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Wa Special Civil Commitment Center Audit 2007

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INSPECTION OF CARE
Program Standards

Evaluation Tool

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..

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The Special Commitment Center
Department of Social and Health Services
State of Washington

Interim Inspection of Care Report
October 2007

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

Staff Competence, Training, Supervision
I-A
I-B
I-C

II

Treatment Program
II-A
II-B
II-C
11-0
II-E
II-F
II-G
II-H
II-I
II-J
II-K
II-L

III

Staff training, licensure
Staffing
Facility
Pharmaceutical services
Documentation, confidentiality
Routine, preventive, emergent care
Support services
Psychiatric services

Program Oversight
IV-A
IV-B

V

Treatment program components
Treatment phases
Treatment plans
Measures of progress
Transition to community living
Management, restraint, use of force
Treatment-oriented environment
Space and group separation
Professional staff behavior
Consistent policy enforcement
Respect and grievances
Long-term care needs

Health Care Services
III-A
III-B
III-C
111-0
III-E
III-F
III-G
III-H

IV

Administrative and clinical supervision
Residential program staff supervision
Staff training

External oversight, incident investigation
Internal quality, protections, review, investigation

New Admissions
V-A Intake and orientation
V-B Health screening upon admission
V-C Determination of risk and needs
V-D Initial treatment planning

2

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

VI

Food Service
VI-A
VI-B
VI-C
VI-D

VII

Safety and Emergency Preparedness
VII-A

VIII

Standards and practices
Menu planning
Health and safety standards
Special health or religious diets

Fire safety, hazardous materials, natural disasters

Security
VIII-A Adequate security
VIII-B Incident documentation and follow-up
VIII-C Investigation of alleged criminal violations

IX

Resident Information
IX-A
IX-B

X

Resident records
Medical research

Physical Plant
X-A
X-B
X-C

Building and safety codes
Housing for residents with physical disabilities
Indoor air quality

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Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

STANDARD I:
I-A

Staff Competence, Training, Supervision

Qualified professionals provide consistent administrative and clinical direction
and supervision.

CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOeTeam
Comments
1. see has made significant strides in the implementation of its new delivery model for Sex Offender
Treatment (SOT) at the facility. The filling of eight Psychology Associate positions in the period since
the earlier 2007 inspection is a major benchmark of this progress.
2.

At the time of the interim inspection, see was experiencing a quite high vacancy rate for its
Psychologist positions, with only one filled position.

3.

Given the specifics of see's situation-i.e., location on an island that complicates working
conditions, a clientele comprised exclusively of high risk sex offenders, and the option for state
employment at other treatment facilities in the immediate area-it is very understandable why see is
facing a very difficult situation in terms of recruiting and retaining certain clinical classifications.

4.

At the time of the interim survey, see had a major training effort underway for new clinical staff.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, SCC Action Plan.
Recommendations

1. In an effort to address the difficulty in recruiting and retaining skilled clinical staffing,
the IOC Team endorses the concept of some sort of "assignment pay" for these
classifications working at SCC.
SCC Response
The Team's conclusion, comments and recommendation are noted.
IOC Team Final Comments
No further comments.

2

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD I:
I-B

Staff Competence, Training, Supervision

Residential program staff are qualified, adequately supervised and trained to
provide residential care and treatment components.

CONCLUSIONS:

rg] Meets expectations.

D
D

D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IDe Team
Comments
1. sec has implemented a tracking and follow-up process for delinquent employee evaluations.
2.

At the time of the interim inspection, the delinquency rate for performance evaluations was basically
at the same place as it was during the March inspection-Le., about one-third of reports were
delinquent. Since the process change implemented by sec will require some considerable period of
time before it has an impact on the overall delinquency rates, the current situation is not surprising.

Evidence/Observations upon which conclusions & recommendations were based
Personnel records, staff interviews.
Recommendations

1. The loe Team recommends that sec continue to monitor compliance and take the
corrective actions outlined in its Action Plan.
SCC Response
The Team's conclusion, comments and recommendation are noted.
IOC Team Final Comments
No further comments.

