A. Admission Standing Orders

1. Laboratory – Obtain U/A, General Health Panel (GHP contains CBC, Comprehensive Metabolic Panel, TSH), Hepatitis C AB, Hepatitis B AB, Hepatitis B Surface Antigen, Lipid Panel, Lead Level if < than 10 y.o. and none documented in chart, RPR, U/A for HCG if have had menarche, medication levels if indicated, varicella titer if exposure history is unknown. If on atypical antipsychotics get Prolactin Level, Glucose and Insulin levels on admission, at six months, and then annually. Other labs as ordered by M.D. Some labs may be omitted if testing within 6 months or less is provided at intake. 2. PPD Testing – On admission if not done within the previous 60 days, then annually. 3. Routine Height/Weight/Blood Pressure/Pulse Monitoring – a) Heights – every 6 months, please plot with corresponding weight b)Weights 1) Once a month for all students- more frequently on students with BMI <19 or as orders by physician 2) Notify nutritionist of any changes (up or down) of greater than 10 pounds in < than 8 weeks OR if BMI < 19. b) Blood Pressure and Pulse 1) Every month for all students a. B/P & P q week As directed by physician. 4. EKG – Baseline EKG for all students. If EKG done prior to admission is available, review with M.D. prior to scheduling. B. Routine Lab Orders 1. Annual Labs – CBC, U/A, Medication levels if indicated. Other labs as ordered by physician or psychiatrist. Previously drawn labs are acceptable if dated in the past 60 days. 2. Other Orders Related to Medications Atypical Antipsychotics – Prolactin levels at baseline and every 6 months. Glucose and Insulin levels at baseline 3 months later then annually, per MD if results are abnormal. Fasting Lipid Profile annually. Trileptal – Sodium level at 4 weeks and 12 weeks Tegretol – Tegretol level, CBC, LFT’s q 6 months Lithium – Lithium level, TSH, BUN, Creatinine, U/A q 3 months. Depakote – Depakote level, CBC, LFT’s, q 3 months. Dilantin – Dilantin level, CBC, LFT’s q 3 months. . Clonidine, Tenex Risperidone(Risperdal), Ziprasidone(Geodon), B-Blockers, Tryciclics, Venlafaxine(Effexor ) and any other medication known to induce arrhythmia. Review with MD re: future EKG monitoring. Clozapine - weekly WBC done and entered into the national database. AIMS testing q 6 months if on neuroleptics, including atypical antipsychotics. 3. Hepatitis C Exposure Protocol for Students – In the event of a student having a possible exposure to Hepatitis C, the following blood work should be obtained: Time after Exposure Blood Work 2 Weeks or less Baseline Liver Function Tests 4 Weeks Qualitative Hep C V PCR TMA 6 Weeks Hep C Antibody, Liver Function Tests 3 Months If Hep C PCR TMA is positive repeat, Hep C antibody, Liver Function Tests 6 Months Hep C antibody, Liver Function Tests In addition, every effort must be made to maintain the highest level of confidentiality possible. Guidelines include but are not limited to the following: a) Source of Exposure should NEVER be explicitly identified in a Hillcrest chart. b) All health referrals for staff made to Occupational Health for counseling need to be made in as confidential a manner as possible. c) If exposed student is a minor, his / her legal guardian needs to be contacted and advised of the possible exposure to Hepatitis C. They also need to be notified of our wish to follow the patient closely with the above mentioned lab work. Hepatitis C is a treatable illness especially when detected in its earliest stages. d) If student had baseline liver function tests within one (1) month prior to exposure, additional liver function tests do not need to be done. C. IDENTIFYING AND COMMUNICATING CRITICAL VALUES AND INTERPRETATIONS OF MEDICAL TESTING RESULTS Purpose: To describe the process of reporting abnormal values and interpretations from laboratory, cardiology and radiology to HEC medical providers. Laboratory results: Critical tests are those tests that always require rapid communication of the results, even if normal Critical tests are ordered specifically by the physician. The physician also indicates the timeframe of the reported results at the time of the written or verbal order. However, results should be obtained and reported to the ordering physician within 8 hours of the test having been performed. Critical results, also known as “critical values,” are test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests. As per the policy of Berkshire Medical Center, the time period for notification to the Licensed Caregiver must be immediate, occurring within 30 minutes from receipt of the result. This communication will occur directly to the ordering physician. If the physician cannot be notified in their office, the RN or LPN for the physician will be notified with the understanding of the urgent need to report the result immediately to the physician. The following are suggested critical values of routine lab testing and should be reported directly and immediately to the ordering physician: Liver Enzymes: SGOT- greater than 150 SGPT- greater than 150 AST- greater than 3 times normal ALT- greater than 3 times normal Bilirubin- greater than 3 Complete Blood Count: HCT –less than 20 WBC- less than 3,000 or greater than 20,000 Platlets- less than 60,000 ANC- less than 1.5 Glucose- greater than 200 Creatinine- greater than 2.0 Prolactin- greater than 100 Amonia- Any elevation above normal level Urine: Positive for STD Positive for beta HCG Positive for blood or bacteria RPR- any positive result Anti- HIV AB- any positive result Blood culture- any positive result Drug Levels: Lithium- greater than 1.3 Depakote (valproate)- greater than 100 Carbamezapine- greater than 12 Cardiology results: Critical interpretations are those that indicate the patient may be in imminent danger of death or serious adverse consequences unless treatment is initiated immediately. These interpretations will be reported, by the cardiologist, immediately (within 30 minutes) to the ordering physician. Other urgent or significant interpretations that are not considered life threatening but may need medical intervention will be reported by the cardiologist to the ordering physician within 48 hours. Radiology results: Critical interpretations are those that indicate the patient may be in imminent danger of death or serious adverse consequences unless treatment is initiated immediately. These interpretations will be reported, by the radiologist, immediately (within 30 minutes) to the ordering physician. Other urgent or significant interpretations that are not considered life threatening but may need medical intervention will be reported by the radiologist to the ordering physician within 48 hours.

