Capital expenditures will be prioritized according to recommendations to bring the Hillcrest Educational facilities in compliance with the applicable standards of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO).

Other deferred maintenance and capital expenditures are prioritized with any safety concerns addressed as they occur. Based on requests by the program directors, along with inspections done by the maintenance department and campus personnel, a capital plan is presented by the Chief Executive Officer.

Checking accounts are maintained at campuses to be used as a petty cash fund, or for minor and unusual purchases until you submit them for reimbursement with the proper documentation. Due to IRS regulations regarding form 1099 Miscellaneous Income, regular vendors should NOT be paid by campus checking accounts because Accounting cannot track vendor history or report on form 1099. Also, no vendor should be paid more than $599 from campus checking. A check requisition should be completed. Please carefully review the check requisitions you submit to reimburse your checking account. Program Directors are responsible for maintaining checkbooks accurately. This includes supervising the staff responsible for maintaining the checkbook to determine all activity is recorded in a timely manner, overseeing proper signature and approval of all checks. Check registers should be sent to the Business Office to be reconciled with bank statements by the 7th of each month. They will be reconciled and returned to the campuses to record any adjustments or fees.

Employees may be reimbursed for the business use of their personal automobile as follows:

1. PER MILE REIMBURSEMENT

Employees may be reimbursed for actual miles driven at the current HEC per mile rate. The rate is established by the Board and is consistent with existing IRS regulations and is subject to change. The established rate is intended to cover all costs associated with the operation of a personal vehicle for business purposes. No other allowances will be provided or considered reimbursable by HEC.

Documentation Required:

• Date(s) of travel
• Travel destination(s)
• Number of business miles driven
• Business purpose
• Original receipts for tolls, parking, etc.
• A log for tracking business miles driven is available through Administration

Note:

• Commuting miles do not constitute business miles for reimbursement purposes.

• Miles traveled between two business locations are eligible for reimbursement.

• Parking and tolls are not included in the per mile rate and will be reimbursed.

Suicide Harm Form & Plan

Preliminary Steps

It is understood that most students at HEC, by virtue of their life histories, behavior difficulties, emotional dysregulation and psychiatric problems, are children at some risk for dangerous and impulsive behaviors. Our residential and day school systems are structured to provide the supervision and monitoring necessary to manage these behaviors in therapeutic ways. Pre-admission intake screening specifically reviews a child’s history of sexual behaviors, fire setting, aggressiveness, and suicidality to identify children whose behaviors preclude safe management in our system. 

 

Admission Screening

Upon admission, an evidence-based suicide risk screening tool will be administered for all youth.  For youth who screen positive for suicidal ideation, a subsequent evidence-based suicide risk assessment will be completed.  Currently, Hillcrest utilizes Columbia – Suicide Severity Rating Scale (C-SSRS) with the SAFE-T Protocol companion C-SSRS Risk Assessment. Safety planning will be implemented as indicated. 

 

For youth at low risk, but with an indicated history of suicidal ideation or self harm, safety planning will be documented in the youth’s ICSP (Individualize Crisis Support Plan).

 

For youth who require a full assessment based on screening at admission, safety planning will also be documented in the companion SAFE-T Protocol and CSSRS Risk Assessment document. Ongoing, daily risk assessment and safety planning will then continue until risk is reduced to low.

 

Additionally, for any youth who are identified to have a problem related to history of suicidal ideation and/or self harm, the program-specific plan of care will also include this issue.  The following are the program-specific plans of care:

 

Highpoint and Brookside ITU: Comprehensive Treatment Plan (CTP)

Intensive Day Program: Behavior Support Plan (BSP) & CTP

Hillcrest Academy: CTP and BIP (if indicated)

Hillcrest Center Residential Program: BSP & CTP

 

Youth and their guardians will be included in safety planning discussions and will be requested to document their support of this plan.

 

New Episodes

After admission, when a youth displays an episode in which there is potential suicide or self harm risk, the following steps will be followed:

 

When a child verbalizes a threat to harm himself or herself or is believed for other reasons to be at risk of suicide, the observing staff shall immediately notify the supervisor on duty. The supervisor shall assess the situation with a direct contact with the student, and the C-SSRS screener will be completed by the supervisor or clinical staff.  Until the risk screening is complete, the student must be closely supervised for the purpose of maintaining safety.

