AuSSLC Onsite Review Presented to the Texas Department of Aging and

Disability Services

August 25, 2014

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The Austin State Supported Living Center: An Evaluation of Performance

August 25, 2014 (Final)

PREFACE

The Texas A&M Health Science Center College of Medicine Rural and Community Health

Institute (TAMHSC RCHI) was contracted to perform a review of policies, procedures, facilities

and functions for the Austin State Supported Living Center (AuSSLC or Center). The goal was

to affirm the implementation and utilization of policies and procedures as well as to evaluate the

skills and expertise of the staff and evaluate the medical care provided at the Center. Particular

attention was to be paid to processes in place for quality of care oversight and control. To that

end, our review was specifically directed toward Center processes of quality assurance, peer

review and the mortality and morbidity review. The goal of the TAMHSC RCHI review was to

provide insight into key issues along with provision of recommendations to enhance care in

response to issues as they were identified.

As the accompanying report demonstrates, the operations of the Center could be enhanced by

implementing a systematic approach focused on performance results that is trended and

benchmarked overtime. Doing so would enable the Center to move from a regulatory focus to

continuous improvement. Frequent changes in leadership and the challenges of selecting and

adopting systems across the breadth of the States IDD programs have all created barriers to the adoption of programs and processes key to the systematic approach referenced above. The lack

of an electronic record has exacerbated problems. The population being care for has become

progressively more complex and fragile requiring modification of medical expectations.

Prior to the site visit, the team reviewed voluminous materials from meeting minutes to incident

reports to policies and procedures. A total of ten team conferences were conducted with group

size varying from three to fifteen attendees. Conferences were spread over a period of four days

on campus and were interspersed with observation visits to individuals homes and therapy services. Attendees at each of the interview conferences were selected by the local AuSSLC

team. A post onsite review was attended by a selected group of the review team with key

leadership staff at the Department of Aging and Disability Services (DADS).

Culture and Environment

Substantial time was spent reviewing documents prior to arrival at the Center for the onsite

evaluation. In the course of record review most of the review team was overwhelmed with what

appeared to be an incident focused environment. Concerns were raised by the team about the

ability to effectively care for clients while completing not only endless paperwork but frequently

changing requirements for documentation. Challenges of adequate time for client care were

exacerbated by the periodic, relatively frequent removal of care givers from interaction with

clients while time consuming investigations of alleged abuse, neglect and exploitation (ANE)

were performed.

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Fortunately, upon arrival on-site, the team met a largely caring, energetic staff who generally

appeared up-beat about their jobs. They shared their concerns but also their commitment to the

residents and the mission of the SSLC.

The Austin State Supported Living Center is one of thirteen such facilities in the State of Texas.

It serves a vulnerable population of individuals with intellectual developmental delays. The

Center has a long history of ups and downs, peaks and valleys, with varying levels of

performance based on both internal and external factors. Historic information confirms that the

Center can function at a high level. Yet, periodically, the performance level has dropped to less

than optimal levels often leading to external oversight, regulation and threats of closure.

Most of the residents have lived in AuSSLC or another SSLC for twenty plus years. Some have

had experience with community facilities while others have never experienced any site other

than the AuSSLC. The clients have aged in place and become predictably more medically

fragile. It is perhaps notable that a significant percentage of these residents have tremendously

outlived their predicted longevity based upon their multiple diagnoses. There is a medical staff

on site along with an infirmary that is able to provide a reasonable level of on-site care.

However, there is also a substantial utilization of the nearby medical facilities for emergency

care, consultation, and inpatient hospitalization.

Findings:

Many of the individuals we talked to described the residents and the core staff as a family. In

fact, when we identified individuals who might be able to be served in other settings, there was a

family push back that suggested that these individuals are family and they should be allowed to stay because this is where their family is; this is the only home they know. Interviews,

particularly with professional staff, recounted many instances of trying to achieve community

placement for an individual only to be rejected because the community location did not have the

equipment to support either general care or particular medical needs such as lifts for bathing,

adaptive devices, availability of medical specialty care, etc. It is the general belief, of those

interviewed, that community placement does not currently offer the needed level of care for out-

placement of the residents.

As a SSLC, the ICF MR regulations apparently require that clients are continually evaluated, individual growth or learning plans devised, and the client continually engaged

in acquiring skills toward normalization. Normalization was a repeatedly articulated objective which in this population would likely need a specific, operational definition. A

good deal of the staff and time were committed to establishing, communicating, and

revising the Individual Support Plans (ISP). Lacking a measurable definition for

normalization or measurable mid- to long-term objectives, reviewers found it particularly challenging to understand many of the residents individual educational/training plans. While virtually every resident had an Individual Support Plan

(ISP) which was expected to move the resident toward normalization, the staff did not seem able to articulate the end-target other than normalization. ISPs might be more easily evaluated if the goals are more crisply articulated such as moving toward

community placement or moving to a higher level of self-care or even improving level of

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alertness for longer time spans each day. These same ISP requirements were embraced

(or mandated) for individuals who are in their 80s and would be fully retired in any other

setting. When considering IDD combined aging and dementia, there did not appear to be

significant modification of the Active Treatment or ISPs.

One aspect of the education and recurrent evaluation is ostensibly to continually seek the least restrictive environment appropriate for each resident. If residents are to be placed in

the community, it is strongly suggested an assessment as to the readiness of the community to accept these individuals be conducted to determine if the community can

meet the complex needs of the medically fragile individuals. These individuals

communicate differently than most individuals; their physical disabilities require non-

traditional approaches to the manner in which these individuals are bathed, placed in bed,

adjustments to wheelchairs and other assistive devices, the manner in which food texture

impacts eating, etc. Even such simple issues as providing primary care are a challenge as

many practices will not accept their disruptive behavior in their waiting rooms, will not

provide the extended time needed for simple care, and are not comfortable providing the

level of complex care required. It was very clear in the family interview that there is a

strong opinion that the community is not ready to have many of the residents transitioned

from AuSSLC to other community living centers. In the event residents are transitioned

from AuSSLC to the community, a multipronged communication plan is suggested to

assure the families their loved ones will be cared for appropriately and at a level they are

currently accustomed too.

Transitions to the community should include oversight of community living arrangements to ensure residents are being appropriately cared for and their needs are being met.

Some individuals will require a high level ICF such as a SSLC as their least restrictive

environment. Individuals who could be transitioned will continue to need availability of

many services including habilitation, activities such as the workshops, and access to

healthcare providers who understand this population particularly dental and routine

medical care.

Whether looking at the resident learning plans or the facilitys approach to staff training, it appeared to be reactive and episode oriented an incident or a site visit recommendation would lead to retraining of an individual staff member. Based on the information in our review it felt

like the solution to most identified problems was holding a meeting, writing a report or establishing another committee rather than actually creating a solution to the identified problem.

Development of a systems based approach to tracking trends, identifying underlying process or policy issues, and more aggressive root cause analyses might well lead to a different approach to

staff education, resident oversight, etc.