All toxic substances are kept out of the reach of students in locked cabinets. Medical supplies and medications will not be stored in the same storage cabinet with toxic substances. All toxic substances are labeled with contents and antidote. The telephone number for the Poison Control Center is clearly posted near the telephone in each Nurses’ Station, in each supervisor’s office, and in the Emergency Manual.
Over the counter and/or prescription medication may not be stored in staff’s clothing or in personal possessions on campus. All medications for staff’s personal use must be stored in a secure, locked area.

(Also see the HEC Hazardous Materials and Waste Management Plan.)

In accordance with Hillcrest’s policy on student sexuality, where deemed appropriate, and with the permission of the parent or guardian, Hillcrest provides family planning information to students. Additionally, students who are considered to be at risk for sexually transmitted diseases or unplanned pregnancy may receive health counseling from the nursing staff. In keeping with the philosophy that students should be prepared for transition to a less restrictive environment, students may be referred to the community family planning clinic for specialized counseling and health services, as appropriate.

Hillcrest requires that all students comply with the Massachusetts Department of Public Health regulations regarding routine immunizations.

Students are screened for tuberculosis within 60 days of admission to Hillcrest Educational Centers. Rescreening with Mantoux test will be performed every year from the date of the last testing on all tuberculin negative students.
Students who are known to be tuberculin positive, or who are unable to receive PPD, will be evaluated by Medical Director and referred as appropriate.
Medical management of the student, including communicable disease precautions, will be at the direction of the Medical Director, in cooperation with the Massachusetts Department of Public Health T.B. Control Unit. No facilities for respiratory isolation are available at Hillcrest Educational Centers. Should respiratory isolation be recommended, the student will be immediately transferred to an appropriate health care facility.

Protocol following a break in skin integrity between students or student/staff.

Due to the possible complications from any break in skin integrity it is imperative that employees take appropriate measures to minimize exposures to blood for both students and staff.

Following a break in skin integrity:

Students:
1. Student should wash their hands with soap and water thoroughly if they were scratching, paying special attention to under the fingernails.
2. Check student for any broken skin areas; these areas should be cleaned with soap and water, and treated with a topical antibacterial cream/ointment.
3. Document the incident and any injuries to students.

Staff:
1. Staff should wash all abrasions, scratches, or broken skin areas thoroughly with soap and water, if available apply antibiotic cream.
2. Staff must complete an ART form to be filed with AO, regardless of the seriousness of the injury. This documents the injury in case a complication occurs.

When dealing with a student who is known to scratch as a defense or mode of aggression, staff should take appropriate precautions to protect themselves. Some suggestions would be to wear long sleeve shirts and pants, the use of gloves (vinyl or padded) or changing the positioning of student’s hands to minimize the ability to scratch skin.

1) Students are required to have a hepatitis profile with admission lab testing if not submitted with admission documentation.
2) No student will be denied admission on the basis of Hepatitis B carrier status.
3) No student will be denied full participation in the school program on the basis of Hepatitis B carrier status.
4) All staff and students of Hillcrest Education Centers will be offered Hepatitis B vaccine.

Students or staff who have a reportable communicable disease will not be allowed to attend school.
If a reportable communicable disease has been introduced into a campus, the nursing staff will notify parents/guardians of students on that campus. The local Board of Health will also be notified, in accordance with MGL Ch. 71, Sec. 55A.
If diagnosis of a reportable communicable disease is made by a consulting physician, the Medical Director will be notified and consulted regarding appropriate precautionary procedures.

A list of reportable Communicable and other infectious diseases follows.

