A Day in the Life: The residential habilitation certification team ensures safety, quality care for residents

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Sandi Frelly and Michaela Tourville, medical program specialists, meet with residential habilitation agency staff during an agency survey.

The Division of Licensing and Certification – not to be confused with Vital Records or Occupational Licenses – licenses and certifies 18 distinct healthcare facilities and agency types in Idaho on an ongoing basis to make sure residents are safe and are receiving high-quality care.

Residential Habilitation (ResHab) agencies are relatively young agencies, born in the 1990s when there was a big push to integrate people with developmental and/or physical disabilities into the community and out of state-run facilities. ResHab facilities are funded by Medicaid, and provide caretaking and education services to help adults 18 and older and who qualify for the program to learn to live more independently in the community with staff support.

Participants may receive support from ResHab staff that could range from caretaker visits of a few hours per day, to a high or intense level of support, such as 24-hour one-to one support. ResHab staff help participants by providing skills training. This can include multiple areas of skills, such as medication management, daily living skills, socialization, behavior shaping and management, mobilization, and self-direction, which is an option for Medicaid participants who choose which services and supports they will spend their budget on.

The goal is to reduce the level of services participants need by teaching the skills participants need to be safe in the community with minimal support. Every participant has a different plan that is developed with the person-centered planning team to fit their individual needs. Participants sometimes learn skills as simple as wiping a counter top, to complex skills such as identifying and taking the correct bus route, which will increase their independence in mobility.

The Boise ResHab survey team is responsible for protecting these participants by ensuring that the services provided by ResHab staff and facilities are high quality and compliant with all of the rules and regulations they are subject to. The team for this survey includes Eric Brown, Sandi Frelly, and Michaela Tourville. “This job allows me the opportunity to make a difference in the lives of people with disabilities,” Sandi said.

Before joining DHW, they all worked at developmental disabilities agencies or ResHab agencies as direct care and administrative staff. The statewide survey team also includes Kimberly Cole, based in Lewiston, and Pam Loveland-Schmidt, based in Pocatello. Combined, the team has over 100 years of experience in the field of developmental disabilities. Since they have worked on both sides of the program, the survey team understands the difficulty of rule compliance and all the nuances of the work the agencies do. This team does approximately 60+ surveys per year, and they often spend more time out of the office than in the office.

The survey process adds up to approximately two months of activity for any given survey. So, to get a clear picture of the survey process, this “day in the life” story covers more than just the day of the survey. I shadowed the survey team twice – once to observe pre-survey work, and again two weeks later to observe an actual survey.

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Michaela Tourville, medical program specialist, works through program records with residential habilitation agency staff during a survey.

I first visit the Boise ResHab survey team at the Elder Street campus in Boise to observe the team as they prepare for a survey. Sandi Frelly, the lead on this survey describes what is involved in preparing for a survey. Two weeks before a survey, the lead surveyor sends a letter to the ResHab agency that outlines exactly what will occur during the visit. This letter includes a checklist of information the survey team will need access to before and during the visit, such as staff and participant files, and the ResHab agency’s policies and procedures. The agency sends over the requested documents and the survey lead reviews the information and prepares for the survey.

Two weeks after my initial visit with the team, I return to the Elder Street campus to join them on an actual survey. Surveys can take one to five days, depending on agency size and how it is organized. This survey will take the team out of the office for two days. We will spend the morning at the agency office looking through files and talking with administrators. The afternoon and next morning, we will visit three participants in their own homes.

I catch a ride with Michaela Tourville, medical program specialist, from the DHW office to the ResHab agency. As we drive, she explains that Idaho’s Developmental Disabilities Program offers many services for both adults and children. Many families have moved from other states to Idaho because of the lack of waiting lists here and the number of agencies available to choose from.

The survey process involves reviewing agencies for compliance with many state and federal rules and regulations. ResHab agencies may also receive funding through the Idaho Medicaid program and must adhere to Medicaid program rules and requirements.

