Standards: Standards are requirements for people who receive supports from DDA. Standards will be listed in this column and numbered accordingly, with a detailed explanation of the standard in the right-hand column. Applies to: The people whom the standard affects will be noted in this column. Introduction The Developmental Disabilities Administration (DDA) is responsible for the oversight and coordination of all services and supports provided to eligible people with intellectual and developmental disabilities in the District of Columbia. One of the key purposes of the Health and Wellness Standards (“Standards”) document is to provide the information and tools necessary to advocate for the best possible health care and health outcomes for people with intellectual and developmental disabilities, thus ensuring a good quality of life. The Standards do not focus on specific health conditions, but rather provide a guide for the assessment, planning, delivery, and documentation of essential health supports. People with disabilities and those who support them must continually seek and be provided with health education and advocacy. Each designated agency, specialized service agency, and person or family member who manages the person’s supports is responsible for ensuring that health services are provided and documented appropriately. This responsibility applies regardless of whether the person is supported through the Home and Community Based Services Waiver for People with Intellectual and Developmental Disabilities (HCBS IID waiver) or, the person lives in an Intermediate Care Facility for Individuals with Intellectual and Developmental Disabilities (ICF/IID). The applicability of these guidelines for people living independently or with family members will vary. DDA’s expectations for health and wellness services emphasize the importance of: Preventative health; Continual assessment for changes in health; and Care coordination. Tools for accomplishing these goals include: Nursing Assessment; Health care management planning; Health Passports to communicate health issues; and Annual Preventive Health Screening Report to guide the scheduling of preventative screening and assessments. Documentation: The documentation of health and wellness supports is an essential part of the provision of quality care. The location of health and wellness related documentation will be noted in this column.
Source: The Transition of Care Guide (Appendix 10) document is available at Standard 3 Preventative Health Care: Preventative health care focuses on optimizing a person’s potential for health, function, and overall wellbeing. Unless a variance can be documented, health practitioners must adhere to the USPSTF Guidelines. Applies to: Required for: People residing in ICFs/IID. People enrolled in a Home and Community Based Waiver receiving residential habilitation, supported living, and host home services. Recommended for: Preventative health care is recommended for people living independently or in a family home. Preventative Health Care DDA’s requirements for preventative health screening by age and gender are found on the Annual Preventive Health Screening Report. The Annual Preventive Health Screening Report offers male and female versions which list the recommended screenings from the U.S. Preventative Screening Task Force (USPSTF) Guidelines. All preventative screenings should be recorded on the Annual Preventive Health Screening Report. (See Appendix.) If a person requires a variance from the USPSTF recommended screenings, its rationale must be documented in the record by a PCP. Health Form 2 (Direct Observation) and Health Form 3 (Diagnostic Review) are supplemental forms used to ensure that people receive quality care. Health Form 2 (Direct Observation) is generally completed by the direct support professionals to assist in the recording of health-related information, and for communicating recent health changes to a supervisor or healthcare provider. (See Appendix) Health Form 3 (Diagnostic Review) offers an instrument to organize a systematic review of a person’s current assessments, physical exam, specialists’ reports, and medical intervention in a systemic way. (See Appendix) While the use of the Annual Preventive Health Screening Report is required, the use of Health Forms 2 and 3 is optional, but highly recommended. Annual Preventive Health Screening Report (male & female), Health Form 2, and 3 are available at: The Glasgow Depression Scale Questionnaire is designed to screen for depression in people with an intellectual disability by assessing behavioral symptoms of clinical depression. There are two versions of the questionnaire (self-reporting Documentation: Annual Preventive Health Screening Report, which is the required form for documentation of preventative health screenings, is to be maintained in the Health Record.
