City of Milwaukee Health Department Childhood Lead Poisoning Prevention Program

Transcription

1 City of Milwaukee Health Department Childhood Lead Poisoning Prevention Program State of Wisconsin Audit MHD Corrective Action Plan 7/11/2018 City of Milwaukee Health Department 841 N. Broadway Ave. Floor 3 Milwaukee, WI 53202

2 2 MHD Plan of Correction Below is the City of Milwaukee (MHD) plan of correction addressing each of the findings to Division of Health Services (DHS) for review? The DHS also, recommended that the MHD s plan of correction takes into consideration the observations and concerns identified by the DHS reviewers and address them in the plan. Program Administration Corrective Actions 1. Develop and implement written policies, procedures, and protocols or standards of practice to guide the daily work of all aspects of the program. [PA1] Corrective Action Plan: The MHD has adopted the policy and procedures of the Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( ), as the standard for the departments overall policy and procedures to guide the daily work of the program. One policy that we are in the process of changing is to have all Milwaukee Health Department (MHD) nurses report to the Director of Nursing. Additionally, the MHD is looking at current job descriptions for key staff to determine efficiencies, and gaps. If gaps are identified, the MHD will expand and/or add activities that are complimentary within their job descriptions to strengthen the Childhood Lead Poisoning Prevention Program infrastructure for the following positions: Data Manager - the data manager for the Childhood Lead Poisoning Prevention Program will be responsible for all data (primary and secondary activities) request and reporting. These requests, not limited to the following requestor: 1. Commissioner of Health 2. Elected officials 3. Grantor Objectives 4. AIM and HEH Annual Reports 5. Open Record Request relating to data. 6. All programmatic reporting a. Quarterly Performance Reports (see attached example and instructions will be sent in a separate ) A. A monthly report for all required data information and provide a written quarterly report to the Commissioner of Health, Program Director, and Program Manager for all primary and secondary activities. In order for you to accomplish this goal, you will need to connect with: 1. OAIII Environmental # s 2. PA II Nursing # s 3. PHN Coordinator/HSA # s B. It is the expectation that the Data Manager will attend all Healthy Housing and Lead Poisoning Surveillance System (HLPPS) meetings and provide a written summary of the meetings as a means of a report-out on the following: 1. Status

3 3 2. Pros/Cons 3. Issues 4. Reporting The HLPSS system is the replacement data system for the CLPPP, and will be replacing the existing Systematic Tracking of Elevated Lead Levels and Reporting (STELLAR) system. C. Data Manager will also obtain information to support the Quarterly Performance Appraisals, using events for Nursing Staff, and newly created performance dashboard for Lead Risk Assessors. Public Health Nurse Coordinator this position is the head nurse for the CLPPP and is responsible for providing day to day guidance to the Public Health Nurses (PHN) and Health Services Assistants (HSA). The Public Health Coordinator and program manager will be instrumental in the training all new nursing staff. The PHN Coordinator will also be responsible for all EBL referrals to the PHN s, nursing quality assurance, and the initiation of the referral process to the Lead Risk Assessor, for environmental assessments. Public Health Nurses The department will add three additional positions so that the PHN s will provide comprehensive and quality Case management services to children with EBLL as defined by the State of WI handbook. Health Services Assistant The MHD Health Services Assistant (HSA) is responsible for completing the Early Intervention home visits at lead levels of 10mg/dL- 14.9mcg/dL with the goal of reducing the lead exposures in a child who has been identified as lead poisoned. Education and Interim controls are used to attain this goal. The department will add three additional positions so that the HSA will be able to provide these services to the residents in Milwaukee at any levels below the State of WI s threshold for nursing case management. The department is looking at expanding the role, to include LPN s. Health Project Assistant this role will be in head HSA will oversee HSA activities and will work closely with the Public Health Nurse Coordinator to assure that case management activities at the lower levels are assured. Environmental & Disease Control Specialist (Lead and Water) Lead Risk Assessor Will complete full lead Risk Assessments for all children with EBLLs, as defined by the policy and procedures of the Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( ). In Progress to completion: Process of Hiring staff (PHN, and HSA). Deadline 10/31/2018 Dashboard is being created to capture Environmental and Nursing. Deadline 10/31/2018 o EBL tracking database, MHD is currently in the process of imputing all the EBL cases into it by early next week. o From the data that s entered the EBL Case Summary spreadsheet will be populated which can be used to provide updates on progress the program is making.

