U.S. v. Virginia

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HB

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VBBP

••••••• » • • • • • •••• •

MR-VA-002-005

IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF VIRGINIA

ALEXANDRIA DIVISION

—..
'MAR 4 1996

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

COMMONWEALTH OF VIRGINIA; GEORGE ALLEN, Governor of

) )

Civil Action No

3 y\

the. Commonwealth of. Virginia; . :. ROBERT METCALF/-'.Acting Secretary,

) )

COMPLAINT

'

Department of Health and . Human Resources;'DR. TIMOTHY

) )

Civil Rights

KELLY, Commissioner, Department of

)

Mental Health, Mental Retardation

)

and Substance Abuse Services;

)

JANET HILL, Director, Office of

)

Mental Retardation, DMHMRSAS;

)

DAVID H. LAWSON, Director,

)

Northern Virginia Training Center,

)

)

Defendants.

)

THE UNITED STATES OF AMERICA alleges: 1. This action is brought by the Attorney General, on
behalf of the United States, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 et seq., to enjoin the named Defendants from depriving persons residing at the Northern Virginia Training Center (hereinafter "NVTC") in Fairfax, Virginia, of their rights, privileges and immunities secured and protected by the laws and Constitution of the United States. The purpose of this lawsuit is to ensure that the needs

of each resident of NVTC are fully met consistent with legal and professional standards, to require essential care, treatment and training for all residents, to safeguard their liberty interests, and to ensure that they are free from unreasonable bodily restraint and are otherwise protected from harm. In addition, residents have the right to an adequate evaluation by qualified professionals to determine the appropriateness of their placement at NVTC, to ensure that their services are being provided in the least separate, most integrated setting necessary to meet their needs, and that for those residents professionals have determined are in need of• alternate placement' in a community-based facility,that those judgments are implemented in a reasonable manner. The goal of this case is to protect the rights of residents; it is not the goal of this case to close the facility.
JURISDICTION, STANDING AND VENUE 2. This Court has jurisdiction over this action pursuant to 28 U.S.C. § 1345. 3. The United States has standing to maintain this action pursuant to 42 U.S.C. § 1997a. 4. The Attorney General has certified that all prefiling requirements specified in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is appended to this Complaint and is incorporated herein. 5. Venue in the Eastern District of Virginia is proper pursuant to 28 U.S.C. § 1391. All claims set forth in the Complaint arose in said District.
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DEFENDANTS

6. Defendant COMMONWEALTH OF VIRGINIA owns and operates

the Northern Virginia Training Center, a state facility located

in Fairfax, Virginia, for individuals with mental retardation or

other developmental disabilities. Some of these individuals are

also elderly and mentally ill.

7. Defendant GEORGE ALLEN is the Governor of Virginia and,

in this capacity, heads the Executive Branch of 'the

Commonwealth's government and, among other duties, reviews and

approves budget requests submitted by Executive Branch agencies.

He selects, and.appoints the Secretary of the Department of Health

and Human Resources ("DHHR"). .' •• .

.. •

. '

8. Defendant ROBERT METCALF is the Acting Secretary of the

Department of Health and Human Resources and, in this capacity,

exercises administrative control of, and responsibility for, the

NVTC.

9. Defendant DR. TIMOTHY KELLY is the Commissioner of the

Department of Mental Health, Mental Retardation and Substance

Abuse Services ("DMHMRSAS") and, in this capacity, exercises

administrative control of, and responsibility for, the NVTC.

10. Defendant JANET HILL is the Director of the Office of

Mental Retardation, DMHMRSAS, who, along with Defendants METCALF

and KELLY, is responsible for the administration of the NVTC.

11. Defendant DAVID W. LAWSON is Director of the Northern

Virginia Training Center and is responsible for the day-to-day

operations of the NVTC.

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12. The individual Defendants named in paragraphs 7, 8, 9,

10 and 11 above are officers of the Executive Branch of the

Commonwealth of Virginia and are sued in their official

capacities.

13. Northern Virginia Training Center is an institution

within the meaning of 42 U.S.C. § 1997(1).

14. Persons residing at NVTC are individuals with special

needs, including persons with mental retardation or other

developmental disabilities. Persons residing at NVTC are

"qualified individual[s] with a disability" pursuant to the

Americans with Disabilities: Act of 1990 ("ADA"), 42 U.S.C..

•.§§' 12101, 12131. . . . .

.. .

.

.

.

15. The Commonwealth of Virginia and the Department of

Health and Human Resources, DMHMRSAS, and NVTC are "public

entities" pursuant to Title II of the ADA, 42 U.S.C. § 12131.

16. Defendants are legally responsible, in whole or in

part, for the operation of and conditions at NVTC, as well as for

the care and treatment of persons residing at that institution.

17. At all relevant times, Defendants have acted or failed

to act, as alleged herein, under color of state law.

FACTUAL ALLEGATIONS

18. Defendants have failed and are continuing to fail to

provide the residents of NVTC with that level of training

necessary to protect the residents' liberty interests, including

their right to training sufficient to ensure safety and freedom

from undue restraint.

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19. Defendants have failed and are continuing to fail to provide residents of NVTC with adequate medical care and related services, including nursing services and physical and occupational therapy.
20. Defendants have failed and are continuing to fail to provide reasonably safe conditions at NVTC and to ensure the reasonable safety and personal security of NVTC residents.
21. Defendants have failed and are continuing to fail to ensure that residents of NVTC are free of unreasonable restraints and that restraints are used safely, are utilized consistent with accepted professional, standards and are not used as. punishment, in lieu of treatment, or for the convenience of staff.
22. Defendants have failed and are continuing to fail to ensure that medications are prescribed and administered to residents of NVTC by appropriately qualified professionals consistent with accepted professional standards, and are not used as punishment, in lieu of treatment, or for the convenience of staff.
23. Defendants have failed and are continuing to fail to maintain professionally appropriate recordkeeping and record review systems at NVTC to ensure that resident records contain accurate, up-to-date and relevant information as is necessary to enable staff to render appropriate medical, treatment, and training decisions.
24. Defendants have failed and are continuing to fail to provide a sufficient number of adequately trained staff at NVTC
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to render essential care, treatment, and training to residents. 25. Defendants have failed and are continuing to fail to
ensure that residents of NVTC are adequately evaluated for community placement, that those individual residents whom professionals determine should be placed in community programs are placed in such programs, and that all residents are served in the most integrated setting appropriate to each resident's individual needs.
26. Defendants have failed and are continuing to fail to meet the requirements of the ADA, 42 U.S.C. § 12101 et. seq. , and the regulations promulgated pursuant thereto, by excluding the NVTC residents, by reason of their disability, from participation in or by denying them the benefits of the services, programs, or activities, or by subjecting them to discrimination, and by failing to administer services, programs, and activities in the most integrated setting appropriate to their needs.
VIOLATIONS ALLEGED 27. The acts and omissions alleged in paragraphs 18 through 26 violate the rights, privileges and immunities of residents of NVTC secured or protected by the laws and Constitution of the United States and deprive residents of such rights, privileges and immunities. 28. Unless restrained by this Court, Defendants will continue to engage in the conduct and practice.s set forth in paragraphs 18 through 26 that deprive residents of NVTC of their rights, privileges or immunities secured and protected by the
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laws and Constitution of the United States and cause irreparable harm to those residents.
PRAYER FOR RELIEF 29. The Attorney General is authorized under 42 U.S.C. § 1997a to seek only equitable relief. WHEREFORE, the United States prays that this Court enter an order permanently enjoining Defendants, their agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, practices and omissions at NVTC set forth in paragraphs 18 through 26 above, and that this Court require Defendants to take the necessary actions to provide NVTC residents with their
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I constitutional and federal statutory rightfs. The United States
further prays that this Court grant such other.and further, equitable relief as it may deem just and proper.
Respectfully submitted,

JANET RENO /Attorney General of the
United

HELEN F. FAHEY

_J

United States Attorney

Eastern District of

Virginia

DEVAL^tTT PATRICK* Assistant Attorney General Civil Rights Division
ARTHUR E. PEABODY, J\ Chief Special Litigation Section

ROBINSUE FROHBOESE Deputy Chief Special Litigation Section

DAVID DEUTSCH ROBERT C. BOWMAN CHRISTOPHER N. CHENG Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section Room 1744 P.O. Box 66400 Washington, D.C. 20035-6400 (202) 514-6270

(Office af % Attorney
, IB. & 2D53O

CERTIFICATE OF THE ATTORNEY GENERAL.

I, Janet Reno, Attorney General of the United States, certify that with regard to the foregoing Complaint, United States v. Commonwealth of Virginia, et al., I have complied with all subsections of 42 U.S.C. § 1997b(a)(1). I certify as well that I have complied with all subsections of 42 U.S.C. § 1997b(a)(2). I further certify, pursuant to 42 U.S.C. § 1997b(a)(3), my belief that this action by the United States is of general public importance and will materially further the vindication of rights, privileges, or immunities secured or protected by the Constitution of the United States.

I further certify that I have "reasonable cause to believe" set forth in 42 U.S.C. § 1997a to initiate this action. Finally, I certify that all prerequisites to the initiation of suit under 42 U.S.C. § 1997 et seq., have been met.

Pursuant to 42 U.S.C. § 1997a(c), I have personally signed the foregoing Complaint. Pursuant to 42 U.S.C. § 1997b(b), I am personally signing this Certificate.

Signed this at Washington, D.C.

day of

1995

JANET RENO Attorney General of the United States

«,

CIVIL COVER SHEET

The JS44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required bylaw. except as provided by local rules of court. This form, approved by the Judicial Conference of the United States inSeptember 1974, is required for the useof the Clerk of Court for thepurpose of initiating the civil docket sheet. (SEE INSTRUCTIONS ON THE REVERSE OFTHE FORM.)

1 (a) PLAINTIFFS

DEFENDANTS

United States of America

Comonwealth of V i r g i n i a , et a l .

(b) COUNTY OF RESIDENCEflF FIRST 1 ISTFTl PI AINTIFF
(EXCEPT IN U.S. PLAINTIFF CASES)

COUNTY OF RFSIDFNCF DF FIRST LISTED DEFENDANT (IN U.S. PLAINTIFF CASES ONLY)
NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LANO INVOLVED

(c) ATTORNEYS (FIRM NAME, ADDRESS. AND TELEPHONENUMBER) Richard Parker , AUSA 2100 Jamieson Avenue
Alexandria, VA 22314
(703) 299-3742

ATTORNEYS (IF KNOWN)

II. BASIS O F JURISDICTION

.PLACE AN * ,N ONE BOX ONLY) III. CITIZENSHIP OF PRINCIPAL PARTIES

(*>CE AN x IN ONE BOX

(For Diversity Cases Only)

F O B "AINTIFF ANO ONE BOX FOR OEFENDANT)

& 1 U.S. Government Plaintiff

G 3 Federal Question (U.S. Government Not a Party)

PTF DEF

PTF DEF

G 2 U.S. Government Defendant

G 4 Diversity (Indicate Citizenship of
Parties in Item III)

Citizen of This State

G1 G1

Citizen of Another State G 2 G 2

Incorporated or Principal Place G 4 G 4 of Business in This State
Incorporated and Principal Place • G 5 G 5 of Business in Another State

Citizen or Subject of a Foreign Country

D3 D3

Foreign Nation

G6 • 6

I V . C A U S E O F A C T I O N <crre THE US. CIVIL STATUTE UNDER WHICH YOUARE FILING AND WHITE ABRIEF STATEMENT OF CAUSE 0 0 NOT CITE JURIS0ICTIONALSTATUTES UNLESS OIVERSITY)

42 U.S.C. § 1997 et seq.

V. N A T U R E O FSUIT (PLACE AN X IN ONE BOX ONLY)

CONTRACT
D 110 Insurance D 120 Marine D 130 Miller Ad D 140 Negotiable Instrument D 150 Recovery of Overpayment
& Enforcementol
Judgment D 151 Medicare Act • 152 Recovery ol Defaulted
Student Loans (Excl Veteransl • 153 Recovery of Overpayment of veteran's Benefits D 160 Stockholders Suns D 190 Other Contract D 195 Contract Product Liability
REAL PROPERTY
D 210 Land Condemnation D 2 2 0 Foreclosure G 2 3 0 Rent Lease * Ejectment O 240 Torts toLand D 245 Tort Product Liability D 290 AH Other Real Property

TORTS

PERSONAL INJURY

PERSONAL INJURY

D 3 1 0 Ai-plane D 3 1 5 Airplane Product

r-, 3 6 2 p e r s o n a | | n j u r Y _ Med Malpractice

rL-J 3i o2 0n LAassba*uVlt. Ubel .1
r-. - J i n I * " 1 0 " Q 3 3 0 Federal Employers
liability

a 3 6 5 PP"r*o"d™uc"t L'i"aibuilrityy-
D 3 6 8 Asbestos Personal lmu~ Product Liability

D M S 2 Z Produc, Liability
D 3 5 0 Motor Vehicle D 3 5 5 Motor Vehicle
Product Liability D 3 6 0 Other Personal
|n|ufy

^PERSONAL PROPERTY LJ 3 7 0 Other Fraud G 3 7 1 Truth in Lending O 3 8 0 Other Personal
Property Damage O 3 8 5 Property Damage
Product Liability

CIVIL RIGHTS
D 4 4 1 Voting O 4 4 2 Employment D 4 4 3 Housing/
Accommodations D 4 4 4 Welfare O 4 4 0 Other Civil Rights

PRISONER PETITIONS
i_ 510 Motions lo Vacate Sentence Habeas Corpus:
IZ 530 General C 535 Dealh Penalty C 540 Mandamus & Ottiet C 550 Other

FORFEITURE/PENALTY
LJ 610 Agriculture D 620 Other Food S Drug D 625 Drug Related Seizure of
Property 21 USC 881 • 630 Liquor Laws Q 640 R.R& Truck O 650 Airline Regs • 660 Occupational
Safety/Health D 690 Other
LABOR
• 7 1 0 Fair Labor Standards Act
D 7 2 0 Labor/Mgmt Relations
• 7 3 0 Labor/Mgmt Reporting & Disclosure Act
• 7 4 0 Railway Labor Act
D 7 9 0 Other Labor Litigation
Q 7 9 1 Empl. Rel. Inc. Security Act

BANKRUPTCY
• 422 Appeal 28 USC 156
D 423 Withdrawal 28 USC 157
PROPERTY RIGHTS
D 820 Copyrights D 830 Patent • 840 Trademark
SOCIAL SECURITY • 861 HIA (1395(1) a 862 Black Lung (9231 Q 863 DIWC/DIWW (405(g)l O 864 SSID Title XVI D 865 RSI (40S(g)|
FEDERAL TAX SUITS
• 870 Taxes (U.S. Plaintiff or Defendant)
• 871 IRS-Third Party 26 USC 7509

VI. ORIGIN
1 Original Proceeding

Q 2 Removed from State Court

(PLACE AN x IN ONE BOX ONLY)

Transferred from

• 3 Remanded from G 4 Reinsl
Appellate Court

Q 5 another district (specify)

6 Multidislncl Litigation

OTHER STATUTES
D 4 0 0 State Reapportionment
• 4 1 0 Antitrust G 4 3 0 Banks and Banking O 4 5 0 Commerce/ICC Rates/etc. G 4 6 0 Oeponation Q 4 7 0 Racketeer Influenced and
Corrupt Organizations G 8 1 0 Selective Service O 8 5 0 Securities/Commodities/
Exchange
G 8 7 5 Customer Challenge 12 USC3410
G 8 9 1 Agricultural Acts G 8 9 2 Economic Stabilization
Act G 8 9 3 Environmental Matters G 8 9 4 Energy Allocation Act
G 895 Freedom of Information Act
G 9 0 0 Appeal ofFee Determination Under Equal Access to Justice
Q 9 5 0 Constitutionality of State Statutes
G 8 9 0 Other Statutory Actions
Appeal to District 7 Judge from
Magistrate Judgment

VII. REQUESTED IN CHECK IFTHIS ISA CLASS ACTION

COMPLAINT:

° UNDER F.R.C.P. 23

Check YES only if demanded in complaint:
JURY DEMAND: DYES aNO

VIII. R E L A T E D CASE(S) (See instructions): IF ANY

DOCKET NUMBER,

I /PL/Is
UNITED STATES DISTRICT COURT

U.S. Departmt of Justice United States Attorney Eastern District of Virginia

Richard Parker Assistant United States Attorney Deputy Chief, Civil Division 2100 Jamieson Road Alexandria, Virginia 22314

(703) 299-3742 FAX (703) 299-2583

March 5, 199 6

William H. Hurd, Esq. Deputy Attorney General Commonwealth of Virginia 900 East Main Street Richmond, Virginia 23219

Re: United States of America, v. Commonwealth of Virginia, et. al., Civil Action Nos. 96-283 and 96-284 (E.D. Va)(Unlitigated)

Dear Mr. Hurd:

Thank you for agreeing to accept service of process on behalf of the State defendants in the above-mentioned cases.

Pursuant to your agreement, in this regard, please find enclosed herewith omnibus summonses addressed to you as well as Clerk-stamped copies of the complaints.

I will serve as local counsel in these matters. Copies of my entries of appearance are enclosed for your files. Thank you for your collegiality in this matter.

Very truly yours,

HELEN F. FAHE1

UNITED

.TTORNEY

by
RP/trp Encl. (6) cc:
David Deutsch, Esq. Mark Masling, Esq.

Richard Parker Assistant United States Attorney

U.S. Departme Df Justice United States Attorney Eastern District of Virginia

Richard Parker Assistant United States Attorney Deputy Chief, Civil Division 2100 Jamieson Road Alexandria, Virginia 22314

(703) 299-3742 FAX (703) 299-2583

March 5, 1996

William H. Hurd, Esq. Deputy Attorney General Commonwealth of Virginia 900 East Main Street Richmond, Virginia 23219

Re: United States of America v. Commonwealth of Virginia, et. al., Civil Action Nos. 96-283 and 96-284 (E.D. Va)(Unlitigated)

Dear Mr. Hurd:

Thank you for agreeing to accept service of process on behalf of the State defendants in the above-mentioned cases.

Pursuant to your agreement in this regard, please find enclosed herewith omnibus summonses addressed to you as well as Clerk-stamped copies of the complaints.

I will serve as local counsel in these matters. Copies of my entries of appearance are enclosed for your files. Thank you for your collegiality in this matter.

Very truly yours,

HELEN F. UNITED

.TTORNEY

by
RP/trp Encl. (6) cc:
David Deutsch, Esq. Mark Masling, Esq.

Richard Parker Assistant United States Attorney

 </s> UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF VIRGINIA Alexandria Division

UNITED STATES OF AMERICA, Plaintiff,
v. COMMONWEALTH OF VIRGINIA, et al.,
Defendants.

8
Case Number: 96-283-A

SETTLEMENT AGREEMENT
The United States of America (hereinafter the "United States"), and the Commonwealth
of Virginia (hereinafter "Virginia"), agree to settle the above captioned matter (hereinafter "this
Action") on the terms and conditions set forth below in this Settlement Agreement (hereinafter
the "Agreement").
I. Introduction.
A. By letter dated May 4, 1990, the Assistant Attorney General for Civil Rights,
United States Department of Justice, informed the then Governor of the Commonwealth of
Virginia that the United States was commencing an investigation of the Northern Virginia
Training Center (hereinafter "NVTC") pursuant to the Civil Rights of Institutionalized Persons
Act (hereinafter "CRIPA"), 42 U.S.C. § 1997 et seq.
B. NVTC is an institution covered by CRIPA and operated by Virginia to provide habilitation and other services to persons with developmental disabilities and mental retardation. <-•
A True Copy, Teste: Norman H^Jjesjye By-
Deputy Clerk
U.S. v. Virginia

~~" ™

HH

••

•• •

B

MR-VA-002-007

C. On July 16-17,1990, and continuing from time to time through September 13-15, 1993, representatives of the United States conducted on-site inspections and evaluations of NVTC.
D. As a result of these examinations and inspections, the United States advised the Governor of Virginia, in letters dated April 9, 1991, May 31, 1994, and February 8, 1995, that, in its opinion, conditions at NVTC constituted a pattern or practice of violations of the constitutional and federal statutory rights of NVTC residents.
E. Beginning in 1991 and continuing from time to time thereafter, Virginia voluntarily developed and commenced implementation of a written plan to address the care provided at NVTC ("the Plan") ("Exhibit A").
F. Virginia has at all times denied that conditions at NVTC violate the constitutional or federal statutory rights of residents at NVTC.
G. Virginia has at all times maintained that, as a matter of state policy, it aspires to provide a level of care to NVTC residents in excess of what it regards as the minimal level of care required by the Constitution and federal law. By entering into this Agreement and agreeing to implement the Plan, Virginia does not admit that any of the terms of such documents or the level of care it provides are legally required pursuant to the Constitution or federal law.
H. On March 4, 1996, the United States filed the complaint in this Action. I. The parties agree it is in their mutual interests to avoid the continuation of adversarial litigation. To that end, the parties have resolved their differences by agreeing upon the Plan and upon methods of communication and conciliation as set forth in this Agreement.

The parties recognize that implementation of the Plan provides NVTC residents with a level of care satisfying all constitutional and federal statutory standards at issue in this Action.
J. The parties agree that the resolution of this case is in the best interests of NVTC residents, and otherwise in the best interests of their common citizens.
Accordingly, the parties agree as follows: II. Rule 41(a)(2) Dismissal Without Prejudice.
Immediately upon execution of this Agreement, the parties shall jointly move the Court for entry of an Order of dismissal without prejudice pursuant to Rule 41(a)(2), in the form attached as Exhibit B. In the event the Court refuses or fails to enter that Order in the attached form, this Agreement shall be null and void. HI. Dismissal With Prejudice.
1. The Court shall enter a dismissal of this Action with prejudice upon the occurrence of one or more of the following conditions:
a. In the event the United States fails to file a Motion to Restore (defined in § V m below), Virginia shall be conclusively entitled to an order dismissing this Action with prejudice exactly nine months from the Notice Date (defined in § VII below);
b. Joint motion of the parties; c. Unopposed motion of defendants; or d. In the event the United States files a Motion to Restore pursuant to the procedures set forth in § V m below, but the Court does not find that Virginia failed to achieve substantial compliance with the Plan.

IV. Plan Implementation. Virginia agrees to implement the Plan by the Notice Date, as defined in § VII(2) below.
V. Consultation Tour. 1. To allow the United States an opportunity to observe Virginia's implementation
of the Plan, and to promote the sharing of technical information and the amicable resolution of any disagreements, the United States shall retain expert consultants to tour NVTC to assess the status of such implementation and to confer with NVTC with respect to such implementation.
2. On dates mutually agreed upon by the parties, but no later than 45 days after entry of the Order described in § II above, the United States shall tour the facility with its expert consultants, after reasonable notice to Virginia of the identity and curriculum vitae of those consultants. Within 10 days of entry of the Order, the United States shall inform Virginia of the documents its expert consultants will need in preparation for the tour. Said documents shall be substantially similar to those previously requested and provided during expert consultant tours of NVTC. The United States agrees to provide information to Virginia based on these tours within 45 days of the tours. The parties agree to confer regarding the desirability of further sharing of technical information, including a conference between the United States' expert consultants and Virginia's professionals.
3. The United States' expert consultants shall tour NVTC utilizing the same procedures used during prior United States' expert consultant tours at NVTC, including but not limited to procedures governing confidentiality of patient records.
4. The United States shall not commence or support any civil action under this Agreement or otherwise, or initiate any other CRIPA proceeding against Virginia, based on any

matter observed during these tours or documents produced in connection with the tours. The findings and conclusions of the United States' expert consultants based on this tour shall not be used by the United States in any court proceeding, nor shall they be disclosed or used by the United States for any purpose other than as set forth in § V of this Agreement. VI. Tnterjm Reports.
1. Beginning on October IS, 1996, and continuing every three months thereafter until the Notice Date, defined in § VII below, Virginia shall provide the United States with quarterly summaries of each reported Category I and II incident as defined in the Standard Administrative Practices and Procedures Manual, Chapter 28, Reporting and Responding to Unusual Incidents, Appendix B (Exhibit C) occurring at NVTC (hereinafter "Incident Summaries11), and each open or founded allegation of abuse and/or neglect as defined in Departmental Instruction #33 (Exhibit D) (hereinafter "Abuse/Neglect Summaries"). The Incident Summaries shall be in the form attached as Exhibit E. The Abuse/Neglect Summaries shall be in the form attached as Exhibit F.
2. The United States may request reasonable follow-up information, including documents from Virginia with respect to any incident identified on the Incident and/or Abuse and Neglect Summaries.
3. The United States shall advise Virginia of any alleged deficiencies in the implementation of the Plan ascertained from its evaluation of Incident and/or Abuse and Neglect Summaries and follow-up information. Virginia agrees to confer with the United States, in person or in writing, with respect to any such alleged deficiencies.

VII. Certification Tour. 1. The purpose of the certification tour is to permit the United States to assess the
status of Virginia's implementation of the Plan before this case is dismissed with prejudice as provided by § m , so that the United States may file a Motion to Restore, if necessary, pursuant
to § vm.
2. On or before June 1, 1997, Virginia shall provide written notice to the United States that it may conduct the certification tour. A copy of the notice shall be filed simultaneously with the Clerk of the U.S. District Court in Alexandria. If Virginia fails to send this notice on or before June 1, 1997, the United States shall have the right to provide written notice to Virginia that it will conduct the certification tour. A copy of the notice shall be filed simultaneously with the Clerk of the U.S. District Court in Alexandria. The date such notice is filed with the Clerk, either by Virginia or the United States, shall be deemed the "Notice Date" for purposes of this Agreement.
3. During the first month after the Notice Date, the United States shall inform Virginia of (i) the identity and vitae of any expert consultants it will retain to assess Virginia's compliance with the Plan, and (ii) the documents it seeks to assess Virginia's compliance with the Plan, which shall be substantially similar to those previously requested and provided during expert consultant tours of NVTC.
4. No later than the second month after the Notice Date, Virginia shall inform the United States of the identity and vitae of any expert consultants it will retain for the certification tour, and shall provide the United States with the requested documents.

5. No sooner than the third month and no later than the end of the fourth month after the Notice Date, the United States' attorneys and expert consultants shall tour NVTC to assess the status of Virginia's compliance with the Plan. The procedures for such tour shall be substantially similar to those previously used during expert consultant tours at NVTC (including, but not limited to, procedures governing confidentiality of patient records), except that Virginia shall have the right for its own attorneys and expert consultants to accompany those of the United States on all aspects of the tour.
6. No later than the fifth month after the Notice Date, Virginia and the United States shall receive from their respective expert consultants their reports evaluating Virginia's implementation of the Plan. In selecting and retaining their expert consultants, the United States and Virginia shall each be responsible for assuring that said expert reports can be completed by their expert consultants within this time period.
7. No later than the sixth month after the Notice Date, the United States shall notify Virginia of any alleged deficiencies in Virginia's implementation of the Plan. The United States shall specify by page numbers, paragraphs and subparagraphs, each provision of the Plan which it alleges has been implemented in a deficient manner. The United States shall set forth in reasonable detail (i) the evidentiary basis of its allegations of deficiency and (ii) the remedial measures which it proposes to remedy each deficiency. The reasonable details to be provided shall include, but not be limited to, a complete statement of all the opinions of any expert consultants, on which the United States relies, the basis and reasons for such opinions and the information considered by the expert in forming such opinions.

8. No later than the seventh month after the Notice Date, Virginia shall notify the United States of Virginia's concurrence or disagreement with each of the United States' allegations of deficiency and proposed remedial measures. If Virginia concurs with any of the United States' allegations of deficiency, but disagrees with the proposed remedial measure, it shall propose an alternative remedial measure.
9. During the seventh and eighth months following the Notice Date, Virginia and the United States shall endeavor in good faith to resolve any disputes over the United States' allegations of deficiency and/or disputes over the proposed remedial measures. The conciliation process shall include at least one face-to-face meeting between representatives of the parties; and if such meeting does not achieve conciliation, then the conciliation process shall continue with a prompt mediation session before a judicial officer, if feasible under the timeframes in this Agreement. During the conciliation process, Virginia shall have the right, but shall not be required, to support its position by disclosing relevant portions of its expert reports. Vin. Motion to Restore the Action.
1. In the event Virginia and the United States are unable to resolve any dispute concerning the United States' allegations of Virginia's failure to implement the Plan or a provision of the Plan, but in no event earlier than the end of the eighth month following the Notice Date, the United States may file a motion to vacate the dismissal without prejudice and to restore the Action to the Court's active docket ("Motion to Restore") for the purpose of adjudicating allegations by the United States that Virginia has failed to substantially comply with the Plan.
8

2. The Motion to Restore shall (i) identify those portions of the Plan the United States alleges that Virginia has violated, specifying Plan page numbers, paragraphs and subparagraphs; and (ii) identify with reasonable specificity the remedial measure sought by the United States.
3. Any Motion to Restore shall be served upon counsel for Virginia by certified mail, return receipt requested.
4. Unless a different time is ordered by Order of the Court, Virginia shall have twenty (20) days from the receipt of such motion to file its response.
5. Upon the filing of the Motion to Restore, the Action shall be litigated in accordance with the applicable Federal Rules of Civil Procedure, Local Rules, and orders of the Court, including but not limited to such rules and orders pertaining to discovery; provided, however, that the Complaint shall be deemed amended and superseded in accordance with the allegations set forth within the Motion to Restore pursuant to 1 2 above.
6. The United States shall have the burden of proof. To prevail, the United States must show that Virginia failed to achieve substantial compliance with the Plan.
7. The parties shall request the Court to hear such motions and to conduct such trial as may be necessary to adjudicate the Motion to Restore and the Action, including the allegations set forth pursuant to 1 2 above. If the Court finds that Virginia is in substantial compliance with the Plan, it shall dismiss this Action with prejudice. If the Court finds that Virginia is not in substantial compliance with the Plan, it may order specific performance of those portions of the Plan which the Court finds Virginia has violated.

8. The exclusive remedy for any alleged failure by Virginia to achieve substantial compliance with the Plan shall be an Order for specific performance pursuant to 1 7 above; provided, however, that this limitation shall not be construed as an attempt to limit the power of the court in the event any such order for specific performance is entered and thereafter violated. Any such order for specific performance may be directed against Virginia and/or such officials whom the Court may determine are responsible for such violations. Neither Virginia nor any officials thereof shall be subject to a finding of, or sanctions for, contempt unless an order for specific performance has been entered pursuant to a Motion to Restore and is thereafter violated in such a manner as to make such a finding or sanctions appropriate. The provisions of this paragraph are of the "essence of this Agreement. DC. Emergency Provision.
1. The United States may seek immediate relief from the Court for the limited purpose of redressing an alleged emergency at NVTC. An emergency shall be defined as a pattern or practice of violating the Plan that creates an immediate, substantial risk of serious bodily harm to NVTC resident(s).
2. In any motion seeking relief for an alleged emergency, the United States shall file an enhanced pleading which sets forth the specific facts on which an emergency is alleged, the specific violations of the Plan, and the legal basis for the allegations (hereinafter "Motion for Emergency Relief").
3. The parties shall confer in good faith in an effort to resolve any such allegations prior to filing any such Motion for Emergency Relief.
10

4. Any Motion for Emergency Relief shall be served upon counsel for Virginia by certified mail, return receipt requested.
5. Unless a different time is ordered by Order of the Court, Virginia shall have twenty (20) days from the receipt of such motion to file its response.
6. Upon the filing of any Motion for Emergency Relief, the motion shall be litigated in accordance with the applicable Federal Rules of Civil Procedure, Local Rules, and orders of the Court, including, but not limited to, such rules and orders pertaining to discovery.
7. The United States shall have the burden of proof. To prevail, the United States must prove the existence of an emergency as defined in 1 1 above.
8. The parties shall request the Court to hear such motions and to conduct such trials as may be necessary to adjudicate the Motion for Emergency Relief, including the allegations as required by f 2 above. If the Court finds that no emergency exists, it shall dismiss the Motion with prejudice. This dismissal shall have no effect on the United States' ability to file a Motion to Restore pursuant to § VIII. If the Court finds that an emergency exists, it may order specific performance of those portions of the Plan which the Court finds gave rise to the emergency.
9. The exclusive remedy for an alleged emergency shall be specific performance, pursuant to 5 8 above; provided, however, that this limitation shall not be construed to limit the power of the court in the event any such order for specific performance is entered and thereafter violated. Any order for specific performance may be directed against Virginia and/or such officials whom the Court may determine are responsible for such emergencies. Neither Virginia nor any officials thereof shall be subject to a finding of, or sanctions for, contempt unless an
11

order for specific performance has been entered pursuant to a Motion for Emergency Relief and
f
is thereafter violated in such a manner as to make such findings or sanctions appropriate. X. Interpretation of the Plan.
1. The parties recognize that portions of the Plan must be interpreted in light of standards not expressly set forth in the Plan. In such cases, for purposes of determining whether NVTC has implemented the Plan, or any portion thereof, the parties agree that the relevant and applicable standard shall be as follows: Decisions by Virginia with respect to the implementation of policies, procedures, and other activities required by the Plan shall be evaluated for the purpose of determining compliance with the Plan by the "professional judgment" standard articulated in Youngberg v. Romeo, 457 U.S. 457 (1982).
2. This Agreement, together with attachments, is an integrated document and contains the entire agreement between the parties, and wholly cancels, terminates, and supersedes any and all previous and/or contemporaneous oral agreements, negotiations, and commitments and writings between the parties thereto with respect to this Action and NVTC.
3. Except as provided in 1 7 below, no change, modification, extension, termination, discharge, abandonment or waiver of this Agreement or any of the provisions hereof, nor any representation, promise or condition relating to this Agreement shall be binding upon the parties hereto unless made in writing and signed by the parties or their counsel.
4. Nothing contained in this Agreement or in the Plan shall be construed as an admission or evidence (i) that practices at NVTC at anytime or in any way violated constitutional standards or other legal standards governing the provision of care at NVTC, (ii) that the terms of the Agreement or the Plan are necessary to meet constitutional standards or other legal
12

standards governing the provision of care at NVTC, or (iii) that the policies, practices, and procedures described in the Plan did not exist at NVTC prior to the initiation of the CRIPA investigation, nor shall this Agreement nor the Plan be used by any person or party as the basis for any liability of Virginia except as expressly provided herein with respect to this Action.
5. Each of the terms of the Agreement and the Plan shall be deemed to have been mutually drafted by the parties, and shall not be construed against either party as the author thereof.
6. Deadlines and time references (e.g. use of present and past tenses) used in the Plan shall be treated as NVTC's internal planning objectives and reflect NVTC's schedule for implementation as of the original and/or a revised date of the Plan. They may be used for purposes of consultation between the United States and Virginia, pursuant to the Consultation Tour provided by § V. Notwithstanding such deadlines and time references, NVTC shall be deemed to have implemented the Plan for all purposes under this Agreement if it has been implemented by the Notice Date.
7. Virginia shall have uie right to propose modifications to the Plan from time to time by giving the United States written notice of the language proposed for deletion from and/or addition to the Plan. Such proposed modifications shall be deemed effective for all purposes under this Agreement on the date specified in the proposal unless the United States gives Virginia written notice of its objection within thirty days of its receipt of the proposed modification.
8. Virginia shall not be deemed to have failed to achieve substantial compliance with the Plan due to any shortage of staff where such shortage is the result of an unusual level of
13

absences beyond Virginia's reasonable control, or vacancies created by the death, discharge, retirement or resignation of any employee or by the creation of new positions in response to an increase in census, so long as Virginia takes necessary steps to fill any such vacancies with reasonable promptness. XI. Miscellaneous.
1. The parties shall request that the Motion to Restore and any other proceeding held in this case be heard by the Honorable Leonie M. Brinkema, United States District Judge. Any party may file a motion to vacate the dismissal without prejudice and to restore the case to the active docket for the limited purpose of adjudicating an alleged violation of § V, VI or VII of this Agreement. Any such motion shall be adjudicated pursuant to the Federal Rules of Civil Procedure and the local rules of this Court. Any such motion shall state the paragraphs of the Agreement that are alleged to be violated. The exclusive remedy for any such violation shall be an order for specific performance. Any such order for specific performance shall be directed against such officials whom the Court may determine are responsible for such violations. No party nor any official thereof shall be subject to a finding of, or sanctions for, contempt unless such an order for specific performance has been hereafter entered and is thereafter violated in such a manner as to make such finding or sanctions appropriate. The parties shall attempt in good faith to resolve any dispute prior to filing any motion alleging a violation of this Agreement.
2. This Agreement shall be applicable to and binding on the parties to the Agreement, their officers, agents, employees, and successors.
3. Notwithstanding any other provision of this agreement, the United States shall
14

have no standing to seek, nor shall it be entitled to entry of, any order for specific performance that would, as a practical matter, require the expenditure of funds in any biennium in excess of the level of funding appropriated for the facility by the General Assembly in the 1996-98 biennium. Virginia represents its good faith belief that the funding for the 1996-1998 biennium is sufficient to implement the Plan.
4. This Agreement and the Rule 41(a)(2) Dismissal referenced in this Agreement resolve all of the allegations raised in the Complaint. The United States shall not amend its Complaint (except as provided in § V m , 1 1 2 , 8 above) nor file any new CRIPA action based on events at NVTC occurring prior to any dismissal with prejudice of this Action.
5. Each party shall bear its own costs, including attorney's fees, except that Virginia may move for attorney's fees pursuant to 28 U.S.C. § 1997a(c) at the conclusion of any proceeding brought by the United States pursuant to §§ VIQ and DC herein.
6. An executed copy of this Agreement shall be filed with the Clerk of the Court, and a copy delivered to the Honorable Leonie M. Brinkema, United States District Judge.
7. The following shall govern the termination of Virginia's obligations under the Agreement and Plan:
(a) subject to the provisions of subparagraph (b), Virginia's obligation with respect to the Agreement and the Plan shall terminate nine months from the Notice Date or with the entry of a Dismissal with Prejudice, whichever is earlier. (b) With respect to any provisions of the Plan which are the subject of a Motion to Restore under § VIE, the obligations of such provisions shall continue pending an adjudication of such Motion to Restore.
15

(c) With respect to any provisions of the Plan for which the Court has entered an order for specific performance, the parties agree to jointly move the Court to dismiss such orders and to dismiss the case with prejudice within one year from the date such order for specific performance was entered, unless and to the extent that the United States has moved for a finding of civil contempt with respect to such order within said one year period. (d) If the United States moves for a finding of civil contempt, but the Court finds no such contempt, Virginia's obligations under the Agreement and Plan shall terminate as of that time with respect to the provision(s) that was the subject of said motion for contempt. (e) If a finding of civil contempt has been made, the obligations under the provisions of the Plan with respect to which such finding has been made shall be extended for such period as may be required by the Court as a remedy for such contempt. 8. This Settlement Agreement is signed on behalf of the United States by Deval L. Patrick, Assistant Attorney General and other counsel of record for the United States, and on behalf of the Commonwealth of Virginia by William H. Hurd, Deputy Attorney General and other counsel of record for the Commonwealth of Virginia. Each of said counsel represents that he has and/or has obtained all authority necessary to sign on behalf of the United States and the Commonwealth of Virginia, respectively. Counsel for the Commonwealth further represent that they execute this Settlement Agreement on behalf of the Commonwealth with the authorization, consent and/or approval of the other Defendants in this case, to-wit: Governor George F. Allen, Secretary Robert C. Metcalf, Commissioner Timothy A. Kelly, Janet W. Hill, Director of
16

Mental Retardation Services and David H. Lawson, Director of the Northern Virginia Training Center.

United States of America

Commonwealth of Virginia

By: DeVaTT. Patrick Assistant Attorney General Civil Rights Division
By: Arthur E. Peabody, Jr. Chief Special Litigation Section

By: William H. Hurd Deputy Attorney General
By/Jane D. Hfckey *O lior Assistant Attorney General

By: David Deutsch Senior Trial Attoi Special Litigation
By: Richard Pa Assistant United States Attorney

By-y/Garland L. Bigl "Assistant Attorney General
By: LyAne R. Fleming Assistant Attorney Ge:

Assistant Attorney General
By: Thomas B. York t / Saul, Ewing, Remick & Saul 240 N. 3rd Street Harrisburg, Pennsylvania 17101
17

 </s> U.S. v. Virginia

111 mil II mil IIIIIII in IIIIII iiiii iiiii mi iiiin IIIII mil mi mi
MR-VA-002-008

.; (]

UNITED STATES DISTRICT COURT FOR THE , . EASTERN DISTRICT OF VIRGINIA / ? j JUL ' O 1996 Alexandria Division

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

) Civil Action No. 96-283-A

) COMMONWEALTH OF VIRGINIA, et al. , )

)

Defendants.

)

ORDER In light of the Settlement Agreement entered by the parties on
1 5? , 1996, which agreement is not so ordered or approved by
7)
the "Court, this civil action is hereby DISMISSED WITHOUT PREJUDICE pursuant to Rule 41(a)(2) of the Federal Rules of Civil Procedure.
The Court retains jurisdiction over this civil action and the Settlement Agreement to resolve any disputes arising out of the Settlement Agreement and to enter a final dismissal of this civil action with prejudice as contemplated by the Settlement Agreement. Adjudication of and remedies for any alleged violation of the Settlement Agreement shall be subject to the procedures and limitations provided by the Settlement Agreement.
The Clerk is directed to remove this civil action from the Court's' active docket and to forward copies of this Order to counsel!of record.
Entered this /% day of July, 1996.

Deputy Clerk

Lfeonie M. Briynk* wnited States District Judge /

 </s> U.S. Department of Ju. i Civil Rights Division

U.S. v. Virginia

FAX Transmiffal
Special Litigation Section
P.a Bm 3?o?6

MR-VA-002-001

Date

To: Name Paula Newett Organization Civil Division FAX Phone No. 557-2913 Office Phone No. 557-9100

From: Name Mellie H. Nelson

FAX Phone No.

202/272-6078

Office Phone No. 272-6018

Subject: Notice ltr. to Governor Wilder per our conversation of todav.

Number of pages transmitted (including this sheet) (max. trans. 30 sheets)

U.S. Department of Justice Civil Rights Division

Office of the Assistant Attorney General

Washington. DC. 20530

REGISTERED MAIL RETURN RECEIPT REQUESTED

MAY .4 1990

Honorable L. Douglas Wilder Governor of Virginia State Capitol Building Ninth and Grace Streets Richmond, Virginia 23212
Re: Investigation of Northern Virginia Training Center Fairfax. Virginia
Dear Governor Wilder:
I am writing to inform you of our intention to investigate conditions at the Northern Virginia Training Center, Fairfax, Virginia. This investigation is pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. 1997 et seq.
The purpose of the investigation will be to determine whether there exist any violations of statutory and federal constitutional rights of clients residing at the facility. The investigation will focus on allegations related to insufficient numbers of direct care and professional staff, inadequate medical care, improper use of medications, improper use of restraints, physical abuse and harm, and the denial of training required by Younqberg v. Romeo. 457 U.S. 307 (1982), i.e.. sufficient training to protect residents from unreasonable risks to their health and safety. The initiation of this investigation in no way evidences any prejudgment on our part that residents' federal rights have been violated. If any violations are found, we look forward to conferring with you and your staff concerning corrective actions that might be appropriate.
As a means of commencing this investigation, I wish to propose an initial meeting in the near future between our attorneys and representatives of your office. It has been our experience that such a preliminary conference can substantially expedite the process. We also wish to arrange for our attorneys, consultants, and perhaps agents of the Federal Bureau of Investigation to visit the Northern Virginia Training Center. We shall be in touch with your staff to work out the specifics

-2of our meeting and later visits. The attorney assigned to this matter is Laurie Weinstein, she can be reached at (202) 272-6453
Your cooperation in this matter is greatly appreciated.
Sincerely,

R. Dunne

_

Attorney General

Civil Rights Division

cc: Honorable Mary Sue Terry Attorney General State of Virginia

Mr. King E. Davis Commissioner Department of Mental Health, Mental Retardation
and Substance Abuse
i
David H. Lawson, Ph.D. Director Northern Virginia Training Center

Henry E. Hudson, Esq. United States Attorney Eastern District of Virginia

 </s> U.S. Department of Justice CM! Richts Division

n-"-c- Gf<ra!

RjW.-.-nv.v:. DC '•••.'.*

REGISTERED MAIL

I

RETURN RECEIPT REQUESTED

£ P p q ,Qq| **n u lwai

Honorable Lawrence Douglas Wilder Governor of Virginia
State Capitol Building
Ninth andGrace Streets
Richmond, VA 23219

U.S. v Virqinia I I I 1 1I I I I I I II11 ••If(| Jf||ii•• ••• •
IIII II I I I I
IIII If \\ \\\ III II IIIIII I
MR VA 002-002 " ' ' "

Re: Northern Virginia Training Center

Dear Governor Wilder:
By letter dated May 4, 1990, we notified you that, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. '' §1997 et sec., the Civil Rights Division of the United States Department of Justice was commencing an investigation into conditions at Northern Virginia Training Center ("NVTC") , a facility for the mentally retarded located in Fairfax, Virginia. As specified by the statute, we are now writing to inform you that our review indicates that unconstitutional conditions exist at NVTC, and also to advise you of the minimum measures we believe are necessary in order to remedy those conditions.

Our investigation consisted, first, of several comprehensive tours of NVTC by independent experts, most recently on October 22-24, 1990. The experts observed conditions in all the residential units of NVTC at various times of the day, interviewed administrators, staff and residents, and examined a variety of records. Further, we gathered and analyzed documentation relating to the operation of NVTC, including: a variety of policies and procedures; information relating to staffing; minutes from various committees, including the Behavior Management Committee and the Senior Staff Committee; incident and investigation reports; injury reports; restraint logs; lists of residents on medications; and residents' records.

Based upon our investigation, we find that conditions exist at NVTC that deprive residents of their constitutional rights. The United States Supreme Court has clearly stated that institutionalized mentally retarded persons have a constitutional right to adequate medical care, reasonable safety, and such training as an appropriate professional would consider reasonable to ensure their safety and freedom from undue bodily restraints.

- 2-
Youncberq v. Poaeo, 457 U.S. 307, 324 (1982).. We have concluded that the State subjects its residents of NVTC to conditions that violate their constitutional rights, including conditions that seriously threaten the health and safety of NVTC residents. These conditions include:
1. Failure to provide sufficient training to residents to avoid undue risks to residents' personal safety and unreasonable use of physical and chemical restraints;
2. Failure to provide sufficient numbers of appropriately trained staff to render and implement professional judgments regarding necessary care, training, and medical treatment and to avoid undue risks to residents' personal safety and unreasonable use of physical and chemical restraints;
3. Failure to provide adequate medical care;
4. Failure to adequately monitor medications;
5. Failure to keep and maintain such records as will allow staff to render professional judgments regarding care and treatment of residents.
Set forth below are our findings and recommendations.
I. Inadequate Behavioral Training
A. Failure to provide and implement training programs
NVTC fails to provide professionally designed and implemented training programs sufficient to ensure that residents are not subjected to unreasonable risks to their personal safety and undue bodily restraint. Our expert psychologist found that the psychologists on duty have excessive caseloads and professional"responsibilities so that they do not have adequate time to render professional judgments with respect to matters within their professional responsibilities, including the design and implementation of training programs and supervision and training of direct care workers. As a result of the shortage of psychologists, treatment programs are not individualized and often contain inappropriate or incompatible goals. They often remain the same, including the use of restraint, from year to year. Our expert psychologist concluded that the current practice of behavior modification at NVTC fails to reduce selfabusive, aggressive,, and other maladaptive and inappropriate behaviors.

- 3-
Due to the lack of training, direct care workers lack skills necessary to implement and monitor behavior training programs. As a result, often data is not collected or the data collected by such untrained and unsupervised workers is unreliable. The individual training programs reviewed reflect this inconsistent and inaccurate data collection, implementation and monitoring. Direct care staff did not know the elements of the residents' training programs or know how to carry them out. The failure to develop consistent and necessary training programs, to implement and monitor them, and to collect and record accurate and pertinent progress data places residents at substantial risk of harm to their personal safety and to excessive mechanical and chemical restraint.
The training programs were seriously deficient in their failure to address residents' needs and to consider alternatives to restraint, especially in cases where restraint had not been effective in reducing maladaptive and inappropriate behaviors, resulting in residents failing to receive such training as is reasonably necessary to protect them from unreasonable risks of harm. Training programs are further compromised at NVTC by a > lack of coordination between professional staff. Medical procedures interfere unduly with residents' programs: routine blood work and the evaluation of even trivial problems often cause residents to be kept out of their programs for half of the day or even the entire day. This evidences a lack of coordination between residents' programmatic and medical needs. There is no justification for preventing residents from participating in their training programs for medical procedures and evaluations that take minutes.
B. Excessive use of restraint
We were struck by the pervasive use of restraint at this facility. Staff regularly resort to chemical and physical restraints to control residents' behavior in violation of the residents' constitutional rights. A myriad of mechanical restraint devices were in evidence and in use during the tours, including leather wrist and ankle straps, helmets with face guards, and papoose boards. Moreover,' it is not uncommon for these restraints to be used in combination with seclusion and with chemical restraint (emergency injections of psychotropic medication).
Although we were told restraints are generally used in connection with behavior programs, these programs do not facilitate a reduction in the uss of such restraints and residents remain on programs with restraint as their central components for long periods of tine. Indeed, for some residents the incidence of restraint and the length of time spent in restraints is increasing. The behavior programs are not modified to address the ineffectiveness of restraints, nor do they direct

- 4-
those inple-6r.t.ing the programs to attempt other measures prior to resort to restraint. On the contrary, restraint is used so frequently that it appears to be the treatment of choice rather than a technique of last resort.
When physical restraints are employed, they are not consistently monitored and evaluated by qualified professional staff. Thus, significant numbers of injuries occur during the implementation of restraints. Moreover, restraint is used for inappropriate reasons and in response to behaviors that are not dangerous. Many residents are restrained in their beds at night, raising serious concerns for the safety of residents in the event of a fire.
In sum, NVTC lacks adequate and necessary training programs. Our consultant concluded that these activities expose residents to undue risks to their personal safety and to undue restraint.
II. Insufficient Trained Direct Care Staff
The safety of NVTC residents is threatened by the inadequate training of direct care staff for the myriad tasks assigned to them. There is a widespread failure to appropriately manage maladaptive resident behavior. Staff questioned about a specific resident's behavioral programs were unaware of the components.
During our tours, we rarely observed competent staff intervention. Our experts observed an almost total absence of staff-resident interaction in daily programs. Some residents in need of assistance were unnoticed by staff for extended periods of time until our experts pointed them out. Residents were not encouraged, praised, or otherwise reinforced for their efforts, nor were they given directions which would keep them on task. Our experts concluded that direct care staff do not possess the technical competence to adequately supervise and train residents of NVTC. Moreover, NVTC has insufficient staff to implement appropriate programs, to provide appropriate encouragement and direction, and to interact with residents in meaningful ways and to further residents' training goals. .<
Direct care staff training at NVTC is deficient and contributes to inadequate care by staff. Our experts' review indicated that the training given to the staff is insufficient in depth and scope to enable them to adequately provide essential care to residents. The direct care staff receives insufficient training concerning how to effectively intervene to prevent or deal with acting out behaviors of residents or to implement residents' individualized training programs. Direct care staff is not trained in the detection and identification of possible side effects of any medications, but is directed to notify nursing staff of "any change" in residents. The absence of training regarding what changes in residents may be significant

- 5-
or, indeed, what constitutes a "change," renders staff wholly inadequate tc protect the health and safety of residents who are receiving psychotropic, anticonvulsant, or other medications and combinations of medications with serious potential side effects.
As a consequence of the foregoing staffing inadequacies, residents of NVTC are exposed to serious risks to their health and safety.
III. Inadequate Medical Care
Our consultant found that prinary care physicians do not provide prinary medical care; instead, various outside consultants provide care to residents of NVTC. As a result, medical care is fragmented and uncoordinated, with little prinary focus. Serious medical conditions and marked functional deterioration are not comprehensively evaluated or effectively treated. Thus, there were inadequate efforts to diagnose residents' medical problems, a process essential to then selecting the appropriate drug, if necessary, and evaluating the efficacy of treatment. As a result, residents' physical " «• conditions often deteriorated and they were placed at risk. In addition, there is little long range therapeutic planning for chronic medical problems and a failure to provide adequate preventative health care. Instead staff merely monitors medical conditions as they worsen, rather than taking preventative measures to protect residents from such deterioration. This failure to adequately monitor and care for serious medical conditions and to prevent deterioration includes the failure to adequately address residents' feeding and positioning needs. Therefore, we have concluded that the care and treatment of such residents is inconsistent with the exercise of judgment by a qualified professional.
As a further result of the reliance on outside consultants at NVTC, the primary care physicians have not acquired expertise in the complex yet common medical problems found in populations of people with severe developmental disabilities. Thus, for example, neurological care at NVTC depends upon the services of a neurolocist who does annual evaluations only. This seriously compromises the medical care of people who live at NVTC.
IV. Inadequate Medication Practices
Medications at NVTC are not adequately monitored. Residents are placed on combinations of drugs, psychotropics, anticonvulsants, and others, which have risks of dangerous side effects, with no adequate review by the pharmacist or other professional to note these combinations and to recommend changes, where appropriate. Moreover, as noted above, there is inadequate monitoring of residents for drug induced side effects, including tardive dyskinesia. Lack of training for direct care staff, who

- 6-
spend the most time with residents, and confusion among staff as to who is responsible for monitoring, coupled with inadecuate review of prescriptions, place the residents of NVTC at severe risk-
There is insufficient effort made to properly diagnose residents prior to prescribing dedications for psychiatric disorders and not all residents in need of psychiatric evaluation receive such evaluations. Careful selection of medication, if necessary, and its trial in conjunction with a behavioral program depend upon adequate evaluation and an initial diagnosis. Overall psychotropic medication usage has declined in the last two years. Yet the positive and negative effects of psychotropic medications, once prescribed, are not adequately monitored at NVTC. Our consultants found that residents who had benefited from psychotropic medication's in appropriate doses nevertheless had their medications discontinued. As a result of such inadequate medication practices, residents' conditions deteriorate, abilities to function decrease, and maladaptive ar.d inappropriate behaviors increase. Residents then are unable to participate in training activities and are subjected to increased physical and chemical restraint.

Medications administered at NVTC include chemical restraint

of residents, using psychotropic medications on an emergency

basis. There are serious problems with this practice beyond the

failure to provide training programs that might reduce or

eliminate the need to resort to chemical restraint in the first

instance. Emergency injections of psychotropic medication are

used repeatedly with some residents, without limitation on the

total number of doses or assurance that repetitive use will

trigger review and revision, if necessary, of the resident's

behavior program. The consulting psychiatrist at NVTC neither

reviews the use of emergency chemical restraint nor participates

in the decision to use it, even with residents who receive a

substantial number of emergency doses of psychotropic medication.

With one part-time consulting psychiatrist for over 270

residents, it does not appear that the psychiatrist would have

time to conduct such reviews.

;

For the reasons enumerated here, medication practices at NVTC are inadequate, expose residents to serious risks to their health and safety, and impair their abilities to function.

V. Inadequate Recorckseoina

Recordkeeping at NVTC is deficient. Behavioral records of residents are not maintained and progress data are not collected in a consistent fashion. The consequence of the failure to maintain adequate records is that responsible staff are unable to render professional judgments regarding care, treatment, and training of residents of NVTC, thereby subjecting them to

- 7 -
unnecessary risks of h a m . NVTC has not established recordkeepir.g systems and procedures to ensure reliability and validity of information relevant to the care and training of residents. Methods for collecting baseline data, follow-up, and progress data are absent or inadequate.
i
Inaccurate or incomplete behavioral data collection and recordkeepir.g present an active danger to residents by depriving professional and other staff of information necessary to make appropriate and safe decisions regarding training of residents. Treatment decisions are implicated as well because, in the absence of accurate behavioral data, management of patients on psychotropic medications cannot take place consistent with professional standards of practice.

Our consultants also found medical records to be cumbersome,

fragmented, totally inadequate, and even dangerous in their

deficiencies. Results of most diagnostic testing and routine

laboratory data often were not found in the charts and

consultations regarding major medical problems were not readily

available. Other documents, while in the records, are not

,.

consistently found in their designated sections. A comprehensive

understanding of diagnostic and therapeutic measures for any

problem is, therefore, a difficult process. Fragmented medical

records, coupled with the lack of coordinated medical care and

inadequate communication among professionals at NVTC severely

compromise adequate medical care.

Minimally Necessary Remedies

As discussed above, NVTC residents are being subjected to egregious or flagrant conditions that deprive them of their constitutional rights pursuant to a pattern or practice of resistance to the full enjoyment of these rights. To rectify the deficiencies at NVTC and to ensure that constitutionally adequate conditions are maintained thereafter, we propose to enter into an agreement with the Commonwealth of Virginia which shall be entered as an order of a Federal Court and which shall provide, at a minimum, that NVTC shall implement the following remedies:

1) The Commonwealth must provide professionally designed training programs to the residents at NVTC who need them and for whom training will reduce or eliminate unreasonable risks to their personal safety and/or the need to use undue bodily and chemical restraints, and must ensure that such programs are appropriately implemented by trained staff. Immediate attention must be given to residents who have been subject to repeated episodes of mechanical or chemical restraint for extended periods of time by identifying them and providing necessary training. In addition, the Commonwealth must discontinue the use of papoose boards and the use of restraints in conjunction with seclusion at NVTC.

- 8-

2) The Commonwealth nust hire, deploy, and provide ongoing training to a sufficient nuaber of competent and qualified direct care and professional staff at NVTC to*provide its residents with adequate care, treatment, and training programs to protect them from unreasonable risks of bodily harm and to their personal safety.

3) The Commonwealth must provide coordinated medical care to NVTC residents, through the use of NVTC's primary care physicians and outside consultants, that adequately addresses their chronic and long-term medical needs and ensures that appropriate assessments, medical care plans, and consultations with specialists are provided to those residents who need them.

4) The Commonwealth must assure that medications are

appropriately monitored, that the effects of medications are

documented in residents' records, and that decisions to

prescribe, change, or discontinue the use of medications are

based upon sufficient data and are the result of qualified

professional judgment.

*

5) The Commonwealth must assure that NVTC develops and implements adequate recordkeeping systems to monitor the use and effectiveness of behavior and other programs and medical recordkeeping systems sufficient to allow identification, monitoring, and follow-up of medical conditions as appropriate.

Information about Federal financial assistance which may be available to assist with the remedial process can be obtained through the United States Department of Health and Human Services' Regional Office (Director, Intergovernmental and Congressional Affairs), and through the United States Department of Education.

Although the primary purpose of this letter, consistent with CRIPA, is to describe the unconstitutional conditions at NVTC that require remediation, we also wish to acknowledge some of the positive steps taken at NVTC. During-our time on-site at NVTC, we encountered many staff who appeared committed to providing residents with appropriate care in a safe environment. Our experts noted that the physical plant at NVTC and its recreation facilities may offer opportunities for residents to enhance their lives through varied activities in different settings. They also noted the opportunities given to a number of residents to work and move about in the community.

Less positive, however, have been the circumstances surrounding our investigation which has been somewhat marred by what may be termed the disruptive and litigious actions of Virginia's attorneys. These actions have impaired our ability to conduct this investigation in the spirit of cooperation intended

- 9 -
by the Civil Rights of Institutionalized Persons Act, but va hope that, cooperatively, our future efforts with Cosuaonwealth officials and attorneys will lead to an amicable resolution of this matter.
Our attorneys will be contacting the Virginia Attorney General's Office shortly to arrange a meeting to discuss this matter in greater detail. In the meantime, should you or your staff have any questions regarding this matter, please feel free to call Arthur E. Peabody, Jr., Chief, Special Litigation Section, at (202) 514-6255.
Sincerely,
c,. .../<*John R. Dunne ssistant Attorney General Civil Rights Division
cc: Honorable Mary Sue Terry Attorney General Commonwealth of Virginia
Henry E. Hudson, Esq. United States Attorney
Mr. King E. Davis, Ph.D. Commissioner Virginia Department of Mental Health, Mental Retardation
and Substance Abuse
David H. Lawson, Ph.D. Director Northern'Virginia Training Center
Michael J. Astrue, Esq. General Counsel United States Department of Health
and Human Services
Gail R. Wilensky, Ph.D. Administrator Health Care Financing
Administration
Mr. Anthony Tirone Chief, Office of Survey and Certification Health Care Financing Administration

 </s> U.S. Uepartment ot Justice Civil Rights Division

Office of the Assistant Attorney General

Wishington, D.C. 20035
U.S. v. Virginia

MR-VA-002-003
The Honorable James S. Gilraore, III Attorney Gensral Commonwealth cf Virginia Suprer.e Court Building 101 North Eighth St. Richmond, VA 23 219

.. M ™ 3./

Re: Northern Virginia Training Center

Dear Mr. Gilr.ore:

In May 1990, we notified then Governor Wilder that, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. §1997 et sea., the Civil Rights Division of the United States Department of Justice was commencing an investigation into conditions at Northern Virginia Training Center ("NVTC"), a facility for approximately 275 developmentally disabled persons located in Fairfax, Virginia. Our investigation, which included a number of tours of NVTC by independent experts, found that conditions at NVTC deprived residents of their constitutional rights. We informed Governor Wilder of our findings in a letter dated April 9, 1991 (attached).

Many neetings between this Department and Commonwealth officials and several more expert tours followed, with the Commonwealth consistently asserting that the numerous deficiencies had been or were being corrected. In 1993, after the latest representations by the Commonwealth, this Department again conducted expert tours of NVTC. Our experts' recent findings make it clear that conditions at NVTC continue to violate the constitutional rights of the residents there, subjecting them to serious harm and unnecessary risk of. harm. Inadequate medical care, physical therapy, feeding practices and training programs continue to contribute to unnecessary resident illnesses, injuries and deaths. Residents continue to suffer fractures, serious lacerations and contusions, kicks, punches and bites from fellow residents; to injure themselves through self-mutilation; to endure unnecessary physical and chemical restraints; to develop acute and chronic respiratory illnesses from aspirating food; to be r.alnourished and dehydrated; to swallow or choke on inedible objects; to have prolonged and unnecessary seizure activity; and to develop chronic deforr.ities

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and concomitant illnesses due to years of neglect and inadequate physical therapy services.
Given the nature of these deficiencies, the h a m that residents have continued to suffer, and the time in which the Commonwealth has had to correct the deficiencies, we can no longer delay legal action if the Commonwealth refuses to sicr. a consent decree.
I• Background
Subsequent to Governor Wilder's receipt of the United States' letter of April 1, 1951, which set forth the findings cf our experts, several meetings were held between attorneys fcr this Department and attorneys from the Virginia Attorney General's Office and officials from the Virginia Department cf Mental Health, Mental Retardation and Substance Abuse Services ("DMHMR5AS"). Following our receipt of an outline of remedial measures Cor.r.o~wealth .officials intended to implement at KVIC, the parties resumed negotiations regarding an agreement to ensure the implementation of corrective measures.
Based on further assertions that corrective neasures had been taken, we agreed to retour NVTC twice in the fall of ISSi v/ith expert consultants. We found that conditions at the facility continued to violate the constitutional rights of NVTC residents and we continued to pursue a negotiated agreement to ensure correction of these violations. In fact, the United States and the Commonwealth appeared to be in substantial accord regarding the terms of an agreement to correct the violations at NVTC — indeed, many if not ir.ost of the substantive terns cf the agreement had been worked out. However, in December 1992, former Commonwealth Attorney General, Mary Sue Terry, declined to ente into any enforceable agreement.
In early 1993, the Commonwealth's Attorney General's office informed us that additional corrective actions had been taken and that the facility was now in full compliance with constitutional standards. Accordingly, it was agreed that Department attorneys and expert consultants would yet again tour NVTC to evaluate the conditions there and that the findings of the experts would ire turned over to the Commonwealth's Attorney General's office prior to the Department taking any additional action.
The findings of the five experts who toured NVTC, as embodied in their attached reports, make it clear that while some corrective actions have been taken at the facility, violations of the residents' constitutional rights continue and the residents continue to suffer serious harm. The deficiencies cited by the five experts (two psychologists, a physician, a registered physical therapist, and a pharmacist) are consistent with the

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whether individualized habilitation programs can meet the r.esds of residents.
B. Failure to provide and implement training proarar.s results in the excessive use of restraints without justification.
The expert: consultants also found that NVTC fails to provide adequate training programs, especially for individuals who exhibit naladaptive behaviors. NVTC's assessments of the underlying function of maladaptive behavior such as aggression and self-injury are inconsistent with professional standards, and the resulting individualized behavior plans are insufficier.- T:O neet the needs of the residents. For example, there is inadequate management of, and training programs for, individuals with serious pica behavior (eating inedibles). The absence of individualized behavior plans based upon appropriate functional analyses, subjects clients to the risk of an over-dependence and misuse of physical or chemical restraint and physical and psychological harm. The excessive use of restraints without adequate justification has been an issue that has been continually brought to the attention of NVTC, and while progress has been made in this area since our first tours, the psychelegy and medical experts discovered that this is still a serious problem at NVTC.
In addition, many residents who could greatly benefit frcr. systematic behavior management programs do not have them. Training in communication, social, self-help, and related skills is essential to promote and protect the health and well-being of these individuals and permit them to function as independer.-iy as possible. Such training at NVTC is grossly'inadequate. Fcr example, safe eating skills often must be taught to individuals who otherwise may be at risk of choking and asphyxiation. However, both psychology and physical therapy experts noted that eating skills simply were not addressed by the staff and the failure to do so has resulted in both an increased risk of injury and the failure of residents to learn these skills. This finding also applies to programs designed to teach residents the activities of daily living, e.g., dressing, toileting, and other self-care skills.
The psychology consultants also found that training and service planning are not directed towards facilitating resident transition into community-based programs which are or can be made available to meet their individual needs.
III. Professional and Direct Care Staff are Inadequate Both in Terms of Numbers and Qualifications.
The expert consultants were unanimous in their findings that, while irVTC has apparently made some recent progress in

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hiring and training both professional and non-professional staff, NVTC still does not employ a sufficient number of trained personnel tc r.eet the basic needs of its residents.. NVTC is critically in reed of more psychologists, and physical end occupational therapists. NVTC also employs insufficient nur.bers of nedical personnel to cover some shifts and weekends. The staff that is presently employed require considerably nore training before they will be able to provide adequate care. Tr.is lack of adequate numbers of trained staff may contribute in part to the lack cf adequate staff supervision and some employees' unfaiailiarity vith "ttte «sfesidents under their care.
IV. Nedical Care is Inadequate.
The medical consultant found substantial deficiencies in a number of key r.edical areas that are resulting in harm ana unnecessary risk of harm to the residents of NVTC. These deficiencies include, inter alia: delayed and inadequate response to r.edical emergencies; inadequate seizure charting and management, including emergency management of prolonged, life-threatening acute seizures; insufficient coverage and co-jnunication by physicians on nights and weekends; over-reliance on use of psychotropic medications without clear indications for their use; lack of quality assurance; and lack of adequately trained professional nedical staff. In a number of cases, these deficiencies or a combination of them, led to potentially avoidable injuries, illnesses and death.
V. Medical Charting and Medication Practices are Seriously Deficient.
The ph.an.acy and medical experts also found medical charting and medication practices to be generally inadequate and observed a lack of documented communication between care providers, physicians, nurses and pharmacists. Adequate record keeping and interdisciplinary communication are essential if residents are to be provided adequate medical care. Both experts found significant deficiencies in individual medical plans, quality assurance mechanisms and data collection. They also found inconsistent monitoring of and follow-up on medication side effects. The pharmacist noted that, although some new policies and procedures had recently been written, they were very new and had not been fully implemented as of the date of our review.
VI. Feedinc: Practices are Dangerous.
The medical, physical therapy and psychology experts all found feeding practices to be dangerously deficient. Residents were observed coughing, gagging and choking due to staff feeding the residents inappropriately, e.g. . feeding residents too r.uch too quickly, or feeding residents with their necks hyperextended. Staff are insufficiently trained to feed residents safely cr

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properly assis: residents to feed themselves or train the- ir. safe eating sV.ills. Such dangerous practices have devastatir.3 results for residents who are medically fragile, or have poor chewing, svalloving skills or compromised gag reflexes.
VII. Phvsicei and Nutritional Management is Deficient.
NVTC has a severe shortage of sufficiently trained physical therapists, occupational therapists and dieticians to adeqvi=.i=ly meet the basic needs of the residents, over 100 of whom have severe physical disabilities. This shortage of trained professionals has resulted in inadequate training and oversight of direct care staff, inadequate identification and compreher.s ive "treatnent of health and nutritional problems, and resident idleness, ir^cbility, physical and nental deterioration, ar.c ill health. A r.ur-ber of residents are substantially undenv'eic'r.;, nalnourished cr dehydrated. in many cases, the residents' physical deformities, and the pain and ill health caused by the deformities, are a result of years of neglect by NVTC. Physical therapy and therapeutic equipment are entirely inadequate tc r.eet the needs of the physically disabled NVTC residents.
VIII. P.ecorckeeoina Fails to Comport with Professional Standards.
Institutional care-providers such as NVTC must keep accurate, co-prehensive and accessible records in order tc r e m i t professional judgment to be exercised and to ensure the provision of adequate care to the residents. The expert consultants vsre unanimous in their finding that recordkeeping at NVTC is grossly deficient. In some areas essential data on resident behavior or health is not recorded, and where it is recorded, it is inaccurate or incomplete. Important behavioral or medical information contained in residents' records is not acknowledged in the residents' comprehensive plans or elsewhere in their treatment planning. Necessary quality assurance mechanisms do not appear to be working or in place.
IX. Conclusion
The long-standing problems cited above continue to pose a substantial threat to the health and safety of NVTC residents, deny them adequate care, and skills necessary to permit the- to function as normally and as independently as possible. Given the nature of NVTC's long-standing constitutional violations, the time that has already passed, and the additional time needed to remedy these violations,' we can no longer delay legal action if the Commonwealth continues to refuse to resolve this matter fcy £ mutually negotiated and agreed upon consent decree. Vihile we believe that it would be mutually beneficial to settle this

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natter and are still willing to do so, action nust be taken expeditiously ir. order to protect NVTC residents. We would appreciate fceir.r informed of your decision at an early date
Sine
- /
Deval L. Patrick Assistant Attorney General
Civil Rights Division
Enclosures
cc: King E. Davis, Ph.D.
Virginia Department of Mental Health, Kental P.etardation and Substance Abuse
'Mr. David H. Lavson Director Northern Virginia Training Center

 </s> U.S. Department of Justice Civil Rights Division

<>r?lV.' of the AS^^K: A:: • ,: U^.::

I U ^ , «.,•:.•«. D.C X<\>.'

