Purpose: It is the policy of Hillcrest Educational Centers (HEC) to provide a safe and healthy work environment which includes proper management of exposure to potentially contaminated blood and/or body fluids. These procedures are meant to ensure that appropriate measures are taken to protect those at risk of exposure.

Background: OSHA estimates approximately 5.6 million workers in health care and other facilities are at risk of exposure to bloodborne pathogens such as the human immunodeficiency (HIV), hepatitis B (HBV) virus, hepatitis C (HCV) and other potentially infectious diseases. Those at risk include anyone whose job may require providing first-response medical care in which there is a reasonable expectation of contact with blood or other potentially infectious materials. Common exposure in settings like HEC may occur from human bites. Although they are rarely associated with the transmission of HIV or HBV infection they are associated with a significant risk for serious bacterial infection and require proper medical treatment. Prevention of exposures is critically important. Regular hand washing, appropriate use of gloves and training are steps that contribute to the prevention of complications from these exposures.
Vaccinations and Incident Reporting
HEC has a vaccination program through Occupational Health Services. This program is offered at no cost to all employees upon being hired and again to those who have an occupational exposure to bloodborne pathogens. In the event of employee exposure to bloodborne pathogens, post-exposure evaluation and follow-up will be provided at Occupational Health Services. Following any exposure incident, the affected employee should immediately report to the campus nurse on duty during normal business hours. After hours, employees are instructed to report to the Berkshire Medical Center Emergency Room. An ART form AND Post Exposure Work Sheet should be completed by the nurse, faxed to Employee Health Representative at HR, a copy should be given to the Program Manager and the original sent with the employee for further documentation by the treating physician.

Procedures after bite exposure (Student to Student or Student to Staff)
• Immediately wash the site for 5 minutes with soap and water or flush eyes with normal
saline or tap water for 15 minutes (remove and discard contact lenses) Mild bleeding should be allowed to continue
• If there is blood in the biter’s mouth it should be rinsed and spit with tap water several times
• Report the injury to a supervisor
• Contact or go to campus Nursing Department who will make an assessment and refer to pediatrician, Occupational Health Services or Emergency Department as necessary
• Initial assessment includes skin integrity (is the skin broken), documentation of the incident and those involved, and initial wound care
• If after hours, go to the Emergency Room for evaluation of a bite that has broken the skin
• Complete incident report form, ART Form and Post Exposure Worksheet. Enter a progress note in the appropriate system.
• Obtain a medical history on the source patient (biter) and have blood specimens drawn within the first 8-10 hours after exposure (consent must be obtained): Rapid HIV and Hepatitis panel. Bites occurring after Nursing hours will have arrangements made to be drawn the next morning. (Previously drawn labs are acceptable if dated in the past 60 days)
• Employees referred to Occupational Health or ER will receive an assessment and treatment which may include but is not limited to tetanus update, antibiotics, and several blood tests as recommended by treating Physician. Treatment options will be discussed on an individual basis.
• Report the results of blood testing of the source (biter) to Occupational Health as soon as available (within 24 hours if rapid HIV done). The status of the Employee should be reported to the campus at this time. If there are positive reports at any time, The Medical Directors of both HEC and Occupational Health will be notified immediately. Referral for appropriate counseling and treatment will be made.
• If exposure occurs when there is no nurse available, a call should be placed to the campus on call Nurse to decide the course of action.
Procedures after body fluid exposure (Student to Student or Student to Staff)
In the event of an accidental exposure to blood or body fluids (e.g., needlestick, blood or body fluid contamination to a cut or scrape, mucous membrane exposure)
• Immediately wash the area for 10 minutes with soap and water or flush eyes with normal
saline or tap water for 15 minutes (remove and discard contact lenses)or rinse mouth for several minutes
• Report the injury to a supervisor
• Contact or go to campus Nursing Department who will make an assessment and refer to pediatrician or Occupational Health Services as necessary
• Initial assessment includes skin integrity (is the skin broken), documentation of those involved, and initial wound care
• If after hours, go to the Emergency Room for evaluation
• Complete incident report form, ART Form and Post Exposure Worksheet. Enter nursing note in appropriate system.
• Obtain a medical history on the source patient and have blood specimens drawn within the first 8-10 hours after exposure (consent must be obtained): Rapid HIV and Hepatitis panel. Bites occurring after Nursing hours will have arrangements made to be
drawn the next morning.(Previously drawn labs are acceptable if dated in the past 60 days)
• Employees referred to Occupational Health or ER will receive an assessment and treatment which may include but is not limited to tetanus update, antibiotics, and several blood tests as recommended by treating Physician. Treatment options will be discussed on an individual basis.
• Report the results of blood testing of the source (biter) to Occupational Health as soon as available (within 24 hours if rapid HIV done). The status of the Employee should be reported to the campus at this time. If there are positive reports at any time, The Medical Directors of both HEC and Occupational Health will be notified immediately. Referral for appropriate counseling and treatment will be made.
• If exposure occurs when there is no nurse available, a call should be placed to the campus on call Nurse to decide the course of action.