One of the challenges of the AuSSLC is that many of the residents have aged in place some of them have been there for 40 or more years. In fact, many have significantly outlived their

predicted lifespan given the health risks attendant on many of the causes of IDD and their

longevity may well be due to the level of care that they receive both medical care and the family effect. Some of the families as well as some of the staff appear to be less than realistic about the health issues as well as the prognoses these individuals face. Their expressed

perceptions - and a handful of anecdotes -suggested that moving individuals particularly medically high risk individuals to the community would likely negatively impact their lifespan.

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That said, there are challenges in caring for this fragile group at the SSLC. We were told that

there is no formalized ethics policy at AuSSLC. There does appear to be a process for the

rights committee, physicians as well as other staff, and guardians to discuss plans for particular

residents. Physicians must agree that a particular patient meets criteria for an out-of-hospital

DNR. And it was noted that annually the guardians and the care team discuss living options and

this would seem to be a time to discuss, when appropriate, end of life care. It was not clear how

the various voices were balanced in the discussion.

One driver of the current culture is certainly the impact of the rights groups. While the attention

of the rights groups have at times uncovered serious problems and have led to some very real and

very positive changes, being under the daily microscope of such groups has complicated the

manner in which staff react to certain situations. For example, a patient with constipation would

normally be treated without transferring to the local emergency room for imaging and other

diagnostics; however, staff operates in a manner to avoid any rights violation accusation.

Seemingly innocent bruises get transferred for imaging and what are described as very minor

injuries following an incident appear to virtually always result in emergency department

evaluation. While achieving balance between disparate perspectives is beyond the purview of

either the Center leadership or this review team, State level leadership is encouraged to remain

cognizant of the need for continually seeking such balance.

Staff is extremely committed to ensuring the rights of the residents. This commitment, while

done in earnest, appears to be complicating care and impacting what in many situations is best

for residents. We were instructed, repeatedly, that residents have the the right to the dignity of risk While the right to the dignity of risk may be correct in theory, it felt to reviewers that this interpretation may have evolved over time to an environment that actually introduces risks to the

residents. In attempting to preserve this right, staff is repeatedly placed in a position where they have to balance resident rights versus health and safety aka situations free from abuse and

neglect. For example a staff member was eating a burger at the canteen when a resident grabbed

the burger from his hands. The staff person said if he had taken hold of the individuals arm, as you would do with a child, and say it was inappropriate and confiscate the burger, he would have

been restraining the patient. Yet, while he did not know the diet texture for this person, he was

aware that he could have a potential neglect accusation if the diet texture was inconsistent with that of the resident. Staff is repeatedly placed in a position where they have to balance resident

rights versus health and safety aka situations free from abuse and neglect. It appeared from

review of incidents and observation that the balance is strongly in the direction of rights with subsequent need to respond to the situations created by rights driven decisions; the incidents created then often lead to allegations of ANE and the investigation into the ANE complaint

remove staff from the work environment and place highly needed direct care givers or

professionals in roles such as working in the kitchen until the complaint can be resolved.

When investigations for allegations occur, resolution could be expedited by reviewing video

tapes or using a streamlined approach as has been approved for individual residents with

frequent, unsubstantiated complaints. In areas where staffing is fragile the requirement for

removing staff from patient contact takes resources away from the resident.

In summary, the culture was perceived to be very caring and protective of the residents but often

driven by reaction to episodes or situations. Reactive change seemed prevalent.

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Opportunities:

The mission should be iterated regularly and the planning processes should identify specific measurable goals and timelines.

The goal of normalization should be operationalized so that it can be applied to the ISPs, Center goals, and family expectations.

Consider engagement of the rights groups, or at least transparency with those groups, to assist in defining goals and expectations, particularly in light of the challenges of an

aging population with complex health issues.

To reduce the reactive culture consider creating a systems approach to management that considers groups of issues, planned interventions, and measurement of trends and

progress toward identified goals.

Utilize quality improvement techniques to drill down on root causes of incidents and/or issues.

Leadership:

The responsibility of leadership is to set the direction of an organization and seek future

opportunities to ensure sustainability. In addition to setting the direction of the organization,

leadership usually engages in the development of a strategic direction which includes mission,

vision and values as well as promoting an environment that demonstrates commitment to ethical

behavior.

Keys to successful organizational performance include communication with the workforce, the

clients and families served as well as the community at large. Communication includes

interaction and evaluation by the governing body, accountability, transparency and consideration

of influences on organizational performance which include regulatory requirements.

In addition to evaluating staff, it is imperative leadership consult with and is evaluated by the

governing body. Successful evaluation(s) include measures or indicators specifying expectations

and acceptable results.

Findings:

Leadership at the AuSSLC has been very fluid for the past eight years. AuSSLC has had seven

leaders (directors) in the last eight years. The lack of consistent leadership has compounded the

challenge of effectively complying with the settlement agreement. However, current leadership

has been in place only a short time and many complimentary comments and hopeful expectations

were voiced. Central Office has helped bridge gaps by providing a number of Central Office

staff who fills a variety of roles at AuSSLC. Nonetheless, there seemed to be a sense of paucity

of communication with Central Office.

Without stabilization of leadership, forward progress toward resolving regulatory issues (Centers

for Medicare & Medicaid Services-CMS) and the Department of Justice (DOJ) suit will be

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difficult if not next to impossible. Each leader, while well intended, comes in with new ideas on

how to fix things. A plan is started and then the leader leaves. While some departures of leadership have been welcomed by staff, it is still very disruptive to the process of care

enhancement and resolution of outstanding citations by regulatory or DOJ.

One of the key tools to guiding the direction of an organization is the strategic plan. While the

Central Office has recently completed a statewide strategic plan, both multiple leadership

changes and the time required to develop the States plan have led to a perception that there is not an overarching document/plan to use as a map for local leadership. Coupled with the

substantial time and energy commitment required to regularly respond to the regulatory and DOJ

oversight, the team perceived a sense of marching in place rather than planned forward progress

toward defined goals.

Throughout the visit, the team heard about the ICF-IID (DADS Regulatory) oversight and the DOJ oversight and particularly the site visit teams monitoring the responsiveness of the state supported living center to the issues that had been identified. The Central Office assured the team that there were no conflicts between the ICF-IID and DOJ requirements. While there are some differences between the two sets of requirements, the requirements are not in conflict with one another. What the team heard while onsite was staff frustrations in that there were different expectations from one site visit team to the next in terms of how to address issues of concern. Therefore, it was difficult to know how to make changes in policy, performance or reporting in order to satisfy those expectations. Staff articulated numerous different interpretations or expectations between the regulatory team(s) and the DOJ team(s). Those interviewed onsite also discussed different interpretations of requirements, often from the same agency, on repeat visits.