Program Manager Eric Brown and his team are as consistent as possible with their application of the rules and regulations. Since the team certifies each of the approximately 140 agencies throughout the state in more than 270 locations, consistency is crucial.

At the agency, we are greeted by the owner, co-owner, and a consultant who works for them. They escort us into a large conference room. On this survey, the agency owner, consultant, and survey staff have known each other for many years, and they greet each other with light and friendly conversation.

The survey lead breaks up the work amongst the team. They spend the morning looking through the files and asking questions. To get a better idea of what is involved, I flip through the file of a participant who we will visit the next day. The file is huge; and pretty much every aspect of the participant is detailed. The file includes an assessment to determine which services the participant needs, and how much Medicaid will pay the agency to provide those services. Each participant has different needs, ranging from needing services a few hours a week to needing daily intensive care around the clock.

When we break for lunch, we head to a local restaurant. The survey team uses this time to discuss issues that have come up earlier but are best discussed away from the agency. The discussion is valuable because each surveyor has a different perspective, which enables the team to be consistent in their survey approach.

After lunch, we head out into the field. Over the course of the afternoon and the majority of the next day, we visit the homes of three participants. Surveys include visits to participants’ homes to get a first-hand view of the participants’ living situations. Surveyors use this time to ensure that services are being provided according to the quality standards and policies, to check the documentation that is in the home, and to make sure medication policies and procedures are being followed. Ultimately, the most important reason for the home visits is to give survey team a chance to talk with participants to ensure that their rights are being respected.

When we arrive at each home, it is clear that this is an exciting moment for the participant. The team has known some of them for many years and they chat casually about the participants’ lives. As we visit the participants, I watch karaoke videos, listen to rap song lyrics, smile as someone brags about his girlfriend, stand in awe at the long list of sports one plays, and am impressed by hearing about someone’s bachelor’s degree in communications.

As we leave one participant’s apartment, he shares his heartfelt praise for the ResHab agency we are surveying, and his appreciation of the services they provide for him. This man is very well-spoken and has had a rough year after losing his companion dog. After going through several agencies over the years, this participant wanted us to know that the agency providing his care now makes him feel valued and truly cared for.

“We really enjoy the relationships we have developed and maintained over the years with the people in the program,” said Eric Brown. On this survey, Eric was able to see a gentleman he has known for 23 years.

When we get back to the agency office for the final portion of the survey, the team goes over their findings. The agency is given a chance to discuss the findings and refute them if necessary. The team gives the agency the opportunity to verify its compliance with any of the findings that are identified as rule violations, which would result in a formal citation for non-compliance.

When the onsite portion of the survey is completed, there is more work to be done by the survey team back at the DHW office. If rule violations have been identified, the lead surveyor drafts the same document and lists the team’s findings. The agency is required to submit a written plan to correct the deficiencies and identify a date the corrections will be completed. Once the agency’s plan of correction is approved, which may involve communication between the lead surveyor and the agency’s administration, the lead surveyor sends the approved plan of correction to the agency along with the renewed certificate(s).

Surveys are stressful for agencies and you can see the relief when the survey is done. The outcome of this survey is positive: The agency earned a full three-year certification, and they will be surveyed again three years from now. It is not uncommon for agencies to have some rule violations that need to be addressed. The most common citations relate to criminal history checks. However, it is also common for agencies to earn a deficiency-free survey. In 2019, there were nine deficiency-free surveys.

“Working in this field changed my life and gave me the opportunity to find my passion and purpose,” Michaela Tourville said. It’s obvious one doesn’t get into this field for any reason other than a passion to help participants who are at risk of being marginalized. It is difficult and emotional work, but the rewards of providing a worthy service are worth it. This, I think, is exactly what the department is all about.

A Day in the Life is a series of stories highlighting Department of Health and Welfare employees and the work they do every day to help Idahoans live their best lives.

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