PHYSICAL INTERVENTIONS (All campuses)

 

INSTRUMENT/DOCUMENT

Physical Interventions are documented on Physical Intervention Report forms.

MEASURE

The number of Restraints, Extended Restraints, and Total Restraints for the month and the quarter. Comparisons are made with the previous quarter and the same quarter in the previous year.

ADMINISTRATION CYCLE

Monthly and ongoing.

ADMINISTRATION & DATA MANAGEMENT

One person at each campus is designated to manage PI data. He/she reports the data to the IS Director by the 15th of each month.

PERFORMANCE MEASURE REPORTING

By the 20th day of the first month following each quarter, the IS Director issues a quarterly report on the Physical Intervention Measure. Current quarter data is compared with the data from the previous quarter and with data from the same quarter from the previous year.

The Program Manager provides interpretation of the quarterly data.

PM OVERSIGHT

The campus IOP Committee is responsible for overseeing the Physical Intervention Performance Measure.The IOP insures that 1) PIs are being documented and the associated data is being managed according to HEC procedures; 2) the PI data is reported to the IS Director and reported according to the schedule required by HEC procedures.

STAFF INJURIES DURING RESTRAINTS (All campuses)

 

INSTRUMENT/DOCUMENT

Staff injuries during restraints are documented on Accident Report & Treatment form (ART form), with a copy of the Incident Report form attached.

MEASURE

Included in this PM are all staff injuries:

  • that occur during restraints;
  • and for which ART forms are completed.

The number of staff injuries that occur during restraints for the month and the quarter. Comparisons are made with the previous quarter and the same quarter in the previous year.

ADMINISTRATION CYCLE

Monthly and ongoing.

ADMINISTRATION & DATA MANAGEMENT

The person designated at the campus sends copies of all ART forms (with copies of Incident Report forms attached, for in juries that occur during restraints) to the Assistant Director of Human Resources. The Assistant Director of Human Resources manages Staff Injury data and reports the data to the IS Director by the 15th of each month.

PERFORMANCE MEASURE REPORTING

By the 20th day of the first month following each quarter, the IS Director issues a quarterly report on the Staff Injuries Measure. Current quarter data is compared with the data from the previous quarter and with data from the same quarter from the previous year.

The Program Manager provides interpretation of the quarterly data.

PM OVERSIGHT

The campus IOP Committee is responsible for overseeing the Staff Injury Performance Measure.

The IOP insures that 1) the injuries are being documented and the associated data is being managed according to HEC procedures; 2) the PM data is reported to the IS Director and reported according to the schedule required by HEC procedures.

STUDENT INJURIES DURING RESTRAINTS (All campuses)

 

INSTRUMENT/DOCUMENT

Student injuries during restraints are documented on Incident Report, Physical Incident Report forms and the Incidents All Sites Database.

MEASURE

The number of student injuries that occur during restraints, for the month and for the quarter. Comparisons are made with the previous quarter and the same quarter in the previous year.

ADMINISTRATION CYCLE

Monthly and ongoing.

ADMINISTRATION & DATA MANAGEMENT

The Nursing Dept. notes any student injury and the severity of injury on the Incident Report or Physical Intervention report form. A specific person at the campus is designated to tally and enter such data. He/she reports the data for campus to the IS Director by the 15th day of each following month.

PERFORMANCE MEASURE REPORTING

By the 20th day of the first month following each quarter, the IS Director issues a quarterly report on the Student Injuries Measure. Current quarter data is compared with the data from the previous quarter and with data from the same quarter from the previous year.

The IS Director provides interpretation of the quarterly data.

PM OVERSIGHT

The campus IOP Committee is responsible for overseeing the Student Injury Performance Measure.

The IOP insures that 1) the injuries are being documented and the associated data is being managed according to HEC procedures; 2) the PM data is reported to the IS Director and reported according to the schedule required by HEC procedures.

 

Improving Organizational performance

PI BASICS

Performance Improvement (PI):

  • is required & evaluated by the Joint Commission (JC)
  • parallels & complements JC’s standards (i.e., PI, Information Management, EOC, Leadership)
  • is a continuous, planned, systematic, interdisciplinary, organization wide process
  • involves measuring the functioning of important processes & services (treatment, care, services, safety)
  • identifies changes that enhance performance, outcomes & safety
  • monitors performance to ensure that improvements are sustained
  • is directed & supported by agency leadership & governance

Fundamental & integrated components of PI:

  • Monitoring & measuring performance through data collection, analysis & interpretation
  • Assessing current performance (using current & comparative longitudinal & aggregated data)
  • Improving performance & maintaining improvements – early problem detection/correction &/or improvement in non-problematic processes (e.g., efficiency, effectiveness)

THE HILLCREST PI PROGRAM

Hillcrest’s PI structure:

1) Campus specific interdisciplinary IOP Committee – meets monthly, provides quarterly reports