The Honorable George Allen
=:::•:;:;,

February S, lv'05
U.S. v. Virginia
nc DHiiiiliiiii

Re: Northern Virginia Training Center
Dear Governor Allen:
My staff and I appreciated the opportunity to meet with your Deputy Attorney General, William Hurd, and his staff on January 31, 1995, to discuss our investigations pursuant to the Civil Rights of Institutionalized Persons Act of three institutions (Northern Virginia Training Center, Eastern State Hospital, and Northern Virginia Mental Health Institute) operated by the Commonwealth. We have agreed to meet again on or before February 10, 1995., in order to determine whether we can cone to some agreements in these matters.
Prior to that meeting, we thought it appropriate to further apprise you of our most recent findings and our determination that federal statutory violations exist at the Northern Virginia Training Center ("NVTC"). Our investigation of NVTC was initiated in May 1990 and has been pending absent any resolution for a protracted period of time.
Following a full evaluation of conditions at NVTC, we nost recently advised Commonwealth officials of our findings of continuing constitutional violations at the facility in a letter dated May 31, 1994, addressed to Attorney General Gilmore. In summary, our consultants found numerous dangerous conditions at the facility. More specifically, they found deficiencies in resident assessment, the design and implementation of training programs, excessive and unjustifiable use of physical restraints, inadequate numbers of direct care and professional staff, inadequate medical care, including medication practices, and improper feeding of physically disabled residents. A copy of our letter to Mr. Gilmore is attached for your further information.

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In addition, our review of this matter has led us to determine that the federal statutory rights of residents are being violated. More specifically, residents' rights pursuant to the Americans with Disabilities Act ("ADA"), 42 U.S.C. §§ 12101 et seq.. Section 504 of the Rehabilitation Act of 1973 ("Section 504"), 29 U.S.C. § 794 et seq.. and the provisions of Title XIX of the Social Security Act ("Medicaid"), 42 U.S.C. § 1396 et sea, are being violated by various acts, practices, and conditions at NVTC. Our review also indicates that the rights of the residents guaranteed by Virginia state law are also being violated. See, e.g.. Va. Code Ann. § 37.1 - 84.1 (Mitchie 1994).
NVTC fails to provide an environment which meets the needs of residents, promotes their growth, development, and social well-being and permits contact with mainstream social institutions. By design and function, residents are separated from society. Where residents can benefit from placement in community based programs and facilities, and especially where professionals have determined that such placement is appropriate, this unnecessary segregation of the developmentally disabled violates both the ADA and Section 504. Moreover, we note that many of the residents at NVTC have behavior problems or medical needs which have been used to justify their continued confinement at the facility. Justifying continued confinement on such grounds, particularly where services ostensibly designed to treat such problems are so inadequate, constitutes the very discrimination both the ADA and Section 504 are designed to prohibit. Justifying confinement at NVTC on the basis of the severity of handicap is likewise discriminatory absent a professional determination that such confinement is essential to the care of an individual resident.
Many of the areas identified during our investigation of NVTC as constituting constitutional violations also are substantive violations of the Social Security Act and regulations implementing the Medicaid program. Deficiencies in the areas of training and medical care are the clearest examples.
As we have specified in other correspondence, we believe that remedies are necessary to eliminate continuing constitutional violations as well as the federal statutory violations set forth here. More specifically, the Commonwealth should implement the following remedies:
1) Provide for each resident a professionally designed and implemented training program that will teach new skills, foster growth and development, and permit each resident to exercise independence. Such programs must be designed and implemented by sufficient numbers of appropriately qualified and trained staff,

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including both direct care and professional staff. Immediate attention should be given to those residents exhibiting the most dangerous behaviors and behaviors presently being managed by the use cf restrictive measures, including physical restraints.
2) Staffing at all levels should be enhanced to provide necessary care, treatment, and training, and to ensure the personal safety of all residents.
3) Assessment and evaluation of the individual needs of residents must be improved to reflect consistent compliance with generally accepted professional standards.
4) Medical care must be significantly improved.
5) Physical restraints should be phased out to be used only in case of genuine emergency; the elimination of the facility's chronic over-reliance on the use of physical restraints will require a complete reviev; of the facility's psychology department, adherence to generally accepted professional standards emphasizing positive reinforcement techniques, and the appointment of facility leadership committed to restructuring the facility's overall approach to training programs, especially programs designed to address behavior problems.
6) Medication and medical charting practices must be revised to conform with generally accepted medical standards.
7) Feeding practices should be revised to ensure the safety and well-being of physically disabled residents who are fed by staff. To achieve this goal, it will be necessary to fully evaluate present feeding techniques, evaluate each physically disabled resident to identify safe feeding procedures, train staff in such procedures, and carefully monitor their implementation as residents are actually being fed by staff. This evaluation process should include assessments both for proper nutritional management and other needed therapies, e.c.. physical therapy.
8) Commonwealth officials need to expand community based programs to meet the individualized needs of NVTC residents who should be served in community programs. All residents should be evaluated for community placement by an inter-disciplinary team, including appropriately trained professionals who have experience in operating community programs. No resident should be precluded from community placement based on their degree of disability or other handicapping condition.
9) Commonwealth officials need to develop an overall plan to eliminate all of the deficiencies identified in the course of this investigation and communicated to such officials, including

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necessary steps to achieve substantive compliance with federal and state lav.
In closing, I can only express my hope that we can work together to resolve this long outstanding matter to the benefit of the developmentally disabled and mentally retarded residents of the Northern Virginia Training Center.
Sincerely,
Deval L. Patrick Assistant Attorney General
Civil Rights Division
Enclosure
cc: Ms. Kay Coles James Secretary Department of Health and Human Resources
Dr. Timothy Kelly Commissioner Department of Mental Health and
Mental Retardation
Ms. Janet Hill Director Office of Mental Retardation
Mr. David H. Lawson Director Northern Virginia Training Center
Helen Fahey, Esquire United States Attorney Eastern District of Virginia

 </s> U.S. v. Virginia MR-VA-002-006
Commonwealth of Virginia
Department of Mental Health, Mental Retardation and Substance Abuse Services
NORTHERN VIRGINIA TRAINING CENTER PLAN
As revised through June 27, 1996

TABLE OF CONTENTS
Preface to the Plan I. Development and Implementation of Training Programs
Utilizing Positive Training Techniques II. Use of Physical Restraint and Time Out III. Staffing Requirements IV. Staff Training V. Physical Therapy and Occupational Therapy Management VI. Nutritional Management and Feeding VII. Medical Care VIII. Medication Management IX. Recordkeeping X. Quality Management Plan XI. Community Placement Attachments 1-35

Page ii
1 5 8 10 16 17 19 21 22 24 24

Department of Mental Health, Mental Retardation and Substance Abuse Services
NORTHERN VIRGINIA TRAINING CENTER
PLAN
March 13, 1995
As revised through June 27, 1996
This Plan has been prepared by the Northern Virginia Training Center (NVTC) in response to concerns raised by the United States Department of Justice (DOj) in connection with its investigation of NVTC under the Civil Rights of Institutionalized Persons Act (CRIPA), and following its original tour of NVTC. The Plan is incorporated by reference into the Settlement Agreement executed by the Commonwealth of Virginia and the United States of America, and is subject to the terms thereof.

I. DEVELOPMENT AND IMPLEMENTATION OF TRAINING PROGRAMS UTILIZING POSITIVE TRAINING TECHNIQUES
NVTC provides training programs developed by qualified professionals utilizing positive training techniques designed to afford skill development, personal safety and reasonable use of restraints and prevent regression of residents. In order to accomplish these programs, NVTC will:
A. By July 1, 1996, NVTC will professionally evaluate and/or re-evaluate each resident using multi-disciplinary evaluations, as needed. Each individual will receive a psychological review or comprehensive evaluation as part of the development of his or her annual habilitation plan. The annual review will consist of a review of previous evaluations to determine continued validity, review of the client's chart, observations of the client, report of behavioral treatment, behavioral data, comparison of the current service period with the previous one to determine relevant changes, and statements concerning a person's needs and recommendations for treatment. If a significant change is noted in the individual, the ID Team will request additional information and the psychologist will provide the necessary evaluations. Full psychological evaluations will be completed for clients every three (3) years, or more frequently if conditions warrant. A full psychological evaluation will include a concise description of the resident, an appropriate assessment of intellectual/cognitive functioning and adaptive behavior, assessment of mental health problems (if appropriate), review of previous evaluations and comparison of the current test results with previous results to determine trend, review of behavioral observations, review of behavioral procedures and data, the resident's strengths, needs and the psychologist's recommendations. These evaluations will focus on the assessment of functional skills and interests through ecological and person-centered assessment procedures. Each assessment will coincide with each client's annual Individual Habilitation Plan (IHP) schedule.
1. By August 1, 1995, all current and future admissions to the Special Behavior Unit will receive a functional assessment. (Attachment 1). A widely used functional assessment tool developed by Robert Horner and colleagues, called Functional Analysis of Problem Behavior, will be used as a primary assessment guide. Other assessment tools, such as the Aberrant Behavior Checklist, the Psychopathology Instrument for Mentally Retarded Adults, the Reiss Screen, the Autism Behavior Checklist, and ecological and analog assessment strategies will also be employed as needed.
2. By March 1,1996, all clients receiving psychotropic medication and/or restrictive behavior support plans will receive a functional assessment as part of their individualized behavioral support plan. A functional analysis will be conducted thereafter as needed, at least on an annual basis.

3. The Director of Center Programs is developing a training curriculum for the psychology staff with specific training in functional and ecological assessment and the use of this information in the development of positive behavior support plans. A major focus for all persons will be on teaching more appropriate skills to replace challenging behaviors. The first training class is planned for August 1, 1995 and training will be completed by March 1, 1996.
4. Every client for whom a behavioral need is identified or who has a behavioral program will receive a formal functional analysis as part of the development of a behavioral support plan by July 1, 1996. In developing and assessing behavior plans, priority will be given to those individuals whose behavior places them at greatest risk. NVTC will establish priority for program development for those residents who exhibit Pica, self-injurious behavior or other behavior that is dangerous to self, others, or property and for those residents for whom relatively high usage of timeout and/or restraint is shown by objective and reliable data. Such individuals will receive functional analyses which are focused on assessing the specific problems demonstrated by the individual. Behavioral plans will be based upon objective and reliable data and interventions documented in those plans will be based upon data collected. When appropriate, current literature will be considered in developing behavior plans.
B. NVTC will continue to develop and implement a professionally based training program for each client and provide each client with an adequate number of hours of training pursuant to applicable standards utilizing positive approaches to enable the client to develop behaviors which will afford safety, freedom from undue restraint and other restraints on the individual's movement within and about the facility and to prevent regression or deterioration of skills. By July 1, 1996, each training program will contain at a minimum:
1. Training objectives developed by an appropriately constituted interdisciplinary team and based upon assessments and evaluations required by paragraph 1 above for those clients who have been identified as needing mental health services, which comport with applicable standards;
2. Specific instructional methods to be utilized by those with responsibility for implementing the program; such methods will emphasize positive approaches and positive behavioral interventions which promote functional skill development and socially acceptable behaviors for the individual client;
3. A specific training schedule to be followed; the number of hours of training to be provided will be sufficient to permit the client for whom the

program has been developed to have a reasonable opportunity to reach the identified behavioral objective(s) of a training program; no schedule will provide for fewer than 40 hours of structured training or activities each week, unless medically contraindicated;
4. Procedures utilized for data collection will be sufficient to permit a qualified professional to evaluate the effectiveness of the training program or any part thereof and to monitor the implementation of the plan and ensure its modification, as necessary. Documentation forms for tracking adaptive and maladaptive behaviors have been standardized. A computerized data tracking system is being used to provide on-going functional assessment of behavior plans. Graphical representations of the data are and will continue to be presented to the Behavior Management Committee (BMC) and Local Human Rights Committee (LHRC) and are used for clinical presentations; and
5. Identification of the persons responsible for the consistent implementation of the program.
C. NVTC will consistently implement the training programs required in Paragraph B. above for all clients by July 1, 1996, and thereafter within fifteen (15) days of the development of the behavior plan by the ID team and full approval by the Behavior Management Committee (BMC), Local Human Rights Committee (LHRC) and parent/guardian. Notwithstanding this time frame, priority in the development and implementation of training programs will be given to any client exhibiting selfinjurious, aggressive or pica behaviors. Any such client will have a professionally developed and consistently implemented training program within sixty (60) days of identification of the problem.
D. In order to afford consistent implementation of training programs, NVTC provides and will continue to provide adequate competency-based training for all staff responsible for implementing the programs specified in Paragraph B above. Staff training will focus on how to implement the programs and collect appropriate data. NVTC will conduct regular periodic follow-up evaluations of staff competency in implementing programs and provide additional training, as necessary.
1. By June 1, 1995, center-wide Psychology Behavioral Treatment Books will be available to all psychology staff, advocate, duty officers and roving team leaders. Also by June 30, 1995, Unit-specific Behavioral Treatment Books will be accessible to all unit staff as a reference for behavioral support plans.
2. Greater emphasis upon the preventive and positive procedures of the "Mandt" Training System have been included in staff orientation and during staff training of individualized behavior support plans. The entire staff

orientation training package for behavior management was reviewed in January 1995 and plans and timelines for a revised training package based upon preventive and positive behavioral support program philosophies and procedures have been established. Implementation of the revised training package is set for August 1, 1995.
E. NVTC has implemented and will fully maintain systems by March 1, 1996 for: (1) observing clients' behavior to determine the effectiveness of the programs and recording those observations; (2) verifying the reliability of the recorded data; and (3) ensuring that a qualified professional reviews and appropriately modifies any client's training program when the professional determines that the resident has exhibited no measurable progress for a significant period of time.
1. Unit-based clinical meetings will continue to occur semi-monthly to monitor clinical issues and address changing client needs. In the Special Behavior Unit (SBU), these meetings will occur weekly.
2. Unit-based psychotropic medication/behavior plan reviews will continue to occur weekly on the SBU and on all other units at least monthly. This interdisciplinary data-based review is attended by the psychiatrist, physician, psychologist, psychological assistant, nurse, direct care staff, program manager or team leader, and Qualified Mental Retardation Professional (QMRP). Vocational staff, parents and other pertinent professional disciplines may also attend.
3. Psychology staff will perform weekly reliability checks of treatment plans using direct observation of client behavior and implementation of behavior support plans by direct care staff. Documentation of behavior support plans will also be checked for reliability on a weekly basis by comparing direct care staff and client observations with log entries, behavior tracking forms, and entries in the client record by March 1, 1996.
4. QMRP's will continue to provide program monitoring at least quarterly as part of the Individualized Habilitation Plan (IHP) review system.
5. Active treatment will continue to be formally monitored using a system designed by Dr. Brian Iwata. Designated and trained staff will record observations at least twice a week for every unit. (Attachment 2). In January 1995, a data system was established in which active treatment information from this form will be used to make management decisions. The Risk Manager will enter the raw data and monthly reports will be generated for review by management staff. Active treatment and other measures will be integrated into a program monitoring plan to be submitted to the Quality Management Committee by August 1, 1995. The results of these measures

will be compiled and distributed quarterly to all clinical and unit departments and to the Quality Management Committee.
F. NVTC will develop by January 1, 1996, a system to regularly train all direct care staff in collecting and maintaining the behavioral data necessary to assess the effectiveness of any behavior program. Staff will be fully trained by July 1, 1996. NVTC will keep written records to document such training.
G. An interdisciplinary team will evaluate the efficacy of the training programs for each client with self-injurious, aggressive or pica behavior on a monthly basis and the efficacy of the training programs for all other clients on at least a quarterly basis. The team will base its review of the efficacy of the training programs on the data collected as well as the occurrence of incidents (events) and the use of restraints. If the team recommends the need to revise the training program, it will be reviewed and revised, if appropriate, by a psychologist within thirty (30) days.
H. The Behavior Management Committee, including the Director of Medical Services and, as appropriate, a psychiatrist, will review behavior plans and supporting documentation relating to each resident who: (1) exhibits self-injurious or aggressive behavior, or (2) is subject to restrictive programming, frequent behavior control procedures, or receives behavior modifying medication, to ascertain whether: (i) there are sufficient behavioral data recorded, (ii) such data have been assessed for reliability, and (iii) the continuation of the current training or treatment program is justified, or the program, including medication, should be modified. Where inadequate or unreliable data are found, or the continuation of the training or treatment program is otherwise not justified, the matter will be referred to the appropriate interdisciplinary team which shall, within 30 days of the referral, modify the existing program in accordance with the judgment of qualified professionals, including the primary care physician, psychologist and psychiatrist, as appropriate. When in the judgment of qualified NVTC professionals, data indicates that individual programs as implemented have been ineffective and outside independent consultation is necessary to assist in devising an appropriate revision to the program, NVTC will obtain such consultation.
II. USE OF PHYSICAL RESTRAINT AND TIME OUT
NVTC has developed and will continue to implement policies and procedures to ensure that time-out and physical restraints are administered only pursuant to the judgment of a qualified professional and are not used as punishment, in lieu of training programs, or for the convenience of staff. These policies and procedures are contained in NVTC Instruction 5300 (Restrictive Procedures) and NVTC Instruction 5301 (Use of Protective Devices) and the Psychology Department's Behavior Therapy Procedures: Philosophy of

Use, Definition and Staff Responsibilities. (Attachments 3, 4, and 5). These policies and procedures will:
A. Protect clients from unreasonable risks to their personal safety from both the conduct of staff and other clients, and from unreasonable use of bodily restraints.
B. Provide for the use of bodily restraint and time-out only in conjunction with a written treatment and/or training program, except in emergency circumstances. An "emergency" is defined as "a situation in which a qualified professional deems a behavior to be likely to cause harm to the client or others or to property unless the proposed intervention is immediately initiated." For each emergency use of bodily restraint or time-out, the decision to use the bodily restraint or time-out must be made by a qualified professional after considering a hierarchy of less restrictive interventions. Each emergency use of bodily restraint or time-out will be described and recorded in the client's record including the identity of the professional making the decision and the justification for the decision. A client who has been placed in time-out or bodily restraints in emergency circumstances three times in the previous year will be assessed and a written treatment and/or training program developed, if necessary, within two weeks of the third incident, except in medical contingencies where the restraint is prescribed by a physician for short term use while the condition is being treated. A standardized Crisis Management Documentation Form has been used since January 1994 to track emergencies and will continue to be used.
C. Require that, in every behavior program that utilizes bodily restraint or timeout, specification of:
1. the behavior to be eliminated and the specific behavior, clearly and objectively defined, which triggers the use of the restraint or time-out;
2. behaviors to be taught to the client to replace the behavior that initiates the use of the restraint or time-out and other programs to reduce or eliminate the use of such restraint or time-out;
3. the restriction, i.e. type of restraint or time-out authorized and, where applicable, the duration of the restriction;
4. the professional responsible for the program and the direct care staff authorized to implement the program;
5. the frequency and manner in which behavioral data are to be recorded by direct care staff.
In order to accomplish the above, NVTC has revised the format of all behavior support plans (BSPs). A major emphasis is placed on functional analysis-based

treatment plans which rely upon individualized preventive and proactive behavioral procedures to address challenging behaviors. (See Attachment 6 for a sample of this new format.) A short summary of each BSP is also written to be used as a quick, easy reference for staff. All behavior plans and short summaries will be rewritten into this new format corresponding with the client's annual staffing. All BSPs will be written into the new format by January 31, 1996.
D. Require that beginning January 1,1996, any treatment and/or training program utilizing bodily restraint or time-out will be reviewed before implementation and at least every three (3) months thereafter by the Behavior Management Committee (BMC) as well as by the Local Human Rights Committee prior to implementation of the program; provided, however, that under emergency conditions, the Chairman of the BMC may approve a program not to exceed 30 days.
E. Prohibit the use of bodily restraint or time-out except in: (a) those situations where there is written evidence in the client's record that other, less restrictive techniques have been considered and/or systematically tried and consistently implemented as part of a professionally designed training program and accurate, objective data have demonstrated such techniques to be ineffective and (b) emergency situations in which there is a risk of harm to self or others. Each time a device is used in an emergency situation or as a protective device, the client record must document that the decision to so use the device was made by a qualified professional; it must identify the professional making the decision, and it must document the justification for such use. Any use of restraint will be the least restrictive form of restraint after consideration of a hierarchy of less restrictive interventions. The use of papoose boards as a form of behavioral restraint was eliminated as of January 18, 1992 and will not be re-implemented. There are and will be no standing medical orders for PRN psychotropic medications.
F. Require that appropriate psychology staff will review monthly each use of bodily restraints or time-out occurring in the previous 30 days to ascertain whether each use was pursuant to the exercise of professional judgment or the behavior program of the resident subject to the use. The results of these monthly reviews, including the conclusions of the psychology staff, will be reported to the BMC every three (3) months, which will review whether a particular client needs a behavior program or whether an existing program should be modified. The BMC may initiate more frequent reviews when indicated. Restrictive measures will be continued in clients' programs only if reliable data supports the necessity of their continued use. The BMC will record these recommendations and transmit them to appropriate staff, as well as NVTC management, who will be responsible for ensuring that any new programs or revised programs are developed and implemented within 30 days.

III. STAFFING REQUIREMENTS
NVTC will hire, deploy, and provide ongoing training to a sufficient number of competent and qualified direct care and professional staff to provide its clients with adequate care, treatment, and training programs.
A. A sufficient number of qualified staff, including physicians, psychologists, registered nurses, licensed practical nurses, registered physical therapists, licensed physical therapy assistants, occupational therapists, speech therapists, dietitians and direct care workers will be available. NVTC will demonstrate continuing efforts to achieve any additions to staff that are necessary for this purpose by January 1, 1996 and will achieve such staffing by July 1, 1996.
B. NVTC will maintain adequate direct care staffing levels while implementing its census reduction plan referenced in Section XI.A. below. NVTC currently meets an on duty direct care ratio of 1:4 on the a.m. shift, 1:5 on the p.m. shift and 1:9 at night. When the client census reaches 200 on July 1, 1996, NVTC will have and maintain a campus-wide staffing ratio of 1:4, 1:4, 1:8 and will continue to deploy staff based on the exercise of professional judgment to provide for the training and safety needs of all clients. NVTC will continue to provide 1:1 staffing for individuals whom qualified professionals at the facility have determined are in need of 1:1 staffing.
C. Direct care staff will not be routinely used to perform such support functions as housekeeping, laundry, other than client personal clothing, maintenance and meal preparation, etc. This requirement does not preclude direct care workers from training residents in these functions pursuant to a written training program developed in accordance with established procedures.
D. NVTC will employ sufficient senior clinical staff to afford adequate clinical supervision, case consultation, education and training of staff and to afford the provision of adequate services to clients.
E. NVTC will continue to employ as Director of Center Programs a behaviorally trained professional to supervise those who design and implement appropriate treatment, training and programming for clients and sufficient psychologists to develop and implement all training programs and data collection and evaluation.
1. NVTC currently employs 5 psychologists and 6 qualified psychology technicians. NVTC will establish and advertise for one additional psychology position and fill that position by July 1, 1996.
2. By July 1, 1996, the overall ratio of psychology staff to clients will be 1:34. The psychologist assigned to the Special Behavior Unit will have a ratio
8

of 1:20 clients plus a small number of clients from Unit 1 with relatively few behavioral needs.
F. NVTC will employ sufficient nursing staff to provide adequate nursing services to appropriately monitor the clients' health and medical needs. NVTC currently has 23 Registered Nurse positions and 4 Licensed Practical Nurse positions representing a staffing of 14 nurses on A.M. shift, 8.5 on P.M. shift, and 4.5 on NOC shift. The on duty nurse to client ratio will continue to be at least 1:25 A.M. shift, 1:30 P.M. shift and 1:55 NOC shift.1
G. NVTC currently employs three physicians who serve as the primary care physicians for the clients. NVTC will maintain this level of staffing. A physician is on-site or on-call and available seven days a week, 24 hours a day. NVTC's current night call schedule is published monthly and includes home and beeper numbers. Two of NVTC's physicians cover one night per week and one weekend per month each including Friday, Saturday and Sunday nights. The Medical Director covers one night per week. A family practitioner covers one night per week. Another family practitioner covers two weekends per month. EMT and ER services are also available and located within five minutes from the Center. NVTC will maintain a night and on-call system, or a similar system, to meet the requirements of this plan.
H. NVTC will afford sufficient consultation with appropriate medical specialists including psychiatrists, neurologists, orthopedists and a physiatrist and otherwise provide services to clients as may be needed to provide adequate care and treatment. (See Attachment 7.)
1. NVTC will continue to contract for the on-site services of a psychiatrist 2 full days per week (at least 6 1/2 hours per day) plus a psychiatric fellow approximately one day per week.
2. In addition to off-site services, NVTC will continue to contract for the on-site services of a physiatrist at least quarterly, an orthopedist quarterly, and a neurologist 2 full days per month. (Full days may be reduced to partial days if and when patient needs allow.) NVTC will also continue periodic consultation with a geneticist for diagnostic purposes.
I. By July 1, 1995, NVTC will hire three (3) full time additional physical therapy positions with the goal of filling these positions by July 1, 1996. These positions include one licensed physical therapist and two physical therapist assistants, bringing the total physical therapy positions at NVTC to 3 registered physical therapists and
:Nothing contained herein shall be construed to prevent NVTC in the exercise of its own discretion, from deploying a greater proportion of nursing staff than is required by this Plan.

3 licensed physical therapy assistants. This will bring the ratio of physical therapists as of July 1, 1996 to 1:34.
J. By July 1, 1995, NVTC will establish and advertise for one additional registered occupational therapist position and 3 certified occupational therapist assistant positions. NVTC's goal is to fill these positions by July 1, 1996. This will bring the total number of funded OT positions to 7. The ratio of occupational therapists to clients as of July 1, 1996 will be 1:29.
K. By July 1,1995, NVTC will establish 1.5 additional dietitian positions bringing the total number of dietitian positions to 2.5. NVTC's goal is to fill these positions by July 1, 1996.
IV. STAFF TRAINING
All staff who provide services to NVTC clients are adequately trained to fully implement the requirements of this Plan and are thereafter provided with in-service training on a regular basis. The training will be competency-based and will include, but not be limited to: behavior management techniques; implementation of individualized treatment and training programs; emergency medical response, including recordkeeping for such procedures.
A. Pre-Service Training
1. All new employees of NVTC will continue to be required to attend a basic orientation program within the first 30 days of employment and successfully complete all components before the end of their probationary period. This orientation provides basic information in the following mandated subject areas: Personnel Policies, Orientation to NVTC, Abuse Policy, Human Rights Regulations, Safety and Security Procedures, Infection Control/AIDS, Normalization, Introduction to Mental Retardation, Seizures, First Aid, Body Mechanics and Lifting, and Sexual Harassment.
2. NVTC will continue to require NVTC direct care staff to successfully complete additional training as part of their orientation training, and a competency-based training program at their worksite. (Attachment 8). Coursework will concentrate on additional health/nursing information and emergency procedures, behavior management techniques, appropriate interactions and teaching techniques, specific clinical information and strategies necessary to be able to implement individual programs, and documentation and data collection. The orientation program will also include Active Treatment, Behavioral Documentation, Use of Mechanical Restraints, Adult CPR, Side Effects of Medications, and the Mandt System for Managing
10

People. (Attachment 9). Most of the orientation sessions in the clinical areas will continue to be competency-based (tests, return demonstrations, etc.). In addition, there is a final written exam. Staff who are unable to demonstrate competency are terminated from employment. In keeping with NVTC's goal to share resources with the community, the orientation program will continue to be offered to all of the local community agencies who frequently attend sessions and comment on the quality of the training their staff receive at NVTC.
3. Training in the Mandt System will continue to be a component of the staff development program and will focus on all interactions between people. The major emphasis of the program is on non-physical interventions. It stresses the need to interact appropriately at all times in an effort to prevent individuals from becoming upset. All direct care staff receive the two-day Intermediate Level of training in pre-service. An annual one-day recertification is also required.
4. All staff development programs will continue to emphasize several major themes which support the Mission Statement of the agency: appropriate staff to client interactions (treatment with dignity and respect), and the need to encourage and teach client independence. The importance of providing an environment which is supportive, protective, encouraging, reinforcing, and proactive is included throughout the entire orientation program.
5. NVTC has developed and will continue to use a competency-based training program for new employees which is utilized at the work site once the employee has successfully completed the orientation portion of the preservice program. The Direct Care Competency Training Program (DCCTP) provides opportunities for new staff to demonstrate to their supervisors competence in all aspects of their job responsibilities. (Attachment 10). The DCCTP includes sections on Philosophy, Personal Care/Health/Hygiene, Active Treatment, Documentation, and Policy. Sections on Understanding Basic Behavior Intervention Programs and Program Implementation have been added to the Active Treatment portion of the original program. New employees continue to have six months (the remainder of their probationary period) to complete the program. Accompanying the DCCTP is a competency book of 50 task analyzed job duties in providing health related care, staff/client interactions, provide/maintain a safe living area, and how to implement program plans.
6. Compliance with the completion requirements for the Pre-service program and DCCTP will continue to be monitored by the Training Department. Notices are sent to supervisors monthly advising them of staff
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2. In addition to Adult CPR, NVTC will continue to conduct emergency medical response drills. (Attachment 13). The purpose of these drills is to allow all staff involved the opportunity to practice responding to mock medical emergencies to better prepare them for a real situation. Nursing staff coordinate, monitor, and evaluate these drills and send documentation to the Training Department.
3. Compliance with mandated training requirements will be monitored by the Training Department. Quarterly summaries of compliance rates with mandated training requirements are sent to the supervisors.
4. NVTC's curriculum on Client Record System and Documentation has been developed and will continue to be included in the Annual Retraining Program. Target date for implementation was June 30, 1995.
5. Recognizing that the skills and knowledge necessary for direct care staff assigned to different work sites will vary depending upon the specific needs of the clients, program managers are in the process of working with the Training Department to determine additional training requirements for direct care staff assigned to each unit. Building 7 began this pilot in late 1994 and began implementing its plan in January 1995. (See Attachment 14 for Building 7 Plan). All residential buildings will have completed plans by September 30, 1995.
C. Physical Management Training
Training the Physical Management curriculum "Challenges in Physical Management", as described in Pre-service Training, Paragraph A.9 above, will begin for direct care and clinical staff by January 31,1996. Staff assigned to Units 1, 3A, 3C, 3D, and 5A will participate in more intense in-services and client specific training at their work sites. These in-services will be provided quarterly at a minimum. Whenever an individual client program is developed or modified, all staff will be trained on these changes.
D. Individual Behavioral Programming Training
1. During pre-service, staff receive training on Behavior Modification, Teaching Techniques (Task Analysis, Prompting, Reinforcement, Error Correction), Crisis Management, Behavioral Documentation, and Use of Mechanical Restraints. This training is meant to be general in nature and provide staff with the "tools" to be able to implement individualized program plans. However, staff are not permitted to implement program plans until they have received additional training on the individual plans.
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2. Once an employee completes the pre-service program, he or she begins working on the assigned work site. If clients on the unit have behavior programs, the new staff member is not allowed to implement them until he or she has been properly trained by the psychologist or psychology assistant. The psychology staff will monitor the training of each new staff member in all aspects of the program (including the specific target behavior, the objective, how to prevent the behavior from occurring, what to do when the targeted behavior is displayed, the adaptive and reinforcement components of the program, and data collection requirements). NVTC policy also requires that staff be re-trained on all behavior programs whenever there are changes to the program or every six months, whichever comes first. This training is documented and forwarded to the Training Department for inclusion in each employee's training record.
3. As new behavior support plans are written and summarized on new forms (Client Behavior Profiles), as described in Section II.C above, these will become a quick study guide and training tool for staff. Completion date is January 31, 1996.
4. To further develop the knowledge of staff regarding behavioral principles, all direct care staff will be required to complete the "Basic Behavioral Principles and their Applications to People with Developmental Disabilities" software package previously mentioned in the section on Preservice Training. The completion date for this training for Units 5C, 6, 7C, 8A, and 8C is October 31, 1995, and for Units 1, 3A, 3C, 3D, 5A, and 7A is June 30, 1996.
E. Feeding/Mealtime Training
1. The Training Department has begun providing and will continue to provide in-services on Active Treatment focusing on the mealtime activity. This training stresses the importance of implementing individual goals and objectives from the I HP into the meal experience. Staff are quizzed on their knowledge of individual client programs, followed by discussion and demonstration of how these client needs can be integrated and implemented before, during, and after each mealtime. NVTC has completed training on Units 1, 3D, 5A, 5C, 6, and 7A. Units 3C and 7C are scheduled to be completed by February 1, 1996. 3A will be completed by March 1, 1996, 8A by April 1, 1996 and 8C by May 1, 1996. All active treatment training will be complete by May 1, 1996.
2. A concentrated interdisciplinary effort around several mealtime issues was begun in the Fall of 1994. The goal is to create a mealtime environment and experience which is more normalizing and more enriching, as well as
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therapeutic in nature. This is accomplished by evaluating the physical environment of the dining areas, the time and resources allocated to mealtimes, and the knowledge of staff in mealtime programs and issues of active treatment. Clinical staff have established days and times to be in the dining areas to assist, model, and provide feedback to staff on mealtime techniques and program implementation. This will continue on an on-going basis. Monitoring is to be done by building supervisory staff. Specific outcome measures will be established by the clinical departments, in conjunction with the I.D. Team, for each specific unit by October 31, 1995.
3. As client programs are developed and modified, direct care staff will continue to be trained in these individual program plans by the appropriate clinical staff. Such reviews are documented and become part of the employee's training record. Clinical staff regularly and periodically review general information as well as client-specific information with the staff. This is documented and forwarded to the Training Department for inclusion in the employee's training record.
4. NVTC has purchased a tutorial software package on Active Treatment which will be included in the pre-service program. All direct care staff will complete the tutorial by July 1, 1996.
F. Continuing Education for Professional Staff
1. NVTC has established minimum continuing education requirements for its clinical staff. (Attachment 15). These were established for professional positions for which there are no state mandated or licensing continuing education requirements. These were established by the appropriate department heads and were based on standards from other states. Clinical staff who attend a training event which meets a continuing education requirement send documentation of this to the Training Department and it is entered into their training record. Summaries of training are provided to the supervisors and employees upon request. This continuing education process will be ongoing.
2. Records will be kept on compliance with required continuing education and reported back to supervisors and the Quality Management Committee on a quarterly basis. Reports will begin with training completed by December 31, 1995.
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V. PHYSICAL THERAPY AND OCCUPATIONAL THERAPY MANAGEMENT
NVTCwill provide clients with adequate physical management, including appropriate physical therapy and occupational therapy programs. In addition to staffing outlined in Section III, J and K, NVTC shall take the following steps to accomplish this:
A. Physical Therapy
1. By March 30, 1995, NVTC will design and provide new wheelchairs and seating systems to 32 residents. (Attachments 16 and 18).
2. By March 30, 1995, NVTC will design and fit 19 new seating systems into current wheelchairs.
3. By December 31, 1996, NVTC will upgrade and/or replace the remaining third of individual wheelchairs. Provision of wheelchairs and wheelchair modifications will be based upon a professional assessment of those most in need; all adaptive equipment will be individualized and there will be a continual adaptation of wheelchairs and other equipment as individual needs change. (Attachments 16 and 18).
4. By March 30, 1995, NVTC will develop and staff an on-site workshop dedicated to wheelchair and positioning equipment.
5. By March 30, 1995, NVTC will complete modifications to the water heating system for the Hubbard Tank to permit staff to conduct hydrotherapy during cold weather months.
6. By June 30, 1996, NVTC will reevaluate all clients with fixed contractures and reassess their potential for improvement with consultation from orthopedic and physiatric consultants.
7. By June 30, 1995, NVTC will establish 24-hour positioning schedules for ail clients in need of positioning on Unit 1 and Building 3:
a. By March 30, 1995, NVTC will begin taking photographs of clients in various positions, with accompanying written descriptions of the benefits of placement in each position. These photographs will be assembled in unit-based books for daily use.
b. By April 30, 1995, NVTC will implement completed positioning programs in Unit 1.
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c. By June 30, 1995, NVTC will implement completed positioning programs in Building 3.
8. By July 1, 1996, NVTC will establish and implement a staff training course for physical management of clients who demonstrate challenging mealtime and positioning needs.
9. By July 1, 1995, NVTC will select a physical management training program following review of several physical management training packages by the Training Department, Director of Occupational Therapy, Director of Physical Therapy and Director of Center Programs.
10. By July 1,1996, physical management training will become part of preservice orientation for all new staff and yearly re-training will also be required.
B. Occupational Therapy
1. A new Director of Occupational Therapy Services was hired on July 18, 1994. The Director will not serve as program manager ior any other Building or Unit at NVTC.
2. By December 31, 1995, NVTC will be established as an internship site for students in occupational therapy professional training programs.
3. By July 1, 1996, NVTC will complete a pilot project involving sensorymotor integration training/treatment for four clients. Data will be collected and assessed. If data shows positive benefits for clients, the training/treatment program will be implemented with other clients whose need for such training/treatment has been identified by professional staff.
VI. NUTRITIONAL MANAGEMENT AND FEEDING
NVTC will provide clients with adequate nourishment, identification of nutritional deficiencies and appropriate feeding programs and adaptive equipment for use at mealtimes. NVTC will take the following steps to accomplish this:
A. By April 1, 1995, NVTC developed and began pilot implementation of a Nutritional Risk Assessment Form.
1. Pilot testing, modification and refinement of the Nutritional Risk Assessment Form will be completed by December 31, 1995.
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2. A Nutritional Risk Screening Assessment form has been completed for each resident determined by staff to have specialized nutritional and/or feeding needs, and such a form will be completed for each resident identified in the future with a specialized need. Training appropriate to the resident's needs, based upon nutritional risk assessment, will be conducted for all staff members having nutritional responsibility and/or feeding responsibilities with respect to the resident. It is understood that staff working with residents with the highest risk will be the first to receive the training.
B. By July 1, 1995, NVTC will establish one and one-half additional dietitian positions. By July 1, 1996, NVTC shall have on staff two and one-half Registered Dietitians.
C. By September 1, 1995, NVTC will have provided consultation to direct care and professional staff on Units 1 and Building 3 by a multi-disciplinary nutritional management team, including an occupational therapist, physical therapist, speech pathologist and dietitian. (Attachments 17 and 18).
D. By December 31,1995, NVTC will receive equipment designated as needed to implement modifications identified by nutritional assessments. Items will include one weighing scale, specialized calipers to assess nutritional status and measuring boards.
E. By December 31, 1995, NVTC will purchase the adaptive equipment for use during meals which has been identified as needed by physical therapy and occupational therapy staff. (Attachments 16 and 18).
F. By July 1, 1995, NVTC will receive 30 dining room chairs and accompanying tables for mealtime use on Building 3.
G. By March 30, 1995, NVTC will install a dishwasher in the Building 3 dining room, so all adaptive equipment can be cleaned on-site.
H. By March 30, 1995, NVTC will install an answering machine in Dietary the Services office to permit units to report, at ail hours, adaptive feeding equipment needs.
I. By July 1, 1996, NVTC will provide for diagrams and photographs of residents to be placed in the dining room next to each resident.
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VII. MEDICAL CARE
Residents will be provided with adequate medical care. In order to accomplish this, NVTC will:
A. Quality Assurance
Implement a peer review mechanism for all disciplines involved in providing health services. The Quality Assurance Program for Health Services (Attachment 19) provides for systematic credentialing procedures, staff education, reviews of adverse events or outcomes by a Clinical Practice Review Committee, as well as for peer review for medical and nursing practitioners.
a. Medical peer review was initiated on November 4, 1994 and the process of this review will continue, with systemic refinements, as needed.
b. NVTC's medical director will serve on a committee which includes the Director of Resident Records in order to develop a system for monitoring and improving physician documentation in charts. This review and planning period will be completed by September 1, 1995.
B. Medical Specialty Consultation
NVTC maintains a regular schedule of consultation with medical specialists. (See Attachment 7.) These include neurology, ENT, orthopedics, ophthalmology, psychiatry, physiatry, gastro-intestinal, podiatry, urology, cardiology, gynecology, dermatology and genetics. Recruitment for additional specialty medical consultants will continue, as needs are identified. Notes from these consultations will continue to be included in residents' records and a procedure for monitoring will be established by September 30, 1995. See also Section IX. Recordkeeping Section.
C. Medical Management of Residents with Epilepsy
1. An interdisciplinary epilepsy committee developed and implemented a new charting system for the epilepsy clinic. (See Attachment 20.) Information from this charting will be incorporated into the new resident record system by March 30, 1995. A procedure for monitoring compliance with the requirement of inclusion of charting information into resident records will be established by September 30, 1995.
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2. By December 31, 1995, semi-annual audits of antiepileptic drug prescribing practices will be conducted by the Pharmacy and Therapeutics Committee, which performs the functions of a drug utilization review committee. Information from these audits will be considered by the interdisciplinary epilepsy committee and will submitted to the Quality Management Director. Appropriate monitoring and follow-up will occur, as necessary.
a. NVTC will emphasize use of monotherapy and deemphasize use of barbiturates and phenytoin.
b. The Pharmacy and Therapeutics Committee will continue to monitor the consistency of charting and medication adjustment/change in individuals with epilepsy and seizures.
c. One index of improved quality of life for clients receiving epileptic drugs has been identified as reduced use of helmets for clients with epilepsy. Monitoring of frequency of helmet use has shown a reduction of 38% in the use of helmets from 45 in 1989 to 28 in February, 1995. NVTC will rely upon controlled medication trials and ongoing monitoring of improvement to determine further appropriate reduction of helmet use. (Attachment 4).
3. Individual treatment protocols for status epilepticus will be implemented by September 30, 1995.
4. A videotape and brochures for staff and family education will be completed by the interdisciplinary epilepsy committee by October 30, 1995.
5. Beginning June 30, 1995, the interdisciplinary epilepsy committee will review epilepsy-related injuries, infirmary and hospital admissions on a quarterly basis and report its analysis of this data to the Quality Management Director.
6. Guidelines were developed in September, 1994 for nursing care of clients with seizures and for first aid by residential staff. Guidelines for residential staff were posted in October, 1994. (Attachment 21).
Compliance with these guidelines will be assessed through routine audits of individual charts by a procedure to be established by September 30, 1995.
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D. Emergency Responsiveness
1. Monthly emergency responsiveness drills, involving nursing, security and residential staff, were begun in May, 1994. (Attachment 22). The nurse manager will monitor the monthly drill reports and forward the analysis of these results and recommendations to the Quality Management Director, beginning on September 30, 1995.
2. Documentation of response times of EMS personnel to 911 calls from NVTC and of NVTC nurses to on-campus emergencies was begun in May 1994. (Attachment 23). The nurse manager will monitor the response times of EMS and nursing staff members and will report the results of this monitoring to the Quality Management Director, beginning on June 30,1995.
3. Emergency notification procedures were posted on residential units in October, 1994. (Attachments 24 and 25). Compliance with these procedures will be monitored by the nurse manager through chart audits, and compliance rates gathered from this monitoring will be submitted to the Quality Management Director, beginning on September 30, 1995.
VIII. MEDICATION MANAGEMENT
Beginning December 1, 1995, a semi-annual audit of psychotropic medication prescribing practices will be conducted by the Pharmacy and Therapeutics Committee, which performs the function of a drug utilization review committee, with the results of these audits transmitted to the Quality Management Director. Appropriate monitoring and follow-up will occur, as necessary.
1. Since mid-1989, NVTC's use of antipsychotic (neuroleptic) drugs has been reduced by 33%. As of December 31, 1994, 26 clients were receiving this class of drugs, in comparison with 39 residents five years previously. (Attachment 26).
2. The Dyskinesia Identification System: Condensed User Scale (DISCUS) was adopted for monitoring tardive dyskinesia and other side-effects of clients on psychotropic medications in August, 1993. (Attachment 27). Information from this instrument will be reviewed quarterly by the Pharmacy and Therapeutics Committee beginning in June, 1995. Information from this review will be submitted to the Quality Management Director.
3. The consulting psychiatrist and Medical Director will continue to serve as members of the Behavioral Management Committee.
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4. NVTC will follow its policies and procedures regarding the use of psychotropic medication, e.g. NVTC Instruction 5302 on Psychotropic Medication (Attachment 28), Medical Plan for Psychotropic Drug Use, consent forms (Attachment 29) and Health Services Policy and Procedures (Attachment 30).
IX. RECORDKEEPING
NVTC will develop and implement a system of records for each client, developed and maintained under the supervision of a qualified professional whose primary responsibility will be to properly maintain client records. Each record will be readily available to all staff and will contain current information with respect to the client's care, medical treatment, and training, and will be organized so as to enable those using it to render professional judgments in providing care, medical treatment, and training to the client. NVTC will require staff to utilize such records in making care, medical treatment, and training decisions.
NVTC has approved for implementation a new Client Records System, the "Source Oriented Medical Record with Integrated Progress Notes". Revision of the record system has been divided into five phases: I. Recruitment; II. Research and Development; III. Training; IV. Implementation, and V. Quality Management. Timetables for each section are outlined in Attachment 31. Phases I and II have been completed. NVTC's plan provides for:
A. Recruitment of a qualified Health Information Manager. A new Director of Resident Records, was hired on August 22, 1994. This position will oversee implementation of the new client records system in 1995.
B. Development of a new Client Records System: Following three months of reviewing the current records management system, site visits to other facilities, solicitation of input from facility staff and researching recordkeeping techniques, a new client record system was proposed. In November and December 1994, the proposal was presented to Resident Record Committee members, clinical and residential staff and Senior Staff. On December 20, 1994, the Source Oriented Medical Record with Integrated Progress notes was approved for use beginning June 30, 1995. Attachment 32 summarizes the system which has been accepted.
C. The most significant change represented by the new client record system is the integrated progress note, "Interdisciplinary Note", section. In this centralized section, professional disciplines will be charting information pertaining to the client. (Attachment 33). Specific documentation instruction to staff include guidelines for all those making entries into the centralized progress notes and contain "prompts" for
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entry of indicators such as "OT Monthly Notes" as a title (qualifier) for easy identification and review.
D. Training: Beginning in March, 1995, Medical Records staff, in conjunction with the Training Department, will begin training in the new records system. Small departmental groups have been targeted for individualized training. Training will require each staff member to convert an existing client record to the format created by the new records system. Instructional guides will be provided for each staff member. Training for all residential and clinical staff will be completed by June 30, 1995. Follow-up sessions will be scheduled, as needed.
E. Implementation: Since records will be revised during training sessions, facility-wide implementation of the new records system will be completed by June 30, 1995.
F. Quality Management: By June 30,1995, the current Resident Records Quality Management Plan will be amended to include quality mechanisms for monitoring implementation of the new system. Amendments will include provisions for:
1. Establishing a random sampling of records from each unit for compliance review by the Medical Record department staff and members of the Resident Record Committee.
2. Completion of initial reviews for all units will be completed by September 30, 1995 and a schedule for ongoing reviews of compliance with requirements of the new system.
3. Establishing criteria for monitoring which include, at a minimum:
a. correct chart identification on each CRS;
b. correct record filing order;
c. correct chronological date order for documents;
d. entries made to the integrated progress notes which are prefaced with qualifiers stating the discipline documenting the note; and
e. correct use of double-sided progress notes.
4. Reporting results of each random sampling on a quarterly basis to the Quality Management Committee and the facility Resident Records Committee.
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X. QUALITY MANAGEMENT PLAN
NVTC will develop and annually update a Quality Management Plan that will monitor, document and evaluate implementation of the activities identified in this Plan. Attachment 34 is NVTC's Quality Management Plan for FY 94-95.
XI. COMMUNITY PLACEMENT
A. NVTC will reduce the number of current clients at NVTC in accordance with the NVTC Community Integration Initiative developed in 1991 with the primary objective of reducing current (i.e. 1991) resident census from 270 to 200 persons. This will be accomplished by securing appropriate community-based placements for those clients it determines in accordance with professional judgment to be eligible and appropriate for such placement, subject to the procedures described in 1 C below. Full implementation of the Community Initiative will occur by July 1, 1996. Attached is a description of the Community Initiative outlining timelines employed, schedule for continued downsizing, and the process that has been used and will be used to meet its objectives. (Attachment 35).
B. NVTC will annually assess the needs of all remaining residents at NVTC as follows:
1. The treatment team will annually assess in accordance with the exercise of professional judgment the needs of all residents at NVTC at the time of the development of the annual IHP to render an evaluation with respect to the appropriateness of continued placement at NVTC. Such assessments will occur more frequently if a change in the needs of the resident so indicates.
2. Subject to the provisions of 9, 4, if all appropriate professionals employed by or under contract with the Commonwealth to assess a resident, including but not necessarily limited to the assigned interdisciplinary team, determine that NVTC is not an appropriate setting for a resident and that a resident would be more appropriately served in a community setting, appropriate professionals will, within a reasonable time thereafter, develop such plan as may be appropriate and feasible to provide necessary services to the resident in a community setting, and will place the resident in accordance with the plan within a reasonable time after such plan has been developed and can be feasibly implemented. Sound, prudent fiscal considerations, and generally accepted business practices may be used by NVTC in determining whether a plan to place a resident in the community is feasible and, if so, when such plan can be feasibly implemented. In no event will NVTC have an obligation under the Plan to discharge or transfer a resident before a
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community setting that would more appropriately serve the resident has been identified and there is such a setting available.
3. In all decisions with respect to individual residents, the views and opinions of the individual resident, parent(s), guardian(s), other appropriate surrogate decision-maker(s) and professionals will be appropriately considered by NVTC. When it is determined that NVTC is not an appropriate setting for a resident, NVTC will ensure that the views and opinions of the individual resident, parent(s), guardian(s), appropriate surrogate decision-maker(s) and professionals will be considered when developing and implementing an appropriate and feasible discharge plan.
4. Where the consent of parent(s), guardian(s), or other surrogate decisionmaker(s) is withheld regarding discharge or placement, in disagreement with the judgment of professionals employed by or under contract with the Commonwealth, NVTC will make its discharge and transfer decisions after consultation with the individual resident, parent(s), guardian(s) or other appropriate surrogate decision-maker(s) and, after such consultation, will engage in a good faith effort to reach a consensus as to what decision about discharge and/or placement is in the best interests of the individual NVTC resident in exercise of its discretion on a case-by-case basis. The parent(s), guardian(s) or other surrogate decision-maker(s) may present the opinion of a qualified professional(s) for consideration by NVTC with respect to discharge and/or placement decisions. If the NVTC decision is ultimately to retain the resident, NVTC will continue to involve the parent(s), guardian(s) or other surrogate decision-maker(s) in the treatment and discharge planning process and continue to make them aware of available opportunities in the community for the care of the resident through parental educational opportunities conducted by community providers.
e:\kbc\cripa\nvtc.cln
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NORTHERN VIRGINIA TRAINING CENTER CASE NO. 96-283-A

EXHIBIT
A
Commonwealth of Virginia
Department of Mental Health, Mental Retardation and Substance Abuse Services
NORTHERN VIRGINIA TRAINING CENTER PLAN
As revised through June 27, 1996

TABLE OF CONTENTS

Preface to the Plan

I. Development and Implementation of Training Programs

Utilizing Positive Training Techniques

II. Use of Physical Restraint and Time Out

III. Staffing Requirements

IV. Staff Training

V. Physical Therapy and Occupational Therapy Management

VI. Nutritional Management and Feeding

VII. Medical Care

'.

VIII. Medication Management

IX. Recordkeeping

X. Quality Management Plan

XI. Community Placement Attachments 1-35

Page ii
1 5 8 10 16 17 19 21 22 24 24

Department of Mental Health, Mental Retardation and Substance Abuse Services
NORTHERN VIRGINIA TRAINING CENTER PLAN
March 13, 1995
As revised through June 27, 1996
This Plan has been prepared by the Northern Virginia Training Center (NVTC) in response to concerns raised by the United States Department of Justice (DOJ) in connection with its investigation of NVTC under the Civil Rights of Institutionalized Persons Act (CRIPA), and following its original tour of NVTC. The Plan is incorporated by reference into the Settlement Agreement executed by the Commonwealth of Virginia and the United States of America, and is subject to the terms thereof.

I. DEVELOPMENT AND IMPLEMENTATION OF TRAINING PROGRAMS UTILIZING POSITIVE TRAINING TECHNIQUES
NVTC provides training programs developed by qualified professionals utilizing positive training techniques designed to afford skill development, personal safety and reasonable use of restraints and prevent regression of residents. In order to accomplish these programs, NVTC will:
A. By July 1, 1996, NVTC will professionally evaluate and/or re-evaluate each resident using multi-disciplinary evaluations, as needed. Each individual will receive a psychological review or comprehensive evaluation as part of the development of his or her annual habilitation plan. The annual review will consist of a review of previous evaluations to determine continued validity, review of the client's chart, observations of the cl ient, report of behavioral treatment, behavioral data, comparison of the current service period with the previous one to determine relevant changes, and statements concerning a person's needs and recommendations for treatment. If a significant change is noted in the individual, the ID Team will request additional information and the psychologist will provide the necessary evaluations. Full psychological evaluations will be completed for clients every three (3) years, or more frequently if conditions warrant. A full psychological evaluation will include a concise description of the resident, an appropriate assessment of intellectual/cognitive functioning and adaptive behavior, assessment of mental health problems (if appropriate), review of previous evaluations and comparison of the current test results with previous results to determine trend, review of behavioral observations, review of behavioral procedures and data, the resident's strengths, needs and the psychologist's recommendations. These evaluations will focus on the assessment of functional skills and interests through ecological and person-centered assessment procedures. Each assessment will coincide with each client's annual Individual Habilitation Plan (IHP) schedule.
1. By August 1, 1995, all current and future admissions to the Special Behavior Unit will receive a functional assessment. (Attachment 1). A widely used functional assessment tool developed by Robert Horner and colleagues, called Functional Analysis of Problem Behavior, will be used as a primary assessment guide. Other assessment tools, such as the Aberrant Behavior Checklist, the Psychopathology Instrument for Mentally Retarded Adults, the Reiss Screen, the Autism Behavior Checklist, and ecological and analog assessment strategies will also be employed as needed.
2. By March 1,1996, all clients receiving psychotropic medication and/or restrictive behavior support plans will receive a functional assessment as part of their individualized behavioral support plan. A functional analysis will be conducted thereafter as needed, at least on an annual basis.

3. The Director of Center Programs is developing a training curriculum for the psychology staff with specific training in functional and ecological assessment and the use of this information in the development of positive behavior support plans. A major focus for all persons will be on teaching more appropriate skills to replace challenging behaviors. The first training class is planned for August 1, 1995 and training will be completed by March 1, 1996.
4. Every client for whom a behavioral need is identified or who has a behavioral program will receive a formal functional analysis as part of the development of a behavioral support plan by July 1, 1996. In developing and assessing behavior plans, priority will be given to those individuals whose behavior places them at greatest risk. NVTC will establish priority for program development for those residents who exhibit Pica, self-injurious behavior or other behavior that is dangerous to self, others, or property and for those residents for whom relatively high usage of time-out and/or restraint is shown by objective and reliable data. Such individuals will receive functional analyses which are focused on assessing the specific problems demonstrated by the individual. Behavioral plans will be based upon objective and reliable data and interventions documented in those plans will be based upon data collected. When appropriate, current literature will be considered in developing behavior plans.
B. NVTC will continue to develop and implement a professionally based training program for each client and provide each client with an adequate number of hours of training pursuant to applicable standards utilizing positive approaches to enable the client to develop behaviors which will afford safety, freedom from undue restraint and other restraints on the individual's movement within and about the facility and to prevent regression or deterioration of skills. By July 1, 1996, each training program will contain at a minimum:
1. Training objectives developed by an appropriately constituted interdisciplinary team and based upon assessments and evaluations required by paragraph 1 above for those clients who have been identified as needing mental health services, which comport with applicable standards;
2. Specific instructional methods to be utilized by those with responsibility for implementing the program; such methods will emphasize positive approaches and positive behavioral interventions which promote functional skill development and socially acceptable behaviors for the individual client;
3. A specific training schedule to be followed; the number of hours of training to be provided will be sufficient to permit the client for whom the

program has been developed to have a reasonable opportunity to reach the identified behavioral objective(s) of a training program; no schedule will provide for fewer than 40 hours of structured training or activities each week, unless medically contraindicated;
4. Procedures utilized for data collection will be sufficient to permit a qualified professional to evaluate the effectiveness of the training program or any part thereof and to monitor the implementation of the plan and ensure its modification, as necessary. Documentation forms for tracking adaptive and maladaptive behaviors have been standardized. A computerized data tracking system is being used to provide on-going functional assessment of behavior plans. Graphical representations of the data are and will continue to be presented to the Behavior Management Committee (BMC) and Local Human Rights Committee (LHRC) and are used for clinical presentations; and
5. Identification of the persons responsible for the consistent implementation of the program.
C. NVTCwill consistently implement the training programs required in Paragraph B. above for all clients by July 1, 1996, and thereafter within fifteen (15) days of the development of the behavior plan by the ID team and full approval by the Behavior Management Committee (BMC), Local Human Rights Committee (LHRC) and parent/guardian. Notwithstanding this time frame, priority in the development and implementation of training programs will be given to any client exhibiting selfinjurious, aggressive or pica behaviors. Any such client will have a professionally developed and consistently implemented training program within sixty (60) days of identification of the problem.
D. In order to afford consistent implementation of training programs, NVTC provides and will continue to provide adequate competency-based training for all staff responsible for implementing the programs specified in Paragraph B above. Staff training will focus on how to implement the programs and collect appropriate data. NVTC will conduct regular periodic follow-up evaluations of staff competency in implementing programs and provide additional training, as necessary.
1. By June 1, 1995, center-wide Psychology Behavioral Treatment Books will be available to all psychology staff, advocate, duty officers and roving team leaders. Also by June 30, 1995, Unit-specific Behavioral Treatment Books will be accessible to all unit staff as a reference for behavioral support plans.
2. Greater emphasis upon the preventive and positive procedures of the "Mandt" Training System have been included in staff orientation and during staff training of individualized behavior support plans. The entire staff

orientation training package for behavior management was reviewed in January 1995 and plans and timelines for a revised training package based upon preventive and positive behavioral support program philosophies and procedures have been established. Implementation of the revised training package is set for August 1, 1995.
E. NVTC has implemented and will fully maintain systems by March 1, 1996 for: (1) observing clients' behavior to determine the effectiveness of the programs and recording those observations; (2) verifying the reliability of the recorded data; and (3) ensuring that a qualified professional reviews and appropriately modifies any client's training program when the professional determines that the resident has exhibited no measurable progress for a significant period of time.
1. Unit-based clinical meetings will continue to occur semi-monthly to monitor clinical issues and address changing client needs. In the Special Behavior Unit (SBU), these meetings will occur weekly.
2. Unit-based psychotropic medication/behavior plan reviews will continue to occur weekly on the SBU and on all other units at least monthly. This interdisciplinary data-based review is attended by the psychiatrist, physician, psychologist, psychological assistant, nurse, direct care staff, program manager or team leader, and Qualified Mental Retardation Professional (QMRP). Vocational staff, parents and other pertinent professional disciplines may also attend.
3. Psychology staff will perform weekly reliability checks of treatment plans using direct observation of client behavior and implementation of behavior support plans by direct care staff. Documentation of behavior support plans will also be checked for reliability on a weekly basis by comparing direct care staff and client observations with log entries, behavior tracking forms, and entries in the client record by March 1, 1996.
4. QMRP's will continue to provide program monitoring at least quarterly as part of the Individualized Habitation Plan (IHP) review system.
5. Active treatment will continue to be formally monitored using a system designed by Dr. Brian Iwata. Designated and trained staff will record observations at least twice a week for every unit. (Attachment 2). In January 1995, a data system was established in which active treatment information from this form will be used to make management decisions. The Risk Manager will enter the raw data and monthly reports will be generated for review by management staff. Active treatment and other measures will be integrated into a program monitoring plan to be submitted to the Quality Management Committee by August 1, 1995. The results of these measures

will be compiled and distributed quarterly to all clinical and unit departments and to the Quality Management Committee.
F. NVTC will develop by January 1, 1996, a system to regularly train all direct care staff in collecting and maintaining the behavioral data necessary to assess the effectiveness of any behavior program. Staff will be fully trained by July 1, 1996. NVTC will keep written records to document such training.
G. An interdisciplinary team will evaluate the efficacy of the training programs for each client with self-injurious, aggressive or pica behavior on a monthly basis and the efficacy of the training programs for all other clients on at least a quarterly basis. The team will base its review of the efficacy of the training programs on the data collected as well as the occurrence of incidents (events) and the use of restraints. If 1the team recommends the need to revise the training program, it will be reviewed and revised, if appropriate, by a psychologist within thirty (30) days.
H. The Behavior Management Committee, including the Director of Medical Services and, as appropriate, a psychiatrist, will review behavior plans and supporting documentation relating to each resident who: (1) exhibits self-injurious or aggressive behavior, or (2) is subject to restrictive programming, frequent behavior control procedures, or receives behavior modifying medication, to ascertain whether: (i) there are sufficient behavioral data recorded, (ii) such data have been assessed for reliability, and (iii) the continuation of the current training or treatment program is justified, or the program, including medication, should be modified. Where inadequate or unreliable data are found, or the continuation of the training or treatment program is otherwise not justified, the matter will be referred to the appropriate interdisciplinary team which shall, within 30 days of the referral, modify the existing program in accordance with the judgment of qualified professionals, including the primary care physician, psychologist and psychiatrist, as appropriate. When in the judgment of qualified NVTC professionals, data indicates that individual programs as implemented have been ineffective and outside independent consultation is necessary to assist in devising an appropriate revision to the program, NVTC will obtain such consultation.
II. USE OF PHYSICAL RESTRAINT AND TIME OUT
NVTC has developed and will continue to implement policies and procedures to ensure that time-out and physical restraints are administered only pursuant to the judgment of a qualified professional and are not used as punishment, in lieu of training programs, or for the convenience of staff. These policies and procedures are contained in NVTC Instruction 5300 (Restrictive Procedures) and NVTC Instruction 5301 (Use of Protective Devices) and the Psychology Department's Behavior Therapy Procedures: Philosophy of

Use, Definition and Staff Responsibilities. (Attachments 3, 4, and 5). These policies and procedures will:
A. Protect clients from unreasonable risks to their personal safety from both the conduct of staff and other clients, and from unreasonable use of bodily restraints.
B. Provide for the use of bodily restraint and time-out only in conjunction with a written treatment and/or training program, except in emergency circumstances. An "emergency" is defined as "a situation in which a qualified professional deems a behavior to be likely to cause harm to the client or others or to property unless the proposed intervention is immediately initiated." For each emergency use of bodily restraint or time-out, the decision to use the bodily restraint or time-out must be made by a qualified professional after considering a hierarchy of less restrictive interventions. Each emergency use of bodily restraint or time-out will be described and recorded in the client's record including the identity of the professional making the decision and the justification for the decision. A client who has been placed in time-out or bodily restraints in emergency circumstances three times in the previous year will be assessed and a written treatment and/or training program developed, if necessary, within two weeks of the third incident, except in medical contingencies where the restraint is prescribed by a physician for short term use while the condition is being treated. A standardized Crisis Management Documentation Form has been used since January 1994 to track emergencies and will continue to be used.
C. Require that, in every behavior program that utilizes bodily restraint or timeout, specification of:
1. the behavior to be eliminated and the specific behavior, clearly and objectively defined, which triggers the use of the restraint or time-out;
2. behaviors to be taught to the client to replace the behavior that initiates the use of the restraint or time-out and other programs to reduce or eliminate the use of such restraint or time-out;
3. the restriction, i.e. type of restraint or time-out authorized and, where applicable, the duration of the restriction;
4. the professional responsible for the program and the direct care staff authorized to implement the program;
5. the frequency and manner in which behavioral data are to be recorded by direct care staff.
In order to accomplish the above, NVTC has revised the format of all behavior support plans (BSPs). A major emphasis is placed on functional analysis-based

treatment plans which rely upon individualized preventive and proactive behavioral procedures to address challenging behaviors. (See Attachment 6 for a sample of this new format.) A short summary of each BSP is also written to be used as a quick, easy reference for staff. All behavior plans and short summaries will be rewritten into this new format corresponding with the client's annual staffing. All BSPs will be written into the new format by January 31, 1996.
D. Require that beginningjanuary 1, 1996, any treatment and/or training program utilizing bodily restraint or time-out will be reviewed before implementation and at least every three (3) months thereafter by the Behavior Management Committee (BMC) as well as by the Local Human Rights Committee prior to implementation of the program; provided, however, that under emergency conditions, the Chairman of the BMC may approve a program not to exceed 30 days.
E. Prohibit the use of bodily restraint or time-out except in: (a) those situations where there is written evidence in the client's record that other, less restrictive techniques have been considered and/or systematically tried and consistently implemented as part of a professionally designed training program and accurate, objective data have demonstrated such techniques to be ineffective and (b) emergency situations in which there is a risk of harm to self or others. Each time a device is used in an emergency situation or as a protective device, the client record must document that the decision to so use the device was made by a qualified professional; it must identify the professional making the decision, and it must document the justification for such use. Any use of restraint will be the least restrictive form of restraint after consideration of a hierarchy of less restrictive interventions. The use of papoose boards as a form of behavioral restraint was eliminated as of January 18, 1992 and will not be re-implemented. There are and will be no standing medical orders for PRN psychotropic medications.
F. Require that appropriate psychology staff will review monthly each use of bodily restraints or time-out occurring in the previous 30 days to ascertain whether each use was pursuant to the exercise of professional judgment or the behavior program of the resident subject to the use. The results of these monthly reviews, including the conclusions of the psychology staff, will be reported to the BMC every three (3) months, which will review whether a particular client needs a behavior program or whether an existing program should be modified. The BMC may initiate more frequent reviews when indicated. Restrictive measures will be continued in clients' programs only if reliable data supports the necessity of their continued use. The BMC will record these recommendations and transmit them to appropriate staff, as well as NVTC management, who will be responsible for ensuring that any new programs or revised programs are developed and implemented within 30 days.
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III. STAFFING REQUIREMENTS
NVTC will hire, deploy, and provide ongoing training to a sufficient number of competent and qualified direct care and professional staff to provide its clients with adequate care, treatment, and training programs.
A. A sufficient number of qualified staff, including physicians, psychologists, registered nurses, licensed practical nurses, registered physical therapists, licensed physical therapy assistants, occupational therapists, speech therapists, dietitians and direct care workers will be available. NVTC will demonstrate continuing efforts to achieve any additions to staff that are necessary for this purpose by January 1, 1996 and will achieve such staffing by July 1, 1996.
" B. NVTC will maintain adequate direct care staffing levels while implementing its census reduction plan referenced in Section XI.A. below. NVTC currently meets an on duty direct care ratio of 1:4 on the a.m. shift, 1:5 on the p.m. shift and 1:9 at night. When the client census reaches 200 on July 1, 1996, NVTC will have and maintain a campus-wide staffing ratio of 1:4, 1:4, 1:8 and will continue to deploy staff based on the exercise of professional judgment to provide for the training and safety needs of all clients. NVTC will continue to provide 1:1 staffing for individuals whom qualified professionals at the facility have determined are in need of 1:1 staffing.
C. Direct care staff will not be routinely used to perform such support functions as housekeeping, laundry, other than client personal clothing, maintenance and meal preparation, etc. This requirement does not preclude direct care workers from training residents in these functions pursuant to a written training program developed in accordance with established procedures.
D. NVTC will employ sufficient senior clinical staff to afford adequate clinical supervision, case consultation, education and training of staff and to afford the provision of adequate services to clients.
E. NVTC will continue to employ as Director of Center Programs a behaviorally trained professional to supervise those who design and implement appropriate treatment, training and programming for clients and sufficient psychologists to develop and implement all training programs and data collection and evaluation.
1. NVTC currently employs 5 psychologists and 6 qualified psychology technicians. NVTC will establish and advertise for one additional psychology position and fill that position by July 1, 1996.
2. By July 1, 1996, the overall ratio of psychology staff to clients will be 1:34. The psychologist assigned to the Special Behavior Unit will have a ratio
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of 1:20 clients plus a small number of clients from Unit 1 with relatively few behavioral needs.
F. NVTC will employ sufficient nursing staff to provide adequate nursing services to appropriately monitor the clients' health and medical needs. NVTC currently has 23 Registered Nurse positions and 4 Licensed Practical Nurse positions representing a staffing of 14 nurses on A.M. shift, 8.5 on P.M. shift, and 4.5 on NOC shift. The on duty nurse to client ratio will continue to be at least 1:25 A.M. shift, 1:30 P.M. shift and 1:55 NOC shift.1
G. NVTC currently employs three physicians who serve as the primary care physicians for the clients. NVTC will maintain this level of staffing. A physician is on-site or on-call and available seven days a week, 24 hours a day. NVTC's current night call schedule is published monthly and includes home and beeper numbers. Two of NVTC's physicians cover one night per week and one weekend per month each including Friday, Saturday and Sunday nights. The Medical Director covers one night per week. A family practitioner covers one night per week. Another family practitioner covers two weekends per month. EMT and ER services are also available and located within five minutes from the Center. NVTC will maintain a night and on-call system, or a similar system, to meet the requirements of this plan.
H. NVTC will afford sufficient consultation with appropriate medical specialists including psychiatrists, neurologists, orthopedists and a physiatrist and otherwise provide services to clients as may be needed to provide adequate care and treatment. (See Attachment 7.)
1. NVTC will continue to contract for the on-site services of a psychiatrist 2 full days per week (at least 6 1/2 hours per day) plus a psychiatric fellow approximately one day per week.
2. In addition to off-site services, NVTC will continue to contract for the on-site services of a physiatrist at least quarterly, an orthopedist quarterly, and a neurologist 2 full days per month. (Full days may be reduced to partial days if and when patient needs allow.) NVTC will also continue periodic consultation with a geneticist for diagnostic purposes.
I. By July 1, 1995, NVTC will hire three (3) full time additional physical therapy positions with the goal of filling these positions by July 1, 1996. These positions include one licensed physical therapist and two physical therapist assistants, bringing the total physical therapy positions at NVTC to 3 registered physical therapists and
Nothing contained herein shall be construed to prevent NVTC in the exercise of its own discretion, from deploying a greater proportion of nursing staff than is required by this Plan.

