1. Definition
Sentinel Events are occurrences that, according to the Joint Commission “…signal the need for immediate investigation and response”.
Hillcrest Educational Centers fully accepts the definition of a sentinel event as employed by the Joint Commission:
“An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase ‘or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” Permanent loss of function refers to the following domains: sensory, motor, physiologic or intellectual impairment, and it refers to loss of function that is not related to “the natural course of the illness or underlying condition.”
Examples of sentinel events that are relevant to Hillcrest students and programs and that require review by the Joint Commission, as cited in various resources, including the BHC standards and other communications, include but are not limited to:
• Permanent loss of limb or major function (e.g., sensory, motor, physiologic or intellectual impairment).
• A suicide while in Hillcrest care.
• Any student death, paralysis, coma, or other major permanent loss of function associated with a medication error.
• Rape (determined, not an alleged; committed by a student or by a staff).
• Any assault, homicide, or other crime resulting in student death or major permanent loss of function.
• A temporally related death (suicide or homicide) or major permanent loss of function that occurs in the course of or during an unauthorized departure (AWOL) from a Hillcrest campus.
• Any student fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall.
Examples of occurrences that do not qualify as sentinel events requiring review by the Joint Commission (but which probably still require investigation):
• Any “near miss”.
• Full return of limb or function to the same level as before the adverse event, or within two weeks of the loss of function.
• Any adverse or sentinel event that has not affected a Hillcrest student.
• Medication errors that do not result in death or permanent loss of function.
• A suicide following an unauthorized departure (AWOL) from a Hillcrest campus.
• Unsuccessful suicide attempts.
• Unintentionally retained foreign body without major permanent loss of function.
• Death or major permanent loss of function following discharge from a Hillcrest program “against medical advice” (AMA).

2. Policy
In the event of a Sentinel Event at HEC, we will follow the guidelines established by the Joint Commission including properly notifying the Joint Commission of the event within the five day window, per the Joint Commission standards, and commencing a thorough root cause analysis as quickly as possible following the Joint Commission guidelines, and consistent with both DEEC and DESE regulations.
Clearly, any adverse event which qualifies as a sentinel event requiring review by the Joint Commission would also be reportable to Massachusetts DEEC, DESE, and possibly, to DCF as well. HEC will also immediately report any sentinel event to any out of state agencies appropriate to the student referring state, including agencies such as the New York State Justice Center for the Protection of People with Special Needs and the commissioner.

