Chapter III

RESIDENTIAL PROGRAM

Individual Planning And Placement

• Before a person becomes a CLA resident, there is a series of steps that include:

_ determining a person's eligibility for services from the department;

_ assessing the person's needs and prioritizing those needs among others also seeking CLAs;

_ identifying a CLA vacancy; and

_ deciding the identified CLA is appropriate for the person.

• After a person moves into a CLA, another series of activities occur that includes individual program planning, implementation, and monitoring.
• Figure III-1 sets out the key points in the individual placement, planning, and program delivery process.

Request for Service: First-Time Residential Placement Seekers

• Any person with mental retardation seeking residential placement for the first time and who is not already a DMR client must go through an intake process to determine eligibility for services, receive a DMR client number, and be assigned a case manager. Persons already receiving another type of service from the department must also go through the residential assessment process.
• Next, a needs assessment is done of the individual by the case manager and a team with a variety of disciplines (e.g., psychologist, nursing, occupational therapy). This needs assessment seeks to establish the level of residential support needed by the person.

Source: DMR

• Written requests for first-time residential placement are prepared by a client's case manager and submitted along with the completed support needs assessment to the pertinent region's Planning and Resource Allocation team (PRAT) for placement on the region's waiting list.
• The regional PRATs are appointed by the regional directors and are responsible for receiving residential (and day) program service requests, reviewing and prioritizing DMR client needs for those services, and allocating residential (and day) resources. For residential services, each team:

_ reviews the priority status of persons on the regional planning list at least annually;

_ reviews the status of persons who are deemed waiting list emergencies on a monthly basis;

_ reviews available resources; and

_ matches resources to individual requests and making referrals to providers.

• Each regional Planning and Resource Allocation team establishes a waiting list priority for each person seeking first-time residential placement, based on the individual's present living situation.

_ Emergency: need for residential supports and services within three months

_ Priority 1: need for residential supports and services within a year

_ Priority 2: need for residential supports and services within two years

_ Priority 3: need for residential supports and services within three years

• This determination is based on the individual's present living circumstances.

People Already in a Residential Placement Seeking Change: Review and Referral

• DMR clients who are already in a DMR operated or funded residential placement may seek a change in placement. Reasons can include: need for more nursing care; conflict with a housemate; or wanting to be closer to family.
• Case managers for these DMR clients will also submit a written request for a change in placement to the PRAT.
• As with first-time placement seekers, the regional PRAT will make a determination of priority status, using the same scale. However, a separate list is kept for persons who already receive DMR residential support but seek a change - a planning list.

Referrals for Possible Placement

• When a placement vacancy becomes available, the PRAT will discuss who from either the waiting list or planning list to refer to the provider for consideration.
• The team knows of vacancies in group homes because private providers and DMR-operated homes must inform the team as they occur. Homes also are to provide profiles of each house and their residents for use by the team.
• Clients with emergency waiting list or planning list status must be considered first when vacancies occur.
• There are several factors impacting whether someone will be referred to possibly fill a vacancy, including physical needs, medical needs, and personality. (Such factors may be less crucial if the placement is an emergency)
• When making a referral, the PRAT distributes a client referral form and information packet to a potential provider (as determined by the team). Referrals are to be made within a week of the team meeting.
• Referral packets vary depending on how much available information DMR has about a person. Ideally, the client information packet will contain pertinent current functional assessments, including medical and psychological.
• Providers are encouraged to meet with potential clients and their families (and vice versa) prior to a placement decision to assess how the client could be supported in the home and fit in with the people already living there.
• A provider must inform the team within three weeks regarding its interest and ability to serve the person. The placement decision must also be accepted by the client and/or his guardian or family member.
• Emergency placements may be made outside of the typical planning and resource allocation process, according to DMR policy. In other words, the above process may not happen when a DMR client has no place else to live.

Transition Plan

• Ideally, per DMR policy, a person will move to a new residence within two months after the provider agency and the client have agreed the move is acceptable. Transition planning is needed to ensure the move into the new home and environment is as smooth as possible, and the client's needs will be met despite the change. A written transition plan should be in place to facilitate the move for both the new resident, the housemates, and staff.
• For example, a client may spend a few hours each evening along with a couple of overnights at the new residence during this period of adjustment. This helps assess the client's compatibility with the other residents and enables staff to acquaint themselves with the client's needs gradually. Also, staff from the new home may visit the client in the client's present setting.

Individual Support Plan

• Once a person has been placed in a DMR run or licensed CLA, a planning process focused on that client begins to determine what services would best meet the client's needs and preferences in that setting, and establishes goals and objectives to address those needs and preferences.
• The process results in a written individual support plan, known primarily as the Overall Plan of Service (OPS). The plan covers all aspects of a person's life, including:

_ residential life at the CLA, (referred to as activities of daily living or habilitative services);

_ any medical, behavioral, dietary, personal care, and health and safety needs;

_ employment or other day activities; and

_ community involvement.