3 licensed physical therapy assistants. This will bring the ratio of physical therapists as of July 1, 1996 to 1:34.
J. By July 1, 1995, NVTC will establish and advertise for one additional registered occupational therapist position and 3 certified occupational therapist assistant positions. NVTC's goal is to fill these positions by July 1, 1996. This will bring the total number of funded OT positions to 7. The ratio of occupational therapists to clients as of July 1, 1996 will be 1:29.
K. By July 1, 1995, NVTC will establish 1.5 additional dietitian positions bringing the total number of dietitian positions to 2.5. NVTC's goal is to fill these positions by July 1, 1996.
IV. STAFF TRAINING
All staff who provide services to NVTC clients are adequately trained to fully implement the requirements of this Plan and are thereafter provided with in-service training on a regular basis. The training will be competency-based and will include, but not be limited to: behavior management techniques; implementation of individualized treatment and training programs; emergency medical response, including recordkeeping for such procedures.
A. Pre-Service Training
1. All new employees of NVTC will continue to be required to attend a basic orientation program within the first 30 days of employment and successfully complete all components before the end of their probationary period. This orientation provides basic information in the following mandated subject areas: Personnel Policies, Orientation to NVTC, Abuse Policy, Human Rights Regulations, Safety and Security Procedures, Infection Control/AIDS, Normalization, Introduction to Mental Retardation, Seizures, First Aid, Body Mechanics and Lifting, and Sexual Harassment.
2. NVTC will continue to require NVTC direct care staff to successfully complete additional training as part of their orientation training, and a competency-based training program at their worksite. (Attachment 8). Coursework will concentrate on additional health/nursing information and emergency procedures, behavior management techniques, appropriate interactions and teaching techniques, specific clinical information and strategies necessary to be able to implement individual programs, and documentation and data collection. The orientation program will also include Active Treatment, Behavioral Documentation, Use of Mechanical Restraints, Adult CPR, Side Effects of Medications, and the Mandt System for Managing
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People. (Attachment 9). Most of the orientation sessions in the clinical areas will continue to be competency-based (tests, return demonstrations, etc.). In addition, there is a final written exam. Staff who are unable to demonstrate competency are terminated from employment. In keeping with NVTC's goal to share resources with the community, the orientation program will continue to be offered to all of the local community agencies who frequently attend sessions and comment on the quality of the training their staff receive at NVTC.
3. Training in the Mandt System will continue to be a component of the staff development program and will focus on all interactions between people. The major emphasis of the program is on non-physical interventions. It stresses the need to interact appropriately at all times in an effort to prevent individuals from becoming upset. All direct care staff receive the two-day Intermediate Level of training in pre-service. An annual one-day recertification is also required.
4. All staff development programs will continue to emphasize several major themes which support the Mission Statement of the agency: appropriate staff to client interactions (treatment with dignity and respect), and the need to encourage and teach client independence. The importance of providing an environment which is supportive, protective, encouraging, reinforcing, and proactive is included throughout the entire orientation program.
5. NVTC has developed and will continue to use a competency-based training program for new employees which is utilized at the work site once the employee has successfully completed the orientation portion of the preservice program. The Direct Care Competency Training Program (DCCTP) provides opportunities for new staff to demonstrate to their supervisors competence in all aspects of their job responsibilities. (Attachment 10). The DCCTP includes sections on Philosophy, Personal Care/Health/Hygiene, Active Treatment, Documentation, and Policy. Sections on Understanding Basic Behavior Intervention Programs and Program Implementation have been added to the Active Treatment portion of the original program. New employees continue to have six months (the remainder of their probationary period) to complete the program. Accompanying the DCCTP is a competency book of 50 task analyzed job duties in providing health related care, staff/client interactions, provide/maintain a safe living area, and how to implement program plans.
6. Compliance with the completion requirements for the Pre-service program and DCCTP will continue to be monitored by the Training Department. Notices are sent to supervisors monthly advising them of staff
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needing to attend specific classes. A quarterly compliance report is also sent to supervisors. (See Attachment 11 for sample of report.)
7. Beginning April 30, 1995, NVTC will include in the pre-service curriculum two software packages from Softpath Habitation which teach (1) Active Treatment, and (2) Behavioral Principles and their Applications to People with Developmental Disabilities. The Active Treatment program is an automated interactive tutorial that teaches the basics of interacting with people with disabilities to ensure their greater independence. The focus of the Behavioral program is to teach direct care residential and workshop staff basic behavioral principles and their applications to people with developmental disabilities. The principles are taught in the context of common life experiences. Applications are taught in the context of working with people who have developmental disabilities. Each program is student-paced and is competency-based. These are intended to supplement classroom sessions, not to replace them.
8. The Behavior Modification curriculum will be implemented by August 1, 1995. The new curriculum will not rely on lecture format solely, but will incorporate experiential learning opportunities. Content will include traditional behavior modification and behavior management information, but concentrate on preventive and positive behavior support strategies, functional assessment, and person-centered planning.
9. NVTC has obtained the "Challenges in Physical Management" curriculum developed by the Oklahoma Department of Human Services. This is a 2-day comprehensive training program. The program is divided into 4 sections: Body Mechanics, Physical Assistance Techniques and Transfers, Positioning, and Putting It All Together. NVTC is also reviewing a program from Texas which provides additional areas of training. A qualified professional will deliver the training. When adequate professional staff are available, this curriculum will be included in the pre-service program for all direct care staff. NVTC will use its best efforts to implement this training program by January 31, 1996.
B. Other Mandated Training
1. NVTC will continue to require the staff to receive refresher training in prescribed subject areas on an annual basis. All staff are required to attend classes on: Abuse Policy, Infection Control/AIDS, Human Rights Policy, Body Mechanics and Lifting, Sexual Harassment, and the Heimlich Maneuver. In addition, direct care staff are required to receive annual training on: Active Treatment, Crisis Management, Adult CPR, and the Mandt System. (Attachment 12).
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2. In addition to Adult CPR, NVTC will continue to conduct emergency medical response drills. (Attachment 13). The purpose of these drills is to allow all staff involved the opportunity to practice responding to mock medical emergencies to better prepare them for a real situation. Nursing staff coordinate, monitor, and evaluate these drills and send documentation to the Training Department.
3. Compliance with mandated training requirements will be monitored by the Training Department. Quarterly summaries of compliance rates with mandated training requirements are sent to the supervisors.
4. NVTC's curriculum on Client Record System and Documentation has been developed and will continue to be included in the Annual Retraining Program. Target date for implementation was June 30, 1995.
5. Recognizing that the skills and knowledge necessary for direct care staff assigned to different work sites will vary depending upon the specific needs of the clients, program managers are in the process of working with the Training Department to determine additional training requirements for direct care staff assigned to each unit. Building 7 began this pilot in late 1994 and began implementing its plan in January 1995. (See Attachment 14 for Building 7 Plan). All residential buildings will have completed plans by September 30, 1995.
C. Physical Management Training
Training the Physical Management curriculum "Challenges in Physical Management", as described in Pre-service Training, Paragraph A.9 above, will begin for direct care and clinical staff by January 31, 1996. Staff assigned to Units 1, 3A, 3C, 3D, and 5A will participate in more intense in-services and client specific training at their work sites. These in-services will be provided quarterly at a minimum. Whenever an individual client program is developed or modified, all staff will be trained on these changes.
D. Individual Behavioral Programming Training
1. During pre-service, staff receive training on Behavior Modification, Teaching Techniques (Task Analysis, Prompting, Reinforcement, Error Correction), Crisis Management, Behavioral Documentation, and Use of Mechanical Restraints. This training is meant to be general in nature and provide staff with the "tools" to be able to implement individualized program plans. However, staff are not permitted to implement program plans until they have received additional training on the individual plans.
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2. Once an employee completes the pre-service program, he or she begins working on the assigned work site. If clients on the unit have behavior programs, the new staff member is not allowed to implement them until he or she has been properly trained by the psychologist or psychology assistant. The psychology staff will monitor the training of each new staff member in all aspects of the program (including the specific target behavior, the objective, how to prevent the behavior from occurring, what to do when the targeted behavior is displayed, the adaptive and reinforcement components of the program, and data collection requirements). NVTC policy also requires that staff be re-trained on all behavior programs whenever there are changes to the program or every six months, whichever comes first. This training is documented and forwarded to the Training Department for inclusion in each employee's training record.
3. As new behavior support plans are written and summarized on new forms (Client Behavior Profiles), as described in Section II.C above, these will become a quick study guide and training tool for staff. Completion date is January 31, 1996.
4. To further develop the knowledge of staff regarding behavioral principles, all direct care staff will be required to complete the "Basic Behavioral Principles and their Applications to People with Developmental Disabilities" software package previously mentioned in the section on Preservice Training. The completion date for this training for Units 5C, 6, 7C, 8A, and 8C is October 31, 1995, and for Units 1, 3A, 3C, 3D, 5A, and 7A is June 30, 1996.
E. Feeding/Mealtime Training
1. The Training Department has begun providing and will continue to provide in-services on Active Treatment focusing on the mealtime activity. This training stresses the importance of implementing individual goals and objectives from the IHP into the meal experience. Staff are quizzed on their knowledge of individual client programs, followed by discussion and demonstration of how these client needs can be integrated and implemented before, during, and after each mealtime. NVTC has completed training on Units 1, 3D, 5A, 5C, 6, and 7A. Units 3C and 7C are scheduled to be completed by February 1, 1996. 3A will be completed by March 1, 1996, 8A by April 1, 1996 and 8C by May 1, 1996. All active treatment training will be complete by May 1, 1996.
2. A concentrated interdisciplinary effort around several mealtime issues was begun in the Fall of 1994. The goal is to create a mealtime environment and experience which is more normalizing and more enriching, as well as
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therapeutic in nature. This is accomplished by evaluating the physical environment of the dining areas, the time and resources allocated to mealtimes, and the knowledge of staff in mealtime programs and issues of active treatment. Clinical staff have established days and times to be in the dining areas to assist, model, and provide feedback to staff on mealtime techniques and program implementation. This will continue on an on-going basis. Monitoring is to be done by building supervisory staff. Specific outcome measures will be established by the clinical departments, in conjunction with the I.D. Team, for each specific unit by October 31, 1995.
3. As client programs are developed and modified, direct care staff will continue to be trained in these individual program plans by the appropriate clinical staff. Such reviews are documented and become part of the employee's training record. Clinical staff regularly and periodically review general information as well as client-specific information with the staff. This is documented and forwarded to the Training Department for inclusion in the employee's training record.
4. NVTC has purchased a tutorial software package on Active Treatment which will be included in the pre-service program. All direct care staff will complete the tutorial by July 1, 1996.
F. Continuing Education for Professional Staff
1. NVTC has established minimum continuing education requirements for its clinical staff. (Attachment 15). These were established for professional positions for which there are no state mandated or licensing continuing education requirements. These were established by the appropriate department heads and were based on standards from other states. Clinical staff who attend a training event which meets a continuing education requirement send documentation of this to the Training Department and it is entered into their training record. Summaries of training are provided to the supervisors and employees upon request. This continuing education process will be ongoing.
2. Records will be kept on compliance with required continuing education and reported back to supervisors and the Quality Management Committee on a quarterly basis. Reports will begin with training completed by December 31, 1995.
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V. PHYSICAL THERAPY AND OCCUPATIONAL THERAPY MANAGEMENT
NVTCwill provideclientswith adequate physical management, including appropriate physical therapy and occupational therapy programs. In addition to staffing outlined in Section III, J and K, NVTC shall take the following steps to accomplish this:
A. Physical Therapy
1. By March 30, 1995, NVTC will design and provide new wheelchairs and seating systems to 32 residents. (Attachments 16 and 18).
2. By March 30, 1995, NVTC will design and fit 19 new seating systems into current wheelchairs.
3. By December 31, 1996, NVTC will upgrade and/or replace the remaining third of individual wheelchairs. Provision of wheelchairs and wheelchair modifications will be based upon a professional assessment of those most in need; all adaptive equipment will be individualized and there will be a continual adaptation of wheelchairs and other equipment as individual needs change. (Attachments 16 and 18).
4. By March 30, 1995, NVTC will develop and staff an on-site workshop dedicated to wheelchair and positioning equipment.
5. By March 30, 1995, NVTC will complete modifications to the water heating system for the Hubbard Tank to permit staff to conduct hydrotherapy during cold weather months.
6. By June 30, 1996, NVTC will reevaluate all clients with fixed contractures and reassess their potential for improvement with consultation from orthopedic and physiatric consultants.
7. By June 30, 1995, NVTC will establish 24-hour positioning schedules for all clients in need of positioning on Unit 1 and Building 3:
a. By March 30, 1995, NVTC will begin taking photographs of clients in various positions, with accompanying written descriptions of the benefits of placement in each position. These photographs will be assembled in unit-based books for daily use.
b. By April 30, 1995, NVTC will implement completed positioning programs in Unit 1.
16
!••'!

c. By June 30, 1995, NVTC will implement completed positioning programs in Building 3.
8. By July 1, 1996, NVTC will establish and implement a staff training course for physical management of clients who demonstrate challenging mealtime and positioning needs.
9. By July 1, 1995, NVTC will select a physical management training program following review of several physical management training packages by the Training Department, Director of Occupational Therapy, Director of Physical Therapy and Director of Center Programs.
10. By July 1,1996, physical management training will become part of preservice orientation for all new staff and yearly re-training will also be required.
B. Occupational Therapy
1. A new Director of Occupational Therapy Services was hired on July 18, 1994. The Director will not serve as program manager for any other Building or Unit at NVTC.
2. By December 31, 1995, NVTC will be established as an internship site for students in occupational therapy professional training programs.
3. By July 1, 1996, NVTC will complete a pilot project involving sensorymotor integration training/treatment for four clients. Data will be collected and assessed. If data shows positive benefits for clients, the training/treatment program will be implemented with other clients whose need for such training/treatment has been identified by professional staff.
VI. NUTRITIONAL MANAGEMENT AND FEEDING
NVTC will provide clients with adequate nourishment, identification of nutritional deficiencies and appropriate feeding programs and adaptive equipment for use at mealtimes. NVTC will take the following steps to accomplish this:
A. By April 1, 1995, NVTC developed and began pilot implementation of a Nutritional Risk Assessment Form.
1. Pilot testing, modification and refinement of the Nutritional Risk Assessment Form will be completed by December 31, 1995.
17

2. A Nutritional Risk Screening Assessment form has been completed for each resident determined by staff to have specialized nutritional and/or feeding needs, and such a form will be completed for each resident identified in the future with a specialized need. Training appropriate to the resident's needs, based upon nutritional risk assessment, will be conducted for all staff members having nutritional responsibility and/or feeding responsibilities with respect to the resident. It is understood that staff working with residents with the highest risk will be the first to receive the training.
B. By July 1, 1995, NVTC will establish one and one-half additional dietitian positions. By July 1, 1996, NVTC shall have on staff two and one-half Registered Dietitians.
C. By September 1, 1995, NVTC will have provided consultation to direct care and professional staff on Units 1 and Building 3 by a multi-disciplinary nutritional management team, including an occupational therapist, physical therapist, speech pathologist and dietitian. (Attachments 17 and 18).
D. By December 31, 1995, NVTC will receive equipment designated as needed to implement modifications identified by nutritional assessments. Items will include one weighing scale, specialized calipers to assess nutritional status and measuring boards.
E. By December 31, 1995, NVTC will purchase the adaptive equipment for use during meals which has been identified as needed by physical therapy and occupational therapy staff. (Attachments 16 and 18).
F. By July 1, 1995, NVTC will receive 30 dining room chairs and accompanying tables for mealtime use on Building 3.
G. By March 30, 1995, NVTC will install a dishwasher in the Building 3 dining room, so all adaptive equipment can be cleaned on-site.
H. By March 30, 1995, NVTC will install an answering machine in Dietary the Services office to permit units to report, at all hours, adaptive feeding equipment needs.
I. By July 1, 1996, NVTC will provide for diagrams and photographs of residents to be placed in the dining room next to each resident.
18

VII. MEDICAL CARE

Residents will be provided with adequate medical care. Inorder to accomplish this, NVTC will:

A.

Quality Assurance

Implement a peer review mechanism for all disciplines involved in providing health services. The Quality Assurance Program for Health Services (Attachment 19) provides for systematic credentialing procedures, staff education, reviews of adverse events or outcomes by a Clinical Practice Review Committee, as well as for peer review for medical and nursing practitioners.

a. Medical peer review was initiated on November 4, 1994 and the process ofthis review will continue, with systemic refinements, as needed.

b. NVTC's medical director will serve on a committee which includes the Director of Resident Records inorder to develop asystem for monitoring and improving physician documentation incharts. This review and planning period will be completed by September 1, 1995.

B. Medical Specialty Consultation

NVTC maintains a regular schedule of consultation with medical specialists. (See Attachment 7.) These include neurology, ENT, orthopedics, ophthalmology, psychiatry, physiatry, gastro-intestinal, podiatry, urology, cardiology, gynecology, dermatology and genetics. Recruitment for additional specialty medical consultants will continue, as needs are identified. Notes from these consultations will continue to be included inresidents' records and a procedure formonitoring will be established bySeptember 30, 1995. See also Section IX. Recordkeeping Section.

C. Medical Management of Residents with Epilepsy
1. Aninterdisciplinary epilepsy committee developed and implemented a new charting system for the epilepsy clinic. (SeeAttachment 20.) Information from this charting will be incorporated into the new resident record system byMarch 30, 1995. A procedure formonitoring compliance with the requirement ofinclusion of charting information into resident records will be established bySeptember 30, 1995.

19

2. By December 31, 1995, semi-annual audits of antiepileptic drug prescribing practices will be conducted by the Pharmacy and Therapeutics Committee, which performs the functions of a drug utilization review committee. Information from these audits will be considered by the interdisciplinary epilepsy committee and will submitted to the Quality Management Director. Appropriate monitoring and follow-up will occur, as necessary.
a. NVTC will emphasize use of monotherapy and deemphasize use of barbiturates and phenytoin.
b. The Pharmacy and Therapeutics Committee will continue to monitor the consistency of charting and medication adjustment/change in individuals with epilepsy and seizures.
c. One index of improved quality of life for clients receiving epileptic drugs has been identified as reduced use of helmets for clients with epilepsy. Monitoring of frequency of helmet use has shown a reduction of 38% in the use of helmets from 45 in 1989 to 28 in February, 1995. NVTC will rely upon controlled medication trials and ongoing monitoring of improvement to determine further appropriate reduction of helmet use. (Attachment 4).
3. Individual treatment protocols for status epilepticus will be implemented by September 30, 1995.
4. A videotape and brochures for staff and family education will be completed by the interdisciplinary epilepsy committee by October 30, 1995.
5. Beginning June 30, 1995, the interdisciplinary epilepsy committee will review epilepsy-related injuries, infirmary and hospital admissions on a quarterly basis and report its analysis of this data to the Quality Management Director.
6. Guidelines were developed in September, 1994 for nursing care of clients with seizures and for first aid by residential staff. Guidelines for residential staff were posted in October, 1994. (Attachment 21).
Compliance with these guidelines will be assessed through routine audits of individual charts by a procedure to be established by September 30, 1995.
20
!••!

D. Emergency Responsiveness
1. Monthly emergency responsiveness drills, involving nursing, security and residential staff, were begun in May, 1994. (Attachment 22). The nurse manager will monitor the monthly drill reports and forward the analysis of these results and recommendations to the Quality Management Director, beginning on September 30, 1995.
2. Documentation of response times of EMS personnel to 911 calls from NVTC and of NVTC nurses to on-campus emergencies was begun in May 1994. (Attachment 23). The nurse manager will monitor the response times of EMS and nursing staff members and will report the results of this monitoring to the Quality Management Director, beginning on June 30, 1995.
3. Emergency notification procedures were posted on residential units in October, 1994. (Attachments 24 and 25). Compliance with these procedures will be monitored by the nurse manager through chart audits, and compliance rates gathered from this monitoring will be submitted to the Quality Management Director, beginning on September 30, 1995.
VIII. MEDICATION MANAGEMENT
Beginning December 1, 1995, a semi-annual audit of psychotropic medication prescribing practices will be conducted by the Pharmacy and Therapeutics Committee, which performs the function of a drug utilization review committee, with the results of these audits transmitted to the Quality Management Director. Appropriate monitoring and follow-up will occur, as necessary.
1. Since mid-1989, NVTC's use of antipsychotic (neuroleptic) drugs has been reduced by 33%. As of December 31, 1994, 26 clients were receiving this class of drugs, in comparison with 39 residents five years previously. (Attachment 26).
2. The Dyskinesia Identification System: Condensed User Scale (DISCUS) was adopted for monitoring tardive dyskinesia and other side-effects of clients on psychotropic medications in August, 1993. (Attachment 27). Information from this instrument will be reviewed quarterly by the Pharmacy and Therapeutics Committee beginning in June, 1995. Information from this review will be submitted to the Quality Management Director.
3. The consulting psychiatrist and Medical Director will continue to serve as members of the Behavioral Management Committee.
21

4. NVTC will follow its policies and procedures regarding the use of psychotropic medication, e.g. NVTC Instruction 5302 on Psychotropic Medication (Attachment 28), Medical Plan for Psychotropic Drug Use, consent forms (Attachment 29) and Health Services Policy and Procedures (Attachment 30).
IX. RECORDKEEPING
NVTC will develop and implement a system of records for each client, developed and maintained under the supervision of a qualified professional whose primary responsibility will be to properly maintain client records. Each record will be readily available to all staff and will contain current information with respect to the client's care, medical treatment, and training, and will be organized so as to enable those using it to render professional judgments in providing care, medical treatment, and training to the client. NVTC will require staff to utilize such records in making care, medical treatment, and training decisions.
NVTC has approved for implementation a new Client Records System, the "Source Oriented Medical Record with Integrated Progress Notes". Revision of the record system has been divided into five phases: I. Recruitment; II. Research and Development; III. Training; IV. Implementation, and V. Quality Management. Timetables for each section are outlined in Attachment 31. Phases I and II have been completed. NVTC's plan provides for:
A. Recruitment of a qualified Health Information Manager. A new Director of Resident Records, was hired on August 22, 1994. This position will oversee implementation of the new client records system in 1995.
B. Development of a new Client Records System: Following three months of reviewing the current records management system, site visits to other facilities, solicitation of input from facility staff and researching recordkeeping techniques, a new client record system was proposed. In November and December 1994, the proposal was presented to Resident Record Committee members, clinical and residential staff and Senior Staff. On December 20, 1994, the Source Oriented Medical Record with Integrated Progress notes was approved for use beginning June 30, 1995. Attachment 32 summarizes the system which has been accepted.
C. The most significant change represented by the new client record system is the integrated progress note, "Interdisciplinary Note", section. In this centralized section, professional disciplines will be charting information pertaining to the client. (Attachment 33). Specific documentation instruction to staff include guidelines for all those making entries into the centralized progress notes and contain "prompts" for
22
Tin

entry of indicators such as "OT Monthly Notes" as a title (qualifier) for easy identification and review.
D. Training: Beginning in March, 1995, Medical Records staff, in conjunction with the Training Department, will begin training in the new records system. Small departmental groups have been targeted for individualized training. Training will require each staff member to convert an existing client record to the format created by the new records system. Instructional guides will be provided for each staff member. Training for all residential and clinical staff will be completed by June 30, 1995. Follow-up sessions will be scheduled, as needed.
E. Implementation: Since records will be revised during training sessions, facility-wide implementation of the new records system will be completed by June 30, 1995.
F. Quality Management: By June 30,1995, the current Resident Records Quality Management Plan will be amended to include quality mechanisms for monitoring implementation of the new system. Amendments will include provisions for:
1. Establishing a random sampling of records from each unit for compliance review by the Medical Record department staff and members of the Resident Record Committee.
2. Completion of initial reviews for all units will be completed by September 30, 1995 and a schedule for ongoing reviews of compliance with requirements of the new system.
3. Establishing criteria for monitoring which include, at a minimum:
a. correct chart identification on each CRS;
b. correct record filing order;
c. correct chronological date order for documents;
d. entries made to the integrated progress notes which are prefaced with qualifiers stating the discipline documenting the note; and
e. correct use of double-sided progress notes.
4. Reporting results of each random sampling on a quarterly basis to the Quality Management Committee and the facility Resident Records Committee.
23

X. QUALITY MANAGEMENT PLAN
NVTC will develop and annually update a Quality Management Plan that will monitor, document and evaluate implementation of the activities identified in this Plan. Attachment 34 is NVTC's Quality Management Plan for FY 94-95.
XI. COMMUNITY PLACEMENT
A. NVTC will reduce the number of current clients at NVTC in accordance with the NVTC Community Integration Initiative developed in 1991 with the primary objective of reducing current (i.e. 1991) resident census from 270 to 200 persons. This will be accomplished by securing appropriate community-based placements for those clients it determines in accordance with professional judgment to be eligible and appropriate for such placement, subject to the procedures described in ^ C below. Full implementation of the Community Initiative will occur by July 1, 1996. Attached is a description of the Community Initiative outlining timelines employed, schedule for continued downsizing, and the process that has been used and will be used to meet its objectives. (Attachment 35).
B. NVTC will annually assess the needs of all remaining residents at NVTC as follows:
1. The treatment team will annually assess in accordance with the exercise of professional judgment the needs of all residents at NVTC at the time of the development of the annual IHP to render an evaluation with respect to the appropriateness of continued placement at NVTC. Such assessments will occur more frequently if a change in the needs of the resident so indicates.
2. Subject to the provisions of ^ 4, if all appropriate professionals employed by or under contract with the Commonwealth to assess a resident, including but not necessarily limited to the assigned interdisciplinary team, determine that NVTC is not an appropriate setting for a resident and that a resident would be more appropriately served in a community setting, appropriate professionals will, within a reasonable time thereafter, develop such plan as may be appropriate and feasible to provide necessary services to the resident in a community setting, and will place the resident in accordance with the plan within a reasonable time after such plan has been developed and can be feasibly implemented. Sound, prudent fiscal considerations, and generally accepted business practices may be used by NVTC in determining whether a plan to place a resident in the community is feasible and, if so, when such plan can be feasibly implemented. In no event will NVTC have an obligation under the Plan to discharge or transfer a resident before a
24

community setting that would more appropriately serve the resident has been identified and there is such a setting available.
3. In all decisions with respect to individual residents, the views and opinions of the individual resident, parent(s), guardian(s), other appropriate surrogate decision-maker(s) and professionals will be appropriately considered by NVTC. When it is determined that NVTC is not an appropriate setting for a resident, NVTC will ensure that the views and opinions of the individual resident, parent(s), guardian(s), appropriate surrogate decision-maker(s) and professionals will be considered when developing and implementing an appropriate and feasible discharge plan.
4. Where the consent of parent(s), guardian(s), or other surrogate decisionmakers) is withheld regarding discharge or placement, in disagreement with the judgment of professionals employed by or under contract with the Commonwealth, NVTC will make its discharge and transfer decisions after consultation with the individual resident, parent(s), guardian(s) or other appropriate surrogate decision-maker(s) and, after such consultation, will engage in a good faith effort to reach a consensus as to what decision about discharge and/or placement is in the best interests of the individual NVTC resident in exercise of its discretion on a case-by-case basis. The parent(s), guardian(s) or other surrogate decision-maker(s) may present the opinion of a qualified professional(s) for consideration by NVTC with respect to discharge and/or placement decisions. If the NVTC decision is ultimately to retain the resident, NVTC will continue to involve the parent(s), guardian(s) or other surrogate decision-maker(s) in the treatment and discharge planning process and continue to make them aware of available opportunities in the community for the care of the resident through parental educational opportunities conducted by community providers.
e:\kbc\cripa\nvtccln
25

BEHAVIORAL PROGRAMS: 2/24/95

ADAPTIVE BEHAVIORS

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Note: In the 2nd column, the clienii identified ai having restrictive behavioral procedure* mjr or ma* not alto he receiving psycbotropic medication asput of tbcir total treatment program. Ellen Babbitt (IC)r«cerMipflycnouopk medication for managameaiiofTardive Dyifciaieala. Functional inalyieihave been conducted for other dients *>tia either have been discharged or no longer have a behavioril program.

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NORTHERN VIRGINIA TRAINING CENTER Fairfax. Virginia

I ATTACHMENT

I

3

mvrr

November 1, 1994

TO:

Staff

SUBJECT: Restrictive Procedures

I. Pt.rpn«ta To define restrictive procedures atNVTC and tospecify philosophy ofuse of restrictive procedures with clients.

II. ranrptigrtnn NVTC Instruction 5300 dated. September 1, 1992 ishereby canceled.

III. nafinmnn A restrictive procedure isdefined as any procedure which:

A. Restncts a client's freedom ofmovement and/or

B. Limits access to activities, objects or events to which aclient would otherwise be entitled as a part of his/her human rights and/or

C. Requires a client to perform a specific behavior , such an over correction procedure, and/or

D. Results in altered states of consciousness (see NVTC Instruction 5302. Psychotropic Medication).

IV. Phiinsnphy it is the policy andphilosophy of NVTC to emphasize positive approacnes to behavior management, the least restrictive interventions for each individual client and to ensure the protection of each individual's rights when restrictive procedures are utilized. The least restrictive alternative is then to be defined as those procedures which most quickly eliminate the behaviors for which they were designed intrusive only to the point required to achieve clinical effectiveness so that the individual isable to participate more fully inail phasesof his/her daily life. Interventions with any degree of restrictiveness must be designed by the IO Team, approved by the individual and his/her representative, the Behavior Management Committee, the Director and the Local Human Rights Committee, and reviewed atleast every six months.

Behavior programs are designed for individual residents taking into consideration not only the above factors but also the individual needs, strengths and developmental/social levels of the clients. Procedural safeguards are also included to ensure that the individual's rights toeffective treatment and freedom from undue coercion are balanced and protected.

V.

Prp/*grttirp

A. Programmatic Uses. Restrictive procedures are one component of a total positive training effort designed by the ID team with the exception ofcertain

VTC INSTRUCTION 5300 AGE 2
emergency situations. See tne NVTC Behavior Therapy Procedures Manual for full description of program elements, limitation of use, reviews and documentation necessary for program implementation. A copy of this manual is located with all NVTC psychologists, ail Senior Staff members. Program Managers, on all residential units, and the Director, NVTC.
B. No staff may initiate restrictive procedures except under those conditions specified under Programmatic Uses, and then only when necessary approvals and documentation have been obtained. Violations may be abusive and considered in accordance with OMHMRSAS and NVTC policy on abuse.
C. Community Programs must contact NVTC in advance to secure the above identified reviews and approvals prior to implementation, per our contractual agreements with them.
D. Restraints used as Protective Devices. Refer to NVTC Instruction 5 3 0 1 .
E. Non-Programmatic Uses. Crisis Management (Emergency Procedures): In the event an emergency situation exists where it is likely that a client couid harm himself/herself or others and less restrictive procedures are not effective, the client can be physically restrained (MANOT techniques) by any staff member for up to one hour. During that hour if the staff member believes that the physical restraint is ineffective the unit psychologist should be called. If unavailable the on-call psychologist should be contacted with the Chief of Psychological Services; Physician and NVTC Director as back-up. A Crisis Management Form must be completed by the staff and forwarded to the NVTC Risk Manager. If the need for an emergency restraint occurs three times in one year, the need for a more restrictive program will be assessed.
VI. Pfforrtvp HatP This Instruction will become effective on the date issued.

DHL:LR/jgf Psychology

David H. Lawson, Ph.D. Director

NORTHERN VIRGINIA TRAINING CENTER Fairfax. Virginia

ATTACHMENT A

mvrr

September 1. 1994

TO:

Staff

SUBJECT: Use of Protective Devices

I.

Ptirfin«iw To establish procedures to be followed in authorizing and monitoring theuse of

"Protective Devices.'

It. Cancgitatinn NVTC Instruction 5301 dated September 25. 1991 is hereby canceled.

III. RaHrgmnnH NVTC Variance fN 81-1 tothe requirements of Section Vl-G of the RM>

Roqtttartnng rn Awiirp rhta ffjghr* nf Po»tonT« and

IV. A.
B.

Ha»TrainT<; include, but are not limited to any mechanical device such as sheets, towels, straps, helmets, posey vests. IV boards, etc.- that is used to restrict or prevent movement of a client's limbs or body for purposes of providing protection of harm due to over aggressive acts to self or others.
Prntprrn/p npvir«* include, but are not limited to any mechanical device that might ordinarily be used as restraints, defined above. Although devices similar to those used as restraints might be used as a Protective Device, their purposes differ. Protective Devices are used to prevent injury or to enhance functioning or environmental interactions for particular classes of residents, and where required, to promote healing or to enable the delivery of acute medical/surgicai treatment.

Protective Devices are those mechanical devices used:

1. For a specific protective/supportive purpose a. to prevent injury, or b. to achieve proper body position, balance or support forthose clients with neurological conditions, non-ambulatory clients, or clients with conditions that impair mobility, vision or strength who would otherwise be restricted in their activities andthus be denied stimulation from interactions with others or their environment: or
2. For acute medical/surgical treatment of clients, where required a. to promote healing, or b. to prevent the interruption of acute medical/surgical treatment, e.g., removing dressings, catheters. IV tubes, nasogastnc intubation, etc.
Pj^n^oWtin* The following procedures apply only tothe use of Protective Devices as defined in IV. B. Procedures pertaining to Mechanical Devices used as Restraints (IV. A.) are contained in NVTC Instruction 5300. However, should theuse of restraints for behavioral purposes overlap with the use of protective devices for medical or other purposes, an individualized program plan shall be developed, approved and implemented in accordance

NVTC INSTRUCTION 5307 PAGE 2
with specifications in NVTC Instruction 5300. Such programs shall be the joint responsibility of the unit pnysician and involved psychologist.

A. Requirements for use of ail protective devices:

1. The useof any protective device on a client shall be ordered and monitored in a manner which is consistent with its specific purpose as outlined in Section IV. B. Unless otherwise stated, physicians are responsible for ordering protective devices and for personally observing the dient prior to making initial or renewal orders.

2. Written orders and accompanying individualized plans shall be entered into the involved client's CHS and shall include: a. reasons foruse: b. specifications for motion and exercise periods: c. appropriate documentation requirements:and d. instructions forterminating the use of the devise as a specific time, if practicaoie.

3. For dients utilizing protective devices, staff shall assure: a. bathroom privileges are provided according to need; and b. that clients are provided the opportunity to bathe at least every 2 4 hours.

S.

Additional requirements for riavietm IHBH fnr P>oTor*Tn/p/^iippnrrh/p Pttrpn^w* as

defined in IV. B..1.

1. Following thephysician's physical observation of the client: a. For new admissions, or for clients with changes in physical condition, orders must be renewed weekly, for the first montn: b. Thereafter, orders must be renewed every 30 days or at the time of any cnange in the condition of the ciient.

2. Physical observation by an appropriately trained staff person of the dient must be made at least every 30 minutes when the protective device used is one which could cause circulatory problems. Documentation in the client's CRS oi the specified observations must be made every eight (8) hours by staff.

3. Specifications forappropriate moton and exercise periods and documentation requirements shall be in accordance with the type andpurpose of the device and written in the client's individualized plan.

4. Devices used specifically to achieve proper position, balance or support, including the use of feeding chairs with clients assigned to other than the infirmary, shall be designed and applied: a. under the supervision of a physician, physical therapist or occupational therapist: b. so as to reflect concern for principles of good alignment, concern for circulation and allowances for changed of position. c. Initial application of the device and staff training for ongoing

NVTC INSTRUCVON 5301 PAGE 3
aooiications shall be the responsibility of the physical thereoist. the physician or the occupational therapist as appropriate. d. On a montnly basis, the responsible therapist shall personally observe the resident wnile he/she is utilizing the device and review those portions of the CHS pertaining to monitoring requirements contained in the client's individualized plan.

5. The use of protective device such as a posey vest ordered specifically to

prevent injury from falls during normal sleeping hours shall be prescribed and

monitored as follows:

a. Initial orders shall be written by a physician based upon documented

evidence that the use of such a device would prevent further injuries

to a client. Orders must be renewed at least every 30 days by a

physician's written entry into the client's record.

b. At the time that changes in condition of the client no longer warrant

me use of such device, its use shall be immediately terminated upon

order of the prescribing pnysician.

c. Opportunity for motion and exercise shall be provided for a period of

ten minutes every two hours, however, if the client is asleep, the

device need not be released unless he/she is showing discomfort or the

device upon visuai and physical examination indicates constriction or

a loss of circulation.

d. Physical observation of the dient in a sleeping device must be made

every 30 minutes and a notation (of J4 hour physical examination of

dient in the sleeping device), will be entered in the unit bedcheck log

and initialed. A monthly 1.0. note must be entered in the dient's CHS.

referencing the log and indicating that physical inspection did occur.

The log must be maintained as a permanent record on the unit.

e. Clients requiring sleeping devices must have rails on their beds. The

protective devices are to be tied in sucn a manner as to allow the

client TO aim from sice to side and to sit uo in bed without restrictions.

f.

Nursing staff shall be responsible for demonstrating/ providing training

to staff in the application and appropriate monitoring of sleeping

devices.

C. Additional requirements for protective devices used for medical/ surgical purposes as defined in IV. B.. 2.

1.

If not directly available, after consultation with registered nurse who has

personally observed the client, the physician may make the initial order by

phone. However, the physician must personally observe the dient and renew

the order within 24 hours.

2. Thereafter, orders must be renewed after personal observation by the physician weekly or at the time of any change in the condition of the dient.

3. Physical observation of the dient by appropriately trained staff must be made every 30 minutes and documented in the client's CRS each eight (8) hours.

4.

Opportunity for motion and exercise periods shall be provided for a period of

not less than 10 minutes each 2 hours in which a protective devise is used

T—mr

NVTC INSTRUCTION 5301 4
unless the client is asleeo (see Section V. B. 5. c. for reautrements pertaining to protective devices used during sleep). Such motion and exercise periods shall be documented as occurring or not occurring. If the latter supplies, reasons shall be noted.
5. If a protective device is to be utilized for a period exceeding one week, the Director, NVTC. and the Advocate wiil be notified by the Director of Health Services. Action on the part of either will be contingent on review of available information relating to the client's status or condition.
D. Uses of feeding chairs and routine night-time bedside rails.
1. The use of feeding chairs during mealtimes, except when utilized in conjunction with plans authorized by a physical therapist or occupational therapist as stated in Section V. B. 5. and/or use of routine night-time bedside rails shall be prescribed and monitored in accordance with standard nursing procedures.
2. Orders may onry be written after physical observation by an RN or Physician and must be renewed monthly.
aro This instruction wiil become effective on the date issued.

DHL:LR/jgf Advocate

David H. Lawson. Ph.D. Director

BEHAVIOR THERAPT PROCEDURES Definition, and

TABLE OF CONTENTS

I. Philosophy

2

II. Design cf 3ehaviar Therapy Programs

4

III. Behavior Therapy Programs: Adaptive 3e&avicrs

Through Positive procedurss

10

IV. Behavior Therapy Programs: Adaptive Behavior

Training and Restrictive Procedures

20

v. Design and Implementation of Behavior Programs . . 22

VT. Summary of Programmatic Uses or Restrictive

Procedures

57

VTI. Staff Training .-

S3

vxil. Definitions

,

66

IX. A2PENDICZS

68

A. Mission and Goals oftfVTC

3. Mission statement Cor tie Behavior Management

C. local Human Rights Csssitcs* D-, Functional Analysis Interview Form E. Crisis Management Documentation Form F.[ Behavior Program Record G.| Monthly Review of Restrictive a n d M a n r e s t r i c C i v e
• Behavior Program H-! B M C / L H R C C p d a t e S h e e t tj Group Active Treatment Outcome Monitoring Form J* Psychotropic Medication Assessment K. The Mandt system L. List of Approved Mechanical Restraint Devices

NORTHZHM VTXGXHX31 TSJLISIHG CZ2OTS

3ZHAVI0R THZRAPY PROCEDURES; PHXLCSOPHY OF USE, DEFINITION

!

AND STAJ7 R£S?0NSX3rLiriIS

PHILOSOPHY
The Northern Virginia Training Canter (NVTC, Is dedicated ta the principle that all individuals are entitled ta develop to their fullest potential and become as independent as their innate capability will permit. (See Appendix A far Missions and Goals of NVTC.) Individuals of all ages and sax vita developmental disabilities, regardless of the nature and degree of their cognitive, emotional, behavioral, or physical disability, are capable of learning and will benefit from tne successrul application of current behavioral tacnnoiogies.
Tne Mandt System of behavioral interaction has been adapted by the commonwealth of Virginia and accurately reflects tne traataent pnilasocny of NVTC. This system not only provides tie underlying foundation for all behavioral interactions vita. tae clients but is also viewed as an integral component of. all formalized behavioral management programs. All staxf are trained in cae use of tae Mandt System and are expected to integrate tie application of nonpnysical and physical methods of interaction vita formalized restrictive and nonrestrictive behavioral programs. (See Appendix K for an outline, i.e., table of content,, of tae Mandt System.)
The policy and philosophy of NVTC is to (a) focus on equipping all clients to ccsaunicate their r.&^ds and desires, providing aoceis of adaptive and socially acceptable behavior, and providing environments and experiences that are reinforcing, and (b) seeic tae least restrictive programming alternative for each client, i.e. , there must be a match between the nature and severity of tae problem and rastricrtiveness/intrusiveness of tae procedure, and (c) ensure the protection of each individual's rights vhen restrictive procedures are utilized. The least restrictive alternative is to be defined as those, procedures vhica will most quicJdy eliminate the behaviors for waica they were iatanded, iatrusive only to tha point required to achieve clinical effectiveness, so that taa individual is then able to participate more fully in all phases of his/her daily schedule of training programs.
Behavior Taerapy Programs are based on the premise that adantive and maladaptive behaviors are learned behaviors, and

hence can be modifisd through the systematic application of principles af learning. These programs aredeveloped vith the parricipacion of individuals served and their parents, guardians, or advocates, aredesigned izr individual clients tatting into consideration not only tieaaove tactsrs bur also "ne individual needs, strengths and developmental/social
l e v e l s o£ <=ia« e i i a n c . ?3?oe««tiral eara«?Uird* iriClUdttfl i n ^Hie
document are designed ts ensure ciat rie individual's rights. to effective habiii-aticn and freedom from undue csercion are balanced and protsctsd.
Tlie purpose of tiiis Behavior THerapy Procedures manual i s to provide policy and procedural guidelines for zh.e design, development, and implementation of tre&csint programs for individuals with specific behavioral training needs. r^ i s our expectation ".ax services delivered tiirsugh. quality behavioral programs v i l l enhance the maturation, development, v«ll-*D«ing, and quality of l i f e of a l l JTVTC clients within the most noraal and least rastricrive environment csnsistant with their needs.

IX. DESIGN OF BEHAVIOR THEHAPY PP.OGSAMS

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3ehavioral therapy programs at ;T7TC ars based on the modal of "Behavioral Deficits/Behavioral Excesses." Therefore, Che individualized habilitation plan far a client who exhibits aaladaptive behavior includes provisions to teach the individual tie circumstances, if any, under vhich the behavior can ba exaibitsd adaptiveiy, to taacn the individual how to channel the behavior into similar adaptive expressions, or to replace the maladaptive behavior with behavior that is adaptive. Reliance on raactive control procedures is unacceptable.
Individuals* behaviors ara reviewed and analyzed to determine potential causes of maladaptive behaviors that say be related to factors in the individual's li*e, such as (a) lacJc of exposure to positive models and teaching strategies, (b) laeJc of ability to ccamunicats needs and desires, (c) lacJc of success experiences, (d) lade cf social, community, and leisure slcills, (e) insufficient quantity of high quality activities at an appropriate level, (f) lacJc cf opportunities to interact vith others, (g) history of inappropriate reinxarcement and punishing experiences, (hj inadequate coping sJcills to deal with frustration, stress, and anger, (i) boredom and environmental stresses, (j) a physiological condition, e.g., pain, discomfort, and law sensory threshold such that 3ialadaptive behavior occurs when the thrashold is breached, or (fc) psychiatric conditions.
Behavior management programs are designed to raduce or eliminate behaviors vhich iirtarfars with ongoing training, and ts taacn the client nore socially acceptable behaviors. Behavior programs provides a hicn degrae of consistancy by identifying t«e ta-rcatad behaviors and specifying vnat the staff response should be. Behavior programs generally consist af tvo main components. The first is a sat cf training procedures taacn clients alternative replacement behaviors which serve the same function fpurpose) as the maladaptive behaviors. For example, taaching a client to gat attention by Jcnocicing on the team station door rather than engaging in self-injury. The second is a reactive procedure to manage the maladaptive behavior when it occurs. This may consist of procedures ranging from vernal prompts to "calm down" to the application cf highly restrictive mechanical restraints.
Several essential procram development components must be addressed before a comprehensive and effective behavioral programs can ba designed. These basic components, as described balow, aust be taken into consideration regardless

of the individuals adaptive oehavior training needs, severity or nacurs or targeted aaiadaptive behaviors, or degree of program rastrir:iveness. See also Section III.
A. Socially appropriate benaviors which are currently available and displayed by the ciianc Bust be identified. Additional training say ba needed Co strengthen these behaviors or develop new behaviors as replacements for inappropriate and maladaptive behaviors.
3. Targeted maladaptive behaviors muse ba claariy defined and described in detail (e.g., operational definitions) to enable staff ta accurately record their frequency, intensity, duration, and other significant behavioral characteristics. There are several categories of inzcrmation vhich should be collected as a parr of baseline data. These, in addition to the behaviors themselves, include: (a) antecedents - what happened or what conditions existed just before the maiadaptive behavior occurred; (b) consequence - what happened to the antecedent conditions as a result of the maladaptive behavior; (c) client's response - how did the client responded to the consequence; and (d) ecological or environmental conditions - where the behavior occurred, time, date, persona present, noise level, etc.
Baseline data are then collected over a specified period of time without any intervention in order to (a) provide information in determining the function or purpose of - the behavior, i.e., why the client engages in the behavior, and (a) determine the effectiveness of the treatment procedure (behavior program) by comparing baseline data to treatment data.
Collection of baseline data can taJce a variety of different fcras depending upon the type and rats of behavior. Generally, low severity behaviors, SUCH as tantrums can be observed over an extended period of tiae with minimal interventions whereas severe self-injurious behaviors cannot be unattended for any length of time. Also, low frequency maladaptive behaviors aay require an extend period to time to observe these behaviors in sufficient frequency to establish a pre-treatment rate of occurrence. On the other hand, high frequency behaviors may ba sampled or probed during specific time periods, e.g. , collecting data for an hour each day for a veeic*
2. An assessment of the client's motivational, bases for the targeted maladaptive behavior(s) is conducted by the_ psychologist through record reviews, direct observations of the client, and vith input frenx ether zemoers of the client's Interdisciplinary Team. This procedure may

include, but not limitad « , m e fallowing forms of assassatnts: structural, functional, and analog. (For a mare data:.lea description or the assessment procedure and an example or t.-s worksheet usad in this process, pleasa refer en Appendix D.)

D. Once the behavioral assassaant has be*n completed, thA psychologist continues his/her leadership rala in tha design and development of a comprehensive behavioral program. Among the issues zz ba addrassad are:

1. Ecology. The relative significance of tie environmen-c on raa client's banavior, i.e., an analysis of taa canxlicri^ig nasds at taa clionr versus constraintst limitations, and/or conditions in the client's physical and social environment which contributes to the occurrence of maladaprive behaviors. Wherever possible, ecological faccsrs should be adi ustad to nesc thtt neads of tha targecad client without impinging on the neads and rights of other clients.

2. Total haoilitation program. Tie interactive nature

between and among haoilltation programs and behavior

requires an analysis of tha clients total

habilitatisn program. Theretore, tha relative

contribution of such programs as speech, recreationr

v

and occupational therapy must be recognized along

i

vith the need to ensure coordination of all

haiailitation programs.

3. Behavioral program. Development of a comprehensiva
behavioral program which address tha identified training needs of the client thrsugn positive rainxcrcament procedures. When applicable, the prcgraa vill also describe the leasz intrusive interventicn pracedure to deal with maladaptive bahaviors related to clients1 health and safety.

E. Priority target behavior(s) will b« identified by the psychologist for behavioral intervention. Tha primary concerns which must be addressed when selecting the targeted behavior(s) for programmatic intervention are:

1. Which behavior or category of bahaviars is most disruptive to the clienr?

2. Will modification of the behavior(s) enahle the cliaat "3 adapt aore efiecrively ta his/her environment?

J

3« Are rssourcas available cs effectively addrsss tha targeted benavior(s) ?
* , Haw can the ocCsirrsncs of the behavior be recorded reliably?
T. Thepsychologist will then generate hypotheses regarding the causes of the maladaptive behavior(s) and procedures will be identified andincluded in the program to increase the probability of socially appropriate forma of the behavior(s) necessary to accomplish the same inferred ends. These procedures may taice the farm of:
1. Specific training sessions to taach the appropriate b«havior(s) , especially itthey are not already in the client's repertoire;
2. a positive reinforcement program "overlay*1 of t client • s daily activity schedule as an integral component of ALL behavioral programs;
3. procedure (a) which addresses the health and safety needs of the client and others; or
4. a combination of the above, whichever is deeaed clinically appropriate.
G. Although not entirely under psychological purview, any behavior therapy programs must pay special attention ta the client's daily activity schedule. Toomuch structure (i.e., to many activities) maycontri-bute to the maladaptive behavior(s) while too little structure (i.e.,
. • too fsw activities) may, likewise, contribute to the maladaptive behaviorfs) . A functional analysis, as noted earliar, =ay indicate chat the same behavior canserve different functions in diffarant situations as well as for different clients and that specific activity components within the daily activity schedule may need examination as they, too, may be contributing to maladaptive behaviors.
H. The design, development,, and implementation of activities within the context of the client's daily routine is the responsibility of all disciplines woricing together as a team. These activities should directly address the individual training needs of the clients but sayalso be used as carriers for other forms of training. For example, communication, leisure, and recreational sicills training can sarve as ends in themselves bur they can also be used to encourage and promote the display of more appropriate forms of behavior in a wide variety of social situations.

Planned. monitoring of tha clients' bahavior aust also ba conducted on a regular basis, m i s may taica tha form or asSASsmg the interaction pa-crams bewean staff and clients as veil as tha cenaviar of the clients themselves. Psychological Services currently usas tha GATOMF (Group Active Traatment Outcome Monitoring Fora) developed by Reid & Parsons (1990) to document tie extant to wnicii clients are engaged in activities which have varying degrees of therapeutic utility from an active treatment perspective (See Appendix I) . Tills information is than provided co residential unit supervisors to enable them to provide the clients viti the most therapeutic environment.
I. , The psychologist also recognizes that contextual influences also shape tne eaergenca and display of • maladaptive behaviors. Environmental factors^ such as tanpara'cure and ciimacic conditions, over-crowding, activity and naxsa levels, social interaction patrarns betveen and among staff and clients, and Z3.SK demands contrxhute to tie development of the client's behavioral topography. In particular, the communicative intent of maladaptxve behavior(s) must be recognized, and addressed. in a comprehensive aabilitaticn program developed by tha psychologist, speech therapist, and/or other significant member of the client's Intardisciplinary Team.
J. An, effective behavior therapy program must also consider the impact of intrinsic and extrinsic factors on tha development and maim»on»nra a c naladaptive behaviors. For example, the dietitian, physician, and other medical practitioners should ba consultart to determine the significance of the client's diet, allergies, and other physiological conditions vnich may be cantributing to the naladaptive behavior(s).
Tie psychiatrist should also be consulted if there are any suggestions that mental health issues may be involved.. If psychotropic medications are prescribed as an adjunct to the client's behavioral program, then the effects of the medications on the client's behavior (i.e., psychiatric features such as hallucinations, delusions, ayperactivity, lethargy, sleeplessness, etc.) will be monitored on a regular basis. (Sae Appendix J for an example of one monitoring instrument.)
Therefore, tha policy of NVTC is to focus on (l) the establishment of the most therapeutic social and. physical environment possible within residential programs participating in Title XI3C Medicaid Program for intermediate care Facilities for individuals with Mental Retardation (ICF/HR) , such as

••p
XVTC. £2) t*. provision of -nrfividuaiized and inzegrataa training Is ==n=?der=a to ce active rrSa«enc. and <3) **« P « « « o n
d use of poamive crai-iiaq cachmcues -= inc.-ase c..e ^ ! i t Y of occurrence of appropriate benavior(s) i=r ti» while ar cae same cia.. anauii-ig " e client =3 actii.v. inferred Bacivmeianal ends. T&iS entails t u o u r c^-nt « maice discriniiiaciona of wHici behaviors ar« ^ or unaccantiiile as wall as when and where carraia. ) is/are aDoronriace. For example, pumping on on tie residential unit may b* dangerous to ta.
e S S r ^ S d i= d M « u e s i v . of property; pumping on approprrat. recreltional equipment aay be safer for cae client, lesa I.aSu«ive of property, and, hopefully, M M enjoyable.

X I I . 3EHAVT0R TEZSAPY PROGRAMS: ADAPTIVE BEHAVTQRS THROUGH POSITTTi PROCEDURES

Behavioral programs are developed for t i e purpose of teaching clients alternative replacement behaviors which serve t i e same function or purpose as their naladaptive behaviors. These behavior programs must be designed to increase individuals' repertoire or adaptive and socially appropriate behaviors to increase their independence and eventual re-integration into their communities.

A variety of training procedures grounded in the principles or

Learning are currently available to assist the c l i e n t s to

develop more socially acceptable behaviors, thereby reducing

the occurrence or maladaptive behaviors. The basic underlying

assumptions of behavior therapy programs are: (a) behavior

problems are learned, (b) behavior problems are learned

separately, (c) behavior pronlems can be modified using the

principles of learning, (d) the behavior problem that a client

exhibits in a particular situation indicates only how that

individual behaves in that specific situation, (e) emphasis i s

placed en treating the c l i e n t ' s behavior in t i e hera and now,

(f) goals and objectives of behavior management programs are

specific, and fg) symptom substitution does not occur i f there

has been an accurate identification and modification of those

~\

factors contribute tc the c l i e n t ' s behavior problem-

'

A variety of behavioral and nonbehavioral ( i . e . , environmental nanipulations) management procedures are available for use v i t i t i e clients cr NVTC. These include, cut are not limited tzo t i e fallowing:

A. All clients should, participate ir. on-ccinc planned activities vhicn are implemented as part of their daily activity schedule. Individuals vho are engaged in
\ activities, particularly activities they enjoy, are leas likely to display inappropriate, disruptive, and other forms of maladaptive behaviors. These a c t i v i t i e s , such as unit-based and structured recreation and leisure, speech and language training, and vocational sJcill training, also serve as excellent carriers or vehicles for individualized and croup training. Adaptive and
' targeted replacement behaviors which can be addressed ; during these a c t i v i t i e s include such behaviors as : cooperation, communication, compliance, social
interaction, and sicil! acquisition.
B« : Positive rsinfsreement systems: The presentation of a •' stimulus ( e . g . , an activity or commodity), the emission

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la

of an adaptive behavior (or "-a absence or a maladaptive behavior), and tie application oc a reward serves ca increase the raaccurr^nce proeabiiity of that behaviorI* the targeted behavior increase in frequency (or other measure o: improved benavicr) as a result of regularly scheduled data probes, then it is highly probable that the contingent stimulus is reinforcing far tha individual. Tills fora of response-reinforcement is the most common and most affective method of developing, strengthening, and increasing tha display of adaptive replacement behaviors.

Since it is not uncommon for an individual to have mars than one targeted behavior which needs to be changed* the behavior that should be changed first is the one that is judged ta be easiest to strengthen. "or a variety at reasons, including generalization, increased self-image because the client; begins ta experience succass, increased numbers of positive staff-client interaction patterns, the success of this response-reinforcement contingency procedure will then maJce it easier ta strengthen and/or develop other adaptive behaviors.

1. Differential Reinforcement of Appropriate Behaviors (DRA) : A basic procedure in which rewards are contingently given for displays of targeted appropriate behavior(s).

2. Differential Reinforcement of Other Behaviors (DKO):

A procedure in which a reinforcement is delivered at

the end of a specified time interval if the client

is engaged in any response other than the targeted.

maladaptive behavior.

;

3. Differential Reinfarcement of Incompatible Behaviors (DRI1 : A procedure in which a reinforcement is delivered if a specified adaptive behavior cccurs that is topographically incompatible with the targeted maladap-cive behavior.

4. Differential Reinforcement of Low Rates of Behavior (DRL) : A procedure in which reinforcement is delivered only if (a) a specified period of time has elapsed since the last maladaptive response has occurred, or (b) fewer than a specified number of the targeted maladaptive behavior has occurred during the preceding time interval.

5. Response Cost: Response cost generally involves a token economy sysrem but can be used when any reward is given for displays of targeted adaptive behaviors. The basic concept is that an individual

11

loses a reward, e.g., a toicen(s) or other desirable item(s) , vnenever an unacceptable behavior is displayed. Response cost does not involve contingent personal property removal or the
:ic-=icn or privileges.

C. Schedules of rewards: Even if it is possible Co reward an individual for each desirable behavior, research has indicated taat this procedure may not be the most effective in maintaining tie learned behavior. In most cases in which rewards nave been given continuously, the behavior rapidly decreases if tie rewards are removed. Tais will not occur if, after tie individual has learned the targeted behavior, rewards are given on an intermittent or partial basis instead of a conrinuous basis.

Among tie four basic reward schedules presented below, tae tvo most videly used schedules witn. severely handicapped individuals are toe fixed Ratio and Variable Ratio scnedules.

1. Fixed Ratis (73) reward schedule: Tie individual receives a reward only arter he has exhibited a fixed number of tae targeted behavior.

2. Variable Ratio (VR) reward schedule: Similar to tna FH schedule except tae individual does not always receive the reward after a fixed number of correct responses. A VR-3, for example* zim&na tnat the in individual receives a reward on the average after every 3 correct responses.

3. Fixed I.-tarval (71) reward schedule: Tae individual receives a reward only after exhibiting tae targeted beiiavior aftar a fixed iaterval of time has passed.

4. Variable Interval (VX) reward schedule: Similar to

the FT schedule except the individual does not

always receive the reward after the same fixed

interval. Rather, the individual is rewarded on a

:

variable tiae interval schedule which is randomly

determined. For examplef VT~3 means that an individual is rewarded an the average of every 3

minutes following the first correct response.