4 4 Meeting with Data Manager to discuss expanded role on 7/13/18 o Batch Processing frequency o Data Custodian for all statistical information, and will provide the figures to support all required reporting for our Commissioner of Health, grantors, and elected officials o Performance Measures for staff quarterly Meeting with PHN s to discuss the following updated policies on 7/12/18: o Workplace Expectations - included o Quarterly Performance Reports developing Monthly 1:1 meeting with PHN s to case conference Monthly PHN group meeting to discuss issue, and concerns surrounding nursing practice. o Policy and Procedures Orientation, Training and Onboarding for PHN, and HSA Lead Nursing Standards of Practice Documentation and Record Keeping Nursing Case Management - included Public Health Nurse Coordinator Process Public Health Nurse Case Management Technical Guidance Chelation Case Closure Meeting with LRA are held weekly to discuss changes in policies 2. Develop and maintain annual program objectives with outcomes measurements documented. [PA2] Response: The Director of Nursing is currently in the process of ensuring that annual program objectives contain outcome measurements which are attainable and documented. The State of Wisconsin Lead Detection Consolidated Contract objectives that the MHD CLPPP will be responsible for are as follows. See Appendix A for strategies and timeline to support these objectives: Objective #1: Blood Lead Testing By December 31, children at risk for lead poisoning who reside in the City of Milwaukee will receive an age appropriate blood lead test. Objective #2: Comprehensive Follow-up for Blood Lead Levels >15 mcg/dl By December 31, residents from the jurisdiction of the City of Milwaukee Health Department will receive environmental intervention services and case management home visits. Objective #3: Lead Safe Housing Units By December 31, pre 1950 housing units located in the City of Milwaukee will be made lead- safe.

5 5 Although it is not required for the department to submit reports, the MHD will generate reports for our internal records, and these documents will be available to the state upon their request. 3. Remove or revise the MHD Intervention Levels for Children by Blood Lead Level, protocol posted on the MHD website. This protocol does not comply with Wis. Stat. ch. 254 requirements, 2017 Program Quality Criteria and the WCLPP Program Handbook. [PA3] Response: The MHD has revised the CLPPP Intervention schedule. Below is what is currently posted on the City of Milwaukee Health Department s website. (These services could be extended if capacity is increased). Blood Lead Result City of Milwaukee Health Department Response All Results / All Ages 5-9 µg/dl Letter with test result mailed to family providing educational materials, prevention information, and contact information for MHD to provide further information. Child <73 months with Venous Draw µg/dl A Public Health Services Assistant conducts a home visit to provide educational information, conduct a walk-through home assessment, and conducts wet washing and/or HEPA vacuuming to remove immediate lead hazards. These services are delivered in the client s home until the service goals are met. Child <73 months with Venous and Capillary Draw µg/dl A Public Health Nurse (PHN) Case Manager conducts a home visit to provide educational information, conduct a growth and development assessment of the child, and provides ongoing monitoring of the child. The PHN will coordinate closely with a Lead Risk Assessor who will inspect the child s home for lead hazards. These services are delivered in the client s home until the service goals are met.