Post Exposure Worksheet

EMPLOYEE HEALTH CARE
Employees

HEC will not dismiss, refuse to hire, refuse to advance in employment, or otherwise discriminate against persons with HIV infection, believed to have HIV infection, or persons believed to be at risk of HIV infection.
HEC will not require that employee or prospective employees disclose their HIV status.
HEC will not require that employees or prospective employees undergo HIV testing as a condition of application or employment.
Information voluntarily provided by an HEC employee of their HIV status shall be kept confidential and contained in a separate medical file.
If requested to do so, HEC will make every effort to accommodate an employee diagnosed with HIV, AIDS, or any other infectious disease.

A. Pre-Employment Requirements
All Hillcrest Educational Centers employees must have a physical examination and essential functions testing prior to starting employment. This examination, which includes tuberculosis screening and Hepatitis B vaccination if wanted, is provided, at no cost to the employee.

B. Tuberculosis Screening
Tuberculosis screening is conducted on all staff at time of employment. If a staff is unable to receive a tuberculosis skin test due to previous exposure or other reasons Occupational Health arranges follow-up testing deemed appropriate, this may include a chest x-ray or referral to a Tuberculosis Clinic. Compliance with these recommendations may be a condition of continued employment with Hillcrest Educational Centers.

C. Employee Injury Procedure – Human Bite Policy
While doing everything possible to prevent human bites, Hillcrest Educational Centers recognizes that, given the behavioral profiles of the students served by Hillcrest, human bites may occur. Hillcrest’s procedure for instances of skin-breaking bites to a staff from a student are as follows:
While other staff notify the Supervisor that a staff has been injured, and as soon as possible after receiving bite, cleanse the area with soap and water for 8-10 minutes and cover with a dry sterile dressing.
Complete an Accident Reporting & Treatment (ART) form, and notify the Administrative Injury Coordinator as soon as possible. Refer staff to Occupational Health or the Emergency Department for treatment.
Nursing will inform Occupational Health or the ER of the Hepatitis B and HIV status of the “biter”, if known.
Treatment at the hospital may include Tetanus booster, Hepatitis and HIV testing as well as antibiotics. These will be available at no cost to the employee.
The Administrative Injury Coordinator will follow up with the employee after the assessment to coordinate care and facilitate the employee’s return to work.
The nursing department will contact the parent/guardian and/or custodial agency of the “biter” in order to attempt to obtain consent for HIV testing of the student if this consent is not already in place. HEC will follow the recommendations of the parent/guardian/custodial agency of the “biter” regarding testing. Consent forms that require parent/guardian/custodial agency signature will be submitted to the hospital/ laboratory at the time of the blood test. The physician must also sign these forms. The Nursing Department will make the parent/guardian/custodial agency aware that the test results will be shared with the injured staff and documentation of the results will be kept in a confidential sealed envelope in the student’s chart. Documentation regarding the attempt to obtain consent will be made on the employee’s Staff Injury Form.
The exposed individual will be informed of the student’s HIV status by the Infection Control Nurse and /or Occupational Health, when the results become available.

Epidemiological studies show that AIDS is transmitted primarily via sexual contact or blood-to-blood contact. Researchers state that casual transmission of the virus has not occurred in close family environments, and opportunistic infections associated with AIDS do not present an appreciable risk to healthy individuals. Since there is no evidence of casual transmission by sitting near, living in the household, or caring for an individual with AIDS, the following policy and procedures are intended to insure the privacy and protect the rights of all students and employees of Hillcrest Educational Centers.

A. Legal Effect of This Policy Statement
This instrument is an expression of policy. It is not intended to and does not want to modify contractual or other legal rights held by the Hillcrest Educational Centers’ students or employees. This statement is not intended to and does not create or modify Hillcrest Educational Centers’ legal duty of care to students or employees.

B. Definitions:
• “HEC” means the Hillcrest Educational Centers, Inc.
• “Student” means a student at, who has been admitted to, enrolled in, and is residing at the agency, and who has not graduated, transferred, or discharged from HEC, or who has been otherwise removed from active status for any reason.
• “Employee” means a person, including an administrator, who receives wages or a salary from HEC.
• “HIV” means the Human Immunodeficiency Virus, sometimes referred to as the Human T-Lymphotropic Virus, Type III (HLTV-III) or the Human T-Lymphotropic Virus, Type III/Lymphaadenopathy Associated Virus (HLTV-III/LAV)
• “HIV test” means a properly performed test licensed by the U.S. Food and Drug Administration to detect the presence of HIV antibodies or antigens in a person’s blood.
• “AIDS” means Acquired Immune Deficiency Syndrome caused by HIV, as well as the condition sometimes referred to as AIDS-Related Complex (ARC).
• “Person with HIV infection” means a person who is infected with HIV, whether the person has AIDS or some symptoms of AIDS or is asymptomatic.
• “Person believed to have HIV infection” means a person believed to have HIV infection by a student or employee of HEC who has not reviewed the results of an HIV test on that person
• “Person believed to be at risk of HIV infection” means a person believed to be at risk of contracting the HIV infection by a student of employee of HEC.