REPORT DIRECTLY TO THE MASSACHUSETTS DPH
DEPARTMENT OF PUBLIC HEALTH

HIV infection and AIDS (617) 983-6560

Sexually Transmitted Diseases (617) 983-6940

Chanchrold Ophthalmia neonatorum:
Chlamydial infections (genital) a. Gonoccocal
Genital Warts b. Other agents
Gonorrhea Pelvic Inflammatory disease
Granuloma inguinale a. Gonococcal
Herpes, neonatal (onset within 30 days b. Other agents
after birth)
Lymphogranuloma venereum Syphilis

Tuberculosis suspect and confirmed cases: Report within 24 hours to (617) 983-6989 or
Toll Free (1-888) MASS-MTB (627-7682) or
Confidential Fax (617) 983-6990

Latent tuberculosis infection: Confidential Fax (617) 983-6990 or
Mall report to:
Massachusetts Department of Public Health
Division of Tuberculosis Prevention and Control
305 South Street, Jamaica Plain, MA 02130

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REPORTABLE DISEASES PRIMARILY ASCERTAINED THROUGH LABORATORY REPORTING OF EVIDENCE OF INFECTION

Please work with the laboratories you utilize for diagnostic testing to assure complete reporting.

Amebiasis
Babesiosis
Calicvirus infection
Campylobacteriosis
Cholera
Cryptococcosis
Cryptosporidiosis
Cyclosporlasis
Dengue fever virus
Eastern equine encephahtis virus
E. coil 0157:H7
Enteroviruses (from CSF)
Giardiasis
Group A streptococcus, invasive infection
Group B streptococcus, invasive infection
Hepatitis B
Hepatitis C
Hepatitis – infectious, not otherwise specified
Evidence of human prion disease
Influenza
Legionellosis
Listeriosis
Malaria
Salmonellosis
Shiga toxin-producing organisms
Shigellosis
Streptococcus pneumoniae, invasive
infection /
Toxoplasmosis
West Nile virus
Yellow fever virus
Yersiniosis

Hillcrest Educational Centers recognizes that many of the students the agency serves may be experiencing some types of psychological and/or emotional pain as a result of their traumatic experiences and/or psychiatric disabilities. This pain may be experienced and manifested in different ways, depending on the student. The treatment of these types of psychological and/or emotional pain is basic to Hillcrest’s evaluation and treatment for all students.
The agency recognizes, however, that some Hillcrest students may also be experiencing transient or chronic physical pain, therefore the agency is committed to assessing whether such pain is present or experienced, and to managing such pain if present. To these ends, the following procedures are conducted for all students in all programs:
1) Pain Assessment will be conducted by the program Nurse as part of the Nursing Assessment, which is conducted within 24 hours of a student’s Admission to the agency.
The results of the Pain Assessment will be documented on the Nursing Assessment form.
2) Pain Assessment will be conducted by the program Physician as part of the Physical Examination that is conducted within 30 days of a student’s Admission to the agency.
The results of the Pain Assessment will be documented on the Physical Examination form.
3) Pain Assessment will be conducted by the program Physician as part of the annual Physical Examination, which is conducted 12 months after a student’s Admission to the agency.
The results of the Pain Assessment will be documented on the Physical Examination form.
4) If either transient or chronic pain is reported by the student or by their staff, or is identified by either the Nurse or the Physician during any routine or special medical examination, diagnosis and treatment of the pain and associated medical conditions will be conducted.
5) If chronic pain is identified as an issue for any student, treatment and management of such chronic pain will be included in the student’s Comprehensive Treatment Plan.
6) If chronic pain is identified as an issue for any student and is included in that student’s CTP, treatment will be followed in monthly nursing progress notes until resolved.

1 Preventive Health Care
a. As noted above (part 1A of this Section) Hillcrest policy specifies the medical information needed before student may be admitted to any agency program.
b. Admission Nursing Assessment
A nurse will assess all students being admitted to any Hillcrest program within 24 hours of admission. The Nursing Assessment includes the following:
1) Medication: last dose given and diagnosis.
2) Physical problems or limitations.
3) Description of allergic response to medication, food and others.
4) Sleeping patterns.
5) Techniques that are effective with administration of health care.
6) Date of last menstrual period and menstrual history, where applicable.
7) Baseline vital signs.
8) Medical history.
9) Review of immunization status.
10) Full body assessment for wounds, rashes, illness symptoms,
scars, etc.
11) Pain Assessment

The psychiatrist will be notified that a student has been admitted and he/she will order medication, as necessary. The nurse will:
1) Order medication from the pharmacy, as needed.
2) Discuss child’s health needs with Child Care Supervisor or administrator.

c. Annual Health Screening
At least once each year, each student residing at a Hillcrest program will receive:
1) Dental evaluation (2 times/year)
2) Visual screening
3) Audiological screening
4) Postural screening
5) Complete physical examination, including assessment and
recommendations for referral to other specialties, and
pain assessment.
These exams may occur at a Hillcrest campus, at the physician provider’s office, at a designated clinic, or, when requested by parent or guardian, at student’s family physician. In the event a parent requests that a physical examination and/or dental examination be done by the student’s family physician, the examining physician will send forms to the parent for completion. These forms must be returned to Hillcrest and are part of the student’s permanent medical record. If documentation of an examination is not returned within a reasonable time, Hillcrest will arrange to have the examination repeated by HEC medical staff.