6 6 All Results / All Ages At this level, an immediate MHD lead poisoning response will be initiated. 45 µg/dl and higher A Public Health Nurse (PHN) Case Manager conducts a home visit to provide educational information, conduct a growth and development assessment of the child, and provides ongoing monitoring of the child. The PHN will coordinate closely with a Lead Risk Assessor who will inspect the child s home for lead hazards. These services are delivered in the client s home until the service goals are met. 4. Develop or adopt criteria for opening and closing nursing case management files for children and environmental investigation files for addresses that meet or exceed EBLL requirements. [PA4 and PA5] Response: The City of Milwaukee Health Department will be adopting the policy and procedures of the Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( ) as the basis for MHD Childhood Lead Poisoning Prevention Program policies (See Appendix B pg. 75). It is the responsibility of the Public Health Nurse Coordinator to review all incoming cases (new and retests) for children of all ages with a venous and capillary blood lead test of >10mcg/dL. Additionally, the Public Health Nurse Coordinator will refer these cases to a PHN, LRA, and HSA for appropriate follow-up based on the child s lead level. 5. Develop and maintain a central filing system for nursing case management files, environmental investigation files, and other key records of the program. [PA6, NC1, EI1] Response: This activity is in the process with a completion deadline of 9/30/2018. This will include very strict protocols as to who has access to files and where they are stored. 6. Develop and implement written protocols for entering nursing and environmental investigation information into the childhood lead database that ensures consistency between information in the paper file and in the database. [PA7] Response: This activity is in process, with a completion date of 8/30/2018. The updated policies will include very strict protocols as to who has access to files and where they are stored. This will also include who enters data and who has the responsibility of ensuring that the data entered into the childhood database will be responsible for timely input and

7 7 accuracy. A meeting with the Nursing Staff will be held on 7/12/2018 to discuss case management and operational policies. 7. Develop and implement written protocols for record-keeping that include required documents for environmental investigation files (including the risk assessment report, written orders with work specifications, and clearance report as required). [EI5]. Response: This activity will be developed by staff responsible for the development, processing, reporting, and storage of environmental investigation files that can be documented to obtain all appropriate data and other documents. Nursing Case Management Corrective Actions 1. Review the 491 EBLL cases identified in MHD between January 1, 2012, and December 31, 2017, to identify and ensure nursing case management is provided for all children who should have had these interventions but who (1) did not receive them, (2) did not receive all required interventions, or (3) had their cases closed before meeting minimum closure criteria. These include the 37 EBLL cases based on two venous BLLs 15 mcg/dl and the 454 EBLL cases based on one venous BLL 20 mcg/dl. [NC1, NC2 and NC3] Response: MHD staff, are currently cross checking to ensure that those who are in the 491 are not counted twice. Each case will be assess to address the specific interventions given or not to clients and what else is needed to correct the previous actions that may have led to them not being serviced properly. MHD CLPPP priority for these cases are as follows: o EBLL mcg/dl o EBLL 20+ The rationale for the priority of the 491 is based on the premise that in past practice EBL cases were not referred to PHN s for case management services, nor environmental investigations. Quality Assurance for all cases moving forward will be done by the PHN Coordinator for the nursing case management, and EBL Manager for the environmental investigations. Projected deadline for completion 8/15/ At a minimum, initiate nursing case management for all children with two venous BLLs 15 mcg/dl that were drawn at least 90 days apart or one venous BLL 20 mcg/dl per the WCLPP Program Handbook and the 2017 Program Quality Criteria [NC2] Response: This process has already begun with a projected 9/30/2018 deadline. The MHD is initiating case management for all EBLL cases at 15 venous/capillary and higher. Due to staffing this is challenging to follow-up with the non-confirmed cases, however the department is looking at what is best practices for case management follow-up for nonconfirmed cases, so that the PHN s can prioritize these cases in addition to the back log, until more staff is hired. The MHD is attempting to find nurses who want to work in public health and also temporary nurses that we can train to go to the homes and work closely with these families.

