1. Provider Human Rights Coordinator Role Accessing HCSIS to Support Human Rights Committee Reviews September 11, 2013

2. 2 Overview - Human Rights Coordinator This presentation is concerned with the role and responsibilities of the Human Rights Coordinator. The scope of this role captures and organizes reporting information from HCSIS and documents the findings of the Human Rights Committee in HCSIS as required. The Human Rights Coordinator is a liaison between the HR Committee and the administration of the Providing agency. It is the task of the Coordinator to gather, compile, and organize reports from several sources within HCSIS: Restraint reporting Incident reports Medication Occurrence Report’s as requested Investigative information as is appropriate and necessary for presentation to the HR Committee. The HR Committee is concerned with all elements of limitation of movement; including restraints, Supports and Health Related Protections, as well as transportation restraints and Limitation Of Movement in Behavior Plans. The Coordinator supports the Committee role as party to complaints and may also ask for other HCSIS information at its discretion

3. 3 Finding Limitations of Movement Emergency restraints [recorded in HCSIS] Supports (115 CMR 5.12) [not recorded in HCSIS, but in ISP] Health Related Protection [not recorded in HCSIS, Dr.’s order, should consider in ISP] Transportation restraint – emergency use of restraint (force over active resistance) during transportation. [recorded in HCSIS Restraint Database]

4. 4 Finding Limitations of Movement [cont.] - Un-Planned transportation restraint event instituted by providing agency in anticipation of safety concern without ISP Team support [HCSIS Incident report – Unplanned Transportation Restraint] - Transportation Restraint [Approved ISP Modification, not in HCSIS] Behavior modification plan [level 2 holding] in ISP - has an identified treatment purpose in plan [not in HCSIS unless injury occurs during intervention, or as restraint if implemented only in an emergency, these should come to you ]

5. 5 Provider Human Rights Coordinator Role The role of the Human Rights Coordinator is to gather all pertinent information and HCSIS reports [compile and print for distribution] for the HR Committee for discussion and review of restraints applied to clients of a Providing agency. This role includes recording the HR Committee’s comments regarding the use of the restraint. The role also includes read only access to Incident Management, MOR and range of Investigations documents for presentation to the Committee as it deems necessary. After review, the HR Coordinator enters into HCSIS the Human Rights Committee’s comments concerning the use of a restraint. Comments on other committee business should be reported in the minutes of the meeting and advocacy follow up on issues such as Investigations appeals etc., done as needed.

6. 6 HCSIS SYSTEM ACCESS – Restraint Reporting HR Committee preparation The HR Coordinator has the following access: Update access to the Provider Human Rights Committee Review and Comment section of the Restraint Module Read-only access to Restraint filing process: - Provider Restraint Report - Provider Restraint Manager Review - Area Management Review Commissioner’s Review Request and view Restraint Reports - Restraint Detail Report - Restraint Status and other Reports

7. 7 Process Management screens - Filing [Provider] and Review [Area Office] Process Management screens Alerts are triggered at the time a report is submitted or finalized. Alerts are ‘real time’ notifications to a specified role, e.g., an Alert is sent to the Restraint Manager at the providing agency, letting that person know, that a report is ready to be reviewed and finalized. Please note: Alerts will expire after 14 days. Actual “Printable Summary” which is a copy of a restraint report, and can be found through the switchboard in “Alerts” or by using event numbers from “Restraint Detail” report to enter into QM, IM, Data Entry Form, depending on what is easiest given circumstances. This access facilitates the HR Coordinator to prepare the reports and materials that are necessary for the HR Committee’s review of Restraints for a specified period of time. The ‘Update’ access to the HR Committee Review and Comment screen is to record the conclusions or findings of the HR Committee in HCSIS.

8. 8 Overview of Report Listing available to the Human Rights Coordinator

9. 9 Restraint Reports Restraint Detail - This report displays detail records for Restraints which fit the filter criteria. The data in the report is grouped by Individual. Summary totals are provided for number of Restraints and the total duration of the Restraints, etc. and includes time and date of restraints along with position of hold. Restraint Status Report - This report displays the status of a Restraint as well as the next step which must be taken. The report contains detailed information regarding the Restraint such as Event ID, Date and Time and the Individual involved. – The report must be viewed from the perspective of DDS or of the Provider Printable Restraint Summary – provides an actual copy of the Restraint report which can be use to provide copies of the report to the Human Rights Committee or its designates.

10. 10 HCSIS SYSTEM ACCESS – Restraint Reporting: HR Committee preparation and tasks Use the Restraint Detail report to: Compile and print documents to be reviewed by the HR Committee and /or an appointed sub-committee. Print a copy for each member of the committee. Print out Restraint Detail Report for established period of Restraint Review. Print copy for each Committee or Sub-committee member Print out one copy of each restraint to be reviewed based on the list created in the Restraint Detail report. If Committee has convened a sub-committee, that sub-committee should review the individual restraints and the pattern they show in the detail reports and prepare their impressions for the main committee on reviewed restraints. Any sub-committee comments, concerns or findings of the sub-committee will be reviewed and approved by main Committee Committee reviews information from HR Coordinator or sub-committee and documents findings on each restraint, but may have their unique questions too. Coordinator updates HCSIS with provider Human Rights Committee Review and Comment for each restraint

11. 11 Sample of Restraint Detail Report: Report selection screen

12. 12 Sample of Restraint Detail Report: Sample of report output

13. 13 Restraint Report Switchboard Screen Capture: Use this screen to print out the ‘Printable Restraint Summary’ for distribution to the Human Rights Committee or its designates. Secondly, the switch board can be used to ascertain the status of a Restraint report; In-progress, finalized, whatever the case may be from the perspective of the the Provider [and/or DDS.] Finally, this view provides the status of the Provider Human Rights Committee Review and Comment screen; in progress or finalized.