3

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

I-C

Staff are adequately trained to competently provide treatment, residential care and
security.

CONCLUSIONS:

ISl

D
D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1.

SCC has developed a Power Point clinical orientation presentation for contracted medical
staff and also included Program Area Nurses (PANs) in unit in-service training.

2.

At the time of the interim inspection, the Clinical Program had a major training underway
for new staff.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, SCC Action Plan.
Recommendations

1. The IOC Team recommends that SCC continue with its staff training efforts as
outlined in its Action Plan.
SCC Response

The Team's conclusion, comments and recommendations are noted.
IOC Team Final Comments

No further comments.

4

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD II:
II-A

Treatment Program

The treatment program offers the components that are typically provided in
inpatient programs for sexually violent offenders.

CONCLUSIONS:

[gJ Meets expectations.

o
o
o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IDe Team
Comments
1. sec has adopted a number of process changes to address the issue of group cancellations: (A)
approval required for group cancellations; and (B) establishing a process for arranging alternative
coverage for co-therapist vacancies.

2.

sec has not established a process for tracking the number of sessions held, the number cancelled,
etc.-Le., the institution has established a procedural "fix" to this issue but it does not collect data
that would substantiate the impact of these procedural changes.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews.
Recommendations

1. SCC should consider establishing a tracking system for therapeutic groups that
would measure the impact of the procedural changes on the issue of group
cancellation. Further, this data may be helpful in assessing other issues that SCC
may face in the future-e.g., litigation over the level of treatment programming,
assessing clinical staffing workload, etc.
SCC Response
The Team's conclusion, comments and recommendation are noted.
IOC Team Final Comments

No further comments.

5

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

11-8

The treatment program has identifiable phases sequentially progressing from
orientation to transition to community living.

CONCLUSIONS:

[:2J Meets expectations.

o
o
o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. Since the March inspection, SCC received court approval to move two residents from the adapted
program's first cohort group to the SCTF-Pierce. This reflects a major programmatic
accomplishment and reflects favorably on the cohort strategy that SCC adopted.

2.

During the same interim period, no SCTF placements were approved for residents in the regular
treatment program track.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews.
Recommendations

1. The IOC Team commends SCC for its accomplishment on these recent placements.
At the same time, it is important that SCC's focus on community transitional
placements fully encompass the conventional portion of its treatment program.
SCC Response
The Team's conclusion, comments and recommendation are noted.
IOC Team Final Comments

No further comments.

6

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD II:
II-C

Treatment Program

Treatment plans are individualized and comprehensive.

CONCLUSIONS:

D
IZl
D

D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. A review of a sample of treatment records indicated that the issue of different formats being used in
treatment plans is not a significant issue. The sample indicated the use of a standard format
throughout the facility.

2.

The record sample indicated that missing treatment plans in resident records remains an issue.
Given the key role that treatment plans play in each resident's care and treatment, it is essential that
all residents have an up-to-date treatment plan.

Evidence/Observations upon which conclusions & recommendations were based
Sample of treatment records.
Recommendations

1. The IOC Team recommends that SCC initiate a QA project that will check each
resident's records for the presence of an up-to-date treatment plan, with an
associated follow-up process to ensure that any deficiencies identified are remedied
in a short period of time. (The Team notes that SCC's own record auditing process
identified the absence of treatment plans in a portion of resident records.)
SCC Response
The Team's conclusion, comments and recommendation are noted.

see had preViously implemented a QA tracking process for this matter and we are working to correct the
backlog.
IOC Team Final Comments

No further comments.

7

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

II-D

Systematic measures of progress are used; feedback is regularly provided to
participants.

CONCLUSIONS:

D

Meets expectations.

~ Meets minimum expectations - requires improvement in some areas.

D
D

Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
lac Team
Comments
1. SCC has committed to an intensive effort to improve the quality and relevancy of residential unit staff
charting. In a number of the charts reviewed by the lac Team, it is evident that the quality of this
progress noting has significantly improved.

