Reports/Open Communication The Director of Quality and Compliance is a direct link to the Quality...

Reports/Open CommunicationThe Director of Quality and Compliance is a direct link to the Quality Council (EMT) – report progress, findings, etc.

The role of the QI Department will be to support the Champions and Quality Improvement Teams. Champions will complete a quarterly report/update on the progress of the QI measure to QI Director and Quality Council.

Quality Initiatives Champion (s) will be assigned to each quality initiative.

Quality Improvement Teams will be created for each quality initiative – consisting of staff with the expertise, skills and knowledge needed. The Quality and Compliance Director is a support to all Quality Improvement Teams for support and guidance of quality initiatives.

VisionA bridge to a brighter future through lifelong learning

Core Values•Learning as a focus across all Glade Run’s programs as evidenced by:

•Discerning the strengths and cultures of families•Emotional and behavioral management to facilitate academic achievement

•Innovative learning opportunities for staff, children and families•Program excellence and positive impacts as evidenced by:

•Partnerships with families to understand their needs and achieve success at home and in the community•Data that indicates successful outcomes for individuals and families

•Improved academic performance•High satisfaction ratings

•A welcoming culture•Working with individuals and families in the most appropriate setting available

•Work environments that thrive on the seven commitments of sanctuary•Our Christian foundation

MissionLinking Faith and Service

Quality and Compliance

The primary focus of this report is to provide the board with an overview of the Quality Management Plan. An action step of the agency 2013-2014 strategic plan was to improve the QI plan and Ongoing QI processes – align the quality improvement plan with strategic goals and identified outcome measures. The Executive Management Group has successfully aligned the quality initiatives with the goals and action steps. The quality initiatives and outcome measures closely align with the following goals and actions steps.

AGENCY WIDE: Goal 1: All programs will demonstrate excellence through integrated approaches within and between program areas - Measurability/outcomes/impacts - Consistency

- Coaching/training - Incorporate agency values

Action Step 1: Identify, develop and implement evidenced based interventions across programs.- Identify the evidence based methodologies (CBIT; CBT; PCIT; PBIS; ABLES; Family Structural Therapy- Train program staff in the identified interventions (trauma informed care;

sanctuary)- Supervise and coach the models (frequency,; content; live observations

Action Step 2: Ongoing implementation and monitoring of the initiatives of generalization, individualization, and family partnership.

The next chart represents the current quality initiatives:

QUALITY COUNCIL (EMT)

Program Excellence Through Lifelong Learning

Life Long Learning: Staff,families/individuals and other professionals gainknowledge and competence through training and skillattainment

EPT: Implements the strategic goals established by the EMT while ensuring program excellence and compliance

EMT: Oversees program excellence and strategic growth

EST: Provides support for the EMT and EPT to achieve program excellence and strategic growth

EMG consists of EMT, EPT, and EST. The implementation and leadership of the Continuous Quality Improvement initiatives is the responsibility of the EMG.

Goals and Action Steps to Achieve Outcome/Impact

Quality Initiatives Impact Statement; The end result of the Quality Initiative

Quality Initiative Measurement Tools

Quarterly Summary/Follow-up

Family Partnership: Families feel empoweredin the decision makingprocess and express asense of connectedness to supportive networks

Academic Excellence:The learning environmentat St. Stephen’s LutheranAcademy reflects academic excellence and an Accountable, Safe and Kind environment

Individualization/Generalization:families/individuals learn and practice skillsthat will transfer to theirunique home and communitysettings

Evidence Based Practices: Program excellence is achieved with the training and utilization of evidence based practices

Training records will identify the completion of career track trainings.

Quarterly training effectiveness survey’s

New hire surveys initial and at first quarter

Google analytics will be used to evaluate utilization of web-based trainings.

Clinical case review evaluations/checklists

Skill evaluation checklists

Exit interviews/ Review and revise to include skill development

Retention rates

Parent survey

PAS audits reviews

Develop career tracks for all job classifications

Assess, prioritize and evaluate training needs for staff, individuals families and other professionals

Educate and train employees and supervisors regarding career tracks.

Design web-based trainings

Develop professional skill evaluation checklistsEstablishment of learning goals for employees

Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools.