• The plan is to be reviewed at least annually, with quarterly implementation updates.
• Each client has an Interdisciplinary Team (IDT) to assist with the planning and implementation of the client's support plan. The team includes: the client (when possible); the client's family member, guardian, or advocate; the DMR case manager; staff from the client's home residence, and any specialists needed (e.g., a behaviorist or speech therapist)
• The plan is specific to his or her current living situation. It must be developed within 45 days after the move to the CLA, and must be implemented within 30 days of development. (The transition plan is to cover any needs prior to the completion of the OPS.)

Program Implementation

• Once a client has been placed in a CLA, his/her individual plan (the OPS) is kept at his home. It is largely the responsibility of the client's residential program to implement the plan.
• The major parts of the plan typically include:

_ habilitative services (i.e., activities of daily living);

_ behavioral program (if one is necessary);

_ health and safety needs;

_ day (i.e., vocational or employment) program; and

_ community living.

Habilitative Services

• The habilitative program encompasses two major components for each client: 1) individual activities of daily living -- moving about, eating, dressing, and individual hygiene for him/herself; and 2) his/her participation with household activities -- assisting with meal preparation, bed-making, clean-up, and the like.
• The residential provider must have a written policy giving employees direction on how the habilitative program will be carried out using sound residential service practices and DMR policies to enhance the client's everyday life.

Behavioral Program

• If a client engages in behavior that is harmful to him/herself or others, or is socially unacceptable, the interdisciplinary team develops a program to reduce the targeted behaviors. (Any medications must be prescribed by a physician.) The residential program must have policies and procedures that will implement the behavioral program through:

_ defining the use of behavior management techniques;

_ obtaining approval from the program review or human rights committees for behavioral plans that include any techniques or strategies for aversive procedures and/or restraints or behavior-modifying drugs;

_ ensuring the use of such restraints is limited by describing when they will be used; that they are designed and used to cause minimal discomfort; that staff are trained in the strategies or techniques; and that the client will be checked at least once every 30 minutes; and

_ ensuring that in a behavioral emergency, the client will be managed using plan-approved techniques before resorting to police intervention or admission to a hospital emergency room or a psychiatric facility. If any of the latter actions must be taken, the residential provider must notify DMR of the action.

• If a behavioral program is in place, residential program staff are expected to implement the program through the strategies laid out (e.g., redirect the client from the targeted behavior) and are generally required to keep data on the behaviors and program implementation so the IDT can monitor whether the behavior-modifying strategies are having an impact. Residential programs are also required to report to DMR any unusual incidents, including behavior issues. Incident reports are kept on an automated database, and incident data are also examined quarterly by the client's IDT when reviewing his or her OPS.

Health and Safety

• A licensed residential facility is statutorily responsible to "insure the comfort, safety, adequate medical care and treatment" of the clients it cares for. By regulation and DMR policy, the residential program must ensure its health and safety practices include the following procedures.

_ Medicines are administered by staff certified by DMR in medicine administration, or that the client can self-administer.

_ Staff are sufficiently aware and trained -- "in-serviced" -- in a client's health and safety issues to provide needed services appropriately and correctly. In many cases, these functions may be delegated by a registered nurse⁴. The registered nurse must: 1) determine whether it is a function that allows delegation; 2) train all staff who will perform the task; and 3) verify, document, and monitor that they are competent to carry it out.

_ Using a newly developed procedure called "risk-screening", which case managers must see that the IDT completes, to:

1. identify clients who may be subject to risks in several health and safety areas - like seizure disorders, severe mobility limitations, and/or swallowing or eating disorders;

2. determine whether more comprehensive assessments are necessary; and

3. ensure a plan is in place for those individuals at risk. Assessments will be conducted on all clients currently in CLAs, updated annually (or earlier if a new risk is determined) and when a new client is screened prior to receiving services.

Medical

• The residential program must provide nursing services - either through its own staff or via RN consulting services -- including coordination, assessment and monitoring and provision of medical services, and planning and implementation of training for direct care personnel.
• A nursing assessment must be conducted for any client living in a CLA. The assessment is conducted within 30 days of placement as part of the client's OPS. It must be updated annually or when a client's health status changes. The RN is responsible for the total plan of nursing care and should be proximately available for on-site visits and available by telephone.
• The residential program is to ensure clients receive medical examinations as indicated by the individual's physician; that any follow-up in the way of exams or testing are carried out; and there exists signed and dated documentation of physician's orders, progress notes, or other medical records that medical attention is provided. Any special health concerns, like a non-ambulatory client requiring repositioning to prevent pressure sores, should be addressed and implemented by the residential provider staff.

