabilities
Blunt Commends State Mental Health Commission for Actions Related to Tragic Patient Death
DMH, Protection and Advocacy discuss client care and safety
Consulting Contracts with Columbus Organization
An Open Letter to Consumers, Families, Advocates and Staff
Assuring Quality of Care in MRDD Community Programs
Department of Mental Health Employees:
I hope that you have taken the opportunity to read my Open Letter published on the DMH website regarding the recent death of Rudy Wallace at the Northwest Campus of the St. Louis Developmental Disabilities Treatment Center . Sometimes persistent problems that keep us from giving consumers the kind of care we would want for ourselves become so routine that we lose our sense of urgency about them and begin to think of them as just "the way things are".
But we cannot let that happen! People's lives depend on how we handle everyday situations.
When we surveyed direct care staff as part of the workplace improvement initiative, they told us that the aspect of the job they valued most was the opportunity to work with and serve the individuals entrusted to our care. They also told us that what they most wanted as DMH employees was to be safe, respected, well supported, and treated fairly: the very things that the individuals and families that we serve want and deserve.
You must not tolerate abuse or neglect of consumers, or a culture of silence that fails to expose abusive or neglectful staff. We must create an environment in which each of us feels obligated to report abusive or neglectful behavior, and in which we are encouraged to identify and correct problems that inhibit our ability to provide the best care possible. If you see something you feel is wrong SPEAK OUT! State statute (Section 105.055 RSMo) prohibits any supervisor or appointing authority from taking any disciplinary action against any employee for reporting:
- A violation of any law, rule or regulation,
- Mismanagement, a gross waste of funds or abuse of authority, or
- A substantial and specific danger to public health or safety.
We value and will support the good staff who comprise the majority of our workforce and who carry out their responsibilities in a caring and competent manner, but we must identify and dismiss staff who do not share our commitment to assuring that consumers are safe, respected, well supported, treated fairly, and receive the services and supports they need.
We are assembling teams of direct care staff to help us better understand and change the conditions that can lead to abuse and neglect, or to a climate in which staff do not report abuse and neglect. One team will be comprised of staff from our habilitation centers, one from our psychiatric facilities, and one from our high security facilities. The teams will examine the abuse/neglect reporting and investigation process from the employee's perspective, identify root causes of abuse/neglect and the failure to report abuse/neglect, and develop recommendations for change. The teams are expected to complete their work and make recommendations by July.
Of course, we recognize that adequate staffing is critical to assure safe and effective facilities and programs, and we have requested additional resources for staffing at several state facilities in order to meet enhanced clinical and direct care staffing standards. We have already begun implementing the enhanced staff at the facilities with the most critical needs.
We cannot be satisfied with "making do". The individuals and families we serve deserve our best. We owe it to them, we owe it to our co-workers and we owe it to ourselves to do what is right.
Please help me and the rest of the DMH administration create and sustain facilities and programs that are of the highest quality. You can do so by identifying problems and recommending solutions. Because those closest to a problem are often the best people to resolve it, I encourage you to first work with your supervisor on resolving issues. Of course, some issues require a broader span of control, so that you should feel free to raise issues to the appropriate level in your local organization. If you do not believe that you are being heard, you can also forward concerns to me at directormail@dmh.mo.gov.
There may be instances where employees are apprehensive in reporting a problem and prefer anonymity; however, please understand it is generally much more difficult to pursue and resolve anonymous tips. I encourage you to be open about your concerns. We can't fix a problem that we don't know about.
Sincerely,
Dorn Schuffman
Director
Blunt Commends State Mental Health Commission for Actions Related to Tragic Patient Deaths
JEFFERSON CITY—Gov. Matt Blunt praised the announcement made today by the State Mental Health Commission that it has ordered the Missouri Department of Mental Health to conduct a full and thorough investigation into the deaths of two patients at a facility in St. Louis and to hold public hearings to gather citizen input on how services to the department’s clients can be improved.
“The State Mental Health Commission has taken strong steps to demand change from the Department of Mental Health and to give Missourians information they deserve about internal problems surrounding these tragic deaths and the opportunity to share their opinions on how services can be improved so no other patients or their families have to endure such a devastating loss,” Blunt said.
The non-partisan, seven-member State Mental Health Commission is charged by law with overseeing the State Department of Mental Health. Members of the commission include physicians, representatives of patients and families, experts in business matters and procedures, in drug or alcohol abuse and a person recognized for their interest in community mental health services.
“The State Mental Health Commission is comprised of eminently qualified members in the field of mental health study and support appointed by governors of both political parties,” Blunt said. “I look forward to hearing future reports regarding the internal changes they have demanded from the department and the public testimony they receive from concerned Missourians. We must always strive to look for the best possible ways to provide services for those in need.”
DMH, Protection and Advocacy discuss client care and safety
Officials from the Department of Mental Health (DMH) and Missouri Protection and Advocacy met Friday, March 31, to discuss ways to best ensure the appropriate care and safety for persons with developmental disabilities served by the Department in the community and state facilities.