D. Factors which influence tha effectiveness of rewards.

1. Immediacy of t£a reward: Tne greater tae immediacy of the reward following a targeted behavior, Uxe greater the effectiveness of tae reward. If the beiiavior cannot be immediately rewarded,, a "bridging

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12

cue41 should be used. for example. staff should say or da something to bridge tie time delay becveen tie behavior and the reward.
Consistently rewarding behavior: During the initial stage of response development, all staff should consistently rsiniorce all targeted, behaviors. Once the benavior is well es-ca.blisb.ea, the "remforcemexit schedule" should be changed to a variable procedure in which a reward does not always follow the occurrence of tne targeted behaviors.
3. Combining praise with the tangible reward: give a tangible reward without praise, unless it is obvious chat the individual does nor like to be commended. As a general rule, nontangible rewards associated vith a staff member (e.g., an approving look, verbal praise, pat on that bacic, ate.) are preferred over more concrete rewards, e.g., drinics and fcod items.
4. Schedule of reward: The contingency between a behavicr and a reward is learned more easily when training begins at a low level FH. schedule. As the btthavior becomes more firaly established, the schedule can be changed to increase response persistence and generalization*
5. Type of tangible reward. Determine what is most desirable for tha individual, e.g., use a reward menu, and begin each session after determining what appears zo be most affective at that time. More than one type of reward may need t3 be used during any given session.
i
6. Quality and quantity of reward. 3e sure to use fresn and desirable tangible rewards and deliver all rewards with sincerity and enthusiasm. Give edibles and liquid rewards in small amounts while other forms of rewards, such as activity and physical contact, should be given for correspondingly short periods of time.
7. Individual who gives the reward. The reward should initially be given by someone who is a meaningrul figure in the individual's life. After the contingency between the client's response and the resulting reward is established, encourage stimulus (i.e., staff} generalization by assigning other staff members as reward dispensers.

5. Symbolic reward systams: Any itsm. person, or event can take on reinforcing properties when it is consistently associated vizi a reward. The following are examples of commonly used symbolic systems.

1. Token Economy System: This is an "economy system* since it is based on a "normal" monetary system. However, instead of receiving a dollar or some other monetary amount, an individual receives a token, A toJcen must (a) be something a person can see, touch, and count; (b) be in a specific place to see haw many is earned; (c) be exchangeable foractual rewards; fd) be obtainable from more than a designated person(s) dispensing the tokens; and (a) ba contingent upon the display or absence of specific behaviors.

Response Cost: once a token economy is well established, a procedure canbe used for placing a price an to.e display of undesirable behavior(s) . (See description under "Positive Reinforcement Systems. '•)

Star ciiar-zs: A. oigixly visible behavior ciarri^

aacnnnism isi vaici Z&A occurrence of targered

bahaviors (usually adaptive benavlars or t^ie absence

of maladaprive behaviors) are hign-Iigiitiad with, a

)

symbol, e.g., vita a "star,'1 "happy-face, •• e t c . , on

a fixed Interval schedule. After a specified mmhir

of symbols are accumulated, they ara than exchanged

for a reward-

other positive symbols: Any items which can be worn and displayed by an individual cansarvs. asa reward. "cr sxampla, a necJclace, bracelet (vrist bands , vrisrvatch, etc.) , or badge (riifaan, buttan, etc.) canbe given to an individual whenever adaptive behaviors areexhibited. The recipient not only "taovs" vhat tha symbol represents but, because the symbol is worn by the individual, staff and significant others can drav attention to the symbol and provide additional rewards in the form of praise, attention, and social interaction.

Laval system: Access to selected activities can also be used to discourage the display of maladaptive behaviors. For example, a client will bagin an the lawes-c level and will ba permitted to participate in a limitad number of activities, e.g., residential unit activities only. Whan he does not display any of the targeted maladaptive behaviors for a specified period of time, he is moved to the

nexr lavel vnars he now has access " a greater varisry and nuaoer at activities, e.g., off-unit hut only cn-<?raunds activities. The chird levei can be supervised orf-grounds activities, e.g., selected cssmunity-oased a cciv itias.
Techniques of training (behavior soaping) include, bur axe not iisired ta tie fallowing hierarchy of prompts. Compliance wita each, promprs should be appropriately reinforced. The goal is to maJce the client as selfsui-ic-anc and independent as passible. i.e.f selfiniriaricn of tasics and acrivicies wirii no or ainiaal
ring.
': l. Vartal Prompring - Lowesr level of prompring in voicn verbal cues are used cs describe and cromcce tie occurrenca of taa targeted adaprive benavior; may also include manual/sign cmnnrnm carion.
2. Gestural Prompring (Modeling) - Snowing tne client tne response ts be learned cirougn modeling or imitation.
3. Shadowing - Following tne client's movements tnxough tne desired response vita start's hands in order to use nigaer levels of prompting if necessary.
4. Physical Prompting - Gently touching the client to initiate and/or continue the response in a correct manner.
5. Physical Guidance - Physically directing a reaisrive client through the entire response sequence. If physzcai guidance is used for more than 1 minute, then zz>&procedure is considered to be rastricrive and rsquxres the approval or the Behavior Management Committee (SHC) , Local Human Rights Ccmnu.-rae (LSRC) , etc. (See Appendices B and C, respectively, for descriptions of their goals and functions.) Attempts should be made to decrease the degree of physical involvement whenever possible.
G. Training procedures for relatively complex behaviors:
1. successive approximation: An individual should be taught a "complex" activity in successive steps with each step gradually leading to an approximation of the desired targer behavior. For example* instead of teaching a person the whole behavior of putting on a pair of pants, this complex behavior would be broken down into its component parts. Each parx vould then be taught separately such that one
L5

component is then chained to the next component

until the wnole behavior is performed

satisfactorily.

;

2. Behavioral chaining: The Uniting of behavioral components until a complex behavior is learned according ta a predetermined saquenca. "or example, brushing taerh can be broken down into a number of isolated behaviors which are taught sapararely (e.g., pick up toorhhrush, pur pasra on the brush, inserr toothbrush inro aouch, ace.) and then combined inro the desired behavior.

Reverse training: Linking of behavioral components in a reverse manner, i.e., the terminal component is taugnr firsr and tiien systematically linking eaca component to tie preceding component in a stapwise faanion unril tne wnole benavior can be perxoraed witaout interruption frcm beginning to end.

b. Forward training: appoaita of reverse training, i.e., taacning a whole behavior by linking the first component with the second, the second with the third, unril all the components are linked together to fora the desired behavior.

H. orher behavior training procedures:

1.
;

Re-diracrion to another activity: When a client begins to engage in a maladaptive behavior, sraff will inrervene to determine probable causes and eliainars or reduce the effscrs of the disruptive influences. Staff vill then attampt tc encourage the client to either return to the rsouirad task or acriviry, or ta engage in another fora of appropriate behavior, ks a rule, redirection is more successful if the suggested activity is easy to perxora and enjoyable to the client. This is not an appropriate procedure if the redirection becomes a reinforcer for the inappropriate behavior.
Redirection should be recognized to be a temporary measure in that the problem or reason for the maladaptive behaviors has nor been directly addressed.

2. Stimulus Control: A technique in which a maladaptive behavior (i.e., typically used far srereorypical and perseverative behaviors and nor a serious behaviors) is broughr under control,by pairing it with a particular stimulus under the

IS

control of sraff. Once cie behavior is lirJced, with a. controlling szisulus, -hac srisai.ua can tien be systematically rsduced to decrease t i e occurrence of t i e maiadaptive behavior. Variations of this procedure include instructianal central.

3. Sactinction: A procedure in vhich positive reinforcement is withheld fallowing a maladaptive behavior. ?or example, a maladaptive behavior t i a t disrupts normal and routine interactions between staff and clients can be addressed throucn active ignoring, i . e . , staff doe* not atrend to or recognize the occurrence or existence or t i e emitted behavior. Ti.e exception i s vaen blocicing or redirection i s needed Car momentary stopping t i e maladaptive behavior if t i e intensity or t i e episode endangers t i e client or staxf * Tie success of t i i s procedure depends on t i e extreme csnsistency of withholding positive r*inr"an=emeirc whenever t i e targeted behavior is displayed (otherwise, a partial rainxorcament schedule is inadvertantly being used to maintain t i e undesirable behavior) .

4. Satiation: A procedure vhici is generally viewed, as

antitietica.1 to extinction. Satiation involves t i e

giving of unlimited access to positive reinforcement:

vhici i s believed to be m^ jrH-ai.rnng a targeted

maladaptive behavior. For example, it a c l i e n t

hoards or steals clothing from other c l i e n t s , then

the client would be given unlimited/excessive

amounts of clotiing with t i e expectation that he/she

would lose interest in t i e items.

,:

3. Modeling (cr imitative learning) : A. procedure in which ^ie desiraci behavior is f i r s t demonstrated to t i e individual and tien rewarding t i e individual for successfully imitating t i e modeled behavior (generally accomplished through t i e techniques of shaping, e.g., successive approximation). Sta£f must be sure that t i e individual i s highly imitative and t i a t t i e person who performs t i e modeled beiiavior i s relatively attractive and/ or prestigeful to t i e individual.

6. Individual counseling: Tie general orientation i s to focus on concrete and specific behaviors commonly expected in certain situations, e . g . , what would normally be expected as a "socially appropriate behavior" in a specific situation, psycicdynamic parameters, such as attitude, expectations, affect, e t c . nay also be incorporated into t i e counseling session when deemed appropriate ( i . e . , based on t i e

• i

. -•.

17

intended cucccse of tha sessions, functioning' lave}, of the individual, ace.) . Individual or group counseling sessions may also be more efiectiva if they are given a sense of importance to both staff and client by prescneduling as to tiae and place, and, in some cases where attending and/or participating t^isasaives are issues, rewards, toJcens, and other fsras of incentives may also be incorporated tie clients' programs-

7. Behavioral contracts: A vrittan contractual agreement betvaen a client and staff in which the occurrence af a targeted behavior vill result in a reinforcing conditioning, e.g., a client agrees to allow staff to inspect his closet for stolen soiled clothing in exchange far the privilege ta lacx his closet. Included in this contract are such items as the identification of specific behaviors to be targeted, staff and client expectations, consequences af targeted maXadaptive behavior, and performance criteria leading to the folfillment of the contract.

Training in sJcili acquisition. The behavioral repertoire

of many mentally retarded individuals is relatively

limited and does not penit them to adequately express

their wants and needs. Therefore, behavioral outlets

x

often include inappropriate, disruptive, and aggressive

'

forms of behavior as well as mere socially acceptable

forms of expression. Areas for continued training

include, but are not Limited to the following:

1. Communication sJcilis training: When maladaptive behaviors have been detersuned to serve a communicative function, che client's haJailitation plan, as developed by the Speech /Language Therapist
. and other Jcey memners of the Interdisciplinary Team, must include plans to taach the client other aeans of communication, thereby significantly reducing the function of the maladaptive behavior.

2. Community, social, and leisure sicills training: Because clients vill engage in both acceptable and unacceptable behaviors to occupy their time, "^iey must be engaged in training programs which, vill increase their interests and competencies in activities other than those which focus on salf-care and vocational needs. The Recreation Tnerapist, Speecn Pathologist, occupational Tnerapist, and other clinical and residential staff members of the Interdisciplinary Team, aust ba involved in these
. programming areas.

i

13

2. Self and/or anger -anageaent "^^"af should te direc^d c= c^e cri n:ng a: acle c e ^

t in niors

y

L^g^d^^
tacaiiiquea of aifecrive management.

ucii. a behavior rierapy program =av « s a l s « or

socially accencaile

^

b a trained in how

b«haviors

iity ro cie client's nomax l i . .

19

rv. 3EHAVTCR THERAPY PROGRAMS: ADAPTIVE 3ESAVTQR TRAINING AND RESTRICTIVE PROCEDURES

In order to address a client's behavioral netds, it may ba necessary to use positive procedures as previously described in conjunction vith either ii^it-setting, nonrestrictive behavioral procedures, or more intrusive and restrictive behavioral procedures. Again, the philosophy and policy of MVTC is ta emphasize cie posirive faarures raraer tian ciie reacrive aspects sucn as liair saczing, nonresrrictive, or restricrive procedures which comprisa only ont saall parr of t^ie clienr's overall behavior therapy program. Several points are significant and should be to be addressad within this context. i

A. Liait-seccing procedure may sarve a variety of functions.

1. Lisit -setting procedures sarve to interrupt a chain of behavior(s) before they escalate to more intense foras of behavior. As such, they may be }ceyed to a clinical knowledge of t^ie client's "typical" behavioral sequence (i.e., chain)-

2. By intervening earlier in the response chain, more

intrusive and restrictive behavioral management

]

procedures say not ba necessary.

3. LDcewise, lev levels of ma1adaptive behavior(s) may ba amenable zz redirection and limit-setting procedures without having ta rssort ta more intrusive ar rastrictive intervention strategies.

3. Generally, rastrictive praceduras are defir.ed as any procedure vtiz.cz,:

1. Restricts a client's freedom af movement.

2. Liaiits access ta activitiesr objects, or events to which a client would otherwise ba entitled as a part
of his/her rights.

3. Causes a resistive client ta perform a specific behavior.

4. Results in. altered states of consciousness, i.e., change in the psyche due ta the administration of psycaotrspic medication.
C. It is along the Lines af perceived restrictiveness of various behavicral intervention procedures that levels

;

20

5*
were established. GUideiir.es i.i establishing tiese levels of rastrictiveness ara:

L. Tie procedure iiseii. Some procedures are, =y tieir very nature, sors raacr:ci;ve/ intrusive c~an others. For example, verbal redirection into a room to «-»^ >n an aggressive client is less restrictive e^an the use of a personal restraint to achieve the same end.

2. The duration of tie prescribed procedures, With tie same procedures, in many cut not all cases - shorrerduraticns were designated as less restrictive than longer durations.

3. The degree to which physical iirtexvenrion is raquirsd to implement tie procedure. Some procedures offer tie possibility of tieir being implemented tirougti verbal control by staff vita no ph.ysa.cai interventions required. Tlxese procedures, under vernal control, are designated as less restrictive taan tie same procedures requiring physical implementation.

0- It is tie position of *TVTC tiat tie following procedures are not used to address m&ladaptive behaviors:

1. Corporal punishment is not employed.

2.. Seclusion, defined as noncontingently placing an individual alone in a room or anotner area from vnici egress is prevented, is not employed.

3. Individuals are not placed in totally enclosed cribs or barred enclosures (otiier tian cribs).

4* "Papoose beards" are not used as a fcra cf mechanical restraint.

5- Individuals served do not discipline otaer individuals served.

Throughout tie instruction, tie greater the perceived restrictiveness of tie procedure, tie higher tie levels of consent and approval required prior to program implementation in order to protect tie above-mentioned interests of tie client. Nonrestrictive programs require the approvals of the IDT and psychologist (and occasionally the physician and dietitian) while restrictive procedures require tie same approvals witi tie addition of: parent/guardian, 3MC (s«* Appendix B) , LHRC (see Appendix C) , and NVTC Director. Tie Client Advocate is informed of all restrictive behavioral progxams.

i

21

V. DESIGN AND IXPL£MZ5TTATrON OF BEHAVIOR PROGRAMS

3ehavioral programs have been demonstrated to be relatively effective in addressing a wide variety at behavioral needs, ranging from tha development and refinement of adaptive and cammunir/ living siciils training ta the reduction and aiiwinagian of highly disruptlv* and aggressive outburstsAll treatment programs are designed, ta use behavioral management procedures which are clinical sound and are r.te least rastrictive and intrusive procedures necessary to bring about behavioral change.
A. Formalized Behavioral Programs - Behavioral management procedures may be implemented either vita or vithout a formal written plan of training and intervention, in some situations tha psycnologist and IOT vill determine that the identified behaviors do not necessitate a formal written program and can be addressed, thxougn tze use of routine behavioral management practices, such as those caugnt in pre-servica and in Mandt System training.
Formal behavioral programs are developed in various vays, depending upon chair need for immediate implementation and degree of restrictiveness. Formal behavioral programs cannot be ianlement without prior approvals.
1. A behavioral program using only nrmreatrigtiv procedures requires the approval of the Psychologist and the Interdisciplinary Team. Sowever, other approvals may also be required, depending upon the purpose, aetncdology, and outcome of the treatment program. "or example, ii edible rsinforcsrs are part of the prsgram, zien advice and approvals of the dietitian and physician should be securad. (Se« Section VT; Summary of Programmatic uses oc Restrictive Procedures.)
2. A behavioral program using restrictive procedures requires the approval of the Psychologist, Interdisciplinary Team, Physician, Parent/Guardian, Behavior Management committee. Local Human Rights committee, and NVTC Director. The Human Rights Advocate is also sent a espy at tha program. (See Section VT.)
3# In some situation vixen a restrictive program must be implemented prior ts tha next scnmtuled meeting of the BMCf a behavior program can be presented for Interim, approval after the approvals of the IDT and

i' :

22

authorized raoresinucive* are oatained. The 3MC chair can approve the pro<?ram for a time period net to exceed riie next regularly scheduled meeting, A S outlined in the DMHMRSAS Rules and Saouiations r^ Assure the Rights of oggidenrs, "interim program*1 requires d a approval of the Psychologist. Authorized representative (Parent/Guardiaru , IDT. BMC, and LHRC. Interim approval can be given far all procedures except for Time-out.
4. Emergency approval for specific treatment procedures may be onrained for 72 hours for macrers of immediate health and safetr/ for che client and loss restrictive alternatives Have been determined to be unfeasible. This is generally a medical cancers and requires tie approval of either the Physician or Psychiatrist and a writtan medical order. ?or example, a mechanical restraint may be ordered to protect a client from serious injury as a result of a sudden appearance of self-autilation behavior.
5. Approvals for cilaical trials must also be obtained when restrictive procedures are under evaluation. On a short-term basis only, not to exceed 2 veeJcs, the psychologist aiay, for diagnostic purposes, implement any procedure up to but not including time-out or aversive stimulation as a consequence of targeted maladaptive behavior(s). Approvals required are the same as those for an interim program.
Immediately following sues implementation, the psycaclogist will enter an ID note in the client's CZS specifying the behavior(s) the client was exniiiti^c, the procedure used, date, time, duration of the procedure, client's reaction to tie procedure, and ether staff who had assisted.
B. Programmatic Use - Restrictive procedures at NVTC cannot exist by themselves except in emergency situations (i.e., Non-Programmatic Uses) . The use of these procedures programmatically must be done in the context of an overall planned behavior management program as designated by the Interdisciplinary Team.
Restrictive procedures, when used programmatically, are designed to be used altar- efforts to use nonrestriccive procedures have been unsuccessful or deemed inappropriate by the functional analysis. However, all restrictive programs are generally designed to use less restrictive nrocedures as the initial reaction to a behavioral issue.
12

Sfc
This is based en rie assumption and expectation that the client: will (1) eventually" learn to appropriately respond to early and nonnnysical/nonrsstrrctive farms of behavioral interaction resulting in t i e tsrainatian of t i e behavioral episode. (2) learn to respond in such a manner that restrictive procedures will be used leas frequently as training progresses, and (3) no longer need restrictive interaction procedures to manage maladaptive behaviors in t i e fuctira.
For example, i* a time out procedure i s indicated by t functional analysis (e.g., t i e client becomes disruptive or aggressive to gee staff's attention), t i e behavioral program should incorporate t i e use of less restrictive procedures as t i e f i r s t stapf suci as problem-solving, redirection to preferred activities, limit-setting, or rediraction to a quiet area, before t i e restrictive procedure of tine out is used*
3eiavioral programs, using boti nonrestrictive and restrictive procedures (waici incorporates nonciiysical and piysical interaction procedures described by t i e Mandt System) nay be viewed as a relatively temporary '•over-lay" af t i e client's daily activity schedule.
1. Restrictive procedures may be used only when t i e individual's behavior:
a. Presents a danger to self, others, property, or is severely disruptive to a therapeutic environment; and/or
b. interferes significantly witi t i e individual's deveicpmental/sociai progress.
2. Prograamat-caliy, restrictive procedures may be used only:
a. As part of a planned, approved, and documented aabilitaticn program designed by t i e psychologist and Interdisciplinary Team t i a t emphasizes the use at positive techniques of behavior management and t i e development of appropriate replacement behaviors.
b. When other less restrictive alternative procedures have been (a) consistently implemented and documented as unsuccessful, or (b) treatment literature or c l i n i c a l judgment indicates that t i e proposed intervention

rapresencs the least rastrictive altamativ* appropriate zZ rasaive the problematic behaviors(s).
c. Vhen they are designed to lead ta less restrictive ways or managing and/or ultimately eliminating the behavior(s) for which ^hey ware employed and subsequently eliminating tie necessity of restrictive components of treatment programs.
Re3tr::::ve procedures may nor be used (a) in the absence of maladaptive behaviors, (b) in retribution, (c) far staff convenience, (d) as a consequence of insufficient staff, (a) in the absence of positive habilitative programming, or (f) as a substitute far benaviaral programming. Ixcspx for valid emergency situations as specified L.i tne MonPrcgrammatic Sections, restrictive procedures may not be used vita clients until individualized plans have o^9a developed, reviewed, and approved as specified in tnas instru.cti.on. To subject a client to tnese procedures may be considered abusive and reviewed i.i accordance viti NVTC Instruction 5002, "Abuse or Neglect of Resident".
No restrictive procedure with, tile exception of mechanical restraint used as a response prevention device may be used during "down time". Down rime is to be defined as periods of time greater t^ian 15 minutes during vhich the client is not under visual but only under auditory supervision and/or staff are not immediately available- This is ra be distinguished from true "Leisure cine11 in which staff are directly available to c:ia client and are offering options of activities rrcm wnich tiie client may choose. During periods of "down time", if the client begins to exhibit saladaptive behaviors, staff are to utilize the sequence of procedures described in Section V.D.3., (Crisis Prevention and Intervention Procedures).
When a client exhibits maiadaptive behavior and systematic efforts to eliminate the behavior have been demonstrated to be ineffective, tne need for the services of a behavioral management consultant will be recommended to the Interdisciplinary Team by the psychologist.
In the design, development, and implementation of a behavicr program, the psychologist is responsible for:
25
"IT Hi

=2*
a. Involving th« participation or mams«rs of the client's Interdisciplinary Team wnich includes personnel frsa rha client's residential unit, clinical support staff, day placement (e.g., school, workshop, etc.) , the client and fciis/nar parents, guardian, or advocate.

b. The clinical design of tie behavior program to ensure that all components below are included. All program components will be discussed vith tne Interdisciplinary Team prior to their implementation.

(1)
:
i i :

Specification of behavior(s) to be decreased or eliminated, i.e., targeted maladaptive behaviorts) . The behavior (s) should be operationally defined to enable sraf£ ta clearly identify the behaviors in question.

(2) Current eperant level of maladaptive beiiavior (s), e.g., frequency, intens itv, and duration.

(3)
\ ; ;

Review of previous programs attempted and specific outcomes, e.g., why they were successful or unsuccessful. If deemed necessary, citation of previously reported or published descriptions of treatment procedures.

(4)
; ; \ \ I :

"unctional motivational analysis to identify inferred motivational factor(s) and communicative intent of maladaptive behavior(s) , This assessment vili include an analysis of the antecedents of the targeted behaviors and a determination whether or not environmental alterations or other manipulations would reduce or eliminate the behavior(s) .

(5) Method(s) of reducing/eliminating targeted

i

maladaptive behavior(s).

(6)
• i I

Specification of targeted adaptive/
replacement behavior(s), i.e., defined operationally to provide objective descriptions of the behavior(s).

(7) Current operant level of adaptive behaviar(s), e.g., frequency", intensity,
I • and duration.

^

26

(3) Metacd(s) at "raiding and/or sr.api.ig targeted adaptive behavior£s) . Whenever appropriate, descriptions of tie training schedule, e.g., -araai vs. vithin tie context of tie clients daily routine, day, time, etc.
(9) Identification of personfs) responsible for implementation of procedures.
(10) Specification of vhen restrictive components are to be implemented.
(11) Proposed objectives) for adaptive behaviors.
(12) Proposed objective(s) for saladaptive behaviors.
(13) Statements crcss-r-ferencizig psychotronic medications(s), day programs, and other agency/disciplines where applicable.
(14) A statement regarding potential physical and psychological risJc(s) and/or side a££ecc(s) of tie behavioral program.
(15) Types of data to be collected, i.e., data collection system to allow data-based decisions to be made regarding program effectiveness.
(16) Frequency O E data collection, summary, and review.
(17) Person(s) responsible for data collection,.summary, and review.
(13) Anticipated duration of program, if clinically indicated or possible. For restrictive benavioral programs, BMC and LHRC approvals ar« given far 6 montis, or indicated otherwise.
(13) A description of conditions requiring thm psycholegist's review beyond tie normaX informal daily/weeicly review or formal monthly review should the maladaptive behavior(s) escalate, especially as tie program.is begun (i.e., an upper limit or - thermostats11 to indicate tie program is to be reviewed).
27

(20) Far chose clients (a) vno have a behavioral conseeruence which is confining in nature (e.g., pasey vest, •;-paint restraints, time-out) ; (b) whose behavior during restraint or time-out could pose a continuing threat: t3 rnpmsalvas or others; (c) vfta manifest a psychotic process; the. plans snail specify" procedures nor protecting the sarecv and vail-being at cne clients in tna event of firs or at&«jr emergencies.

(21) ir a rsatraisr or any otiaer rasrri

procedure is Co b« us«d as part of

b«navior program, a statastant by tne unit

physician indicating toat she/he has

examined and approve ins use, i.e., chere

!

are no medical contraindications.

(22) A statement-by tae dietitian tiax cirinics

and edible reinzorcers nave been evaluated

based on tie individual's nutritional and

;

dietary needs.

c. Securing all necessary approval, consents, and notifications for tiie program prior to it's implementation for tie s-cated duration of tne program•

d. Training staxr and docusuuxting such training for proper implementation of all poases or components of the program, i.e., training tiuroucn. positive reinforcement procedures to develop appropriate replacement benaviors or ennance existing adaptive benavicrs as wall as intervention tacflniques to addrsss maladaptive behaviors. (See Chapter VTI on staff training for additional information.}

(1)
I I i I I i | • : I j

The psychologist and/or psychology assistant (trained by the psychologist) will train the Unit sixpervisors, i.e., the program manager, team leader, and AM, ?M, and NQC developmental technicians, and as many developmental aides as possible in all phases of the program prior to program implementation. Ttiose aides remaining untrained will be trained by th.eir designated supervisor(s) . Retraining by the psychology assistant or psychologist per afiove procedure will occur at least every six months thereaxtar.

23

(2) 7i:e training will consist of demonstrated competence in ail *acets c: tie behavioral program. This includes: (a) vernal and vrittan understanding or tsa program procedurss, (b) deaanatricion of ail adaptive behavior training, and (c) tie application and direct experiencing of reactive interventions techniques.

(3) Documentation of tiiis training as indicated by tie signature of the individual conducting the training, i.e., psychologist, psychology assistant, •••» leader, or developmental tacftni.cians, vill be fcrvarded ts tne cnaixtrersan of tie Benavxor Management Commieta- (3MC1 and tae Training Departaent.

; (4) The team leader and developmental technicians, fallowing training ay the psychologist and/or psychology assistant, will be authorized and responsible for training all remaining staxf in all phases and components of the program. In addition, the Unit psychologist and/or psychologist: assistant is on the Cnit daily and are able to modal planned intervention procedures as well as respond questions or concerns regarding any aspect of the behavioral program.

(5) cnly individuals who have been formally train will be considered authorized to implement behavioral programs.

(6) Training and cccumentaticn thereof will be

;

conducted pricr to program implementation

I

and at least every six months thereafter.

1

(7) Persons who have not been trained may not

i

implement any phase or component of the

]

program until such time as they have

;

received training and documentation there

;

of provided as above.

e- At least monthly monitoring of the program by the psychologist or psychology assis*cant to include:

(1) A. period of direct observation of behavioral intervention procedures conducted by staff.

29

i (2) Discussions with residential staff (and

I

involved clinicians) regarding the

|

effectiveness of program procedures.

f.| At least a monthly review of adaptive and maladaptive data by the psychologist, including trend analysis, explanations of the behavioral
i trend if applicable, possible program cnanges, •; etc. in the*Interdisciplinary Progress Note
section of the Client Record System (CSS). Behavioral data may be furnished to parents, guardians, or authorized representatives who follow existing procedures to obtain information from the CSS.

g. As a general guideline, a restrictive procedure should be considered for discontinuation if it has not be*n implemented for 2 consecutive months, inceptions za this guideline should ba justified and approved by the psychologist and IDT and then presented ta BMC-

h. Reviewing the progress of clients with restrictive procedures through BMC and LHHC at specified intervals for those programs which require BMC and LHRC approvals.
i. Reviewing of the preceding month's data in order to authorize continuation of the procedures for the next month.

j. All consents, approvals, and notifications resulting ia the formal approval of the program will remain ia effect as long as the program is active. la tie event that a parent /guardian withdraws consent or approval despite the continuing need for the program, as indicated by the psychologist: and the IDT, the issue may be presented to the Senior Interdisciplinary Team for consultation and approval. If necessary, an outside consultant acceptable to both parties will be obtained to review the case and attempt za mediate a resolution.

Ic. copies of all restrictive and nonres-crictive programs will be sent to the ^hair7i«n of EMC, Client Advocate, and client parent or guardian after all necessary approvals and csnsents are secured. Approvals and consents may be withdrawn at any time by a client's parent or
guardian.

30

TBT --n

IT"! ••

I 1. ] j ]

Sanding a list monthly (or as needed) to the Chief cf Psychological Services of the names of clients for vnon behavioral programs have been designed and contain restrictive components.

C. changes in Behavioral Program and Procedure: The Paycnolagisz vili provide on-going monitoring and assessment cf the ecology as wall as the c 11 ants' total training program, (recreation, speech, vocational, etc.) at NVTC. Therefore, adjustments in a client's behavioral program may need to be made on the baais of the client's changing behavioral topography. For example, changes in the positive reinforcement procedure aa well as the level of intervention may be necessary, e.g., degree of restrictiveness may be changed from a guiat room consequence to an extinction procedure because of a change in the function served by the maladaptive behavior. All changes must be approved by the Interdisciplinary Team and, if the restrictiveness of the program is increased, additional approvals must also be obtained.

X* Definitions:
i !
a. Restrictive behavioral program: Personal and mechanical restraint procedures, time—out, modification of client's rights, psychotropic medication, etc. (see summary table of Programmatic Procedures far mare details).
b. Program deferral: A. temporary short-term discontinuation of a behavioral program approved by the Interdisciplinary Team.
If a client has a restrictive behavioral program (whether because of a restrictive behavioral procedure or the use of psychotropic medication) , the program cannot ba deferred. L£_ a behavioral procedure far a restrictive program must be changed (e.g., a procedure is no longer effective and/or appropriate and other adaptive and/or maladaptive procedures used) , then the procedure(s) must be incorporated (i.e., written) Into the behavioral program far the duration of its usage.

A nonrestrictive behavioral program can be deferred with the approval of the client's Psychologist and Interdisciplinary Team. However, during the interim, residential staff must be provided with clearly writtan intervention procedures to address the client's training needs. The psychologist must

31

' *mr

also specify zixe. conditions under which the original behavioral program will ba reinstated, raodifiad, ar discontinued.
4. When a restrictive behavioral program is changed toward greater rastrictiveness, all original approvals must again ba secured by tie psyciologisr. Additional approvals may be required in some cases when other1 professional disciplines axe now involved, sucn as the addition of edible reinf orcaments as a part of the training program (e.g., tie dietitian's approval should now be added to the list of approvals) . (see summary table of Programmatic Procedures).
5. When a behavioral program is changed from being nonrastricxive no restrictive, tie standard procedure for securing approvals for a restrictive program aust be fallowed*
6. When a restrictive behavioral program is changed toward lesser rastrictiveness or is now nonrestrictive, tne change must be approved: by tie Interdisciplinary Team and a memo describing the change farvarded to the chairperson of BHC.
Programmatic Procedures (see summary table for approvals, concerns and notifications necessary).
1. Calm: A clinically determined period of time of sustained non-agitated behavior not to exceed tan (10) minutes. It's function is to ensure that tne client is, indeed, clinically calm before returning to tie activities available ta aim/her and tiereiy rsduca cia probability of a ratum ta tie previous state of disruptive behavior. Duration of calm, e.g., calm for 2 mnutes, is to be established based on prior experiences with observations of tie client.
2. Overcorraction: Any type of repetitive actions implemented as a consequence of behavior. Overcorrsction procedures shall not be prescribed for* a period in excess of 3 0 minutes. The total amount of time per day a client spends in overcorraction procedures- shall not exceed tvo (2) hours within a tvanty-four (24) hour period for repeated incidents without prior approval of tie Director of NVTC.
32

a. Graduated Restitution: AeCurr.;.ig the

environment tc it normal state with, ~«a minimum

pnysical intrusion necessary. For example,

oicicmg up ciotimg, placing tiea on hangers,

.

and returning tiem to tie ciossc after thay

have bamn tirewn out by tie individual.

b- Graduated Positive Practice: Repeating the appropriate form of tie behavior with tie atinimum pnysical intrusion necessary. "or example, as a consequence of deliberately spilling or rftrowing food during a meal as an intentional act of misbehavior, a client will not only p e r r o n restitution but also wipa tie table and clean tie immediate area after a meal.

c. Graduated Contingent Exercise: Repeating a topographically dissimilar response with respect to tie targeted maladaptive beaavior(s) witi tie minimum pnysical intrusion necessary. For example, as a consequence of ^-^appropriate sexual touching of another client or staff, a client will touch his toes ten times for a specified period of time.

d. Graduated Negative Practice: Repeating the targeted maladaptive behavior with tie minimum physical Intrusion necessary. For example, as a consequence for constantly moving furniture resulting in the disturbance of other clients, a client will bs guided through tie act of moving furniture tar a specifiad period of rime.

Contingent Exclusion: Temporary removal cf a client from ongoing activities as a consequence cf a maladaptive behavior. As with all programs, but especially with contingent exclusion procedures, it is necessary to specify those conditions under which a psychologist's review will be done. This is to ensure that tie client is not excluded unduly from significant portions of training for unnecessarily prolong period of time, with tie exception of "On unit During Program Time," "Unit Restriction," and "Contingent Access to Activity, " no order aay exceed one hour. See Section rv.B.9.f Extension of Procraamatic Procedures.

As a general policy, exclusion procedures are not used in response to self-injurious behaviors (SIB). Tiere are exceptions, however, when exclusion may be

33

an appropriate response to SIS as determined by functional analysis and the clinical judgment of the psychologist and IDT and approved by BMC and LHRC. For example, exclusion may be an appropriate procedure if the SIB is motivated by attention and does not escalate to an intensity where personal restraints are required to prevent possible tissue damage.

If exclusionary procedures are used, as reactive interactions to physical aggression to people and the client begins to display SIB, the psychologist, in conjunction with the physician, must clearly described the contingency procedures in the behavior program to address this situation. Tnat is, the program must indicate the conditions under which staff will intervene, e.g., when to ignore the behavior and when they will physically stop the SIB.

a. In Room: Tae client is escorted to his/her ovn bedroom or to a vacant room with the minimum physical intrusion necessary. P&ysical procedures should not be used to maintain tie client in the designated room.

b. In-Seat: Tne client is escorted to and sea-ted (but not held in) with tne minir™"" physical intrusion necessary, tfonpaysical procedures can be used to keep the client seated.

c. Off-Unit: The client is escorted off the unit (e.g., to a hallway or outside the building) with the minimum physical intrusion necessary (MOTE: If this procedure is utilized the writtan narrative ts tne behavior program
. : should include documentation that the client is capable of utilizing this procedure in a positive manner, i.e., not running away or resorting to displacing anger/aggression to passersby or property.)

d. In Corner: The client is escorted to a corner of the room with the minimum physical intrusion necessary. The client is maintained in the designated area through verbal /gestural prompts, physical presence, and other
; ,nonphysical procedures.
i
e. Quiet Roes/Area: The client is escorted to a neutral unlocked room/area other than his/her bedroom with the minimum intrusion necessary. The room/area should be ventilated, veil lit,

*

34

free of safety hazards, and unless otherwise ccncr^uidica ted, equippea v i z i a aac. Zgiress frcm cie ream/area i s not pravtntcd by t i e
staff monicsring cne prscedure.
Time out from reinforcement vizi staff in tic room viti tie client: Tie client is esccrxad with minimum physical intrusion zc a room with a staff member in che same room. Tie room should be ventilated, wail lit, free of safety hazards, and. unless otiervisa ccnzraindicated, equipped vith a mat.
Time out from reinforcaaant vith staff outside tie room: Tie client is escorted to a time out room with tie least amount of physical intrusion necessary. Tie client is prevented from leaving tie time out room vith a hand-held lacking bar (i.e., tie door becomes unlocked when che bar is released) rather cian a keyed locic. Tie room is ventilated, veil lit, free of safety hazards, and, unless otherwise contraindicated, equipped viti a mat.
(1) Tie individual vili be released after- a rescribed period of calm, not more t»ftan -minutes in. tie room. However, if.itis clinically indicated that a longer
duration is necessary to achieve calm and/or significantly increase tie ' probability that f-artier aggressive episodes can be reduced, tien tie interdisciplinary'taam, viti tie approval of BMC, LHRC. and ether approving bodies, may extend the duration far specifically identified clients to not acre tian 60 minutes in tie room. This change is tien reflected in tie client's formal program.
(2) Staff must remain immediately outside the door at all times far purposesof unobtrusively monitoring tie client.
(3) criterion for use and discontinuance of time-out procedure, i.e., plans to moveto less restrictive means of modifying tua
-• targeted behavior, must be clearly specified in tie client's program.
On unit during program time: Tie client isto remain on the unit for only the duration of
35

j program tiae in which he/she was intentionally I disruptive or refused to attend, e.g., remain | on the unit rather than go. to recreational I activity such as a dance or swimming.
i
i. Unit restriction: As a consequence of specific maladaptive behaviors, e.g., consistently runs away ta avoid doing his/her assigned chores,
; tiie client is required to remain on tie unit .1 for a period of time greater than tiie duration I of program tiae where he/sha was disruptivebut: i not to exceed twelve (12) hours.
i
j ; Contingent access to activity: A c l i e n t ' s ! access to preferred activity not related ta | training needs or goals i s contingent upon i demonstration of 'targeted adaptive behavior(s) ; or withholding targeted maladaptive behavior I for a specified period of time, e . g . , not I becoming upset for an entire veeJc when asJced by i staff to bathe will e n t i t l e the c l i e n t ta go an a field trip to the circus.

4* Meal Modifications: Altering any condition of a c l i e n t ' s normal meals, including the amount consumed, where the meal i s consumed,, and when tha meal i s consumed when the modifications are part of a'planned behavioral program- Behavioral programs do not employ techniques that may r e s u l t in denial of nutritionally adequate diet.

a. Limitations:

(1)
: | •j i ••

Access to meals may not be used contingently as part of the behavioral program. The client must ba allowed reasonable access to his/her meal on a non-contingent basis at the prescribed time.

(2) , ! . i , j i | j i

If a client, through his/her own behavior, refuses the meal, staff must attempt to ascertain the reason(s) for the meal refusal. If the client simply did not want that particular meal, then, short of danger to health and depending on the developmental or functioning l e v e l of the client, staff i s under no obligation to maice special arrangement ta feed,

(3) Zl a client should reiusa or miss :vo (2) csnsecinve meals, the unit: physician must be notified by the unit staff and ba
I responsible far monitoring tie client's nutritional intaice and overall health. Each aieai missed or refused must ba documented by the unit staff.
(4) I* a client is involved in a behavioral procedure prior to and extending zirougii
; mealtime, unit s-cafi aust arrange for izhm i meal to ba provided ts tie client aitar . the procadure is tarminated and tne client
is reruraed. ta a state of calm. if ti« naai vas originally served off the Unit:, the meal say subsequently be offered again at the off-Unit site or brought bacJc to tha Unit vita the client, whichever is more appropriate.
b. Procedures:
(1) Contingent access to extra portions; client gains access to extra portions of identified favorite foods by demonstrating targeted adaptive behavior(s) at mealtim*. "•Extras14 are defined as approved portion (by the dietitian and physician) abovm thosa already indicated by the physician*s dietary prescription for that client.
(2) Removal from the group at mealtime: client remains in the designated dining area to complete his/her aeal; contingent upon the presence of targeted aaladaptive behaviorfs), the client is removed from the group to a separate table. (NOTZ: This procedure is a consequence az targeted maiadaptive behavior(s) and is not to be equated vith seating a client at a separate table as prerequisite for intensive eating skills training.)
(3) Alternate location of Meal: A programmatic extension of limitation described above in which meal(s) is /are served, to a client in a designated location other than the designated dining area.
37

Modifications of Residents' Rights: Se* Instruction 5810, "Resident Sill of Rights" and Rules and Regulations to Assure the Rights of Residents o Facilities operated by t.ie Oeparraenc of Mental Health and Mental Retardation (DMH 2S 7/33) .

Rights which say be rastricxad include but are not: liairad zz:
a. "freedom to have or refuse private visitation with anyone the client chooses";

b. "freedom to keep and usa personal clothing and other personal items";

'•freedom to possess and spend personal funds";

"freedom to view, hear or racaive television, radio, books and newspapers whether prxvately owned or in a convenient library or day room**;

"freedom zo. maJca purchases in canteens, vending machines, or stores selling a basic selection at frod and clothing"; and
rtfreedom to usa leisure material, recreational facilities, and enjoy the outdoors".

Rights which may not be restricted, denied or otherwise abridged include:

q*j "The right to be called by his preferred legal name".

h. "The right ta be protsctad frsa harx, abuse and exploitation".

i. "The right to a nutritionally adequate, varied and appetizing diet prepared and served under sanitary conditions and served at an appropriate temperature".

j. "The right to a safe, sanitary, and humane
physical environmentf including but not limited to:

(1) 'access to the outside and leave the

j

residential Unit';

(2) 'residential acccmmodations affording

I

reasonable privacy and private storage

I

soace';

31

(3) 'operating toilet, lavatories, showers, and tubs -hat are adequate in number and desiqr. and that affcrd privacy';
(4) 'iirect outside air ventilation provided by an operable window or air conditioner';
(5) 'windows or skylights in ail aia^or areas used by pacients or client' ,*
(€} 'clean air, free or noxious odors';
(7) 'room temperatures that are comfortable in ail seasons4."
"The right to comfortable, clean, and seasonally suitable clothing appropriate ta the age and size of the client, for the exclusive use of the client, and in sufficient quantity to allow for a daily change of clothing, provided however that:
C D 'the facility need only provide a client with such clothing if th.e client is unable otherwise to ontaxn i", in which case the cast of the clothing may be added to the
: cost of treatment subject ta >. reimbursement', and
(2) 'the use of such clothing may be : restricted if specifically ordered by the ; same person and for the same period or shorrsr, who orders rise out pursuant to Section VTI, if the client is provided with alternative clothing adequacs fsr warmth and modesty•."
Each client shall be treated in that setting and under those conditions that are least restrictive of his physical and personal freedom while being consistent with his/her individual habilitation needs and the safety and rights of others.
'•The right to apply for and ta receive assistance in applying for and maicing full use of any public services or benefit to which the client may be entitled, including but not Limited to educational or vocational services, housing assistance, welfare benefits, benefits

or services unciex Titles ZZ. , XVT. , and XIX., or tie Social Security Act, and servicss from a legal aide society."

n. "Tie rignt re communicate in confidence with any person by mail or telephone, and to be assistad in exercising tiis rignt subject zo tie iallowing conditions and limitations.

(1) 'whenever a staff aemser has probacle causa co believe tiat mail received by a ciienr contains contraband or anything tiat would creata a danger to tie client or otiers, tie mail may be oaened (bu~c not r-ad) , by t^e staff aemiser in tne presence of tie client and tie advocate' ;

(2) 'upon request, an indigene client is entitled to sufficient iettar vritir.g material and postage to ma.ll one letter par day, or tie equivalent' ;

(3) 'upon raquest, and subject to appropriate management limitations, an indigent client is entitled to maJce, wit&out caarge, local telepnone calls from a talepnone vitoin tne facility, provided sucn calls do not result in additional cost to tie facility'; and

(4) 'notning aerein shall obligate tie facility to assist in perpetration cf or to refrain frsm raportmg or ctnervise intervening to prevent any criminal acx'."

o.

"Tie right to communicate or consult, in

private, witi any lawyer, judge,

legislator, regularly ordained clergyman,

licensed health care practitioner, tie

client's authorised representative or tie

advocate who visits tie client, provided

however, tiat whenever a physician or

doctoral level psychologist believes tiat

suci access will create a danger to tie

visitor, tie communication may be

prohibited or restricted unless tie

visitor has been informed of tie danger

involved and has agreed to hold tie state

harmless for any injury sustained by tie

visitor during tie visitation."

40

p. "The right - = atzand or rsrusa c= attend any

religious services field on cza premisas of the

hospital or ether facility, and to engage in

any recognized raiio/ious practises, including

refusal ci traatsant cr other sarvicas.

provided that sues, services or practice neither

present a danger of bodily injury ta tha

client cr owners, or interfere with tha rights

|

or other patients or clients under this

1

paragraph11.

6. Rules and Regulations to Assure the Rights of
Residents of Facilities Operated by the Department of Mental Health and Mental Retardation, DMH 2 5 7/83. As such, restriction of client1 right falls into tvo categories, each having its own set of approvals and review sequences.

a. Unit based Rules of Conduct: "...the freedom of clients say be restrictsd in the enforcement of rules of conduct designed to maintain an orderly, safe and therapeutic environment when such rules are generally applicable to groups of clients and have been approved by the LHSC." (Rules and Regulations to Assure the Rights of Residents VTI.3.1. p. 13). Managerial, unit-based rules of conduct must ha written and approved by the Interdisciplinary team serving that particular unit. Subsequently, the rules of conduct must be presantad ta and approved by LHRC. Limitations, justifications and review sequences for unit-based rules of conduct ars delineated in the Rules and Regulations tc Assura the Rights of Residents (VII.3. ?.13). As such, unit-based rules of conauct are nianaceriai issues, and net individualized behavior therapy procedures. They are only described here to provide a basis for distinguishing the two.

b. Individual Behavior Therapy Programs: These rights may be modified as part of a planned behavior therapy program and not according to "on the spot* or arijitraxy decisions by staff. In the program, evaluation by the clients1 Interdisciplinary Team must be made to respond to the rights modification being proposed- Tne plans must include a clear rationale for tha proposed rights modification as well as specify the conditions under which the modification would be removed,

7. Protective/Prevencative clothing: Arriciss of non-rsaavaiale clothing (including gloves and shoes) which 1 laics a client's ability to engage in maladaotive behaviors bur da noc restrict ills/her freedom of zzavemenr. When used contingently as parr of a behavioral program (as opposed to a medical order) , protective/praventative ciorhing should nor be applied fcr aora than 2 csnsecurive hours unless there is a clear jusrification fsr a longer duration documenred in the behavioral program. This procedure is nor cansiderad rs be rsarricrxve per NVTC policy.

3. Rearrainr: A. procedura whicii Limits thm frandom of mavesenr at a clienr. Unless clinicall/ indicated, less rasrricrive mecnads musx ^irsr be a-cremnred ia&ediarely prior ca tne dpclicarion of a physical resrraj^ir. Only tna minimum amounr. o: rasiramc necessary zs aanage rise individual' s benavior is os«d during r^e impleaenrarion of a resrraxnr program*

employed on a response conringenr basis

are used only until the individual is calm (*ar

example, calm may be defined as "2 minurss calmf"

i.e., cae individual has damaastra-ted that: he/sne is

nor clinically calm unless 2 consecutive minutes of

.

nonagizared behavior have occurred.) .

(

The excenr and frequency of monitoring of resrraints will vary according to toe type and design of the device and the condition of the individual. For example, 4-point restraints will rsquira constant visual aonitsrir.g while soft mitrans or a helmet may raquirs lass.

With the exception of mechanical restraints used as response prevention devices, no order may exceed one hour. See Section V.D.10. Extension of Programmatic Procedures.

a. Instructed relaxation: The client is verbally or gesturally promptad or physically guided inro bur nor physically held in a specified relaxarion position. Shadowing is permitted bur at no time is the clienr to be physically maintained in the position. Therefore, this is not a form ox restraint.

b. Personal Restraint: The client is physically guided into and aaintained in a specified

41

position based en the systam of physical interaction as prescribed by tie Mandt System. ~f r^iere are any significant deviations frsm the recommended restraint procedures, as determined by the I.itarziscisiinary team, than these diffarencea auar be clearly described in tie client's nehavicral program. The specific restraint paaition will be individually determined based on restrictions or limitations imposed for medical, physical, and behavioral reasons.
c. Blocking: A lower level fora of personal restraint in which aovement of the client's
I limb(s) are severely limited by staff, e.g., hands are held at his/her sides by staff ta prevent the display of a targeted behavior.
d. Hecnanical Restraint: Hot to be equated with. protective or supportive devices defined in NVTC Instruction 5301, a mechanical restraint involves the us* of a devices to restrict or prevent expecrad movement of a client- The visual/auditory monitoring of the client while in restraint varies with the type of restraint and conditions under which the restraint is applied. For example, a client in a 4-point supine restraint is under continuous visual monitoring while a client in a helmet for biting is under auditory but not necessarily visual monitoring.
(1) Mechanical restraint devices are inspected prior to each use to ensure that they remain in good repair s.nd are free of protrusions that aay cause injury.
(2) Only devices identical to those specified in the written behavior management: program are used to restrain the individual. Please refer to Appendix L for the list of all mechanical restraint devices approved by NVTC.
(3) Safety and well-being of the individual is checxed at least every 3 0 minutes during each application. If more frequent caeeics of the mechanical restraints are indicated, such as for a highly active and resistive client, aore frequent checics must be clearly specified in the behavioral program. If staff has any
43

rsason ca believe chat the client is in pain due tc paysical/medical conditions, they snould immediately contact the_nurse or pnysician. Medical treatment, i* warranted, will taica precedence over the use of behavioral consequences.
(4) Althougn the duration in mechanical restraints varies from case to case, depending upon such conditions as natura, severity, and function of the maladaptive behavior, environmental/residential limitations, behavioral history, and documented learning history and potential of the client, all individuals in mechanical restraints must be released for a minimum of 10 minutes every 2 hours and, unless asleep, provided with an opportunity for motion, exercise, liquid intaJce, and toileting.
(5) Procedures:
(a) As a response consequence, the mechanical restraint functions as an analogue to timeout from reinforcement procedures. The
v duration in restraints will be "until calm" to .a ™»y^wiwH of 1 hour, For examole, a hairnet may be contingently applied "until cairn" for headbanging but not to exceed 1 hour.
(b) As a response prevention procedure, a mechanical restraint is
•; differentiated frcm a medical • protective device on the basis of tie 1 degree of control the client has over ; the behavior(s) for which they are : being used. A.helmet worn to protect
a client from passible injury due to > seizures is a medical protective ? device? similarly, a helmet to
prevent pica (after possible medical causes such as nutritional deficits :: have been eliminated) is a • behavioral/medical mechanical !• restraint. Tne former helmet usage • is not subject to this policy whereas the latter is.
44

til

Zn addition, '-a«n used as a raspons*

prevention procedure, the duration ir*

restraints aay vary frcm "until calm"

to a maximum of 2 hours, £•<?•, a

helmet far pica may be applied as a

consequence "until calm" or applied

j

noncontingently for 2 hours vnere

pica is perceived by the pnysician to

=

be a healHi. and safety :ssue.

(c) Screening: A special casa of u s * of

a oecnanical restraint in which a

device is placed on the client but

dees not interfere vita normal

scheduled activities or training.

For example, a surgical Bask, is

placed over the client's moutii fox a

lioitsd period of tima as consequence

S

\

for spitting.

9. Aversive Stimulation: According to the 1587
standards or ACDD (Accreditation Council on Services for People vita Developmental Disabilities) , nAversive conditioning refers to tae application, contingent upon tne exoibition of maladactive b«ha.viorr of startling, unpleasant or painful stimuli, or stimuli tnat have a potentially noxious effect*1 (page 65). ACDD also states taat: (1) aversive conditioning "'aust also be limitad to situations in vnicn the interdisciplinary team, the behavior management committee, and the human rights committae concur that to withhold the procedure vould cause Irreparable harm to the individual" (page 67) , and (2) the procedure is used only vti&n tie client's behavior "precludes his or her development, and less negative procaduras have, in the izimediata cast, been documented to be ineffective ia reducing or eliminating this particular behavior'1 (page 72) .

HVTC does not subscribe to the use of aversive conditioning as a treatment procedure.

LO. £xtension of Programmatic Procedures: Although most orders cor programmatic procedures do not exceed one hour, it may be necessary, from time to time, especially during the initial phase of program implementation, to extend the duration of the procedure, based on the client's behavior, i.e., not calm. If, toward the end of the hour, the client continue to exhibit signs of not being calm, staff

45

should contact the following- for authorization to extend the procedure: (1) the unit psychologist; (2) on-call"psychologist; (1) Chier of Psychological Services; (4) physician; (5) NVTC Director, or; (S) Acting WVTC Oirector.
Tlie extension will be for only one additional hour "until calm," The extended procedure must be terminated once the client returns to a calm state or at the end of the additional hour regardless of the client's behavior, whichever occurs first. In extreme emergencies where ic is unequivocally clear that the client will be a significant threat to him/herself or others, the Psychologist should be contacted for consultation.
Following the extension of programmatic procedures, a Crisis Management Documentation Form must be completed and forvarded tc the Program Manager within tventy-four hours or the first wording day following the incident. Th.e crisis Management Documentation Form will then be routed first to the Program Manager and the CTnit Psychologist and then to selected members of the Interdisciplinary Team, chairaan of BMC, RisJc Manager, NVTC Director, and the Resident Advocate for their review and comments.
E. Non-programmatic Uses of Restrictive Procedures
X. Collection of Baseline Data: During this period, it may be necessary to try a variety of behavioral procedures not only for the purpose of managing the client and deal with situations as they arise but also to collect data to document each behavioral episode. Baseline data is essential in the event of future program development: and evaluation.
Procedure which may be used during this time are:
i ft. Restitution
b. Quiet room/area, bedroom, Ln-seat until calm
c. Physical guidance
d. Personal restraint until calm (requires completion of the Crisis Management Form) .
2. Day ta day procedures: Data and documentation arm not required in these situations as they are standing procedures which, are available to staff to
46

help bring a given (low frequency) behavioral situation under centre!. These procedures include:

a. Restitution b. Quiet: room/area or bedroom until calm c. Removal frcm che group unril calm

3. Crisis Prevention and Management Procedures: On an emergency basis, certain restrictive procedures may be implemented inorder tamanage a client's behavior that clearly poses a threat to self or others.

It is critical todistinguish between procedures used in crises management and t^osa used as part of a planned behavior treatment programs. A behavioral crisis is an exceptional event which occurs so infrequently tiar a systematic plan of intervention has not been formally developed. Restrictive procedures in tnis context may not: be used as an aversive consequence but rather strictly as a method of calming the client and managing his/her behavior.

When a client becomes highly aggressive, there is typically a reason (with the possible exception of dually diagnosed individuals) . In most cases, there are early signs that he/she is stimulated and is building up ts .an aggressive outburst. Therefore, an attempt at early intervention designed ta prevent the outburst or deal with itbefore itbecomes violent is necessary and expectsd before restrictive procedures are applied.

Crisis management may be conceptualized as a sequence or procedures that progressively become more restrictive for the client. Interactions with the client should begin with nonphysical procedures whenever passible (i.e., the graduated approach as described bythe Handt system) . Tne point atwhich staff enter into this sequence will depend on the behavior(s) being exhibited by the client.

a. Preventive/Supportive intervention

! (1) A client's behavior may typically include

|

an unusual departure from his/her normal

j

routine, e.g., agitated behavior such as

|

complaining, screaming, pacing or possibly

j

withdrawing from others.

(2) Appropriate staff response at tiiis stage includes a variety of supportive
sucii as:

(a) Atrampting ta determine whetner or nor the client is in physical discomfort, e.g., ill or injured, and requires medical treacaenc;

(b) Talking to the client to find out

what is wrong, helping ta

problem-solve, or simply calm tie

••

client with a soothing tane of vaica;

(c) Providing riie clienr vith sufficianr personal space and reducing excessive environmental stiaulacion, suci as noise and activity immediately around cne client;

C<i) Redirecting tne client into a specified activity tnat ne/she can easily perform and tiat will maintain his/her interests;

(a) Presenting requests in a positive,

supportive manner and giving tne

i

client more fleacibility where

passiisle in meeting tnese requests;

(t) Keeping other clienrs away-who may teasef bother, or somehow stimulate tae agitated client or away until the client is calm.

Limit setting intervention

(1) client's behaviors may typically include a vide range of behaviorsr such as continued agitation, tantrums, verbal aggression, threats of aggression, or isolated acts at aggression to self., others or property.

(2) Appropriate staff responses at tiis stage include:

(a) • \

Identifying the most effective strategy to manage the individual, including using the right person(s), approaching the client in a nonrnreatening manner, using a calm

centre lisa voica, respecting tie client's personal space, etc.;

("o) Identifying and iaieiir.g tie client's

sehavior and/cr aaoticnal state far

> him/her and suggesting an immediate

course of accisn, e.g., "(Name),

you'rs upset so lac's sit down and

:

•a.JJc about what's troubling you.11

(c) Identifying appropriate limit-aartlag procadura(s) fsr ^ e client given tie client's background, previous training and experience, and tie present situatisn. As a rule of thumb, tie client snould be offered 2-3 options in order to perait
• him/her soma centre! as ta what vill ba done. For example, the client aiay ba given tie instruction "hands
'. down, "or "Let's go to your room,11 or "lat's go to tie quiet room.11

If the client is exrxihiting rasponsas related to aggression to self, a limit-setting procsdure designed to stop tie behavior mi.gh,t be "Hands down". On the otier hand, It tie client is exhibiting a response related to aggression to others, a suggested liait-setting procedure aright be, "Let's go to your room-" However, i* tie client is exhibiting responses related to aggression to property, a liait-setting procadure might be, "Let's go to tne quxet room." Tie duration of any limit-setting procedure would be until tie client is calm.

If tie client refuses to comply witi tie limit setting prompt, bacicup assistance should be obtained and tie client once again given tie prompt. Tie staff who began tie procedure should generally continue tie exchange unless tiere is clear indication tiat anotier staff would be more effective, if tie client again .refuses to comply witi tie limit setting prompt, he/she should be physically guided into tie prompt

4§

"3ft
(e.g., hands biociced at tie side, escorted to ream, or escartad to quiet area) . Follow tirouga ac this stage is important; a ciienr siiculd not be give a specific prompt unless tiie prompr can be carried our.
Crisis Intervention Procedures
(1) The client's behavior is out of control in a manner that is harmful to self or others. Tie behavior at tiis stage is typically characterizad by repeated acts of aggression or self spouse and the client' s inability to respond to supportive or iiait setting procedures.
(2) Staff Responses:
(a) Crisis Management: As always, tne graduated procedure as prescribed by the Mandt system of staff-client interaction should be used. For example, consideration snauld be given to such factors as the need to separate the client from tie groupf whether or not the types and number of staff are optical to manage tie client, what fora of staff-client interaction is needed, etc. Only when deemed necessary for the protection of the client, others, or significant property, should physical interaction procedures based on the Mandt system ce used to manage the client saxaiy.
physical interactions must use tie least amount of external management ta brin? the crisis under control. If there is any significant departure fram tie - prescribed physical interaction procedures, this must be described In tie Crisis Management Documentation Fora (see Appendix El .
It is especially important to note here that tie Handt system of physical restraints should be used in which tie intent of tie procedure is to manage tie aggressive behavior
SQ

using tie least amount of external aanageaent necessary zz deal viti tie client's behavior. If necessary, ^u.s may involve noiding cie arms, body, and legs in sues, a way as ts ensure a safe and effective restraint.
The client should be regularly assured tiat he/she will be released as soon as he/she calms down and is quiet for a couple of minutes. However, staff should not attaapt ta yell or shout instructions over tie client's loud or inappropriate verbalizations but wait until tie client is able to understand what is being conveyed by staff. When tie client is quiet for a full tvo minutes, he/she should be released and tien slowly reintegrated into tie on-going activity.
If, (a) staff believes tiat physical restraints is inappropriate or ineffective, i.e., imminent tireat of injury to staff or client or (b) thm client remains highly agitated after approximately 30 minutes of Crisis Management and is showing no signs of calming, tie unit psychologist should be contacted. If unavailable, tien call tie on-call psychologist; Ciief of Psychological Services; physician; ^^^^c sirsctrr; :r JTVTC Acting Director for consultatisn regarding other possible interaction strategies. Alternative actions which may be taicen includes: mechanical restraints, program extension, psychotrcpic medication, or other emergency procedures) .
KOTS: "In order to expedite reaching on-call psychologists during evenings, nights, weekends, or holidays, tie units are reouested to notify tie Roving Team Leader (STL) or Duty Officer of need- Tie RXL/Duty Officer will evaluate tie condition and call/page tie
51

••at
' appropriate psycnologist." (Memo ' dated. 11/4/92 from Leon Rose.)
Crisis management during venicuiar transportation: I' crisis management procedures are required vehicular • -ransportaticn, e.g., a client becomes highly disruptive or : aggrsssive and (a) cannot be managed by nonpnysical and physical Mandt i procadures and (a) the client's ' behavior is judged by start t: • jeopardize tie vall-being and safety t of other passangers and motorists, then mechanical restraints may be used as part of the crisis management procedure.
(b) Program Extension: Intension of > Crisis Management procedures beyond
t&e hour cannot be far more n^an one additional hour. Tnis must be autnonzed by the unit psychologist; : or ii unayailaiale, thm. on*call psychologist; Chief of Psychological ; Services; physician; MVTC oirector; t or NVTC Acting Director prior to t&a ; actual extension.
(c) Psychotropic Medication; If the client's behavior is out of central
• and (a) his/her behavioral program, and/or (b) crisis Management have been tried rspeatedly, including the use of program extensions, and/or has baan implemented tzr a. long duration, stafz should contact the unit psychologist for consultation. If the psychologist is unavailable, contact the on-call psychologist, Chief of Psychological Services,
i physician; MVTC Director, or MVTC i Acting Director.
When the ongoing behavioral procedure - is interrupted, to administer an
emergency psychotropic medication, : tha behavioral procedure may be
interpreted to have been discontinued depending upon the nature of the orocedure. For examole, if the
52

client was in Tiae Out and tie client did not attempt ta aggress or leave tie area witiout approval immediately after tie medicaticn was given, tien tie procedure has seen tarsmated and any subsequent use of Time Our can be viewed as another behavioral episode. On tie other hand, if tie client was in resrraxnr at tie time emergency medication was administered, tien tie benaviorai procedure has nor been significantly changed and should be interpreted as a contxnuing behavioral episode.

If emergency paychctrcpic medication or orher emergency measure is indicated, tie individual who was contacted will fallow tTVTC Ijisrrucrxcn 5302, " Psycaotrcp ic Medicarxon", Emergency Procedures Section.

(d) Mechanical Restraints: However, if, in riie opinion of tie physician conracred that emergency psycho tropic medication is nor indicated, the physician may authorise the emergency use of mechanical restraint (see KVTC Instruction 5301, "Use of Protective Devices."

Mechanical restraints may also be

ordered by a psychologist it it is

indicated by tie cehaviorai crisis.

For example, if the psycnciogist

conractad believes that significant

health and safety issues is or may be

present with the continued use of

personal restraints, then mechanical

)•

restraints may be authorized. (See

"•Rules and Regulations to Assure tie

Rights of Residents of Facilities,"

DMHMRSAS, 7/83).

(3) Psychologist's responses:
When a psychologist aust be reached for consultation because a client is in crisis, the unit psychologist should be called first. If he/she is unavailable, a bac&zp psychologists should becontacrad

:;

S3

using the posted "backup" schedule. The psychologist will then solicit information from staff to d e t e r a m e the most appropriate course of acticn. The psycnologisz will ask:

(a) Actual or hypothesized antecedents or

;

precursors to- tna crisis and what

steps have been taken to address the

proeaJale causes. Particular

attention should be given to whether

considerations have been given to

[

environmental and medical issues.

(b) why a specific crisis intervention

procedure is being requested, i.e.,

'

program extension or emergency

";

paychotrcpic medication.

^ (c) when the behavioral crisis began.

••

including frequency, duration, and

'

intensity of the behavioral

;:

episode(s) .

; (d) Tne client's mood, behavior, and

general vall-being prior to the

i

behavioral crisis.

^ (e) Lf applicable, if specific behavioral

interventions have be«n tried in th*

past, what procedures have been

;

successful, etc.

(t) If emergency psychotrcpic dedication

is indicated, then, if known, vhat

*

and when the iast prescription was

' . administered and the client's

reaction to the medication.

The psychologist will then provide the staff with, a recommended course of action and the rationale for that decision.

(4) Documentation of Crisis Management: When crisis management, extension of crisis management, the reactive component of a formal behavioral program, emergency psychotropic medication, or other emergency procedures must be implemented, a Crisis Management Documentation Form must be completed immediately after the

54

behavioral episode. The report i s than routed according to the sequsnca specified in t i e Jcra, i . e . , forwarded f irrz* ta t i e Program tianager, ciien to t i e Unit Psycnoiogist, Nursing/Medical, QMRP, Risx Manager, Client Advocate, tfVTC Director, and then to Psychological Services for pxirposes cf documentation and monitoring.

The c r i s i s Management Documentation Farm requests the fallowing information:

Name and registration number

Time of c r i s i s management

Location of c r i s i s management

Type of c r i s i s management and person

authorizing the procedure (a)

3ehaviar(s) displayed vhich resulted

in the use of c r i s i s management

Antecedents ta maladaptive

behavior(s)

ratervention procedures usmd prior to

and during c r i s i s management

Client's response to c r i s i s

management ( i n t e n s i t y in 5 minute

increments)

Medication and dosage,, ix applicable

(including c l i e n t ' s response ta

medication)

Injuries and other outcome of c r i s i s

management procedures

Person completing form

Other staff persons involved in the

crisis management

3ouzmg order for ccsaents and /or

•

recommendations

Whenever emergency intervention procedures are repeated more than three times vithin tveive months, the psychologist must review the reports and enter an ID note in the c l i e n t ' s CSS regarding suspected or actual motive (s) for the behaviors and proposed course of acxion to be taJcenThe response by the psychologist can take various farms, including statements that (I) modifications be needed in the existing behavior management program, e . g . , changing a training procedure or adding a restraint component, or (2) no prccram changes are being considered, e.g., the conclusion of t i e psychologist

55

aft
and til* IDT that emergency intervention procedures were used because of a medical condition (for example, zZe.client vas in pain because of a raoccurring illness) and tile client had no otner ways to express his/her extreme discomfort. (5) Interim Procedures: In cases vhera true aenavioral emergency situations arise (e.g., a sudden display of hignly intense aggression to self or otaers) in which immediate intervention procedures are necessary, emergency interim procedures may be implemented for a period of time not to exceed the next scheduled meeting of BMC or LHRC, vniciiever occurs at tiie latest date. (See page 20 for details.)
56

VI.

OF FP.OGRAMKATIC 'JSZS OF XZSTSICTrTS ??.