Staff did indicate that recently the Central Office appears to be attempting to address these

discrepancies through challenges of site visit findings, but in the meantime staff has believed

they had no choice but to try and address/respond to the issue(s) of the day which is dependent

upon who is onsite. This creates a chaotic environment and makes it difficult to train and educate

staff. Compounding this situation, many times teams sent to review or monitor from DOJ do not

have a full range of professional expertise for the breadth of programs and staffing they are

reviewing. For example there is no pharmacist on the DOJ team nor is there knowledge of

pharmacy requirements yet recommendations and/or citations are made.

At the time of the survey the current director had been in place for four months. Like those

before her, she is setting her agenda and doing her best to address issues. It does appear she has

made a difference in her four months. She appears to have the respect of the staff, in part due to

her requirement for accountability. This leader has implemented a process in which staff doing

positive things is acknowledged through a catch me in the act program. Additionally, she has reinstituted town hall meetings to enhance communication and is visible in the cottages doing

walking rounds. Suggestion boxes have appeared (or more accurately, reappeared) and a staff

committee (Employee Advisory Council) has been appointed to evaluate recommendations and

to interface between staff and leadership.

When establishing the itinerary for the visit, we asked for a meeting with the facility leadership.

While a local (AuSSLC) group of staff are informally designated as the Center leaders (i.e. the

group selected by AuSSLC for the Leadership interview), there appeared to be a paucity of

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active leadership demonstrated. The reasons for this may be that they have elected not to

function as a leadership team or do not feel empowered to do so. Certainly one of the impacts

of the frequent changes in director is for the mid-level leadership to be cautious about the

expectations of newly arrived leadership. However, repeated statements by members of the

leadership group suggested that they perceived a need for a culture change; they perceived an

environment unwelcoming of feedback or suggestions. These concerns are noted with some

caution as the team heard repeated positive comments about the newly arrived director and the

climate changes being experienced.

Opportunities:

Defining a clear strategic direction that incorporates regulatory and DOJ requirements into operationally defined and discretely measurable goals has the potential of moving the

organization from the current perceived reactive mode which to a more proactive and

accountable mode of operation and leadership.

Stabilize leadership. If it is felt the current leader is the right leader, develop this individuals capacity and knowledge to lead and provide adequate time for implementation of change and evaluation of the impact of those changes. Because of the

proximity of the Central Office to the AuSSLC, there is the opportunity for relatively

easy regular communication and joint efforts toward mutually endorsed goals.

Facilitate communication and adoption of the recently completed State strategic plan including identification of vision and values for staff and residents

Leadership training both for current leaders and for staff who appear to be moving from mid-level to leadership roles. Leadership training should include principles of quality

and performance improvement. Leading by fact promotes an environment of learning as well as a fair and transparent organization

Leadership at the central office and AuSSLC are encouraged to challenge or seek clarification on citations when they are felt to be incorrect and/or inappropriate.

Without seeking clarification or challenging the site visit citations, monitoring has the

possibility of continuing into perpetuity. The majority of review organizations have a

defined process when citations are not felt to correctly reflect policy or practice.

It is suggested Central Office investigate the interpretation of what rights a resident has and how they are to be prioritized to ensure safety. The current process needs to be re-evaluated because of its negative effects on organizational efficiency and effectiveness

e.g. cottages that are already short staffed will have staff removed from resident care until

charges are resolved. It is felt providing more definition as to what is and is not

appropriate to address certain citations is needed. The team also perceived that there was

some aspect of double jeopardy in that a finding of no evidence of ANE by DFPS might lead to secondary investigation by the office of the ombudsman or the human

rights committee or occasionally sequentially by all three. Clear definition of the areas of

responsibility of each of these entities might remove the perception of multiple jeopardy

and reduce the time to return staff to resident care duties.

o Consideration might be given to having AuSSLC pay for a DFPS worker who could be officed on site in an attempt to reduce the time delays in incident

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investigations which would in turn return staff to direct resident care more

quickly.

o While it is felt there are some individuals who could potentially move to the community, the team was impressed with the complexity of providing such care

in the community and the need for caution when evaluating the capacity of the

community to provide the necessary level of care.

Quality Data Collection and Analysis Issues

A continuum of terms is used to identify processes to collect, analyze and learn from

organization work processes and services. Terms like Quality Assurance (QA) or Quality

Control (QC) are frequently used to describe data collection processes and interventions to

reduce defects in work or manufacturing processes. Quality Improvement (QI) describes

processes that encompass QA/QC and also include analysis of results, a learning cycle, followed

by analysis of results from the altered work process. Performance Improvement (PI) expands

from QI by integrating an organizations stated goals and priorities.

A culture of QI includes many attributes. Some of these are data driven planning; empowerment

of staff to identify problems and initiate solutions; benchmarking, comparison, and trending; and

ability to tolerate measured risk.

Systems of quality improvement require both commitment and leadership from the top of the

organization and engagement of staff at all levels. It is only with both that a culture of QI can

develop and flourish. While staff members are willing to engage in a quality improvement

process, much work remains for transition to and adoption of such a substantive paradigm shift.

However, the team was told that acquisition of a commercial quality program for the system of

SSLCs is under consideration. With or without acquisition of a particular program through the Central Office, it is most important that the AuSSLC initiate a QI/PI program, provide

appropriate education to the involved staff, and implement the program in a progressive but rapid

fashion.

Findings:

During consultation with the Central Office leaders following the site visit, the team discussed

and was provided a copy of the DADS quality improvement plan. However, during the site visit

with the AuSSLC Quality (QA/QI) interview, the staff was only able to articulate the awareness

of anticipated implementation. A result is that neither leaders nor staff identifies significant

goals except compliance with external regulators. Without articulation of measurable goals, it is

likely that the AuSSLC will remain in a reactive mode and not achieve the level of performance

desired. Leaders expressed a desire to have a QI plan.

The AuSSLC has robust data collection resources that are significantly responsive to the Systems

Improvement Agreement (SIA) and DADS Regulatory compliance. These are referred to as

audits. For example, the DOJ consists of 27 sections labeled alphabetically A-Z. Tools listing

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specific measures to demonstrate compliance with the DOJ are used. The total number of

measures was not known to staff. Approximately 18 FTEs are assigned to the QA/QI department. Similarly, when regulatory findings are identified, data collection assignments are

matched to the respective compliance issues and as regulatory or monitoring findings occur,

often another audit sheet is created to monitor compliance. Staff voiced a sense that data

collection measures frequently change and very few are internally identified with a specific goal

of improving quality of services and care.

In part, due to limited access to technology, the QA/QI staff, expressed challenges regarding

current processes to collect data for quality improvement purposes. This may result in minimal

or missing data. Staff sometime devises work arounds to identify and collect data they believe are important or necessary. Meaningful data is not conveyed to all staff in an easily and readily

understood format such as a dashboard. Of the data that is collected, much of it is anecdotally

aggregated and analyzed. A best practice adopted from another facility is a software program

that pulls data into a Microsoft Access database which can then be converted into a report. The

report is then manually reviewed to determine if errors are present before being released to

leaders. Although this is an improvement, there is not a centralized system of data input, storage

or reporting. Further, there is not agreement among system facilities about what data should be

collected and reported.

