LSMHU MINUTES Page 1

Date: February 7, 2017 Attendees: James Gannon, Kathryn Rucker, Jackson Cash (staff to committee)

Topic Discussion Assignment/Task Point Notes Person INTRODUCTIONS n/a Approval of Prior Previous minutes approved Meeting Minutes

Review of Open Discussed DMH memo; adoption of new minutes HRC with assistance of HRO HRO Meeting Law format and process for posting of minutes and meeting Requirements notices

HRC staff unit visits Discussion of relaxation rooms; observed to be very Patient council is looking at HRO bare; furniture in poor condition; only old stereo this issue; consider ways to systems; clients reported no access to sensory carts or support and partner with other sensory items for use; desire for ambient council to advocate for lighting; aroma therapy; sensory items. These kinds additional resources; request of resources are available at the Tree program, but minutes next council meeting many clients are restricted to the units and unable to access these treatment resources. Inquire with COO re: facility budget line item for resources KR

Follow-up with Sharon Gaffney in OT re: wish list for relaxation room resources; any HRO obstacles to purchasing LSMHU MINUTES Page 2

Fresh Air complaint Review of 2016 initiative in this area. A number of Outreach to new, former HRO the clients HRC/HRO met with last year have left clients re: complaint facility, but six individuals remain on bail status of participation without bail. Discussed a more stream-lined approach to complaint development; selection of 2 exemplars; Draft legal section of KR request treatment plans; confirm no clinical obstacle complaint to exercise of off-unit privileges RN staffing Reviewed prior meeting notes on efforts to fill empty HRC will seek update on HRO nursing positions and eventually improve RN/client hiring process ratios Physical plant Observed new steel plates screwed over window and No further action; repairs window repair around air conditioners on two units in relaxation reportedly complete rooms and solariums Review restraint data Review list of clients with recent restraints, focusing Continue monthly review and HRO on those multiple restraint events; in December 2016 monitoring of client subject to 3 people restrained a total of 4 times; average 1.4 frequent restraints hours duration; 13 restraints in January impacting 10 clients; 2016 restraints trending generally down

No clear trends in start time of restraint events; Continue to monitor issues observation that after 5:00 social work and rehab staff arising on 3-11 shift; inquire if are gone, HRO gone; many restraint are occurring mandatory overtime could be between 3-11 contributing

One client referred to HRO after restraint had full investigation/DPPC complaint but was unsubstantiated LSMHU MINUTES Page 3

Review complaint First “administrative review” complaint since HRC will monitor use of AR in HRO log regulation change. Discussed in complaint review complaint process through committee; HRO was asked to weigh in. regular review of complaint log

In this case there was informal problem solving with client; a face-to-face meeting and resulting solution to address concern.

AR to be used when complaint doesn’t meet criteria for dangerous, illegal, inhumane treatment; where complaints concern issues between clients (not otherwise covered by complaint regulations); appeal process still available.

Recent training of additional fact-finders; now 20 No current backlog of HRO available in order to avoid backlog in complaint complaint; HRC will continue investigation; complaint review committee discusses to monitor through monthly appropriate assignments to avoid any conflict of reporting interest

Issues of mistreatment of lack of respect by staff to be HRC will monitor outcome of raised in complaint process at facility response to these investigations HRC and patient counsel letters; two recent complaints on 9N on this issue; HRC spoke with one of client/witnesses ADJOURNMENT/ March meeting date TBD by email HRO . NEXT MEETING