Lifelong LearningChampion Nickole Pribozie

Staff, families/individuals and other professionals gain knowledge and competence through training and skill attainment

Measurement Tool Responsible Person Frequency

Review training records for career track completion

Nickole Pribozie Quarterly (Oct, Jan, April, July)

Training effectiveness surveys

Nickole Pribozie Quarterly (Oct, Jan, April, July)

Training Needs survey Nickole Pribozie Semi-Annually

Clinical Case Review evaluations

Program Managers/supervisors

90 days and Annually

Retention Rates Tina Lynch Semi-Annually (Sept, March)

Summary/follow upLife Long Learning

TRAINING ASSESSMENTS– 105 Training Assessment needs have been completed. This is a six Question survey to identify training

needs by position. This data is currently being evaluated to help assist in the continued development of Career Tracks.

CAREER TRACKS: – Six career tracks have been developed. These career tracks will be available to staff on a voluntary basis.

They are designed to help enhance skills and competencies. The six staff categories are:

• Direct care – includes TSS, MHW’s, Teaching Assistants, Adventures staff• Therapist – MHP, BSC, Mobile therapists• Clinical Supervision• Leadership• Support Staff• Case Management

ORIENTATION AND TRAINING SURVEYS :

•70 Training Evaluation surveys have been completed. The surveys are administered after new hire training and then again at the quarterly basis. The survey is an eight question survey that evaluates the employees skill confidence to job duties and an evaluation of the effectiveness of the trainer to deliver the material in a way that the employee is able to relate the training to skill development and job preparedness.

•Average score of 4.27 on the Question I feel the training provided me new knowledge or insight.

•Average score of 4.67 on the question “I feel confident that I have the knowledge and skills to be able to use what I learned in my work”

•Average score of 4.59 on the question “Overall, this training will help me do my job well.”

NEW TRAININGS:

•Residential 3800 regulations•Child Psychomarmacology•Sanctuary module 3 and 4•Creating a welcoming environment •HIPAA security•Progress note training utilizing DAP format: This training is an agency wide format on progress note writing.•BHRS Redesign: A service delivery model that enhances family strengths, natural resources and transfer of skill.•Sanctuary Modules: Five sanctuary modules are available agency wide.•Adolescent and Autism•CAASP principles•Suicide Prevention•Generalization Part I and Part II: This training focuses on how individuals can effectively transfer skills to parents/caregivers and create positive behavior change.

Training Survey’s

Q 1 Overall Score

Q2 Overall Score

I feel confident that I have the knowledge and skills to be able to use what I learned in my job

81 4.28% 76 4.38%

I feel the training provided me new knowledge and insight 81 4.63% 76 4.53%

Overall, this training will help me do my job well 81 4.64% 76 4.47%

1st Q Agree Strongly Agree

2nd Q Agree Strongly Agree

Employee orientation has increased my excitement about working at Glade Run

4 25% 75% 8 12.5% 75%

I have a clear understanding of the history of Glade Run

4 25% 75% 8 37.50% 62.5%

I understand how the values of Glade Run impact the work that we do

4 25% 75% 8 12.5% 87.5%

I am familiar with the services provided by Glade Run

4 25% 75% 8 50% 50%

I have a basic understanding of the sanctuary model

4 25% 50% 8 37.5% 62.5%

I know where to learn more about any of the topics covered

4 50% 50% 8 37.5% 62.5%

I feel welcomed by Glade Run 4 100% 8 25% 75%

New Hire Campus Orientation Survey

Community New Hire Orientation survey

1st Q Agree Strongly Agree

2nd Q Agree Strongly Agree

Employee orientation has increased my excitement about working at Glade Run

3 33.33% 66.67% 2 100%

I have a clear understanding of the history of Glade Run

3 66.67% 33.33% 2 100%

I understand how the values of Glade Run impact the work that we do

3 33.33% 66.67% 2 100%

I am familiar with the services provided by Glade Run

3 66.67% 33.33% 2 50% 50%

I have a basic understanding of the sanctuary model

3 66.67% 33.33% 2 50% 50%

I know where to learn more about any of the topics covered

3 66.67% 33.33% 2 100%

I feel welcomed by Glade Run 3 50% 50% 2 100%

Family PartnershipChampion Leslie Walter

Grow the Glade Run Family network data base

Increase decision making and participation of families in agency events/activities

family partnership support will increase visibility and continue communicating their role in glade run culture

Family advisory counsel continues to grow and become involved in decision making and planning.