Modern day resources, which include technology, are required to function in todays environment. Information must be shared with numerous providers and yet AuSSLC remains

paper based. Whether it is medicine, nursing, quality or direct care professionals, they are all

functioning in a 60s or maybe 70s environment. The Individual Notebooks or I-books that contain the residents ISP and function as a chart for each resident are three ring binders - the same type of binder that has plagued students for decades as essential papers fall out or are

misplaced in the volume of important papers. As such, the number of man-hours lost to this

inefficient paper system severely impacts continuity of care as well as staff time with residents

and it means staff is working harder not smarter. Hindrances to communication and continuity of care have been shown to contribute to medication errors which at the SSLC also

count as ANE cases. It is our understanding from both AuSSLC and the Central Office that the

state is in the process of identifying a vendor and acquiring an electronic record. The slowness

of the acquisition process will be compounded by the complexity of implementing a system

across the state and the forward motion of this facility is further challenged.

While the paper based system has a low cost and little cost of staff training, it represents low

value for communication and care and an increased risk to staff for errors and the consequences

of such errors. The lack of technology and the inability to consistently communicate effectively

in real-time increases the risk for allegations of abuse or neglect and the multiple consequences

that follow. The implementation of technology has the potential to proactively provide an

opportunity to track and trend issues, share status changes in real time, and timelier

documentation of care.

Pharmacy and the ombudsman offices regularly share with peer offices across the SSLCs. There

appears to be some sharing of best practices regarding data gathering and safety metrics. But although there is some evidence of sharing of quality information among SSLCs, there appears

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to be a significant lost opportunity to have meaningful horizontal system learning, benchmarks

and comparisons of results. Horizontal system learning may accelerate improvement efforts and

is critical to analysis of results.

QA/QI appears to be a group of formalized QA data collection and informal QI. The data

collected in the QA process for the DOJ is not used in QI projects. The organization could not

identify barriers to using the QA audit data for QI. Instead, they noted that the QA audit process

consumes significant time and staff resources leaving no time to conduct QI. Tools to meet the

DOJ measure numerous processes, many of which the staff feel have no impact on care. Further,

there is no aggregated report and the total number of measures is not known. Leaders are tasked

with analyzing and preparing a pre-visit assessment for the SIA monitors. It is unknown who

reviews the analysis or whether the analysis results in process changes to improve care or if

overarching themes is identified for the facility. The QA/QI Council minutes do not reflect

analysis, discussion, or prioritization of the QA data. Further, discussion with leaders and staff

did not evidence evaluation of cycles of refinement or organizational learning. While the

measures may be required to comply with the DOJ, this contributes to a staff feeling that

compliance is the functional mission of the organization.

Implementation of the QI processes being acquired by Central Office should help move the

current data collection processes in the direction of a specific quality improvement model.

Acquisition and implementation of a systems-based approach to identifying problems,

developing approaches to address issues, deploying the improvement across the organization,

learning from the process of QI/PI, or integrating the learnings to other areas of the organization

would address many of the teams concerns.

Many of the databases appear to be locally developed using standard desktop software. All

personal computers were updated to Windows 7 following the publishers recommendation for security and function. Locally developed programs fulfill needs identified at the facility but

introduce risk, as updates and support are reliant on the programmer. It is not clear that other

staff is cross-trained to support the numerous software programs. Also, opportunities for use of

data collection across several reports, ability for users to know of or access the full range of

available reports, or to align and integrate data reporting may be lost resulting in lack of

information or duplication of efforts. A possible model to coordinate efforts is a change control

board.

Review of the QA/QI Council minutes does not demonstrate consistent analysis of the data

collected through audits. Rather the limited minutes are dominated by responses to external

findings. Follow up assignments do not include due dates. There is no sense of alignment or

integration of efforts. An example of many of these issues is a newly revised process to weigh

patients. Although the reason for the development of the activity was not evaluated during this

review, the majority of staff interviewed felt the new process is overly prescriptive and wasteful

of staff time. Briefly, all residents are weighed on Saturday on home specific scales. The

weights are sent to Habilitation Therapies where the data are entered into a computer worksheet.

If the residents weight changed more than five pounds in a week, then the resident is weighed again. The data is reported back to Habilitation Therapy. If a variance of more than five pounds

continues to be found, then the nurse supervisor weighs the resident and reports the weight to

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Habilitation Therapy. This means that some residents may be weighed three times in a single

day. Residents can be weighed more frequently than once per week with medical orders.

However, it is not clear why all residents need to be weighed once per week nor why a more

efficient method of weighing and evaluating could not be implemented. Many staff said that they

were not involved in process redesign and were not included in the revisions to the process. As a

result, staff engagement for this process is poor and improvement opportunities may be lost

because no organizational learning occurs.

There was universal agreement that little or no training in quality concepts, tools, or processes is

or was recently available. This includes staff in the Quality Department. Basic QI principles are

not used. Other tools such as Six Sigma and LEAN would seem beyond the capacity of AuSSLC

at this time but should be considered as an ultimate goal. Utilizing a formal process, which

includes the model discussed with Central Office, will support fact-based decisions that set and

align organizational direction, enhance resource utilization, and provide opportunities to measure

and evaluate performance over time. Doing so will also assist in the identification of best

practices within the organization. Training and implementation of a QI system would more

completely close the loop on QI issues.

In conclusion, AuSSLC has not evolved beyond a culture of quality control and compliance. This

is not an issue of broken QI processes. In fact, AuSSLC currently has no QI processes. Therefore, the organization will be challenged with starting from scratch in creating or adopting

a QI program. Both vertical and horizontal integration of data sharing and processes is missing.

This results in lost opportunities to learn and accelerate efforts that may improve care and

improve organizational sustainability. It is unlikely that AuSSLC will emerge from a cycle of

compliance/noncompliance without taking steps toward a QI/PI culture that will engage and

empower its employees to improve care.

Opportunities:

Adopt a QI model. Many exist and a simpler model will be more effective at this stage of organizational development. The Central Office selection of and implementation of same

should move this along.

Provide adequate and appropriate training for staff that collect, analyze, and identify important processes and outcomes. Very basic and widely accepted training such as -

TeamSTEPPS are available. Consider utilizing this or similar training to address basic

knowledge gaps as well as teach communication and hand-off techniques.

Develop documentation of software used to evaluate critical processes and outcomes. Staff should be cross-trained on these databases to decrease risk.

The Central Office adoption of both strategic and quality improvement plans should be expeditiously implemented at AuSSLC.

Identify gaps in resources and knowledge to create and maintain a culture of QI.

Consider using all or part of the DOJ as well as the SAI as the foundation for measures in the QI plan.