2.

The impact of this quality improvement effort is more evident in certain program areas than it is in
others.

3.

The lac Team concluded that the rating from the March inspection should remain, but if the
improvement in charting continues to expand throughout the facility, we would anticipate that the
scoring will likely be raised in the next full inspection.

Evidence/Observations upon which conclusions & recommendations were based
Treatment chart reviews, program documentation.
Recommendations

1.

see should continue with the QI efforts relative to residential unit progress noting.
The institution should ensure that this improvement project is followed throughout
all of the program areas.

SCC Response
The Team's conclusion, comments and recommendation are noted.
IOC Team Final Comments

No further comments.

8

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD II:
II-E

Treatment Program

The program has a component to assist residents in systematically preparing for
transition to community living.

CONCLUSIONS:

I:8J

o
o
o

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments

No further comments.

9

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD II:

n.. F

Treatment Program

The program has adequate policies and procedures on the intensive management
of residents, use of seclusion or restraint of residents, and graduated intervention
and the use of force.

CONCLUSIONS:

D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
IS] Does not meet expectations - requires significant improvement.
D Not Reviewed.
Reviewer(s)
IOCTeam
Comments
1. Unit resident care staff was able to verbalize the protocol for placing residents in
isolation/seclusion or restraints which includes the notification protocol, correct assessment
practices, the need for proper location of staff for frequent viewing of the resident and
documentation of the process. Since there were residents in the IMU, the IOC team member was
. able to validate the knowledge of the process by observation of actual practice and
documentation.
2.

It was determined that there are two types of isolation/seclusion which are used at SCC: (1)
Administrative Isolation for behavioral reasons and (2) Seclusion as psychiatric
treatment/management for the resident. These two types of isolation/seclusion or need for
restraints are treated much the same as follows:
a. Unit staff identifies the need for isolation/seclusion or restraints and notify the on-site
administrator.
b. The on-site administrator notifies the Psychiatrist or Clinical Director of the need for
isolation/seclusion or restraints.
c. Concurrently the on-site administrator notifies the QRT (security) who assist to place
residents in Isolation/Seclusion or restraints.
d. The on-site administrator also notifies the Medical Services staff (either the Nurse
Manager of Health Services or the PAN nurses) of the need for their services.
e. Medical services staff do an initial assessment and two hour assessments to ensure
resident safety.

3.

While there is a policy for the use of "controlled segregation" a written policy was not found for the
use of physical restraints-e.g., the "restraint chair" which is used on an ongoing basis.

4.

A written procedure or protocol to follow was not found. While staff members who were
interviewed by the IOC team member were able to describe the process, there is no method to
determine knowledge of all staff. This lack of specific procedures or protocols also presents a
problem in the training of new staff.

5.

The Nurse Manger did not know how many times the staff under her direction (PANs) was
involved in the use of isolation/seclusion or restraints. The Health Services staff also lacks a
written policy and procedure for their role in isolation/seclusion and restraint of residents.

10

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

EvidencelObservations upon which conclusions & recommendations were based
SCC policies, staff interviews.
Recom mendations

1. The lack of written procedures in the use of isolation/seclusion or use of restraints is a
critical omission which needs to be remedied immediately. The IOC team recommends that
this be carried out as soon as possible.
2. The two types of isolation/seclusion-- Administrative Isolation for behavioral reasons or
Seclusion as a part of psychiatric treatment/management--need to be addressed in two
separate policies and procedures.
3. It should not be necessary for the psychiatrist or clinical director to give permission for the
use of Administrative Isolation, since this usage is not geared towards psychiatric issues.
The proper chain of command for approval could be the Superintendent or designee.
4. The Health Services staff does not need to be involved in Administrative Isolation unless
there are certain circumstances which would make their participation critical to the well
being of the resident. These circumstances should be spelled out in the policy and
procedures.
5. Once the policies and procedure are revised or created, all staff should be trained in content.
This training should be continued on an on-going basis.
6. It is also recommended that the Nurse Manager of Health Services design a QI system where
the PAN nurses send written documentation of their participation in the use of seclusion and
restraints so any problems with the process can be identified and corrected.
SCC Response
The Team's conclusion, comments and recommendations are noted; acknowledging the need for clearly
articuiated policies and procedures covering the use of Administrative Isolation, Seclusion and Restraint
interventions.