3. Identifying a Sentinel Event
The Hillcrest policy on NOTIFICATION TO CENTRAL OFFICE ADMINISTRATION states:
The Executive Director and/or Senior Vice President of Hillcrest Educational Centers must be contacted when any of the following situations occur. In the absence of the Executive Director and/or Senior Vice President, and/or if he/she is on call at the time, the President/CEO of Hillcrest must be contacted.
a. Incidents of child abuse.
b. Missing or runaway student.
c. Student received a chemical restraint.
d. Staff/student death, and/or injury requiring hospitalization.
e. Serious physical plant/vehicle damage.
f. Loss of power/heat for fifteen minutes. (Contact the Director of Maintenance.)
g. Staff disciplinary action resulting in suspension.
h. Inquiries from press or media.
The notification procedure will include the manager making the notification and/or the Executive Director and/or Senior Vice President, or President/CEO together determining whether the event or situation in question constitutes a Sentinel Event.
In order to institutionalize and standardize event notification procedures, each and every notification to Central Office Administration will include such Sentinel Event determination, regardless of the nature of the event being reported.
This determination will not require documentation unless, of course, it is determined that the event does constitute a Sentinel Event.
4. Adverse Event Procedures
a. If the event/situation does not constitute a Sentinel Event:
Documentation, reporting and investigation procedures, as outlined in Hillcrest Policies and Procedures and in state agency regulations, will be followed, including notifications to state oversight agencies, as necessary.
b. If it is not clear whether the event/situation constitutes a Sentinel Event:
The Executive Director and/or Senior Vice President, and/or President/CEO will confer with members of the Management Team and/or Board of Directors as necessary in order to make such determination. If necessary, a designated manager will confer with the Joint Commissions Standards Clarification section or the BHC section.
c. If the event/situation does constitute a Sentinel Event:
The Executive Director and/or Senior Vice President, and/or President/CEO will notify the Board of Directors and the Management Team. She/he will direct a standing Quality Assurance Team to initiate: 1) an investigation consistent with DEEC and DESE regulations and, 2) a Root Cause Analysis and recommendations for an Action Plan. If necessary, he/she will designate an ad hoc Quality Assurance Team to initiate those activities outlined.
The Joint Commission will be notified within 5 days of the event, or of the discovery of the event, in a manner consistent with Joint Commission standards and protocols (i.e., using resources such as the Sentinel Event form and Framework for Conducting a Root Cause Analysis and Action Plan). A through and credible Root Cause Analysis and an Action Plan will be made available to the Joint Commission within 45 calendar days of the event or of the discovery of the event, as appropriate.
All Massachusetts and out of state oversight agencies will be notified, as required.
5. Root Cause Analysis
The Root Cause Analysis is a process for identifying the causes, factors and conditions associated with an adverse or sentinel event.
The RCA will:
a) focus primarily on systems and processes, not on individual performance.
b) progress from special causes in clinical processes to common causes in organizational processes.
c) identify potential improvements in processes or systems that will decrease or minimize the likelihood of such events in the future.
After analysis, however, the RCA may determine that no such improvement opportunities exist.
Hillcrest will conduct Root Cause Analyses in a manner consistent with Joint Commission standards, protocols and guidelines, as well as with those of state oversight agencies for investigations. Additionally, Hillcrest will seek the advice and guidance from the Commission as needed, and will seek the advice and guidance of state oversight agencies and of the Joint Commission if inconsistent or contradictory requirements exist.
6 Action Plan
The Root Cause Analysis will lead to the development of an Action Plan that identifies the strategies that Hillcrest will consider or will implement to reduce the risk of similar events occurring in the future.
The Action Plan will address:
a) responsibility for implementation of the strategies.
b) responsibility for oversight of the implementation.
c) responsibility for pilot testing, as appropriate
d) time lines.
e) strategies for measuring the effectiveness of the actions for improvement.

The safety and security of students, staff, and visitor’s safety are of primary concerns to Hillcrest. Each work site has an EOC Committee, which meets at least bi-monthly. During these meetings, in addition to reviewing the seven EOC components, reported campus accidents from the previous month are reviewed, and corrective actions are proposed. Staff are encouraged to participate in these committees and to report any unsafe conditions or ideas regarding safety to their supervisors.

Hillcrest’s EOC Leadership Committee, consisting of the CEO and EOC associated Department Heads, meets on a regular basis to review EOC related activities and issues, and EOC issues and associated activities are discussed periodically by the Senior Management Team.

The agency’s Hazard Vulnerability Analysis and EOC Management Plans are reviewed and updated annually.

In the case of a severe storm, students shall be kept safely indoors and staff will, on a regular basis, take a head count to ensure that all students are present and accounted for.

In the event of severe weather, staff will remain on duty until driving is again possible and a change of shift can be effected. Staff will not be allowed to leave until they are replaced.

In the event of a power outage of any duration, in any Hillcrest building or location:

1) Call IT Dept.  immediately @ 413-499-0607 between the hours of 7:30 am – 5:30 pm or 413-266-1124 outside of regular business hours.

2) During the day shift (7 am-3 pm), Monday through Friday, also contact the maintenance person assigned to your work site.

If the power outage lasts more than 15 minutes, regardless of the time of day or day of the week, please call the maintenance emergency cell phone at 413-770-9425. Leave a voicemail if necessary.

In some circumstances when the mandated policy above is not sufficient to cover our staffing needs, or when a crisis situation is presented, the following guidelines apply:

1. In addition to the “rolling list” above, all employees will be asked to volunteer to work overtime.

2. If the number of volunteers stepping forward is insufficient, all other positions on the campus may be mandated to work overtime. The methodology for scheduling and assignments will be determined by the Program Director/Manager.