Dental

• The residential program must ensure that: dental exams occur as required by the dental provider; follow-up or testing occurs as required; signed and dated documentation of dental services by the dental provider is furnished; and ongoing dental care is overseen as written in the orders (e.g., use of special oral rinses; assistance with tooth brushing).

Dietary

• The residential provider must also ensure each client is given adequate nutrition and liquid to meet their needs. Residential staff are responsible for implementing programs requiring:

_ special diets, like low cholesterol, specific caloric intake, or a diabetic diet;

_ special consistency diets (e.g., ground, pureed, or thickened liquids only); or

_ adaptive equipment for eating (like special cups or plates).

Health Oversight

• Each region employs a Health Services Director who is a Registered Nurse. The regional health directors are responsible for the coordination and delivery of health care services (nursing, physical, speech and occupational therapy, and dietary) for clients in publicly run residential programs, ensuring quality medical and dental care are provided in the community, and providing support to private sector agencies and their staff.
• Each regional health services director (HSD) establishes preventive health care programs for individuals in DMR's own residential programs and issues comparable care guidelines for private providers that comply with department policies, medical advisories, and federal and state health care standards. Each HSD also develops in-service (training) programs in health care areas, and meets monthly with private provider nurses on residential health care issues.
• DMR has a Director of Health Services (see Figure I-5 for organizational chart) located at the central office. While the regional health services directors report administratively to the regional directors, the HSDs have a clinical link with DMR's health services director in central office. The regional and state DMR health services directors currently meet at least quarterly to identify issues of health and safety, and develop bulletins and advisories that inform and assist private residential agencies and DMR in providing health and safety for their clients.
• Other advisories may be developed by physicians familiar with persons with developmental disabilities on health issues, and disseminated through DMR's website to providers and the agency. Sometimes, as a result of regional or statewide mortality reviews, (See Chapter VI) a health or safety issue will surface that requires a bulletin or advisory to be issued by the mortality review board. Over the years, DMR has issued 14 bulletins, five nursing standards and associated guidelines, and 22 medical advisories. (See Appendix D for a list).
• DMR's Quality Assurance Division, through licensing inspections and follow-up at each home, ensures these health and safety policies and practices are being implemented. In addition, Quality Assurance may, at times, issue a safety alert as a result of inspection results.

Day Program

• An integral part of a client's individual plan is how they will spend those critical hours during the day - i.e., the work or vocational plan otherwise known as their day program. Almost all CLA clients have some type of day program.
• Typically, a client's day program occurs at another location than his/her residence, although for a minority of clients the day program is operated at the clients' home. Even if the client goes off-site, the residential program must ensure the client gets ready for his or her day program, and often for transporting the person as well.
• Programs vary depending on the client's level of independence.
• In FY 01, 7,985 clients were involved in day programs - 7,028 at privately contracted day programs and 957 at DMR-run services.

Community Living

• A final part of a client's plan is his/her participation in the community. While often a less formal part of an individual's program, the residential provider must ensure this community component occurs. These individual activities might range from helping with household functions - like grocery shopping - to trips to the library or social activities like movies, dances, or community concerts.

Individual Plan and Program Oversight

• Once a client's plan has been developed and the residential program is implementing it, there are a number of mechanisms in place to ensure the plan is carried out, whether it needs adjustment, and how modifications should be made. Some protections, in the way of regional committee approvals, are put in place to ensure a client's rights are considered in the plan implementation.
• The client's case manager is responsible for ensuring the plan is appropriate and being implemented. If changes need to be made, the case manager is to bring them to the client's IDT.
• Case managers are "responsible for assisting individuals to gain access to department services, managing development, modification, and implementation of a client's OPS, securing and/or coordinating services, monitoring client progress, maintaining family contact, collecting and disseminating data and information."
• The case management function occurs at the regional level. In recent years, partly because of changing services and supports DMR provides, case management has been changing.

_ Traditional case managers serve people living in CLAs, CTHs, or supervised living.

_ Since a 7/1/01 regional reorganization, case managers are assigned to clients who are either all in public programs or all in private programs.

_ Case managers for clients in DMR-operated CLAs do more of the actual case manager functions (e.g., coordinate IDT activities and produce the OPS), while case managers for private provider clients are in more of a monitoring role to ensure the private provider performs these activities, depending on the provider.

· Traditional case managers also serve persons who live at home or on their own, but they have somewhat different functions, and are less involved.

_ Advocates are DMR employees who serve people who are more independent and need less attention. These can be DMR clients living in supported living or with their families or on their own.

_ Brokers, the newest wrinkle related in case management, are DMR employees who assist DMR clients who have individual support budgets.