C. General Policy
HEC will not discriminate against students or employees with HIV infection, students or employees believed to have the HIV infection, or students or employees believed to be at risk of the HIV infection on the basis of their perceived risk.
HEC will conform its policies regarding persons with HIV infection to the law, the best available scientific and medical evidence and the imperatives of human dignity, including privacy.
HEC will treat students and employees with HIV with respect and will, where necessary, accommodate such students and employees accordingly.
Since HIV is not known to be transmitted by food or air, according to the latest available scientific and medical evidence, HEC’s students and employees will follow standard sanitary procedures related to preparing food and cleaning eating-ware, regardless of the presence at HEC of a person with HIV infection or believed to have HIV infection.
Since HIV is not transmitted through sharing bathroom facilities, and standard sanitary procedures will prevent the growth of fungi and bacteria that may potentially cause illness to immune-compromised people, HEC’s students and employees will follow standard sanitary procedures in sharing and cleaning bathroom facilities, regardless of the presence at HEC of a person with HIV infection or believed to have HIV infection. Toothbrushes and razors should not be shared under any circumstances but in particular because of HIV status.
Since HIV is transmitted through blood, semen and vaginal secretions, as are other pathogens, and since according to the latest scientific and medical evidence HIV is not transmitted by sweat, feces, urine, vomit, tears, saliva, sputum or nasal mucous, unless these fluids contain blood, HEC’s students and employees will follow the Universal Precautions issued by the Center for Disease Control to clean up all bodily fluids, in handling materials, such as clothing and sanitary napkins, that have come in contact with bodily fluids, regardless of whether those bodily fluids are from a person with HIV infection or believed to have HIV infection and regardless of whether or not the body fluid is considered to contain blood.
HEC will educate students and employees about HIV infection/AIDS so that they will understand that they need not feel threatened by the simple presence at HEC of persons with HIV infection, persons believed to have HIV infection, or persons believed to be at risk of HIV infection.
HEC will not tolerate, and will strive to prevent and eliminate, any possible discrimination or harassment by students or employees directed at persons with HIV infection, persons believe to have HIV infection, or persons believed to be at risk of HIV infection.

D. Students
Students or prospective students, or their parents or guardians who know that the students or prospective students have HIV infection must disclose this information to the Coordinator of Nursing Services in order to facilitate appropriate medical treatment and counseling. Students with AIDS or with clinical evidence of HIV, who are too ill to receive treatment in a residential facility should have an alternative treatment in an appropriate medical or hospital setting.
It is assumed that HIV infected students can be served in residential facilities and that their diagnosis does not pose any special consideration in terms of physical facility requirements. In some unusual circumstances, however, a student may exhibit exceptional behavior that poses a theoretical risk to other students or employees. Such behavior would consist of engaging in sexual activity with other students, using parenteral drugs, frequent incontinence and public defecation. Those students whose behavior is determined to be unmanageable should be transferred to an appropriate setting.
HEC will not require prospective students to undergo HIV tests as a condition of admission. However, HIV testing may be done after admission in the following circumstances:
If the authorization for Diagnostic Testing has been signed by the legal guardian during the pre-placement process and that student has exposed peers or staff to his/her own body fluids.
If testing for HIV is requested by a student and the guardian consents and, an HEC physician orders testing. In this case, results would be available to HEC staff as outlined in section D, # 10 of this policy. If the student were 18 years old or older, and competent, guardian consent would not be needed.
Anonymous testing may be arranged, if requested by a student, for any student 13 years old or older, at the Neighborhood Health Clinic with no guardian consent, in this case results will not be made available to HEC or any HEC staff.
HEC will not deny admission to prospective students with HIV infection, believed to have HIV infection, or believed to be at risk of HIV infection, on the basis that they have HIV infection, are believed to have HIV infection, or are believed to be at risk of HIV infection. HIV infection is not considered a communicable infectious disease for the purpose of the provision elsewhere in this policy. HEC will not admit a student without verification that the student is free from communicable / infectious disease.
The person with HIV infection and /or AIDS has a somewhat greater risk of encountering infections in a residential program. In the event of an outbreak at HEC of a communicable disease, nursing will immediately notify the Medical Director of any students with HIV/AIDS infection and follow the directives given, including if necessary transfer and/ or quarantine within HEC, if possible, or at another facility.
HEC will not deny students with HIV infection , believed to have HIV infection, or believed to be at risk of HIV infection, any rights, privileges, benefits, or status as students on the basis that they have HIV infection, are believed to have HIV infection, or are believed to be at risk of HIV infection.
HEC will not require or request students undergo HIV testing as a condition for obtaining, or retaining rights, privileges, or benefits as a student,
If a Program Director has a reasonable belief that a student has HIV infection, the Program Director may request that the school physician refer the student to an appropriate medical setting for an HIV test and, if necessary, treatment. At an appropriate medical setting, the student will be administered an HIV test only after the student or the student’s parent or guardian voluntarily signs an informed consent form consistent with section D, #5 above.
A student’s HIV test results, whether positive or negative, will be placed in a sealed envelope labeled “Confidential Medical Information.” HEC will determine whether to maintain any such sealed envelopes in individual students’ medical records or in a separate file with restricted access. Release of test results shall be in accordance with Section D, # 10 below.
Testing for HIV antibody is not recommended for any purpose other than early intervention and treatment. HEC will restrict information regarding a student’s HIV status to as few employees as is possible, and will strive to maintain maximum feasible confidentiality. Only employees with an absolute need to know should have medical knowledge of a particular student. In individual situations this might include one or more of the following:
• Student
• Parent or guardian
• Administrators
• Direct care staff, if deemed appropriate by HEC’s community based healthcare provider for employees (e.g., occupational health) after an exposure.
• Nursing/medical staff
• Clinical staff
If the Medical Director determines that he/she should release a student’s HIV test results in circumstances not mandated by law to anyone other than an employee of HEC, the managing physician, or the student’s parent or guardian, HEC must first obtain the voluntary consent, in accordance with Section D, #3 above, of the student or the student’s parent or guardian.