The following t a i l s summarizes programmatic uses of intrusive and restrictive procedures. As an aid, generic example are also provided. level cf consent :sr tiia various procedures are indicated. To interpret t i e levels of consent columns:
"X" Indicates prior written consent/ approval necessary
"O" Indicates prior notification necessary-
"C" Indicates copy of t i e program is to bft forvarded to tni.s person as cne program is being implemented.
"P" Indicates notiziration is necessary but aay be after tae fact.
In tnose cases where no sucstit".ita consent can be oatained for a client for wncm restrictive procedures are c l i n i c a l l y indicated, tae psychologist will, notify the Directsr, ^^^rcf and Resident Advocate.
The psychologist will also notify the Director, 1TVTC, and the Resident Advocate in those cases where substitute consent i s not required but only notification is indicted and there i s not parent/guardian/relative invpived for the c l i e n t .
See NVTC Instruction 5713 for additional inforaation.

57

APPROVALS/NOT!" CATICN

All programs must be approved by tie IDT and Psychologist:. However,, programs categorized as restrictive by bTVTC requires additional approvals. The fallowing procedures are illustrative of tie diffarsnt types of raactive procedures and the levels of approvals required before a they can be implemented.
MD =• Physician P/G » Parent/Guardian BMC » Behavior Management Coamittae HRC = Local Human Rights CoTmnittse DIH = Director of NVTC ADV = Human Rights Advocate (notification required only)

Procedure Graduated positive practice
Graduated contingent exercise

Generic Description MD of Use

As a consequence of 0 toileting error, client is guided througn cleanup procedure vita minimal intrusion necessary fcr a time period not to exceed
10 mins.

For fixed time

X

periods greater than

1Q mojiutas but not

to exceed 3 0 mins.

As a consequence for 0 teasing, a client is guided through a non-s trenuous activity with minimal intrusion necessary far a period of time not to exceed 10 mins.

?/G BHC HRC DIR ADV

PC

C

XXX

0

?c

c

58

Procedure Generic Description

1 P/G BMC HHC

ADV

1 or Use

For fixed tiae

XX X X

0

pmriads greater

tian 10 ains. cut

less tian 30 mins.,

for strenuous

activity of any

duration not to

exceed 3 0 mins.

Graduated As a consequence

XX X X - 0

negative for Throwing

practice objects. client is

guided tirougn tie

act of tircwmg tiese objects viti

TTTPTT'l **^T»W*^T nrr

necessary ror any

time period, not to

exceed 2 0 mins.

Graduated As a consequence

0p c — - c

restitu- for overturning

tion

furniture, tne

client is guided

taxougn tie act of

restoring tie

environment to its

normal state witi

minimal intrusion

continent As a consequence

0? c - - c

access to for stealing food.

extri

client loses access

portions

to designated extra

portions or

approved favorite

food

Removal

As a cansecruence

0p c

from croup for stealing food.

at

client is seated at

mealtime anotier table away

from tie group to

eat his ar tier meal

-c

In room. quiet area., corner, seat, or off unit On unit during
Time out from reinforcement vita sta£i in room witii client Time cut from reinforce* men-c vita staff outside. tie room

Generic Description MD

As a consequence for disruption. client is escorted to room. etc., until cairn. Notre exceed 60 mins.

As a consequence Cor disruprion during a day program, client spsnds tie following voricday on tta unit for tie duration of tie day orocrram

As a consequence for disruption during a day program, client is required to remain ontie unit for a period not to exceed 12 hours.

As a consequence for disruption, client is placed in a room vitn a staff memcer in tie same room. >Jot to exceed 60 m^ns.

As a consequence

X

for aggression,

client is placed in

a room viti tie

door held by staff

to prevent egress.

Mot to exceed 60

mins.

?/G ) 3MC

X

X

X

DIR I ADV
X

60

Procedure Generic Description MD

Instructed relaxation

As a consequence for tan-crass, client is verbally promoted or guided to maintain a specified position (relaxation) until calm. Hot to exceed €0 mins.

Protective Clo tiling

As a consequence
for stripping and/or tearing cioties, clotning whici cannot be removed cr torn by tae client will be anniied fcr 2 hours

Personal restraint

As a consequence for aggression, client is physically guided and maintained in a specified position until calm. Not to exceed €0 mins.

Blocking

As a consequence for hitting, client's hands ars held at his/her side until calm. Mot zz exceed 60 mins.

Physical screening

As a consequence. for spitting, a surgical aasic is placed over the client's mouth until calm. Hot to exceed 60 mins.

P/G 3MC IHRC ! DHL X

il T m\

Procedurs Generic Description

Visual or As a consequence

X

Facial

for aggression zz

Screening others, a hand is

placed over tie

client's eyes until

calm- Mot ta

exceed €0 minutes.

Mechanical restraint

As a consequence for selX-iniury, clienr is placed in arm restraints until calm. Mot ta exceed 60 mins.

Ccncir.gent access ta

As a consequence for aggression, clienc loses access to specific preferred activity (not related ta trainincr needs)

Alternate location of meal

As a consequence of
disruption in tie dining area, client's next meal is served in the activity room

Modification of cliant's rignts

In order ta teach, appropriate budgeting sJciils, ciisnt denied access ta monev is limited

3MC I HRC I 013. ADV

X

X

X

X

62

VII. STAJT TS

Staff training i s an integral parr of a l l behavioral programs at NVTC. ?re-servica training Cor a l l employees i s conducted by Psychological Sarvicas to ensure that a l l individuals involved in t i e d i r e c t cars of clients are provided with information and s k i l l s to effectively implement- a l l behavioral programs. * '

In addition, a l l s t a f f ara trained on t i e behavioral programs of each c l i e n t before they are permitted to implement their programs. Tnis training i s competency baaed, i . a . , staff must verbally describe the prescribed treatment plans, pass written t e s t s , and demonstrate the techniques used in both the training and r e a c t i v e components of the program.

Staff are then retrained on a l l c l i e n t s ' formal behavioral programs at l e a s t every 6 months or whenever a s i g n i f i c a n t aspect of the c l i e n t ' s program i s changed. In addition, on-going i n - a e r v i c e s and staxx training/ r e t r a i n i n g are conducted on an as needed basis along with regular monitoring of program *implementation and documentation to ensure both consistency and r e l i a b i l i t y .

The following i s a topical outline of the information presented by Psychological Services to a l l developmental aides and other s t a f f vho interact d i r e c t l y with c l i e n t s on a regular basis:

I . Describing behavior and behavioral o b j e c t i v e s A. Ways in which behavior can be changed i 1. Acquire/improve sJcili Z. Xncrsase behavior 3 . Appropriate stimulus conditions 4. Decrease/eliminate behavior B. Assumptions of behavioral approach C Components of behavioral o b j e c t i v e s
I 1. Learner 2. Target behavior
j 3- Criterion ! 4 • Conditions
5. Target date
0. Activity (critique goals, objectives, plans)

Observing and recording behavior: Measurement

A. Steps in measuring behavior

1. " Identify target behavior

. 2. Select observation method

i

a. continuous

!

b. interval

. i

"r

!

63

z. ciae sample

d. cast method

3 . Select recording aethod

a. frequency

'!

a. duration

;| ,

c. intensity

•| •

d. level of support

4. Chart/graph data

3. Phases in data collection

- , i •. 1. baseline

i1

3. follow-up

III. Increasing behaviors: Rainxorcers

A. Types of consequences

5. Types of relax crcsrs

1. Idibles

• i

2. Social

i 3- Manipulahle or activity

:;:i "

4. 5.

TaJcens Sensory

C Guidelines for use of rsinforcers

: j,. , I '.' ! ' i ! 0.
1
E.
; | ;' | ' !

2. consistency 3. "Bridging signal" 4. "Natural" vs. "arrificial" s . ^ n 4 ™ " " effective quantity Schedules of reinforcement l. Continuous 2. Interaitrant Identifying rainforcars 1. AsJc tne person 2. Observe tie person 3. k3K otners 4. Observe similar persons 5. Reinxorcer sampling

17. Teacning new behaviors

A. TasJc analysis

a. Chaining

, .1. Backward

1

2. Forward

C- Prompting

1. Verflal

1

2. Gestural

•i 3. imitative

4. Physical

D. Fading

£. Shaping

F. Graduated guidance

1. Levels of graduated guidance

2. Guidelines for use

v, Taacaxng —z& right ciae/place A. ; Stimulus control B. J Diffsrsntiai reinforcement

VT. Decreasing/Eliminating behaviors

A.. Reasons to decrease/el inmate

B. Steps in planning behavior programs

. | i. Define target behavior

2. 3aseiine

|

a. antecedents

;

b. consequences

j

c. setting(s)

i ' d. function

3- Develop plan - least restrictive treatment

alternative

4. Apply and measure impact

5. Revise plan

C. Positive reductive procedures
1. Differential reinforcement of other

behavior

2. Differential reinforcement of appropriate

behavior

3. Differential reinforcement at incompatible

0* Other procedures X. Extinction 2. Restitution 1. Quiet room/area 4* Restraint 5. Overcorrection Disadvantages of punishment 1. Aggrassion 2. Injury 3. Tiae consumption 4. Avoidance ci punisher 3.. Emotional raactions

65

VIII. DEETOTTIQNS

Adaptive behavior: That behavior which i s considered appropriate for a given individual in a specific context. This tarm u s u a l l y r e f e r s to behavior that" i s fudged a c c e p t a b l e by p r o f e s s i o n a l s sues as educators and s e r v i c a providers, and not i n need of modification. These judgments are guided bydevelopmental and s o c i e t a l norms.

Aversive c o n d i t i o n i n g : The a p p l i c a t i o n , contingent: upon t l a of maladapptive behavior, of i n t e n t i o n a l lyy
startling, unpleasant or painful stimuli, or stimuli that have a potentially noxious effect.
Behavior management: Procedure to increase adaptive behaviors and co modify maladaptive or problem behaviors and replace them with behaviors that are adaptive and socially acceptable.

Behavior Management Committee: A committee responsible for the periodic raview and approval of behavioral programs. The committee includes (a) persons qualified to evaluate published behavior management research studies and the technical adequacy of proposed behavior management interventions, and (b) a physician, pharmacist, or-other professional qualified, ta evaluate proposals for the use of drugs to manage behavior.

Emergency procedures: The use of procedures necessary to manage severely aggressive or destructive behaviors that place the individual or other in imminent danger when those behaviors reasonably could not have been anticipated.

Maladaptive behavior: Those behaviors judged as i_iappropriate or Ineffactive ir. a given context, such as a residential living environment cr a worJc site- In general, such behaviors interfere with a client's learning or social interaction and leaas to discomfort.

Mechanical restraint: The use of mechanical devices to restrict the movement of normal functioning of a portion of an individual's body. Examples of this method Include helmets, arm splints, posey mittsns, posey vests, seatbelt, wrist
cuffs, and 4-point bed rastraint-

Personal restraint: The use of manual methods to restrict the movement of normal functioning of a portion of an individual's body. At NVTC, the graduatad approach to the use of physical interaction procedures described by the Mandt System will be used. If these physical restraint procedures have been demonstrated ta be ineffective, then approved modifications must be written into the client's behavioral program.

M

66

?Jiysical ras-craini: Tie use of aanuai setnccs or aacnanicai devices t i a t are intended ta restrict —e movement of noraal functioning of a par:::n of an individual's body.
?sycnotropic medication: Medications usually prescribed and administered to individuals v i t i a psychiatric diagnosis {or symptoms) for the purpose of aodirying ^ e naladantive benavicr of an individual. Ixamplss include antidepressants
and aa]or and ainor rranquiiizars.

Restr-ictive behavioral pracram: Tie use of psyciiotrrpic aedication, restraints, ^aan>n tiie-outf ana modification of clien-c*s riqhZs ars considered as restrictive procedures ac N"VTC. Certain otaer procadurea, as specified in tn« Summary of Programmatic Uses of Restrictive Procedures, are also r e s t r i c t i v e under certain situations.

Seclusion: Tie nonccntir.gent placement at an individual alone

in a rcom or otner area frcm waici egress is prevented. T!iis

cioes not inclucte placement in a tiae-out rcom as part of a

behavior management program that meets a l l applicable

standards. ;I ^

\

Tiffle-out: An enclosed area in vnicn t i e individual i s placed contingent upon t i e exnJJ3ition of a aaladaptive benavior, in whici. reinforcement is not available, and from wni.cn. egress i s denied until appropriate behavior is exhibited.

,

IX. APPENDIX

A. Mission and Goals of NVTC

B. Mission statement tzr t5.e Benavior Management

i

Committse

C. Local Human Rignts ccmmittae
i i

D. Functional Analysis Interview Fora

E. Crisis Management: Documentation Form

F. Behavior Program Record

G. Mon-ciiiy Review of Rea*cricrive and Monrestriccive

3enavior Program

S. BKC/LHRC Update Sheet

I. Group Active Treatment outcsme Monitoring Form.

J. Psycaotrapic Medication Assessment

R. The Mandt System L. List of Approved Mecnanical Restraint Devices

63
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TAHGETED MAI ADAniVE DEIlAVlOHS

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CATA SUMMARY SHEsT. ADAPTIVE SE-iAVICfiS

LIENT; 745

MCNTH JANUARY

ADAPTtVE BEHAVIORS
•ERFRGBB
14.253

P—HUARY

32.75!

MARCH

38.91

APRIL

36,75.-

MAY

34.75*

JUNE

32.75 a

-LILY

34.3.1

AUGUST

33.84

SEPTEMBER

28 ]j

CCTCSE3

28.671

NOVEMBER •

CECEMBER

2a.75ii

UNIT:

1 1.57: 7.44! t4.4) 16.71 0.32! 2-041
s.ai 0.B2! :.29t
01 3.1'
7'

CCMPUANCc

coattAnvErotcarr

1 VP

2VP

3VP ' ^

33:

98!

TOO!

931

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94-

391

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94;

37:

99.57'

as.

96f

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36 i

981

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301

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97:

331

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:0OI

36!

99.57' NO3-S i

37'

971

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73:

94;

99.561

90i

97.SI 99^91

i
233* 215 =
i
2381 2331
i
2441
t
2231 2431 232!
231 i
zznt 2421

"ARGETS AOAPTTVE 5E-iAVtCRS:

YEAR: T994

1

!

i

i

I

i

•

'

1

!

j

I

1

1

1

1
1

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P53 CF ?=
^CG?AM CHANGES.

.HOR2SE8U TZZGZXIX TXASTIHG TOR

Mame:

"et—sic

Sniz: 5

SOS:

3£G NO: QQ07*S

of Paycsotropic Orag us* wd Previous 3eaaTs.aral Prouathzras Triads

W nas seen on a rariecy sr zsycrrcrrzrsic aedieacioa ovtr zhm 7«trs.

rwmnciv, he has seen crsatea v^za i csmsi-sa^-on of U r i

l I— ciio s u e , wain ^e was a -e«na.qer, -i«r« war*

or aeuraiepc«c aed^cacico ^zac iile^«ci.y led zo a l a v f n zoriira

?cr r^sa* rsaaoas, s^nca he was a zaan apar, aauroiapclc

atoicatisn naa .lever aean ?r*acriiec iqa^a. Jaiarr^aatal-/-, ! • • orraa

accaara crtiica caycaocis ana ms auiLirss'ca'C^.ana at aLa ssyesos^a I T S ace

l

suca =y c^s prascrz^c^sa s i * —•"*« and

ri

of Psrcixo'Croplc Drag, 7raqoanc7, Ooa«g», Hotttta of

and

aiadicar.oa cs be tr^ad i~s Clozaai^e ap rs a dosage or 900 mq d a l l y . Badicac-on riaa ae«a sr^sd :_s 5ursce fsr c i s ?aac 20 years *"^ rcund
i s causa exsz'S.pyraniidal sympesms ar zardlve dy3Jtuiesi.a.

Targar. Ma i iriapCATa aaAa-rxor Co b« aodi.fi.ad:

•tier? S«li-4X3U3o, pisyaicai aqqr^aaion,

7 requanci.aa; Sa« PTyeiwJLo^ixc ' s so*caa.

Moari

Total

Monci

ro-cal

>Tanw of Psychiatric Conaultaar: -r. Hcward I. ?ressman

^ J t ar Pocairc^ aI Sui* £ffsos2 ox tie psrcaocsopic

a) Majoc Side ZitBonaz

Aqranulocyrosi.3, hypocanaxon, seuuzsa

i) Minor Side 2f*ecx3:

lsacisn.. dic=i^asa, fsvar, hreerranaian, s n.r cacaycardia, and we^

Medical arriew ox Side Effects (by *ma*, frequency,

of

iT"-iT"4'iT"7 Laboratory Woric iJ

Secondary zs rie possibility of agrasalocyrssiar anyone who takasa Clo&aril anise be inocicsrsd. 'inrfffTT cia Closacil aonitisr'ii.g! syvcaoi- Tills includes a weekly whi^a csunr and 11 itor—f' a' • wdica is reviewed, by zi(
araacr^iing- anysician 4nd anarsacist aefors cie aedicarion cien =an be
?raacrij=ed. Zz. addition, srser 3^ie—-ffecra witi be aoni-sr*** by
.n .-.ursea, rile •isu.z. pnyaiciin, and cocaulzintj payca^.a'cr—

Medical plan for Paycao-czwic Dn<q

P il ans ta be Isplemestad in tie treat ox Side Effects:

Zz. zr.a evtnt of Signs or symtrcssis or agranulccycssis, r i

ajrij.

be ioaiadiacsiy discontinued and «Bm' 9 wni=a ccucc w i l l 2a aetni^srad

rf^iJLy - Qtaer aide—»ri«ers ira deals wi.zn by dos&ga rsoucsianoc ciiaag* — ;ui_".g af da3*ge prsscrisnxsa.

**id«x-c' s 2axarul. Sid* Zf^sc^s:

Zt i s tha opiiioa of tiiia cayciiacriaw ziac rhe W s

i T i - 7 scAectui.es far z~m r
alana or cie tarqec

P'ani^ iacXodimg Ob'jeeu.T* for aarlaM ba*»d on Avai_Lai3la C u r t a ' " ' • l ^ i n ? SLmrxmi Frwqrimnef, ham docammazad and i_
Plaa for Asadjo.siUAcr, 2adncia? or Oxjcpnri-anin*r tit* Drag:

y

aectlca^ioa reviews will csnt^iuB, as they always 5o«CiCis daca, w i l l be csllaczsd and srssttn-ceci ac

ca a

-n—Jcly reviews and than decuioaa atada aacuc ci« dosage of •nedica'Cion...

la ria e-v«n-c of lacJc of rssponse* "ztnoedicarian w i l l be

dscrsased and dlacoari-saed.

Sign

Data:h / ;

/

•

3y Sesic a) ccsicetent adult "consent signed ( ) . Enable zs make aedicaJ. deci3ians

3y

a) Psycoia-crv conierencs ar=ended and -reraal csnsenc gi-mn ( j

b) csnaenc giT»n by cslepnona{/).

c) Consent giT^n La. writing {]/).

.

Oct. 13,1993 Over 7e?eonone,.4oorovea fay
LHRC: Mrs. Claire Jacques, Mrs. Ann Sale

PERMISSION ?OR

OF isa

Z iiereoy give ccnsant ts Norriera Virginia Training Cantar medical staxr to adm inlstar ts:

t i e medication:

Clazapine

• •

«

Tlie following adverse conditions waicii niay occur as a result of tie prescribed aedicax-on are listed below and nave been explained to you tv:

4) Jiajor sida 1 •; Agranulocycssis, iiypcransion, seizures

h) Hinor sida Sfrecta:
: ' Canstirationf dizziness, zaver, ayperrrsnsion, seda-cicn, salivation, tachycardia, and veighr gain
I have been fully inzorsed of t i e nature of t i e aiacve medication, potential side effects and t i e reason for t i e use of t i e medication. I understand I can viridraw ay consent at any t i a e .

Signed:
J
Data
Witness: .^WU

Reiaticnsiis: Data:

MM 543( I M . 12/811 CMVTC a * * . S/901

INTERDISCIPLINARY NOTES - (PSYCHOTRCPIC MEDICATION PROBLEMNO

Dace

Prescribed

Target Seiiaviors | Medications

Status

Dosage/Signature

Physician's Comments

Adverse

PfC*q.

?/«
\?t-

m vi ,. *

^

•£&*

V.
^:?3«*a»S38Ssew

:>3s&£ '^r

'

•

'•\~MT - i.—?*~-\ r ; - j - ; - • • •

' *"*—*V •-•si-** -«-y(**-S*:a_-=>; t '

•-•* A . _ i . - * - ~ - " • - '" r l - i i i j . ' -•*»-)T".*^ •?*'»-'—- >• —
••. •-—3^S'
- « . . _-f :.»

Date

CHVFC * « . S/9Q)

KOT£S - (PSYCHOTKOPIC JIEDICAXZON PROBI^M W

Prescribed

Target Behaviors

Medications

Status

Dosage/Siqnature

Physician's Comments

Adverse Raacricns

U l «icrf«s >i«r b* ai^wd witlr n w . title.

!S£fS@SMF

OHM 3&S Cl«v. t Z / 8 1 ) (WTC * * v . S/90)

INTERDISCIPLINARY NOTES - (PSYCHOTROFIC MEDICATION PROBIZM NO

Date

Prescribed

Target Behaviors Medications

Status

Oosage/S ignature

Physician's Camnmnts

Adverse Reactions

f i

&S&82£sz2SS*£fi£*~~£i'}

^ •^^^a^sasE^^r^^K^vfe^

OMN J4 CKVTC J*v. S/90>

INTEXDISCXPI^ARY. MOTSS - (PSYCHOTSOFIC MEDICATION PROBLEM NO

Date

Prescribed

Target Behaviors Medications

Status

Dosage/S ignature

Physician's Comments

Adverse Reactions

'fi
<j-rv'/<r

*-.- W.«W*« • "•-..-•3£2S**
" './* = " -

-•

••••>_

.-/;.•

—

*-

- '-• * :.*>i

s.^• - n

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r^j*if?^'Vf'^=:£-- ;

1 r * • ^r^^r?^V'^r ^^*T*i£j ;r- *" •' *""**"
-:-^

n 1

—fO—1993

.gEUROLOGY Tun, 2xmo
•>pm
iccker

352-6996

. V •'-. •

ENT 4tbThun/mo 9.30 am Dr. Rooney

281-2266

ORTHOPEDIC 3rdFrl/mo 1:00 pm Dr.Rogen

998-1110

OPHTHALMOLOGY

4thTuuq2mo

2:30 pm /1:30 eye dropi

Dr. Forator

FC 334-3900

PHYSIATRY Monq2mo 9:30 am Dr. Oaihi

938-5744

GI UK Monday q2 mo 9:30 am Dr. Fischer

860-1700

PODIATRY ndayqmo pnv dtmnar

941-7770

UROLOGY LutWed q2mo 1:00 pm Dr.Glovw

591-5443

CARDIOLOGY 2nd Mon qi mo 9:00 am Dr. Singh

591-7770

GYNECOLOGY 3rd Mon q3 mo 9:3O«n Dr. Leary

281-5000

DERMATOLOGY 3rd Thura q3 moi 9:30 wn Dr. Silvcmmn

641-0083

ALLERGY 3rd Thun q3 mo 9:30 am Dr. Schueter

689-2000

GENETIC

''"•'flar tOMnboum (202)8842187

\ ATTACIiriENT 1

NORTHERN VIRGINIA TRAINING CENTER BEHAVIOR INTERVENTION PROGRAM APPROVAL/SIGNATURE SHEET

Name: Residential Unit: 6

Reg#: 745

DOB: 06/13/65

Date of Admission: 01/07/36

Problem sU: Needs to rsduce aggression.

Program Goals: J M H B W H I have no more than 5 episodes of aggression to people permonth for 3 consecutive months.

Program Title: Treatment of severely aggressive behaviors through the useof Clozapme and behavioral management procedures.

Staff: Tad Unof ?ii.D.P Psychologist, 3uild.ing 6

Approvals:
"it
InterdiscipidJiary Team (.QHRP)

Interim Approval final Approval

Ptfex* Review C^miLittae (C^lair)

Interim Approval rinai Approval

Psychologist

Interim Approval FinaZ Approval

ni ^ r r . " r of Psychology
//i
Physician - " ^'/j

laterm Approval Finad, Approval
d
Interim Approval Final Approval

• 1
Parsnt/Guarcfian S^/1 /
BMC

LHRC

^ j/

Advocate A /[^S

Director

Tntarim Approval Final Approval Interim Approval Final Approval

Interim Approval Final Approval Interim Approval Final Approval

Notification

Notificati

Interim Approval Final Approval

NORTHERN VIRGINIA TRAINING CEN" BEHAVIOR INTERVENTION PROGRAM BEHAVIORAL OBJECTIVES

3e3i.deaei.al 0n.it: 6

745 Date of

Problem 3*4: Meeds t: raduce acgrsssicn.

DOB: 06/13/65 01/07/36

Program Goals: 4 M vii; iiave no mara than 5 episodes of aggression
ta people per month fcr 2 consecutive months.
Relevant strengths: Friendly; inquisitive; desire to please, learn, and succeed; able ta asic far assistance; good expressive and receptive verbal communication sJciils (but may be difficult to understand at tiaes) ; rsads, writes, and do ari thematic problems at approximately the 2nd/3rd grade levels; relatively social and initiates interactions with others; interested in his health care needs; responsive ta staff praise and attention; good short and long-term memory; aany leisure and racrsational sJcills £ interests; understands value of money; usually cooperative; and initiates interactions.

Program Title: Treatment of severely aggressive behaviors through the use of Clozapine and behavioral management procedures.

Ob jeetivea:

1/36

05/15/94

IBM vill receive at least 30 reinforcements

per prcbe far adaptive behaviors each month

fcr S consecutive manphs,,ay 06/01/95.

Psychologist:

~~s3&£/%& fjfl

Date net:

1/37

12 /23/94

WBm vill have no sore than I episode cr aggression ta people each month for consecutive months by ^.^Ql/^S. Psychologist: Date Met;

NORTHERN VIRGINIA TRAINING CENTER PSYCHOLOGICAL SERVICES
BEHAVIOR INTERVENTION PROGRAM

Name: H M H l H H M i Residential Unit: 5

Reg*: 745

DOB: 06/13/65

Date of Admission: 01/07/86

Pro&lem a*4: Needs to reduce aggression.

Program Goals: mam will have no more than 5 episodes of aggression to people per month far 3 consecutive months-

Relevant Strengths: Friendly; inquisitive; desire to please, learn, and succeed; able to asic for assistance; good expressive and receptive verbal communication s k i l l s (but may be d i f f i c u l t to understand a t tines) ; reads, writes, and do arithematic problems at approximately the 2nd/3rd grade levels; r e l a t i v e l y s o c i a l and i n i t i a t e s interactions with others; interested in his health cars needs; responsive to staff praise and attention; good short and long-term memory; many leisure and recreational s k i l l s & i n t e r e s t s ; understands value of money; usually cooperative; and initiates interactions.

Program T i t l e : Treatment of severely aggressive behaviors through the use of Clozapine and behavioral management procedures.

Responsible staff: Tad Uno, ?h.D., Psychologist, Building 6

Trainers: All S3U and ciir.icai staff involved in the provision of treatment and training to San.
Implementation Date: 9/23/94

I . DESCa^PTION OF CLIZST: The following program plans have been recopied numerous times sinca flat was originally admitted, to NVTC on 5/29/83, including the most recent revisions on 6/14/94. The current revision reduces the r a s t r i c t i v e n e s s of his behavioral program by discontinuing the l a s t contingent mechanical restraint procedure ( i . e . , 2-point v r i s t r e s t r a i n t s ) in 12/1994. In addition to the information provided below, mora extensive background information and previous behavioral plans can be found in Resident Records -
A- Biographic/Diagnostic Cnaracteristics: M l is a mildly mentally retarded 29 year old man with a diagnosis of encephalopa-chy due to psychiatric disorder (Autism) . gpft is also diabetic (diagnosed with juvenile diabetes in 10/33) and receives insulin almost on a daily basis-

BEHAVIORAL INTERVENTION PROGRAM Reg. ,#74S)

1/03/95

M R was originally admit-ad to the Northern Virginia Training cantar (>TVTC; from DeJametta Cenxer for Human Development an 6/29/83. According to his parents , ••» experienced a savera toxic drug reaction to Haldol in 2/82 whiia at DeJarnetre, resulting in tardive dysJcinesia with concomitant loss of speech, incontinence „ and behavioral ragrassion to early infantile lavels.
From a/15/33 - n/13/34, H B K resided on tire Special Behavior Unit at Cantral Virginia Training Canter (CVTC) because of his increased aggression and his residential tJnit at ^^VTC to effectively manage his behavior. Because M m continued to display psychotic-liJce behaviors as well as eictrameiy aggressive behaviors to himself and others, he was transferred to NVMHI shortly after his return to NVTC, and then zo Western State Hospital on 12/12/85. mm* returned to MVTC on 1/7/36, again relatively unchanged, and was admitted to the newly created NVTC Special 3ehavior Unit.
A wide variety of restrictive treatment programs have been used over the years to address Utot' s zxaladaptive behaviors, including behavioral and psychopharmacological approaches. (?or more detailed information, please rarer to Sectisn I-c below and written records filed in Resident Records).
At the present time, Warn, is generally a friendly and sccial individual who raadily initiates and sustains interacticns with staff and appears to en^oy their attention (see ahove for additional developmental strengths) . His self-care and community living sicills are relatively veil developed rafinement in specific araas are needed (see Residential Servicas reports for additional information) . His receptive verbal and exprassive communications sicills are relatively good (aJale to appropriately express his wants, needs, and refusals) although some slurring in his svsech.maJces him difficult to understand at times. He frequently initiates independent leisure activities and particularly enjoys such activities as looJcing/reading magazines and books, writing and drawing, watching television, movies, foods and cooJcing, swimming, biking, walking, a-ncl soc hops, and visiting with family-

BEHAVIORAL

PROGSAH Reg.

1/03/95

V h has displayed a vide range of maladaptive behaviors in the past beginning in early childhood, inducting perseveration, appcsicional behavior, inappropriate toileting, agitation, hallucinations, aggression to people and property, and self-injurious behaviors. However, since ••• began receiving Clozapine in 10/93, he has shown a ramaricahle reduction in the frequency, intensity, and duration of these aaiadaptive behaviors. This improved behavior was maintained through 1994 and he continues to do well despite occasional occurrences these behaviors (see Figures on pages 5 and 6 for frequencies of targeted maladaptive behaviors and intervention procedures) . As notad earlier, mechanical res"Craints have now been completely discontinued.
For additional background and psychosacial information, please refer to the admission indorsation and annual staff reports filed in Resident Records.
B. Frequency /Duration/intensity o£ Baseline /Comparative Data: M B behavior is under relatively good management at this time, relative to his behaviors prior to the beginning of Clozapine in 10/93, and his rate of targeted maladaptive behaviors is relatively law at this time.
Baseline data frsm home or other treatment programs are not rsadily available prior to flMH admission to NVTC. Since tihe rate cf aaladaptive behaviors have been relatively unchanged f sr the last several years beginning approximately a year fallowing his sost recent NVTC admission and prior to the start of Clozapine, data of 1 specific maladaptive behaviors and intervention, procedures collected during these latter years ax& graphically presented below and on pages 6 and 7. It should also be noted that the majority of the behavioral 1 episodes consistently occur during the p.m. shift.
In addition, since many of his episodes include more than : a single maladaptive behaviors and multiple interaction
procedures, i.e., one behavior may merge into the next, | the duration of each type of maladaptive behavior is not
possible to determine. However, the average monthly duration of nonphysical and physical interactions are , presented on page 7.

BEHAVIORAL IOTESVEHTION PROGHAM. (Reg, *f745 J

1/03/95

Additional intervention procedures used to assist in tiie management S H V aggressive behaviors have included program sxtansions (i.e., when a behavioral apisode exceeds SO ainutas and additional time is required ta aciiieve a szacs of calai) and emergency psycaotrooic medication. Tliis inxoraarion is presented on page 7".

rargetea Maiaaaonw denaviors: Unit

90 r 70 r 50 r

Cozaoine oequn in iQ/93

u

50r

40 r

30 r

20-

10 r
Q —

-n - I A

I3l5i7'gl

11 I 1 i 3 " S I 7 '

A

5

a

10

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2

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3

Montniy (1/93mru 12/94)

Aggression P-oota (^3 Self-Injury r ^ TOTAL c?!SO0E3

9 I T11

10

12

wa Muaoasov* 8*nawoti: STC

UontMv (1/93 aim (2/94) AggrM»on P«OQI« ^ 3 S«d-*ntwfV ' " ^ "TOTAL SPtSOOES

BEHAVIORAL IOTZRVEOTXON PHOGSAil ( R e g . £7AS)

1/03/95

TO

{

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TO r
JLJ

L1.

i

7 i 9 ' 11 ;

1

10

52

Monrtvd/Uthru

i

*

a

10

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2 - Stam unat Calm

14 — 13 r i t f» io ^

EMERGENCY tNTERVENTION PflCCEDUHES

1 -

1 i

o —

7

I 3 : T1 * 1

3

3

TO

'Z

io

Uonmv (1/93 thru 12/94)

Proqnm cawwcni -

Saftcvmrai kitwrvmmon Oursoons

40 f

30 r

20T

r I 10 I I I

I

3 - 5 ! 7 I ginI

Z

4

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MontfttV(1/93 9mi

1 3 I 5i 7 i 9

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11 12

Nonrhysicai Matnoas

Sit on Mai

2 -Point ftasmtncs

tSUBJIU

BEHAVIORAL lOTERVEHTiaN PROGRAM Reg. .5*745)

X/03/95

The above rationale also applies to the determination of behavioral intensity for eacn targeted zaladaptive behavior. The intensity of each episode of maladaptive behavior ranged from 1-5 (i.e., l=low 5 5=*high) with, an average of 4.0 per episode.
Previous Interventions: ^^g has a history of maiadapcive behaviors dating from early childhood. He has been enrolled in several residential and educational programs designed to address the needs of individuals with mental retardation who are also diagnoses with psychiatric disorders. A. variety of training and intervention procedures have been tried to address his maladaptive behaviors, particularly his self-injurious and aggressive behaviors to others.
An assessment of previously used interventions suggests that the most effective program involved a combination of preventative, training, and rsactive procedures which incorporated in vivo training and protective and calming procedures.
Training and reactive procedures which have been used in the past when • • became agitated or upset included problem-solving, verbal redirection, relaxation, and Limit-setting. He has been on a token economy program, DRO for absence of aggressive behaviors, and social reinforcement for displaying appropriate/replacement/ etc. behaviors using various DRI schedules.
When flpl became aggrassive, reactive procedures have included behavioral procedures (i.e. , personal restraints, 2-point wrist restraints, 5-points supine bed restraints, and a "papoose board" as well as emergency psychotropic medications. At one point, M I V aggrsssion rate was so high (i.e. , almost continuous at times) that medical orders were written to remove him from the other clients on his Unit and place him in 4-point bed restraints for extended periods of time. On many occasions, M M would have difficulty calming down within SO minutes and program extensions have been required. For a graphic display of various intervention procedures used over the past tvo years, please refer to the preceding graph.

BEHAVIORAL X3TSKVESTIOH PROGRAM (Reg.

1/03/95

A behavior which has not been displayed since approximately L989 is running away from wherever he happened to be, e.g., home or NVTC. 3ecause of potential health issues associated with his diabetic condition, (l) M was always accompanied by staff whenever he was off the Unit, (2) an educational program was implemented to teach ^ ^ what foods he should and should not eat, tne health consequences of eating the wrong roods, the need for insulin, etc., and (3) a 24 hour Unit restriction whenever M left the Unit without staff permission. The only component remaining to the above plans at this time involves his dietary needs.

II. FOTCTIOHAL ANALYSIS:
Based on a review of m ^ B l ^ B written records prior to his admission to NVTC (s.g.f home, DeJaxnette, C7TC, Western State Hospital, etc.), staff reports, personal observations, and an examination of his behavioral data, his maladaptive behaviors appear to be motivated by a combination of factors.

A. Psychiatric Diagnosis: The large majority of • • • • •

behaviors appear to be motivated by conditions associated

with his diagnosis. He is a relatively nervous and

anxious individual who appears to have many autistic-liJce

behaviors.

According to a 10/16/39 psychiatric

evaluation, IBl ". . . . suffers from autism. He manifests

the classical triad of severely impaired interpersonal

relaticnsnips, severe impairments of ability to

communicate eifactively, and a rigid repertoire of

abilities zo interact in the world." His current

diagnosis is: Axis I - Autism; Axis II - Mild Mental

Retardation; and Axis XII - Diabetes. See records in

Resident Records for previous diagnoses.

B. Sensory Stimulation: Many of his infrequent Selfinjurious behaviors (SIB) are reported to occur when appears to be having a relatively good day, is alone (usually in his bedroom or bathroom, and with no clear antecedent conditions.

C. Attention: Agitation and aggression may occur when his repeated attempts to attract staff attention are unsuccessful.

BEHAVIORAL IOTSHVCTTXaN PROGRAH

"

^ (Rag. #745)

1/03/95

D. Sscape/Avoidanca: There have been times when H V have engaged ir. aggression, either zz staff or himself, as a way cf tailing staff he prefers not to participate in negotiable (i.e. , voluntary) cr non-negotiable staff requests (i.e., requests for health and safety reasons).
S. Interruption, at on-going activities: Occasionally, JI|M may become upset when he is engaged in a preferred activity and does not want to stop, whether it is a recreational or vocational activity.

IZZ. DESCRIPTION OF TARGETED BEHAVIORS:

A. Definition:

1. Inappropriate Urination - Intentionally urinating

in inappropriate areas, such as in his bed or on

:

the floor in the bathroom, bedroom, dayruom, etc.

2. Agitation - Behaviors which typically precedes more

disruptive behaviors, including:

Significant

dilation of his ayes, red nose, facial contortions,

'

constant flipping cf his glasses, odd physical

movements, increased motor activity, threatening

gestures, oppositicnai behaviors, and inappropriate

vocalizations.

3 . Aggression .; ceooie - Out of anger, any behavior whicn could result m significant injury to others, including: Hitting, Jcicicing, punching, pinching, scratching, using an object as a weapon, etc.

4. Self-Injurious behaviors - Out of anger, any behavior vUica could result in bodily injury to himself, including: Facial hitting, pinching self, headbanging, hitting or kicking self, etc.

5. Ri-sJc/Implication of Targeted Behaviors: ^ B has clearly demonstrated his ability to be highly disruptive and aggressive toward himself and others to the point where injury occurs unless the behavior is stopped. His maladaptive behaviors have also significantly hinders his ability to engage in a vide variety of community

10

3EHAJX0RXL I3TERVEHTI0H PROGRAH

"

(Reg. ,#745)

1/03/95

activities and praclu.de him from residing in a more normalising community environment:.
The proposed proqxam procedures are designed ta provide • A with an opportunity to i e a m aors appropriate ways to deal with his frustration and anger and to live in a less restrictive setting. Tiiis treatment program includes establishing prsventative procedures and conditions, training of replacement behaviors, and implementing nonrestrictive and restrictive intervention procedures to protect him and others from injury.

TSEATHEJTT PROCEDURES i

&• Preventive Program Components:

- V ., Environmental Adjustments - M i generally prefers a relatively quiet and cala environment which enables hia to occupy his time with leisure activities, such as drawing, writing, doing math problems, and
: look at magazines. On some occasions, when the : noise and activity levels increase, particularly
when other clients become disruptive, he may become distracted, annoyed, and agitated and begin to have behavioral difficulties. Therefore, Staff should attempt ta maintain a relatively quiet and ; therapeutic environment while at the same time :< i raspcnd to his attantional and training needs.

2. Independence - 3ecause fl^ is a very capable individual who is able to initiate and complete the majority of his self-care and community living
: activities, he should have some control over as many of these activities as possible.

Staff must also not only enable M to maintain his

: current level cf independence but develop and

refine additional social and interpersonal sJcills ;: to prepare him for the eventual move into a less

restrictive environment, preferable into a

,: community-based residential program. To this end,

:

H I should be offered a variety of community-based

activities, e.g., recreational programs, shopping,

restaurants, etc. (particularly since he enjoys

3EE&VT0RAL

PROGRAM Reg. #745)

1/Q3/9S

going into the' community)

W

currently

participates in community Awareness Special

0lympics, and occasionally

ioncvioilervedoffi-ntfnaicttiavcittiiveistiewsith(e.g.,peeirs

group in 3uiiding 3 ) .

3 • Individualized Choices - Vft has clearly demons-era,tec his ability to aaJca appropriate choices in a number of areas, including those in leisure and community living. Therefore, to the greatest extent possible, he should be directly involved in aaJcing choices whenever they axe possible, such as his clothing as veil as vocational, recreational, seals/snacics (if possible) , and leisure activities for his daily activity schedule. Since food has historically been a source of difficulty for flft, he should continue Zo receive information and training regarding his dietary needs as well as the rationale for any iced restrictions.

4. Attention - flBPl need for attention continues to be regularly displayed. This is particular ly
: • evident in h^s effort ^3 communicate with staff and will frequently become perseverative if he does not immediately receive a response from staff. Staff should talk with Bft whenever he wants to talk, regardless of the topic. At the same time, staff roust respond to him in an appropriate manner, i.e., answer his questions but redirect and set limits when he begins ~c cerseverats. Therefore, staff should periodically communicate or interact with ^•l in such a manner that each event is clearly and appropriately initiated and terminated.

B. Positive Program Components: Adaptive Behaviors will be reinforced within the context of fll^B daily activity schedule. Staff attention and/or interaction will be used as the primary form of reinforcement but, in some situations, other more tangible reinforcers will be used (Note: all foods/drinks used as reinforcsrs must be approved by the Dietitian.) The use of response contingent procedures appear to be the mast clinically appropriate procedure at this time.

12

BEHAVIORAL ISTERVEHTION PRQGRAH (Rag. J7AS)

1/03/95

cooperation - g ^ will continue to remain on a cooperation training program in which he will be requested to complete a variety of a c t i v i t i e s as parr of his treaoenr and "raining program, including but not limited to the following: participation in group and individual leisure and recreational activities, completion of salx-care tasks, and related community living a c t i v i t i e s . Cooperation v i l l be defined as responding appropriately to staff requests witiiin 3 verbal prompts.

A Differential Reinforcement of Incompatible behaviors (DRI) schedule will be used to reinforce a l l cooperative behaviors. Data will be collected every Wednesday by Unit staff, summarized monthly by the Psychology Assistant, and reviewed monthly in the CSS by the Psychologist.

Relaxation Training: M§ has been trained in this technique since his admission to NVTC. currently, he responds relatively consistently to s"ta£f when prompted and continued training is not necessary at this time. Relaxation techniques will continue to be suggested whenever • • becomes agitated and problem-solving procedures are ineffective. Staff v i l l ask him to be seated on the mat or a chair and take some deep breaths. Staff may try to keep him calm by reminding M i " 3 stay relaxed and, if necessary, aay ask him t r count as he continues zo take a specified number cf deep breaths.

Prosocial Behaviors - A DRI reinforcement scaedule

will be used to verbally reinforce a l l appropriate

behaviors.

Behaviors to be reinforced will

include, but not limited to the following: use of

leisure time and material, socially interacting

with a l l staff, performance of daily living s k i l l s ,

and participation in individual and group

a c t i v i t i e s . Data will be collected every Wednesday

by Unit staff, summarized monthly by the Psychology

Assistant, and reviewed monthly in the CSS by the

Psychologist.

•"

BEHAVIORAL ZBTERYENTION FROGXAH

" " -"

C^

#745)

1/03/95

Interdisciplinary Training programs: J [ will be provided with f ormai raining from other NVTCDepartaients as part cf his tstai Liabiiitation program- These programs will be desicned to provide him with self-care and community living skills as well as alternative replacement behaviors to his maladaptive behaviors- •
1. Communicaticn - M l is currsntly able and willing to parr:c:pace in a conversation and can relate events sequentially. V M will now focus on staying on topic and developing turn-taking skills- See Speecn Therapist's program for details.
2, Therapeutic P.acrsaticn - The need for physical activity is addrassed through racraation, i.e., given choices among 3 different circuit stations, stationary bjJce, and the trampoline. Cammunity-
: based and off-Unit activities are also offered ; through Therapeutic Recreation. See Recreation
Therapist's program for details.
3-, Academic Skills fcommunication) - | M has 2 formal programs which provides him with regular training and individualized attention. One is co maintain
; his reading and arithmetic skills and the other is to use the computer for training in specified
; arsas, skill acquisition, and leisura. See Speech . Therapist's program for details.
4:. • Skills Training -antar 'STC1 - This is a ;; vocationailv-aased program in wnich work producticn
is targeted. See STC program for details.
V. BEHAVXORAI* I3T2E.VCTTZCN
The following reactive procedures will be implemented until ^ j | becomes calm. Calm will be defined as the absence of ail targeted maiadaptive behaviors for 5 minutes, not to exceed 50 ainutes. All interventions are not to exceed 60 minutes without the approval of a Psychologist.
A. Kaladaptive Behaviors: Reactive Procedures. A.11 targeted maladaptive behaviors will be addressed using (1) a graduated system of interaction ranging from verbal
14

BEEAVTORAI*

PHQGXAH Rag.

1/03/95

and nanphysical nethads to physical interactions as well as (2) the specific procedures designed to address eacii category of identified behaviors.
I- Inappropriate CJrina-cion - This behavior tends to , occur between the time • • goes to bed at night and i waJcing up in the morning. Staff will verbally
prompt him to use the bathroom when he gets up at any time during the night. However, if" he ;, inappropriately urinates, either in his bed or on •; ! the floor, he will be requested to restitute using ;' verbal and gestural prompts. After the araa is clean, he may return to bed.
2. Agitation - Staff should immediately intervene in a I supportive manner and attempt to problem-solve and
redirect W H H t when he becomes agitated and ! begins to display precursors to aggression (see ''' definition above).
; A graduated system of interaction will be used beginning vies (1) Nonphysica.1 techniques, i.e., problem-salve, instructed relaxation, retiirect, and limit-set. (2) If he remains agitated, he will be promptad to sit an a mat until calm. (3) If he remains agitated or refuses to comply the request to sit on the mat, he will be prompted to self restrain until calm.
If the above procedures are ineffective and. Mfc becomes a threat t2 himself cr others, {4) staff will iapieaent Crisis Management procedures as described in Section VT: PHYSICAL X2TrESACTXOH

Aggression to oeopla - If

is aggressive to

staff or clients, (1) he will be prompted to sit on

a mat and go through the relaxation sequence until

calm. (2) If he remains agitated or refuses to

comply the request to sit on the mat, he will be

prompted to self restrain until calm.

If the above procedures are Ineffective and f^» becomes a threat to himself or others, (4) staff will implement Crisis Management procedures as

BEHAVIORAL INTERVENTION PROGIUH (Rag. ?

1/03/95

described in Section vx: PHZSIC3U. Z3TE2ACTI0H

4. Self-in^urv - Same as Aggrsssion tc people.
B. Crisis Management: Crisis management procedures will be used at any time or place, as described in Section VT: PHYSICAL INTERACTION TECHNIQUES, if ttB'S behavior is determined to be a potential danger to himself or others. The Crisis Management Form must be completed as soon as possible if crisis management procedures are used.

VI. PHYSICAL OTTH?ACTION TECHNIQUES: Restraints
In the event that personal and/or mechanical restraints are required to assist in the management of W s behavior, as prescribed in either (1) his behavioral program or for (2) health and safety reasons, i.e., Crisis Management, these procedures will be based an the Mandt Svstem and implemented according to DMHMRSAS and MVTC policies. Since restraints are not a part of Ken's formal program, all restraints must be conducted and processed as a form of Crisis Management.
If a restraint is needed to manage Mfc's behavior, staff will first implement a personal restraint. If, according to the judgement cf the shift supervisor or the in-charge person, ^ B ' s condition (i.e., his emotional stats, severity of his aggression, etc.) can be cettar managed with mechanical restraints, then a Psychologist aust be contacted far consultation and then approval. It is recommended that the Psychologist be notified within 10 minutas following the initiation of the personal restraint.
The interactive procedures as well as theguidelines described below were developed according to feB's current behavioral needs.
A. Personal Restraint: The nature of the restraint should always be dictated by the individual, i.e., sufficiently flexible within specified limits to consider ^fcy s psychological responses to restraints, the behavioral topography, his strength, size, ate. Therefore, whenever possible, the restraint should be conducted according to the fallowing preferred sequence of alternatives.

:

is

•wrr

3£HaVT0RAL IHTSRVEHTXOtf FHOGRAH (Rag.

1/03/95

Number

Staff - The minimum number of s t a f f

rsquired to implement a personal restraint is tvo

trained staff with sufficient physical interaction

skills to deal with • • ' £ sizs and strength. And,

if additional staff are present, then their

involvement will be directed by trie restraint "team

leader.11

Restraint Position - The preferred restraint position is standing because it will make movement into a quiet area or his bedroom, if necessary, easier and safer. As indicated by David Mandt, "it may become necessary to restrain a person viio has become aggressive or out-of-control on the ground. We feel it is best Zz try to restrain tie person standing up first; however, you may not have any choice (The "andt Svsten, page 4-14) ." This is applicable toM B .

The order of preferred restraint positions is as follows:

(1) Standing 2-3 person restraint (2) Sitting down (2-3 staff) (3) Lying down (at leasr 3 s-caff and preferably
with Wm lying en his side)
5odv Mass - The most typical method of initiating a restraint is to bring the individual' s body under control by securing "body mass." Therefore, the most experienced star* should be the person to make the first physical contact to at laast manage his body. The second staff will then assist in managing the arm(s) and, if necessary because of the presence of other clients or activities, begin moving I^B into the Quiet Room. If M M drops to the floor, the 2nd/3rd staff will be responsible for managing the legs.

4. Management of Arms / Leas - As a general rule, physically manage only as much of ifc's body as necessary to protect him and staff from harm. If • A is retrained in a standing position, staff must be aware that he will attempt to bite, headbutt, and kick (however, his legs do not need to be held

3EK&VT0RAL INTERVENTION PKOGHAH (R«g. 5*745)

1/G3/95

if he is properly position away from other people) . If the restraint is conducted in a sitting or lying ! • • position, "hen the lags must be held by at least : one staff.
The order of preference in securing M A ' s arms, regardless of the restraint position, is as ;. follows:
(1) one-arm standing/seated/lying down ; (2) Two-arms standing/seatad/lying down
B. ', Mechanical Restraint: If mechanical restraints are required, per Crisis Management policy, then the following adjustments will need to be made:
1. vnpHor- of staff - A Tnir.-i-rmrm O f 3 staff should be involved. The first step involves the management of M B by placing him in a personal restraint.
The second step will involve a lift and carry procedure. One staff will place ^ M in a 2-ana ; restraint while the other 2 staff will securely [ hold each of his legs. Care must be taken sines §•• will attempt to headbutt and bite. l^fe will then be lifted and carried to his bed.
2. Restraint Position - S B ' s bed will be prepared as follows: (a) A pillow positioned at the headJaoard ~z prevent headbanging when ••• is transferred to
: the bed. (b) Wrist and ankle restraints will be attached to the bed. (c) The chest rastraint will be nearby for easy access when needed.
; M i will be placed in a supine position (facing up) on his bed. The restraint will be maintained whila the lags are secured with anJde cuffs by each staff. The staff will then take each of •••'s arms while the restraining staff removes her/himself
: from S B . Each arm will then be secured with wrist cuffs. The chest restraint will be added to prevent M H from bouncing on his bed.
Staff must be able to put two fingers between Mfc and the wrist and ankle restraints to ensure their
13

BEHAVIORAL IOTEKVENTION PSOGRAH (Reg. ^745)

1/03/95

:

proper application. There must also be sufficient

padding to prevent irritation of the arm pits when

tie chest rastraint is applied and at least 1 inch

of space between tie ciiest restraint and pBS's

caest when the restraint is pulled away from his

:

chest.

: 3.
1
:
;

Monitsrincr tav Staff - V > will be under constant visual monitoring while he is in restraints. Particular attention will be given to (a) •••'s physical condition, i* e., breathing, temperature, perspiration, sicin color, and any other atypical bodily changes. The restraints will also be physically checked at least every IS minutes.

VXX. SCHEDULE OP PROGRAM IMPLEMENTATION:

The behavioral program should be implemented at all times and all locations except in emergencies situation when adjustments may to be made for programmatic and/or for health and safety purposes. For example, in the event of an emergency, e.g. firs, all formal interaction procedures will be immediately terminated and ^m will be escorted out of the building. If he remains disruptive and/or becomes aggressive, and is a threat to people," property, or himself, a physical restraint procedure as describe above will be implemented (Section VT PHYSICSi I2TT2SACTICN TSCHNIQtJES) . The Crisis Management Fors aust be ccmpiated if either a personal or mechanical restraint is used.

19

BEHAVIORAL XOTERVENTION PROGRAM (Reg.

1/03/95

VXII. ?SYC2OT2tOFIC DEDICATION:
Wmt currently receives psychotrcpic medication in the fora of Clozapine and Lithobid. Other medications wnich have been tried in tie past to assist in the management of his behavior include: Tegretol, 3uspar, Klonopin, Ativan, and Ciomipramine.
Additional information can be found in tie notes filed in tile CSS and in Resident Records by the physician, pharmacist, and psychiatrist.
IS. BKTiSTaOT LIT2RATURS:
Tae proposed treatment procedures are consistent with current professional practice.
X. ADVERSE REACTIONS:
No adverse side-effacts are anticipated at this time as a result of implementing the currant program other than what would normally be expected when an individual is upset and physical interaction procedures are required to manage the aggressive behaviors, i.e. , physically guiding Wm onto the mat, assisting l^» assume tie learned relaxation pasture, and the application of a personal restraint. As with all physical intervention procedures, rhe probability of injury ~o staxf or client (i.e., in the form of bruises, scratches, fractures, and biting) always exists. With proper training in all aspects of nonphysical and physical intervention procedures (i.e., Mandt Systam of Interaction) as veil as the application of mechanical (s.g. , if needed as part cf a Crisis Management procedure) , no significant injuries are expected to either M s or staff.

20

lira

SHHAVXCKAL rHTsavsirrioK PROGRAM
(Reg. .#745)

1/Q3/95

ZX. A.
B.

Adaptive 3e&aviors: All targeted adaptive and/ or replacement behaviors displayed by M B . will be documented by s-caff according to the data collection schedule noted above.
Ha I adaptive Ba&aviora: The fallowing information vill be recorded an tie 3enavior Program Record each time JMi displays a targeted maladaptxve behavior: Date and time of the maladaptive behavior; type of behavior; frequency, duration, and intensity of the behavior; the behavioral intervention(s) ; and the antecedent(s) to the behavior.

Z. PROGRAM EVALUATION:

A. Adaptive and maladaptive behavior data will be collected by Residential Services staff. The data will be summarized and reviewed regularly, i.e., weekly, monthly or as needed, by the Psychologist: and/or the Psychology
Assistant.

3. Adaptive and maladaptive behavior data will be reviewed, evaluated, and reported in the client's CRS by the
, Psychologist on at laast a monthly basis.

• C.

Consultations with clinical and other NVTC staff involved . in VBk's treatment will be documented in the CRS. All
outside consultants' reports will also be entered into the CSS along with their recommendations. I* the IDT does not accept any or all at the recommendations, the IDT's rationale will also be entered into the CSS*

. 0. • There will be programmatic revisions or a total rewrita
if data, dirsct observation, and/or input from diract 1 care staff suggest the need. All revisions will require
, the approval of the Interdisciplinary Team.

21

BEHAVIORAL INTERVENTION PROGRAM

1/03/9S

XIII. MZDICATION INFORMATION:
These ars the medications prescribed at tietime this program vas writ"an. Changes in specific medication and/or dosage may occur during tie course of tils program- ?ortie most current medication orders, rarer to tiePharmacy report. Physician's notes, and Psychiatrist's orders.
• H i receives psychotropic medicaticn at this time. In tie event tiat additional medication is needed to assist in tie management of his behavior, tie minimal tierapeutic dose of psychotropic medication (I.e., medication prescribed specif ically to help manage behavior) will be used in conjunction witi tils behavior program to help maintain tie lowest possible rate of target behavior(s). There is a goal to gradually rsduce and finally eliminate all psyciotropic medication when possible; however, it can be.expected that some individuals may function better with medication than without. Therefore, the type of medication prescribed,and it's dosage level will bemodified (increased or decreased.) as dictated by the client's behavior and side-effects of medication. Anypotential harmful effects from tie drug have been weighed against tie potential behavioral benefits andthe benefits clearly outweigh tie side—effects of tie drug. Reviews of medication and target behavior(s) will be conducted at laas'C aoxrtiiy, and more oftsn if necessary to facilitate an cotiaal zieraoeutic rasconse.

Medication Clozapine Litiobid Insulin

Dosage 4-00 mas. 1200 mcs.

Prescribed for Behavior Behavior Diabetes

PJfysiciati

Date 22

BEHAVIORAL

.7*745)

1/03/95

XXV. SPECIAL CONSIDERATIONS: Use of restrictive procedures.
I am fully aware of tie physical interaction teciniques of the Mandt Sysrem that may be used to assist in tie management of M B ' s behavior, aithar (1) as part of tie approved plan of intervention specified in his behavioral program, or" (2) in tie form of a personal and/or mechanical restraint in tie event tiat Crisis Management Procedures are required. There are no medical contraindications for tieir use at this time within tie context cf the preceding intervention plans.
s*~\

Physician

Date

XT. STAFF THAXHXHG:
Tie Psychologist will in-service tie Psychology Assistant(s) woricing directly with Ken and tie staff on his Unit. Tie Psychologist and/or Psychology Assistant will then in-service all staff working directly with M | . This in-service will include tie following: (X) reading of tie behavioral program witi staff and providing staff with tie rationale for tie various traataenc procedures; (2) being available to answer ques-cions asaut: tie program; and (3) modeling tie correct implemenraticn of tie program. Tie Psychologist and Psychology Assistant will provide on-going dirsct observation and give izimediate feedtoacx to staff concerning csrrsct and/or incorrect implementation of tie program procedures.

Taa Uno, Ph.D.

/ /Date Tad Uno, Ph.D.

Date

Licensed Psychologist #648 Supervising Psychologist

23
TT

NAMb.

IINI1: SHU

liLIIAVIOli t'lK M HtCOUl)

(NSIHItCllON I Ha •atlituccaading Ima wtiantlia IWERVtNUON PfiQCEDtJHfc iluiig«v bom(1)• now atltcUva to(wil/tUva of \i) *ia*klciwa lotiiottiai la

DATE

lit T

TIME (in rninulM

AWTCS UAJ ADAPTIVE

START

BfiTK (bafowj

BEHAVE

IHrEHVENTlON

I'M

A B C D E F G U I 1 2 3 4 5 1 2 3 4 6 6 7 B e 10 11

PM

A B C D E F G U I 12 3-15 1 2 3 4 5 8 ? A fi 10 11

PM

A B C D t p G I I I t 2 3 4 f t I 2 3 4 6 A 7 I 9 1011

PM

A B C D E F G i l l 1 2 3 4 5 1 2 3 4 5 0 7 8 9 1011

PM

ABCDEF Gill 12 3 4 5

2 34 567BOIO II

PM

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CATA SUMMARY

. ADAPTIVE 5&!AVlCfiS

CLIENT; 745

MCNTh

AOAPTTVE

^NUARY P—RUARY MARCH APRIL MAY JUNE JJLY AUGUST S E P T E M B E»! CCTCHEn NOVEMBER :

14.253 32.753
26.5' 38.75i 34.751 32.751
34.31
28C 28.671
25-2-1
28.75:1

UNIT:

r
1.57' 7.44! T4.4I 16.71 0.32! 2.041 5.3 f 0.82!
T.aai
01
3.1' 7'

CCMPUANCc

CUMULI

t VP

2 VP

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301

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1 1
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"ARGSTS ADAPTIVE SEHAVtCRS;

3 CF =£!

PflCCPAM CHANGES.

YEAR: -994
QfriS
l
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1
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1

1 1

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FOR 3 3

3EZ3UU3ED

Medical ? ' ! • - ~

Mama:

3niZ: 3

3OB:

*EG » 0 : GQQT4S

of

Drug aaa and Prevs.1

aeaariorxl ?ioo«tiiir»» Triads

VaW 3aa se*n sn a Tariatv 5; csrvcsc^xz^iic aedicacioa ov«r zaa yaaxa.

Movc rsciKi*/, he ftaa sama zrsazea wisz a ccmciiacion oc l l z i l u a and

~

: i . Iz z i e saaz, wnan .ie was a ts«naqor, z^ara war* aarera^L

of aeuralaptic oadi=azisa -^zac a l l e g e d ? lad zs a s t v t n zardi.r

"cr :^aac rsaaana* slaca i e w«» a zaanagaj, aauroiapcisr

aecLLcaz.cn saa aevtr =e«a zrsacr^zec agajLa. -c acpa&ra stiiza -avcsffcis ana zze 3iAni_zs3<caz—ona oc nls

3xucn =y zze a r s s c r i r z i s c zt ^izzJ'-il^.m and regr^r

of Psrciotnwic

, Da**qm, .lotrta of

and

t i a aiacilcac^an cc ba rri.sd 13 Clorarn ne up zc a dosage of 9Q0 sq riai'y. t*:i3 aadlcac^=a aaa de«n zr^sd in ZUTTDV :=r z i a paar 2Q v-eaxa «nd icunct not: zc causa «xcr3nyraaujia-l sympcsaia ar zariLT

targac Mai.aftapei.va aaaavxar t s b« aodiiisd:

Sali-ifcmaa, paysreoi. aggraaa^on, dlaru-s

banavisr

' s saefts.

Monri

Totai.

Moaci

of ?3yciiarirzc Canattltaat;

•z ox pg'Canxi.al Side S2isc*za a

a.)

Ma^or Side £2'scz3:

Agraim locyroala, hyr

a)

Hlnor Side ZZtscz.31

cwari Z- ?rsaaman Psrcno-cropic
. aaisuraa

, and we
Medical 2*riew of Sldo Ztincza (by wneai* i-'eqneacy, a u i u i i of r \TI*"^y*^***j LJb<juatory Work If Indie3Twds
Sacsndar-r za z i e ooaaiai_LLz7" af agraEttJ-ocTroa^, anyone wtxo CloaariJL * 3ni3-c be nanizcrad.. iv™$#~ zr.9 CloiariJ. aionizsruig ayacaminciades a veaicly vbixm csunc aad li-ffsrenc^aJ.. whicii i s re^iewa«l by z
= i i l a g onyale^an and pnaraaeiac before z i e oedlcazlon cien =aa =a z i i e d . " r i addi.zi.on. otsar 3ide-—ffa<r=3 witA aa arani.=3rtt<i 3-carz, u s i t -uraes, zi:e uait zavaic^an. and csaauiz^sg pay

Medical ?iaa for

CTs

to be I»oiom«n«ed ia tie Event of Side S**ecc3:

a

on 3j.?Z3 or y

;

be ismediaM i y dj-scaacuued And eVsfc.' 9 vnita ccunt w i l l h

z

riaiiy- o&3«r 3ida-»r=»c^3 ara dealz wtsi 3y dosage, rscuczisa or

^i *-rn r*7 af dosage ars-acri.st.is a.

Staraocsc Hazarding/ Aasidaat' s HiraroJ. And 0zidasiraJ3X* 3*o«Tior Sid* ZZt

r i i siia «si«c-=3 ai Clazar^..

Coacurrmt for tii«

behavior? Psyc&ologxj^'s

5«« i c t i 7 i t y schedules far ZZM r

Sea beixa.vi.araJ. plans of t i e

{ See aacrcicn i
?iaaa» i t * - i ^ i ^ ob*)*csj.T« for U r i M based oa Beiiairior d a r t s inTTlnrivnT 3MTT*MM rrwqaamjcr, liow doeaxBencetl and Plan for Saad-jasciag-, Sadaclaq- or DijennrTantaT c^* Drag:

p aedicacz-oa rsvrews wjj.1 sancisa*. as t^ey always ^ave, en a baaxa. spec^ii= data uzJJ.te ccXZaczfid and arsaenrsc ac u a yjc-Ly reviews and f^an decisioss aada aaauc l i e dosage or aedicaxioa. la -^o «vear of iacic of rsapoase, zzn medicar^ca w i l l be gradually
decreased and

Sign

»/-

3y aesi a) Ccapecenc adult-ccnaenc signed (

-= tnajca sedicol i a c i s i

3y Parent/Guardian:

a) PsycaiArrT* conrsrencs acraaded and serial ccasaoc g'i

b) Ccasent g^TBa by talepaoae i/).

c) Caaaent qzrran

f

(y) .

/<? S<~-

Suoau.z-ls,g Aczandiac; Pirysiczzar^

Oct. 13,1993

/

Over Telephone>Approved by

LHRC: Mrs. ClaTra Jacques,

Mrs. Ann Sale Mr. J^*»p Tieman

—*

*

?OR
iersby give consent to Portia: icii staff to administer to:

OF
rg^r.ia Training Cantar

tte medicacion:

Clozaplne

-

T i e fallowing adverse canditiens vtiicii nay occur as a result of prascriied nedicarian ars lisrad below and have been ta you toy:

a) HAjor Sida STi

b) iliaor Side R i s

, saizurss

ri?a"cicn, dizziness, raver, h sedation, salivation, tachycardia, and weigat gain

I have been f'iliy inforaed of tne narura of t i e above medication, cctantial side erfacts and tne reason for t i e use of t i e niedication. I understand I can vitidraw ay consent at any tizte.

Da. t a : W i t n e s s : Jj>*4i+.

Reiaticnsiia:

Data:

/-\

Dare

W* W 5 (I,*. CKVTC Jcv. S/90)

NOTES - (PSYCHOTRCPIC MEDICATION PRQBLZX NO

Prescribed

Target Behaviors i Medications

Status

Dosage/Siignature

£-»<»

Physician's comments

Adverse

T7^Sfr?.»- '
B^SSa****

'

/

-

•

set
4. * f

-r.i j «--"f

,t

' i , ' -»•

EKVTC Jt». S/901

ZNTSHOISCIPLINAKY HOTSS - (PSYCHOTSOPIC MEDICATXON PROBLEM NO

Data

Prescribed

Target 3ehaviors Medications

Status

Dosage/S ignature

Physician•s Cojnaancs

Adverse

aw* J4 <WVTC ««v. 5/90)

INTERDISCIPLINARY NOTES - (PSYCHOTROPIC MEDICATION PROBLZM NO

Prescribed

Target: Sehaviors Medications

Status

Dosaqe/Signacure

physician1 s comments

Adverse

-CT UCO-j

•' > * # . ' * / > -

•

;

^

-

-

5/ -5

' CO* J+*-1»O-<i 4 •
t --.-•j*i*ji.t. V- •. "•,-' '.'r^*/fj£

II S !

