Report - Disability Rights Texas

clinical outcomes.
The Facility may be overly focused on processes associated with various elements of the QA process and
not identifying and using readily available data to aggressively address what appear to be significant issues.
The Monitoring Team did not identify substantive activity occurring that would measure whether any set
of activities implemented in multiple CAPs directed at similar subject matter (i.e. Incident Management or
infection control) were effective in preventing the recurrence of problems.
The Facility is to be commended for the system it has put in place to identify the need for a CAP, track CAP
assignments and completion status, periodically review CAP status, and require evidence to substantiate
CAP completion. CAP evidence reviewed by the Monitoring Team for a small sample confirmed the
implementation of this system.
As noted in the last report, the Facility had adopted a methodology for review of data referred to as
CATW2. CATW2 refers to Check, Ask, Think, Why, and What. This methodology was developed to
encourage those reviewing data reports to engage in critical thinking. The Monitoring Team observed
continued implementation of this process.
As noted in the last report, the Facility had revised much of its trend data to include longitudinal data. This
has continued and is especially important at RGSC because the ICF‐ID program is so small.
# Provision Assessment of Status Compliance
E1 Track data with sufficient
particularity to identify trends
across, among, within and/or
regarding: program areas; living
units; work shifts; protections,
supports and services; areas of care;
individual staff; and/or individuals
receiving services and supports.
Facility self‐assessment:
The self‐assessment reported noncompliance with this provision of the SA and the
Monitoring Team concurs.
Note: The Facility had continued use of its CATW2 methodology for review of data.
CATW2 refers to Check, Ask, Think, Why, and What. This methodology was developed by
the Facility to encourage those reviewing data reports to engage in critical thinking. The
Facility is to be commended for the development of this methodology as it helps facilitate
the use of data and thoughtful discussion in identifying systemic issues. Throughout this
section of the report whenever there is reference to review or analysis the CATW2
methodology would have been used unless otherwise noted by the Monitoring Team.
Noncompliance
The Facility reported it had engaged in the following activities to conduct its selfassessment:
1. Reviewed monthly/quarterly Trend Analysis Reports for Restraint, Injuries, Falls,
ANE/Unusual Incidents and Peer to Peer Aggression from 2/12 – 7/12.
Rio Grande State Center, November 19, 2012
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