The fact that a student has sustained an injury is determined by the need for either first aid or some type of medical treatment, other than diagnostic procedures. The purpose of body checks and diagnostic procedures (e.g., examination, x-rays, etc.) is to determine whether an injury has occurred, and/or the extent or severity of an apparent injury.
If neither first aid nor medical treatment is required, there is no injury.
If it is determined by a medical provider that the student has sustained an injury, it still must be determined whether the injury is a minor or a major injury.

a. MINOR INJURY
A minor injury is defined as”…one which requires only first aid to be provided on site”.
(OCCS communication, March 2000).

According to this definition, if on site (e.g., nurses station) first aid (non-diagnostic procedures) is necessary for the injury (e.g., ice pack, Bandaid), the student has received a “minor injury”.
If the student does not require first aid, even if a body check or examination has been conducted, the student has not received a minor injury.

b. SERIOUS OR MAJOR INJURY
A serious or major injury is defined as “…one which requires a visit to a physician, ER or hospitalization”. (DEEC communication, March, 2000).

If it is determined that the student should be sent to a community physician or to the ER to determine if an injury has been sustained, and the extent of that possible injury, the act of sending that student to a community provider does not in and of itself result in a classification of “major injury”.
If the student receives a diagnostic examination and either receives subsequent medical treatment for an injury that goes beyond first aid, or is hospitalized for medical treatment of an injury (rather than for additional diagnostic work), the student has received a “major injury”.
If the student receives a diagnostic examination without receiving medical treatment because no injury was sustained, the student has not received a major injury.

If the student receives a diagnostic examination and, subsequently, only first aid because the injury was minor, the student has received a “minor in jury”, and not a “major injury”.

c. DOCUMENTING RESTRAINT RELATED BODY CHECKS AND INJURIES
1. The injury notation on the Physical Intervention form should be completed in a manner consistent with these definitions.

2. It is sometimes necessary to restrain a student more than once and sometimes with little time in between restraints and before a body check can be conducted. In such cases the body check and finding (e.g. “minor injury”) will be documented only on the most recent or last Physical Intervention Report form for the series, even though there will be a PI form completed for each restraint (incident).
On the most recent or final PI form in a series, the nurse conducting the body check will include the following note: “Body check for multiple physical interventions”.
On all other PI forms in that same series, the nurse conducting the body check will include the following note: “See the most recent PI form” with both date and time of the final PI form noted.
Sequential PI forms should be clearly marked to show the sequence of events.

3. If the student is sent to a community physician or to the ER for diagnosis and/or treatment of possible injury, the nurse does not complete the PI form related to injury until the final determination has been made by the community based provider as to whether an injury occurred and the extent of any injury.
In this case, the Nurse notes the action in the Medical Attention comment section (e.g., sent for X-Ray on 5/12/07) and circles the right hand section regarding injuries. She/he does not check off any injury box until the form is retuned for completion and the determination is made as to whether there was an injury.
The form is then circulated as usual.
Given these types of notations, after signing off on the form, the last person to review the form returns the form to the Nursing for completion.
When the form returns to Nursing, the nurse will complete the form in a manner consistent with the findings, including any explanatory notes and check offs (no injury – in which case the entire section is Xed out, minor injury or major injury), and the form is routed to the person who enters PI/injury data before the form is filed.

