review of unit practices that may restrict or inhibit access to outdoor areas and the roles of employees to relieve these restrictions. The use of seclusion and The Risk Manager reviews The Risk Manager continues to restraint requires continued 100% of cases of seclusion and review 100% of of independent review to ensure restraint events including the seclusion and restraint events that there are adequate content and timeliness of including the content and alternatives designed and events. The hospital sends timeliness of events. implemented for any class weekly reports of seclusion and member potentially subject to restraint events to the Court A weekly report of seclusion such restrictive measures. Master. The Staff and and restraint events is sent to Specifically, class members Organizational Development the Court Master weekly. with a history of unacceptable Office will conduct its first behavior, such as aggression annual review of the MOAB towards peers and/or staff, program and present results to The Staff and Organizational need to be reviewed again by Executive Leadership in Development Office identified the January 2015. a consultant to conduct a review of the CONSENT DECREE Quality Improvement Actions Taken During the Measure Quarter Recommendation treatment team, and, if MOAB program. A draft necessary, by an independent report was developed. clinical consultant, to Additional testing of the determine whether sufficiently MOAB program occurred in individualized interventions are October 2015. The report was designed and consistently submitted to Elizabeth Jones, implemented to replace auditor for the Court Master. unacceptable behavior with appropriate alternative behaviors. The reporting requirements by On an annual basis (starting in Riverview identified a Paragraphs 188 and 189 of the January 2015), the Staff and consultant with expertise in Consent Decree should be Organizational Development MOAB. A report on the completed as mandated. Office will present a report to MOAB review has been sent Executive Leadership at the to Elizabeth Jones, auditor, for hospital on the Behavioral the Court Master. Management system being used. The report will include Training data are reported in (but is not limited to) the hospital’s Quarterly information on: Report. Documentation on certification and
review of unit practices that may restrict or inhibit access to outdoor areas and the roles of employees to relieve these restrictions. The use of seclusion and restraint requires continued independent review to ensure that there are adequate alternatives designed and implemented for any class member potentially subject to such restrictive measures. Specifically, class members with a history of unacceptable behavior, such as aggression towards peers and/or staff, need to be reviewed again by the The Risk Manager reviews 100% of cases of seclusion and restraint events including the content and timeliness of events. The hospital sends weekly reports of seclusion and restraint events to the Court Master. The Staff and Organizational Development Office will conduct its first annual review of the MOAB program and present results to Executive Leadership in January 2015. The Risk Manager continues to review 100% of of seclusion and restraint events including the content and timeliness of events. A weekly report of seclusion and restraint events is sent to the Court Master weekly. The Staff and Organizational Development Office identified a consultant to conduct a review of the CONSENT DECREE Recommendation Quality Improvement Measure Actions Taken During the Quarter treatment team, and, if necessary, by an independent clinical consultant, to determine whether sufficiently individualized interventions are designed and consistently implemented to replace unacceptable behavior with appropriate alternative behaviors. MOAB program. A draft report was developed. Additional testing of the MOAB program occurred in October 2015. The report was submitted to Elizabeth Jones, auditor for the Court Master. The reporting requirements by Paragraphs 188 and 189 of the Consent Decree should be completed as mandated. On an annual basis (starting in January 2015), the Staff and Organizational Development Office will present a report to Executive Leadership at the hospital on the Behavioral Management system being used. The report will include (but is not limited to) information on: Documentation on certification and Riverview identified a consultant with expertise in MOAB. A report on the MOAB review has been sent to Elizabeth Jones, auditor, for the Court Master. Training data are reported in the hospital’s Quarterly Report.