St. John’s Home for Children

Deficiency cited, survey : C 124 64-11-5.5.b.5. Center Responsibility

Based on review of policies and procedures and interview, the Center did not develop and implement a written code of ethics that included a means of resolving differences with regard to care and treatment decisions affecting consumers. Findings include: (a) Written policies and procedures did not address the issue of resolving differences with regard to care and treatment decisions affecting consumers. (b) The Assistant Director confirmed the above in interview at the Center on 1/23/02 at 2:15 p.m.

Deficiency cited, survey : C 143 64-11-5.6.b. Personnel

Based on review of personnel records, the Center did not ensure completion of a background check for one (1) of four (4) direct care staff in the personnel sample in order to verify that the staff was not convicted of consumer or child abuse or neglect. The staff identifier is Youth Care Worker B. Findings include: (a) There was not a completed background check in the personnel file for Staff B, a Youth Care Worker who was hired on 10/12/99.

Deficiency cited, survey : C 148 64-11-5.6.d.4. Personnel

Based on review of personnel records, the Center did not maintain verification of education in the personnel file for three (3) of four (4) direct care staff in the personnel sample. The staff identifiers are A, B and D. Findings include: (a) Education was not verified in the personnel record for Youth Care Worker A who was hired on 2/2/01. (b) Education was not verified in the personnel record for Youth Care Worker B who was hired on 10/12/99. (c) Education was not verified in the personnel record for Relief Youth Care Worker D who was hired on 9/26/01.

Deficiency cited, survey : C 152 64-11-5.7.a. Staff Training

Based on review of personnel records, the Center did not ensure that one (1) of four (4) direct care staff in the personnel sample received training in the use of emergency procedures, such as crisis intervention and restraints (CPI). The staff identifier is Relief Youth Care Worker D. Findings include: (a) There was no documentation of CPI training in the personnel file for Relief Youth Care Worker D, who was hired on 9/26/01.

Deficiency cited, survey : C 153 64-11-5.7.b. Staff Training

Based on review of personnel records, the Center did not ensure that one (1) of four (4) direct care staff in the personnel sample received training in cardiopulmonary resuscitation (CPR) and first aid, including infectious disease control. The staff identifier is Youth Care Worker A. Findings include: (a) There was no documentation of CPR and first aid training in the personnel file for Youth Care Worker A, who was hired on 2/2/01. (b) There were two (2) written notices in the personnel file for Staff A that CPR and first aid training needed to be obtained.

Deficiency cited, survey : C 159 64-11-5.9.a.1. Human Rights Committee

Based on review of the minutes of the human rights committee meetings, the Center did not include in the written minutes the titles of members present or the names and titles of absent members. Findings include: (a) The minutes of the human rights committee meetings dated 6/11/01 and 10/22/01 lacked the titles of members present and the names and titles of members absent.

Deficiency cited, survey : C 161 64-11-5.9.a.3. Human Rights Committee

Based on review of the human rights committee minutes and record review, the Center did not ensure that the human rights committee reviewed, approved and monitored the use of aversive procedures, such as the use of medication for the control of inappropriate behaviors, for two (2) of two (2) consumers in the sample who received medications for the control of inappropriate behaviors. The consumer identifiers are #1 and #2. Findings include: (a) The initial evaluation for Consumer #1 dated 8/2/01 included the identification of inappropriate behaviors, i.e., assault at school, setting fires and property destruction. A psychiatrist stated in an evaluation dated 4/25/01 that Consumer #1 required medications to control the consumer's behavioral symptoms of Attention Deficit Disorder (ADD) and Oppositional Defiant Disorder (ODD). The medication Concerta 54 mg. in the morning for ADHD was listed in the master treatment plan dated 11/28/01. It was documented on the medication logs for December 2001 and January 2002 that Consumer #1 self administered Concerta 54 mg. at 8:00 a.m. and Concerta 18 mg. at 8:00 a.m. There was no reference to the medications to control the behavior of Consumer #1 or any other consumer in the human rights committee minutes dated 6/11/01 and 10/22/01. There was no other documentation in Consumer #1's record to indicate that the human rights committee reviewed or approved the use of the medication. (b) The initial evaluation for Consumer #2 dated 9/6/01 ...

Deficiency cited, survey : C 234 64-11-7.2.e. Assessment and Planning

Based on record review, the Center did not ensure that the legal representative for one (1) of three (3) consumers in the sample signed a written consent prior to treatment. The consumer identifier is #3. Findings include: (a) The consent for treatment for Consumer #3 dated 10/24/01 was not signed by the legal guardian, who was the protective service worker assigned by the West Virginia Department of Health & Human Resources, since the consumer was in the custody of the Department at the time of admission.