2) Management Team

3) Policy & Operations Group

4) BOD Quality Assurance Subcommittee & BOD

Hillcrest’s PI program consists of 2 components:

1) Campus specific, short or long term IOP performance measures

(e.g., HP measures/analyzes sexual incidents)

2) Agency-wide IOP performance measures:

  1. Student Injuries During Restraints
  2. Staff Injuries During Restraints
  3. Physical Interventions
  4. Medication Errors & Adverse Drug Reaction
  5. Student Perception of Care
  6. PRN usage
  7. Exposures to infection/communicable disease
  8. Timeliness of documentation
  9. Environment of Care (e.g., safety, security, injuries, utility management, hazard surveillance, emergency preparedness, fire & evacuation drills)
  10. Incidents/incident reports
  11. General improvements

Agency-wide IOP performance measures a) thru e): Details

a) Student Injuries During Restraints (All Campuses)

The number of student injuries that occur during restraints, for the month and for the quarter (as documented on Incident Report and Physical Incident Report forms).

Administration cycle: ongoing

b) Staff Injuries During Restraints (All Campuses)

For the month and the quarter, all staff injuries:

  • that occur during restraints;
  • and for which ART forms are completed

Administration cycle: ongoing

c) Physical Interventions (All Campuses)

For the month and the quarter, the number of:

  • Restraints
  • Extended Restraints
  • Total Restraints.

Administration cycle: ongoing

 

d) Medication Errors & Adverse Drug Reactions (All Campuses)

The following medication errors are tracked:

  • wrong medications (a medication not prescribed by a physician).
  • wrong dosages (for medication prescribed by a physician, a dosage not prescribed by a physician is administered; higher or lower than prescribed).
  • omissions/missed medications (medications prescribed by a physician but not administered).
  • Adverse reactions to medications

Administration cycle: ongoing

e) Student Perception of Care (All Campuses)

Average “cluster scores” for each of 7 subsections on the HEC CS Survey:

  • Environment of Care
  • School/Education
  • Medical/Dental
  • Staff
  • Treatment
  • Program

plus an average of the total ratings for survey. Scores reported by campus and in aggregate form for the agency. The PM consists of the averaged scores themselves (cluster scores and survey total score; campus + agency), and the differences between (+/-) the current quarter and those of the last quarter and the previous year.

Administration cycle: annual for all students (90 or more days after admission & w/in 6 months of discharge)

The Reporting cycle & content for all PMs: Quarterly

For Quarterly data, comparisons with the previous Quarter of the current year, and the same Quarter in the previous year.

PLAN FOR FOLLOW-UP SERVICES

Hillcrest will work collaboratively with the student’s custodial agency to determine what aftercare services are necessary and/or preferable for the student being discharged from Hillcrest. However, Hillcrest will not directly provide aftercare services for students who have been discharged from Hillcrest, nor will Hillcrest be financially responsible for the provision of services.

Following discharge, students’ status and progress are tracked for one year. The results are compiled into an annual outcome study.

 

INTRA-HEC TRANSFER PROCEDURE (FOR NON-EMERGENCIES)

  1. The sending campus hosts Transfer Planning Meeting with receiving campus, prior to projected transfer, as a part of a CTP meeting when appropriate.
  1. The purpose of the Transfer Planning Meeting and form is to involve the receiving campus in the decision making process around the transition, identify and make plans to address concerns, and to help ensure thorough communication in all areas of transfer planning.
  1. A campus administrator from the receiving campus must attend. Other representatives may also be required to attend depending on the student’s individual treatment issues. The sending campus should have all parties present.
  1. The Transfer Planning Meeting’s agenda must include the completion of the Intra-HEC Transfer Planning Form.
  1. The sending program will email the completed plan to the psychiatrists, the Senior Vice President, and the campus administrators from both campuses for final review.
  1. The digital history of the email will act as record of their notification and agreement with this plan, unless they respond to the email with a specific concern and related suggestion to remedy the concern, within two business days of its being sent.
  1. If there are no objections, the Program Director or designee of the receiving campus will e-mail a final message to the aforementioned parties confirming the transition plan and time line.
  1. If necessary, another meeting can be held to follow up on the first Transfer Planning Meeting before the student transfer occurs. If this occurs, further notes should be indicated on another Intra-HEC Transfer Form. Unchanged areas from the previous form do not need to be repeated a second time.
  1. Intra-HEC Transfer Forms are for internal use only. They are not to be filed in the student’s record. When the student transfer occurs, the HEC Discharge/Transfer form is completed according to paperwork timeliness and becomes a part of the student’s case record. It should reflect any necessary information from the Intra-HEC Transfer Planning Form.

MEDICAL REQUIREMENTS FOR ADMISSION

The following is a listing of medical information required for admission to Hillcrest Educational Centers. This information must be submitted prior to admission of all new students. It is preferred that this information is submitted on HEC forms. However, agencies may submit the information on their own forms if they prefer to do so.