A. Associated With Restraints and Altercations

A body check of the student is to be conducted by the nurse within 24 hours or sooner if indicated, whenever any of the following conditions are met.
1. A physical intervention has been “difficult”, severe or such that injury may have occurred, regardless of the duration of the hold or restraint e.g., the student has struggled and the staff has had to apply some degree of force to maintain safety.
2 The student has been involved in a “floor restraint” (i.e., prone, on the floor–not seated).
3. The restraint exceeds 20 minutes.
4. The student reports any pain or discomfort, or the student appears to be in pain or uncomfortable, regardless of whether or not he/she reports or confirms pain or discomfort.
5. After a physical altercation between students that meets any of the criteria outlined above (i.e., difficulty, severity or duration of physical altercation; report or appearance of injury, pain or discomfort).

If there is no nurse on duty at the time of the incident, the on call nurse will be consulted by telephone. If it is determined that the on call nurse need not come to program to do a body check, the body check will be done as soon as possible at the beginning of the next nurse’s shift on campus.

B. Prior To and On Return from Unsupervised Leave Of Absence

A body check is also done prior to, and upon returning from, an unsupervised home visit or an unsupervised off-campus visit. This is not a contraband check; it is a visual inspection looking for signs of illness or injury.

C. Student Refusal

If a student refuses a body check, the supervisor is notified, and the event is documented on the Incident Report form and in the case record Progress Notes. Additional attempts are made until body check is completed.

A. Schedule and Availability
A Registered Dietitian (RD) is available to evaluate the nutritional requirements of students as referred by the nursing staff or the pediatrician. The Dietitian works with the Director of Food Services and the Nursing Department; he/she is available for consultation when needed.
The Dietitian covers all campuses and accommodates the needs of all students. The Dietitian reports to the Nursing Office on each campus to address all nutritional consultation issues.
The Dietitian also helps to insure that Nutrition Services meet or exceed applicable state regulations and JCAHO standards.

B. Levels of Care

1. Using data obtained during the nutrition assessment, a nutrition level of care (LOC) is assigned. The LOC may be changed after meeting with the student; meeting with clinical and medical staff; guardian; or at the discretions of the RD. In all situations, the RD needs to use his/her professional judgment to provide the appropriate and highest of quality nutritional care. In all situations this must take into consideration the medical, social, and environmental needs of the student and be consistent with the services provided at Hillcrest Educational Centers.
2. Students will receive ongoing nutritional care consistent with the standards specified for the assigned level of care.

C. Criteria for Levels:
a. Level of Care 1
Any student in need of a specialized or modified diet due to a chronic nutrition-related condition or acute malnutrition will be classified as Level of Care 1: (LOC 1)
a. Including but not limited to the following diagnoses:
1) active eating disorder
2) uncontrolled diabetes
3) malnutrition
4) malabsorption
5) enzyme deficiency (excluding lactose intolerance)

Level 1 Nutritional Care Standard:
1. When referred, the Registered Dietitian will complete a nutrition assessment. The assessment is documented in the student’s master medical file under Nutrition. The Dietitian will use his/her professional judgment as to whether a specific nutrition care plan is needed at this time and a treatment plan will be documented in the student’s medical record.
2. Follow-up nutrition care and documentation will be completed at least monthly thereafter for as long as the RD working in conjunction with the Medical team determines it necessary. Follow-up nutrition care will include re-evaluation of LOC.

2. Level of Care 2
Any student with one or more of the following criteria will be classified as Level 2:
a. Abnormal Growth- including but not limited to the following:
1) Obesity
2) Weight for Length >95% or Body Mass Index (BMI) = >95%
3) Growth Failure – also known as Failure to Thrive (FTT)
• Weight for Length <5%
• Unexpected weight loss or inability to maintain an appropriate weight
b. Fasting blood cholesterol on admission exceeding 199
Policy: Hypercholesterolemia (I. – below)
c. Abnormal Nutrition related lab values on admission- including but not limited to the following:
1) Albumin less than 3.2
2) Anemia related lab values: Hct, Hgb, MCV
d. Documented food allergies/intolerance that may put a student at risk for malnutrition or require a significantly modified diet (other than sick day diet)
e. Non-insulin dependent Diabetes
f. Anorexia (Vs. Anorexia Nervosa)
g. Unmanaged lactose intolerance
h. Any diagnosed condition in which the RD and Medical team deem it necessary for close nutrition follow-up.