Develop more robust quality documentation particularly in minutes reflecting discussion, follow-up and enhanced staff accountability through documented and tracked due dates

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Consider establishing statewide metrics or benchmarks across all SSLCs to facilitate development of best practices, enhance cross training across institutions, provide team

depth by enhancing the capacity for staff movement across facilities and to capitalize on

the proven effectiveness of performance improvement through data comparison with

peers.

Consider development of State-wide SSLC councils. This may include periodic (perhaps quarterly), leadership discussions and organization-wide quality improvement councils

which could strive to reach the metrics and benchmarks discussed above.

a. Benchmarking across all SSLCs. Performance usually improves when one sees how one is functioning compared to peers.

Use evidence based monitoring and evaluation. This will move the current quality process from an audit function to a true monitoring and evaluation process. It is

necessary to close the loop from findings to plan to implementation to evaluation.

Acquisition and implementation of electronic records systems should be strongly encouraged and expeditiously acquired to enhance the QI process, reduce errors, and

improve communication in real time and across multiple campus sites.

WORKFORCE

Medical:

Repeatedly through the visit it appeared there was either feast or famine too many or too few staff in a particular area. The medical staffing is one example of what appeared on the surface to

be very generous when looking at the physician/resident ratio in comparison to the ratio

maintained by private sector clinicians. However, in discussion with these providers, they

believe they are staffed at an appropriate level and that they struggle to complete the expected

work within the scheduled time.

The type of client cared for today as compared to the type of client residing at AuSSLC in past

years has changed significantly. The residents have aged in place and over time these changes in acuity levels have created new challenges such as end of life decision making, level of

medical support on site, decisions regarding transfer for more aggressive medical interventions,

etc. It has been approximately 31 years since the filing of the Lelsz case. A resident who was 31

at the time that case was filed is now 62. Due to physical disabilities compounded with aging

processes, we are now looking at individuals who are of a higher acuity requiring more

medical intervention than previously and perhaps less education toward normalization, particularly for the resident who has reached advanced years. Many of these individuals appear

to have reached the pinnacle of their learning potential. Yet, they must continue to have

educational plans. To create an education plan for any 80 year old is difficult, much less an 80-year old with physical and mental challenges combined with usual aging processes which

include dementia. This aging and increasing medical fragility further complicate requirements to

meet some regulatory and DOJ requirements. However, as noted above, many of these residents

have lived much longer than their anticipated lifespan as predicted by their underlying medical

conditions and a share of that longevity is likely intense attention to the care needed for their

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multiple disease processes and the role of the medical staff in acquiring the specialty care

periodically required for management of their conditions.

While there are 5 providers on sight, some specialists come to the facility to provide care and for

other specialty care, arrangements are made with community physicians who are willing to

provide care. Often there are challenges in acquiring such care as it can be complex, time

consuming even for relatively minor or chronic concerns, and occasionally there are behavioral

issues with residents in waiting rooms of other patients.

While numerous community placements have been recommended or even tried by staff, anecdotal reports suggest that the community is not prepared to address the range of medical needs of this aging population. Physicians all agreed that the patient population is very complex

and very fragile and requires significantly more care than either the usual community geriatric or

intellectually developmentally delayed individual. And lack of experience with many of the

medical conditions linked to the underlying causes of IDD mean that often community providers

are not prepared to care for this clientele.

However, the most trying aspect of their work appeared to be the inordinate amount of paper

work required. One of the clinicians indicated that if the care they provided were moved to a

non-SSLC site, they could increase the work done by 33-50%; this could occur because of the

differences in documentation requirements.

In addition to extraordinary documentation requirements, physicians indicated that policy

required their presence in a substantial number of meetings. Some of the meetings occur in

response to reviewer recommendations regarding sharing information, timely communication,

and closing the loops of hand-offs. However, the physicians questioned the value of many of the

meetings noting that they attended as a requirement but had little to contribute to the discussion.

Physicians expressed some chagrin that when they were in interdisciplinary meetings, which

they perceived to be mandatory, that the other disciplines were not medical in orientation and

required extensive justification of relatively simple medical interventions. These

interdisciplinary meetings occur annually for every resident, periodically in response to

incidents, and with each change of resident situation such as returning from the infirmary or the

hospital. Even with status changes that lasted only hours, the entire risk and active management

plan had to be reviewed and physicians were in attendance. Clinicians also perceived that the

culture rightly had zero tolerance of neglect and that that zero tolerance was coupled with a high

level of suspicion and accusation. Therefore, whenever a resident had a bruise, fever, or other

minor symptom, maximum evaluation including laboratory and imaging are done to avoid

accusations of neglect; this culture leads to high risk of overtreatment of residents.

While regulators rarely bring medical surveyors and say they do not look at medical, often there

are medical issues that are pursued to the point of minutiae. For example, when asked about

calcium and vitamin D intake for residents, a general nutritional evaluation was not acceptable

but rather a request was made to have the diet of every resident evaluated for quantitative

amounts of vitamin D and calcium.

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Despite a small patient load and the acknowledged fragility of the client base coupled with

microscopic oversight, the formal peer review process to evaluate the medical care is less

education and collegial than task audit oriented. There are quarterly audits looking at defined

metrics which they perform on one anothers charts. This appears to be primarily a documentation check. Physicians indicated that the audit questions were not always clear and

they did not know for sure what they were looking for. They did say that periodically outside

clinicians reviewed the records but no quality improvement process was attached to either the

internal or the external review.

Specific discussion about the review of mortality indicated that the medical staff believes that the

current process is adequate. The review process has multiple steps including: AuSSLC medical

staff review; an external company review; and a Central Office medical officer review. Review

of several of the outside reports suggested a reasonable review of the cases occurs. However, a

substantial portion of each review and each of the serial levels of review seems to be more audit

than quality evaluation. And the very valuable process of peer discussion and consideration of

evidence based decision making appears to be minimal thereby losing an excellent opportunity to

improve the quality of care for the entire interdisciplinary professional team..

Peer review allows colleagues to discuss and evaluate care in a protected fashion so that

evaluation of the care and identification of opportunities for change/improvement can be open

without threat of litigation. Without a medical staff organization, protected peer review cannot be

conducted as it is in all hospitals and an increasing number of ambulatory care settings. Without

the protections of peer review it is challenging for clinicians to vigorously critique the decision-

making in a particular case without concern for liability. Yet, the medical staff of AuSSLC

clearly cares for a very fragile, medically challenging population with a high level of community

interest in the outcomes of that care. Providing a structure that encourages continuous evaluation

of best practices, evolving practice guidelines, emerging literature, etc. would enhance the ability

of this dedicated team to continually improve the level of care and outcomes of care under their

supervision. While the medical staff of AuSSLC is small, a regional or statewide approach to a

formal medical staff organization may be reasonable. Such an organization could identify

potential practice guidelines or opportunities for developing best practices for this particular

population. It may also improve recruitment and retention of physicians as the organization

would be more consistent with other medical practice settings and offer a broader collegial

support system.