The SCC Superintendent has issued a directive to form these policies. All applicable staff will be
provided training about the new policies and procedures.
A project lead has been established and work is underway. Comparative research has been conducted,
including obtaining relevant polices from a local state psychiatric hospital and other Sex Offender Civil
Commitment Programs and obtaining relevant JCAHO standards and CMS regulations.
A workgroup, with medica; services and psychiatry representation, has met and is forming an immediate
measure to address the IOCC findings by developing a new flow-sheet that will improve documentation of
the use of the interventions, including authorization for use and monitoring of the resident while in
seclusion or restraint.
The workgroup is also underway with drafting the new policies.
•

It is anticipated that the flow-sheet will be completed by February 27, 2008.

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Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

•

It is anticipated the new policies will be completed by March 26, 2008.

•

It is anticipated staff training will be completed by April 30, 2008.

IOC Team Final Comments
The IOC Team acknowledges the workgroup and associated work plan on this issue. SCC's planned
approach to the issue is sound. It is, however, unfortunate that the workgroup's schedule was not better
coordinated with the next full IOC visit, since neither the policies nor staff training will be completed prior
to that survey.

12

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD II:
II-G

Treatment Program

Residents are housed in a facility that provides a treatment-oriented environment.

CONCLUSIONS:
~ Meets expectations.

o
o
o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. In response to an observation in the March inspection,
include a brief discussion of psychiatric services.

sec has modified the Resident Handbook to

Evidence/Observations upon which conclusions & recommendations were based
Resident Handbook.
Recommendations

SCC Response

The Team's conclusion and comment are noted.
IOC Team Final Comments

No further comments.

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Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

II-H

Adequate space is provided for resident living, treatment, other activities, and
separation among resident groups.

CONCLUSIONS:

[g] Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

o
o
o

Reviewer(s)
lac Team
Comments
1. The lac Team did not specifically review this issue during the interim inspection. However, a
general concern is expressed about this issue in our addendum to our report.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion and comment are noted.
IOC Team Final Comments
No further comments.

14

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD II:
II-I

Treatment Program

Behavior of all staff is therapeutic and professional.

CONCLUSIONS:

D

Meets expectations.
cg] lVIeets minimum expectations - requires improvement in some areas.
D Does not meet expectations - requires significant improvement.
D Not Reviewed.

Reviewer(s)

loe Team
Comments
1. sec has revised this standard to establish a more realistic standard-Le., the standard has been
revised to state that staff are trained to, and held accountable for, professional and therapeutic conduct.
Evidence/Observations upon which conclusions & recommendations were based
SCC Action Plan
Recommendations
SCC Response
The Team's conclusion and comment are noted.
IOC Team Final Comments

No further comments.

15

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

II-J

Program policies are consistently enforced.

CONCLUSIONS:

o
r;gJ
o
o

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
D.oes not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOeTeam
Comments
1. See II-F for concerns about the lack of written procedures for Isolation/Seclusion.
Evidence/Observations upon which conclusions & recommendations were based
Policies, interviews.
Recommendations
SCC Response

The Team's conclusion and comment are noted.

see recognizes that the seclusion and restraint policy needs improvement. Please see Standard II-F for
our detailed plan to address this matter.
It is sec's view that citing this single policy issue does not demonstrate how we are meeting minimum
expectations.
IOC Team Final Comments

The loe Team understands why see views it as inappropriate to score this item as "meets minimal
expectations" while only citing one specific deficiency. With the caveat that the Team will shortly be
revisiting this and all other standards in the 2008 fulllOe survey, the Team's thinking on this issue was as
follows:
1.