Linda Roebuck, interim director of the Division of Mental Retardation and Developmental Disabilities (MRDD), said the Department will strictly enforce its policy of sharing information with Protection and Advocacy regarding consumers served in the community and in state facilities.
"Protection and Advocacy has a critical role to play in ensuring client care and safety," Roebuck said. "We are asking Protection and Advocacy to assist us in assessing how we do quality assurance for community-based services." She said the Department will notify Protection and Advocacy immediately of the death of any DMH client as well as any other significant incidents.
Roebuck and Protection and Advocacy Director Shawn DeLoyola discussed ways to ensure the quality of community-based services for persons served by the Department. This includes the appropriate reporting of abuse or neglect, ongoing assessment of individual client care, review of the measurements of client care, and the analysis of actions taken to improve quality and client safety.
The Division of MRDD will provide Protection and Advocacy with all policies for quality assurance and information on current practices used to ensure quality care. Protection and Advocacy will review the information and provide feedback within 30 days.
"We value their participation and feedback on our efforts to assure quality of care for the persons we serve," Roebuck said.
Protection and Advocacy is a federally mandated agency providing for the protection of the rights of persons with disabilities.
Consulting Contracts with Columbus Organization
Following the death of a consumer at Bellefontaine Habilitation Center in August 2004, the Department of Mental Health (DMH) requested the State ICFMR Medicaid Survey Team conduct a survey around issues of client care and safety at Bellefontaine. At the same time, the Department conducted its own administrative and clinical review of the facility. Both the ICFMR Medicaid survey, and the Department's own review identified a broad range of clinical and administrative issues. Based on that survey, the facility's certification was in jeopardy and as a result, the state was in danger of losing more than $15 million in federal reimbursement.
The Department contacted the National Association of State Developmental Disabilities Services for suggestions on obtaining help for Bellefontaine. The Department contacted the two organizations they suggested - the Columbus Organization and Liberty Healthcare Corporation.
In recognition of the emergency needs at Bellefontaine to assure client care and safety, and to retain federal reimbursement, the Office of Administration's Division of Purchasing advised that, pursuant to Section 34.046 RSMo, the commissioner of administration may utilize a contract established by another governmental entity in order to purchase needed goods and services, and recommended that we request that each provider submit their existing contracts with other states for consideration. Upon review of the existing contracts submitted by the two providers, it was determined that a Columbus contract with the State of California was the best fit for what the DMH needed.
That original contract with the Columbus Organization was for Quality Management Training and Consulting at Bellefontaine and was signed October 22, 2004. It was amended in December 2004 to also include services for the state's five other habilitation centers, if needed. The original contract was extended in August 2005 to allow time for development of a bid request for ongoing consultation and training. On January 25, 2006, a Request for Proposals was published by the Office of Administration, Division of Purchasing, describing the scope of work. March 10 was the closing date for bids. Three organizations submitted bids: the Pennhurst Group, LLC; the Columbus Organization; and the Consortium on Innovative Practices. The evaluation committee is scheduled to meet on April 6. The Office of Administration, Division of Purchasing is managing the bid process.
These contracts provide consultation and training to existing staff. They do not replace or assume the responsibilities of existing staff. They strengthen the care provided at the facilities, and are not responsible for any activities related to efforts to downsize or close any facility.
The consultation and training provided by the Columbus Organization focuses on three key areas:
Psychology and Behavioral Services
- Developed new process for reviewing restraint procedures
- Developed alternatives to using restraint
- Replaced a "level system" designed to control behavior with a Positive Behavior Support approach that enables individuals to develop the skills to better manage their own behavior
- Developed and implemented guidelines for psychological evaluations consistent with creating Positive Behavior Support plans
- Provided individual case consultation on behavior management
Active Treatment
- Developed and implemented a variety of scheduled activities and lesson plans for each program area
- Consulted with Unit Managers, Habilitation Specialists, and other facility staff on program development and implementation
- Monitored implementation of new programming throughout the facility
Quality Assurance, Risk Management, and Investigations
- Developed a system to track incidents from the initial report to completion of investigations
- Re-established an effective facilitywide quality assurance system
- Assisted quality assurance staff in developing effective systems for monitoring implementation of Plans of Correction for the ICF/MR survey
- Conducted and completed numerous abuse and neglect investigations
The Columbus Organization also provided consultation in the areas of physical and nutritional management, medical and nursing care, psychiatry, and human resources.
As a result of the consultation, technical assistance, and training provided by the Columbus Organization at Bellefontaine Habilitation Center, the facility has been able to:\
- Maintain its ICF/MR certification, resulting in more than $15 million in federal Medicaid reimbursement
- Eliminate the use of prone restraints and mechanical restraints
- Reduce the number of consumers who require one-on-one supervision by 47%
- Significantly expand both on-campus and community-based programming and activities
In anticipation of the possible loss of clinical and administrative staff due to the possible closing of the Bellefontaine Habilitation Center, a second contract was developed with the Columbus Organization utilizing an existing contract with the State of Indiana. This contact is for personnel services. To date, this contract has been used to contract for a facility administrator for Bellefontaine Habilitation Center as a result of the facility superintendent stepping down due to a serious illness, and to access a registered occupational therapist.