Nursing:

While staffing levels for nursing may be appropriate for a living environment in which education

is the focus for the clients, the intensity of medical care at AuSSLC creates a challenge for nurse

staffing and establishment of appropriate levels of staffing. To assist in right staffing it is suggested the nurse staffing plan be completed and implemented. The current director of

nursing has developed a staffing plan to meet the acuity; however, implementing the plan has

been difficult due to the shortage of available nurses. Since the arrival of the new director, steps

have been taken to try to increase staffing by advertising, which has never been done before, and

hiring agency nurses on long term contracts. These two steps have been positive yet there

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continue to be significant shortages. Certified nursing assistants are not used; only Registered

Nurses (RNs) and Licensed Vocational Nurses (LVNs) are employed.

The nursing market in Austin is highly competitive. The two primary healthcare organizations in

Austin, St. Davids and Seton, have rich benefits and salaries. They have career ladders, engage nurses in Associate Degree Nursing (ADN) to Bachelor of Science in Nursing (BSN) degree

programs by paying for this education, have rich continuing education programs and offer a

better work environment which includes automation and the opportunity for three 12 hour shifts

per week in place of a straight 40 hour week. Depending on the position, salaries across the

board are estimated to be $10K or more per year more than those offered at AuSSLC. It should

also be noted nurses in these SSLC environments are subject to the constant threat of rights violations and investigations.

Compounding the staffing shortage is the lack of automation coupled with requirements for

documentation in numerous locations. Nursing, particularly at the management level, spends a

considerable amount of time in meetings that are often felt to be relatively non-productive.

Practices used in acute care such as a 24 hour chart check to ensure orders have been

administered and documented correctly as well as determining if appropriate documentation is in

place cannot easily be done in this environment due to the numerous locations in which

documentation occurs and the current reliance on a paper record. Such a practice could be

valuable in ensuring documentation is correct and that all needed activities have been carried out

but would be difficult with the current disseminated documentation.

Nursing has been cited numerous times from a regulatory and a DOJ perspective. There is a

feeling that nursing is often a great scape goat for citations. This can be demonstrated in the medication variance reporting. Most of the medication variance severity findings are category A

and B. Category A is defined as a circumstance or event that has the potential to cause variance

and category B is a variance that occurred but the variance did not reach the patient. Category C

variances do reach the patient and in some situations do cause harm (categories G-I). The report

reviewed onsite, prepared by Pharmacy, cited nursing with a 6.7% variance. The variance was

actually .067%. In part due to the lack of domain understanding by the monitors, nursing was

again cited. If the team was to work collaboratively and review the report together before it was

presented, this issue could have most likely been resolved without errors attributed incorrectly.

While this finding was challenged internally it is not known if the facility was able to make this

correction with the monitors and appropriately adjust their findings.

While a peer review process is in place for nursing it functions at AuSSLC, as in many other

institutions and facilities, as a disciplinary action rather than an education oriented process

improvement tool.

Pharmacy:

There was no mention or appearance of being short staffed. Overall, they are satisfied with how

they interact with medical staff. Effective clinical tools/reviews are in place for

pneumonia/constipation/chemical restraints/medication refusals/ and polypharmacy.

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For the most part, pharmacy is not targeted by the monitoring teams representing the DOJ, the

independent settlement agreement monitors, nor DADS Regulatory. As a result, they have more

time to devote to resident focused pharmacy work. The most evident impact of these regulatory

teams is the resultant required meeting load. There are many meetings that are mandated but

which are perceived to be limited in the value add in the care of SSLC residents or pharmacy

operations. For example, the Medical Morning Meeting has its agenda set by DOJ inspectors.

This meeting has the potential to improve resident care by engaging professionals from different

focus areas; yet its current form does little more that satisfy a DOJ requirement while

monopolizing staff time without the kind of robust discussion among providers that might either

reduce errors or enhance care. The inspectors that do come to pharmacy do not seem to have the

qualifications to do pharmacy assessments, some seem to lack even the basic understanding of

what a pharmacist is licensed to do. Pharmacy has had some success in challenging these non-

clinical auditor findings yet this process takes pharmacy staff away from resident care.

Pharmacy leadership at the Austin SSLC is unique in that the top 2 positions are filled by people

with outside managerial experience rather than promotions from staff already at the SSLC. This

influx of external experience without the time burden of extensive regulatory citations may be

what allows the department to have some QI work. An example of a successful project is the

process change for medcart fill. They were able to determine a potential source of medication

errors, assess ways to decrease distractions during the work flow, track error rates, and

subsequently fine tune the process. This was a systems approach to quality improvement while

still holding individual employees accountable.

During discussions with Central Office, a variety of SSLC functions and/or staff levels were

identified that come together regularly to discuss common challenges and recommended or

identified best practice solutions. The pharmacy department coordinates activities with other

SSLC departments across the state and perceives that this has been very effective not only for

AuSSLC but for other SSLCs in identifying opportunities for care process improvement. Several

SSLCs share clinical work such as Drug Use Evaluations and even notes on Regulatory

Auditors. They are able to meet regularly and annually have actual face time which further

encourages the informal sharing that occurs on an as-needed basis. They are able to provide

better resident care by working together and not solving the same problem in isolation over and

over.

Pharmacy has identified the potential of serving as preceptors for pharmacy students at the

University of Texas College of Pharmacy. The SSLCs offer a unique care environment for

pharmacy students and in the long term this knowledge can be utilized for IDD community

health care. The pharmacy lacks access to an online medical library but some articles may be

requested thru the library at ASH. A partnership with the University of Texas or other Health

Science Centers may provide more free resources. Pharmacy is excited about the online

adjudication process and transitioning to an EMR whereby the physicians will enter orders. The

current paper medication order entry process is cumbersome and offers higher potential for error.

Quality Improvement:

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The Quality Department appears to be generously staffed. While our team was not able to get an

exact count of staff it appeared there were 18 individuals assigned to this department. Sections of

the DOJ report have been divided among the staff. Staff has in turn created audit sheets. Audit

sheets are completed by the staff, handed off to data entry individuals to enter findings in the

locally created Access database. This information is then utilized to determine if the audit

findings were met. These individuals attend meetings and perform audits. Without a formal

quality process and specific metrics goals, this information is helpful but less than optimally

effective in either resolving monitoring issues by regulatory or DOJ or in moving the

organization toward planned goals.

Staff in the quality department has varied backgrounds. While this is certainly acceptable it did

appear that many of professions such as nursing and social work might be better utilized to

address some of the other staffing needs within their specific training. Implementation of the

planned QI program should be more efficient and potentially allow some of these individuals to

fill more clinical areas.

Social Workers:

While the specific needs for staffing cannot be determined in a one week onsite visit, it should be

noted that in many interviews the lack of social workers was felt to hinder discharge planning

and communication with families. Elimination of this group of positions occurred prior to the

arrival of the current leadership team. Apparently this staffing change resulted in moving the

work of social workers to either the quality department or the case managers or Qs. It did not appear the Qs felt comfortable assuming some of the roles of the social workers. It was stated in the QIDP interview that the loss of the social workers resulted in a 1.5 year backlog

completing SAPs (skill acquisition plans and a backlog in resident reviews which was believed

to contribute to an increase in incidents secondary to delays in responding to resident behavioral

issues.

