CAFCA Children's Treatment Services Committee Minutes

August 18, 2006

Host: Devereux Cleo Wallace

Present: Ann Afton (Families First), Judy Hall (Devereux Cleo Wallace), Dave Dillingham (El Pueblo), Don Moseley (Family Tree), Pam Hricik (Shiloh House); Arnie Goldstein (Excelsior); Jana Welsh (Kidz Ark); Jedd Hafer (Children’s Ark); Kirk Ward (Mt. St. Vincent’s Home); Perry May (Devereux Cleo Wallace); Angela Bornemann (Arapahoe House); Peg Long and Susannah Carroll (CAFCA)

The meeting was called to order at 10:30 a.m. 

1. Welcome & Introductions 

2. 8/11 MSB Meeting Update

The Medical Services Board (MSB) amended the PRTF-TRCCF rules to prohibit personal restraint in the prone position in PRTFs.   Perry May testified on behalf of Devereux Cleo Wallace against this total ban and cited Devereux’s policy and practice experience from its national perspective of operating in 13 states.  Specifically, Perry testified that, although prone restraints may be dangerous for some clients, for other clients, a prone restraint is preferable to a supine restraint. The language adopted by the MSB was:

Definitions (8.765.1) Prone Position means a client lying in a face down or front down position. This does not include the act of getting the client under control and in position for restraint.

(8.765.6.F) 5.  A Personal Restraint when a client is in a Prone Position is prohibited.

The definitions do not include the act of getting a person under control and in a position of restraint. The ban on restraints is for PRTFs but not TRCCFs.  The ban becomes effective 9/1/06.

Peg Long and Skip Barber also testified. The MSB members are willing to look at a white paper and review the prone restraint policy in light of more information. Board members want to hear from physicians re: medical risks. The subcommittee working on the white paper will continue to meet with the goal of having a final paper ready by October 1. The White Paper needs more documentation and more information on the various national restraint training programs.  Peg will contact Dr. Jennifer Hagman at Children’s Hospital for more medical information on prone restraints.   Peg will also ask Pam Neu to distribute an email survey to TRCCFs and PRTFs inquiring about the use of TCI/CPI or other restraint models.  

The paper should outline how different systems address individual client evaluation and crisis management protocols.  A member of the MSB said that prone restraints were outlawed in 17 other states but Jedd Hafer stated that restraints aren’t outlawed in any state.  Jedd also stated that his facility has used restraints for more than 12 years without incident. The committee would like to add a medical expert to the group as a participant or reviewer. The goal of the paper would likely be to modify the complete ban on personal restraint in the prone position based on consideration of all situations.  Peg pointed out in her testimony that safety concerns go beyond the individual being restrained to include all of the children present as well as the staff. 

Federal policy appears to favor a ban on the procedure in PRTFs.  There isn’t any research that compares supine v. prone. The deaths that are seen almost invariably occur when the client is dramatically obese or has developmental disabilities accompanied by a medical condition that may be known or unknown. Jedd pointed out that nationally recognized behavior management programs that include training on prone restraints say to avoid abdominal or thoracic compression. The group generally agreed that a child should have an individual crisis plan that indicates which restraints may be used while the actual use of a restraint requires an order in a PRTF. We should look at using prone restraints in a restricted way with the few kids who are appropriate for it. 

A concern was raised that CDHS may soon be looking at banning prone restraints in TRCCFs and we may want to add this to the mix.  

3. Workgroup to Address Creation of Juvenile SOMB and Recommend Its Replacement

Peg was asked to join the SOMB Appointing Authorities meetings as a provider representative. The SOMB has indicated a willingness to consider creation of a separate Juvenile Sex Offender Management Board. Peg would like provider input on the pros and cons of doing this and, if such a board is created, recommendations for where it would be housed—at the Colorado Department of Public Safety (as the adult SOMB is) or within CDHS. Peg feels that if this issue can be successfully addressed, we can foster awareness within the counties and get them to see the value of SO treatment for kids who are not adjudicated offenders. There is a concern that too much oversight could result from a separate board and that people will get overexcited about all the kids who are not mandated for treatment.   The biggest issues for providers is the co-therapy requirement and actual treatment of the children. 

Peg asked if providers who treat SO kids would be willing to form an advisory group on this issue and would at least discuss how the subject of a separate board should be approached when the discussions arise. There was interest in doing that and Pam Hricik agreed to look at some options for ways to collect and report the data about juvenile offenders as well as the development of a CAFCA position on how juvenile offender differences should be addressed.   Gail Ryan, MA, Senior Instructor and Director of Perpetration Prevention Program was suggested as a potential resource.

4. Discussion—residential provider management can address the impact of TRCCF/PRTF changes on staff; what CAFCA can do to assist providers

Providers report their staff are under extreme stress, and Peg wants to know how CAFCA can help.  Several CAFCA members agreed and have already called upon their employee assistance programs for support. Peg asked if providers were interested in having Marguerite McCormack out for an on-site training on vicarious trauma. Marguerite's keynote and workshop presentations at the June 2006 conference were extremely well-received. She offered to further assist providers with the challenges they are facing.   Perhaps we can get a group rate from her.  Devereux has used her in the past and found her to be very helpful. The group also discussed options for supporting the clinical and financial directors. Dave Dillingham will work with Peg to develop a brown bag lunch series for CFOs and Clinical Directors to share strategies for dealing with stress and change.

5. Items for 8/24 RTC Redesign Meeting

How can counties be encouraged to get their negotiating process approved for TRCCF services?  The group discussed the CDHS rules prohibiting appeals, questioning the legality of this position.  Jedd raised the question that if CDHS projected that providers would be able to bill about $23 for Medicaid FFS and providers can’t bill that much, isn’t that a mathematical error on the part of the Department? Peg will also ask that the agenda reflect an explanation from CDHS on what criteria it will use to determine whether to request a supplemental from the JBC. 

Peg urged the providers to remain unified during these times of change.

Meeting adjourned at 12:10 p.m.

Respectfully submitted,

David Dillingham