The total cost of the services provided through both contracts over the past 17 months has been about $2.3 million, of which about 40 percent has been recouped through federal reimbursement.
Last week, the DMH Facility Operations Team conducted a review of the programming, staff, environment of care, and quality assurance systems at St. Louis Developmental Disabilities Treatment Center (SLDDTC). Based on that review, a decision was made to expand the scope of the Columbus Organization's oversight, training, and technical assistance to include SLDDTC in addition to Bellefontaine Habilitation Center. The additional oversight is being provided at no additional cost, and plans are being developed to determine which current resources can be shared across facilities in order to keep additional costs low.
When the new consultation and training bid is awarded, transition will be made to the successful bidder.
March 30, 2006
Department of Mental Health statement on investigation into November, 2005, death of Northwest Habilitation Center client.
The Department of Mental Health today issued a statement on findings of an investigation into a November, 2005, death of a habilitation center client.
A 24-year-old man became ill at the Northwest Habilitation Center November 1, 2005. He vomited that day and on each of the next three days. An x-ray on November 4 indicated that part of an ink pen was in his abdomen. He was taken to DePaul Hospital on November 4. A medical procedure was performed to remove the pen. He died on November 8 at the hospital. Cause of death was a perforation in the small bowel. Other non-food items were found in his intestine.
An investigation was initiated November 9 by the Department of Mental Health. The report was issued March 15, reviewed at the facility level, and then reviewed at Central Office on March 21.
The individual's plan called for one-on-one level of supervision. The investigation could not substantiate abuse or neglect against any one staff person. This was a factor in the decision to bring in Columbus Organization to Northwest Habilitation Center and review staffing and other quality of care issues at the facility, and to assign the department deputy director as interim director of the Division of Mental Retardation and Developmental Disabilities. Those changes were announced March 24, by Department Director Dorn Schuffman.
The investigation was provided to the guardian. The Department does not have permission of the guardian to disclose the name of the individual.
Assuring Quality of Care in MRDD Community Programs
On Friday, March 24, Dorn Schuffman appointed Linda Roebuck Interim Director of the Division of Mental Retardation and Developmental Disabilities. Mr. Schuffman instructed Ms. Roebuck to make the Division oversight of the quality of community-based programs her top priority.
The Department's Facility Operations Team is carefully assessing the quality of care in the Division's facilities. Concerns raised by recent audits and a review of historical incident and injury data require that we make every effort to also assure the adequacy of the Division's quality assurance and improvement processes for community programs. Ms. Roebuck will work with consumers, advocates, and providers to conduct timely and thorough review of current systems, and to make immediate changes as appropriate to assure consumers and families that the Division is providing appropriate oversight.
The Department has made a wide range of data available to the press regarding incident and injuries dating back to 2000. We anticipate that this data will raise a variety of questions.
However, it should be noted that recent changes in policies and processes have significantly strengthened reporting and tracking requirements, and implementation of the CIMOR system this summer will further strengthen our ability to monitor the quality of care, as well as to track important reporting requirements.
For example, facilities and regional centers are required to notify the parents of minors and guardians of any allegations of abuse or neglect, and to notify law enforcement of alleged or suspected:
- sexual abuse
- abuse, neglect or misuse use of funds/property for which there is cause believe that criminal misconduct is involved; and
- abuse or neglect that results in physical injury.
Our current incident and injury database does not require that facilities or regional centers enter data regarding these required notifications. However the incident and injury data base that is included in the CIMOR system does require that this data be entered, and will allow automated tracking of compliance.
In addition, since September 2005 when DMH centralized all abuse and neglect investigations, DMH facilities and regional centers have been required by Department Operating Regulation to supply investigators with documentation that parents and guardians have been appropriately notified. Investigators have also been tracking compliance with the requirement to notify law enforcement since last September, and Department Operating Regulations now also require that this information be supplied to investigators, and it is included as a routine part of every investigation.
Prior to September 2005, it was not possible to determine whether the required notifications had been made without surveying a variety of sources. The Division of Mental Retardation and Developmental Disabilities recently asked its facilities and regional centers to assess the extent to which they could document that the required notifications to law enforcement had been made for reported allegations of sexual abuse recorded in the incident and injury system going back to 2000. This survey suggested that the required notifications could not be documented in a significant percentage of the cases. While some explanations have been offered for the discrepancies, without accurate data the adequacy of the explanations cannot be verified.
Mr. Schuffman has requested the participation of Missouri Protection and Advocacy in assisting in the review of the Division's quality assurance and improvement processes, and has asked for a status report from the Division within thirty days.