Level 2 Nutritional Care Standard
1. When referred, the registered dietitian will complete a nutrition assessment. The assessment is documented in the student’s Electronic Progress Notes under Nutrition. The dietitian will use his/her professional judgment as to whether a specific nutrition care plan is needed at this time and a treatment plan will be documented in the student’s medical record.
2. Follow-up nutrition care and documentation will be completed at least quarterly thereafter for as long as the RD working in conjunction with the Medical team determines it necessary. Follow-up nutrition care will include re-evaluation of LOC.

The dietitian and nurse will develop a Treatment Plans for students with a level of care of 1 or 2, as deemed necessary. The treatment plan will be part of the student’s medical chart.
Treatment Plans are designed to satisfy the student’s special diet requirement and may include exercise goals as well. These plans must also take into consideration the medical, social, and environmental needs of the student and be consistent with the services provided at the Hillcrest Educational Centers. These plans are updated and reevaluated quarterly to coincide with each student’s quarterly reviews.

3. Level of Care 3

Students considered to be at minimal nutritional risk upon admission are classified as Level 3 (LOC 3). (Regular Diet)

Level 3 Nutritional Care Standard
Screening will be provided only at RN or MD’s request. Staff should be encouraged to write down their concerns and submit them to the Nursing Department for review, as they are the campus’s link to medical/clinical providers.

D. Assessment of Students
Nutritional assessment is done by nursing on every student upon admission and will be reviewed by the pediatrician with referral to the RD as indicated.

E. Dietitian Role and Responsibility
1. The Registered Dietitian assists the Director of Food Services in providing students with safe and nutritionally adequate meals. He/she provides nutritional assessment, and evaluations of student as needed, and consults with the medical, clinical, educational, and administrative community at Hillcrest Educational Centers to help foster the highest quality of healthcare to our students.

The responsibilities of the R.D. include but are not limited to:
a. To serve as a consultant to the Food Service Director, Nursing Dept., and other involved staff.
b. To approve all menus in accordance with the diet manual.
c. To participate in the development and ongoing monitoring and evaluation of departmental Quality Improvement indicators.
d. To periodically observe the serving of meals.
e. To review special diets and provide nutritional counseling as needed.
f. To review food acceptance survey results and aid in determining the response to students’ requests for menu changes.
g. To act as a resource for the Education Dept., to support health teachers in their role as nutrition educators.
h. To review student medications for drug nutrient interaction, implications and providing nutrition information and counseling where needed.

2. Nutrition Counseling/Education
The R.D. is responsible for nutrition counseling and diet instruction for students that are in need of this type and degree of instruction. All staff are encouraged and expected to support each student’s nutritional goals. The goal for the diet instruction is to involve the student in learning simple concepts about the diet and to become responsible, to some extent, for self-care of the component of his/her treatment. The degree to which each student can participate in his or her nutritional care plan is dictated by the stage of his or her treatment and may vary greatly from student to student.
a. Upon receipt of a physician’s request for a consultation or diet modification, the R.D. will review the medical record, access the patient’s nutritional status, consult with the physician and other treatment team members, and develop a nutrition care plan which includes appropriate nutrition counseling.
b. Appropriate written instructions should accompany a verbal instruction. Where indicated, other staff (i.e., teachers, Youth Development Professionals) shall become involved in student education and/or implementation of special diet.
c. Follow-up visits should be made to each student receiving instruction in order to evaluate the effectiveness of the instruction.
d. All diet instructions should be documented in the medical record, including a description of the diet instructions and materials given to the student, a summary of the diet history, an assessment of their diet knowledge, and a recommendation for post-discharge follow-up, as appropriate.

F. Diet Orders
1. The attending physician orders a regular or special diet upon admission or at any other time during a student’s placement that is deemed necessary by the medical team. The Food Service Dept. receives the order from Nursing. The R.D. acknowledges implementation of the diet in the student’s chart in the nutrition assessment and progress note section. Any change in the diet order is documented by the nursing staff and forwarded to the Dietary Department.
2. The dietitian will meet with all students on special diets. Special diets are identified in the student’s medical record chart and in his/her Treatment Plan.
3. Food service staff are informed of students’ dietary needs, and direct care staff are notified as well.
4. At the time of discharge the student’s current diet plan is included in the student’s discharge summary.

G. Consumer Satisfaction Surveys
Food will be prepared in an environment suitable for safe food production and served in an atmosphere suitable for the students. To monitor quality and overall food service acceptance, at least annually a consumer satisfaction survey will be utilized to address food service and nutrition issues. The Food Service Director will oversee the monitoring; the Registered Dietitian will consult when necessary.
1. Approved CSQ forms are used. (See Attachment 7 – B)
2. All students are given the opportunity to complete the CSQ annually.
3. Results are reviewed. Corrective Action reports are discussed, and menus are revised and circulated through the Dietitian, FSD, Program Director and Cooks as needed.