Restraint and seclusion is one of the most intrusive and high risk procedures for any
facility/program. Thus, the Team viewed the improvements needed in this area as a critical part
of the assessment of policy application consistency.

2.

There are other policies where compliance appears to be problematic-such as the one stating
the need for a current treatment plan for each resident-that also could be cited under this item.

3.

The Team's interim survey was targeted at the responses made by see in its response to the full
2007 loe survey. Thus, the 2007 interim survey did not attempt to provide a comprehensive
review of this entire standard.

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Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

17

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

IJ-K

Residents are treated with respect and have opportunities to have their
grievances addressed.

CONCLUSIONS:

[g] Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. As a result of the review during the interim inspection, the IOC Team has rated SCC's performance
as meeting expectations for this standard.

2.

It should be noted, however, that the short time frame for the interim inspection precluded the Team
from tracking and reviewing individual cases throughout the process. The Team plans to undertake
a more detailed review during the next full annual inspection.

Evidence/Observations upon which conclusions & recommendations were based
Policies, staff interviews.
Recommendations

SCC Response

The Team's conclusion and comments are noted.
IOC Team Final Comments

1\10 further comments.

18

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD II:
II-L

Treatment Program

The program addresses the long-term care needs of residents who do not choose
to participate in sex offender specific treatment activities.

CONCLUSIONS:

[g] Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
loe Team
Comments
1. sec has developed a menu of potential incentives for treatment that could be implemented, and
several of them are very creative. However, at the time of the interim survey, none of these options
had been implemented.
Evidence/Observations upon which conclusions & recommendations were based
SCC Action Plan, staff interviews.
Recommendations

1.

see should select one or more of the potential incentive packages and implement it
in the near future.

SCC Response
The Team's conclusion, comment and recommendation are noted.

IOC Team Final Comments

No further comments.

19

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD III:
III-A

Health Care Services

Health care services staff are trained and licensed to provide care adequate to
meet the routine and emergency medical needs of residents.

CONCLUSIONS:

~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOeTeam
Comments
1. The new organizational chart reviewed has a line of authority for the contracted nursing staff to
report to the Health Services Administrator. Since this position is vacant, the Nurse Manager is
carrying out the supervisory tasks of this position.

2.

According to the Nurse Manager, the use of contract nursing staff is a direct result of inadequate
salary levels. Adequate payment is needed to attract these nurses as permanent employees of
see. It was stated by the Nurse Manager that many of the contract nurses who are familiar with
the institution would be interested in permanent positions if the salaries were adequate.

3.

The scope of medical care provided by see to its resident populations is now commensurate to
that found in the Basic Health eare Plan of Washington. This information is found in Policy 801.

4.

Resident must now pay for some aTe medications with the exception that when the physician
orders the medication, there are no charges. In this regard, there is now an extensive list as to
what residents can purchase from off island stores

5.

There is now a policy to allow see residents to make decisions related to their end of life care
and exercise those rights.

6.

There remains an issue with the lack of coordination between psychiatric services and general
health care providers at see. While the loe Team did not identify any specific instances where
this lack of coordination had a negative impact on the quality of care, the lack of a coordinated
approach is an unacceptable situation.

Evidence/Observations upon which conclusions & recommendations were based
Interviews, observations and document review.
Recommendations

1.

The IOC Team recommends that the Nurse Manager continue to carry out the
supervision of the contract staff.

2. It is also recommended that the Health Services Administrator position be
modified to require a clinical nurse specialist to serve in that role.

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Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

3. It is recommended that the nursing positions at see be upgraded to that of a
clinical specialty which would facilitate the application of assignment pay. There
is precedent for this action in other state facilities.
4. It is recommended that see establish a specific plan intended to improve and
facilitate communication and cooperation between psychiatric service and general
health care providers. As a starting point, it may be appropriate for the
Superintendent's Office to be directly involved in the resolution of any
issues/barriers that may serve to inhibit the necessary
cooperation/communication.