Families/Individuals feel empowered in the decision making process and express a sense of connectedness to supportive networks

Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools

Review the number and percentage of active participants in the Glade Run Family Network Database

Review family participation/voice in treatment plans, progress notes and ISPT and treatment plan signature pages

Training recordsReview advisory counsel minutes.

3, 6, 9 month aftercare calls

Family satisfaction surveys

Database communication form.

Summary/follow upFamily Partnership

DATA BASE:

•To Date there are 194 families active in the family partnership data base.

– 97% would like to receive updates on family/community events– 79% would like to become more involved and share their voice and experience with us.– 79% would like information on how to connect with other families– 48% would like to be connected to spiritual and/or other supports within the community– 90% would like to receive the Glade Run newsletter, The Bridge.

FAMILY SATISFACTION SURVEYS:

•Parent satisfaction surveys have been streamlined across all program areas of the agency to one survey that focuses on four major categories: Family partnership, sanctuary, generalization and individualization. The survey will be sent out twice a year in January and July. The first survey’s went out in July of 2013. All current active clients in treatment or in the education setting received a survey. Surveys are sent out in a multitude of forums: email, mail or face to face. •Over 2000 surveys went out in July and over 200 have been returned. The following charts represent the results of the family partnership section of the survey.•In the survey, parents are able to identify what trainings they would like to have. The common theme is behavior management and parenting skills. The family partnership staff are working closely with the Training department to develop curriculum. •A process has been put in place to provide immediate follow up to any family that expresses concern regarding the quality of service delivery when reviewing the surveys.•As a result of feedback from a survey, the Residential Treatment Facility changed the way they do medication sheets for therapeutic leaves to improve the communication and instructions on medication use.

Strongly Disagree

Disagree Neutral AgreeStrongly Agree

Rating Average

Response Count

1 1 12 65 107 4.48 186186

0

Strongly Disagree


Rating Average

Response Count

1 4 12 67 102 4.42 186186

0

Strongly Disagree


Rating Average

Response Count

1 4 16 75 89 4.34 185185

1

Strongly Disagree


Rating Average

Response Count

1 1 6 61 115 4.57 184184

2

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Answer Options

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4. Glade Run staff are friendly and polite.

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Family Satisfaction Survey

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2. I am asked for my input about the strengths and needs of my family.

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3. I helped to create the current goals.

1. I feel Glade Run staff are welcoming.

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Answer Options

Strongly Disagree


Rating Average

Response Count

0 13 22 58 90 4.23 183183

3

Strongly Disagree


Rating Average

Response Count

2 7 24 78 72 4.15 183183

3

Strongly Disagree


Rating Average

Response Count

1 4 21 60 95 4.35 181181

5

Strongly Disagree


Rating Average

Response Count

2 3 9 67 102 4.44 183183

3

Strongly Disagree


Rating Average

Response Count

4 4 23 74 79 4.20 184184

2

answered question

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7. Glade Run staff show concern for my family's improvement.

5. I receive updates on progress towards goals.

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9. My needs are being addressed.

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8. I have a voice regarding decisions involving care, treatment and services.

6. I receive information about the services available at Glade Run.

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Answer Options

Strongly Disagree


Rating Average

Response Count

4 9 32 71 68 4.03 184184

2

Strongly Disagree


Rating Average

Response Count

4 16 48 54 62 3.84 184184

2

answered question

11. Glade Run staff are helping/have helped me build a supportive network in my community (family, friends, resources, etc.).

Answer Options

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10. I receive information on resources/events that are relevant and beneficial to me.

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Summary/follow upFamily Partnership

FAMILY ADVISORY BOARD:

•Family advisory counsel continues to meet quarterly with 5 new family members having recently been added. The family representation is across the full continuum of services for Glade Run.