Qualified Intellectual Disability Professional (Qs):

The Qs are responsible for coordinating many resident activities as well as family communication. Clients must have annual as well as ongoing staffing meetings when there is any change in their care or status. It was stated there are approximately 28 Qs in some capacity or another. Qs state they do not have a career ladder nor are there classes to prepare a Q to do their work. They do not feel listened to. Staff stated that on numerous occasions they have

tried to do community placement for residents felt to meet criteria. Residents often fail

community visits and/or when the level of care is more fully known to the community

organization they decline to accept the resident as they do not feel they can meet the residents medical need(s).

Direct Support Professional (DSP):

DSP turnover at the Austin SSLC is 35-40% as per documents provided. DSP staff articulated

they felt this is in part due to burnout some of which is related to staffing shortages. When asked

what the staffing plan was for coverage it was reported that if short, then you dont go home.

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Some regulatory findings have led to meaningful changes however it is unknown if staffing

ratios have been adjusted to accommodate the expanded workload of regulatory documentation

on top of direct resident needs. In the interview with the DSPs it was stated the ISP, while

required for every resident, is a very long document that is not user friendly with respect to communicating the daily care of the resident.

Opportunities:

Implement a medical staff structure and a peer review process that will be education centered, evidence based, and directed to care improvement.

Evaluate the role of the medical staff in the committee structure and attempt to moderate the number of non-medical roles they fill.

With the aging population the needs of AuSSLC clients have changed over time. It is suggested consideration be given to the medical and educational needs of this aging

population and how to meet them within the regulations and with the highest possible

quality of life.

Implementation of evidence based staffing plans - Right staffing for the acuity of the resident served. Staffing plans can assist in this determination; however, creating staffing

plans should be accomplished by ensuring the needs of the residents are met and not

backing into a plan that justifies or utilizes existing staffing patterns. Staffing must take into account the acuity of these aging and medically complex residents.

Competitive salaries. Without competitive salaries AuSSLC will continue to be in a position where they cannot compete with the local market.

Career ladders for all staff. This may require increased opportunities for education and training.

If training is offered, such as for the Behavioral Health Certification, the Center needs to be able to require a commitment for service beyond the training before investing

time/money in training people who tend to leave within 6 months

Consideration of the role of social work(ers) and evaluation of recreating positions in this arena.

While hiring from within can be advantageous it can also place an organization at a disadvantage for learning and implementing new processes, ideas and best practices.

This is a delicate balance; however, the teams perception was that there had been little new blood introduced to the leadership particularly if movement across SSLCs is perceived as internal hiring. This finding was identified through the numerous interviews

in which staff related their years of experience within DADS and how their respective

roles have evolved at AuSSLC through the years. While this is not necessarily a negative,

this process has the potential to stifle new ideas, innovations, and fresh perspectives.

Customer: Residents and Guardians:

A key challenge to any organization is the balancing of differing customer expectations. Austin

SSLC is responsible to their residents, the residents guardians or LAR, and the State of Texas. The needs of each customer will dictate their expectations and at times these needs may conflict

with another customers expectations. Active treatment may not align with the wishes of the

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resident and for some of the older residents with progressive dementia the active treatment plan

must be coordinated with the medical reality of their situation. At other times, the safety needs

and civil rights of an individual resident present divergent expectations which a Direct Support

Professional (DSP) must prioritize. For example, a resident has the right to the dignity of risk

and is allowed to explore the facility and is not prohibited from departing the grounds which may

pose a safety risk due to the proximity of a busy roadway.

On the individual level, the family members (guardians) that spoke with our team were happy

with the Austin SSLC. They considered the facility as an extended family and had seen positive

changes in their loved ones as a result of living at the Austin SSLC. They virtually all expressed

concern about not being able to get the same level of support and care if their family member

were to be moved to a community setting. In terms of desired improvements of the facility,

disjointed communication was a common theme. Communication breakdowns seem to occur

mostly due to staff turnover and failure to notify families of these changes.

The Austin SSLC seeks to obtain actionable information from residents and guardians/LAR from

town hall type gatherings, annual guardianship meetings, and ad hoc communication.

Opportunities:

Define parameters on resolution of expectation conflicts to remove decision making point from DSPs who have minimal education requirements.

Proactively listen and learn what your primary customer needs and tie this information into the organizational strategy to align available resources.

Internal and External Engagement

One measure of customer engagement is the willingness to actively advocate for and recommend

the care at the Austin SSLC. This may not be possible for all the residents but many of the

guardians, LARs, and the surrounding neighborhoods are engaged in grassroots support efforts to

keep the Austin SSLC open. These efforts have not been highlighted by the media but remain

available for the SSLC to showcase in its favor.

Successful management of complaints results in enhanced customer relations. The Austin SSLC

has multiple opportunities for lodging complaints or registering concerns. However, the

institution lacks an effective method or iterative process of deploying information throughout the

organization. The facility is functioning with isolated silos. For example, the QIDPs (which

exist under the QA service line) report Settlement agreement citations that the pharmacists and

physicians (which exist under the Physician Services service line) are not aware of. There does

not appear to be a systematic approach to handling concerns or learning from complaint

resolution; however, on the level of individual departments, employees are working hard to

resolve citations and raise the standard of care at the Austin facility.

Opportunities:

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The committed staff and the satisfied families offer an opportunity to leverage traditional and social media. An outside specialist may be the most effective means to achieve this

task as workforce at SSLC are otherwise occupied and not trained in this area.

Create a forum for lessons learned. These lessons could be shared at the morning medical meeting which is attended by a representative of a majority of employee

stakeholders or as part of a weekly email blast. The object is to be short but supply

enough information to avoid duplication of efforts.

Summary:

The team would like to thank the leadership of the Texas Health and Human Services

Commission (HHSC) and the Department of Aging and Disability Services (DADS) for the

opportunity to evaluate the AuSSLC from a perspective different than that of regulatory agencies

or the DOJ. We would also like to express our appreciation of the open reception we received at

the AuSSLC. It was our intent to identify opportunities in which DADS and AuSSLC can

improve and continue to meet the needs of this special population.

An organizations success depends increasingly on an engaged appropriately trained workforce that benefits from meaningful work, clear organizational direction, and accountability for

performance. When an organization takes a systems perspective to management, the senior

leaders can focus on strategic directions while meeting the needs of residents, families and

regulators. Senior leaders at both the central office and local level must monitor, respond to, and

manage performance based on results. Implementing a systems perspective to management will

assist ones ability to measure what is important for the right reasons. Setting indicators and metrics will assist in developing core competencies and organizational knowledge. Linking this

knowledge to key strategies and processes will assist in better resource allocation and

management while improving overall performance focusing on residents, families, other

customers, and stakeholders. Thus, a systems perspective means managing the whole

organization, as well as its components, to achieve sustainability.