• A difference in case management is that one region (Eastern) for DMR-run residential services has 19 program supervisors functioning as Team Leaders, providing case management functions for about 21 individuals each. These people also supervise DMR residential programs.
• All this variation makes comparing numbers and caseloads difficult. However, as of October 2002, there are 267 DMR employees providing some kind of regional case management function: 12.7 are advocates, and 21 are brokers. 233.25 are considered traditional, with 113.5 for CLAs, CTHs and supported living ,and 119.75 for individual and family services.

· Table III-1 shows the CLA case manager caseloads (includes clients in CTHs and SLA) broken down by region and by public or private program. The public client case manager caseload varies by region from 21 in Eastern to 47 in North Central. (As noted above, case management is provided by residential program supervisors in the Eastern region). The private provider case manager caseload also varies, from a low of 46 in Eastern to 60 in Southwest.

Appeals of DMR Services

• Any individual client or his representative can appeal any need evaluation, priority designation, or other CLA service provision decision (e.g. staffing) under the process of programmatic administrative review (PAR). The first level of appeal is to the regional director. If the person disputing the regional decision is still not satisfied, he or she can appeal to the DMR commissioner.
• In the five year period FYs 97-2001, 305 appeals were filed at the regional level. 27 were appealed to the commissioner. In most cases the regional director decision was upheld, but in some, the decision was modified.

Program Review Committee

• Any behavioral program for DMR clients living in public/private provider residential (and day) settings using behavior modifying drugs or aversive procedures must be approved by the applicable regional director prior to its implementation.

_ An aversive procedure is "the planned use of an event that may be unpleasant, noxious, or otherwise cause discomfort to alter the occurrence of a specific behavior or to protect an individual from injuring individual or others. These procedures include the use if physical isolation, mechanical and physical restraint."

• Before the regional director makes his/her decision, a Program Review Committee (PRC) must first review the proposed program for clinical appropriateness prior to its use, and make a recommendation to the director.
• The PRC also reviews procedures used during an emergency intervention and monitors their use.
• Each region and the training school has a Program Review Committee, a requirement of the 1985 Mansfield Consent Decree.
• The PRC, appointed by each regional director, is a "group of professionals," including a psychiatrist, assistant regional managers, executives of contracted agencies, contracted specialists in the disciplines of special education, psychology and medicine, and a representative from the Human Rights Committee. (see below) The committee members elect their own chair and typically meet monthly.
• Clients, parents, guardians, and/or advocates may attend the committee's meetings, which provide technical assistance to the regional or STS directors pertaining to client program policies.
• The person's IDT is responsible for preparing information packets to be considered by the PRC. The actual presentation to the PRC can be done by a psychologist or nurse.

_ Informed consent from either the client or guardian is required for use of behavior modifying drugs or aversive procedures

• In reviewing the above, the committee is to ensure that any proposals are clinically sound, supported by proper documentation, and are for uses in accord with DMR policies.

Human Rights Committee

• Any restriction on a DMR client's civil rights must also be approved by the regional director prior to its implementation (e.g., a person's privacy right to be in his or her own room without being monitored at all times by a room monitor).
• Before the regional director makes a decision, a Human Rights Committee (HRC) reviews the proposed restriction, and make a recommendation to the director. This is mainly accomplished by reviewing client behavior programs.
• Each region and Southbury Training School are required to have a Human Right Committee, also a requirement of the 1985 Mansfield Consent Decree.
• Examples of issues that come to HRCs are use of house alarms, audio room monitors, locked bathrooms, closets, sharp utensils, cleaning supplies, or locked refrigerators and cabinets, dating guidelines, restrictions and/or supervision, search and removal of personal property, and sedating medications prior to medical and dental appointments
• The committee is made up of six to ten people who serve three-year terms. By DMR policy, the regional director was to make the first appointments when the HRCs were first created; after that, the committee makes appointments to fill vacancies. Members are to include a physician, a lawyer and at least one parent (and no DMR employees). The regional director or designee is supposed to attend all committee meetings in a liaison capacity. A DMR regional staff member is assigned to assist the committee in its work.
• The committee considers the following questions.

_ What is the purpose for the proposed restriction?

_ Is it a safety issue, and why? Because of person's age, health, or medical condition; type or pattern of behavior; environmental issue beyond control of provider?

_ What less intrusive/restrictive means have been attempted to address problematic behavior?

_ Has the impact of the restriction been assessed on housemates, and have all housemates/guardians agreed to restriction?

_ Is the restriction needed at all times?

_ What are the criteria for discontinuing the restriction?

⁴ In January of 1989, the CT Board of Examiners for Nursing issued declaratory ruling concerning delegation of nursing responsibilities. Some clarification regarding the ruling was issued in April 1995, and DMR has issued its own policies to guide implementation.