FAMILY ENGAGEMENT:

•Family partnership continues to develop strategies and opportunities to enhance family engagement within the agency. There has been a recent culture change to include families in events.•Reiber cottage had an open house to showcase their sensory room. They had 100% family participation.•Marthen’s cottage is also scheduling family events.•Beaver Falls office conducted a positive parenting group.•Many of our families were invited and attended the Jeremiah Village community information sharing meetings.

Academic AchievementChampion Amy Williams

The learning environment at St. Stephens’ Lutheran Academy reflects academic excellence and an Accountable, Safe and Kind environment

85% attendance Rate

Grades will improve school wide

Major incidents will decrease (Acts of violence, self injurious behavior, AWOL, restraint, police involvement, psychiatric hospitalization)

Students will demonstrate increased proficiency in reading comprehension and math

Implement the CBITS

Classroom Engagement

Attendance Records

School wide grade reports

Positive Behavior Support Assessment; Incident Report review; ASK points

Aims-WEB reports

CBITS evaluation tools

Walk through observation/evaluation cards

Goal Attainment Scale Leadership groups

Teacher and teacher Aid staff retention

Staff, student, parent, school district surveys


Education

Measurement Tool Person Responsible FrequencyAttendance Records Jayme Glover 9 week intervals and end of school

year

School wide grades Jayme Glover 9 week interval and end of school year

PBIS Keenan McGaughey Semi-annually

Walk thru engagement cards Amy Williams, Keenan, McGaughey, Ruth Girton, Beth Hines, School Leadership team, Nickole Pribozie

30 per month

Student, family surveys Amy Williams, Leslie Walter 2 X per year

ASK points Jayme Glover Semi-annually

Incident report review Jayme Glover Quarterly

POSITIVE BEHAVIOR INTERVENTIONS IN SCHOOLS

Critical Elements of PBIS implementation include•PBIS Team•Faculty Commitment•Effective Procedures for Dealing with Discipline•Data Entry and Analysis Plan Established•Expectations and Rules Developed•Reward/Recognition Program Established•Lesson Plans for Teaching Expectations and Rules•Implementation Plan•Classroom Systems•Evaluation

•On October 24th, 2013, education staff were sent an anonymous survey for the National PBIS team to evaluate the staff perceptions of implementation of PBIS at St. Stephen’s. 70 school staff completed the survey. The areas evaluated for implementation include System: school wide; (18 items) System: non classroom (9 items); System: classroom (11 items); and system: individual (8 items). This survey is repeated yearly and provides the certification team a tool to determine the schools readiness for certification process.

In place Partial Not in place

System: School wide 6 11 1

System: Non classroom 0 9 0

System: classroom 2 9 0

System: Individual 0 7 1

Summary/Follow upAcademic Excellence

STUDENT/TEACHER ENGAGEMENT:

•Walkthroughs have become increasingly popular as a tool for improvement. They are brief, informal and focused. In essence, they are a quick snapshot that gathers data and documents trends over time. St. Stephen’s views walkthrough observations for a shared leadership perspective where staff expertise is valued. We believe that staff involvement is instrumental in using walkthroughs as a tool for promoting reflection in the art of teaching and the improvement of instruction and learning. Below you will find a snapshot of the walkthroughs from the end of the last school year.

Observed to a high degree

Observed to be effective and appropriate

Observed Needs further development

Not observed Needs improvement

StudentEngagement

11/46 24% 19/46 41% 16/46 35% 0

TeacherEngagement

5/46 11% 23/46 50% 16/46 35% 0

Classroom engagement

9/46 20% 12/46 26% 12/46 26% 0

POSITIVE BEHAVIOR SUPPORT

•St. Stephen’s utilizes a positive behavior point card in which students receive points in the areas of Accountable, Safe and Kind. These points are utilized in the overall positive behavior support system, which is tied into the PBIS Reward/Recognition Program. The following chart provides a quick overview of the percentage of points earned. The chart represents elementary, middle school and high school classes.

% of Accountable points achieved

% of Safe points achieved

% of KindPoints achieved

% ASK Points achieved

Elementary 90.12% 96.03% 97.79% 94.19%

Middle 93.30 100% 99.24% 95.25%

High School 92.12% 96.57% 93.74% 94.49%

Total Education 92.39% 97.48% 95.11% 94.42%

Individualization/GeneralizationChampion Beth Hines

Families/individuals learn and practice skills that will transfer to their unique home and community settings.