3. Staff required to work the mandated overtime will be notified as soon as possible.

4. As stated above, it is the employee’s responsibility to be present for any and all assigned overtime shifts. Failure to do so will be viewed the same as failing to show for a regular shift and will result in disciplinary action up to an including termination.

At various times throughout the year, overtime may be mandated due to a shift staffing shortage. In the event a staff must be mandated to stay, the following guidelines apply:

1. Overtime may be mandated for the following positions: Youth Development Professional (YDPs), Assistant Supervisors, and Supervisors.

• Residential staff – will not be mandated on Saturday or Sunday nights due to having worked a 14-hour day. They may volunteer to work a weekend overnight with administrator approval. If there is no other option the administrator will come in and cover the weekend overnight shifts.

• Overnight staff – may be mandated on school days, but should be released as teachers, clinicians and administrators arrive. Overnight shift may be mandated on weekend mornings, but every effort should be made to release them by noon, even if the administrator must come in and cover.

• Day staff – is always eligible to be mandated for the subsequent residential shift.

• On-Call and overtime staff – are not subject to the mandate procedure.

2. A “rolling list” with all employees’ names (in the above categories) based on seniority will be created to determine the order in which employees will be mandated. The least senior employee will be at the top of the list. Once mandated, the employee’s name will go to the bottom of the list.

3. When possible, those staff at the top of the mandate list will be given at least 24 hours’ notice that they are now at the top of the list and expected to work the next mandated shift.

4. It is the employee’s responsibility to be present for any and all assigned overtime shifts. Failure to do so will be viewed the same as failing to show for a regular shift and will result in disciplinary action up to an including termination.

All HEC staff, especially Youth Development Professional and teaching staff, are instructed in their responsibility for the safety of the students, are required to report safety hazards, and are asked to make recommendations to the appropriate administrator for accident prevention.

A. All Serious Injuries or Accidents are reported to a supervisor, thoroughly investigated and documented, and reviewed by the Program Director/Program Manager or his/her designee. Copies of these reports are sent to the appropriate regional office of DESE.

In the event of a major illness or emergency medical treatment, parents and / or guardian are to be notified as soon as possible by telephone by the nurse administrator and/or attending physician. In the event that the parents cannot be reached immediately by telephone, a nurse or administrator may send the local police to their home. By phone or telegram, the parents should be informed of the nature or circumstances of the illness or injury and the student’s medical treatment explained. In life-threatening situations, where no parent or guardian is available, the physician or school administrator must take responsibility for decision-making.

B Fire Emergencies (Please see Fire Evacuation Emergencies & Fire Drills, this section.)

C. Staffing Shortages
See Mandatory Overtime section below.

For concerns about or suspicious of child abuse or neglect, please refer to the policies cited above. The following policy pertains to concerns regarding safety and/or quality of care that do not or may not qualify as child abuse or neglect.

As stated in Hillcrest’s Policies and Procedures, and in the agency’s Code of Ethics, which is reviewed and formally accepted by all staff each year, the safety of students and staff, and the quality of the care and treatment of students are Hillcrest’s highest priorities. Therefore, staff are expected to report any and all concerns about safety or quality of care to their immediate supervisor, Program Director/Program Manager, Department Head or other agency administrator as soon as possible so that corrective action may be taken quickly and decisively.

However, if a staff member reasonably determines that Hillcrest has not adequately prevented or corrected problems that can or have had a serious adverse impact on students, and notifies the Joint Commission about such concerns, the notifying staff member will not be subject to retaliatory action, formal disciplinary actions, or informal punitive actions.