8 8 3. Conduct nursing home visits for all children identified with an EBLL as specified in the WCLPP Program Handbook. [NC3] Response: This process has started. The CLPPP PHN s are currently providing case management services for all EBL cases at 15 mcg/dl venous and capillary and higher. 4. Develop and implement nursing case closure criteria that meet or exceed state program minimum case closure criteria as specified in the WCLPP Program Handbook.NC4] Response: The City of Milwaukee Health Department will be adopting the policy and procedures of the Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( ) as the basis for MHD Childhood Lead Poisoning Prevention Program policies. It will be the responsibility of the Program Manager to review and case conference with the Public Health Nurses regarding all of their open cases, prior to closing. The Public Health Nurse Coordinator is expected to review all closed cases for appropriate documentation, and STELLAR entry. This twostep approach will be used as a checks and balance to assure that cases are closed and documented appropriately. 5. Develop and implement protocols to reopen closed nursing cases when the child has another EBLL. [NC4] Response: This activity has been completed. The City of Milwaukee Health Department will be adopting the policy and procedures of the Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( ) as the basis for MHD Childhood Lead Poisoning Prevention Program policies. Environmental Investigation Corrective Actions 1. Review the 491 EBLL cases identified in MHD between January 1, 2012, and December 31, 2017, to identify and ensure environmental investigations are provided for any of the EBLL cases that did not receive required services. These include the 37 EBLL cases based on two BLLs 15 mcg/dl and the 454 EBLL cases based on one BLL 20 mcg/dl. [EI2, EI3, EI4] Response: This process has started with reviewing the list of 491 EBLL cases to identify duplicate addresses. The duplication is due to the MHD internal assessment that had determined that 168 EBLL cases from that were identified as incomplete. Additionally, there were 252 cases which received some abatement from 2014 that may have had some EBLL that were missed. Through this review of all cases that have been identified as inadequate, a significant number of them were determined to be duplications with the 491 that was identified by the State of WI. With limited certified staff a significant amount of time will be needed to address the backlog of environmental investigations. deadline of staff to be trained and certified by 10/31/2018.

9 9 2. Develop and implement program criteria that require conducting a complete lead risk assessment and provision of a full lead risk assessment report for each address associated with an EBLL case, as referenced in the 2017 Program Quality Criteria and described in the WCLPP Program Handbook. [EI2, EI3] Response: The City of Milwaukee Health Department will be adopting the policy and procedures of the Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( ) as the basis for MHD Childhood Lead Poisoning Prevention Program policies. MHD LRAs will conduct a complete lead risk assessment and provision of a full lead risk assessment report for each address associated with an EBLL case per WCLPP Program Handbook 3. Develop and implement program criteria that require conducting a complete lead clearance and provision of a full lead clearance report for each completed lead hazard remediation, as required under Wis. Admin. Code ch. DHS 163, for each lead clearance conducted. [EI4] Response: The City of Milwaukee Health Department will be adopting the policy and procedures of the Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( ) as the basis for MHD Childhood Lead Poisoning Prevention Program policies. MHD LRAs will conduct a complete lead clearance and provision of a full lead clearance report for each completed lead hazard remediation per WCLPP Program Handbook. 4. Develop and implement program criteria that require written orders for each property where a lead hazard is identified as required under Wis. Stat. ch [EI6] Response: The City of Milwaukee Health Department will be adopting the policy and procedures of the Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( ) as the basis for MHD Childhood Lead Poisoning Prevention Program policies. Any property with an EBL and where we find lead hazards lead orders will be written, and we are currently doing so. The MHD does have the ability to enforce direct administration with and without consent for warrants, etc., when indicated.

10 10 Appendix A (see attachment) Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( Chapter 7.0, pg. 77 Environmental Assessment and Intervention for a Child with Lead Poisoning Lead Risk Assessments 7.7, pg. 78 Lead Hazard Reduction Activities 7.13, pg. 89 Written Order 7.18, pg. 94 Lead Clearance and Reporting 7.19, pg. 95 Enforcement 7.21, pg. 97

11 11 Appendix B (see attachment) Consolidated Contract Objectives, Timeline, and Strategies

12 12 Appendix C (see attachment) Wisconsin Childhood Lead Poisoning Prevention and Control Handbook for Local Health Departments ( Chapter 6, pg. 67 Nursing Case Management of a Child with Lead Poisoning Introduction 6.2, pg. 68 Assessing Child 6.4, pg. 70 Developing a Care Plan 6.6, pg. 72 Evaluation of Care 6.8, pg. 74 Case Closure 6.9, pg. 75