March 15, 2013
To customers, families, staff, donors, community members and friends of LIFEDesigns:
As many of you who are part of our community know, a tragic incident occurred with a customer of LIFEDesigns, Tammy West, who passed away January 26, 2013. The Board and staff of LIFEDesigns are extremely saddened by Tammy West’s death, and our deepest sympathies are with her family. We are writing to update you on what has taken place since we learned of Tammy’s death and to assure you that our first priority is to provide outstanding care to all our customers and families. We are taking all of the necessary steps to prevent any such events from occurring in the future.
We immediately launched a total and complete review of all of our operations and used our findings to strengthen our care system. LIFEDesigns has made all necessary reports to the state, checked all of our services and customers, and will continue to look for opportunities to improve in all aspects of our services. The following are specific examples of changes we have made:
- Document updates and oversight: All documentation is up to date and has been verified. We have visited every setting we support across our systems to make sure that documentation is in place and is current and that individual support and high risk plans are being implemented as written.
- Electronic customer records: We currently use an electronic customer record, but will be moving as quickly as we can to a new web-based system. This will enable us to give all staff greater access to the most current information about a customer.
- Increased access to electronic records: We are establishing new computer kiosks in customer settings that can be updated electronically from anywhere, again to ensure ready access to updated information.
- Nurse visits: We have arranged for nursing services to visit individuals in Host Families, like the one Tammy was in, and other Supported Living services with risk plans that indicate a health issue that should be monitored and who do not have home health services. Those visits will occur monthly on an ongoing basis.
- Quality Assurance: Our quality assurance program now includes cross monitoring (people from different service areas observing and completing checklists on requirements) and random record checks. These checks are done monthly and cover medical, financial, programmatic and health and safety issues. Problems found will be dealt with through training and discipline, where necessary.
- Structural changes: In some supported living settings, we are instituting an additional onsite supervisor to oversee in-house documentation, finances, medical appointments, environmental review, and team meetings. The position will provide direct service and have an allocation of administrative time for the above tasks. We evaluated and redistributed supervisor caseloads to be sure they were equalized and provided for maximum direct customer contact.
- Compliance review: The Bureau of Quality Improvement Services, a part of Family and Social Services Administration, has reviewed all of our Host Family Settings. We have developed an action plan with them which they have approved. They should be back to monitor our compliance with the plan in the next 30 days.
- Other external investigation: We have scheduled an audit of all programs and services in April by trained CARF surveyors. The Commission on Accreditation of Rehabilitation Facilities (CARF) is an international accrediting body that certifies compliance with their standards. Indiana requires CARF certification for employment, community habilitation and community living services. Our surveyors, Julia Dotson of Bloomington and Debra Capuano of Xenia, Ohio will also be evaluating supported living, group living, employment, host families, and respite services. This will enable us to have another set of eyes evaluate all our services not just the ones the state requires us to survey.
- Supervisor and DSP training: We have improved our supervisor training to ensure a more thorough review of all state and federal regulations and required documentation. All current supervisors have completed this training and there will then be a required annual renewal for all supervisory staff. All supervisory staff have received increased training by our nursing staff on recognizing potential signs of medical issues. Currently we have a two week training for direct service staff and have augmented that with information provided by the nurses.
LIFEDesigns is committed to our customers and quality of their services and over the past 30 years has done much good for our communities and customers. We currently serve 400 individuals and families in south-central Indiana; were one of the first providers of supported living in the state and now support 200 people in that program; secured $6 million in grants to provide affordable, accessible housing; achieved three-year CARF accreditation in every year surveyed since the initial survey in 2000; provide thousands of hours of respite services to families with the support of our communities; and helped 175 people with disabilities get jobs in local businesses. We hope that in the wake of this tragedy the positive impact our organization has on the lives of many individuals with disabilities in our communities over the years is not forgotten.
We are always looking for ways to improve, so we want your feedback. You can contact Susan Rinne, CEO (firstname.lastname@example.org or 812-322-5197) at any time should you have any concerns, questions or suggestions on what we can do to improve. In the near future we will be implementing a suggestion line for staff, customers and families and we will announce the number in future communication. Additionally, we would ask customers give us their feedback by completing our annual survey and can do so by clicking the link on our website www.lifedesignsinc.org.
Thank you for your continued support during this difficult time. Please be assured that LIFEDesigns takes this incident with the utmost seriousness. We will continue to be vigilant in reviewing our care for all of our customers and promoting independence and inclusion. We will do what needs to be done to protect the individuals we support and to provide them with the best services.
LIFEDesigns’ Board of Directors & CEO