Strength Needs and Cultural Discovery Treatment Plan Reviews

Goal Attainment Scale

Parent/client surveys

3, 6 and 9 month after care surveys

Treatment plan reviews

Progress Notes review

100% of Treatment plans will identify family strengths and prioritized needs

100% of Treatment plans will develop goals and interventions to include natural and informal supports

Progress note format training

Progress notes reflect evidence of skill transfer through teaching, modeling, evaluation and/or monitoring


Summary/follow upIndividualization/Generalization

GOAL ATTAINMENT SCALES (GAS)–is a means of measuring outcome data that is directly related to clients’ goals set out on a 5 point scale of -2 to +2. –All programs implemented GAS in October of 2012, however it was discovered that there was inconsistency in scoring of the scales and unclear parameters to establish the timeframes of collecting the scores. Staff will be retrained and user guides are being developed.–Moving forward scores will be utilized in a more consistent manner making the data more reliable.

PARENT/CHILD SURVEYS:–As mentioned under the Family Partnership Quality Initiative a standardized family satisfaction survey has been developed and is sent out at the same time for all program areas. The following reflects the overall parent satisfaction in regards to generalization.

Strongly Disagree


Rating Average

Response Count

1 4 16 75 89 4.34 185185

1

Strongly Disagree


Rating Average

Response Count

2 3 9 67 102 4.44 183183

3

Strongly Disagree


Rating Average

Response Count

4 9 32 71 68 4.03 184184

2

Strongly Disagree


Rating Average

Response Count

4 16 48 54 62 3.84 184184

2

Strongly Disagree


Rating Average

Response Count

2 3 34 67 77 4.17 183183

3skipped question

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Family Satisfaction Survey - Generalization

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5. I feel confident the skills I have learned can be used in my home, community and/or the school.


answered question

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Strongly Disagree


Rating Average

Response Count

1 4 12 67 102 4.42 186186

0

Strongly Disagree


Rating Average

Response Count

1 4 16 75 89 4.34 185185

1

Strongly Disagree


Rating Average

Response Count

1 9 12 62 99 4.36 183183

3

Strongly Disagree


Rating Average

Response Count

0 13 22 58 90 4.23 183183

3

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Answer Options

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4. I receive updates on progress towards goals.

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Family Satisfaction Survey - Individualization

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3. Glade Run staff routinely communicate with me.

1. I am asked for my input about the strengths and needs of my family.

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Answer Options

Strongly Disagree


Rating Average

Response Count

2 7 24 78 72 4.15 183183

3

Strongly Disagree


Rating Average

Response Count

1 4 21 60 95 4.35 181181

5

Strongly Disagree


Rating Average

Response Count

2 3 9 67 102 4.44 183183

3

Strongly Disagree


Rating Average

Response Count

3 7 25 55 94 4.25 184184

2

Strongly Disagree


Rating Average

Response Count

4 4 23 74 79 4.20 184184

2

answered question

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5. I receive information about the services available at Glade Run.

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9. My needs are being addressed.

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8. The program is helping my family.

6. Glade Run staff show concern for my family's improvement.

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Answer Options

Strongly Disagree


Rating Average

Response Count

4 9 32 71 68 4.03 184184

2

Strongly Disagree


Rating Average

Response Count

4 16 48 54 62 3.84 184184

2

answered question


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Summary/follow upIndividualization/Generalization

AFTERCARE CALLS

•The Community programs and the RTF both do follow up aftercare calls. The questions and frequency of the calls are somewhat different. The RTF does 30, 60, and 90 day follow up calls and the community programs do 30 day and 6 month aftercare follow up surveys.

•In previous years there were not a lot of calls being completed for the community programs. During this past year the aftercare call surveys have been centralized and are electronically entered into Survey Monkey. This has significantly improved the number of calls being completed as well as the ability for immediate analysis of the data being collected.

•Please find below in the next few pages the results of survey’s completed during this fiscal year. The RTF completed 103 surveys out of 214 attempted calls. The community programs attempted 665 calls and successfully completed 177 surveys.

