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Letter to Providers and DMR Public Assistant Regional Directors

May 22, 2006
 TO:  Private Provider Executive Directors
 DMR Public Assistant Regional Directors
Over the past several months, our department and the private provider community has experienced the loss of a small number of people we serve due to tragic incidents. I know for any staff who knew these individuals, that I share your sense of sadness and loss. We all extend our condolences to the families whose sense of loss is even greater. These tragedies have caused us to reflect on the approaches we can take to learn from these accidents and use this information to improve the quality of care for others entrusted to us.

The department is planning a Safety Campaign to bring heightened awareness to all staff of their responsibility to ensure the health and safety of the people we serve. I am writing to you to ask for your full cooperation in one of the most important aspects of this campaign - a team review of each person who has a serious identified risk. The following areas of risk are of most concern to us and I ask you to focus your attention on these in particular:

  • Individuals who have dysphagia and/or swallowing risks.
  • Individuals who eat non-food items-PICA.
  • Individuals who engage in maladaptive eating behaviors (impulsive food or liquid ingestion including rapid ingestion of large quantities of food or edible liquids).
  • Individuals who require supervision or supports during bathing to prevent serious injury or incident. This includes hot water safety.
  • Individuals who are at risk for serious injury due to falls resulting from transfers or mobility limitations.
  • Individuals who require bedrails or side rails, special mattresses, etc. and are at risk of serious injury or incidents due to entrapment hazards.

For further information on these topics, refer to DMR medical advisories, bulletins and alerts previously issued.

I am declaring that June be DMR Safety Awareness Month. During the month of June, I expect that each agency will ensure that the supervisors of day and residential services meet with all of their direct support employees to review the health and safety screens, individual plans and safety protocols for anyone served by your agency who has an identified risk in one or more of the areas listed earlier.

Specifically, I expect that each supervisor will take the following steps for each individual identified for this review:

  1. Review the health and safety screen and the individual plan with all direct support staff to make sure all risk areas are identified and known to the staff.
  2. Review the action plans that have been developed to carry out objectives in the individual plan related to health and safety.
  3. Verify that these action plans and precautions are still relevant to the person's needs, modify them if necessary and ensure that all staff understand them.
  4. Verify that all necessary training has occurred to allow staff to carry out these plans and precautions.
  5. Each supervisor should document that this review has taken place with all direct support staff involved with the person who has identified risks, using the agency's review documentation procedure.

I have prepared a DVD with my safety message that I want shown to all supervisors and direct support staff. A copy of the DVD is included with this letter. Also enclosed is a script in Spanish and English that can be used by supervisors and direct support staff when they review the DVD. Please ensure that supervisors watch and discuss it with their employees to reinforce the importance of this safety review and to inform them of the other actions the department is taking over the next several weeks that are part of our Safety Awareness Campaign.

Thank you for your anticipated cooperation in conducting these important safety reviews. I hope they serve as an important reminder to staff of their primary responsibility to keep our consumers safe, healthy and free from harm.

If you have any questions about the safety review you may contact the DMR Regional Health Services Director, the STS Director of Nursing or DMR Director of Health and Clinical Services.


Peter H. O'Meara's Signature

Peter H. O'Meara Commissioner

cc: Council on MR
DMR Executive Management Team
Regional Health Services Directors
David Carlow, Director of Health and Clinical Services
Case Management Supervisors

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