Deficiency cited, survey : C 252 64-11-7.3.g.4. Treatment Plan

Based on record review, the Center did not ensure that the treatment plan reviews included a review of drug dosages and types and explained the rationale for changes or continuation of psychotropic drug regimens for two (2) of two (2) consumers in the sample who receive psychotropic medication and had a review. The consumer identifiers are #1 and #2. Findings include: (a) Consumer #1 received psychotropic medication - cross reference to C161 - \'a764- 11-5.9.a.3.(1)(a) for specific findings. (b) The treatment plan review dated 11/28/01 for Consumer #1 included the medication at the beginning of the review; however, there was no documented review of the types and dosages of drugs or an explanation of the rationale for changes or continuation of the psychotropic drug regimen. (c) Consumer #2 received psychotropic medication - cross reference to C161 - \'a764-11- 5.9.a.3.(1)(b) for specific findings. (d) The treatment plan review dated 12/21/01 for Consumer #2 included the medication at the beginning of the review; however, there was no documented review of the types and dosages of drugs or an explanation of the rationale for changes or continuation of the psychotropic drug regimen.

Deficiency cited, survey : C 254 64-11-7.4.a. Treatment Plan Review

Based on record review, the Center did not ensure that ninety (90) day treatment plan reviews for two (2) of two (2) consumers in the sample who had a review, summarized the amount of treatment and training provided. The consumer identifiers are #1 and #2. Findings include: (a) The treatment plan review for Consumer #1 dated 11/28/01 did not summarize the amount of treatment and training provided the consumer. (b) The treatment plan review for Consumer #2 dated 12/21/01 did not summarize the amount of treatment and training provided the consumer.

Deficiency cited, survey : C 335 64-11-8.1.a.7. Basic Rights

Based on record review, review of policies and procedures and interview, the Center did not ensure that the legal representative for two (2) of three (3) consumers in the sample received information concerning the rights of the consumer and signed an acknowledgement of receipt of rights information as required by regulation and Center policy. The consumer identifiers are #1 and #3. Findings include: (a) West Virginia Behavioral Health Centers Licensure regulation \'a764-11-3.24.i. defines the legal representative of a minor child as a parent or guardian. Since a minor child lacks capacity to legally sign documents due to the child's young age and since the Center only accepts minor children as consumers, each consumer is in need of a legal representative. (b) Consumer #1's birth date was 12/21/89 and Consumer #3's birth date was 1/20/89, making them minors. Both consumers were in the custody of the West Virginia Department of Health and Human Resources at the time of their admission to the Center, which made the Department their legal guardian. (c) Center policy required that an acknowledgement of the receipt of consumers' rights be signed by the consumer and his legal guardian. (d) The Center's procedure was for rights to be included in the Residents Handbook. In the cases of Consumer #1 admitted on 7/31/01 and Consumer #3 admitted on 10/24/01, the legal guardian (the protective service worker assigned from DHHR) did not sign for receipt of the Residents Handbook or any ...

Deficiency cited, survey : C 351 64-11-8.1.a.23. Basic Rights

Based on review of policies and procedures and the Residents Handbook and interview, the Center did not ensure that consumers and their legal guardians were informed orally and in writing of all of the rights described in Section 8 of the West Virginia Behavioral Health Centers Licensure Rule, 64CSR11, effective July 1, 2000.. Findings include: (a) Neither the Residents Handbook, which is given to consumers, nor the policies and procedures contain all of the rights described in \'a764-11-8.1.a.1. through \'a764-11-8.1.a.24. of the licensure regulations. (b) The Executive Director confirmed the above in interview at the Center on 1/23/02 at 11:40 a.m.

Deficiency cited, survey : C 356 64-11-8.1.b. Basic Rights

Based on review of policies and procedures and interview, the Center did not establish a written policy or procedure to ensure that when a consumer's rights and personal liberties are limited, that such limitation be clinically appropriate and clearly justified in writing in the consumer's record (as well as approved by the human rights committee). Findings include: (a) There was no policy or procedure to ensure that limitations of the rights and personal liberties of consumers would be clinically appropriate and clearly justified in writing in the consumer's record. (b) The Executive Director stated in interview at the Center on 1/23/02 that the Center does in fact restrict rights and liberties of consumers when clinically appropriate. The Executive Director confirmed that the Center has not established a written procedure to ensure that limitations are clinically appropriate and clearly justified in writing in the consumer's record.

Deficiency cited, survey : C 361 64-11-8.2.d. Violation of Consumer Rights

Based on review of policies and procedures and the Residents Handbook and interview, the Center's grievance procedure did not include that the consumer or his legal representative may appeal unfavorable decisions to the governing body of the Center, the State licensure body, the West Virginia Advocates or other appropriate resource. Findings include: (a) Neither the Center's policies and procedures nor the Residents Handbook included any appeal procedure beyond the Executive Director or the human rights committee. There was nothing in writing to indicate that a consumer or his legal representative may appeal unfavorable grievance/complaint decisions to the governing body of the Center, the State licensure body, the West Virginia Advocates or other appropriate resource. (b) The Executive Director confirmed the above in interview at the Center on 1/23/02 at 11:40 a.m.