0** 5*5 ( l * r . 12/811 (KVTC *•». S/WJl
Y HOTZS - (PSYCHOTROFIC MEDICATION PKOBLSi NO

Prescribed

Target: B e h a v i o r s Medications

Status

Dasage/S ignature

Physician1s Comments

Adverse Reactions

^

.

. J,

ATTACHMENT Pre-Servicc Training for Direct Care Staff | Q

Policy: Ail new employees classified as direct care staff must attend the orientation program and pre-service training classes required before beginning work on their assigned unit

Purpose: The purpose of the pre-service training program is to prepare new employees to perform their assigned duties competently.

Responsibility: The Training Department is responsible for the administration, scheduling and coordination of the facility's pre-service training program.

Exception: An Assistant Director or Department Chief may submit a request for temporary deferral of pre-service training to the Training Director. Employees who obtain approval for temporary deferral must be scheduled for pre-service classes within the probationary period.

Exemption: If a supervisor wishes to exempt an employee from any part of the pre-service program, a request may be submitted in writing to the appropriate Senior Staff member. If approved, this wiii be forwarded to the Training Depanment for information and documentation in their Pre-Service Training Record.

Direct Care Staff Defined: Direct Care Staff include those staff whose job responsibilities necessitate interactions with the client.

Direct Care Staff shall typically indnde employees classified as:

•

Developmental Aides

•

Developmental Technicians

•

Medication Aides

•

Team Leaders

•

Program Managers

•

Recreation Therapists and Aides

•

Special Activity Supervisors and Aides

•

Other staff having direct contact with clients

Required Pre-service Training for Direct Care Staff: All direct contact staff will be required to attend Orientation and Pre-service training classes during the first month of employment.

The employee with receive orientation and training in the following areas:

Personnel Policies and Procedures

•

Resident Abuse Policy

Resident Rights

•

Safety and Security

Mission Statement and Philosophy of NVTC

Sexual Harassment

Introduction to Mental Retardation

•

Signs and Symptoms of Illness

Vital Signs

•

First Aid

Nursing Arts/Personal Hygiene

•

First Aid

Body Mechanics/Lifting

Nutrition and the Mentally Retarded

•

Mealtime Techniques

•

Mandt System of Managing People

•

Normalization

Behavior Modification

•

ID Team Process

Volunteer Services

•

Sensitivity to People with Developmental Disabilities

•

Teaching Techniques (Task Analysis, Prompting, Reinforcement, Error

Correction)

•

Data Collection

•

Behavioral Documentation

•

Client Record System

•

Sexuality and the Mentally Retarded

Communication and the Mentally Retarded

Sign Language

•

Dental Health

Therapeutic Recreation Services

•

Mechanical Restraint Procedures

•

Side Effects of Medication

•

Missing Client Policy

•

Seizure Recorgnition and Observation

•

Infection Control

•

Crisis Management

Direct Care Competency Training Program

•

Cook-Chill Techniques

Adult CPR

•

Working with Families

•

Active Treatment

On the Job Training: As soon as a new staff has been assigned to a unit, and before the end of the employee's probationary period, approximately six (6) months, all new direct contact staff will complete the Direct Care Competency Training Program. (See separate section for description)

Class Schedules: Training schedules shall be prepared by the Training Department and disseminated to employees, supervisors, and instructors.

Attendance Required of Re-hired Employees: Employees re-hired twelve (12) months or more after separation from the facility are required to attend orientation and pre-service training classes upon their return. Employees re-hired six (6) months or less after leaving the facility are -equired to attend the Abuse and Human Rights classes only.

10

If there have been no signincant changes in the training program since the empioyee last attended a particular class, attendance at those particular sessions may be waived, pending approval of the employees Department Chief or Program manger and the Director of Training.
Transfers Within the Facility: Employees transferring within the facility from a support classification into a direct contact position must complete all required pre-service classes for direct contact staff during the month following the date of transfer.
Expectation for Employees: Employees in training programs are expected to: Attend ail classes for which they are scheduled Be on time for each class Return from breaks and lunch periods at appropriate time Participate appropriately in the class activities Achieve established training competencies with established rime frame
Recording Attendance: A pre-printed class roster will be available in the Training Room. Each instructor will circulate this roster for those in attendance to initial beside their name or sign if their name is not on the roster. Upon completion of each session, the instructor will send this roster to the Training Department, where the attendance will be noted on each individual's PreService Training Record.
Evaluation of Performance: Each Support and Clinical Staff member is expected to perform at his/her optimal level and is required to attend all mandatory Pre-Service Training Classes.
Performance in each class will be evaluated in die following manner 1. Numerical score of 75% or better (unless otherwise determined); or 2. Participation/attendance in required classes
Any Direct Care Staff member whose score fails below the designated mark or who fails to attend a required class will be notified in writing to attend the necessary classes the following month. A copy of the written notification will be sent to the individual's supervisor also.
Incomplete Training Notifications: If an empioyee needs to attend a pre-service class due to absence or failure to successfully complete it, the Training Department will send a written notice to the empioyee and their supervisor informing them of the schedule to return to training.
Completion of Required Training: Successful completion of the pre-service training requirement shall be documented on a Pre-Service Training Record by the Training Department. A copy of this form shall be sent to the Personnel Department for filing in the employee's personnel record. Employees tailing to successfully complete the training program will be terminated from the agency or transferred to a position with different training requirements.
Participant Evaluation: Employees shall be given the opportunity to anonymously evaluate each pre-service training class they attend.
Evaluations are reviewed by the instructors and supervisory personnel staff in the Training Department. Feedback will be considered in making changes in the Pre-Service Training
Program.

TRAINING OUTLINE FORMAT
1. Title of Session: Policy on Abuse
2. Trainer(s): David H. Lawson
Back-up Trainer(s): Lee Hilton and video
3. Time Required: 1 hour and 3 0 minutes
4. Materials or Equipment Required; NVTC Policy on Abuse
5. Site of Session: Building 4/Training Room
6. Learning objectives for Participants in Training Session:
1. To explain nature of policy and rationale for State/NVTC
2. To discuss ways to prevent situations which commonly lead to abuse.
7. Instructor Guide or Outline of Training Session (be very specific so that baclc-up trainer could teach from it effectively). Attach any handouts used in session
A. Statement of policy 1. historical perspective 2. rationale for its stringency
B. Definition and prevention 1. physical 2. verbal 3. neglect
C. Responsibility of reporting 1. to Director 2. penalities
D. Investigation 1. preliminary investigation 2. full panel 3. director's findings 4. appeal to circuit court
TESTING - PENCIL AND PAPER TEST
EM: Proman\plcyabus

Subject Area: Purpose: Audience: Learning Goals:
Teaching Method(s) Time Required: Materials Used:
Physical Setting: Evaluation:

Human Rights
orient new employees to Human Rights Program
All new employees
- Discuss rights both for NVTC and DMHMRSAS Regulations
- Role of the advocate understood Complaint review process understood
Lecture
1 hour 3 0 minutes
(Handouts) Outline Staff Responsibilities Resident Rights Classroom Pencil and Paper Test/70% to pass

HUHANRTS

SUBJECT APEA: PURPOSE : AUDIENCE: TflftFMTNG GOALS:
TEACHING METHODS: TIME REOUTRED: MATERIAT-S USED: EVALUATION:

Safety and Security
To acquaint new employees of safety and security programs.
All Employees
- Instruct on rules and regulations - Instruct on use of fire extinguisher - Instruct on oneration of state-owned vehicle
Lecture Demonstration: Use of fire extinguisher
One (1) hour and 3 0 minutes
Handouts Videotapes Fire Extinguisher
Return demonstration: Use of fire extinguisher

SUBJECT AREA:

Sexual Harassment:

PURPOSE:

Acquaint staff with Sexual Harassment Policy

AUDIENCE:

All employees

LEARNING GOAL(S):

-definition of sexual harassment by Dept. of Personnel and Training -penalties for engaging in sexual harassment -reporring allegations of sexual harassment -management responsibilities

TEACHING METHOD(8) Lecture Scenarios to emphasize definition

TIME REQUIRED:

30 minutes

MATERIALS USED:

Handouts

EVALUATION:

Class Participation

SUBJECT: PURPOSE:
AUDIENCE: LEARNING GOAL(S)
TEACHING METHOD(3): MATERIAL(8) USED: TIMS REQUIRED: PHYSICAL SETTING: EVALUATION:

Introduction to Mental Retardation and Developmental Disabilities
- To acquaint staff with the American Association on Mental Retardation's definition of mental retardation.
All Staff
- Look at the definition phrase-by-phrase.
- Define the 10 adaptive skill areas.
- Define levels of support.
- Causes of mental retardation.
Lecture
Handout: The Definition and its application.
45 minutes
Classroom
Paper, Pencil, Test; 7 0%

Subject Area: Purpose:
Audience: Learning Goal(a):
Teaching Method(s) Time Required: Materials Used: Physical Setting: Evaluation:
a .-Normal

Normalization

To discuss issue of normalization as

foundation for planning and

providing

services

to

developmentally disabled people.

All Employees

Heighten sensitivity to needs of institutionalized, disabled persons for dignity and respect-

l hour Handouts, Videotape Classroom Class Participation

Subject Area: purpose: Audience: Learning Goal(s)
reaching Method(s) Time Required: Materials Used: Physical setting: Evaluation:
a: Seizures

Seizures ...._:„ staff with seizure

reporting.

All Employees

To swerve report the

a,so~enx^izruarrtY ee l

v record b-havior
o

and to
vide

medical »%*"'
appropriate^ *£**

?a i d t o to

person
provlde

: _ £ — ^«< i f i n n

diagnose. Lecture 2 hours Handouts, videotape Classroom

Paper/penc il test:90%

SUBJECT AREA: PURPOSE:
AUDIENCE: LEARNTNG GOALfST
TEACHING METHOD(S)
TIME REQUIRED: USED:
EVALUATION:

Infection Control
To establish measures which will prevent or limit the spread of infections and communicable diseases.
To minimize the risk of exposure to blood and body fluids, and prevent transmission of disease that is transmitted through blood or body fluids, i.e., AIDS and Hepatitis B.
All employees at NVTC
To prevent the spread of infections and disease to other clients, personnel and visitors. Handwashing is the single most important means of preventing the spread of infections.
Lecture Demonstration of how to wear and remove
disposable gloves Universal Precautions Video
One (I) hour
Handouts
Class Participation

SUBJECT AREA: PURPOSE:

Body Mechanics and Proper Lifting Techniques
To go over lifting and transfer techniques in an effort to reduce absenteeism due to jobrelated injuries resulting from body mechanics.

AUDIENCE: LEARNING GOALS:

All new employees
Basic anatomy and posture Proper body mechanics Use of back support Lifting guidelines

TEACHING METHOD(S): Lecture, demonstration

MATERIALS USED: «3Videotape^Saf-t-Lift belt, box to lift

EVALUATION:

Return demonstration: lifting box

BODYLIFT

AREA: PURPOSE: AUDIENCE: T.PARNTNG GOALXSJ.:
TEACHING METHODfS)
TTME REQUIRED: S USED:
EVALUATION:

First Aid
T-O teach new staff basic aid, what to do until medical help arrives.
All Employees
To provide information to a s s i s t in identification of emergency situations and care to provide at that time.
Lecture Demonstration: Heimlich Maneuver
Rescue Breathing 2 hours and 45 minutes
Handouts, Manikins
. o«n«r«ion:
Written test: 90%

SUBJECT AREA: PURPOSE: AUDIENCE: LEARNING GOAI*(S)
TEACHING METHOD:
TIME REQUIRED:
MATERIALS USED: PHYSICAL SETTING: EVALUATION:

Common symptoms of Illness To detect clients" symptoms of illness
Direct Contact Staff T o provide information to assist in the Identification of illness To orovide information.onL t*. cause and care of symptoms or illness
Lecture 1 Hour, 3 0 Minutes
Hand-out
Classroom Paper pencil test, 75%

SYMPTOMS

SUBJECT AREA: PURPOSE:
AUDIENCE: LEARNING GQALfsJ
TEACHING METHODSSI
TIME REQUIRED: MATERIALS USED: EVALUATION:

vital Signs
The taking of temperature, pulse and respiration is one of the first means used to try to learn about a client's condition.
Direct Contact Staff
Instruct staff on how to recognize the vital signs of the clients. Instruct staff on the detection of changes in vital signs.
Lecture Demonstration of howto take temperature Pulse Respiration
One (1) hour
Handouts Thermometers - Mercury and Digital
Return demonstration of TPR

111 > i

n

TRAINING OUTLINE FORMAT

1. Title of Session: Dental Health Education

2. Trainer(s): Dental Staff

Dental Hvaienist

BacJc-up Trainer(s) : videotape 3. Time Required: I hour and 30 minutes 4. Materials or Equipment Required: Slide projector; other
materials provided through clinic. 5. Site of Session: Building 4/Training Room 5. Learning Objectives for Participants in Training Session:

- Philosophy of dental care
- Staff responsibility re: client oral hygiene
- Demonstration of proper teethbrushing technique
7. Instructor Guide or Outline of Training Session (be very specific so that back-up trainer could teach from it effectively) . Attach any handouts used in session.

SEE ATTACHED

SIDE EFFECTS OF MEDICATIONS

Purpose: Objectives: Materials;

To acquaint new residential service staff with side effects of medication.
To have all new residential staff be aware that medications have side effects.
Video: Cognitive and other Side Effects of Medications Handout

1. Information given includes, but is not limited to, a discussion of common side effects (e.g., nausea, vomiting, GI distress, rash, and elevated temperature)

2. Anticonvulsant medication discussion

addresses

sedation, dizziness, vision problems, and confusion.

3. Psychotropic medication discussion includes sensitivity to the sun and heat, as well as dry mouth, weight gain, etc.

SENSITIVITY to PEOPLE with DEVELOPMENTAL DISABILITIES
I. Introduction to Sensory Integration A. Definition 1. ability to take in, sort out, and connect information 2. in normal development sensory integration is usually automatic B. Description of Senses andHowWe UseThem 1. tactile (touch) 2. vestibular (balance) 3. olfactory (smell) 4. vision (sight) 5. auditory (hearing) C. Concept of Postural Security D. Concept of Motor Planning E. Summary of Sensory Integration
II. Experiential Exercises
TIME REQUIRED: I hour and 30 minutes

SUBJECT AREA: PURPOSE:
AUDIENCE: LEARNING
TEACHING METHOD(SI REQUIRED:
MATERIALS USED: EVALUATION:

Introduction to Sign Language
To introduce to staff a system of communication that uses symbols to express thoughts or share information.
Direct Contact Staff
- Understand what sign language is. Understand how signing is used with
deveiopmentally disabled people. - Introduction of most commonly-used signs
at NVTC. Lecture anddemonstration of signs.
One (1) hour
Handouts, Sign Language Book
Return demonstration of signs

SUBJECT AREA: PURPOSE: AUDIENCE: LEARNING
TEACHING METHODS: TIME REQUIRED: MATERIALS USED: EVALUATIONi

Services for the Hearing Impaired
To familiarize staff with the services provided to our hearing impaired clients.
Direct Contact Staff
- Prerequisites of normal and abnormal language development
- Indicators ofhearing problems - Hearing problems with people who are
developmentally disabled Habilitation/intervention
surgical/medical andhearing aids - Hands-on experience with hearing aids
and management tips - Responsibilities of staff regarding
hearing aid
Lecture Demonstration of how to putonhearingaid One (l) Hour
Handouts, hearing aids, ear putty, ear plugs
Class Participation

SUBJECT AREA: PURPOSE:
AUDIENCE: T-EARNTNG GOALfS);
TEACHING METHOD(S) TIME REQUIRED:
MATERIALS USED: EVALUATION:

About the Art of Communicating with Mentally Retarded People
- Understand what communication is - Understand the problems of communicating
with people who are mentally retarded.
Direct Contact Staff
- Understand Speech and Language Development - Understand problems in language growth - Understand alternatives in verbal
communication - Understand helpful hints for successful
communication
One (1) hour
Hand-outs Videotape Communication devices
Class Partiicpation

SUBJECT PURPOSE: AUDIENCE: LEARNING GOAL(SI:
TEACHING METHODS, TIME REQUIRED:
MATERIATfS T7STT);
EVALUATION:

Nutrition
Familiarize staff with nutritional needs of client population.
Direct Care Staff
Provide information on the role of the dietitian of NVTC. Provide information on different therapeutic and textured diets available at NVTC.
Provide information about the nourishment and food reinforcement procedures at NVTC.
Lecture
Minutes
Handouts
Class Participation

SUBJECT: COOK CHILL PROCEDURES
PURPOSE: TO ACQUAINT STAFF WITH COOKING PROCEDURES/ EQUIPMENT
AUDIENCE: DIRECT CONTACT STAFF
TEACHING METHODS: LECTURE/RETURN DEMONSTRATION
TIME REQUIRED: 1 HOUR MATERIALS: COOK CHILL EQUIPMENT
FOOD TO COOK
EVALUATION: RETURN DEMONSTRATION

Subjeer Area: Purpose: Audience: Learning Goal(s):
Teaching Method(s) Time Required: Materials Used: Physical Setting: Evaluation:

Mealtime
To provide information to staff regarding mealtime.
Direct Contact Staff
- provide information regarding the role of staff at mealtime/when feeding clients.
- provide information regarding the role of the O.T. in the context of mealtime. provide education concerning the appropriate use of feeding equipment.
Lecture Recurn demonscracion of feeding cechniqut I hour
Adaptive Equipment fcr Mealtime,brought by O.T.
Classroom
Class Participation Return demonseration of feeding techniques

A:FEEDING

SUBJECT AREA: PURPOSE: TARGET AUDIENCE; LEARNING GOAL(SI
TEACHING METHOD(S) TIME: MATERIALS USED: EVALUATION:

Interdisciplinary Process

To introduce the concept of Interdisciplinary Process

Direct Contact Staff

Develop familiarity with role of ID team memoers
Provide information regarding the various systems which effect client care and training

LECTURE ROLE PLAY

One (l) hour

Hand-oucs of c l i n i c a l clinical minutes

agenda,

Class Parricipation Role Play of IDTeam Process

Subject Area: Purpose:
Audience: Learning Goal(3)
Teaching Method(s) Time Required: Materials Used: Evaluation

Active Treatment
To define Active Treatment as continuous aggressive, consistent implementation of a program, and specialized and generic training. Direct Contact Staff
T-O familiarize staff with their role in providing active Treatment for clients.
Lecture
1 hour
Handouts, Videotape
Wei cten Tea c/705

A:ACTIVE

SUBJECT AREA.: PURPOSE:
AUDIENCE: LEARNING GOALS
TEACHING METHOD(S) TIME REQUIRED: MATERIALS USED: PHYSICAL SETTING: EVALUATION:

Crisis Management
To provide trainees with techniques to use in a situation where a client is acting inappropriately and has no behavior program.
Direct Contact Staff
- The trainee will become familiar with the basics of how crises get started.
- The trainee will became aware of what happens to people in crisis.
- The trainee will learn some questions to help guide them through a crisis.
Lecture
1 hour
Handouts, Videotape
Classroom
CLASS PABTICIPATION

CRISIS

TRAINING OUTLINE FORMAT
1. Title of Session: Client Record Svstem (CRS) 2. Trainer(s): Chris Morin
Back-up Trainer(s): Glenna Hatcher 3. Time Required: 1 hour and 15 minutss 4. Materials or Equipment Required: CRS and CRS Manuals 5. Site of Session: Building 4/Training Room 6. Learning Objectives for Participants in Training Session:
-provide general overview of content and order of CRS 7. Instructor Guide or Outline of Training Session (be very-
specific so that back-up trainer could teach from it effectively). Attach any handouts used in session.
1. Distribute materials 2. Define CRS 3. Content and Order of CRS 4. Go through each section of CRS 5. CRS manual
6. Interdisciplinary (ID) Notes -define -how to write -confidentiality

EVALUATION:

TEST/70S

CTTB.TKCT AREA:
PURPOSE: AUDIENCE:
ftOALfST:
TEACHING METHOD(S) :
MATERIAL-?
T7V&T.T7ATTON:

Data Collection
Understand system for objectively gathering information on progress or lack of progress for client programs.
Direct Contact Staff
1 hour 2 0 minutes
Understand the training plan for a client as written on the data form and correctly score or record client's participation and performance on the form.
Lecture Role Play
Hand-outs Items for handwashing and dressing
(shim) programs
Demonstrate recording data on Data Sheet

Subject Area:
Purpose: Audience: Learning Goal(s):
Teaching Method(s) Time Required: Materials Used: Evaluation:

3ehavior Modification #1 Describing Behaviors/Behavioral
Objectives Behavior Modification if 2
Observing and Recording Behaviors, Behavior Modification #3
Increasing Behaviors: Reinforcers
Introduce staff to behavior modification principles
Direct Contact staff
1. Learn about behavior, behavior modification techniques, behavioral programming.
2. Using this information/training when working directly with clients
Lecture
1 hour and 45 minutes
Hanc-cuts
Class Participation

BEHAVMOD

SUBJECT AREA:
PURPOSE: AUDIENCE: LEARNING GOAL:

Behavior Modification

^iae/Right Place

MMCodduiiVVI- - * £ £ S J 3 & 2 Z £ 5 Behav1Or

To gain familiarity with typical methods to modify maladaptive behavior..

Direct Contact staff
about behavior, behavior modification behavior programming

TEACHING METHOD(S): Lecture

TIME REQUIRED:

1 hour, 30 minutas

MATERIALS USED:

Handouts

PHYSICAL SETTING: Classroom

EVALUATION:

Class Participation

BEHAVWI

TRAINING OUTLINE TOR BEHAVIORAL DOCUXENTATION

SUBJECT: PURPOSE:

BEHAVIORAL DOCUMENTATION
To acquaint staff with the method of documenting behavior program implementation

AUDIEHCE: Direct Contact Staff

LEARNING GOAL(3):

-Explain importance of accurate documentation of behavior programs -Go over line by line the NVTC BEHAVIOR PROGRAM RECORD

TEACHING HETHODS: Lecture

TIME REQUIRED: MATERIALS USED: EVALUATION:

l Hour Handouts of Behavior Program Record Use of form/return demonstration

-.-=*

SUBJECT AREA: PURPOSE:

Mechanical Device Procedures
Give a overview of the types of mechanical devices used at NVTC

AUDIENCE:

All Direct Contact Staff

LEARNING GOJLL(S)

-Instruct on reasons for mechanical devices -Show types of mechanical devices -Highlight safety measures

TEACHING METHOD(S) Lecture and Demonstration

TIKE REQUIRED:

1 hour and 3 0 minutes

MATERIALS USES:

Types of restraints

EVALUATION:

Return demonstration/applying different mechanical devices

SUBJECT AREA: PURPOSE:
AUDIENCE: LEARNING GOALS:
TEACHING METHOD(S): TIME REQUIRED: MATERIALS USED: PHYSICAL SETTING: EVALUATION:

Behavior M o d i f i c a t i o n : Wrap-Up "Harry"

Illustrate points made in previous B-mod

sessions:

Reinforcers,

and

Decreasing/Eliminating Behaviors

Direct, Contract staff
Behavior changes occur as a result of consistent implementation of the programs by staff
Videotape, Discussion

1 Hour, 15 Minutes
Videotape: "Harry", handouts: Discussion guide and ten-year follow-up article

Classroom Class Participation

BHVWRAPUP

TRAINING OUTLINE FORMAT
1. Title of Session: Missing Residenr Policy / What is a Roving Team Leader fRTL)
2. Trainer(s): Carla Mills RTL BacJc-up Trainer(s): PM Developmental Technicians who have been cassed off to rove.
3. Time Required: 1 Hour 4. Materials or Equipment Required: MVTC instruction 5000.
Missing Resident Plan and procedures for Roving Team Leader and written tast on Missing Resident Plan. 5. Site of Session: 3uilding 4/Training Room 6. Learning Objectives for Participants in Training Session:
1. Duties of RTL 2. Missing Resident Procedures 7. Instructor Guide or Outline of Training Session (be very specific so that back-up trainer could teach from it effectively). Attach any handouts used in session. 1. Names of RTL's (PM and NOC Shifts) 2. RTL Responsibilities and Duties 3. Missing Resident Plan and Procedure
TESTING - PENCIL AND PAPER
EM: Proman\msngres

SUBJECT AREA: PURPOSE: AUDIENCE: LEARNING GOAL(S)
TEACHING METHOD: TIME REQUIRED: MATERIALS USED: PHYSICAL SETTING: EVALUATION:

Volunteer Services
To acquaint new staff with department services
Direct Contact Staff
- Educate staff on the value of volunteers
- Encourage them to participate in the volunteer program as volunteer supervisors or volunteers themselves.
Lecture
1 Hour
Flipchart, Handouts
Classroom
Class Participation

VOLUNT1

-.•3*
TRAINING OUTLINE FORMAT
1. Title of Session: Working with Families 2. Trainer(s) : Alice Mary Hvrnel. ACSW
Back-up Trainer(s): Leslie Katz 3. Time Required: 1-1/2 hours 4. Materials or equipment Required: VCR. Monitor and video Tape 5. Site of Session: Building 4/Training Room 6. Learning Objectives for Participants in Training Session:
- To inform and sensitize incoming employees of concerns, reactions, feelings and experiences of families. If possible, we have a family member tell of their experience of having a developmentally disabled family member.
7. Instructor Guide or Outline of Training Session (be very specific so that back-up trainer could teach from it effectively) Attach Any handouts used in session. I. Overview of Families Reaction to a Developmentally Disabled Child, Sibling, etc. a. developmental sequence experienced by family members b. guilt, mourning, grief, anger, disappointment, jealousy c. roles of new employee in working with family d. possible problem situations/solutions
II. Family Presentation (ON VIDEO) a) NVTC family presents their response, difficulties, actions, etc. in dealing with their developmentally disabled child b) expectations of staff
III. Questions, Concerns, Feedback and Closure
EM: Proman\wrkfam
TTTi-

Subject Area: Purpose: Audience: Learning Goal(s): Teaching Method(s) Time Required:
Materials Used:
Physical Setting: Evaluation:

Human Sexuality create a level of comfort discussing sexuality.
Direct Contact Staff
Make trainees aware of NVTC sexuality policy
Lecture, Discussion

2 Hours

statement

n sexu*lity/norBs

Classroom Class participation

A:HUMSEX

SUBJECT AREA: PURPOSE:

Therapeutic Recreation Services

To acqua•in•t. nneoww recreation services

f with therapeutic

AUDIENCE: LEARNING GOAL(S):
TEACHING METHOD: TIME REQUIRED: MATERIALS USED: PHYSICAL SETTING: EVALUATION:

Direct Contact staff
-To educate trainees on the importance of recreation in meeting basic needs of people, specifically ourclients. -How meeting of these basic needs results in the enhancement of one's life, andimproves self-esteem. -Familiarize trainee with expectations, rules, andregulations of the pool, gym, and adult complex. And provide ageappropriate leisure options on the unit.
Lecture, Learning Activity
1 hour
Handouts, activity items, hullahooo, bean bags, cards. Classroom
Class Participation

TRS1

TRAINING OUTLINE FORMAT
1. Title of Session: Residential Services 2. Trainer(s): Mac McDonald
Back-up Trainer(s): Program Managers 3. Time Required: 1-1/2 Hours 4. Materials or Equipment Required: 5. Site of Session: Building 4/Training Room 6. Learning Objectives for Participants in Training Session:
- general orientation to Residential Services - basic "do's and don'ts" - introduce concept of Active Treatment 7. Instructor Guide or Outline of Training Session (be very specific so that back-up trainer could teach from it effectively). Attach any handouts used in session.
SEE ATTACHED
3. EVALUATION: CLASS PARTICIPATION

SUBJECT AREA: PURPOSE:

Direct: Competency Training Program
introduce staff to the on unit package

training

AUDIEHCE: LEARNING GOAL(8) :

Direct Contact Staff
Show staff how to use training package to assist in learning jobs

TEACHING METHODS: THIS REQUIRED:

Lecture Use of manuals
1 hour

U d O X U D i Direcr Care Comp.cancy Training B O O K

*".«

Trainee Manuals

Supervisors' Manual

EVALUATION:

To be determined during probationary period

Direct Cars Comoetsncv ^"ainina Program
The Direct Care Competency Training Program (DCCTP) is designed for new employees to provide a standardized competency based training teal. The training package is developed to orient new employees to their jobs; to list and document ability, skills and knowledge necessary to perform their duties. It will provide the trainee with enough tachnicai information and practice to become a successful Developmental Aide, capable of performing all required duties and responsibilities.
In addition, DCCTP can be used in conjunction with an employee's performance evaluation. The supervision should review each of the competency items to ensure that the employee has maintained competency in each required area.
The Direct Care Competency Training Program has two parts: first, gix (6) Learning Areas that are knowledge and information related to the Developmental Aide jobs description:
1. Orientation and Training 2. Philosophy 3. Personal Care, Health, Hygiene 4. Active Treatment 5. Documentation 6. Policy
The Learning Areas have objectives, questions, resources and performance criteria which may be a written test or return demonstration cf the task. Each trainee will be required to succassfuily complete each Learning Area.
The second part is a list of competencies which are jcb duties that are task analyzed. They are divided into four (4) groups:
1. Provide Health Related Care 2. Staff/Client Interaction 3 . Provide/Maintain Safe Living Araa 4. Implement Program Plan
The task analyzed duties are used as resources in Learning Areas 2 and 4. The criteria for passing Learning Areas 3 and 4 is mastering the competencies by return demonstration of the task in the situation or a simulated* situation as verbally recalling "Che procedure. The supervisor/trainer would document whether- or not the trainee performs the task in an "acceptable" or "unacceptable" manner. The trainer should indicate under "comments" if the employee needs additional practice, training, or needs to attend Pre-Service Training Classes in related areas.
14
II •

When the trainee reports to his/her unit af-tar pre-service training, he/she will have a blue notebook which includes the six (6) Learning Areas. There is a book of competencies already on each unit. The Training Coordinator will have trainees work on and complete Learning Areas l and 2 while in training class. The trainer will then work exclusively on Learning Area 3 until he/she successfully completes the performance criteria. Since Learning Area 3 is so time-consuming, the maximum amount of time allowed to complete it will be three (3) months. Then go on in sequence to the other Learning Areas 4, 5, and 6; maximum amount of time allowed for each Learning Area will be one month. The trainee then can take up to six (6) months to complete the program.
The trainer will receive a notebook containing a Unit Competency Checklist, casts, answer sheets and task check sheets. The trainer will administer the performance criteria, be it written tests, performance check-offs, or both and document the results on the Unit Competency Checklist. This replaces NVTC form 162 Unit Training Checklist.
When the training is completed, the Unit Competency Training Checklist is reviewed and signed by the Team Leader and Program Manager and then sent to the Training office to be forwarded to Personnel with the Pre-Service Training Record.

DCCTPDR5

15 l III1

UNIT7C TRAINING STATUS OF STAFF

ATTACHMENT 11

30-
O4
25 r

20 iL

<

15-"

03

10"

c

LU

5r

i
0MANDT

CPR

ANNUAL

PRE-SVC

STRAINED ^ NOT TRAINED

UNIT7C TRAINING STATUS OF STAFF

O

CD

z
LU
CcJ
LLJ C

MAND"

CPR

ANNUAL PRE-SVC

STRAINED ^ NOT TRAINED

TWT

-rr

Annual Re-Training Requirements for IWTC Staff

Policy: All employees will receive mandatory re-iraming in designated topics on an annual basis.

Purpose: The purpose of this re-nraining is to ensure competence in Hgffn^H criricai topic areas. The topics covered are determined to be important to allow staff to perform their duties in a manner which will protect themselves and the ciienrs from injury.

Schedule: Re-training in the mandatory courses will be reouired annually; the anniversary month of the dare of hire ro the faciiiry. Some courses are scheduled by the instructor with each department and are not included in the monthly Annual Re-
program.

Required Training: The following courses are required for the specified departments.

Abuse Policy and Procedures Sexual Warag<^ngTir Infection Control Proccdures/AIDS Body Mechanics and Lifting Human Rights Crisis Management Active Treatment

All Staff All Staff All Staff All Staff All Star! Direct Care Starr Direct Care Staff

Special Training Requirements: la addition to the above training requirements for all staff, some classifications require additional training. All Clinical and Direct Care star? are required to be recsnined in the Mandt System annually. If staff are in a position which requires CPR cermicanon (direct care staf£ STC staf£ and recrearion therapists) they must attend arecerrtncnTionclass annually.

Responsibility: It will be the responsfoiliry of the Training Department to notify individual employees when they are scheduled to attend the Annual Re-training or recertxrlcanon sessions. The Training Department wfll also notify the employee's supervisor so that schedule adjustments can be made, if necessary. It will be the responsibility of the individual employee to notify the Training Department if they are unable to attend the required classes.

2L

ii i "'I' ' ! • r mi

dilation of Performance: Each employee is expected co perform ar his/her uprimai level and is required to attend ail mandatory classes. Performance in each session will be evaluated in the following ways:
i
1. Numerical score of 75% or better on written tests, or 2. Satisfactory demonstration of required skills, or 3. Famcipaaon/arTfrnrmnce m required classes

Any employee who does not perform satisfactorily in the required re-training sessions, will be notified in writing to repeat the session unni competence is obtained. A copy of the written norincanon will also be sent to the individual's supervisor.

Record of Training: Upon successful completion of ail required in-service training

classes, the Training Department wiil document in the employee's computerized

training record.

;

22

•

-.-=*

P U R P O S E : T O es-ahllsh a systam for staff to reviav and/or practice appropriate responses to medical emergencies. Through macx emergency situations which, siauiata those most lively to occur in a particular voric sita, nursing and paraprorassional star* will be able to practice siciils and agency procsduras in medical emergencies.

TARGET STaiT: Tie primary szax- required "a participate in emergency drills will be unit nurses, CTR and infirmary stiazf, and unit, dixecx care srazf.

following szaxf will have designarad rssponsi".lities in ensuring that staff have adequate information and .opcrtunitr/ ta practics and understand their role in a medical emergency on a monthly basis:

r - c3mmunica"C2 the requirements t the apprccriaca nurses; develop specific aaergency situations/scanarios
generic ca dizfsrsnt vorx si~2s; schedule 3LS classes for nursas.

un

- coardinata scheduling of drills; select

apprcpriata scenarios; process with participants aftarvards.

•

Superri gars - participate in needed

training for appropriate emergency medical cars; participate in

d r i l l s in preparation -cr real situations; process aftarvards.

" Tr^i_r;r.g ngQarT-.g^t - provide on-going c?R classes to direct care staff; assist in d r i l l s and processing as requested by unit nurses; document participation in individualized computerized training records.

5 See a t t a c h e d ?rrte?-rrgr!crr

7 g ?•?*.

PROJECTED BUILDING 7 1995 TRAINING

ATTACHMENT 14"

MOi>rra/TRAij>aNG
JANUARY BM Routine New Fever Rounne Nursing GOP for Seizures in Seizure Book
FEBRUARY Family Ceniered Training (Pan I) Manril Review ^fandr Review Active Treatment Active Treanneni
MARCH Behavior Pass Off Mandt Mandt Seizures Seizures
APRIL Behavior Pass Otf Mandt V£anrir CRS Training CRS Training Supervisory Training
MAY Sign Language

DATE
1/24 1/24 1/24
TBD 2/21
2/2J
2/9 2/22
TBD 2>21 1^23 2/28-2-2:45 1^30-2-2:45
T3D 1'25 2^7 TBD TBD TBD
5/2

Sign Language

5/4

Sign Language

TBD

Mandt Review

5/23

Mandt Review

5/25

UNIT
7A/7C 7A/7C 7.V7C
7A/7C 7C 7A 7A/7C 7A
7A-AM/PM 7C 7A 7C-AM/PM 7A-AM/PM
7C-AM/FM 7C 7A 7A/7C 7A/7C 7AJ7C
7G7A-AMS (10:00 & 11:00) 7C/7A-PMS (1:30 & 2:30) 7A/7C NOCs 7C 7A

r.vIONTH/TRAIiNIN'G
•JUNE Emergency Response Training Conflict Management Mandt Review Manor Review Family Centered Traimns (Pan U.)
JULY Mandr Review Mandt Review
AUGUST Mandt Review Mandt Review
SEPTEMBER Behavior Pass Off Mandt Review Mandt Review !
OCTOBER Behavior Piss Off \ Mandt Review { Mandt Review Family Centered Training
Famiiv Centered Traimns
NOVEMBER Mandt Review Mandt Review
DECEMBER N'fandt Review Mandt Review Stress Mnnapgmeat •TBD = To be determined

DATE
TBD TBD 6/20 6/22 TBD
7/25 7/27
3/22 S/24

LMT
TA/TC-AMs 7A/7C 7C 7A 7A/TC
7C 7A
7C 7A

TBD 9/26 9/2S
TBD 10/2410/26 10/3
10/10
Il/U il/16
12/12 12/14 TBD

7A/7C 7C 7A
:c
"A 7C-10:00AM 7A- LI:00AM 7C- t :50 PM 7A-2:30 PM
7C 7A
7C 7A 7ATC

CONTINUING EDUCATION 3E0UTHZMENTS
3elow ara the minimum continuing education requirements established :'cr NVTC clinical stai:'. These were established for processional positions far vhicn "hers ara no stata raandatad or licensing continuing education requirements. These were established by the appropriate Department Heads and were based an standards from other states.

Position Administrator

Continuing Education Requirement -2Q hours per year

Dental Department*
i •
i •'
Nursing* ); \\
Occupational Therapist*
(•
i

-1 CS meeting per year at DC Dental ',

Society Spring meeting

•

-In-house in-sarvicas provided by ;

dentist

-3 NVTC in-servicas per year -12 contact hours by completing a
home study program

-3 hours per year (conferences, in-\

services, assistance centers,

facility tours, academic

courses}

.

Physical Therapist-*

-15 hours per year

Physicians

-90 hours on cnE every 1 years

;

Psychologist*

-60 CEU hours every Z years

Radiologic Technologist* -3 sessions per year

Recreation 1'herapist

-Community C?R (annual)

-Lifeguarding (every 3 years)

-Pool Operators (one time)

'

-10 hours T.R. courseworic or in-

service/year

Social Worker

-WorXshops, etc- 15 hrs/year -Professional meetings - 10 hrs/yr , -Self-directed study - 3 hrs/year

Speech Therapist Audioioqist

-Readinq ASHA publications and sharing info at department meeting
-Reading "Clinical Connection" -Attending local workshops -Attending 2 professional meetings
per year

* No s t a t e CME/CEU requirements established

91 PROPOSED RESIDEMTIAL/CLINICAL SERVICES PRIORITIZED EQUIPMENT LIST | lU3WH0ViXtf
FROM FY '95 - '96
February 27,

PHYSICAL THERAPY Wheelchairs - Electric
Seating Systems f/wheelchairs Tilt-inpace Wheelchairs Seating f/wheelchairs Reel ining Wheelcharis Seating system f/wheelchairs Wheelcha irs, regular manual Seating system f/wheelchairs
POSITIONING EQUIPMENT Rifton Lift Walker
Rifton Prone Stander Rifton Supine Stander

$2,083.00 $1,200.00 $2,837.00 $1,200.00

$16,664.00 $9,600.00
$11,348.00 $4,800.00

$2,030.00 $!fi,210.00

5121,336.00 $111,736.00 $100,388.00
$95,588.00
$79,348.00

$500.00 $1,000.00

$75,348.00

$0.00

$0.00

$75,348.00

$1,995.00 $1,995.00

$73,353.00

$1,200.00 $1,200.00

$1,200.00 $1,200.00

$72,153.00 $70,953.00

Rifton Adult Gait Trainer
Rifton Sidelyers
Rifton Mobil Stander

IBHIlHiflW^lllIi] HnBK
$870.00

igiiTinOMi
•HSppBranHp

$1,740.00

$69,213.00

2

$439.00

$878.00

$68,335.00

1

$1,723.00 $1,723.00

$66,612.00

Night-time Sidelyers
Droff-off Wedge Sets
Incline Wedges
Supine Leg Supports
Head Supports
SPEECH £ HEARING
SCAN-A Test f/Auditory Processing Disorders
Auditory Continuous Performance Test
Auditory Enhancement Trai ning -VA Foundation for the Exceptional Child S Adolescent
Custom Audio Design Room System
Computer Table
Recumbent/reeling chair
Attendant seating (chairs)
Wheelchair ramp to tee' ith

20

$105.00 $2, 100.00

$64,512.00

8

$2,400.00 $19,200.00

$45,312.00

10

$115.00 $1,150.00

$44,162.00

10

$120.00 $ 1 , 2 0 0 . 0 0

$42,962.00

15

$70.00 $ 1 , 0 5 0 . 0 0

$41,912.00

$0.00

$41,912.00

1

$100.00

$100.00

$41,812.00

1

$100.00

$100.00

$41,712.00

3

$750.00 $2,250.00

$39,462.00

1

$735.00

$735.00

$38,727.00

1

$400.00

$400.00

$38,327.00

1

$500.00

$500.00

$37,827.00

4

$125.00

$500.00

$37,327.00

2

$100.00

$200.00

$37,127.00

IWlMICTffTJMM^WBBl

Satellite Network System
Physical Management Training Program Package (Manuals £ Training Books)
Contract for Physical Management Training Program Master Trainer to train NVT C in-house Trainers
Clinical Presentations
Training Packages on Supervisory/Management Topics & Cultural Diversity
Nutrition Services
Weighing Scales
Specialized Calipers (to assess nutritional status
Measuring Boards
Adaptive Equipment
Workshops
Subscriptions (Pediatrics & Dysphagia
~ive Feeding

$6,700.00 $6,700.00 $3,800.00 $3,800.00

($3,673.00) ($7,473.00)

$5,000.00 $5,000.00 ($12,473.00)

$2,500.00 $2,500.00

$2,500.00 $2,500.00

($14,973.00) ($17,473.00)

$700.00

$0.00 $700.00

($17,473.00) ($1B,173.00)

$350.00 $1,400.00 ($19,573.00)

$600.00 $4,000.00
$400.00 $500.00

$1,200.00 $4,000.00
$800.00 $500.00

($20,773.00) ($24,773.00) ($25,573.00) ($26,073.00)

$350.00

$350.00 ($26,423.00)

Shelf f/audlo equipment Desk f/audio equipment Bookshelves f/RM. 247B Filing Cabinets Chairs (Upholstered) SCAH-Screening Test f/Audiotory Processing Disorders Ages 3-11 Audio Enhancer/Trainer Unit-based IBM or Apple computer (w/peripherals)
Occupational Theray Electronic Feed Device
ADL Supplies Splinting Equip Sensory Stimulation Equipment Sensory Integration Equipment Adaptive Switches & Devises Measurement Devices

U DS5#S3S53EXffl Safe

i 1

Ban?
$200.00

I

$300.00

2

$200.00

3

$200.00

4

$125.00

1

$100.00

MESVEHK
BBsntEsS
nShXSffi

1III
Bi BBSS

m

$200.00

$36,927. 00

$300.00

$36,627. 00

$400.00

$36,227. 00

$600.00

$35,627. 00

$500.00

$35,127. 00

$100.00

$35,027. 00

1

$5,000.00 $5,000.00

$30,027. 00

1

$5,000.00 $5,000.00

$25,027. 00

$0.00

$25,027. 00

$0.00

$25,027 00

2

$2,000.00 $4,000.00

$21,027 00

1

$700.00

$700.00

$20,327 00

1

$2,500.00 $2,500.00

$17,827 .00

1

$4,600.00 $1,600.00

$13,227 .00

1

$2,100.00 $2,100.00

$11,127 .00

1

$9,000.00 $8,000.00

$3,127 .00

1

$100.00

$100.00

$3,027 .00

0

$0.00

$0.00

$3,027 .00

•HiIlMl

l PROPOSED RESIDENTIAL/CLINICAL SERVICES PRIORITISED EQUIPMENT LIST

FROM FY •95 - '96

| J

I

February 27, 199£"

»' * '*
PHYSICAL THERAPY Wheelchairs - Electric
Seating Systems f/wheelchairs Tilt-lnpace Wheelchairs Seating f/wheelchairs Reclining Wheelcharis Seating system f/wheelchairs Wheelchai rs, regular manual Seating system f/wheelchairs
POSITIONING EQUIPMENT Rifton Lift Walker
Rifton Prone Stander Rifton Supine Stander

Avaiiabla*
i~.l
$150,000.00

$800.00 $4,800.00

$1,200.00 $7,200.00

$2,083.00 $1,200.00 $2,837.00 $1,200.00

$16,664.00 $9,600.00
$11,348.00 $4,800.00

$2,030.00 $16,740.00

$500.00 $4,000.00

$0.00

$0.00

$1,995.00 $1,995.00

$1,200.00 $1,200.00

$1,200.00 $1,200.00

$145,200.00 $138,000.00 $121,336.00 $111,736.00 $100,388.00
$95,588.00 $79,348.00 $75,348.00
$75,348.00 $73,353.00
$72,153.00 $70,953.00

Bifton Adult Gait Trainer Rifton Sidelyers Rifton Mobil Stander
Night-time Sidelyers Droff-off Wedge Sets Incline Wedges Supine Leg Supports Head Supports SPEECH £ HEARING SCAN-A Test f/Auditory Processing Disorders Auditory Continuous Performance Test Auditory Enhancement Training -VA Foundation for the Exceptional Child fi Adolescent
Custom Audio Design Room System Computer Table Recumbent/reeling chair Attendant seating (chairs) Wheelchair ramp to testbooth
i '

$870.00 $1,740.00

$69,213.00

$439.00 $1,723.00

$878.00 $1,723.00

$68,335.00 $66,612.00

20

$105.00 $2,100.00

$2,400.00 $19,200.00

10

$115.00 $1, 150.00

10

$120.00 $1,200.00

15

$70.00 $1,050.00

$0.00

$100.00

$100.00

$64,512.00 $45,312.00 $44,162.00 $42,962.00 $41,912.00 $41,912.00 $41,812.00

$100.00

$100.00

$41,712.00

$750.00 $2,250.00

$39,462.00

$735.00
$400.00 $500.00 $125.00
$100.00

$735.00
$400.00 $500.00 $500.00
$200.00

$38,727.00
$38,327.00 $37,827.00 $37,327.00
$37,127.00

Training Department
Satellite Network System
Physical Management Training Program Package (Manuals & Training Books)
Contract for Physical Management Training Program Master Trainer to train NVT C in-house Trainers
Clinical Presentations
Training Packages on Supervisory/Management Topics & Cultural Diversity
Nutrition Services
Weighing Scales
Specialized Calipers (to assess nutritional status
Measuring Boards
Adaptive Equipment
Workshops
Subscriptions (Pediatrics & Dysphagia
Intensive Feeding Program

$0.00 $6,700.00

$0.00 $6,700.00

$3,800.00 $3,800.00

$3,027.00 ($3,673.00)
($7,473.00)

$5,000.00 $5,000.00 ($12,473.00)

$2,500.00 $2,500.00

$2,500.00 $2,500.00

($14,973.00) ($17,473.00)

$700.00

$0.00 $700.00

($17,473.00) ($18,173.00)

$350.00 $1,400.00 ($19,573.00)

$600.00 $4,000.00
$400.00 $500.00

$1,200.00 $4,000.00
$800.00 $500.00

($20,773.00) ($24,773.00) ($25,573.00) ($26,073.00)

$350.00

$350.00 ($26,423.00)

Shelf f/audio equipment Desk f/audio equipment Bookshelves f/RM. 247B Filing Cabinets Chairs (Upholstered) SCAH-Screening Test f/Audiotory Processing Disorders Ages 3-11 Audio Enhancer/Trainer Unit-based IBM or Apple computer (w/peripherals)
Occupational Theray electronic Feed Device
ADL Supplies Splinting Equip Sensory Stimulation Equipment Sensory Integration Equipment Adaptive Switches 6 Devises Measurement Devices

$200.00 $300.00 $200.00 $200.00 $125.00 $100.00

$200.00 $300.00 $400.00 $600.00 $500.00 $100.00

$36,927.00 $36,627.00 $36,227.00 $35,627.00 $35,127.00 $35,027.00

$5,000.00 $5,000.00

$5,000.00 $5,000.00

$30,027.00 $25,027.00

$2,000.00

$0.00 $0.00 $4,000.00

$700.00 $2,500.00 $4,600.00

$700.00 $2,500.00 $4,600.00

$2,100.00 52,100.00

$8,000.00 $8,000.00

$100.00 $0.00

$100.00 $0.00

$25,027.00 $25,027.00 $21,027.00
$20,327.00 $17,827.00 $13,227.00
$11,127.00
$3,127.00
$3,027.00 $3,027.00

The purpose of this Request for Proposals is to solicit sealed proposals from qualified sources t= establish a contract, rhrougn competitive negotiations for consulting services ts. tha areas ot dystpfcagia and nucriti.an management, for Nartnem Virginia Training Center an agency o£ tie CaHnonwaaltii of Virginia.
Background: The Northern Virginia Training Center is aa agency of the Department of Mental Health, Mental Retardation, and Substance Abuse Services of the Commonwealth of Virginia. Located in Fairfax county on an 86 acre campus tie Training Center is a residential f acility f or approximately 250 severely retarded clients with multiple handicaps and disorders. Tne Training Center provides a complete milieu of medical, psychological, recreational, occupational and other therapeutic services. To arrange for a site visit or for additional information about tne facility please contact Mr- Leon Rose at 703-323-4007.
JU Statement of Need; Tne Contractor shall provide services and meet tne qualifications as listed below:
1. The Contractor shall have demonstrable experience, in providing consulting services in the areas of dysphagia and nutritional management with an adult population of deveiopmentally disabled and mentally retarded individuals in both institutional and
jcommunity settings.
The contractor shall vorfc with the AgencyJ s Dysphagia committee to achieve the following goals:
a. To assist in the establishment of policies and procedures which can be practically implemented and practiced by Agency clinicians and direcr care staff.
b. Tne policies and procedures shall assist in the development of the scope of responsibilities of the committee as an adjunct to the Interdisciplinary Team (ID

Team) . These policies/procedures shall include but nor be limited to:

(i; Improving nutrition risJc screening assessments.

(2) Involvement and education of parents when

recommendations are made.

!

(3) Follow up procedures for recommendations made by the Committee and/or outs ide consultants.

(4) Establishing relationships with community resources which shall address but not be limited to the area of diagnostic testing.

(5) Establish policies in the area of tube feeding management.

3. The Contractor shall provide training to further

establish the Agency Dysphagia Committee in the

clarification of the individual roles and

responsibilities of each clinical discipline on the

team.

,

:

The Contractor shall provide case study reviews of 4/5 Agency clients.

The Contractor shall provide one training session to Agency direct care staff on dysphagia and related feeding problems of Agency clients. This training shall include but not be limited to the following:
I- a. A basic overview of dysphagia and mealtime
difficulties with this type of client population.

b.
S
!
I I
! c. !

An overview of how the feeding programs axe designed and why tie proper implementation of feeding programs is required.
Proper positioning during implementation of the program.

! d. Proper use of adaptive feeding equipment. i
e. Mealtime management issues including both, food consistencies and thicfcener use.

f. Reflux;rumination management.

g. oral desensitization and stimulation.

6. The contractor shall provide consult a t i on and •training to Agency clinicians in the f o llowing areas:

Oral motor screening and assessment.

Oral desensitizaticn and stimulation, including a program design for enteral feeding with oral testing.

Nutrition rislc assessment and intervention.

d . Mealtime management issues including food consistencies and thicXener use.

«. Reflux/rumination management.

t - Establish quality assurance in clinical management of nutrition/dysphagia.

g• Establish a quality assurance program f or ongoing competency based training program to be used with direct care staff on feeding and positioning difficulties.

Assist in tie development of procedures and appropriate docusentatisn v i t i t i e purpose ct avoiding negligence regarding f sed-rrg and aydratian issues.

i . Rehabilitation techniques ta increase

i compensatory strategies and

* aizvav

I protection,

including

medication

administration witi dyspnasic individuals.

3. ISie canLTAcsar shall consent to tse video recording- at any andai i training sessions provided to Agency staif. All video recordings snail become tne property at tie Agency and will be for Agency use only.

c. TSe Contractor shal.l provide telepnone consultationsfar eacii discipline artar tie initial inservice at a cost ta be determined. Tie Agency vill coordinate all additional consultations tirougn tne contract Manager (Director of Nursing).

D. The Canrractsr snail agree to provide additional fallow up sessions ?sr either Individual disciplines or far tie entire graup, an an as needed basis, as required by tie Agency at a cast to be determined. Tae Agency will coordinate ail additional consultations tirougn tie canrracz Manager.

THe Cantractsr shall pian and coordinate tie entire project viti tie Contract yannger.

Articles publisned by tie contractor during or a^ter t i e period of tie cantr^ct snail have t i e written permission of t i e Agency director and s i a l l give credit ta t i e Agency if any of t i e information in t i e article evolves from t i e Agency.

RESIDENTIAL/CLINICAL SERVICES PRIORITIZED EQUIPMENT LIST FROM FY '93 - • 94 RETURN YEAR END MONEY February 24, 199f

PHYSICAL THERAPY

Puritan-Bennett Percussor

P.T. (Unit 1)

Positioning Chairs for

P.T. - (Bldg.

30

Mealtime

3)

$113,000.00

$450.00

$150.00

$112,550.00

X

$177.30 $5,319.00

$107,231.00

X

OCCUPATIONAL THERAPY

Sensory Integration

O.T

T.V. Monitor

O.T.

VCR - video-

O.T

fluoroscopies

Cart (f/monitor S VCR) O.T.

Portable Forma-Splinting O.T. Pan

SPEECH £ HEARING

Board Maker

Speech

Board Maker Supplies

Speech

Color Ink Jet Printer

Speech

$2,041.02 $2,041.02

$105,189.9B

X

$369.96

$369.96

$1O4,B2O.O2

X

$525.00

$525.00

$104,295.02

X

X

$109.00

$109.00

$104,186.02

X

X

$594.00

$594.00

$103,592.02

X

$399.00

$399.00

$103,193.02

X

X

$350.00

$350.00

$102,843.02

$315.00

$315.00

$102,528.02

X

1Hi
AUGMENTATIVE DEVICES LISTED BELOW

fB™fflWftraffHl»nP
HHIIIRPfl

Speak Easy AlbeNet

Speech

3

w/keyguard

Hawk AdamLab

Speech

2

Cybersmith's VRA

Audiology

1

System VI-Deluxe

Bioacoustics, Inc

DynaVox Augmentative

Speech

1

Advice

Walker-Talker Prentke- Speech

1

Romich

Alpha Talker with

Speech

1

Headset + 4 S 6 location

operating kits Prentke-

Romich

Shelving for

Speech

1

Agumentative/

Assistive Library

RECREATION

Basketball Rim/Hoop

Recreation

1

n ran
BUS

$383.00 $1,149.00

$175. 00 $1,200. 00

$350. 00 $1 ,200. 00

$4,525. 00 $1 ,525. 00 $1,543 00 $1 ,543. 00 $1,495 00 $1 ,495. 00

$1,067 00 $1 ,067 00

$700 .00

$700 00

MftMMHf 33BB9I
BSB
$101, 379. 02 $101, 029. 02
$99, 829. 02
$95, 304. 02 $93, 761. 02 $92, 266. 02
$91, 199. 02
$90 499 02

Tent (large 2 rms.) Tent (small) Roller Skates Sleeping Bags Padded Folding Chairs
Upri Chair Rack

Recreation Recreation Recreation Recreation Recreation
Recreation

1 1
8 8
32
1,

$299 .00
$70 .00 $40 .00
$28 .00
$12 .60
$283 .00

$299 .00 $70 .00
$320 .00 $224 .00
$403 .20
$283 .00

$90 200 .02 $90 ,130 .02 $89 ,810 .02 $89 ,586 .02 $B9,182 .92
$88 ,899 .82

I
mi

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

1

X

H H C B H J '< \'-' ii $'- '~

• : '"

PSYCHOLOGY

Video Camera (w/accessories )

•' \
Psychology

'"•'•• r.:~'-i

iiiiBii!
,.A .. •... ji

1

$1,117.50 $1,117.50

$87,782.32

X

X

VCR

Psychology

1

$525.00

$525.00

$87,257.32

X

X

Cart f/monitor 6 VCR

Psychology

1

$109.23

$109.23

$87,148.09

X

X

Stat/Graphic Computer Software Pkg.

Psychology

1

$800.00

$800.00

$86,348.09

Desk

Psy<2>

2

$253.00

$506.00

$85,842.09

X

TV Monitor

Psychology

1

$369.96

$369.96

$85,472.13

X

RESIDENTIAL SERVICES

$0.00

$85,472.13

EQUIPMENT/SERVICES

$0.00

$85,472.13

Nutritional Consultant Management Team

1

$15,000.00 $15,000.00

$70,472.13

X

Mats for Quiet Rooms (Closed cell foam)

Bldg.5, 6, 7, 8 12 all quiet rooms

$170.60 $2,047.20

$68,424.93

X

Desk

Bldg. 3(10, Bldg. 5(1)

2

$253.00

$506.00

$67,918.93

X

Computer Tables Printers - Ink

Bldg. 3(1),

7

5(3), 6 (2), 7

(1)

Bldg. 3(1),

5

5(20, 7(1),

891)

$150.00 $1,050.00 _ $66,668.93

X

$256.41 $1,282.05

$65,586.88

X

X

Pr inters - Laser

Bldg. 6(10, 7(10, 891)

3

$500.00 $1 ,500.00

$64,086.88

Me(d

on Carts

Bldgs. 1, 3, 5, 6, 7, 8,

11

$1,000.00 $11,000.00

1

$53,086.88

IHHKHHHHHHH|HH^H

BUM
HHHMHH

Hi

nn BBBBHBBHH RRHHH

FURNITURE

Table (End)

Bdlg. 6

10

$284. 50 $2,845. 00

$50, 241. 88

X

Television (20")

Bldg. - 6 ( 2 ) ,

1

7(1),

$210. 00

$210. 00

$50, 031. 88

X

X

Television (24' Console) Bldg. 3 9 1 )

1

$330. 00

$330. 00

$49, 701. 88

X

X

Entertainment Cabinets

Bldg. - 3 ( 6 ) ,

21

5(3), 6(3),

7(4), 8(4)

$800. 00 $16,800. 00

$32, 901. 88

Chairs (Office & Recliner

*Unit 1(2

4

Recliners)

Bldg. 6

<4roller/4 arm)

***hold***

$479. 50 $1,918 00

$30, 983. 88

HOME FURNISHING

$30, 983 88

Unit 1 Ambience Bldg. 3 Ambience Bldg. 5 Ambience Bldg. 6 Ambience Bldg. 7 Ambience Bldg. 8 Ambience

1

$1,000. 00 $1,000 00

$29, 983 88

X

X

1

$3,000. 00 $3,000 00

$26 983 88

X

X

1

$3,000. 00 $3,000 00

$23 983 .88

X

X

1

$2,000. 00 $2,000 . 0 0

$21 983 .88

X

X

1

$1,000. 00 $1,000 . 0 0

$20 983 .88

X

X

1

$1,000. 00 $1,000 . 0 0

$19 r9B3 .88

X

X

$0 .00

$19 ,983 .88

$0 .00

$19 ,983 .88

*

SU
•+*?,?

ASTROLOGY Tuat,2xma
*> pm
Seeker

332-6996

EffT

9:30 am
Dr. ROOMV
ORTHOPEDIC 3rdFrl/mo 1:00 pm Dr. Rogen

281-2266 998-1110

OPBTHALMOU>GY

4th TUM q i s u

2:30 pm/1:30 eye drapt

Dr. ForWcr

FC 534-3900

PHYSUTRY Monqimo 9:30 *m Dr. Oashi

93R-5744

Gl Utt Monday q2 mo 9:30 am Dr. Fischer

860-1700

PODIATRY

UROLOGY LanWed q2mo 1:00 pm Dr. Glover
CARDIOLOGY 2nd Mon qi mo 9:00 am Dr. Singh
GYNECOLOGY 3rd MOD q3 ma 9:30 am Dr. Learv
DERMATOLOGY 3rd Thun q3 mot 9:30 am Dr. SUvennan
ALLERGY 3rd Thun q3 mo 9:30 am Dr. Schuiter
GENETIC

041.7770 591-5443 591-7770 281-5000 641-0083 689-2000

OMnbaum (202)8842187

l i « RESIDEHTIAL/CLINICAL SERVICES PRIORITIZED EQUIPMENT LIST FROM FY '93- '94 RETURN YEAR END MONEY February 24, 199$"

I

iftib1 1 L * ELCOl * Pri

Availa
l

$113,000.00

PHYSICAL THERAPY

Puritan-Bennett Percussor

P.T. (Unit 1}

$450.00

$450.00

$112,550.00

X

Positioning Chairs for

P.T. - {Bldg.

30

Mealtime

3)

$177.30 $5,319.00

$107,231.00

X

X

OCCUPATIONAL THERAPY

Sensory Integration

O.T

T.V. Monitor

O.T

VCR - video-

O.T

fluoroscopies

Cart (f/monitor & VCR) O.T

Portable Forma-Splinting O.T Pan

SPEECH £ HEARING

Board Maker

Speech

Board Maker Supplies

Speech

Color Ink Jet Printer

Speech

$2,041.02 $2,041.02

$105,189.98

X

$369.96

$369.96

$104,820.02

X

$525.00

$525.00

$104,295.02

X

X

$109.00

$109.00

$104,186.02

X

X

$594.00

$594.00

$103,592.02

X

$399.00

$399.00

$103,193.02

X

$350.00

$350.00

$102,843.02

X

X

$315.00

$315.00

$102,528.02

X

AUGMENTATIVE DEVICES LISTED BELOW

Speak Easy AlbeNet w/keyguard

Speech

Hawk AdamLab

Speech

Cybersmith's VRA System VI-Deluxe Bioacoustics, Inc

Audiology

DynaVox Augmentative Advice

Speech

Walker-Talker PrentkeRomich

Speech

Alpha Talker with Headset + 4 £ 8 location operating kits PrentkeRomich

Speech

Shelving for Agumentative/ Assistive Library

Speech

RECREATION

Basketball Rim/Hoop

Recreation

Tent (large 2 rms.) Tent (small) Roller Skates Sleeping Bags Padded Folding Chairs

Recreation Recreation Recreation Recreation Recreation

Upr' ••. Chair Rack
i •

Recreation

$383.00 $1,149.00

$101,379.02

$175.00

$350.00

$101,029.02

X

X

$1,200.00 $1,200.00

$99,829.02

X

$4,525.00 $4,525.00

$95,304.02

X

$1,543.00 $1,543.00

$93,761.02

X

X

$1,495.00 $1,495.00

$92,266.02

X

$1,067.00 $1,067.00

$91,199.02

$700.00

$700.00

$90,499.02

X

$299.00

$299.00

$90,200.02

$70.00

$70.00

$90,130.02

X

$40.00

$320.00

$89,810.02

X

X

$28.00

$224.00

$89,586.02

X

32

$12.60

$403.20

$89,182.82

X

X

$283.00

$283.00

$88,899.82

X

PSYCHOLOGY

Video Camera (w/accessories )

Psychology

$1,117.50 $1,117.50

$87,782.32

X

VCR

Psychology

$525.00

$525.00

$87,257.32

X

X

Cart (f/monitor S VCR)

Psychology

$109.23

$109.23

$87,148.09

X

Stat/Graphic Computer Software Pkg.

Psychology

$800.00

$800.00

$86,348.09

Desk

Psy(2)

$253.00

$506.00

$85,842.09

X

TV Monitor

Psychology

$369.96

$369.96

$85,472.13

RESIDENTIAL SERVICES

$0.00

$85,472.13

EQUIPMENT/SERVICES

$0.00

$85,472.13

Nutritional Consultant Management Team

$15,000.00 $15,000.00

$70,472.13

X

Mats for Quiet Rooms (Closed cell foam)
Desk

Bldg.5, 6, 7, B 12 all quiet rooms
Bldg. 3(10, Bldg. 5(1)

$170.60 $2,047.20

$68,424.93

X

$253.00

$506.00

$67,918.93

X

Computer Tables Printers - Ink

Bldg. 3(1), 5(3), 6 (2), 7 (1)
Bldg. 3(1), 5(20, 7(1), 891)

$150.00 $1,050.00

$66,868.93

X

$256.41 $1,282.05

$65,586.88

X

Printers - Laser

Bldg. 6(10, 7(10, 891)

$500.00 $1,500.00

$64,086.88

Medication Carts

Bldgs. 1, 3, 5, 11 6, 7, 8,

$1,000.00 $11,000.00

$53,086.88

FURNITURE

Table (End)

Bdlg. 6

10

Television (20")

Bldg. - 6(2), 7(1),

Television {24' Console) Bldg. 3 91)

Entertainment Cabinets Bldg. - 3(6),

21

5(3), 6(3),

8(4)

Chairs (Office & Recliner

*Unit 1(2 Recliners) Bldg. 6 (4roller/4 arm) ***hold***

HOME FURNISHING

$284.50 $2,845.00

$50,241.88

X

$210.00

$210.00

$50,031.98

X

X

$330.00 $800.00

$330.00 $16,800.00

$49,701.88 $32,901.88

$479.50 $1,918.00

930,983.66

$30,983.88

Unit 1 Ambience Bldg. 3 Ambience Bldg. 5 Ambience Bldg. 6 Ambience Bldg. 7 Ambience Bldg. 8 Ambience

$1,000.00 $1,000.00

$29,983.88

X

X

$3,000.00 $3,000.00

$26,983.88

X

X

$3,000.00 $3,000.00

$23,983.89

X

X

$2,000.00 $2,000.00

$21,983.88

X

X

$1,000.00 $1,000.00

$20,983.88

X

$1,000.00 $1,000.00

$19,983.88

X

$0.00

$19,9B3.88

$0.00

$19,983.88

QUALITY ASSURANCE PROGRAM FOR HEALTH SHSVICZS

ATTACKI1EFT 19

POI»XCr:

Health Services snail maintain a quality assurance

program to provide a structured ziecnanism whereby the

q u a l i f i c a t i o n s of staff can be assured, performance of s t a f f andof

programs can be c i a r a c t a n z e d , and c s r t a m f e a t u r e s of s e r v i c e s ,

s u c h a s , p r e s c r i b i n g p r a c t i c e s and outcome v a r i a b l e s „ can ba

measured and compared t= standards of p r a c t i c s i n our community and

i n t i e MR f i e l d n a t i o n a l l y . A pear review component s n a i l ba

i n c l u d e d . The program s h a l l operate through t i e - Medical D i r e c t o r ' s

O f f i c e ; s n a i l involve several of the committaes of t h e Department,

and s h a l l ba coordinated with and an i n t e g r a l p a r t of t h e o v e r a l l

NVTC QA program.