 

If there are active treatment interventions in the student’s ICSP, BIP,  CTP and/or BSP related to the management of this risk, those treatment strategies should be implemented immediately. Unless there is a documented treatment intervention indicating that the screening is contraindicated, the supervisor or clinical staff will utilize the C-SSRS.  

 

In order to document these initial statements, behaviors, observations, and screening, the supervisor on duty will complete their portion of the “Suicide/Self Harm Initial Assessment” located in the youth’s electronic record. The supervisor will also take steps to make immediate notifications to ensure completion of any needed medical care, further clinical assessment, and/or further program interventions. 

 

Notifications

The Program Administrator in consultation with the supervisor, will notify the appropriate Clinician and Clinical Administrator to conduct a clinical interview and any indicated risk assessment as soon as possible. The supervisor will also notify the nurse on duty.  If there is any health concern, the youth will be assessed by the nurse, receive any needed medical care, and a body check form will be completed. 

 

Clinical Assessment

Upon notification, the youth’s clinician or another designated clinician will gather information and conduct a clinical interview (unless there is a documented intervention in the youth’s treatment which identifies an alternative assessment and identifies the interview as contraindicated). The clinician will utilize sound clinical judgment and the guidelines set in the C-SSRS screening tool to complete the clinical interview and any further assessment, interventions, and safety planning.  

 

 The C-SSRS screener guidelines indicate the following regarding the subsequent clinical assessment:

• If screener indicates low risk for suicide: Complete clinical interview. Clinician must document on the Suicide/Self Harm Initial Assessment and clinical note in the youth’s electronic record. 
•  If screener indicates moderate risk for suicide: Complete clinical interview, complete  SAFE-T Plan and C-SSRS Assessment, document on the Suicide/Self Harm Initial Assessment and clinical note in the youth’s electronic record.  
• If screener indicates high risk for suicide:  Complete clinical interview, complete  SAFE-T Plan and C-SSRS Assessment, document on the Suicide/Self Harm Initial Assessment and clinical note in the youth’s electronic record. Additionally, the clinician must consult with clinical administrator, campus administrator, and agency psychiatrist to determine what other interventions, such as the use of Individualized Programming, Crisis Team involvement, medication intervention, and/or outside medical treatment.

Please note, if the clinical interview indicates that risk is either higher or lower than the initial C-SSRS screener, other steps may be taken. Please see the Safety Planning section below which describes safety planning once clinical risk status has been identified.

 

If the episode involves potential or actual self harm: Complete clinical interview, safety planning for moderate or higher risk of self harm risk will be implemented and documented on the Self Harm Safety Plan document located in the youth’s electronic record.

 

The Clinician will inform the Program Administrator, Nursing and Supervisor of the outcome of the assessment and the final interventions/safety plan.  Please note that before finalizing interventions and safety plans, the clinician will consult with the clinical administrator or designee regarding their findings and recommendations. Depending on risk level, the clinical administrator or designee may also consult further with the campus administrator or agency psychiatrist in order to ensure timely notification and safety interventions for the youth.  The Executive Team shall also be notified if further consultation is needed to determine appropriate intervention for the child. Notification to agency and caregivers will be made per the agency’s requirements and as considered useful for effective intervention.

 

Safety Planning

Once the clinical assessment is completed, a formal clinical risk status will be assigned in conjunction with the Clinical Administrator. Suicide risk status is defined as Low, Moderate, High, or Extreme. The risk status, along with identified risk factors and protective factors, will determine the action steps taken for the student’s safety.  The safety planning measures for suicide risk and/or self harm risk will be documented on the HEC Self Harm Safety Plan document.  Re-assessments will occur daily on regular business days (and on non-regular business days as deemed necessary). Any adjustments to the Safety Plan will be documented until such time that the youth has returned to baseline.  If the youth’s ICSP, BIP, BSP and/or CTP already include suicide risk or self harm risk safety measures, these will continue to be utilized.  However, if the team determines that the youth’s baseline presentation indicates the need for new baseline safety measures, these will be added to the youth’s ICSP/BSP.  At the youth’s next treatment review, the team will then determine if the safety measures still need to be in place.  If they are to be continued in the ICSP, then the CTP, BSP and/or BIP will also be updated to include these safety measures.  Please note: Youth and their guardians will be included in safety planning discussions and will be requested to document their support of this plan.

 

Students at low risk do not require a safety plan. 

