SUMMARY OF HCFA LICENSING SURVEY AT FAIRVIEW DEVELOPMENTAL CENTER 8/22/97

The facility failed to ensure the governing body provide, monitor, and revise, as necessary, policies and operating directions which ensure the necessary staffing and training resources to provide individuals with active treatment and to provide for their health and safety.

This was evidenced by a failure of the facility to:

ensure that there were sufficient number of competent, trained staff to provide active treatment and protect individual's health and safety.

exercise general policy and operating direction over the facility.

ensure that client records were accurate.

ensure that each client received a continuous active treatment program.

The cumulative effects of these systemic practices resulted in the facility to deliver statutory mandated governing body services.

The facility failed to develop a policy and procedure (P&P) for:

the use of on and off grounds privileges.

address the needs of those clients who were identified as suicidal.

The use of wheelchairs with non-releasable seatbelts.

Clozapine therapy.

For implementing a system that protected the client's health and safety.

Alerting staff for choking precaution.

Maintaining accurate diet orders.

The facility did not ensure the rights of clients by failing to:

allow clients to manage their financial affairs to the extent of their capabilities.

ensure clients retained and used appropriate personal possessions and clothing.

The facility failed to ensure that the results of all investigations of any allegations of abuse were reported to the administrator or designated representative or to other officials in accordance with State law within five working days of the incident.

The cumulative effect of systemic practices resulted in the failure of the facility to provide statutorily mandated staffing sufficient in number and training to implement client programs and to manage client behaviors.

This was evidenced by failure:

to ensure each client received the professional program services needed to implement the active treatment program defined by each client's individual program plan.

to ensure that qualified professional staff was available to carry out and monitor the various professional interventions in accordance with the stated goals and objectives of every individual program plan.

to provide sufficient direct care staff to manage and supervise clients in accordance with their needs.

to ensure that the staff were able to demonstrate the skills and techniques needed to implement the individual program plan.

to ensure that each client received a continuous active treatment program.

to ensure that it does not serve individuals who are able to care for their own basic needs.

to include a vocational assessment.

to ensure that the IDT developed and prioritized specific objectives based on individual needs.

to ensure that the training programs provided specific methods to staff persons working with the individuals.

to ensure program plans for clients who lacked training in personal skills essential for independence.

to ensure that clients were provided opportunities for choice and self-management.

to ensure that a parent or guardian was designated as a member of the committee or committees.

to ensure that restrictive programs were reviewed and monitored to protect the rights of clients.

to ensure that the practice of locking all client units had been reviewed and monitored for infringement of client's rights.