is suspected, and the outcome. Standard 7 Incident Reporting: All people supported by DDA will be monitored for neglect, harm or abuse and all suspected incidents reported to DDA’s Incident Management Enforcement Unit. Applies to: All employees of DDA, all individual agencies that provide services to people with intellectual disabilities through funding, contract, or provider agreement with DC Government. Reporting Critical Incidents It is DDA’s policy to ensure that all people receiving services as part of the DDA service delivery system are protected from neglect, harm, and abuse. It is essential for providers to implement and maintain an incident management system, and report critical incidents to DDA. There are two types of reportable incidents: Reportable Incident (“RI”): An RI is an event or situation involving a risk, threat or actual event that impacts a person’s health or safety that includes, but is not limited to: Emergency relocation Emergency room or urgent care visit Emergency unauthorized use of restrictive controls (that are in a category typically approved by DDS, but that have not been approved for use with this person) Fire Inappropriate use of approved restraints (no injury) Incidents involving the police Medication error Physical injury Property destruction Suicide threat Vehicle accident Other Serious Reportable Incident (“SRI”): An SRI is an RI that due to its significance, severity, or repeated instance within a period of time, requires immediate response and notification to DDS/DDA. SRIs include, but are not limited to: Abuse Death Exploitation Inappropriate use of approved restraints that results in injury Documentation Incident reports are never part of the medical record. Incident reports are to be filed with DDA via MCIS. Follow agency procedures when filing copies of incident reports within an agency.
Standard 10 Universal Precautions/ Bloodborne Pathogen Training: It is a federal requirement that Bloodbourne Pathogen training be presented to employees with the potential for occupational exposure. This training must be provided in accordance with the requirements of the Occupational, Safety, and Health Administration (OSHA). Designated agencies must have written policies consistent with OSHA rules. Applies to: All DDA employees, subcontractors, providers, vendors, consultants, volunteers, and governmental agencies that provide service and supports to people with disabilities. Universal Precautions/ Bloodborne Pathogen Training "Universal precautions," as defined by CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), Hepatitis B virus (HBV), and other bloodbourne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other bloodbourne pathogens. The term, bloodbourne pathogens, refers to pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV). All agencies must comply with Occupational, Safety, and Health Administration (OSHA) requirements related to bloodbourne pathogens and universal precautions. According to OSHA Regulation 29 CFR § 1910.1030, all employer agencies must: Provide an initial Bloodbourne Pathogen training, and annual retraining, for all employees. Provide training at no cost to employee and during work hours Provide additional training if modification of tasks or new task occur that may affect occupational exposure Make copies of the agency’s Exposure Control Plan available to all employees Offer the Hepatitis B vaccine, at no cost, to all employees with potential exposures, within 10 days of their initial work assignment. Provide immediate post-exposure evaluation to all employees with an exposure incident Provide personal protective equipment (e.g. gloves, gowns, masks, as needed. A record of the training and annual retraining for all workers is required. In accordance with OSHA regulations, the Hepatitis B vaccine is offered to DDA employees with potential Documentation: Documentation of Bloodborne Pathogen training sessions will be maintained in agency training records. A copy of the agency’s Exposure Control Plan must be available to all employees.