14. 14 Restraint Report Screen Capture - Human Rights Committee Review and Comment screen This view displays the screen content for the HR Coordinator to fill out. Alerts – Please note that the alerts sent to the HRC are general and only note that a Restraint report has been ‘Marked Complete and Finalized’. The creation of the HRC review and comment is not dependent upon the Area Office review.

15. 15 Restraint Status Report - report selection screen: use this report to display all reports within a given period of time and the next step to be taken in the reporting process.

16. 16 Sample of Restraint Status Report: Sample of report output

17. 17 HCSIS SYSTEM ACCESS – Restraint Reporting: HR Committee preparation and tasks Use the Provider ‘Filing Process Management’ screen to identify if there are any restraints not reported in the detail report, because the “initial restraint” is in the ‘In-Progress’ status from the Provider’s perspective. This will enable you to be aware of restraints from the period you are reviewing that haven’t been fully processed.

18. 18 Filing Process Management – Again, use the Provider Filing process management screen to display Restraint reports that are ‘In-Progress’; the ‘Recent Milestone’ of ‘In-Progress’ will not be captured or displayed on the Restraint Status report.

19. 19 HCSIS SYSTEM ACCESS – Incident Reporting Data Summaries Read-only access to the submitted/finalized Initial Report and Final Report, Area and Regional Management Review. Click on Reports tab, select “Events by Individual Detail Report” Pull data for period of review from HCSIS Incident Report List for “All Events” for your agency Present copies of summary report to HRC. Have copies of each incident report available if needed (select QM; IM; Event Data Entry, select by event ID number from summary report). Follow up with agency as requested

20. 20 Events by Individual Detail Report - Fill in dates, from and to, event type (All Events) the name of your Provider; and Report Format, print out product for HRC

21. 21 Enter Event ID: for Each Incident # on Summary Report to Obtain Full Reports

22. 22 HCSIS SYSTEM ACCESS – Investigations The HR Coordinator has the following access: Read-only access to: Intake Printable Summary Disposition Letter Notice Action Plan/Resolution Action Plan/Resolution Report Notice Process Management screen Alerts When the Senior Investigator finalizes a Disposition When the Area Office issues an Action Plan This access facilitates the HR Coordinator work preparing the reports and materials that are necessary for the HR Committee’s review of Investigations according to change in status, disposition, or Action Plan/Decision/Resolution.

23. 23 HCSIS SYSTEM ACCESS – Investigations (Disposition Phase) Use the Process Management Screen to identify cases created since the last meeting: Select Intake Received Date From = 1 week prior to last meeting Select Intake Received Date To = Today’s Date Click Search Click on each Log # hyperlink Print out for each member the DPPC Intake Printable Summary for each case. Print out one copy of the Disposition Letter Notice for each case.

24. 24 HCSIS SYSTEM ACCESS – Investigations (Decision Phase) Use the Process Management Screen to identify cases where an Action Plan was issued since the last meeting: Select Status = Action Plan/Resolution Issued Click Search Click on each Log # hyperlink If the Action Plan/Resolution Issued Date is after the last meeting, print out one copy of the Action Plan Resolution Report Notice. If necessary, obtain a copy of the Decision Letter from the Agency. If necessary, obtain a copy of the Investigation Report from the Senior Investigator. Repeat the previous process, but this time select Status = Case to be Closed if No Appeal

25. 25 HCSIS SYSTEM ACCESS – Investigations Smaller agencies may be able to obtain all of the information needed from one Process Management Screen by entering no selection criteria and sorting by Date Received from DPPC Committee should have procedure in their by-laws to authorize actions by chair as needed between meetings within time-lines. Committee is party to each complaint.

26. 26 Investigations Data Entry Screen Capture Clicking on Action Plan Issued Alert will display Investigations Switchboard

27. 27 Clicking on the Action Plan hyperlink on the Switchboard will access the Action Plan screen

28. 28 Clicking on Disposition Letter Alert will display the Disposition Letter Selection screen

29. 29 Clicking on the Open button will display the Disposition Letter (this is a partial display) This letter can also be printed if necessary.

30. 30 Alternative Approach to Investigations Click onto Process Management tab Click on log # on left Use this screen to navigate to Printable Summary (which describes the allegation), or to notices If your agency is small and you don’t identify a period, the list will show you the current status of all complaints.

31. 31 Questions Contact your Human Rights Specialist to answer any questions. Go to mass.gov//dds and click on “Human Rights” in top left column and scroll down to Human Rights Specialist list, or call: Tom Anzer, DDS Director for Human Rights 617-624-7738