PROCEDURES;

1 . L'nder the supervision of the Medical -iractor and with written consent of the applicant, the Administrative Secretary obtains direct written -.'er if icsticn cf medical s choc 1 graduation. postgraduate medical education, aedicai licensure, board certification, liability insurance coverage, and hospital a f f i l i a t i o n s of staff physicians and consultants.

2. Analogous information is obtained regarding other professional staff aemcers of the department.

3. In addition zz the above, current copies of the physician's Federal VEX Registration, State Controlled Substance Registration, state license, and t i t i a page of malpractice policy are leapt on f i l e in the Medical Director*s office.

STAFF ZDUCATION:

1.

Each s t a f f l e s s e r w i l l be encouraged t o a t t a i n board

c e r t i f i c a t i o n and/or q u a l i f i c a t i o n by n a t i o n a l l y recognized

a c c r e d i t i n g bodies pertaining to competency in t h e i r particular

discipline.

2. Staff will be encouraged to became members of professional organizations relevant to developmental d i s a b i l i t i e s and to attend as many pertinent educational courses as time and resources permit.

3. The Department will sponsor regular educational events, such as* journal clubs, grand rounds, guest lecturers, and other didactic events to specifically focus on timely topics of assessment and management.

COMMITTEE PARTICIPATION:

1# The C l i n i c a l P r a c t i c e Review Committee w i l l convene promptly a f t e r an adverse event or outcome to review t h e f i n d i n g s of t h e
D i r e c t o r of Quality Assurance and of the Medical D i r e c t o r regarding

...4.

the case and/or event and ta devise changes in practice, procedures, or sysrems cz care farougnr -2 lignt by the inquiry; results will be rsporrsd to the Facility Director.
2, To*. Pharmacy and Therapeutics Committee azid the lafictioa Control Committee will regularly evaluate prescribing practice* and other aspects of care wirhin their respective domains; results will be reported to the Director of Quality Assurance, the Medical Director, and the Facility Director..
3. Various committees of the Health TasJc Force, for example, the Dyspnagia Committee and the Epilepsy Committee, may, from tiaa. to time. evaluate various parameters of care and clinical outcomes vitnin tneir respective domains; results will ba reported to thm Director of Quality Assurance, tiie Medical Director, and Facility Director.

?EZS RZVI37:
1. ?&ysician peer r-view will ie csnducrsd quarterly under tiia professional guidance o: tne Director of Medical Records.
2. Tlxe Medical Director and tiie Director of Medical Records will devise and revise caart review criteria for each review session, depending upon tiie stage of evolution of tiie NVTC plan for madical ' records improvement.
3* Tne Director of Medical Records will utilize standard professional criteria to salect cnarts to be reviewed.
4. Tie peer review physicians will consist of the Medical Director and a visiting, coard certified, primary care physician with experience in residential care of people with developmental disabilities; the Medical Director will not review charts of clients wnom he has served as the primary physician.

5. At the conclusion of the pear review session, a briefing will be conducted by the reviewers for the Director of Medical Records, the Director of Quality Assurance, and the mem&ers of the medical and nurse practitioner staff; a report will be written by the
Director of Medial Records for the Director of Quality Assurance, the Medical Director, and the Facility Director.

6.

Annually, Columbus Medical Services will conduct a

comprehensive peer review of records utilizing a physician-nurse

team in concert with on-site staff; a report will be submitted by

Coluniiaus Medical Services to the Facility Director.

r

M^URO LOGY CT TNIC-AMTTCONVULSANT MEDfCATTON REV!FW

NAME LAST CUNIC VISIT TYPE OF VTSrT; CURRENT AED

AGE

OATE

UNTT

DOB

WSGHT

PftQBL^Ul NO

MESICATION C^ANGSS:

AMMMAf HEVIEW:

TOTAL DAILY DOSS

CHANGES IN A S SINCS LAST HEVJEW AND OATH'

*

LABORATORY RESULTS: DATH: WBC HG3 HCT PLCT

DATE: SGCT SSPT SSMA MH3 GGT

J"c OF LAST RECORDED SddUR£ PHYSICIAN RECCMMSIDATiaNS;

OATH: DttAATITN

Tps^TTTDL D^AKOTT

, „ .,

PfraiOSARTTAL

MYSDUNE

GAHAPPWTTN ,

.

LAMLi 1 KJisiiUE

NVTC SEIZURE RECORD: FORM #141
Guidelines for f frg or" Form
PURPOSE: To document the number of seizure wisodes that have occurred during a designated pence of nine.
1. Hie form is startea on the nrsr of saca montn. Tae montn ana vear are wnrteri on the lower ieft corner of the form. If no seizures nave occurred during the montn. "0" is wnnen alter the month and the form is used repeaiedry urmi seizure acnvny occurs.
2. Mark an "X" in the coiumn for the appropriate shin with the correc: time. An "X" with the time is written tor seizure ernsode.
J . TTie deauiuiion of the seizure is documented on the back of the form to indicate what. the observer has witnessed instead of ciassuVme the seizure.
Form ??14I are iocatea m a rca DOOK on sicn of :he indrviduai ciient units.

-41 a tr\Mv not a*

NORTHERN VIRGINIA TRAINING CENTER. SEIZURE RECORD

^caj seizures oy moncn

\OTtt

Julv

;r Previous Year 19

Man*

tun*

7 .AM - 3 TM i 3 ? M - 11 I'M j :: ?M - 7 AM
I

Date or Last Seizure

i

'

* 1

i

i

3.

i

i

•i.

i

i

'

i

i

in

6.

:

i

i

-

i

3.

i

i

Start tonzx on the nzst of the month, and

9.

r

10.

i

1

11.

;

1

ii.

i

1

wilts month on lower iefL If no seizures occur during the month, write '(T 'after the month and use the same page for the

13.

i

1

next month (add month name to next

14.

I

1

blank line on sbest)

t

i

t

i

1

i

Exampie: January - 0

18.

f

1

Febnuny - 0

19.

1

1 I

MttFBl • 6

—

1

— t

t

Mark X in correct time and date.box on

j.!

1

IefL

«*.

•

-= (

"A

J . For seizures in duster crde the (X).

—,

1

Document seizure with description on

1

20.

i

back of this form.

1

TOTAL

1

In January of each year, summarize

number of seizures for previous year at

the top of this form.

traa)

!ate*iina describe type oi seizure acoviry below.

Ti

the following when appropriate: ioss of consaousness. fail from upright position, rieidirv.

irsons. limp dropping to ground, staring, rotation ot eyes or head, sudden arm or head jerks, parts

r body involved, change of skin color, incontinent of urine or feces. Duration of seizure. State or

onsdousness during and after seizure (confused, sleepy).

'ROBLEM NO.

DATE ( TIME

I

DESCRIPTION OF SEIZURE OBSERl^D

!

i

1

I

I

!

:

I

Meeded.

nt Name:

ISO

145

140

135

130

125

A 120 US
D no
105

I 100

E
V 90
t E as
80

S 75

70

; S 65

F SO

I 55
I
z SO u 45
R 40

j E 35

i S 30

I

25

i ZO

.i

15

10

Vear Under Reuieiu:
3EB LEUELSiSEIZUHES 19 |
Q SEIZDHES Q QEPHKENE QTESHETOI QMVSOLINE DPHENOBHHB QOILHNTIN DSSBBPENTIN QlflMOTHIGINE

JflN FES MSB flPH MflVJUNEJUL? HOG SEPT OCT Nflff OEC
MtWTH

ndditionai Data:

SEIZURE TOTALS

Month Jan Feb Mar Apr Mav Jun Jui
Auq Sep

1992

1993

1994 !995

1996 1997

Nov Dec

EPILEPSY MANAGEMENT
PURPOSE; To provide guidelines for epiiepsy management.
PROCEDURE; The following procedures are followed for Clients at NVTC with a diagnosis of epiiepsy:
1. Seizure nursing care oians are monitored at least monthly by a registered nurse.
2. Each client has an individualized nursing care pian that addresses:
- following the physician's orders regarding medications, protective devices and arra-epiiccnc drug ieveis.
- accurate documentation of any seizure activity on NVTC Form £141 (see attached form).
3. Provide first aid precautions or proper care during seizure activity:
- place something son under the head - dear the ar-a of sharu or hard objects - do not force any ooiec: onto the moutn - do not restrain the client's movements - turn the diem on side when aoie to allow saiiva to drain rrsm the moutn - stay with the ciient until the seizure naturaiiy enas - do not pour any liquids into the client's mouth or offer any food, drink or
medication until fully awake - give armciai respiration if the ciient does not resume breathing after the
seizure.
4. Each client's individualized seizure care pian. located on the unit in a red book, describes the usual, rypicai seizure pattern and duration. Any changes, unusual occurrences, or if the seizure activity is prolonged and another one starts soon alter first, call the innrmary at extension 4028 or 4029.
5. The registered nurse assesses seizure activity by evaluating:
- the type of seizure - if the number and character are unusual for the client, check for temperature
elevation and constroauon - respirator.' status.
• ' ' n " i—irwr

•••**
Eoiieosv Management - Pane Z
6. If die ciient is diabetic, evaluate the following:
- any presence of injury - check that labs are within theraDeunc leveis - any evidence of missed medications - check for any standing recommendations for stams episodes.
7. The registered nurse wij] provide die following measures:
- a safe environment and position on side to keep airway open if unconscious - remove glasses - do not restrain movements or put anything in the mouth - perform a rectai examination and temperature check if an unusual number of
seizures - allow to sleep/rest until fully aiert - bring to the innrmary if in status or if the character is unusuai and persists - call 911 if does not wake up after seizure or does not breathe - if the ciient is not breathing, begin respiratory management and call 911.
S. Tnz registered nurse will notify the physician if.
- there is no history of seizure episodes - unusuai character or excessive numoer of seizures - any injury reiatec- to seizure episodes - the client rs in starus eoiiepucus - need to obiain physician's oraer ro initiate medical treatment for status
epilepticus - there is a need to transport the client to the infirmary - a need for physicians order regarding nrst aid, medications or protective
appliances.
References:
- Client's individualized GOP for epilepsy management. - Nurses' pocket guidelines for secure management.

DMH 554A (ftrv.

Probtsm; Nmd No.
Relevant iircaguu:

10 Drevenc --jury cu :z seizure ac:iv:;\

TWcnxntM (

Obwcuve No.

Datt

OBJECTIVES

Daw
Mti

To have

incidences of seizure-related injuries

throuzh

Nursinz Care PLA#.s Direct Care Siaft Will:

1

Follow ohvsician's orders.

;

Keeo accurate documentation of seizu re activi tv.

-

Give nrooer care durirs seizur e (sae rsvers s side).

Encourase additicnai fluids be eve en meals.

5

Report any changes in seizure n a t t e r n t o MDor RN.

6

Report to MD or 3N anv seizure l a s t i n a mare than

7

Observe for srs-seizurs activi tv

-

Monitor monthly by RN.
Dept. of Mental Haiti), Menzti Reardsaoo. znd Subsance Abuse Services
GOALS. OBJECTIVES. AND PLANS
1. Jf t f i n t i o ofardan f w mwafae-docamxaie4 on the ID Nots. 2. Objectives mvs ipci«d* tarf«t darat.

A D O R E SS O G R AP M

-\SStiSN\niNT -muic^ca ervtrhma/>kiu cuat • incrcay«*d sweihnc - spiinier vwiwan - bieedinc - sonsnessrpm < - anon at'fJB - type of sponw nvoori. meai etc.} - etevaced 7 - aiicrpes - ingpumzauons currsn
ASiiHSSMENT
- type OJ jiazure - if nunrocr and chancier are unusual tor ciiexu cnecK ;cr tdro slevantan ana consuoauon - respiraiory status - is the cnrai diaoetic? -injury - \abs (wnfam iheioumuc levds) - rmsseci medieaiioos • sumdine order tor status episode
i

SPUMTRS IMMEDIATE rtX 'JsiUU Uimci-
- dean ores with scan and water. If splinter is wood, dcaa nut uo not soak.
- cattiv rcmoxx with clean m-o2ers. steniizea nesole
• wash acain oner sptintcr is Tttooveo
- appty IX SgtaaJne/Basiramn
- swnie dressms (if nested)
• Tyieaoi XI for dtsconuort

NOTIFY M.D. IF • splinter cant be rcmyvca
- area appears tnieeteu
- need i"or tunher pain transient ion

KXKEI GUIDELINES

SEIZURES
IMMEDIATE RX

NOTIFY M.D. IF;

- pnnide soi'e ent-troRment and position on side to keep ainvav opes u" ancsnsaous
- remove aiasscs
- do not restrainroo^'cmentsor put anv thzoc in mouth
- dicitai trecuu exami and temp check if unusual number 01 sozurci
- allow to sieeprren unai rullv aicn
. bring to uuirman- if in smus or if number and cfaaraoer are unusual and persist
- call 9! I ifdoo not wake up alter seizure or does not breathe
- if does not breathe, bean respiratory manasement and call 91!

- status -911 cziied - seizure -reiatec iniun* - no nision- of seizures • unusual character or excessive number - constipated —order far supp/enema • S.O. medication is administered

?;ssz aid for epilepsy is basically very snnpie, and is designed co protec; me safer/ of me person tmrri the secure sious oaruraily by trsei£ If you see someone having a ssizie, say caim and follow mese snnpie rules:
- PROTECT FROM NEARB Y HAZARDS - LOOSEN TIES OR SHIRT COLLARS - PLACE SOFT MATERIAL UNDER THE HEAD - D O N T RESTRAIN - DONT ?LT ANT HARD IMPLEMENT IN MOUTH - DONT TRY TO HOLD TONGUE - IT CANT 3E SW.ALLOWED - DONT ~ Y TO GIVE LIQUIDS DURING OR JUST AFTER
SEIZURE - TURN ON SIDE TO KEEP AIRWAY CLEAR - REASSURE WHEN CONSCIOUSNESS RETURNS - DONT USE ARTIFICIAL RESPIRATION UNLESS BREATHING IS
.ASSENT AFTER MUSCLE JERKS SUBSIDE, OR UNLESS WATER HAS 3EEN INHALED
- .EF SEIZURE IS PROLONGED OR ANOTHER ONE STARTS SOON .AFTER THE FIRST, CALL THE INFIRMARY AT X^02S/4029.

2HERGEHCY

i DRILLS

PHSPOSE: Ta establish a system for staff toreview and/or practice appropriate responses ts medical emergencies. Through mocic emergency situations which simulate those most likely to occurin a particular worX sits, nursing and paraprofessional staff willbe able to practice skills and agency procedures in medical emergencies.

TARGET STaTP: The primary staff required to participate in emergency drills will beunit nurses, CTK and infirmary staff, and unit diract care staff.

RESPONSTTSTLTTT: The following staff will have designated responsibilities in ensuring tiiat staff have adequate informationand opportunity to practice andunderstand tiieir rale in a medical emergency on a monthly basis:

ommunicata the requirements -c the appropriata nurses; deveicp specific emergency situations/scenarios generic i : diffsrant worx. sitas; scneduis BLS classes for nurses.

ani- Nurses - coordinate scheduling of d r i l l s ; select appropriate scenarios; process with participants afterwards.

rgcr. Carg

^5uper<r.gors - participate in needed

training for appropriate emergency medical care; participate in

drills inpreparation for raal situations; process afterwards.

ning pepament - provide on-going C?R classes to direct care staff; assist in drills and processing as requested by unit nurses; document participation in individualized computerized training records.

PROCEDURE: See a t t a c h e d

w»diga.l

1 Is Procedure.

1. Unit nurses will prepare a scenario.
2. A cats and tiae will be sec by tie unit nurse and siift developmental technician.
3. Unit nurse will notify ail participants an Cancer grounds tiat a "nocK drill" -H.as fceen scheduled and give zhe date and tiae.
4. Unit szaif discover viczi= and becin eaergency procedures.
5. One s~ar* raaams vvcii vicrzis, one s-aff i^iir^aras calls "3 inriraary and swizciboard.
6. Infirsary nurse rsceives call Zr'sm. cie unir and rasponcs.
7. Inflraary nurse maXes assessmenr rien direcxs unit srafi to call 911.
8. Izifiraary nurse/unit srafi continue wicst rescue br R until ZMS arrives.
9. Infiraary nurse gives IMS report, prepares emergency transfer papers, calls unit physician, tiosaitai, parents facility director.
-0. "Jnit nursa rscorzs sequence of svents and rise. Also critiques tie emergency medical response drill. Tie drill report is forvarded to tie director of nursing.

FREQUZ8CZ OF DRILLS

January February Marci April May June July August September October November December

unit i
Unit 3A Unit 3C Cnit 3D STC Unit 5A Qnit 5C anit 6A CJnit 7A Unit 7C Onit SA Unit SC

--,•5*
Drills Procedur! Page 2
The d r i l l procsdurs is an adjunct -3 NVTC Instruction 5500: Medical Emergency Procedures.
The basic steps for medical emergency procedures have been outlined f laminated, and placed by a l l t slephones on the r e s i d e n t i a l units and tiie Skills Training Canter (STC) .
DOCUMENTATION: The thrse-page form t i t l e d "Medical Emergency Response D r i l l , " along with an attendance sheet, will be forwarded to the training department and the nurse manager. (Fora i s attached.)
EVALUATION: The nurse coordinating the mocic review will c r i t i q u e the d r i l l with chronological events, and sends the original copy to the nurse manager. The nurse manager reviews the medical emergency response d r i l l and mates referrals to appropriate personnel as necessary.

ATTACI-IMEN 23

;

MEDICAL EMERGENCY RESPONSE DRILL

DATE:

UNIT:

PARTICIPANTS:

l.

VICTTM

Z. UNIT STAFF

3

*UWT NURSE IRECORDSLOTnOUB

4. 'INFIRMARY NURSE (ASSFSSES VICTIM. DIRECTS SEQUENCE OF EVBtfTS. PRH>ARES

5UL PAPS1S. CALLS MD. HOSPTTAU PAHSTTS. FACILITY DIRECTOR!

5. THSHONE OPSWTOR (NOTIFZE5 SECURITY AND RTU

i.

BUT (SIMULATED)

9* SECURITY 9. ROVING TEAM LEADS (4PM-8AM) 10. HOSPTTAU PARBTTS, FACOJTY DIRECTOR
•TOLE5 WILL ALSO BE REVHISHJ

SCENARIO:

TIME AND SEQUENCE OF EVSTTS

DATE:

EMERGENCY MEDICAL RESPONSE DRILL
PAGE 2
UNIT:

CRITIQUE;

MEDfCAL EMERGENCY RESPONSE DRILL.1 !

PAGE 3

I }

-'gQCSDURE:
'_ UNIT NURSE WILL P5&ARE A SCENARIO 1. A DATE AND TIME WILL SE S£7 3Y UNIT NURSc AND SHIFT TETA. 2. UNIT NURSE WILL NOTIFY ALL PARTICIPANTS ON CSTTEH GROUNDS A 'MOOC- DRILL HAO 3EEV
SCHEDULSD. DATE AND T7M£. i . UNIT STAFF RND VICTIM AND SS3IN EMERGENCY PROCEDURES. 5. ONE STAFF REMAINS WITH VICTIM. ONE STAFF INITIATES CALLS TO INHRMAftY AND SWITCHBOARD. 5. 1NRRMARY NURSE RECEIVES CALL r^OM UNIT AND RESPONDS. 7. INRRMAflY NURSE MAKES ASSH33MBfT THEN DIRECTS CARE. DIRECTS UNIT STAFF TO CALL 9 1 1 . 3. JNRRMARY NURSE-UNIT STAFF CONTINUE WITH RESCUE 3R£ATH!NO'C?R UNTIL =MT ARRIVES. 9. INRRMARY NURSS GP/ES EVfT RE»ORT. ? o » A H £ 5 S t E l G a i C Y TRA«S?=? PAP=*S. CALLS UNIT
PHYSICIAN/ON CALL PHYS1CAN. HOSPrTAL PARSTS. DR. LAWSON.
; 0. UNIT NURSE SECOROS ScO/SYCE OF"SVETTS A«0 TIMES AND DOES OTTTCUE.
' THE ROLE OF TtiS UNIT NURSE AND INRRMARY WILL 3B REVERSED ON OCCASION.

SCHEDULE:

JANUARY:

UNIT I

F=3RUARY:

UNfTZA

MARCH:

UNIT3C

APRIL.

UNIT 3D

MAY:

STC

JUNE;

UNIT 5A

JULY: AUGUST;

UfltfT SC UNIT SA

SSTHMBEH;

UNIT7A

CCTCSEfc

UNIT 7C

.CVEMBBb DECEMBER:

UNIT SA UNIT 8C

e FORMS TO SE COMPLJETcD AND T U R N S IN TO DE3ORAH COOK. R.N. WITHIN 3 DAYS.

EMS LOG PROCEDURE
PURPOSE: To have an accurate record ofrhe response rime of the rescue squad and nurse in implementing the emergency medical system (EMS) 911 caiis.
PROCEDURE; 1. The nurse answering tne teieshone in the infirmary is responsible tor recording the
following information: a) time of the cail from the unit b) nature of the emergency c) time the nurse is dispatched to the unit d) arrival rime of the nurse to the unit e) arrival time of EMT to the unit. 2. The infirmary nurse may delegate the steps above to a unit nurse if the ceiephone czils
made by the nurse/staff direcriy rrom the unit. 3. The unit nurse is resDonsibie for providing the infirmary wuh :he information in steps a.
b. c. a and e if she/he was on me unit or responded io the emergency. 4. The nurse recording the information shouid be precise in nouns the response time of the
nurse and rescue squad. 5. The log is reviewed daily by the charge nurse in the infirmary. 6. The recording of the information is monitored by the infirmary supervisor for
completeness. 7. The information is forwarded to the risk manager on a quaneriv basis.
b ems. pro

i

I

1

1

1 =i
11 *> 1

ci.iEiir

n
Z H n •« s "o
no oi

1 R O

5-

a

2?

na= az
e H z c n
— 9
Z. s
552 3 ~

MEDICAL EMERGENCY PROCEDURES
FOLLOW THESE PROCEDURES INLIFE THREATENING EMERGENCIES (UNCONSCIOUS, NOT BREATHING AND/OR CARDIO-PULMONARY ARREST):
1) Begin rescue breathing or CPR immrriiatefy.
2) Instruct available staff to call 911. The cailer will: - dial 911 andaskfor an emergency rescue squad for NVTC,
9901 BraddockRoad, Fairfax, VA. Give buiiding number. He/She ill indicate thetelephone number that he/she is calling from, what Happened, howmany persons need help, what is being done for the
victim(s). Allow theemergency personnel to hang up first; cailer should hang up last.
3) Telephone the infirmary (CXL 4023/4029) to notify them of the emergency.
4) Keep the telephone line clear to receive incoming calls from the emergency rescue service personnel
(These procedures are posted on a l l residential units)
m t

ATTACHMENT

_

9 e;

NORTHERN VIRGINIA TRAINING C E N T S

; Fairfax Virginia

February 1, 1994

MVTC INSTRUCTION 3600

TO:

Staff

SUBJECT; Medical Emergency Procedures

L Purpose. To disseminate information concerning management of medical emergences on and off campus.
H. Cancellation. NVTC Instruction 5600 dated August 16, 1993 is hereby canceled.
EEL Procedure.
A. life Threatening Emergency (Unconscious, Not Breathing and/or Cardie— Pulmonary Arrest);
1. A certified CFR technician located on the unit/ department will be notified immediately.
a. begin rescue breathing or CPB. immediately, b. instruct available staff to call 911.
2. The caller wilt
a. Dial 911 and ask for Emergency Rescue 5auad Service at NVTC, 9901 Braddock Road, Fairiax Virginia. Building* . He/she will
: indicate the telephone number that he/she is calling from, what happened, how many persons need help, and what is being done for the victim(s). Allow the Emergency personnel to hang up first Caller should hang up last
b. Next, phone the Infirmary/ Central Treatment Room (duty hours) or the Infirmary (non-duty hours) to notify them of the emergency.
c Then keep the phone line dear to receive incoming calls, from the Emergency Rescue Service personnel.
3. The Central Treatment Room/Infirmary shall:
a. Notify the attending/on-cail physician in order to dispatch him/her to the emergency location.
b. Dispatch a nurse to the emergency location. c Notify the Director's office (duty hours) or the Staff Duty
! Officer/Roving Team Leader (non-duty hours). It may be necessary to do this through the switchboard-

C INSTRUCTION 5600
emergency has been evaluated, uniess the parents / guardians have beer, called by the hospital emergency room physician.
4. When the client returns to NVTC he/she shall be brought to the CTrL during work hours or to the innrmary at other tunes. Pne client shall be evaluated by a nuzse and if additional treatment by the attending or on-call physidan is warranted the physician shall be notified.
D. The following documents and information should accompany the client to the hospital when possible:
1. Consent for Medical/ Surgical Treatment (copies available in the Infinnarv).
2. New Admission Medical Summary, Physician's Medical Suimnarv, Laboratory results. X-ray alms (if done at NVTQ, and Nursing Transfer Summary.
3. Current Medication Order, Physician's Orders, diet and allergies, contagious disease information, and pertinent behavioral problems.
4. Insurance information.
5. Name and address of parents/ guardians.
a Xame of the attending physician and /or physician on calL
7. Name of consultant if known.
E. When the medical emergency is poison related, the Poison Control Center at Georgetown University Hospital will be called by the CTR or infirmary nurse. The attending or on-call physician is then contaaed by the nurse and informed of the circumstances and will provide additional instructions to that given by the Poison Controi Center. The telephone number of the Poison Control Center will be posted in the Central Treatment Room and the Infirmary.
F. The telephone numbers of the rescue squad and emergency rooms of the nearby hospital shall be posted at telephone sites in the CTR and Innrmary.
IV. Effective Date. This Instruction will become effective on the date issued.

DHL:LR/jgf Health Services

David H. Lawson, Ph-D. Director

CHANGES IN PSYCHOTROPIC MEDICATION PRESCRIBING PATTERNS 1989 - 1995

Mid'89

10/93

2/95

PSYCHOTROPIC

DRUG CATEGORIES Antipsychoncs

T ithtTirp

AnQdepressams

Anti-anxiety/

\

Sedative drugs

Antiepilepric drugs

(Cotherapy)

58/278 (21%)

39/253 (15%)

35/236(15%)

39

33

26*

2

4

6

5

11

5

0

1

6

0

0

-7

-3

-6

This represents a one-third reduction of anripsychonc (neuroiepric) drugs over a neariy 5 year period. ;

Michael B. Kurtz, M.D. Medial Director 1/28/95

NVTC HEALTH SERVICES STANDING ORDER NO. 23 (Rev 3 / 9 3 )
TSRDITE OYSXXSSSXA
Clients receiving anti-psychotic medications will be evaluated at least quarterly by nurses who have received special training and at least annually by primary physicians and nurse practitioners at the time of the annual physical evaluation. If signs and symptoms suggesting tardive dysitinesia are detected, clients will be referred for further evaluation and treatment.
PROCEDURE:
1. Nurses will screen all clients receiving anti-psychotic medications on a qTiarterly basis, asset forth in Nursing Policy #28.
2- Physicians and nurse practitioners performing annual physical examinations onclients receiving psychotropic medications will observe involuntary movements, postural and muscular tone changes and document them on NVTC Form 99.
3. Persons suspected of tardive dysXinesia will be referred for further psychiatric and/or neurologic consultation to confirm or refute the suspected diagnosis and to rule in or out alternative diagnoses.
4. The unit ID Team and the client, family, and/or authorised representative will bemade aware of and participate in the diagnostic process and intreatment decision-making, according to NVTC policy.

Michael B . Kurtz, ft.D Medical Director

Darte

NVTC NURSING SERVICES SOP #3 0
TAKDXVE DYSXCTESIA
POLICY: Clients receiving anti-psychotic medications will be evaluated at least quarterly by nurses who have received special training, and at least annually by primary physicians and nurse practitioners at the time of the annual physical examination. If signs and symptoms suggesting tardive dyskinesia are detected, clients will be rsferrsd for further evaluation and treatment.
PROCEDURE:
1. Clients will be systematically assessed according to the DISCUS examination procedure or, if uncooperative, the client may be observed at a distance for five minutes.
2 - Nurses will screen all clients receiving anti-psychotic medications on a quarterly basis, as set forth in Nursing Services SOP #28.
3. Physicians and nurse practitioners performing annual physical examinations on clients receiving psychotropic medications will observe involuntary movements, postural and muscular tone changes, and document them on NVTC Form 99.
4. Persons suspected of tardive dyskinesia will be referred for further psychiatric and/or neurologic consultation to confirm or refute the suspectsd diagnosis and to rule in or out alternative diagnoses.
5- The unit ID Team and the client, family, and/or authorized representative will be made aware of, and participate in, the diagnostic process and in treatment decision-making according to NVTC policy.
6. The unit nurse supervisor is responsible for keeping the client tardive dyskinesia screening list current and for coordinating the unit nurses screening schedule.
1. Nursing department tardive dyskinesia screeners are recertified every two (2) years as recommended by DISCUS certifiers.
a. This SOP operates in conjunction with the Health Services Dept. policy on Tardive Dysicinesia screening.

SOP # 2 8

NURSING SERVICES - STANDARD OPERATING PROCEDURE TARDIVE DYSKINESIA SCREEHXHG

PURPOSE: To perform a standardized tardive dyskinesia examination.

i
j
1
i

.

PROCEDURE:

|

i

" New admissions and rs-admissians to NVTC shall be evaluated

|

for tardive dyskinesxa at the tiae of admission by the health care

i

practitioners.

i

i

j

" Clients at NVTC an anti-psychotic medication or

j - metoclopramide shall be assessed at least quarterly by a registered

J

\iurse under the direction of the psychiatrist.

" Clients who are discontinued from anti-psychotic medications with a history of 90 days or longer cumulative exposure shall have a rating within 2 weeks, 5 weeks, 3 months, 6 months and 12 months after discontinuation.
a) If a 12 month rating is negative, ratings may be discontinued.
b) If a 12 oionth rating is positive, ratings shall be performed annually thereafter.

" The DysJcinesia Identification System: Condensed User Scale (DISCUS) shall be used as the assessment tool. (NVTC Form #99B)

" The dysicinesia monitoring racord shall be filled out to provide long-term data on tardive dyskinesia. (NVTC From #99C)

" All clients identified by the unit nurse as having signs of tardive dysXinesia will be referred to the consulting psychiatrist.
~ This SOP operates in conjunction with the Health Services Dept. policy on Tardive Dyskinesia screening.

MAHAGEHEHT PLAN OF CLIENTS WITH TARDXVE DYSZXHESIA
For clients identified as having tardive dyskinesia, attempts will be made to decrease and ultimately discontinue anti-psychotic medication, unless there are documented medical and/or psychiatric conditions which would make the decrease and/or discontinuation not in the best interest of the client.
The family guardian or authorized representative of the client will be informed of the diagnosis and of the recommended plan for treatment bv a member cf the health services team.
Tardive dyskinesia monitoring will continue according to the procedure for tardive dyskinesia monitoring.

Simplified Diagnoses for Tardive Dyskinesia (SD-Tu)

. — ~n* -3 =rsr«cuisues ars as rsiiows. ixcsctiona .T:av

- •itstorv ar at teas: rnrss ccrrc:s :zrzi r~-r:uianv« neuroiesnc sxccsure. incuce smoxaoine m e ca m ail cstecsnes :e:ow «s

L=YES_ The sresencs ar 3 TOTAI. S C 2 R E OF FTVH (El OR Also se aierr xr anv ctance rrsm sssenne or scsres seicw nve writer: nav« it seast a "••naaeraTB ' iZi sr sevmrw "I'AJ movwnem an anv item ar at l e a s rvwo '.-nitc" fZI movements on cwo items tacsna m mrteetu saav areas.

2. Ctner 1 minions are not r^sscnstoie rcr me icnannai involuntary movements.

3 I A G N Q S S S . — The diagnosis is sasec uccn r:e c i i a i t sxam and its reianan ca me tasr sxam. Tne riagncaia can snift cesencmn ucont raj wnemer movements are sresenr or not. (b) wnetner movements are sresent ror 3 mornns or more (6 montrts if an a semiannual assessmem scneouiei. ana ic* wnemer
oczirr ano errecr .T

NO To. ^

n o t enssenr on tms Gam or •no

are sresenc zm some

IOTmem. Tne las: saqraaia miai =e NO 7u. rHCEASLSTu. cr wrTr-GRAWAc Tu.

PffOHAflLE 73* — •Wiovemens ar« JEJBU =n m s earn. Tnts 15 r « nrsc srr» tnev are nr^^wiir or tnev •*ove OSMT Dean cresent xr 4 >:uiua cr rncre. Tne USE HrffjHTTt w s se NO 72 or r5OBA£L£ TO.

P S H S W a J f T T D . — Wovemena arvcresencan a ^ s u a m andinev naveoesn a e s e m ror 3 uiuiiuia or more wrm STSJ s o m ar ar some scint m 3 ^ sasL. The las; s a c n e s a an se anv *»^]r NC 70.

MAS3G33 TD. — A4ovements ara noc ^'eaern. on TRS SGUTT bur ma ts aue «a a neuroiesoc

i

or retnsnuoan arcer a orror c o m wnen mawements vwre LJII mir Also use cms c^

if movements are noc sresenr sue to me aceraon or a nort-neuroieooc meojeanen to treat TUT The

l a s axaancsis ,-nusi =e r3GEASl_£ TO. ? S » S E T S f r 7 0 . 'A/TTKORAWAL TO. or MASX2D TO.

RE3HITTTO TO. — -wlovemenB are not snss sn mis exam o u t P r t i a 1 ci'TT . - h^s seen aiaqnesas

nas u—u.ee. ~ne tasz ciaqncsis musrse ?=?SiS7s2(T

TZ or nSvbt i ^ TO. If rnovemerns re-smenie. Tie

snircs Z3BL to .^SHSIi»' c:TTTO.

WTTHDRAWAi. i w. — .Uovemesig ar* not smmnwntit recsrvmo neuroieoncs =r at me *asr 'jvet out ar* saen wicnui a v * o a icuowmc a neurotescc resucssn or •!!—n:mi lujnon. 1 ne last oiaonasis
se NO TO cr '/VfTKCnAWAC 1*0. .f ."novemenn scrrnnue icr 3 ..'•uiiuu sr .T:cre aner me neuroiesac (QU^zcn or 11'i^jflcmjdDOi'V ~ B oacncsis smrrzs 3 ^^RSJSTSTT IU. Jf .-novernenrs co net ccntmue,
ror 3 .Tiorara or more aiusf Tre reTULiimi or ''^ !iiw"Tnr" ste daortcsis snins IDNO i L—

The rater csmotezes errs Assessrnenr nt'.mmisiuj TO me sancaruisa c o m orocsoure. tf me rarer aiso
IT7USC
sion me weoarer Oox. 1 ne farm ts $iven os cne snvsican. Aicemanvefv. ffte ortvsHsan may seftorm me assessmerv.

1 ne onrsKsan csmotesasm syatuanon

the

gnvsigsan a nssoansnte ror rne ennrs r

s e d o n ana ics tessner.

rr is REcoMMeros THAT THE PHYSICAL
EXA.VUNE ANY INDIVIDUAL WHO MEST3 THH 3 MSEGUtSTTcS OR WHO HAS MOV&iefTS NOT S<P_AINE SY QTWS FACTORS. N£JHOLQGCAi.
OR 0 l F = = ^ m A L CUGNCSTTC TESTS WHIG MAT BE NECSSAflY TriOULD 3E
OBTAINS-

OTWEH

(carnal

!. Aoe

T2- Htarongmn s 1 1 Hyoea cnvroniaiw

2. Careorai Pztset <t Contacz'-arises 5. Dentures/No

I A.
£. HvDcoaiJUiviuniiain s. idiooatnic Torsion

d. Oown s Svncrome

/. Oruo/ iiiujxicacon

*7. MeicB. 5vnorcme 12. r3ixjiisons Di

3. Si

12. Sierotvoies

20. Svciennam s Oorea

10. ranr's 5vncrcme : t. Heavy .vtetai
limur.ii 11 imsaecrvt

I". TouraoB's
2Z- '/Viison 3 Disease
22- Ctner tsneeryi

.^te form acsromo IDodicv or orocedure.

•m-

(Htv. HVU) MAME: AHEA TACE
EYES oriAL
LINGUAL
MEAD/NECK THUNK LHTEI1 LIMB 1.0 WEfT LIMB

DYSKINESlA MONITORING nECOflU

neg. 0:

ITEM

DATE

I. Tics

2. Grimaces

3. Blinking

A. Chewing/Up Smacking

5. PucherlngfSucking Thrusting Lower Lip

6. Tongue Thiustlng/Tongue In Cheek

7. Ionic Tongue

--

8. Tongue Tremor

9. Atlielold/Myokyinlc/LnleinlTongU-

10. n@Uocotls/Torllcolll<)

I I . SNoufder/flfp Torsolft

12 Alliolokl/Myokymln finger - W i l g l - A t m

13. Pill Moiling

M Ankle Flexion/Fool Tnpplrig

15. foe Movement

SCimiNOKYSM'.M It - Al«rnl I — (JiirsiituiflMc 7. - Mihl .1 - Motlci:ilr 4 - Srvcic
$•>

•

.

r—„

II. V. YUS {}) III. OUAI^4-5) IV. I.IN0UAL(ri-9) V. IIHAD/NliCK/lllUNK (10-11) V|. UITI;KI.IMII(I2-I.1}
vn. l.UWI-ll I.IMM(H-IS) /

Unit*: ______

MVTC rNSTffUCTTON 5302

NORTHEnN VIRGINIA TRAINING CEMTcn Fairfax, vironia

I ^ATTACHMENT

I*

28

i
July 14. 1SS2

TO:

Blast

SUBJECT; Psycnotropic Medication

I. Purpose. To estaiiish denniiion. policies, sna procedures for the use of psyciotroptc medication.

II. Cancellation. NVTC Instrucacn z2Q2 dateo Marcn 4, 1993 is hereoy cancsied.

III. Poficv.

A. The usa of psycnotrooic medcations snail adhere to sound ciinicai standarcs. The assessment process ana treasnent course ana aocroonate rotiow-uo of incividuais receiving these meacanons-snaii be monitorea acserv oy auaiined orcfessionais. These meaicanons snail be Qrescnbed and admmcierea pursuant to professional luccmem oy appropnateiy auaimea aroressionais in accsrcancs with State ana Federal regulations.

B. Psycnotrooic meoications snail only be used:

1. When less restrictive methods have been considered and tried when appropriate, 2. as an integral pan of a program ptan designed by an imeraisacunary team to manage specific
nenavior(s) in the least resinaive manner and ultimately to eliminate targeted behaviors). 3. for the treatment of soecaic psyditatric disorder(s); or 4. In an emergency situation only when the dient presents a clear danger to himseif or others and less
restrictive alternatives nave been considered, tried and/or are contra-indicated.

C. Psycnotrooic medications snail oniy be used T the harmftri sifects of the behavior riearty outweran potennaiiy harmful effecs of the meoicaiion. Behavior mcoifying meoicanons snail not be usea:

1. as a punishment:
2. for staff conveniencs; 3. as a suostitute for behavioral, deveioomentai. ecucancnai and/or theraoeutic programs: 4. excessively nor in Quantities that interfere wrirt an tndb/idusi's haai&tatton program: 5. in the aosencs of a ?/stemanc data collection methoa with wnicn to evaluate meaicanon efficac/.

0. Althougn the concurrent use of more than two psycnctropic meoications rrom different therapeutic dassss is sccspraofe, this pracncs shodd net occur sxcsui in cases justmed and documented by a psyeniatrist.

IV. Definition.
'Psycnotrooic medjeatjons-1 means medications which are prescribed by licensed physicanis) and administefea for the purposes of modifying specne benavions) 2nd tresnng specric csycriiatric oisorderrs). These induce, out are not limited to, the following classifications of mecicsnons:

A. annpsyenotic (neuroieptics. major tranoumzersn

NVTC INSTRUCTION 52QZ PAGE 2 ' -
S. anxraivtic;

C. antidearessams:

':

0. anti-manic mecicsncn:

5. anticanvuisants (wnen ussd as oenavicr management agent) or to treat specie ssycniairic cisonier(s);

F. stimulants;

;

G. sedative - hypnotics:

H. csrtain somatic medications (when used as behavior management agent(s) orto treat sceonc psychiatric disoraerts)).

V. Procedure. i

-:

'

A. The Inrerdisdoiinary Team with leaaershio by the psycnoiogist must identify the clients spearic maladaoave oehavior tnraugn a functional analysis or trie Oenavior to determine a variety or solutions to the behavior prooiem.

5. if psyenotrooc meaicanon is viewed as a viaoie option, the ctiera wiii be referred, througn the attending physician and/or unit psychologist for complete psychiatric diagnostic evaluation.

C. Psycnotraoic medicaiian may not be ordered for more than one month. Arenewal order by the physician must oe basea on collected data presented at the medication review, interdisciptinary Team discussion (when indicated) or psychiatric censuitatten and must review any side effects incurred by the diem.

D. Side erfecs cr Dsycnotrooic meoicason wiii be aiscussaa wnn the Inter aisdeiinary Team and monnoreo iy the unit nurse. pnys;csn. ana the psycnoiogisi. Cirea cars also snail be mace aware of side eifecs and instructed tofiringtheir ODsarvations to the nurse or pnysioan.

E. Problematic issues associated with psyenotropic medications that occur between scheduled reviews wiii be brougnt to the attention of unit artenamg pnysican wno decide upon the necessity of an interim psychiatric censuttancn. ?

VI. Documentatron.

;

A. The attending physician wiil design a written medical plan for the diem using the recommendations made by the psychiatrist This medcal plan wiii be an addendum to any existing behavioral plan interfacing with behavior management, if a behavioral program is not indicated for the problem, the prtystdan wut indicate mis in the medical plan, if a benaviorai program is indicated, the psychologist and physidan wiii wnte separate but concurrent and interfacing program plans for oehavior management Specnc content for pnysioan and psychologists behavior management plans snail be elucidated in writing in departmental procedures. Both plans shali become pan of the diem's acive treatment plan.

3. If me diem, or his/her guardian or authorized recresentative did not paracoate in the process of designing the medical and/or benaviorai program Diamsj, a statement of rationale for his/her not being induced must Oe made by the responsible physician and/or psychologist on the appropriate plan.

A/'/n; INSTRUCTION 5302

'

^ PAGE3

\

G. Tne following aporovats. csnsams ana normcancns are necessary pncr to imciemsntaticn cf osycnotrcmc meoicancn ana must oe reviewed at least annually:

1. interdisciplinary Team Acprovat: Must alreaay inauce: a. Physician's Approval: b. Psychologist's Acprovat; c Psycmatnst acprovai
2. Approval of other clinicians as aooroonate to other program plan components: 3. Behavsorat Management Committee Approval; 4. Advocate Notification: 5. Client, (if over the age or 18 and not adjudicated incompetent), parent, legal guaraan or authorized
representative. 5. Directors approval when restncrive procedures of locked Tlme-Gut or mechanical restraints, and
'personal restraints'1 are included in the behavioral plans (See NvTC Instruction 5300); 7. LHRC Review.

NOTE: Cliem/ParentatfGuaraian/Authonzsa consent s sougnt after a

futf presentanon of the written plan. These individuals have the rignt

to refuse consent for the adrninistranon of the medicaton(s) as

described in the program, if consent is rerused. after iuii descnuaan

\

of the program and explanation of components as weti as cirocai

-

sounmess of the total program. NVTC may take adon to appeal for

a court aoiudicanon on the issue.

0, The NVTC Taraive Oyskensia monitoring procedure wiii be initiated.

£. '* there are maior ae»;iarions tchanging type of meaicsiion ana/or type of restncave orocsdure) from the onginailv aescnbec crccram oians. new otans ana orocsaures must &ewritten to renect trtese cnanges ana all aoorovais. ccnsanis. ana notmcanons must ue secursc for the newty aeveiooea plans just as ror ^ e onginai olans.

F, If designated levels of benavior(s) are reached (i.e.. objectives are met) which entail alteration in procedures ireducsc teves of meoicanon. less restncove proceaures) which have oeen described in the pfcns. 8MC, Aflvocste. LHRC, ana parems/guaraians or auinonzed resresentanve wiil be notmed of these cnanges in wrmng.

G. Smergency Uses of Psycnotrooic Medications:

1. PsychotroDtcmeaicanon may be used in emergency situations only when the diem presents a dear

dancer to nimseri/herseif or others and after ail sifons nave oeen msoe to bring behavior uncer

control

i :

2. Slanoing or P.R.H. orders of a psycnotropic meoicarion may not be used.

3. Tne unit psychologist - or i unavailable, other NVTC psycnciogist the Director MR Programs or

tne Director. NVTC - wiii contact the pnysioan explaining the situation and recuesring assstancs

nrorn the onysiaan in the form of psycnctrapic meoicanon.

a. During regular wonting hours, the psycnotcgst wiii contaa the pnysican airectty.

;::

b. Cutsiae of regular wondng hours, the psycnciogst wiii ccntact the Innrmary and request the

nurse on duty to contaa the physician on c a l

HVTC INSTRUCTION 53D2 PAGE 4
4. If the pnysioan concurs mat psycnctrooic metrication is inaicatea for me client me pnysiaan wiil oraer an aoarcprtats meaicanon, meaning aasaoe. to be aaxntntsrerea by nursing starf. The oraer wiil be written oy the anystcan aunng regular wonting nours or may oe oiacsc by teieonone to nursing stsrf outsiae of regular wanting hours. The pnysiaan wiii co-sign me orcer on the nexi wortting aay if the oraer is given oy pnone.
5. After receiving me onysiaan's oraer. the nurse wiii assess me diem. If the msoicanon. by then appears no longer necessary, then nurse wiii contact me pnysiaan for autnonry to cancel me meaicanon.
6. The nurse wiil aoorconaiew monitor me diem alter the medcanan has been given. 7. If emergency aamtnisiranons of psycnotropic mearcanans are not inauded in the approved written
plan, the pnysiaan or aesignee wiii natnythe clients parems/guaraians or authanzs4 reoresemanve wtthm twemy-four (24) hours of an emergency drug adrnmistranan. 8. Foflowing the use ai psycnotrooic meaicanon in emergency situations, an NVTC 8/ent Report (Form ?67A) wiii be oreoarea by una starr and sent to the Risk Manager with ccoies circulated to the unit Qsycnaogisi una pnysiaan. Program Manager. Advocaxe. ana BMC. "The Event Report wtii induce a aescnution of me oenavtcr warrammg the use of Dsycnotronic meaicanon ana aocumemaaon of artemots to imaernent other oroceoures onor to csycnotrootc meaicanon. 9. When mree emergency oraers of psycnctronc meaicanon are requirea wnhin twelve momns. the dients pnystaan. <£ psycnomst and psycniairst must review the prooiemanc behavior after the third incdent with the ID Team ana document tne review in the CHS. 10. The pnarmaast wiil review ail emergency cnerracai interventions me next working day. The psychiamst wtii review them at least weety.
VII. Erfecnve Date. This instrucion wiii become eifedire on me date issueo.

QHLLH/jgf Hearth Services

Oavid H. Lawson, Ph.D. Director

NVTCMR Form* 159 Revised 2/95

NORTHERN VIRGINIA TRAINING COTTER FOR TEE vnmTj.v REZ&ROES

Plan for PaTcfaotrapifi

Naui

: Unit:

DOB:

HZG. NO.

History of Psychotropic Drug use and Previous Behavioral Procedures Tried:

Mame of Pgycnotropic Drug, Frequency, Dosage* Route of Administration and Plans to Achieve Therapeutic Level:

Haladaptive Behavior to be Modified:

Monthly Frequencies: Month

See Psychologist's notes.

Total

Month

Total

Name of Paychotropic Consultant: Dr. Howard I. Pressman List of Potential Side Effects of the Psychotropic Drug:
a) Major Side Effects:
b) Minor Side Effects:
Medical Review of Side Effects {by whom, frequency, outcome of review) including Laboratory WorJc of Indicated:

T T

NVTCMRFonn*159 Revised 2/9S

Medical Plan for Paychotropxc Drug V*m Plans to be Implemented in the Event of Side Effects:

Statement Regarding Resident's Harmful and Undesirable Behavior Overweighing the Drug's Potential Harmful Side Effects:

Concurrent Behavior Programs (if any) Designed by the Interdisciplinary Team for the Target Behavior: Psychologist's section

See activity schedules for the reinforcing environments.

See behavioral plans for the target behaviors

,

(See section 5)

w-«tical Plans, including Objectives for Review based on Available Collected Behavior

\ rts including Review Frequency, how do

and if possible. Plan for Readjusting,

•. ..ucing or Discontinuing the Drug:

Signed: Howard I. Pressman, M.D. Consulting Psychiatrist

Date:

CONSENTSS By Resident: a) Competent adult - consent signed ( ) . Unable to make medical decisions ( ) By Parent/Guardian:
a) Psychiatry conference attended and verbal consent given ( ) . b) Consent given by telephone ( ). c) Consent given in writing ( ) .

APPROVAL: By Interdisciplinary Team: By Psychologist:
": Approval: Approval:
Submitting Attending Physician:

Date: Date: Date: Date: Date:

NVTCMR FORM # 159B Revised 2/95

NORTBZRN VTXGIHIA TRAI2USG C2HTZR

coy

yog ADMTifTBTRvrTow O P PSYCHO'ritqpyg

I hereby give consent to Northern Virginia Training Center medical staff to administer

to:

The following adverse reactions which may occur have been explained to me by Dr.

In addition, I am aware of the small risk of unexpected and unpredictable side effects; including paradoxical reactions and the possible worsening of symptoms, which may occur. Alternative methods of treatment, if any, have been explained to me.
The anticipated benefits of the medication appear to outweigh the above risks. I therefore give my consent. I understand I can withdraw my consent at any time.

Clients signature (or mark) S igned: Relationship:

Date:

Witness:

Date:

NVTCMRFonn#159A Revised 2/95

ADDKHDOH TO MEDICAL PLAN FOR PSYCSOTROPIC DRUG USE

NAME:

UNIT:

REG NO.:

PROBLEM #:

Previous behavioral procedures tried prior to institution of current psychotropic drug:

Current target maiadaptive behavior to be modified:

Non-compliance Self-Abuse Physical Aggression Tantrums

Property Damage Toileting Disruptive Behavior other

Current behavior programs by the ID Team for the target behavior:

Current medical plan including objective and plans for readjusting, reducing or discontinuing the drug:

Statement regarding resident's harmful and undesirable behavior overweighing the drugs potential harmful side effects:

Up to date consents by the parents/guardians:

By Whom:

telephone:

Writing:

jate:

Physician:

Date: Verbally:

HEALTH SERVICES POUCY AND PROCEDURES REGARDING PSYCHOTROPIC MEDICATIONS
POUCY
Psychotropic medications are ordinarily used as an adjunctive treatment within the framework of a previously arranged, interdisciplinary management program with a psychiatric diagnosis and target symptoms. Ordinarily, the medication having the most favorable benefit vs. side effects profile in the lowest effective dose for the shortest period necessary for each individual will be utilized. Sound medical judgment will be the primary decision-making criterion, both under ordinary circumstances and for determining exceptions.
PROCEDURES
1. Interdisciplinary assessment and decision-making processes, tempered and guided by sound medical judgment, shall be employed in the initiation, adjustment, and withdrawal of psychotropic medications.
2. Decisions must be supported by objective data, to the extent practical, as well as by subjective observations and opinions, and must conform with sound medical judgnu
3. Involvement of diem, family, and/or authorized representative will take place, as specified bylaw.
4. Review by the Behavior Management Committee and by the Local Human Rights Committee will take place, as specified by NVTC Instruction 5302.
5. The Medical Plan for Psychotropic Drug Use, Form #159, which also includes consent forms, will be completed by the psychiatrist or primary physician: the plan and consents will be updated at least annually on form #159A.
6. Emergency uses of psychotropic medications will be handled according to NVTC Instruction 5302.
7. The clinical course and dosages for ail clients receiving psychotropic medications will be reviewed at monthly interdisciplinary medication review conferences by a psychiatrist and/or by the client's primary physician.
3. Monitoring by direct client observation for adverse side effects of psychotropic medications by nursing and medical staff members will regularly occur, at least as often as the quarterly physical assessment and tardive dyskinesia assessments by registered nurses and the annual physical examination by primary physicians; tardive dyskinesia assessments will be conducted according to HS Standing Order #28 and Nursing Services SOPs # 28 and 30.

9. Clients manifesting signs or symptoms suggesting possible new psycfaotropic medication side effects will be promptly referred for medical, psychiatric, and/or neuroiogic evaluation and treatment, if indicated.
10. Candidates for medication reduction and withdrawal may be individually identified according to the guidelines in 1 through 3, above, and such adjustments planned if the anticipated benefits to the client appear to exceed the risks of decompensation, in the judgment of the consulting psychiatrist.
11. An audit of the quarterly tardive dyskinesia screening program will be conducted semiannuaily by the nursing department and the results submitted to the quality assurance committee.
12. An audit of psychotropic medication prescribing practices will be conducted annually by the pharmacy and therapeutics committee and the results submitted to the quality assurance committee.
Michael B. Kurtz, M.D. Medical Director 2/28/95

ATTACHMENT 31
NORTHERN VIRGINIA TRAINING CENTER'
CRS IMPLEMENTATION TIMETABLE (Attachment One)

PHASE I. Recruitment II. Research &. Development III. Training IV. Implementation V. Quality Management

TIMETABLE August 1994 December 1994 March - June 1995 July 1. 1995 30 -90 days

STATUS completed completed pending pending ongoing

SECTION ONE SECTION TWO filed alphabeticaitf

PROPOSED SECTION DIVIDERS AND PURGING SCHEDULE Ver.l. PART I - DEVELOPMENTAL (Attachment Two)

Facesheet Assessment Process MAP 121 A/MAP 119
TDENTTFVTNG INFORMATION Identifying Info/Photograph Visiting information Sheet Daily Activity Schedule

updated annually removed permanent
PllROF SCHEIMTT.F. current current current

mP/ASSESSMFNTS/FVALUATIONS

IHP/IPP/EEP*not separated by discipline current

Discharge Plan (filed with IHP)

current

Restrictions of Rights/Freedoms

current

Audiology

current

CABS

current

Comprehensive Development Assessment current

FriMCtflioiml and Vocational Plans

current

Occupational Therapy Comprehen Eval current

Physical Therapy Evaluation Form

current

Psychological Evaluation

current

Recreation Evaluation/Screening

current

Speech/Language Evaluation

current

SECTION THREE SECnONFQUR

PROBLEM USTS/TRFATMF.NT PLANS

Goals/Objecnves/Plans

one year

filed by Prob# and Date

ID NOTES Notes
Nutrition Quaneriy Reviews (interfiled) Progress Reviews (behind ID Notes) QMRP Quarterly Reviews

one year
one year
one year
one year

Ver.i PART - MEDICAL

SECTTQN FTVE

HEALTH ASSESSMENTS
Physician Medical Review (physical exam) Psychiatric Evaluation Psychiatric Annual Review Tea Year Medical Summary New Admission Medical Summary Nursing Assessment Nursing Annual Nursing Review (IHP)( Devei Section) Admission Dental Review Dental Annual Staffing ReportlHP-in Dev Sec)

PURGE SCHEDT TTF
current current current current current current current current current current

SECTION STX

CONSULTATTONS/HOSPTTAL REPORTS Medical Clinical Consultations(list)

six months permanent

filed by chrono date not specialty

SECTION SEVEN HEALTH GOPS/TREATMENT PLANS
Goals/Objecrives/Plans Psychotropic Drug Plan and Addenda Psychotropic Consents ED Notes-Psychotropic Medication and Reviews ID Notes-Psychotropic Medication Probl List Psychotropic Side Effects Summary Sheets Psychiatric Weekly Notes

one year one year one year one year one year one year one year

EIGHT PHYSICIANS ORDERS

six months

SECTTONNINE

HEALTH ID NOTES Plan of Care/Recenification (interfiled by date) Nursing Monthly Reviews Nursing Assessment Form (quarterly)

one year one year one year

- J5ECTTON TEN

MEDICATTON RECORDS Pharmacist's Notes Medication Administration Record Medication Record for Fever Routine

SECTION ELEVEN
filed chono order

CLINICAL LAB/X-RAY Laboratory Data Radiology (sonograms. ultrasounds. MRI")

one year one year one vear
six months
one year one year one year

SECTTQN TWELVE

GRAPHICS Seriously/Critically 111 Blood Pressure Graph Height/Weight Seizure Record Health Maintenance Record Diabetic Chan Drug Profile Graphic Chan Breast Examination Menstruation Record Tardive Dyskanesia Charts Psychotropic Side Effects Summary Sheets

current current current current current current current current current current current current

SECTION THIRTEEN

CORRESPONDENCE/LEG AI. Consents

current

Form deleted 4/95.

SOURCE ORIENTED RECORD WITH INTEGRATED PROGRESS NOTES (Attachment Three)
THE PLAN
• MEDICAL, NURSING. DENTAL AND PHARMACY WILL DOCUMENT IN THE "HEALTH" SECTION.
• WITH THIS TYPE OF RECORD, EXCEPT FOR MEDICAL (HEALTH), EVERY DISCIPLINE DOCUMENTS IN THE ID NOTES.
•ID NOTES ADDRESSING EACH PROBLEM WOULD BE DOCUMENTED WITH THE CORRESPONDING NUMBER IN THE ID NOTES.
• MONTHLY REVIEWS ARE ALSO DOCUMENTED IN THE ID NOTES AND PREFACED WITH "OT MONTHLY REVIEW", ETC.
• QUARTERLY REVIEWS SUCH AS QMRP REVIEWS ARE CHRONOLOGICALLY FILED BEHIND THE ID NOTES FOR QUICK IDENTIHCATION.
• PROBLEM LISTS FILED TOGETHER IN ONE SECTION.
• DEVELOPMENTAL GOALS, OBJECTIVES AND PLANS (GOPS) FILED IN ONE SECTION.
• THE GENERAL LOG SECTION WOULD BE ELIMINATED.
• SOME OF THE INFORMATION THAT IS NOW KEPT IN THE UNIT LOG WOULD BE WRITTEN IN THE INTEGRATED ID NOTE SECTION.
THE UNIT LOG: WHAT IS DOCUMENTED IN THE UNIT LOG NEEDS TO BE DEFINED BY RESIDENTIAL SERVICES SO THERE IS UNIFORMITY IN THE "FORM" ITSELF AND THE DOCUMENTATION ENTERED INTO THE RECORD.

NORTHERN VIRGINIA TRAINING CENTER QUALITY MANAGEMENT PLAN FY 94-95

I.

Purpose:

The purpose of the Quality Management Program for NVTC is to establish, organize, and implement an effective program through monitoring, evaluating, and documentation to improve the quality of life for each individual served.

II.

Goals:

The goals of the NVTC Quality Management Program are as follows:

A. To organize and facilitate the systematic monitoring and evaluation of the quality and appropriateness of consumer services and client care and treatment in relation to established standards of care and practice.

B. To identify problems/risks and areas for improvement .rough gathering, aggregating and analyzing data.

C. To resolve identified problems/risks and to seize opportunities to improve consumer services and client care and treatment.

D. To d o c u m e n t the p r o c e s s of p r o b l e m / r i s k identification and quality improvement through resolution and follow-up.

E. To coordinate and integrate quality management into the ongoing operational activities of all clinical and support services.

F. To minimize the potential for liability to NVTC related to the provision of professional services.

G. To encourage the communication of information, findings and quality improvement efforts between services, departments and committees so as to increase clinical and administrative knowledge and to positively affect consumer services and client care and treatment.

H. To evaluate annually the effectiveness of the Quality Management Program.

III.

Background:

A. Quality Management is a dynamic process of monitoring and evaluating the habilitation and care programs and services provided to consumers and clients so as to produce strategies for change and improvement. Quality Management processes generally adhere to a problem solving module. Data from a variety of sources is utilized to identify existing problems, risks or potential for improvement. Once problem areas, risks or improvement opportunities are identified information is translated, assessed and analyzed so as to formulate a strategy for change. This problem-focused approach to Quality Management has five components:

1. Identification of existing/potential problems, risks or potential for improvement.

2. Assessment to determine the cause and scope of problems, risks or barriers to improvement.

3. Development and implementation of a corrective action or quality improvement plan.

4. Monitoring and follow-up to determine if desired results and outcomes have been achieved and sustained.

5. Documentation and communication of the results and outcomes of the quality management/ improvement effort to appropriate management, staff and consumers.

B. It is the intent of NVTC's Quality Management Program that issues be addressed and resolved at the lowest possible level. Primary responsibility for providing quality services lies with the individual service provider and the responsible unit, team, department or service. Each unit, team, department and service must insure that services are developed in accordance with specific regulations, standards, policies, procedures, agency instructions, and Departmental Instruction No. 74 (QA/RM Program).

IV.

Authority and Responsibilities:

A. DMHMRSAS Commissioner. The ultimate authority of the administration of the Quality Management Program r e s t s with the Commissioner DMHMRSAS. The Commissioner w i l l d e l e g a t e t h e authority for development and organization of the program to the D i r e c t o r of NVTC. The Commissioner s h a l l , however, r e c e i v e p e r t i n e n t records and reports from the Director of NVTC concerning f i n d i n g s , a c t i v i t i e s and accomplishments.

B. NVTC Director. The Director of NVTC i s recognized as e delegated and u l t i m a t e authority t o r e p r e s e n t the DMHMRSAS
>mmissioner at the agency l e v e l . The Director, i n l i a i s o n to the

Commissioner, will establish, give direction to, monitor the activities of and routinely evaluate the effectiveness of the Quality Management Program to ensure continued evidence of improved consumer services and client care and treatment.
C. Quality Management Committee. The NVTC Director shall establish a Quality Management Committee for the purposes of implementing the NVTC Quality Management Program. The committee shall function as a direct liaison between units, departments and services and the Director of NVTC in regard to Quality Management matters. The committee's primary charge shall be to assure that suitable solutions are found for identified problems, risks and improvement opportunities and that corrective action and/or improvement plans are implemented.
1. Responsibilities of the Quality Management Committee are to:
a. Interpret the intent and application of standards and regulations.
b. Monitor facility compliance to standards and regulations and facilitate correction of deficits and/or the implementation of Quality Improvement Plans.
c. Administer priorities for Quality Improvement Activities.
d. Assist units, teams and departments in establishing their Quality Assurance and/or Quality Improvement activities.
e. Identify problems, risks and potential for improvement and advise management and standing committees of issues and/or situations requiring the attention of the appropriate committee.
f. Make expeditious reviews of serious unanticipated outcomes where client injury has occurred or client safety has been jeopardized.
g. Review, aggregate and analyze trend data related to the quality of consumer services and client care and treatment.
h. Monitor solutions to Quality Management problems and risks by the appropriate action authority.
i. Take action to i m p l e m e n t Q u a l i t y Improvement efforts on matters referred to the committee.

j. Plan, conduct and perform follow-up monitoring of formal internal program or service delivery audits and/or surveys as assigned by the NVTC Director.
k. Evaluate the effectiveness of the Quality Management and Quality Improvement efforts of NVTC annually.
1. Prepare periodic reports of status and quality management activities and accomplishments to appropriate NVTC and DMHMRSAS staff.
m. Perform other activities as assigned by the NVTC Director.
2. The composition of the Quality Management Committee is as follows:
a. Quality Management Director (NVTC Risk Manager), Chairperson
b. Director, Community Programs c. Director, Social Work d. Facility Advocate e. Infection Control Nurse f. Training Coordinator g. Director, Resident Records Department h. Facility Director (Ex-Officio) i. Others (Indicated by Need or Function of
Issue Being Addressed)
D. Quality Management Director. The Quality Management Director will have the responsibility for the overall operation of the Quality Management Program. He/she shall ensure the participation of all involved units, teams, departments and services in the program. The NVTC Quality Management Director is the facility Risk Manager. The responsibilities of the Quality Management Director shall be to:
1. Report directly to the NVTC Director.
2. Coordinate daily Quality Management activities.
3. Chair the Quality Management Committee.
4. Receive Quality Management data from committee members to review and to determine patterns indicative of problems, risks or opportunity for improvement.
TIBT

5. S h a r e d a t a and i n f o r m a t i o n and participate in appropriate management, committee, and unit/team/department and service meetings where issues of quality service delivery are to beaddressed.
6. Consult with units/teams/departments and services to determine Quality Management/Improvement issues.
7. Coordinate Quality Management reviews and surveys.
8. A s s i s t s u p e r v i s o r s i n using q u a l i t y management findings to improve service delivery.
9. Maintain records of completed Quality Management a c t i v i t i e s , reviews and accomplishments.
10. Prepare, review and update NVTC policies, procedures, plans and resource documents related tothe Quality Management Program as required.
11. Report Quality Management f i n d i n g s , a c t i v i t i e s and accomplishments t o appropriate NVTC and DMHMRSAS staff.

V.

Program Components:

A. Department-Based Quality Assurance Program. Each NVTC Department is responsible fordeveloping and implementing its own Quality Assurance System so as to monitor operations and improve the quality of its service delivery on an ongoing basis. Numerous methodologies for accomplishing this task have been proven to be effective and it is not the purpose of this plan to dictate required methods or mandatory processes to specific Departments. The Quality Management Committee shall assist individual Departments in selecting an appropriate model and in formulating their written plans as requested. Copies of Departmental plans must, however, be provided to the Quality Management Committee and they are to adhere address the following areas:

1. Policy Statement. Statement should state that the quality and appropriateness of services provided by each Department are monitored and evaluated in an ongoing, systematic effort to promote high quality care, to act on opportunities to improve care and to resolve identified problems.

vv
2. Responsibility. A responsible individual should be assigned overall responsibility for monitoring and evaluation activities. The plan should also indicate who is delegated the responsibility for day to day coordination activities, the development of monitoring indicators, data collection, analysis of information and documentation.
3. Scope of Services. This section describes the general services provided by the Department, the types of clients/others served, and the types of staff (i.e. professional, clinical, direct care, administrative, support, etc.) utilized.
4. Identification of Important Aspects of Care. The critical elements of vorJc that the Department is responsible for accomplishing are identified. Generally, these are related to appropriate regulatory, accreditation, professional or auditing agency standards.
5. I n d i c a t o r s . A c r i t e r i o n of competent performance is established. This criterion ought to be easily observable, measurable, and outcome based.
6. Monitoring Methodologies. Data sources available to evaluate performance in relation to established indicators are to be identified. Information can then be routinely collected, evaluated and compared to established standards to assess quality, identify potential for improvement, and/or identify problems.
7. Evaluation. This may include examination of specified important events at the time of occurrence as well as an analysis of lesser information on a periodic basis to identify patterns and trends, assess quality, to identify opportunities to improve service and/or to identify problem areas.
8. Documentation and Reporting. Monitoring and evaluation activities must be summarized and recorded. Quality improvement efforts and accomplishments must be reported to the Senior Staff Manager on a periodic basis. The Senior Staff Manager shall then consolidate Department efforts and provide a written report detailing all Quality Improvement efforts within his/her area of responsibility to the Quality Management Committee quarterly. Relevant information shall be shared with the Facility Director, representatives from the Senior Staff Committee and with appropriate Department Managers as deemed to be appropriate.
9. Evaluation. Department Quality plans are to be evaluated and revised annually. Revisions may also be made throughout the year as new issues arise or as monitoring activities indicate that a change is warranted.
-mmr

B. Quality Management committee Activities.

The

responsibilities and composition of the Quality Management

Committee are detailed in Section IV C of this plan. In order to

implement the responsibilities of its charge the Quality Management

Committee shall meet monthly to review formal and informal

information sources that have been identified as having specific

Quality Management implications. Written minutes from these

meetings shall be prepared and provided to the NVTC Director. Data

that is reviewed shall be analyzed so as to identify areas that

require improvement and appropriate Units/Departments shall be

tasked to develop the necessary corrective action and report that

action to the Committee.