exposures. Payment for non-DDA employees is the responsibility of the employer or the person/organization contracting for services. Source: OSHA Regulation, 29 CFR § 1910.1030 Standard 11 Management of Infections: People with antibiotic resistant bacteria, who do not require hospitalization for an acute infection or comorbid condition, can be safely cared for and managed at home by use of standard universal precautions. The service provider shall ensure that staff receives training regarding MRSA or VRE infection management, and specific concerns for the affected person. People with a MRSA or VRE colonization or infection shall not be refused services based on his or her MRSA or VRE status. Applies to: People who live in an ICF/IDD. Management of Infections MRSA and VRE Antibiotic resistant bacteria such as Methicillin Resistant Staph Aureas (MRSA) and Vancomycin Resistant Enterococci (VRE) are the most commonly encountered drug-resistant infections in people residing in non-healthcare facilities, such as long-term care facilities. In recent years, there has been an increased incidence of these infections which can be acquired in both the health care and community settings. In the healthcare setting, MRSA occurs most frequently in people with weakened immune systems, and can occur as a wound infection, urinary tract infection, bloodstream injection, and pneumonia. It is transmitted by direct contact, often on the hands of caregivers. In community settings, infections usually manifest as skin infections (pimples and boils) in otherwise healthy people. VRE usually comes from the person’s own bowel flora, and can be spread by direct person-to-person contact or on the hands of caregivers. People may have a: MRSA or VRE “colonization” (the organism is present, but not causing illness) MRSA or VRE infection (the organism is present and causing illness). The risk factors for both colonization and infection include: severe illness, underlying health conditions (i.e. kidney disease, diabetes, and skin lesions), urinary catheter, repeated hospitalizations, and previous colonization by a organism, and advanced age. Documentation: Information related to management and individual response to treatment will be documented on the HCMP and in the nursing and physician progress notes.
Standard 12 Annual Physical Exam: Annual physical exams are required for all people receiving supports and services from DDA, unless otherwise documented, in writing, by the primary care physician. Applies to: All people receiving supports and services through DDA. Annual Physical Exam Comprehensive Medical Service Delivery: The medical needs of the person should be addressed by the person’s primary care provider. This can include a physician, nurse practitioner or physician’s assistant. Annually, the primary care provider should complete a thorough physical assessment as needed for the person’s age, gender and general physical health and provide a summary of the assessment and any recommendations in writing. (See Medical Evaluation Form in Appendix.) Consultations with specialists will usually be ordered by the primary care provider, but any changes to the person’s medical plan of care should be coordinated with the primary care provider. Documentation from the specialty consult must be shared with the primary care physician. The PCP in turn should document in writing that they have reviewed the results of these consults and any follow-up as recommended by the PCP. Any decision to decline a recommendation should also be documented including rationale. All laboratory and procedural reports should be obtained and placed with the person’s record as quickly as possible. The primary care provider must be notified of any laboratory tests not within normal limits. Recommendations for general medical care, specialty care, and medical follow-up should be carried out by the residential service provider, within the time frame prescribed by the physician and/or specialist. Annual medical assessments are to include: All medical and psychiatric diagnoses Current medications Recent illness profile History Physical exam Laboratory test results. The assessment is to be appropriate for the age and gender of the person, and tailored to the special characteristics/needs of Documentation: Documentation of comprehensive health services including health assessments, lab, diagnostic, and screening tests, and specialty consultations will be maintained in the health record.
Passport. Applies to: People who live in an ICF/IDD. People enrolled in a Home and Community Based Waiver receiving residential habilitation, supported living, and host home services. The Adult Immunization Schedule Recommendations are available at , and are incorporated by reference. Suggested format for documenting the vaccination record is available at http://www.immunize.org/catg.d/p2023.pdf Source: CDC Adult Immunization Schedules. Standard 17 Medication Prescription & Administration: All people will receive or self-administer medications in a safe, timely manner in home and community settings. Applies to: People who are living in an ICF/IID. People enrolled in a Home and Community Based Waiver receiving residential habilitation, supported living, and host home services. Medication Prescription and Administration Note: See additional information in Section 18 that specifically addresses Psychotropic Medications. Medication Prescription 1. Medication orders must include the person’s name, name of the medication, name and telephone number of the licensed health care practitioner, time of administration, dosage, method of administration, and duration of medication. 2. All prescription medications, not including psychotropic medications used for behavioral purposes, are reviewed and renewed annually at the time of the annual physical exam or as indicated by the physician or practitioner. Prescriptions for psychotropic drugs must be re-prescribed every 30 days. 3. A change in medication dosage requires a new prescription with a written order by the licensed physician/practitioner. 4. Only a licensed nurse (RN or LPN) shall accept a telephone medication order from a licensed physician/practitioner for a new prescription or change in dosage or frequency. 5. PRN medications are medications that are ordered by the physician /practitioner to be administered on an “as needed” Documentation Medication administration will be documented in the MAR (Medication Administration Record) for people who live in an ICF/IID.