The Executive Director and/or Senior Vice President of HEC must be contacted when any of the following situations occur. In the absence of the Executive Director, the CEO/President of HEC must be contacted.
a. Incidents of child abuse.
b. Missing or runaway student.
c. Any time that staff levels go below minimum ratios.
d. Staff/student injury requiring hospitalization.
e. Serious physical plant/vehicle damage.
f. Loss of power/heat for fifteen minutes. Contact the Director of Maintenance as well.
g. Staff disciplinary action resulting in suspension.
h. Inquiries from press or media.
POLICY ON CALLING FOR COMMUNITY EMERGENCY SERVICES
In the event of urgent and/or life threatening circumstances (as defined herein):
1) If staff can access an outside telephone line, staff are authorized to call 911 for emergency assistance from fire and rescue or emergency medical services.
2) If staff cannot access an outside telephone line, staff will notify the supervisor or available administrator of the need for community emergency assistance.
If the circumstances or conditions are potentially dangerous, but are not urgent and/or immediately life threatening, staff will notify the supervisor.
If the situation might require police intervention rather than fire and rescue or medical services, staff will notify the supervisor.
The supervisor is authorized to determine further action, such as immediately notifying external authorities (e.g., calling 911, fire or police) or notifying a program director.”
“Urgent and/or life threatening circumstances” – Definition:
• A situation that poses an immediate and unexpected risk to health, life or property, and that requires urgent intervention from community services (e.g., fire and rescue) to prevent further injury, death or serious damage.
• A condition of urgent and immediate need for action and/or assistance by community services.
• An apparent and presenting (not potential) condition that presents a very serious, clear, present injury, damage or danger to persons or property, and that cannot be managed by HEC personnel, Supervisors or Managers..
• A state of crisis that is present and unfolding in the present (rather than potentially or possible), and that presents an unmanageable threat to lives or serious and major damage to property.
Examples of Urgent and /or Life Threatening Circumstances:
• A person has lost consciousness, or cannot breathe, or is losing copious amounts of blood.
• A fire in a building.
• Serious, major storm damage to a building to the extent that lives or well-being is threatened.
Examples of what does NOT constitute Urgent and /or Life Threatening Circumstances:
In these types of situations, the Supervisor should be notified, not community intervention services.
• A student is verbally or even physically threatening, destroying property or is running away.
• A student or staff has physical symptoms that should be checked by a nurse but are not serious or life threatening.
• A situation that might eventually require police intervention.

The following procedures will be followed as soon as a staff person becomes aware that a student is missing:
A. Perform a brief search of the immediate area, not to exceed one minute. Staff person should then inform another staff that the student is, indeed, missing.
B. If the student is not located in the preliminary search, the staff person must notify the supervisor, providing the following information:
1) Name of student
2) Location at last sighting
3) Description of clothing
4) Mood of student
5) Information that might indicate destination
6) Time of disappearance
C. The supervisor will organize a search of the grounds and immediate area around the campus. (Each campus-specific missing student procedure details area buildings, outside areas and nearby streets to be searched.)
D. If the student is not found in the immediate area around campus, the supervisor will assign specific routes to be covered (see campus-specific procedures). If the student is not found within five minutes, the search will be widened (see campus-specific procedures).
E. During the first fifteen minutes, the supervisor will obtain the following information from the nurse on duty:
1) Height 4) Age
2) Weight 5) Distinguishing marks
3) Medical problems 6) Recent photograph
F. At the end of fifteen minutes, the supervisor will notify the following, giving information from paragraphs 2 and 5:
1) Program Director or administrator on call
2) Local Police
3) Others as listed in campus-specific procedures.
G. All agencies and involved people will be notified when the student is found. Once the student has been returned to school, the following shall occur:
1) The search coordinator will call in all search teams.
2) The Program Director, Executive Director and/or Senior Vice President, CEO or designee, and appropriate agencies will be notified. Any Hillcrest campus that may have sent staff should also be called.
3) If the student was a runaway, they should be placed on close supervision until their Treatment Team meets.
4) Any equipment used (e.g., walkie-talkies, cell phones) must be signed in and placed in the administrator’s office. The walkie-talkies must be recharged.
H. The reasons why the student was missing will be reviewed by the administrator, and the staff responsible for the student will be counseled to prevent the recurrence of a similar situation.
The search procedure will also be reviewed and critiqued to be sure it was implemented properly.