 

Students at moderate or high risk for suicide (as well as youth at risk for self harm) will have safety planning that includes interventions in the following areas:

• Increased supervision in milieu, bedroom, bathroom,and during transitions
• Restriction or removal of identified items connected with suicide or self harm risk
• Searches
• Verbal check-ins
• Therapeutic supports and skill rehearsal/implementation
• Behavior Management planning

 

Additionally, youth at extreme risk for suicide or self harm may be determined to require the use of Individualized Programming, or until alternate placement can be secured. The psychiatrist and Executive On-Call must be notified immediately of this status. For these students the Program Administrator should call an Emergency Team Meeting as soon as possible or take actions to secure safety for the student in an external setting with emergency personnel.

 

Hillcrest utilizes Berkshire County’s Behavioral Health Emergency Services (BHES) provided by the Brien Center for Mental Health and Substance Abuse Services, and the Berkshire Medical Center Emergency Department, as well as with County Ambulance in the event of a significant psychiatric crisis. Options available through BHES include utilizing a crisis alert system, an on-campus crisis assessment, and crisis assessment in the Emergency Room of Berkshire Medical Center. The Clinician and Clinical Coordinator on the case, along with the Program Administrator, Clinical Director, and Executive On-Call will make a determination about utilizing any of these processes.

 

The supervisor is responsible for notifying pertinent staff on the present and incoming shift that the student has been placed on a safety plan and provide information related to perceived level of risk and strategies for maintaining the child’s safety. The supervisor is responsible for making sure that appropriate incident reports are completed, documenting all notifications in the Supervisor’s Log and logging the actions taken to secure the safety of the child.

 

Treatment Planning

Within 24 hours or on the next business day following assignment of a student as a High Risk for Suicide, a Special Team Meeting shall be called to review the student’s status and treatment plan, generating necessary interventions to include as amendments to the treatment plan. The Program Administrator or designee is responsible for assuring the Special Team is scheduled and convened with membership as defined by the HEC procedure for Special Team Meetings. The Special Team Meeting shall address short term interventions, plans for continued assessment, method for determining change in status, client involvement in treatment planning and goals and consider whether the child can be maintained safely in the current treatment setting. 

 

Should the Special Team Meeting determine that the child cannot be maintained safely in the present treatment setting, an Emergency Team Meeting must be called by the Program Administrator, following the procedures defined by the HEC policy for Emergency Team Meetings, as soon as possible to determine the placement setting the child requires.

 

No student may be removed from suicide risk status without the involvement of the Clinical Administrator and Program Director. Should verbalizations of self harm or suicidal behaviors occur, whether chronically or episodically, these symptoms must be addressed within the student’s CTP, citing specific interventions useful for that particular student.

 

24 Hour access to Crisis Support

After regular business hours, HEC also has an on-call assessment and notification process. If the event occurs after business hours, the On-Call Program Administrator or designee will notify the Clinical Administrator On-Call of the event and the outcome of the screening. The On-Call Clinical Administrator may also direct a supervisor to complete a risk assessment tool. Safety interventions will be identified and implemented, and depending on the severity, a face-to-face assessment by the Clinical Administrator On-Call or designee will occur. If not deemed in need of immediate assessment, the student’s clinician will conduct additional screening and/or assessment the next business day. If necessary, the Clinical Administrator On-Call or designee will notify and consult with the Executive On-Call to determine services and interventions to implement in order to ensure the safety of the student.

 

Should the student’s condition worsen or change dramatically, the supervisor on duty must notify the Program Administrator or designee and Clinical Administrator or designee to determine appropriate actions relative to the change in condition. 

 

Clinical On-Call

HEC employs clinical administrators who are independently licensed.  Clinical Administrators hold MA LICSW,  MA LMHC, or MA LMFT licensure.  These clinical administrators’ regular schedule is Monday through Friday.  Additionally, the clinical administrators maintain a rotating on-call schedule to ensure 24/7 availability. The department maintains an on-call calendar accessible to campus clinical staff, supervisors, and administrators in order to ensure clear communication for contacting the clinical on-call to address clinical needs.  Once contacted, a determination is made about whether support can be provided by phone or if the on-call administrator needs to come to campus to provide support, assessment, and/or safety planning.  If outside crisis support is required, HEC utilizes the Brien Center Crisis Services. See Safety Planning section above for additional info on utilization of the Brien Crisis Services.  

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.