6. The supervisory registered nurse is responsible for ongoing monitoring of all people who administer medications to insure safe medication administration practices - documentation of this monitoring is required. (DC Board of Nursing Delegation) Source: DC Code 21-1201-12061 and the DC Municipal Regulations for Trained Medication Employees (TMEs). S Standard 18 Psychotropic Medications: All psychotropic medications are administered in a manner to ensure that people benefit from their use and that their rights, health, and well-being are protected. All people will have appropriate access to information and treatment with psychoactive medications, and shall have reasonable protection from serious side effects or the inappropriate use of these medications. Applies to: All DDS employees, providers/vendors, community representatives, government entities and individuals who provide support or services to people receiving services and supports from DDA. Psychotropic Medications Psychotropic medications when used should strive to find a minimal effective dose, and be part of an overall treatment strategy that includes psychosocial treatment interventions. These interventions include the identification and management of stressors, changes needed in the environment, teaching people and caregivers and other treatment approaches such as cognitive-behavioral therapy. DDS has adopted the following standards: A licensed, board-certified psychiatrist must make all decisions: a) if a person should undergo a formal assessment for a mental disorder; b) if the person is likely to benefit from taking a psychotropic medication; and c) the prescription, administration, monitoring, and oversight of such medications. Psychotropic medication shall only be prescribed to people with intellectual and developmental disabilities that have a formal psychiatric assessment and a diagnosed mental disorder. Documentation from the provider will be required acknowledging the psychiatric assessment recommendations for psychotropic medication use for the person. The plan must be incorporated into the ISP, and a behavioral support plan will be in place prior to the prescription of the medication(s). The concept of “minimal effective dose” (MED) needs to be reflected in medication orders. This term refers to use of the lowest dose of medication that produces the desired effect. Prescribing practitioners shall assess people for Documentation: The psychotropic drug review form will be used to document the interdisciplinary review of prescriptions for psychotropic medications. The critical incident report will be completed when medications are administered on a one-time basis to address a psychiatric health problem.
will be considered valid and will be honored by Fire/EMS. Please note that Fire/EMS will not honor DNRs signed as a part of an Advance Directive, Living Will or Durable Power of Attorney without a corresponding Comfort Care bracelet for Fire/EMS. Comfort care bracelets are available through the Department of Health. For More Information Please contact the DC CCO-DNR Program at (202) or visit the CCO-DNR website at . For more information about supporting people to make end-of-life decisions, please visit the End-of-Life Decisions for Adults with Significant Intellectual Disabilities website developed by Georgetown University Center for Child and Human Development and the Department on Disability Services (DDS): http://gucchdgeorgetown.net/ucedd/complex/ Additional information on End-of-Life planning can be found in the Appendix – see “Thinking Ahead”. Standard 25 Alternative/ Complementary Therapies: The PCP must be consulted prior to the initiation of therapies. Applies to: People who are living in an ICF/IID. People enrolled in a Home and Community Based Waiver receiving residential habilitation, supported living, and host home services. Alternative/Complementary Therapies All alternative and complementary therapies need the input of the PCP prior to implementation. Alternative and complementary healthcare and medical practices are those that are not currently an integral part of conventional healthcare. Conventional healthcare refers to medicine as practiced by individuals who hold a medical doctor (MD) or doctor of osteopathy (DO) degree. Alternative and complementary healthcare and practices may include, but are not limited to, chiropractic therapy, homeopathic and herbal medicines, acupuncture, naturopathy, mind/body therapy, etc. Any alternative or complimentary medication (e.g., herbal or homeopathic) needs to have a written order by the PCP. This documentation must be kept in the person’s file. Documentation: All alternative and complementary therapies should be documented in the health record and on the Health Passport.