SCC Response
The Team's conclusion, comments and recommendation are noted.
IOC Team Final Comments
No further comments.

21

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD III:
111·8

Health Care Services

Health care services staffing is sufficient to provide residents with routine and
emergent medical care.

CONCLUSIONS:

IZl

D
D
D

Meets expectations.
Meets minimum expectations· requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.
IOC Team Final Comments
No further comments.

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Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

III-C

Health care facility is sufficiently equipped to provide routine and emergent health
care services to residents.

CONCLUSIONS:

[8J Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1\10 comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.
IOC Team Final Comments
No further comments.

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Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

11I-0

Pharmaceutical services are sufficient to meet residents' routine and emergent
health care needs.

CONCLUSIONS:

I:8J

D
D

o

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. As a result of the interim inspection, the IOC Team rates
standard.

sec as meeting expectations for this

2.

There is an improved system of reordering drugs in place with a designated person providing support
to this activity. This person is eligible for the necessary credentials to serve as a pharmacist
technician when the pharmacy service is licensed

3.

There is no automatic refills program in place and no complete/current list of physicians/ARNP
orders was found in the records.

4.

The team was informed of a plan to collaborate with Western State hospital in setting up a more
comprehensive system to manage medication services.

Evidence/Observations upon which conclusions & recommendations were based
Staff interviews, medical records review, tour of medication room.
Recommendations

1. SCC's plan to collaborate with Western State Hospital for medication service
improvements seems to be a sound plan.
2. The IOC Team suggests that as an interim approach SCC staff might consider
working with off-island pharmacies in setting up a system of automatic drug
reordering. This is a common practice in off-island community care facilities
and not difficult to access. This service can also provide a current list of
physician/ARNP orders and a pharmacist review of orders for quality purposes.

SCC Response
The Team's conclusion, comments and recommendations are noted.
IOC Team Final Comments

No further comments.

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Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD III:
III-E

Health Care Services

Resident health care records include information essential to the residents' health
care needs and are prepared and maintained in a manner that supports the
residents' treatment and respects confidentiality.

CONCLUSIONS:

D

Meets expectations.

~ Meets minimum expectations - requires improvement in some areas.

D
D

Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)

loe Team
Comments

1.

sec is now providing administrative and nursing support targeted specifically for the facility's
psychiatrist.

2.

The progress notes completed by the psychiatrist are excellent. Also, it is noted that initial

psychiatric evaluations are now routinely being documented on new referrals for psychiatric services.
3.

During chart reviews, it was noted that in some cases there was too long of a delay before a new
admission on psychiatric medications was seen by the psychiatrist. While these delays did not
disrupt the resident's access to his psychiatric medications, an extended delay in these sorts of
cases is not an acceptable practice.

EvidencelObservations upon which conclusions & recommendations were based
Resident health record reviews and staff interviews.
Recommendations

1. It is recommended that the initial psychiatric assessments should be completed in
the context of addressing all five axis in the report.

SCC Response

sec notes that the loee is addressing three aspects of this standard:
•

The importance of timely interaction between the sec facility psychiatrist and new admissions
known to be on psychiatric medications in order to ensure medication continuance.

•

The value of baseline psychiatric assessments, and

•

The quality of psychiatric progress notes.

IOC Team Final Comments
The loe Team acknowledges sec's response and is supportive of the view that psychiatric services at

sec have improved significantly over the last several years.

25

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

STANDARD
III-F

III:

Health Care Services

Residents receive adequate routine, preventive, and emergent health care
services.

CONCLUSIONS:

[g] Meets expectations.
D Meets minimum expectations - requires improvement in some areas.
D Does not meet expectations - requires significant improvement.
D Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. As a result of the interim inspection, SCC's rating for this standard is increased to meets
expectations.
2.

It was noted that SCC does not run practice emergency codes

Evidence/Observations upon which conclusions & recommendations were based
Observations of clinic and program area, staff interviews, health record reviews, and review of
other documentation.
Recommendations

1. It is recommended that SCC develop a practice of running practice emergency
medical codes.
SCC Response
The Team's conclusion, comments and recommendation are noted.
IOC Team Final Comments

No further comments.