H. Off Campus Meal Policy
The following policy applies to all students and all meals when it is deemed necessary to provided meals in the community, away from a Hillcrest campus.

Hillcrest Educational Centers
Off-Campus Meal Policy

Students under 10 years:
1 burger or sandwich 1 small fry
1 medium non-caffeinated beverage

Students over 10 years:
2 burgers or 2 sandwiches 1 medium fry
1 large non-caffeinated beverage

Points to remember:
Foods and/or beverages may have an effect on medication utilization in the body.

No Caffeinated Beverages, which may include:
 Soda
 Coffee
 Sports Drinks that contain:
 Caffeine  Mau Hung
 Ephedrine

Excessive amounts of high fat foods, high calorie foods are not appropriate for anyone. No super-size meals.

High sugar items should be kept to a minimum.

All foods are acceptable in moderate amounts.

Please contact student’s Clinician and Nursing if you note any of the following:
 Individuals hoarding food
 Consuming excessive amounts  Consuming food in an abnormally rapid fashion
 Refusal to eat at multiple or consecutive meals

I. Hypercholesterolemia Policy

Goal: The reduction of elevated cholesterol levels in our students.

Definition: hypercholesterolemia will be defined by a fasting cholesterol level greater than 199.

Procedure: all students will have a fasting cholesterol test upon admission and follow up testing annually. If an elevated level (greater than 199) is found the level will be repeated in three-month intervals and assessment for referral to endocrinologist will take place.

Evaluation Process:

1. Fasting cholesterol will be ordered and completed as part of admission process.

2. Medical Director, Registered Dietitian, and Registered Nurse will review all Cholesterol studies.

3. An elevated (over 199) cholesterol level will be repeated in three months.

4. In the case of hypercholesterolemia the Medical Director will review and consult with RD and Nurse. The following considerations shall be made:
• R/T medication
• Family history, if possible
• Dietary intervention
• Lipid profile
• Cholesterol lowering medication

5. After careful review and consideration for the student’s age, independence, maturity, diagnosis, current medications, history, and the effects of additional medication a treatment plan will be established.
• There will be documentation in progress note of the plan regarding hypercholesterolemia.
• Reviews for students with hypercholesterolemia will take place quarterly.

6. When the cholesterol level has returned to less than 200 or when deemed appropriate by the RN, RD, or MD the time between testing will be modified.

A. Department Philosophy
In addition to servicing and treating health problems, the medical component of the Hillcrest program, teaches the students to maintain a healthy life-style, to recognize illness when it occurs, and to appropriately access community medical systems when necessary.
HEC provides nursing coverage at all campuses. Each campus nursing department consists of a registered nurse as head nurse and staff nurses, consisting of registered nurses and licensed practical nurses. A Coordinator of Nursing Services oversees the campus nursing services.

B. Health Care Providers
Physicians on staff of Hillcrest Educational Centers include a Director of Psychiatry and Consultant Psychiatrists; a Medical Director and one or more Consultant Physicians and Nurse Practitioners. On an as needed basis, the agency uses the services of specializing physicians who maintain private practices in the community. Additional, non-routine medical treatment is provided when indicated by order of the medical director. In addition, as noted above, Hillcrest provides nursing coverage at all campuses.
The agency also has healthcare related consultants on staff including a Registered Dietitian.

C. On-Call Nursing Coverage Procedure
On-call nursing coverage is provided when there is not a nurse physically present on campus. The on-call nurse, when contacted, will make a medical assessment of the situation based upon the information provided by campus staff. Based on the information provided, the on-call nurse will either give instructions to the staff or will travel to the campus to make an in person assessment of the situation.
On-call nurses can give phone authorization for administration of certain medications. This policy does not include medications that have to be signed for or IM medications. It is also limited to medications approved in the standing orders.
The on-call nurse will return to campus under circumstances including, but not limited to, the following:
1. Assessment of illness or injury in which an adequate medical judgment cannot be made through telephone consultation.
2. Medical or psychiatric situations requiring the administration of medication by a licensed nurse.
3. Immediate assessment following student incidents involving sexually inappropriate behavior that warrants physical assessment.
4. Immediate assessment following suspected physical abuse.
5. If injury occurs or may have occurred during a physical intervention.
6. The request of the Program Director/Manager or on-call administrator.
7. Restraint situations requiring the assessment of an independent licensed practitioner.

In order to maintain uniform standards of care, a procedure manual and physician’s standing orders are maintained in each campus nursing office. Standing orders are reviewed once yearly by the Medical Director.

A. Pharmacy Standard
A registered pharmacist or designee will review the medication cart, emergency box and documentation once every three months. The date of the next inspection will schedule in writing with the Head Nurse prior to the inspector leaving. Head Nurses will notify the CNS if any inspections are not done on the specified day. The CNS will immediately contact the pharmacy owner should this occur. A registered pharmacist will provide Four hours of in-service education to the nursing department.