The format of this report was intended to offer opportunities for improvement for each category

or function listed above. Here we will summarize general or overarching opportunities for the

AuSSLC.

Implement the Central Office Strategic Plan with local institutional specificities.

Create a culture of learning and teamwork. Such paradigm shifts take time and require intense leadership to accomplish

Reorienting staff to the protocol or process in which regulatory and/or DOJ findings can be questioned may assist in resolving staff confusion and perceived differences between

the two oversight teams. Creating a positive culture will require resolving the conflict

specific rights issues.

Stabilize and develop local leadership at the AuSSLC. There are numerous courses and/or programs that can assist in building local leadership.

21

Empower local leaders to take charge and ownership of their facility. o This should include development of a plan and accountability for carrying out the

agreed upon plan.

Implement the Central Office quality improvement plan to assist in moving from an audit model to one of quality improvement. Utilization of the DOJ findings as the goals of the

QI plan should have dual impact by addressing the ongoing monitoring as well as

creating measurable forward momentum.

Staff have been pleased the new administrator has again implemented town hall meetings. This is a great process which can help stabilize the flux of leadership as well as

demonstrate Central Offices commitment to the mission and purpose of the SSLCs, provide an opportunity to have honest dialogue when change is needed (transparency),

and get input from those at the point of service so that the impact of decisions or changes

do not impede but facilitate progress. Such meetings help foster a top down/bottom up

management style.

Create an ongoing process to evaluate salaries/benefits in comparison to those in the local community, develop career ladders. Consider how to take advantage of the institutional

knowledge of long-term staff while looking for opportunities to bring in new staff with

fresh ideas.

The age of technology is here. Survival will require the ability to provide evidence they are meeting regulatory and DOJ requirements along with measuring performance in

general. Such performance measurement requires the use of technology. It is strongly

suggested, that while it can be initially disruptive, AuSSLC move to an electronic format

for QI, charting, communication, etc.

Investigate opportunities for streamlining staffing and incident response. Currently one incident may include all of the organizations mentioned. It takes time for these issues to

be resolved. Professional staff members can be relocated for up to 3 months while an

investigation is completed. This is crippling to staffing and over-extends the use of

staffing resources across all the mentioned organizations.

Throughout the visit one of the issues the team looked at was the question of whether some/many of these residents could be effectively cared for in a less restrictive setting.

Recurrently we heard about the paucity of IDD specific services, as well as the difficulty

of having community professionals respond to the complex needs of the IDD community.

One solution might be to look at enhancing the availability of some of the AuSSLC

services for IDD individuals living in community settings. For example, the Habilitation

services could continue to make adaptations to wheel chairs and assist in developing

other assistive devices. Pharmacy could possibly continue to provide medications

consistent with the State Formulary as a cost savings measure. Clinic (ambulatory)

medical and dental care could be provided by medical and dental staff that are familiar

with and know how to treat this population.

We appreciate the opportunity and look forward to working with HHSC and DADS in the future.

Please contact us if you have any questions or are in need of clarification of our findings. Thank

you

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APPENDIX

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Department of Aging and Disability Services Site Visit Itinerary May 27-30, 2014

Monday, May 26, 2014 Hotel Accommodations: Omni Austin Hotel Downtown 700 San Jacinto Blvd. Austin 512-476-3700 Tuesday, May 27, 2014 Address of site visit: 2203 W. 35th St., Austin

Upon entry onto campus, go to the Administration Building (first big

building on the left 3 stories) WARNING: Speed Limit is 5-15 MPH and it is heavily patrolled. Becky Schock will be you point of contact upon arrival on campus. Laura Cazabon-Braly, Director of AuSSLC, may appoint someone else during the Opening Conference for the remainder of the week.

9:00 10:00 am Review Team arrival and set-up. No on-site internet access

available.

10:00 11:00 am Opening Conference (Library). Introduce the review team,

meet AuSSLC leadership and discuss the purpose of the onsite review.

11:00 am 12:00 noon Campus tour/Document review 12:00 1:30 pm Lunch and Reviewer Huddle 1:30 3:00 pm Leadership Conference 3:30 4:45 pm Human Resources Conference

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Jennifer Mears, Sylvia Valdez-Ledbetter and Byron Swor 4:45 5:00 pm Review Team Huddle Wednesday, May 28, 2014 9:00 9:30 am Review Team arrival and pre-review Huddle 9:30 10:00 am Opening Conference. Meet with facility designee(s)

seeking clarifying information or document from preceding day.

11:00 am 12:30 pm Quality Improvement/Assurance Conference (All team

members)

Holly Lindsey, Melissa Klopf and the program auditors as a group 12:30 1:30 pm Lunch and Reviewer Huddle 1:30 3:00 pm Risk Management Conference (Dickey, Watzak, Mechler) Sherry Roark, Dana Mungia and Carol Fresch 3:30 4:30 pm Clients Rights Conference (Dickey) Keith Robinson, Desiree Martinez 4:30 5:00 pm Review Team Huddle Thursday, May 29, 2014 9:00 9:30 am Review Team arrival and pre-review Huddle 9:30 10:30 am Case Management Team Conference Tristan James and 4 QIPDs as a group 11:00 am 12:00 pm Caregiver Conference (Dickey, Watzak) At least 6 as a group 12:00 1:30 pm Lunch and Reviewer Huddle 1:30 3:00 pm Break-out Conferences (90 minutes per

group/simultaneous or sequential) - Medical Staff Leadership (Dickey, Moy)

Dr. Chrishanthi Perera, Dr. Bill Race - Nursing Leadership (Mechler)

Sharon Price, CNE; Mary LeLeFebvre, NOO, Nurse Educator, Sylvia Valdez Ledbetter

- Pharmacy Leadership (Watzak)

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Kenda Pittman, Guy Campbell 3:00 5:00 pm Review Team Huddle Friday, May 30, 2014 9:00 10:00 am Review Team arrival and pre-review Huddle 10:00 am 12:00 pm Unit Observations 12:00 1:30 pm Lunch and Reviewer Huddle 1:30 4:30 pm Unit Observations 4:30 5:00 pm Review Team Huddle Team Members: Nancy W. Dickey, M.D. (979-777-6196) President Emeritus and Co-Director of the Texas A&M Health Science Center Rural & Community Health Institute Kathy Mechler, M.S., R.N. (210-213-7133) Co-Director and Chief Operating Officer, Texas A&M Health Science Center Rural and Community Health Institute Bree Watzak, Pharm.D. (281-451-7412) Assistant Professor, Texas A&M Health Science Center College of Pharmacy Clifford Moy, M.D. (512-695-1867) Psychiatrist Amanda Klekar, LMSW 512-438-5023 office; 512-993-7138 cell Quality Assurance Director, Dept. of Aging & Disability Services, State Supported Living Cent