1. Presentation of Formal Data Sources:

a. Quality Management Director (Risk Manager).
The Quality Management Director is responsible for the administration of the Quality Management function and for chairing committee meetings. He/she shall establish a schedule for Committee activities, assign duties to the various team members and coordinate the preparation and follow-up of Committee reports. The Quality Assurance Director shall also be responsible for obtaining various reports required by the Quality Assurance committee in order to properly execute its function. Among these reports are:

1) Quality plans and reports from all NVTC Departments.

2) R e p o r t s of Q u a l i t y e f f o r t s and accomplishments undertaken by other NVTC standing and management committees.

3) Written internal and external reviews conducted at NVTC.

4) continuous Quality Improvement plans and reports prepared by Center Program Units and Total Quality Management projects.

5) Written communications related to the NVTC Quality Management effort prepared by management, regulatory, accreditation or program audit entities.

b. Risk Manager. The Risk Manager shall
coordinate the various elements of the Risk Management plan. In addition the Risk Manager shall review:

1) Serious incidents and trend data from the Incident Reporting System.

2) Activities of the NVTC Safety Committee.

8
3) Activities of the NVTC Clinical Practices Review Committee.
4) Activities of the Workers' Compensation Review Committee.
c. NVTC Advocate. The Advocate shall make recommendations to the committee in the realm of Human Rights which require immediate attention. At his/her discretion the Advocate may review specific cases deemed to be of concern. Specifically, the Advocate shall review:
1) Human rights complaint data trends.
2) Restrictive program trend data.
3) Activities/issues that the Local Human Rights Committee has referred to the Quality Management Committee.
d. Infection Control Nurse. The Infection Control Nurse shall review:
1) Infection surveillance data trends.
2) Activities/issues that the Infectious Disease Committee has referred to the Quality Management Committee.
e. Training Department Representative. The Training Department Representative shall review:
1) Active treatment and staff interaction data trends.
2) Activities/issues related to Active Treatment and Staff Development which warrant aggressive treatment by the Quality Management process.
f. Social Services Director. The Social Services Director shall review data and activities related to the QMRP and IHP processes. He/she shall make recommendations to the Committee related to client program assessment, development, delivery and change. Specifically, the Director of Social Work shall review:
1) QMRP data trends.
2) Activities related to t h e admission, transfer and discharge of clients.
-rr

. .-*.#'. =v - . - • - , - -
3) Activities/ issues referred to the Quality Management Committee by the Admissions and Ethics Committees.
g. Resident Records D i r e c t o r . The Resident Records Director shall review:
1) Client record audit data trends.
2) A c t i v i t i e s / i s s u e s related to the maintaining of the integrity of client records.
3) Activities/issues referred to the Quality Management Committee by the Resident Records Committee and the u t i l i z a t i o n Review process.
h. Community Programs Director. The community Programs Director shall review:
1) Complaint and comment trend data received from community educational and vocational placements.
2) A c t i v i t i e s and i s s u e s of Q u a l i t y Management concern t h a t have been generated as a result of relations with the various Community Services Boards and, L i c e n s i n g , C e r t i f i c a t i o n , Accrediting, and Reviewing bodies.
2. Informal Information Sources. A variety of informal information sources, in addition to those discussed above, are available to assist in evaluating agency performance. Among these are:
1) Committee Meeting minutes.
2) Observation of client services.
3) Interviews with staff, c l i e n t s , family and consultants.
4) Department andunit logs.
5) Staff Duty Officer and Roving Team Leader reports.
6) Security Officer reports.

10
7) Problems encountered by similar agencies.
8) Literature reviews.
9) Media exposure.
10) Etc.
3. Problem Identification and corrective Action. Opportunities for improvement and/or problem and risk areas identified in the review of the formal and informal data discussed above shall be identified by the Quality Management Committee and directed to the appropriate Unit/Department Manager in order to affect corrective action. The Committee shall generate a problem oriented report document that identifies the issue and provides the documentation as to why the problem was i d e n t i f i e d . The Unit/Department shall be responsible for identifying the factors causing the problem and for developing a corrective action plan to address the i s s u e in question. The c o r r e c t i v e action plan developed by the responsible Unit/Department must identify the actions that must be taken by the Unit/Department i t s e l f and those actions that must be completed by those outside of the affected Unit/Department. The plan shall i d e n t i f y the responsible individuals for completing the actions required and provide completion dates. The Quality Management Committee shall monitor the effectiveness of the actions taken by conducting follow-up evaluations.
C. Quality Management Activities of Management and Standing NVTC committees. Several NVTC committees have been identified whose principle functions involve responsibilities that can have a significant impact upon the quality of the NVTC service delivery system in one capacity or another. The chairpersons of these committees have been charged with the responsibility to document and report a c t i v i t i e s and projects that have been undertaken and which are deemed to have Quality Improvement implication. Reports of these activities and accomplishments are to be forwarded to the Quality Management Director on a quarterly b a s i s so t h a t they may be incorporated as a part of the comprehensive NVTC quality effort. The Committees are listed below:
1. Admissions Committee 2. Behavior Management Committee 3. Ethics Committee 4. Research and Development Committee 5. Resident Records Committee 6. Infection Control Committee 7. Safety Committee 8. Workers Compensation Review Committee 9. Clinical Practices Review Committee 10. Pharmacy and Therapeutics Committee

11
11. Habilitation Committee 12. Equal Employment Opportunities Committee 13. Others as Identified by the Quality Management
Committee
D. TQM/CQI projects and project leaders are assigned by the NVTC Director as deemed appropriate. The Quality Management Committee shall serve as resource individuals and as facilitators for the Project Leaders should those leaders desire to utilize the assistance available. The Quality Management Director shall maintain a file of various TQM/CQI models and methodologies and shall provide any required training or guidance to TQM/CQZ Team Leaders and/or Project Teams as indicated. TQM/CQI Project Leaders shall provide quarterly reports to the Quality Management Committee related to project status and quality improvements accomplished as a result of the activities of the effort. (See Appendix A)
E. Unit-Based Habilitation and Active Treatment Program Continuous Quality Improvement Activities. Unit service delivery systems are evaluated on a periodic basis utilizing the concepts of the TQM/CQI method in accordance with the certification standards published by HCFA for Intermediate Care Facilities for the Mentally Retarded. This program audit is conducted by the NVTC Quality fanagement Committee but is accomplished with the participative contributions of Unit Managers, Clinicians and Direct Care Staff. The procedures for the conduct of these Unit-based reviews and Quality Improvement efforts are as follows:
1. The Quality Management Committee chooses a Unit in which to conduct a certification standard related survey and initiate a Continuous Quality Improvement effort. Several factors are utilized to make this selection:
a. Quality Management indicators and trend analysis.
b. Senior management preferences.
c. R e s u l t s of r e v i e w s from p r e v i o u s evaluations.
d. Invitation by the Unit managers and/or treatment team.
2. The Quality Management Committee evaluates all trend data available so as to provide a focus for the Unit survey. Data to be examined includes but is not limited to:
a. Event Report data. b. Employee injury data. c. Human Rights complaint data.

12
d. Client restraint data. e. QMRP reports. f. Client Record System audit data. g. Active Treatment and Staff Interaction
data.
3. A general meeting is conducted among the Quality Management Committee, the Unit ID Team and Residential Services staff. At this meeting the Unit Team is advised that they have been selected for a Continuous Quality Improvement effort and are provided with the details and procedures that will be utilized by the Quality Management Committee during the conduct of the survey and improvement effort. The trend data that had been previously analyzed by the Quality Management Committee shall be discussed and management, clinicians and Unit staff are encouraged to assess the quality status of the Unit. Participants are also given the opportunity to address and identify any obstacles that prevent improvement of care and treatment.
4. The Quality Management Committee conducts a series of on- unit and at-work observations, record reviews and program audits. Numerous observations are made on all shifts and full program audits and records reviews are conducted of between 20-40% of records. A Quality Management Client Review Checklist developed from the HCFA regulations and guidance to surveyors has been formulated and is used to conduct these audits. Audit results are shared with the ID Team principals as they occur.
5. The Quality Management Committee conducts a team meeting and identifies a few to several areas where problems and potential for improvement as identified in program audits, unit observations and in staff interviews appear to be concentrated. The identified areas are then chosen as recommended projects for Unit Team TQM/CQI Focus Group processing. The Quality Management Committee also identifies some possible resource individuals from among its own Committee as well as from other NVTC resources outside of the Unit being reviewed. In addition, some preliminary ideas for addressing problem areas are devised.
6. The Quality Management Committee meets with the entire Unit Team again and presents the results of the audit process, the identified potential TQM/CQI topics and the initial suggestions for how each topic area may be improved. Input is solicited from the Unit Team Members and TQM/CQI Focus Group topics are finalized. A leader for each Focus Group is identified and Unit Team members are permitted to choose the Focus Group with which they would like to participate. A member of the Quality Management Committee is assigned to each Focus Group and additional resource individuals are identified and invited to participate.
7. Each Focus Group, consisting of a mixture of management staff, clinical staff, personal care staff, members of

13
the Quality Management Committee and additional resource individuals meets, utilizing the TQM/CQZ methods discussed earlier, for a period of about four to six weeks for the purpose of identifying process changes required in their project area. Each Focus Group shall prepare a series of suggestions/recommendations designed to achieve Quality Improvement related to their Focus Group topic.
8. The Quality Management Committee and the Focus Groups then meet as a whole and each Focus Group presents its recommendations. Recommendations are discussed and expanded upon by the whole group and the several recommendations are synthesized.
9. Many of the initial recommendations can be immediately implemented, and if this is deemed appropriate immediate change is instituted, other recommendations may require the approval of higher level NVTC Management and if this is the case the recommendations are taken to that level by the Quality Management Committee. Likely, many of the recommendations will have to be adapted and redesigned.
10. Focus Groups shall continue to meet to advance more recommendations and to refine implementation. The Unit Team will eventually assimilate the accomplishments and recommendations of each Focus Group and develop a fluid and on-going Continuous Improvement Plan for the Unit that will implement all of the recommendations. The Unit Team shall address the Improvement Plan periodically at clinical and administrative meetings to insure that recommendations and efforts are not neglected. The Unit management shall revise the Continuous Improvement Plan as accomplishments are achieved and as new areas for improvement are identified.
11. Unit management shall provide copies of updated Continuous Improvement Plans and reports of efforts and activities related to the Quality Improvement project to the Quality Management Committee quarterly.
F. Other Formal Program or Service Reviews. These types of reviews are non-routine evaluations. They are normally a very formal process and they require the development of a specific evaluation format.
1. Topic Selection. Topics for formal review are either recommended by the Quality Management Committee or are assigned by the Director of NVTC. These reviews are indicated when:
a. There is statistical evidence to indicate that the problem of concern occurs frequently.

14
b. The problem is so severe (though perhaps not widespread) that the facility's clients or resources are at significant risk.
2. Development of Assessment Criteria. The criteria for selecting performance standards to be assessed must be such that the elements that are essential to producing quality care, treatment or service are evaluated. The criteria selected should be outcome based to the extent that this is possible, however, process (what the provider does and the degree to which this conforms to accepted standards) shall not be overlooked. Standards selected are to be ratified or confirmed as essential by those who are responsible for the service being evaluated. This is necessary, not only to be fair to those responsible for the service, but also to enlist their support for and commitment to the process.
3. Program and Documentation Review. Case Treatment or service delivery is evaluated and reviewed in accordance with the established criteria to determine what, if any deficiencies, problems or opportunities for improvement exists.
4. Identification of the Problem or Improvement Opportunity. Once identified, problems or improvement opportunities shall be briefly, but fully stated. Measures of the extent, location and frequency of the difficulty shall be utilized to complete this process.
5. Problem Analysis. The responsible unit, department or service must then determine what has caused the problem. No corrective action plan can be successful unless it is appropriate to the cause of the difficulty. The three most common causes of problems are defects in system processes, insufficient knowledge and deficient performance. Each of these areas must be evaluated.
6. Corrective Action Plan. Once causes of a problem have been identified, a corrective action plan can be developed and implemented. The unit, department or service shall fully document the procedures which shall be instituted to bring about resolution. The plan shall identify corrective actions to be taken, assign a responsible individual and establish the suspense dates for the completion of the actions. The unit, department or service may find that it does not have the resources available to fully correct deficiencies noted. Should this be the case, additional corrective action requirements shall be coordinated with the Quality Management Committee.
7. Follow-Up. The unit, department or service shall provide the Quality Management Committee with regular progress reports related to the implementation of its improvement plan. The schedule for the submission of these reports shall be

15
established on an individual basis as determined to be appropriate by agreement between the unit, department or service and the Quality Management Committee. Continued monitoring and evaluation shall be implemented by the Quality Management Committee or by the appropriate Senior Staff Committee representative to insure that the approved correction plan has been implemented and the corrections implemented have produced the required change.

VI.

Quality Management Program Evaluation:

The effectiveness of the NVTC Quality Management Program must be formally evaluated on an annual basis during the period of August - September by the Quality Management Committee and by the Senior Staff Committee to insure that the collective effort has been comprehensive, cost effective and that it has achieved the desired goal of enhancing the quality of services provided by NVTC. This evaluation must also assess the degree to which the annual performance objects of the Quality Management Program have been realized. The results of this annual program evaluation shall be fully documented and utilized to revise the NVTC Quality Management Plan and to establish objectives for the following year.

VII.

Quality Management Program Documentation:

A. Annual Report. The Quality Management Director is required to submit a formal Quality Management Program annual report to the DMHMRSAS Office of Quality Assurance. This report must be submitted in October of each year and consists of the following elements

1. A report of the activities and accomplishments of the Quality Management Program realized during the preceding semi- annual period. The report submitted shall be a synthesis of all of the efforts, activities and accomplishments generated by each of the Quality Management Program components detailed in this plan.

2. The results of the annual formal NVTC Quality Management Program evaluation of effectiveness.

Plan.

3. A copy of the revised NVTC Quality Management

4. A listing of the planned objectives to be accomplished by the NVTC Quality Management Program during the following year.

B. semi-annual Report. The Quality Management Director is required to submit an interim Quality Management Program report to the DMHMRSAS Office of Quality Assurance semi-annually. This interim report must be submitted in February of each year, and as

16
in the case of the annual report, consists of a compilation and synthesis of the activities and accomplishments realized by each of the NVTC Quality Management Program components.

VIII.

Quality Management Plan Revision.

The NVTC Quality Management Plan shall be reviewed annually. Any revisions shall correspond to and be in accordance with the findings produced during the annual Quality Management Program evaluation. This does not preclude the plan from being revised and improved at any time that circumstances warrant.

All Quality Management Plan revisions shall be submitted to the NVTC Director and to the DMHMRSAS Commissioner as they are made.

IX.

Confidentiality:

All information, both verbal and written, pertaining to the NVTC Quality Management Program shall be held confidential and is considered to be the sole property of this facility as part of DMHMRSAS. This information is protected from disclosure by specific exclusion from the Freedom of Information Act and is considered as privileged communication under the terms of the Code of Virginia, Section 8. 01-581.16 and Section 8.01-581.17.

Revised: March 1995

APFEMDXX A
TOTAL QUALITY XAMAOZMEBT /CONTINUOUS QUALITY IMPROVEMENT (TQM/CQI)
TQM/CQI is the terminology applied to the method of providing for a fluid, ongoing and continual enhancement of the quality, as defined by the customer (those who use and/or are impacted by the service), and achieved through a systematic analysis of the service delivery system processes by means of a team approach in which management leads and facilitates employees who are empowered to make a significant impact upon the nature and methods of the processes utilized.
1. Elements of a TQM/CQI Approach. Numerous TQM/CQI programs and models have been advanced. Most of them incorporate several, if not all, of the following elements:
a. Customer Oriented. In the TQM/CQI concept quality is defined as meeting and/or exceeding the customers' expectations. When this is accomplished the customer is satisfied that the system has done the correct things in the correct manner. Key to the approach is being able to:
1) Identify who the customers are. In general Customers are the ultimate target or beneficiary of the agency's service. Customers may also be those who assist in making the service available to the primary target and even anyone within the organization who receives or utilizes the work of another employee or team. simply stated, the customer is anyone who uses or is impacted by the service.
2) Identify the critical expectations of the customer. This means that the focus of Quality Improvement efforts must be at the point where services are actually delivered to the system's users.
3) Keep in touch with the customer. This means knowing them and viewing all that is delivered from their perspective. Any outcomes that are measured must be the outcomes that are experienced by the customer.
b. Team Approach. The TQM/CQI concept emphasizes the team approach to problem solving and decision making. The value in utilizing the team approach is that it allows the introduction of a broad knowledge base to the problem identification and problem solving process. Ideally, Team Members will be assembled from among a broad range of employees who have expertise in all of the several components of the system being evaluated. The team approach allows for the pooling of skills, talents and knowledge so as to permit the identification of more, if not all, of the hindrances to Quality Enhancement as well the introduction of a wider range of solution options. With proper guidance and

f a c i l i t a t i o n , teams can often tackle complex and chronic problems and generate effective, permanent solutions.
c. Management Leads and F a c i l i t a t e s . The TQM/CQI process i s dependent upon management being willing to forego more traditional directing roles and assume a leadership s t y l e that supports and f a c i l i t a t e s the group p r o c e s s . Some of the requirements for management in the TQM/CQI process include the following:
1) Adopt the TQM/CQI philosophy.
2) Demonstrate a support for and give direction to TQM/CQI process.
3) Demonstrate a participative attitude in the process.
4) Encourage ideas and theories for improvement.
5) Provide r e s o u r c e s and o t h e r a s s i s t a n c e necessary for the process to be successful.
6) Institute a program of education, training and self-improvement for employees.
7) Make changes based upon the recommendations generated in the process.
d. Employees are Empowered. The TQM/CQI method i s based upon including a l l levels of employees into the process of identifying areas for improvement and s o l i c i t i n g their involvement in developing the mechanisms by which t h i s may be accomplished. There are several principles that may be applied in order to empower employees:
1) Treat a l l employee with dignity and respect.
2) Provide employees with important work to do on critical issues.
3) Give employees d i s c r e t i o n and autonomy over their tasks and resources.
4) Allow employees to find ways to better serve their customers.
5) Encourage employees to find and f i x problems.
6) Enable employees t o put t h e i r ideas i n t o action.

7) Assist employees in building relationshipsand
supports.
e. Systematic Evaluation of Processes. The TQM/CQI model incorporates the concept that the potential of eliminating mistakes and errors lies not in changing worker behavior but in improving the system through which work is done. Emphasis is placed upon evaluating and analyzing the workplace systems so as to change them in order to facilitate a process that will result in improved quality when the final product is delivered. Therefore, TQM/CQI methods center about a scientific or systematic approach to studying and evaluating processes. Decisions for change are based on data analysis rather than hunches, root causes to hindrances are sought rather than reacting to superficial symptoms and permanent solutions are sought rather than relying on quick fixes. Thus, the TQM/CQI approach involves the use of a number of scientific tools and data collection mechanisms in order to analyze system processes and evaluate the improvement generated when changes are implemented. Some of the data gathering and analytical systems used in the TQM/CQI method include:
1) Flowcharts - simple to construct charts that emphasize the major steps to a process.
2) Work Flow Diagrams - Show the movement of materials, people or information within a system.
3) Pareto Charts - Focus improvement efforts by ranking problems or their causes. It is a chart depicting a series of bars whose heights reflects the frequency or impact of the problem.
4) cause and Effect Diagrams - pictorial displays of a list. They identify and organize the possible causes of problems.
5) Operational Definitions - Precise definitions of important terms and procedures used in a project. They simply describe what something is and how it is used.
6) Histograms or Frequency Distributions Pinpoint problems by identifying where and when problems do and do not occur.
7) Time Plots - Are used to examine data for trends and patterns that occur over time.
8) Dot Plots - Show what values occur and how often. They are used to quickly examine the distribution or spread of data.

9) Checfcsheets - structured forms that facilitate the recording and analyzing of data.
10) Scatter Diagrams - Display the relationship between two variables. The shape of the scatter indicates if and how the two factors are related.
f. Monitoring the Results of Improvement Strategies. Most TQM/CQI models consist of studying data to identify system problems and suggesting solutions that are believed to correct the system problems. Results (outcomes) are then evaluated and measured to assess if improvement has occurred. If improvement is realized, steps are taken to incorporate the changes permanently and retain the enhancements. If positive results are not achieved, the process is repeated and an alternative enhancement strategy is developed. To accomplish this objective it is imperative that performance indicators are:
1) The best indicators of performance
2) Outcomes that the identified customers desire and expect (customer oriented).
3) Operationally defined (clearly understood by all).
4) Easily identified
5) Measurable
g. Project Selection. Most successful TQM/CQI efforts are project based. The processes or subsystems that are best suited for TQM/CQI treatment are those that are utilized by a broad number of users throughout the service delivery system. The following are guidelines that are to be considered when considering TQM/CQI projects:
1) The project is considered to have a significant impact on improving the quality of life for clients and/or the quality of work for employees.
2) The project allows for the collection of data that can be easily measured in observable terms.
3) Results can be obtained in 4 to 6 months.
4) The process is not one that is currently under revision or scheduled to be substantially changed in the near
future.

5) The process has clearly defined starting and ending points.
6) The project represents a process /subsystem that needs improvement. The redesign of an entire service delivery system is not likely to be benefitted by the use of the TQM/CQZ method.

I. NVTC INITIATIVE Current Status Timelines
January 1992 February 1992
April 1992
September 1992

The NVTC Community Integration Initiative is the NVTC downsizing project with the primary objective of reducing the resident census from 270 to 200 persons during a three-year period as determined in 1991 under Governor Wilder's administration.
A special allocation was requested and appropriated from the 1992 General Assembly in order to support funding for community placements of individuals to reduce to a census of 200 over a three-year period (July 1993 to June 1996).
From July 1, 1992 through June 30, 1993, a total of $180,000 in start-up funds was made available to community planners for leasing of homes and purchasing furnishings, equipment, etc. A total of $2,100,000 was also appropriated over a three-year period beginning July 1, 1993. This funding was to be utilized as Home and Community-based Medicaid Waiver match for all services that were appropriate for the individuals re-entering the community from NVTC.
The State established a three-year budget, matching State General Funds with Medicaid Waiver funds to cover the re-entry to the community. The schedule involved three years, allocating funds for community placement of 30 persons for the first year (1993-1994), 20 for the second year (1994-1995) and 20 for the third year (1995-1996). Later this schedule was revised as individual needs and high costs of residential services required.
A steering committee for the Initiative was formed. Membership consists of staff from the Northern Virginia Community Services Boards (CSBs), parents of individuals living at the Training Center, Virginia Office of Mental Retardation Services (OMRS) staff, the Northern Virginia ARC, Parents and Advocates of the Institutionalized Retarded (PAIR), private providers and staff of NVTC. The steering committee has met quarterly throughout the project.
1

March-September 1993
March 1993 April 1993 December 1993 December 1994
June 1995 July 1995

The NVTC Steering Committee required that detailed information about the quality and scope of community residential providers be sent to all families interested in the community re-entry. Also, families developed a set of questions to be asked of prospective program providers to assist them in making informed choices.
Families, NVTC staff, private providers, and CSB staff began meeting to plan for the first round of placements of individuals interested in community re-entry (Continued throughout 1993).
The first individual moved out of NVTC to a community placement via the Medicaid Waiver.
A total of 10 individuals moved into community homes in calendar year 1993.
Twenty-eight additional placements were finalized at the rate of two-to-three placements per month during this calendar year. All placements were in small community residences with intensive involvement of parents/families in choice and selection of providers.
The total number of discharges has been 41 for the first two fiscal years of the Initiative. These 41 placements have depleted the first two years of funding of the special allocation.
The remainder of the original funding from the special allocation funds for the third year of the Initiative will become available. These funds will serve approximately 12 additional persons.
A supplemental funding request of $600,000 to assist in placing the remaining 17 persons was included in the FY96 NVTC Continuous Improvement Plan submitted to and approved in the 1995 General Assembly Session.

...
II. SCHEDULE FOR CONTINUED DOWNSIZING

TARGET DATE DISCHARGED
6/1/95 7/1/95 10/1/95 1/1/96 4/1/96 7/1/96 III. PROCESS
Collaborative Planning Emphasized
Parent Involvement Emphasized
Family choice was Emphasized

NVTC CENSUS 232 228 224 216 208 200

TOTAL # DISCHARGED 41 45 49 57 65 70

The DMHMRSAS, five Northern Virginia Community Services Boards (CSB's), the NVTC Senior Staff, and representatives from the parent and advocates group of NVTC residents, spent 18 months planning ihe move into community residential settings (January 1992-September 1993).
Most NVTC parents had never considered the possibility that their sons and daughters with severe/profound mental retardation would ever live in the community. Many of the potential residents of NVTC for the Community Initiative had/have multiple disabilities with significant physical and behavioral problems. Frequent parent meetings established assurances that the community environment would be sufficiently supportive and help consumers attempt to attain personal goals (February/December 1993). Many parents were empowered for the first time with choices for community residential options for their sons and daughters. Parents helped select providers and roommates configuration for the developing community homes (Beginning Summer 1993).

Individualized placements were designed
Persons Prioritized for Placements
IV. OUTCOMES
By July 1, 1996

i
Based on information regarding the consumer's friendship choices, needs, interest, etc., community placements were highly individualized. The staff at NVTC developed and sent a questionnaire to all family members, advocates or guardians of every person residing at NVTC. This questionnaire consisted of basic information describing the project and solicited feedback on community placement and choice of living options of the families for those individuals at the Center. Such questions as type of living arrangement (i.e., group home, foster home, supported living, etc.) desired by the families, as well as roommate selection and time frames were surveyed. About 50% of the questionnaires were completed and returned (Summer/Fall 93).
NVTC did not simply prioritize the "least disabled persons" for placements. Instead, with the involvement of families, a roster of individuals who were interested or volunteered for community placement was developed. The individuals on this list were discussed and described with each CSB that would be serving the individuals (Summer 1995 throughout project)

The census of NVTC will be reduced to 200 persons on schedule.

•

Strong collaborative relationships have been developed between NVTC

and Community providers. These relationships will greatly assist

NVTC in further downsizing efforts.

•

NVTC parents and families now understand that persons with severe

disabilities can live in community options, due to the success of this

Initiative.

I. NVTC INITIATIVE

Current Status

The NVTC Community Integration Initiative is the NVTC downsizing project with the primary objective of reducing the resident census from 270 to 200 persons during a three-year period as determined in 1991 under Governor Wilder's administration.

Timelines

January 1992

A special allocation was requested and appropriated from the 1992 General Assembly in order to support funding for community placements of individuals to reduce to a census of 200 over a three-year period (July 1993 to June 1996).

February 1992

From July 1, 1992 through June 30, 1993, a total of $180,000 in start-up funds was made available to community planners for leasing of homes and purchasing furnishings, equipment, etc. A total of $2,100,000 was also appropriated over a three-year period beginning July 1, 1993. This funding was to be utilized as Home and Community-based Medicaid Waiver match for all services that were appropriate for lhe individuals re-entering the community from NVTC.

April 1992

The State established a three-year budget, matching State General Funds with Medicaid Waiver funds to cover the re-entry to the community. The schedule involved three years, allocating funds for community placement of 30 persons for the first year (1993-1994), 20 for the second year (1994-1995) and 20 for the third year (1995-1996). Later this schedule was revised as individual needs and high costs of residential services required.

September 1992

A steering committee for the Initiative was formed. Membership consists of staff from the Northern Virginia Community Services Boards (CSBs), parents of individuals living at the Training Center, Virginia Office of Mental Retardation Services (OMRS) staff, the Northern Virginia ARC, Parents and Advocates of the Institutionalized Retarded (PAIR), private providers and staff of NVTC. The steering committee has met quarterly throughout the project.

t
1

March-September 1993
March 1993 April 1993 December 1993 December 1994
June 1995 July 1995

The NVTC Steering Committee required that detailed information about the quality and scope of community residential providers be sent to all families interested in the community re-entry. Also, families developed a set of questions to be asked of prospective program providers to assist them in making informed choices.
Families, NVTC staff, private providers, and CSB staff began meeting to plan for the first round of placements of individuals interested in community re-entry (Continued throughout 1993).
The first individual moved out of NVTC to a community placement via the Medicaid Waiver.
A lotal of 10 individuals moved into community homes in calendar year 1993.
Twenty-eight additional placements were finalized at the rate of two-to-three placements per month during this calendar year. All placements were in small community residences with intensive involvement of parents/families in choice and selection of providers.
The total number of discharges has been 41 for the first two fiscal years of the Initiative. These 41 placements have depleted the first two years of funding of the special allocation.
The remainder of the original funding from the special allocation funds for the third year of the Initiative will become available. These funds will serve approximately 12 additional persons.
A supplemental funding request of $600,000 to assist in placing the remaining 17 persons was included in the FY96 NVTC Continuous Improvement Plan submitted to and approved in the 1995 General Assembly Session.

\

, >

II. SCHEDULE FOR CONTINUED DOWNSIZING

TARGET DATE DISCHARGED 6/1/95 7/1/95 10/1/95 1/1/96 4/1/96 7/1/96
III. PROCESS
Collaborative Planning Emphasized
Parent Involvement Emphasized
Family choice was Emphasized

NVTC CENSUS
232 228 224 216 208 200

TOTAL # DISCHARGED 41 45 49 57 65 70

The DMHMRSAS, five Northern Virginia Community Services Boards (CSB's), the NVTC Senior Staff, and representatives from the parent and advocates group of NVTC residents, spent 18 months planning the move into community residential settings (January 1992-September 1993).
Most NVTC parents had never considered the possibility that their sons and daughters with severe/profound mental retardation would ever live in the community. Many of the potential residents of NVTC for the Community Initiative had/have multiple disabilities with significant physical and behavioral problems. Frequent parent meetings established assurances that the community environment would be sufficiently supportive and help consumers attempt to attain personal goals (February/December 1993). Many parents were empowered for the first time with choices for community residential options for their sons and daughters. Parents helped select providers and roommates configuration for the developing community homes (Beginning Summer 1993).

Individualized placements were designed
Persons Prioritized for Placements
IV. OUTCOMES
By July 1, 1996

Based on information regarding the consumer's friendship choices, needs, interest, etc., community placements were highly individualized. The staff at NVTC developed and sent a questionnaire to all family members, advocates or guardians of every person residing at NVTC. This questionnaire consisted of basic information describing the project and solicited feedback on community placement and choice of living options of the families for those individuals at the Center. Such questions as type of living arrangement (i.e., group home, foster home, supported living, etc.) desired by the families, as well as roommate selection and time frames were surveyed. About 50% of the questionnaires were completed and returned (Summer/Fall 93).
NVTC did not simply prioritize the "least disabled persons" for placements. Instead, with the involvement of families, a roster of individuals who were interested or volunteered for community placement was developed. The individuals on this list were discussed and described with each CSB that would be serving the individuals (Summer 1995 throughout project)

The census of NVTC will be reduced to 200 persons on schedule.

•

Strong collaborative relationships have been developed between NVTC

and Community providers. These relationships will greatly assist

NVTC in further downsizing efforts.

•

NVTC parents and families now understand that persons with severe

disabilities can live in community options, due to the success of this

Initiative.

EXHIBIT

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF VIRGINIA Alexandria Division

UNITED STATES OF AMERICA,

)

Plaintiff,

)

v.
COMMONWEALTH OF VIRGINIA, et al..
Defendants.

) Civil
) ) ) ) )

Action No.

96-284-A

ORDER

In light of the Settlement Agreement entered by the parties on

, 1996, which agreement is not so ordered or approved by

the Court, this civil action is hereby DISMISSED WITHOUT PREJUDICE

pursuant to Rule 41 (a) (2) of the Federal Rules of Civil Procedure.

The Court retains jurisdiction over this civil action and the

Settlement Agreement to resolve any disputes arising out of the

Settlement Agreement and to enter a final dismissal of this civil

action with prejudice as contemplated by the Settlement Agreement.

Adjudication of and remedies for any alleged violation of the

Settlement Agreement shall be subject to the procedures and

limitations provided by the Settlement Agreement.

The Clerk is directed to remove this civil action from

the court's active docket and to forward copies of this Order to

counsel of record.

Entered this 4th day of June, 1996.

Leonie M. Brinkema United States District Judge

APPENDIX B TABLE OF REPORTABLE PATIENT/RESIDENT INCIDENTS

INCIDENTS
All Deaths:

within 7 days of discharge it. if known Los of a limb or use of a limb, whether the los is permanent or temporary:
a) All amputations b) Allfractnres c) Joint dislocations d) Paralysis, paraplegia, quadripiegia

Spinal cord or serious back injury

Nerre injury or neurological deficit including los or impairment to any aensuiy organ

Brain damage or

bead injury

Temporary or permanent disability or disfigt meat (indudes first, second, and third bums and other injuries)

Internal injuries (e.g., torn iq ruptured internal organs, internal bleeding)

All serious wounds or sutures

requinng

Sexual rioUtaonof a minor or a or incompetent adult

Los or impairment of a reproducOTe organ

CATEGORY I EXAMPLES
Suicides Violent Deaths Accidental

All except fingers and toes multiple

Requires

hosnitaltzan'on or surgery

IT*

OT
or TJfnhlinr

or third degree burns; life threatening

Ruptured internal organs; life emergeucy surgical repair
surgical repair; life threatening;

Forced

with injuries requiring

Emergency surgical

APPENDIX B TABLE OF REPORTABLE PATIENT/RESIDENT INCIDENTS

Self-injury:

INCIDENTS

CATEGORY I EXAMPLES

a) Category I and Category II levd

b) jj
7 days after if known

M

errors and drug

which

repairs; life

dudes, but a not limited to, ' p H * of drug ic malignant syndronM
overdose (prescripooo drugs)

All transfers for unexpected, unol
for

medical care all innatient

Other advene patient/resident incidents, to be

hospitalis

pump

acy surgery; hospiulizatioo resulting fi rioknt injury

liabOity

Guideline for Determining SgyeritT of an Incident (Refer to Section 18.7 A and B.)
The facility director or risk manager must determine whether reportable incidents should be classified as Category I or Category II events to determine reporting procedures. It also must be determined whether an incident meets or might meet the four elements of a professional or medical malpractice cause of action.
Cattvorr I Incidents are major crises or events including, but not limited to, those which are life threatening or potentially life threatening; require emergency or surgery; require extensive recuperation: are permanently disabling or disfiguring; or, where there is, or is likely to be, significant adverse press. Decisions about the degree of seriousness of an injury or medical incident should be made with physician and risk manager input. Category I incidents must be reported promptly to the Associate Commissioner, Community/Facility Services by telephone/pager and also entered into the CIDB.
CateeonrII Incidents are the other reportable, iiQfliU incidents listed above. These are generally serious (but non-iife threatening or permanently disabling; patient or resident injuries and situations that require medical and/or clinical intervention. Category II incidents are also reportable and must be entered into the CIDB.

-nr

- EXHIBIT

Departmental Instruction No. 33

"

Reporting of Abuse of Clients

33 - 1 Purpose

To establish policies, procedures and responsibilities for reporting and responding to allegations of abuse of clients in state mental health and mental retardation facilities.

33 - 2 Definitions The following definition applies to this instruction.

AbuM

• physical acts such as, butnot limited to:
choking hair pulling hitting striking kicking pinching pushing scratching slapping spitting
• sexual activity or any type of inappropriate touching such as, but not limited to touching, stroking or fondling of breasts, genitals or buttocks, directly or through clothing, of a client.
• coercion, threats or intimidation that are statements or actions that would evoke fear in a reasonable person or that could reasonably be expected to evoke fear in the client.
• neglect in care that is the failure to provide:
a care a goods a services a treatment
necessary to thehealth, safety or welfare of a client.
• statements or actions that would humiliate, demean or exploit a client.
• condoning or permitting the abuse of a client, including client to client conflict, that mayresult in physical, emotional, or psychological harm.

!••

Departmental Instruction No. 33 October 20, 1994
3 3 - 3 Procedures - Facility Director
Any employee, volunteer, contract employee, consultant, visitor or relative who has knowledge or reason to believe that a client may have been subjeaed to abuse or other inappropriate behavior shall report such informationIMMEDIATELY to the Facility Director. While it is recognized that this is not the normal flow of information and most staff members do not routineiy report directly to the Facility Director, an allegation of possible patient abuse is so serious that any information regarding it should be given directly to the Facility Director so that immediateaction can be taken to safeguard clients. The report of the aileged abuseshall describe the incident as fully as possible, giving the names of the persons involved, the time, date and location of the incident, and the.names of any witnesses.
Upon Receipt of The Director shall: an Alkfiboa
• immediately take steps to protect the safety and welfare of the ciient/s.
• immediately initiate action to protect any physical evidence.
• immediately notify the Advocate of the allegation and provide all the information obtained from the report.
• conduct a preliminary assessment in accordance with Departmental Instruction No. 114, Generic Investigation Guidelines.
• assure that the client's authorized representative is notified about any alleged abuse and informed that an investigation has been initiated. If the client does not have an authorized representative, obtain the client's permission to notify the firmly.
• confer with the Advocate within 24 hours of the report of the allegation.
• determine whether there is a ream to suspect that abuse has occurred.

Upon a

The Director shall • immediately initiate an administrative investigation of the incident.

Departmental Instruction No. 33 October 20, 1994
• immediately notify the local Department of Social Services in accordance with 5 63.1-55.3 and 5 63.1-248.3 of the Code of Virginia and the Interdepartmental Agreement between the Department of Social Services and the Department.
• in all cases of suspected criminal activity such as sexual abuse, immediately contact local law enforcement authorities and/or State Police.

If an Employee Hat Been Identified as the

The Director shall • charge the employee with alleged abuse.

• immediately suspend the employee pending final disposition of the case.

• inform the employee of the charges and require him or her to with the administrative investigators.

Suspensions shall be in accordance with the Employee and Performance

o f Conduct

IT the Director AbtoeHas

The Director shall -
• meet and inform the employee of the finding and issue a Group III written notice under the FnTjjQyccStarjdarris of Conduct and Pe> fonitancft policy.
Such notice normally results in termination, however the Director has the discretion to mitigate the disciplinary action to an appropriate sanction other than termination.
• take any action necessary to prevent future

If other Inap- Hie Director shall take appropriate administrative action under the
propnat* Acs flC I5tiinri3rri.il of Conduct and Are DiacBTcrad in the Cmane at IareRtfaaos

•wr

Departmental Instruction No. 33 October 20, 1994
At Conciunoo of The Director shall
* • notify the client's authorized representative and the Advocate of the results of the investigation, the determination and the action taken.
• report all allegations made under this instruction, the results of any subsequent investigation, the determination, and the resulting action to the Associate Commissioner and the State Human Rights Director.
Facilities who treat minors must notify the Ucensure Office.
3 3 - 4 Procedures • Advocate
The Advocate shall -
• meet with the client and explain the role of the Advocate and the abuse investigation process.
• represent the client during the investigation.
• monitor the investigative procedures.
• review the written investigative report.
• conduct an independent investigation and submit a report of findings to the Director for review and consideration in making the determination of the disposition of the case, if deemed necessary.
• discuss the decision of the Director with the client and advise the client of the right to pursue the maner through the Human Rights Review Pmrm, if the client is «4iT«ati«fi—< with the Director's ricrition.
• consult with the Director about the implementation of recommendations developed as a result of the investigation.

Departmental Instruction No. 33 October 20, 1994
3 3 - 5 References
a Code of Virginia, §§ 63.1-55.3 and 63.1-248.3. a Code of Virginia, 5 37.1 - 84.1. O FmpjpvggStandards. of Conduct and Performance. a Departmental Instruction No. 114, 'Generic Investigation Guidelines.
33 - 6 Distribution
A copy of this Departmental Instruction shall be given to each employee to be reviewed during the initial orientation. Employees' written acknowledgement of their understanding of this Instruction shall be placed in their personnel file. A copy of this Instruction shall also be given to each volunteer, contractor, contract employee or consultant who will have direct contact with clients.
fimothy AMttity, Ph.D. Commissioner
This revised Instruction replaces Departmental Instruction No. 33, "Reporting of Abuse of Patients or Residents," issued November 15, 1991. EFFECTIVE DATE: October 20, 1994

1223

Virginia Department of Mental Heaith. Mental Retardation and Substance Abuse services
Office of Management Information Services Incident - Detail Report NVTC
From: 01/01/92 To: 01/15/92 Incident Number: 25000009

Date: 05/30/1996 Time: 14:05

incident Date: 01/14/1992 Time: leporting Person: LEE HILTON 'atients Involved:
R
staff Involved: NONE

11:15
Age 33
0

Building/Ward

3

' C

'ersons Contacted: FAMILY
.OCATION: BEDROOM

Date 01/14/1992

Time
16:00

TYPE: FRACTURE/DISLOCATION

)escription of Incident: R M B KflHHR FELL IN BEDROOM WHEN HIS FOOT BECAME TANGLED IN FURNITURE. AS HE FELL HIS LEG TWISTED CAUSING SPIRAL FRACTURE TO BOTH LEFT LEG BONES.

06-11-1996 is

703321

P.03^03

EVEtfT REPORT By Unit And Event POft:

CONTROL NUMBER RESIDENT-NAME REC NO TIME-OF-EVCNT TYPE-EVENT INJURY-CAUSE NARRATIVE
COMMENTS-ACTION

9407069

EVENT-DATE 07/07/94 THR

DATE-CLOSED 07/81/56

000049

UNIT 3D

0720

LOCATION 30

ABUSE ALLECATN

TYPE*INJURY

INJURY-LOCATN

ROCHE LABORATORY PMLEBOTOMIST REPORTS THAT 6TAPP ON UNIT 3D

UA8 A5ITATED AND UPSET. SHE PUSHES B « H B HVBBBHI' 5 UHEELCHAI

ACCR0S8 T8 AND rNTO A CHAIR IN AN ABRUPT WANNER.

FORMAL ABUSE INVESTIGATION CONDUCTED 8Y RISK MANAGER AND ADULT PROTECTIVE SERVICES. CHARGE UA8 FOUNDED AND EMPLOYEE WAS DISMISSED: TERMINATION UAS EVENTUALLY UPHELD BY CIRCUIT COURT

nr

 </s> APPENDIX B TABLE OF REPORTABLE PATIENT/RESIDENT INCIDENTS

INCIDENTS

All Deaths:

a)

b)

c)

within 7 days of discharge <

u known

Los of a limb or use of a limb, whether the loss is permanent or temporary:

CATEGORY I EXAMPLES
Violent Accidental

a) Ail amputations b) All c) Joifli disJoouioos d) Paralysis, paraplegia, quadripkgia

All

fingers and toes

Requires

Fen

or drahling; ezteosTe

Spinal cord or serious back injury
Serre injury or neurokMricai deficit including l a s or imnairment to any JUJBU* i onran

OT
or ttfinhlf"T ioss/impaiiTnent

3rain damacc or

bead injury

Temporary or permanent disability or disfigurement (tndudes first, second, and third degree burns and other injuries)

or

'"f; kss/nnpai

or third '^ g n ' bums; life thnsuening

Internal injuries (c-g.t torn ligament ruptured internal organs, internal

All sutures

requiring

Sexusi riolahoa of a minor or a noo-ooi or t " " " ] ' " ' ' " aouit

Ruptured internal organs; life threatening surgical

surgical

life threatening;

f o r c e d ^M ti^ww%tm* w i t h injuries requirinc

Loss or imnai

of a reproductiTe organ

Emergency surgical repair;

U.S. v. Virginia

1R-VA-002-009

APPENDIX B

TABLE OF REPORTABLE PATIENT/RESIDENT INCIDENTS

Self-injury:

INCIDENTS

a) Category I and Category II levd injuries
b) Suicide « H T * T mHwWwg those
7 dayi after discharge or if known

Medication errors and drug dudes, but is not limited to,

which Tbisin-
of drug

overdose (prescripooo and

CATEGORY I EXAMPLES

life

suicide

pump

Ail transfers for boos for acute

medicBl care and all

J Oil Ml J J

•wlent injury

Other adrerse pariwif/readent tactdeno. to be
by the ditumsances and degree of liahOitr

uioa resulting from

Guideline for Determining

of an

(Refer w Section 18.7 A and B.)

The fadiity direcxor or risk manager must determine whether reportable incidents should be dassxfied as Category I or Category Q events to determine reporting procedures. It also must be determined whether an inddent meets or might meet the four dements of a professional or medical malpractice cause of action.

CgfffC"T //

are major crises or events induding, but not limited to, those which are life threatening

or potentially life threatening; require emergency or surgery; require extensive recuperation: are permanently

disabling or disfiguring; or, where there is, or is likely to be, significant adverse press. Decisions about the

degree of seriousness of an injury or medical inddent should be made with physidan and risk manager input.

Category I incidents must be reported promptly to the Associate Commissioner, Community/Fadlity Services

by tdephone/pager and. also entered into the CIDB.

Cqtegyry // Incident^ are the other reportable. serious inddents listed above. These are generally serious (but non-iife threatening or permanently disabling; patient or resident injuries and situations that require medical and/or dinical intervention. Category U inddents are also reportable and must be entered into the CIDB.

 </s> Departmental Instruction No. 3 3
Reporting of Abuse of Clients
33 - 1 Purpose
To establish policies, procedures and responsibilities for reporting and responding to allegations of abuse of clients in state mental health and mental retardation facilities.

33 - 2 Definitions The following definition applies to this in

• physical acts such as, but not limited to:

choking hair pulling hitting kicking pinching pushing scratching slapping spitting

striking

• sexual activity or any type of inappropriate touching such as, but not limited to touching, stroking or fondling of breasts, genitals or buttocks, directly or through clothing, of a client.

• coercion, threats or intimidation that are statements or actions that would evoke fear in a reasonable pei son or that could reasonably be expected to evoke fear in the client.

• negiect in care that is the failure to provide:

a care a goods a services a treatment

necessary to the health, safety or welfare of a client.

• statements or actions that would humiliate, demean or exploit a client.

• condoning or permitting the abuse of a client, including client to client conflict, that may result in physical, emodonai, or psychological harm.

U.S. v. Virginia

MR-VA-002-010

Departmental Instruction No. 33 October 20, 1994
3 3 - 3 Procedures - Facility Director
Any employee, volunteer, contract employee, consultant, visitor or relative who has knowledge or reason to believe that a client may have been subjected to abuse or other inappropriate behavior shall report such information IMMEDIATELYto the Facility Director. While it is recognized that this is not the normal flaw of information and most staff members do not routinely report direaiy to the Facility Director, an allegation of possible patient abuse is so serious that any information regarding it should be given direaiy to the Facility Director so that immediate action can be taken to safeguard clients. The report of the alleged abuse shall describe the incident as fully as possible, giving the names of the persons involved, the time, date and location of the incident, and the. names of any witnesses.
Upon Racapt of The Director shall: in Ailcfmoaa
• immediately take steps to protect the safety and welfare of the cliem/s.
• immediately initiate action to protect any physical evidence.
• immediately notify the Advocate of the allegation and provide all the information obtained from the report.
• conduct a preliminary assessment in accordance wim Departmental Instruction No. 114, Generic Investigation Guidelines.
• assure that the client's authorized representative is notified about any alleged abuse and informed that an investigation has been initiated. If the client does not have an authorized representative, obtain the client's permission to notify the family.
• confer with the Advocate widiin 24 hours of the report of the allegation.
• determine whether there is a reason to suspect that abuse has occurred.

Upon a

The Director shall •

Tte* • " ' • • • « immediately initiate an administrative investigation of the incident, to S u n a s AOSBB

Departmental Instruction No. 33 October 20, 1994
• immediately notify the local Department of Social Services in accordance with 8 63.1-55.3 and 5 63.1-248.3 of the Code of Virginia and the Interdepartmental Agreement between the Department of Social Services and the Department.
• in all cases of suspected criminal activity such as sexual abuse, immediately contact local law enforcement authorities and/or State Police.

If an Employee Hit Been Identified as the
Abuser

The Director shall • charge the employee with alleged abuse. • immediately suspend the employee pending final disposition of the case.

• inform the employee of the charges and require him or her to with the administrative investigators.

Suspensions shall be in and Pgrfon nance.

with the Employ**;

fff Conduct

If the Director
AbUMflM Occurred

The Director shall •
• meet and inform the employee of the finding and issue a Group m written notice under the Employee fitafidarris of Conduct and Pgrfoiiiianfy policy.
Such notice normally results in termination, however the Director has the discretion to mitigate the disciplinary action to an appropriate sanction other than termination.
• take any action necessary to prevent future occurrences.

ITother Inespropnste Acs Are DocDYcred in the C o m e o/ Inn

The Director shall take appropriate administrative action under the Emptnvee Standards of Conduct and Performance.

Departmental Instruction No. 33 October 20, 1994
At Cooduaoa of The Director shall
* • notify the client's authorized represemative and the Advocate of the results of the investigation, the determination and the action taken.
• report ail allegations made under this instruction, the results of any subsequent investigation, the determination, and the resulting action to the Associate Commissioner and the State Human Rights Director.
Facilities who treat minors musx notify the Ucensun Office.
3 3 - 4 Procedures • Advocate
The Advocate shall -
• meet with the client and explain the role of the Advocate and the abuse investigation process.
• represent the client during the investigation.
• monitor the investigative procedures.
• review the written investigative report.
• conduct an independent investigation and submit a report of findings to the Director for review and consideration in making the determination of the disposition of the case, if deemed necessary.
• discuss the decision of the Director widi the client and advise the client of the right to pursue the matter through the Human Rights Review Process, if the client ii with the Director's
• consult with the Director about the implementation of recommendations developed as a result of the investigation.

Departmental Instruction No. 33 October 20, 1994 33 • 5 References a Code of Virginia, §§ 63.1-55.3 and 63.1-248.3. a 'Code of Virginia, § 37.1 - 84.1. a Empiovce Standards of Conduct and a Departmental Instruction No. 114, 'Generic Investigation Guidelines.'
33 - 6 Distribution
A copy of this Departmental Instruction shall be given to each employee to be reviewed during the initial orientation. Employees' written acknowledgement of their understanding of this Instruction shall be placed in their personnel file. A copy of this Instruction shall also be given to each volunteer, contractor, contract employee or consultant who will have direct contact with clients.
rimothy AMWity, Ph.D. Commissioner
This revised Instruction replaces Departmental Instruction No. 33, "Reporting of Abuse of Patients or Residents,' issued November 15, 1991. EFFECTIVE DATE: October 20, 1994

 </s> :rcr223

Virginia Department cf Mental Heaith. Men-cal Retardation and Substance Abuse Services
Office of Management Information Services Incident - Detail Report
NVTC
From: 01/01/92 To: 01/15/92 Incident Number: 25000009

Date: 05/30/1996 Time: 14:05

Incident Date: 01/14/1992 Time: Reporting Person: LEE HILTON Patients Involved:
R
Staff Involved: NONE

11:15
Age 33
0

Building/Ward

3

' c

Persons contacted:

Date 01/14/1992

Time 16:00

FAMILY

TYPE: FRACTURE/DISLOCATION

LOCATION: BEDROOM

Description of Incident:

RWKt K«HBBi FELL IN BEDROOM

WHEN HIS FOOT BECAME TANGLED IN FURNITURE. AS HE FELL HIS

LEG TWISTED CAUSING SPIRAL FRACTURE TO BOTH LEFT LEG BONES.

U.S. v.Virginia

MR-VA-002-011

06-11-1996 15

70332

P.03/03

EVEtfT REPORT By Unit And Ev»nt TOR:

CONTROL NUMBER RESIDENT-NAME
REG NO
TIME-OF-EVCNT TYPE-EVENT
INJURY-CAUSE NARRATIVE

94070M

EVENT-OATE 07/07/54 THR DATE-CLOSED 07/81/96

000049 0T20 ABUSE ALLESATN

UNIT 3D LOCATION 30 TYPE-INJURY

INJURY-LOCATN

ROCHE LABORATORY PHLE50T0MIST REPORTS THAT STAFF ON UNIT 3D

WAS AGITATED ANO UF5ET. SHE PUSHED B 1 H B HWBIBHB'S WHEELCHAIR

ACCR0S8 TS AND INTO A CHAIR IN AN ABRUPT MANNER.

COMMENTS-ACTION FORMAL ABU8E INVESTIGATION CONDUCTED 8Y RISK MANAGER ANO ADULT PROTECTIVE 6ERVICE8. CHARGE UAS FOUNDED AND EMPLOYEE WAS 0I8HIS8ED: TERMINATION UAS EVENTUALLY UPHELD BY CIRCUIT COURT.

1—

 </s> CM/ECF - vaed - Docket Report

https://ecf.vaed.uscourts.gov/cgi-bin/DktRpt.pl?338496072778268-L_9...

U.S. District Court Eastern District of Virginia (Alexandria) CIVIL DOCKET FOR CASE #: 1:96-cv-00283-LMB

CLOSED

United States of v. Commonwealth of VA, et al Assigned to: District Judge Leonie M. Brinkema Demand: $0 Cause: 42:1983 Civil Rights Act

Date Filed: 03/04/1996 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

Plaintiff United States of

represented by Deval L. Patrick United States Department of Justice Housing & Civil Enforcement Section PO Box 65998 Washington, DC 20035-5998 **NA* (202) 514-4738 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Helen F. Fahey United States Attorney's Office 2100 Jamieson Ave Alexandria, VA 22314 (703)299-3700 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Richard Parker United States Attorney's Office 2100 Jamieson Ave Alexandria, VA 22314 (703)299-3700 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Defendant Commonwealth of Virginia

represented by Jane D. Hickey Office of the Attorney General 900 E Main St Richmond, VA 23219 (804) 786-2071 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Defendant

1 of 4

3/24/2006 11:18 AM

CM/ECF - vaed - Docket Report

https://ecf.vaed.uscourts.gov/cgi-bin/DktRpt.pl?338496072778268-L_9...

George Allen
Defendant Robert Metcalf
Defendant Timothy Kelly
Defendant Janet Hill Director, Office of Mental Retardation, DMHMRSAS
Defendant David H. Lawson Director, Northern Virginia Training Center

represented by Jane D. Hickey (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Jane D. Hickey (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Jane D. Hickey (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Jane D. Hickey (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Jane D. Hickey (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Date Filed 03/04/1996 03/04/1996 03/05/1996 03/25/1996
04/15/1996

#

Docket Text

1 COMPLAINT (clerk) (Entered: 03/05/1996)
NOTICE of Lawsuit and Waiver of Service forms given to attorney for service by mail as to defts (clerk) (Entered: 03/14/1996)
2 NOTICE of Attorney Appearance for United States of by Richard Parker (clerk) (Entered: 03/05/1996)
3 ORDER that the Summons and Complaint shall be deemed to have been served on all defts on 3/6/96 and defts shall serve a responsive pleading by 4/15/96-ent.& filed ( signed by Judge James C. Cacheris ) Copies Mailed: y (clerk) (Entered: 03/27/1996)
4 MOTION with Memorandum in Support thereof by Commonwealth of VA, George Allen, Robert Metcalf, Timothy Kelly, Janet Hill, David H. Lawson for More Definite Statement (Will Notice) (clerk) Modified on 04/19/1996 (Entered: 04/19/1996)

2 of 4

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CM/ECF - vaed - Docket Report

https://ecf.vaed.uscourts.gov/cgi-bin/DktRpt.pl?338496072778268-L_9...

04/15/1996 04/15/1996 04/29/1996 04/29/1996 04/29/1996 05/01/1996 05/09/1996 05/09/1996 05/10/1996
05/10/1996 05/21/1996
07/18/1996 07/18/1996

5 MOTION by defendants to Dismiss pursuant to Rule 12(b)(1) (Will Notice) (clerk) (Entered: 04/19/1996)
6 MEMORANDUM of Law by Commonwealth of VA, George Allen, Robert Metcalf, Timothy Kelly, Janet Hill, David H. Lawson in support of [5-1] motion to Dismiss pursuant to Rule 12(b)(1) (clerk) (Entered: 04/19/1996)
7 MEMORANDUM of Law by United States of in opposition to [5-1] motion by defendants to Dismiss pursuant to Rule 12(b)(1) (clerk) (Entered: 04/30/1996)
8 MEMORANDUM of Law by United States of in opposition to [4-1] motion for More Definite Statement (clerk) (Entered: 04/30/1996)
9 NOTICE of Hearing: Motion Hearing set for 10:00 5/10/96 for [5-1] motion by defendants to Dismiss pursuant to Rule 12(b)(1), set for 10:00 5/10/96 for [4-1] motion for More Definite Statement (clerk) (Entered: 04/30/1996)
10 SCHEDULING ORDER setting Discovery cutoff 8/30/96 ; Pretrial Conference for 10:15 9/19/96 ; ( signed by Judge Albert V. Bryan Jr. ) Copies Mailed: yes (clerk) (Entered: 05/01/1996)
11 REPLY by Commonwealth of VA, George Allen, Robert Metcalf, Timothy Kelly, Janet Hill, David H. Lawson to response to [4-1] motion for More Definite Statement by defendantsssss (clerk) (Entered: 05/09/1996)
12 REPLY by Commonwealth of VA, George Allen, Robert Metcalf, Timothy Kelly, Janet Hill, David H. Lawson to response to [5-1] motion by defendants to Dismiss pursuant to Rule 12(b)(1) by defendantsssss (clerk) (Entered: 05/09/1996)
Minute entry: Judge Brinkema. Reporter: McCoy; matter on for hrg. on defts.' motions; appearances: of counsel; defts.' motion to dismiss - not ruled on; defts.' motion to transfer case - argued(perfunctorily granted), final ruling held in abeyance, U.S .has ten days to get a proper cert. w/appropriate language; counsel to meet w/LMB in chambers on 5-15-96 @ 9:00 for settlement conf. (clerk) (Entered: 05/14/1996)
13 ORDER granting motion for pro hac vice admission of Thomas B. York - entered and filed in open court ( signed by Judge Leonie M. Brinkema ) Copies Mailed: yes (clerk) (Entered: 05/14/1996)
14 ORDER For the reasons stated in open court, pltf's motion to consolidate cases 96-283- and 96-284 is denied. Deft's motion to dismiss pursuant to Rule 12 (b)(1) is granted and it is hereby ordered that pltf file an amended certification within 10 days of the issuance of this order. This ruling is stayed to allow for settlement efforts. Defts motion for a more definite statement is denied. Because of intense settlement efforts, all discovery is stayed until further order of the court. Entered and Filed [5-1] ( signed by Judge Leonie M. Brinkema ) Copies Mailed: yes (clerk) (Entered: 05/28/1996)
15 Settlement Agreement-filed (clerk) Modified on 07/19/1996 (Entered: 07/18/1996)
16 ORDER in light of the Settlement Agreement entered by the parties, this civil action is dismissed without prejudice pursuant to Rule 41(a)(2)-ent.& filed (

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CM/ECF - vaed - Docket Report

https://ecf.vaed.uscourts.gov/cgi-bin/DktRpt.pl?338496072778268-L_9...

07/18/1996 07/18/1996 05/30/1997 06/03/1997 06/10/1997 08/29/1997 06/02/1998
06/03/1998

signed by Judge Leonie M. Brinkema ) Copies Mailed: y (clerk) (Entered: 07/18/1996)
CASE assigned to Judge Leonie M. Brinkema (clerk) (Entered: 07/19/1996)
Case closed (clerk) (Entered: 07/19/1996)
17 Modification of Settlement Agreement by United States of, Commonwealth of VA (clerk) Modified on 06/09/1997 (Entered: 06/02/1997)
So Ordered: granting [17-1] set ( signed by Judge Leonie M. Brinkema ) Copies Mailed: yes (clerk) (Entered: 06/05/1997)
18 Second Modification of Settlement Agreement filed by plaintiff United States of, defendant Commonwealth of VA (clerk) (Entered: 06/12/1997)
19 NOTICE for Certification Tour by Commonwealth of VA (ltun) (Entered: 09/04/1997)
20 MOTION by Commonwealth of VA, United States of to Dismiss , and by Commonwealth of VA, United States of Ame Stipulation of Dismissal (clerk) (Entered: 06/03/1998)
So Ordered: granting [20-1] motion by Commonwealth of VA, United States of to Dismiss, granting [20-2] motion by Commonwealth of VA, United States of Ame Stipulation of Dismissal.-ent. & filed. ( signed by Judge Leonie M. Brinkema ) Copies Mailed: yes (clerk) (Entered: 06/04/1998)

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[CONTENT] May 4, 1990 | the United States Department of Justice Civil Rights Division | Virginia | the Civil Rights of Institutionalized Persons Act | 42 | 1997 | the Northern Virginia Training Center | Fairfax | Virginia ||| Five | the Department of Justice | NVTC ||| April 9, 1991 | the Department of Justice ||| The Department of Justice | NVTC ||| NVTC |||  |||  ||| NVTC ||| NVTC |||  ||| the Department of Justice ||| May 31, 1994 | the Department of Justice | NVTC ||| the Department of Justice | NVTC ||| pica ||| One | seven | one | the span of two days |||  ||| Virginia | the Department of Justice ||| February 8, 1995 | the Department of Justice | Virginia | NVTC | the Americans With Disabilities Act | 42 | U.S.C. | § | § | 12101 | Section 504 | the Rehabilitation Act | 1973 | 29 | U.S.C. | § | § | 794 | the Social Security Act | Medicaid | 42 | U.S.C. | § | 1396 | Virginia ||| March 4, 1996 | the Department of Justice | the United States | the Eastern District | Virginia | NVTC ||| 1 | 2 | 3 | 4 | 5 | 6 | 7 ||| May 21, 1996 | Leonie M. Brinkema | United States | Virginia | 96 | MH-VA-0002 | Virginia ||| May 21, 1996 ||| July 18, 1996 |||  ||| NVTC |||  |||  |||  |||  |||  |||  ||| May 30, 1997 ||| August 29, 1997 | the Department of Justice | NVTC ||| June 3, 1998 [SUMMARY] On May 4, 1990, the United States Department of Justice Civil Rights Division announced, in a letter to the Governor of Virginia, its intent to launch an investigation, pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997 et seq., into conditions at the Northern Virginia Training Center (NVTC), an institution for individuals with developmental disabilities in Fairfax, Virginia.  Five experts from the Department of Justice toured the facility, reviewed policies and procedures, interviewed NVTC staff, and audited reporting and investigation practices.  

On April 9, 1991, the Department of Justice announced its findings.  The Department of Justice reported that the health and safety of people living at NVTC was at risk for a number of reasons.  NVTC employed too few people and inadequately trained those it did employ, which placed residents in danger of unnecessary chemical and physical restraint.  Often mechanical restraints were accompanied by seclusion, which was a fire hazard.  Individualized programming for residents was inadequate and recordkeeping deficiencies made it impossible to monitor an individual's progress.  In addition, NVTC's medical care, physical therapy, occupational therapy, and medication and side effect monitoring we all inadequate.  In addition, NVTC provided insufficient medical care, including medication monitoring and occupational therapy.  Recordkeeping made it difficult to track the efficacy of individualized programming and medical care.  In closing, the Department of Justice expressed the desire to negotiate a resolution.

Negotiations did not make enough progress and, on May 31, 1994, the Department of Justice threatened to file a CRIPA lawsuit to challenge the constitutionality of conditions at NVTC.  In addition to its earlier concerns, the Department of Justice chronicled systematic abuse and neglect at NVTC.  For instance, individualized training programs were so inadequate that individuals became seriously sick or died as the result of aggressive, pica, and other self-injurious behaviors.  One resident asphyxiated on a rubber glove, while another ate a reported seven cigarettes and one feminine hygiene pad in the span of two days.  Similarly, inappropriate feeding techniques and poor nutrition endangered residents' health. 

Virginia may have made an effort engage in productive negotiations, but the Department of Justice was not satisfied.  On February 8, 1995, the Department of Justice notified the Governor of Virginia that, in addition to being unconstitutional, the conditions at NVTC violated the Americans With Disabilities Act, 42 U.S.C. §§ 12101 et seq., Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. §§ 794, the Social Security Act ("Medicaid"), 42 U.S.C. §§ 1396 et seq., and Virginia law.

On March 4, 1996, the Department of Justice filed a CRIPA lawsuit in the United States District Court for the Eastern District of Virginia, challenging conditions at NVTC.  The plaintiffs sought injunctive relief to address (1) individualized programming, (2) undue physical restraint and isolation, (3) facility safety, (4) medical care, (5) physical and occupational therapy, (6) medication monitoring, especially for tardive dyskenesia, and (7) staff numbers and training.  

On May 21, 1996, the court (Judge Leonie M. Brinkema) refused to consolidate this lawsuit with United States v. Virginia, No. 96-284, MH-VA-0002, an action challenging the constitutionality of conditions at a Virginia psychiatric hospital.  On May 21, 1996, the court also granted the defendants' motion to dismiss, but stayed its ruling to allow for settlement.  On July 18, 1996, the court approved a settlement agreement.

The settlement agreement itself was mostly concerned with procedural elements, such as development of a plan for improvement, compliance deadlines, evaluation, and dismissal.  The NVTC plan describes the required compliance.  The plan emphasizes the importance of trained staff in the provision of developmental disability services.  The plan stated detailed training requirements for direct care staff and incorporated training into almost every solution.  For instance, the plan mandated the dismissal of employees who neglected or abused residents.  Similarly, the plan sought to reduce the need for restraints by both improving staff development and requiring the interdisciplinary treatment teams' advance approval for the type of restraints to be used for each individual.  Thus, both chemical restraints and draconian physical restraint techniques, such as papoose boards, were eliminated.  Similar clauses addressed medical care, medication administration and tracking, physical and occupational therapy, abuse and injury reporting and investigations, recordkeeping, functional planning, community placement, and quality assurance.  

The parties modified the settlement on May 30, 1997.  On August 29, 1997, the Department of Justice inspected NVTC and found it was in compliance with the plan.  On June 3, 1998, the court dismissed the lawsuit.