26

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

III-G

Health care support services are available to the program.

CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. As a result of the interim review, it was determined that SCC meets the expectations for this
standard.
2.

Program Area Nurses regularly attend weekly staffings.

Evidence/Observations upon which conclusions & recommendations were based
Interview and health record review.
Recommendations

SCC Response
The Team's conclusion and comments are noted.
IOC Team Final Comments
No further comments.

27

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

STANDARD III:
III-H

Health Care Services

Residents receive adequate psychiatric services necessary to support their
progress in treatment.

CONCLUSIONS:

IS] Meets expectations.

o
o
o

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. Mental status exams are now routinely being documented in the chart. Also, the quality of the
psychiatric progress notes is very good.

2.

Medication renewal orders are now being better documented in the chart.

Evidence/Observations upon which conclusions & recommendations were based
Chart reviews, interviews.
Recommendations

SCC Response

The Team's conclusion and comment are noted.
IOC Team Final Comments

No further comments.

28

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD IV:
IV-A

Program Oversight

The program has external oversight, either through a licensing organization or
other entities (a governing body, inspections by outside professionals,
ombudsman services, and external investigation of incidents).

CONCLUSIONS:

r:gJ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further com ments.

29

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

IV-B

The program has internal review procedures covering quality assurance,
protection of residents' rights, policy review and compliance, and internal
investigation of incidents.

CONCLUSIONS:
~ Meets expectations.

D
D

D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
lac Team
Comments
1. As a result of the interim inspection, SCC's rating for this standard has been increased to meets
expectations.
2.

The timeliness of policy reviews for sunset purposes has improved.

3.

SCC continues to collect a considerable amount of data on its activities.

4.

A number of SCC's internal QI audits/assessments were very helpful to the lac process.

Evidence/Observations upon which conclusions & recommendations were based
Document review and interviews.
Recommendations

1. sec should continue to develop its ability to monitor, track, and analyze data.
Recognizing that resource constraints may preclude this as a possibility, the loe
Team recommends that sec assess the feasibility of increasing the level of staffing
resources available for QI purposes.
SCC Response
The Team's conclusion, comments and recommendation are noted.

IOC Team Final Comments
No further comments.

30

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

STANDARD V:
V-A

. New Admissions

Residents are involved in a comprehensive intake and orientation process upon
admission to the program.

CONCLUSIONS:

IZI
D
D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based

Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
1\10 further comments.

31

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

V-B

Residents receive a health screening upon admission to the program.

CONCLUSIONS:

C8J

D
D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

32

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

v-c

The program follows an established process for determining each resident's risk
level, housing and treatment needs.

CONCLUSIONS:

IZ1

D
D
D

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments

Evidence/Observations upon which conclusions & recommendations were based

Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

33

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

V-D

An initial treatment plan is developed for each resident following his/her
admission to the program.

CONCLUSIONS:

IS] Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Chart reviews.
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments

No further comments.

34

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD VI:
VI-A

Food Service

The program's food services department is managed by experienced staff who
follow established standards and practices.

CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations· requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer{s)
IOC Team
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

35

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

VI-B

The food service program meets established health and safety standards.

CONCLUSIONS:

IZ1

o
o
o

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer{s)
IOC Team
Comments
No comments.
Evidence/Observations upon which .conclusions & recommendations were based
Review of menus and the comprehensive computerized system for nutritional analysis.
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

36

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD VI:
VI-C

Food Service

The program's menu planning is adequate to meet the residents' needs.

CONCLUSIONS:

[Z] Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
1. At the time of the interim inspection, the benches and tables in the dining area were being painted.
Evidence/Observations upon which conclusions & recommendations were based
Observation of dining area.
Recommendations

SCC Response
The Team's conclusion and comment are noted.

IOC Team Final Comments

37

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

VI-D

The program provides adequate and appropriate meals for residents with special
diet needs because of health or religious reasons.