            Students will not be admitted without complete submission of this information.

  1. Documented, complete physical exam within past 12 months
  2. A current medical history including any allergies.
  3. List of Current Medications
  4. Results of most recent laboratory and other indicated testing (i.e. EEG, EKG, etc.).
  5. Roger’s order if applicable
  6. Report of results of TB testing or risk assessment.
  7. Reports of most recent vision, hearing, dental and specialist examination.
  8. Prescription(s) from ordering physician and two week supply of all medication(s)
  9. Proof of valid medical insurance
  10. Physicians statement that child is free of communicable and   infectious disease
  11. Immunization requirements for Massachusetts are:

DTaP/DTP/DT/Td/Tdap: 5 doses of DTaP/ DTP required for school entry.

One dose of Tdap is required for all students entering grade 7-8

If it has been more than 5 years since the last dose of tetanus it is recommended that Tdap be given regardless of the time interval

Polio:   4 doses

MMR: two doses

Varicella vaccine 2 doses or laboratory proof of immunity

Hepatitis B: 3 doses or laboratory proof of immunity

Meningococcal: 1 dose for residential students or signed waiver

 

POLICIES ON INFORMED CONSENT

The goal of Hillcrest’s informed consent policy and process is to establish a shared understanding between Hillcrest, the student, and the parent, guardian and/or public agency that has legal custody of the student, about the care, treatment, and services that the student will receive. This process allows each participating party to fully participate in informed decisions about the student’s care, treatment, and services.

HEC POLICIES & PRACTICES REQUIRING INFORMED CONSENT

The following policies and practices, among others, require informed consent:

  • Behavior Management Policy
  • Physical Restraint Policies and Procedures
  • Student Immunizations – Hepatitis B vaccine; Varicella (Chickenpox) Virus vaccine; Meningococcal vaccine; DPT, MMR, IPV; Human Paillomavirus vaccine.
  • Consent, Waiver and Release Agreement for Vaccinations and Immunizations (on religious grounds)
  • Dental Treatment at Hillcrest Dental Care
  • Athletics, Field Trips, Off Campus Trips
  • Healthy Sexuality Curriculum

This list will be updated, as necessary with each revision of HEC Policies & Procedures.

For Mass students only, the following consents will be obtained annually during each student’s annual IEP review:

  • Emergency medical treatment
  • Medication administration
  • When applicable: Human Sexuality Education

THE PROCESS USED TO OBTAIN INFORMED CONSENT

When a student who has been referred to a Hillcrest program is accepted, the Admission Dept. sends an Intake Packet to the parent, guardian and/or public agency that has custody of the student. Among other things, the packet contains information about each of the policies and practices that require informed consent, along with consent forms for these policies and practices. The recipient is also specifically informed about whom to contact at Hillcrest if there are questions, concerns or comments about any part of the Intake Packet, including the policies and practices that require informed consent.

Once returned, the documents in the Intake Packet become part of the student’s Case Record.

EXCEPTIONS TO OBTAINING INFORMED CONSENT

There are certain specific situations in which Hillcrest must make an exception to the informed consent policy, and/or may not be able to seek or receive consent for the release of certain kinds of information, because of the dire nature of the situations and the risk of harm to self or others.

Such situations include but are not limited to, for example, the threat of harm to self or others, and a reasonable suspicion of child or adult abuse.

WAITING LIST POLICY & PROCEDURES

Introduction & Policy Statement:

Hillcrest Educational Centers manages student waiting lists in order to ensure that students who have been referred to and accepted for a Hillcrest program are admitted in a systematic, fair and equitable manner.

Waiting lists are maintained separately for each Hillcrest program. The only students placed on waiting lists for these programs are those students who have been assessed and accepted for admission, with no documentation or information required for referral to the HEC program still pending.

Though a student may be placed on a wait list, students will not be admitted without medical clearance from head nurse as well as receipt of requested documents.

Procedures:

The waiting list procedures for these residential and nonresidential treatment and education programs are the same.

In the event that a referred student has been accepted for admission but there are currently no appropriate openings in the program for that student, the student is placed on a waiting list for that program. Students on a program’s waiting list are considered for admission on a chronological, “first accepted, first admitted” basis. The basis for the chronological list is the date of the student’s acceptance (rather than on the date of the referral).

As openings in that program occur, the program considers additional factors that impact program operations, program space allocation, and student group constituency and balance. These factors, which may vary by program, include but are not limited to: the referred student’s age, gender, grade and academic functioning level, clinical and behavioral history and profile.

If for any reason the “first accepted” student is not available for admission to the program within a reasonable period of time, the next student on the waiting list will be considered for admission.

If HEC is notified that the student has been placed or admitted elsewhere, or that the student does not require Hillcrest services for any other reason, the student’s name is removed from the waiting list for that HEC program.