B. Nursing Standard
All personnel administering medication will be accurate in terms of right medication, dose, time, route, site and documentation. Each student will have an accurate physical assessment completed within 24 hours of admission by a registered nurse. Each student on medication will be observed on a daily basis and any adverse reaction to medication will be documented and reported to the prescribing physician.

C. Psychiatric Standard
Each student will have an assessment completed by a licensed psychiatrist within 7 days of admission; within 72 hours for the ITU. All students will be seen every eight weeks. Each student receiving medication will be seen and his/her medication regime will be reviewed at a minimum of every eight weeks by a licensed psychiatrist.

The “Nursing Occurrence” form (see Attachment 7-A) must be completed whenever the medication administration procedure is not followed.

A. Reporting Pharmacy Errors
At the time a pharmacy error is discovered, the following steps are to be taken:
1. Notify the pharmacy.
2. Notify your charge nurse and the Coordinator of Nursing Services.
3. If there has been a medication error, an Occurrence Form is to be completed. Send a copy to your Coordinator of Nursing Services.
4. Make a report about the pharmacy error in narrative format, sign it and include the following:
a. Dates
b. Personnel involved
c. Sequence of events
d. Corrective actions and resolution.
e. Copy the original pharmacy order. Copy any supporting evidence. Send note and copies to your Nursing Coordinator.

These steps are to be completed by the nurse discovering the error before the end of his/her shift.

The Coordinator of Nursing Services will notify the Executive Vice President, or, in the absence of the Executive Vice President, the CEO/President

(Also see Section 5, URGENT EVENTS AND EMERGENCIES, Chemical Restraint)

1. Policy
Hillcrest does not perform Chemical Restraints. As stated by the Massachusetts Department of Early Education and Care (DEEC) in policy statement number P-OCCS_R&P-02 (revised 1/05/04): “Chemical restraint is defined as the administration of medication for the purpose of restraint. Medication administered according to requirements and procedures for treatment authorized by a court (a Rogers order) is not a chemical restraint. …a PRN …taken voluntarily is not a chemical restraint. A psychotropic medication administered involuntarily in an emergency to prevent immediate, substantial and irreversible deterioration of serious mental illness is not a chemical restraint.”

According to DEEC a program may request a variance to use chemical or mechanical restraint.

1. Notification
The Supervisor or Nurse will contact the on call Administrator to inform him/her of the situation which constitutes an immediate danger presented by a student, and to describe interventions which have been attempted to deal with the danger. If the on call Administrator determines that the situation constitutes an immediate danger of serious harm to the student and/or others, and that other interventions have been properly employed but have not been successful, he/she will instruct the onsite or on call Nurse to consult an agency physician.

Final notification routes for each occurrence will depend on the urgency of the situation and other current conditions.

2. Determination of Need for involuntary anti-psychotic medication
Through first hand, on site assessment, or through telephone consultation with a physician or nurse who is present at the site of the emergency, the agency physician will determine whether involuntary psychotropic medication administration is the least intrusive intervention necessary to prevent further deterioration of a student’s emotional/psychological well-being.

3. Administration
Only a physician, or a nurse acting on an order from a licensed physician, will administer the medication. He/she will monitor the student in person immediately afterward for negative effects, and will reassess the student’s condition 15 minutes after the administration. The student receiving the medication will continually remain in the presence of an assigned staff member trained in assessing for distress. The practitioner who administered the medication will inform the assigned staff member of any possible negative effects of the medication and the amount of time necessary for the student to remain in close supervision.

4. Documentation
The time and date of the order for involuntary anti-psychotic medication administration must be documented on the doctor’s order sheet by the physician, or documented by a licensed nurse as a telephone order from the physician. The use of medication will be documented in the student’s case record with at least the following information:
a) A description of the precipitating incident or series of incidents, the alternative interventions attempted including all efforts to prevent the use of chemical restraint, and the reasons the medication was necessary.
b) The fact that involuntary medication was the least restrictive alternative and why.
c) The time and from whom the order for administration was obtained, and the names and titles of all other persons notified and/or involved in the decision.

5. Incident Review/Treatment Planning:
At all Hillcrest sites except for the Intensive Treatment Unit (ITU), the use of an involuntary PRN requires a Special Team Meeting to discuss the circumstances of the event and revise the student’s crisis intervention plan accordingly. A second involuntary PRN for the same student requires an Emergency Team Meeting to determine the student’s appropriateness of placement.

The ITU may request a waiver by D.E.S.E. to allow involuntary PRN’s as a part of a student’s intervention plan for severe cases. In such cases, a monitoring plan must be incorporated into the student’s Comprehensive Treatment Plan to assure frequent and proper assessment of the intervention’s benefit. Without such a waiver in place, the ITU must follow the general protocol described above.