CONCLUSIONS:

r:g] Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments

No further comments.

38

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

STANDARD VII:
VII-A

Safety and Emergency Preparedness

The program has adequate procedures for managing fire safety, handling and
disposing of hazardous materials and natural disasters.

CONCLUSIONS:

IZ1

o
o
o

Meets expectations.
Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
1. At the time of the interim inspection, SCC was still in the process of installing wall lighters
throughout the facility.

2.

Clearly, this project was much more complicated than originally anticipated.

3.

Matches are still routinely made available to all residents. Given the method of distributing
matches (i.e., a bowl of available matches on the units), it is likely that many residents have more
than one book of matches.

4.

Based on limited contacts with residents, it appears that there is considerable resistance to the
concept of wall lighters.

Evidence/Observations upon which conclusions & recommendations were based
Interview, observations and document review.
Recommendations

1. Notwithstanding the difficulties and delays encountered in the wall lighter project,
the IOC Team remains committed to the position that residents should not possess
matches. Accordingly, the Team recommends that access to matches by residents
be eliminated in as timely a manner as possible.
SCC Response

The Team's conclusion, comments and recommendation are noted.
IOC Team Final Comments

No further comments.

39

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD VIII:

Security

VIII-A The program's security measures and practices adequately protect residents,
staff, and the community.
CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed~

Reviewer(s)
loe Team
Comments
1. Per loe Team comments during the March inspection, sec has removed the punching bag in the
recreation yard.
2.

sec has decided to address the issue of plants in resident rooms as a part of a larger plan to control
and manage resident property.

3.

sec has built language into its computer policy clarifying sanctions that are associated with the
misuse of personal computers by sec residents.

4.

sec has purchased and constantly uses sophisticated computer equipment that allows the facility to
investigate potential computer misuse. The use of this equipment has led to referrals and
prosecution for child pornography.

Evidence/Observations upon which conclusions & recommendations were based
Tours, staff interviews.
Recommendations

1. The IOC Team endorses SCC's plans to develop and implement a comprehensive
plan for managing and controlling resident property. We would, however, urge
the facility to act in a timely manner.
2. It is also recommended that-subject to resource constraints-SCC assess the
feasibility of increasing the level of resources (e.g., personnel, equipment, etc.) for
the assessment of potential computer misuse. Staff indicate that a large backlog
exists, and the results of these tests have produced positive results.
SCC Response
The Team's/conc/usion, comments and recommendations are noted.
IOC Team Final Comments
No further comments.

40

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

VIII-B The program documents incidents and takes appropriate follow -up action.
CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

41

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

VIII-C The program assures that incidents involving allegations of criminal violations are
properly investigated.
CONCLUSIONS:

[gJ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
No comments.
Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

42

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD IX:
IX-A

Resident Information

The program adequately compiles, maintains and protects resident records.

CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
No comments.

Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

43

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

IX·B

The program has a policy regarding medical research.

CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations· requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
No comments.

Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

44

Inspection of Care Survey Tool October 22 & 23, 2007
Washington State Special Commitment Center

STANDARD X:
X-A

Physical Plant

The facility meets all applicable building and safety codes.

CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
No comments.

Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

45

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

X-B

The program assures that the facility's indoor air quality is adequate.

CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOC Team
Comments
No comments.

Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments
No further comments.

46

Inspection of Care Survey Tool October 22 & 23,2007
Washington State Special Commitment Center

STANDARD X:

x-c

Physical Plant

The program provides adequate and appropriate housing for residents with
physical disabilities.

CONCLUSIONS:
~ Meets expectations.

D
D
D

Meets minimum expectations - requires improvement in some areas.
Does not meet expectations - requires significant improvement.
Not Reviewed.

Reviewer(s)
IOCTeam
Comments
No comments.

Evidence/Observations upon which conclusions & recommendations were based
Recommendations

SCC Response
The Team's conclusion is noted.

IOC Team Final Comments

No further comments.

47

 

 

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