Community Programs Aftercare calls

Response Percent

Response Count

12.2% 8114.1% 9412.6% 849.3% 6230.4% 2026.6% 446.3% 421.4% 97.1% 47

6650

Family Preservation-ReunificationFamily Focused Solution Based

BHRS - Butler

5. Program:

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BHRS - Pittsburgh

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Family Based - BeaverFamily Based - Butler

BCM - ButlerBCM - Beaver

BHRS- Beaver

Response Percent

Response Count

88.2% 15711.8% 21

178487

Response Percent

Response Count

2.8% 597.2% 172

177488

Response Percent

Response Count

6.8% 1293.2% 165

177488

Response Percent

Response Count

8.0% 1492.0% 161

175490

Yes

Answer Options

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6. Are you currently living in the same home as when you were discharged?

No

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9. Have you been voluntarily hospitalized?

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Yes

Answer Options

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8. Have you experienced a crisis that resulted in a psychiatric hopsitalization?

No

Yes

Yes

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No

Answer Options

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7. Have you been arrested since discharge?

No

Response Percent

Response Count

62.3% 10914.9% 2622.9% 40

175490

Response Percent

Response Count

7.0% 1293.0% 160

172493

Response Percent

Response Count

7.4% 1336.6% 6456.0% 98

175

Answer Options

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Yes

NoN/A (Consumer is a child)

Yes

12. Are you currently employed?

No

No

Answer Options

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N/A (No medications prescribed)

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11. Are you currently involved with or receiving services from CYF (Children, Youth, and Families)?

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10. Are you currently taking your prescribed medication?

Yes

RTF Aftercare Calls

Response Percent

Response Count

89.3% 924.9% 52.9% 31.0% 11.0% 10.0% 00.0% 01.0% 1

2103

0

Response Percent

Response Count

30.1% 3119.4% 2021.4% 2229.1% 30

1030

Response Percent

Response Count

79.1% 340.0% 020.9% 90.0% 0

4360skipped question

Detention

No Response (family did not return call or answer Client Re-Admitted to Program/Treatment

Foster Care

60 Days90 Days

Shelter

No Contact Information (phone number is no longer in

Independent Living

3. Client was discharged to:

180 Days

4. Type of Interveiw

Other (please specify)

Client/Family Refused to Answer Questions

CRR

5. If survey cannot be completed, indicate why.

Answer Options

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CYS

Answer Options

HomeGroup Home

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30 Days

Response Percent

Response Count

71.2% 426.8% 43.4% 20.0% 03.4% 21.7% 11.7% 15.1% 31.7% 10.0% 01.7% 13.4% 2

05944

Response Percent

Response Count

85.0% 5115.0% 9

6043

Response Percent

Response Count

86.7% 5210.0% 63.3% 2

26043

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Shelter

Don't Know

CYS

Home

Yes

8. Did your child go to his/her first aftercare appointment after leaving Glade Run?

Group Home

No

Unknown


Detention

Answer Options

Foster Care

answered question

7. Staff Question - Is this child CURRENTLY in a Less Restrictive Setting?


answered question

RTF

Yes

Independent Living

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6. Where is your child currently? (Please indicate where this child is on the day of the survey, i.e home, hospitalized, runaway, unknown)

Answer Options

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Runaway

No

CRR

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Hospitalized

Response Percent

Response Count

78.3% 4720.0% 121.7% 1

6043

Response Percent

Response Count

55.0% 3321.7% 1323.3% 14

6043

No

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10. Since your child was discharged, do you think he/she is doing better, the same, or worse?

Unknown

Worse

9. Is your child still following his/her aftercare plan?

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Better

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Same

Yes

TREATMENT PLAN REVIEWS

•In the treatment planning process parents should be involved from the beginning and the treatment plan goals and interventions are to individualized and demonstrate transfer of skill back in the homes and community’s. The treatment plan should also reflect goals and interventions that include natural and informal supports. The following are results of treatment plan audits conducted for this fiscal year.

Response Percent

Response Count

40.0% 20.0% 00.0% 040.0% 220.0% 1

457

Response Percent

Response Count

83.3% 1016.7% 2

3120

Response Percent

Response Count

75.0% 916.7% 28.3% 1

120skipped question

IF NO, list incomplete sections:

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Answer Options

No

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3. Preliminary Treatment Plan - Parent/Guardian/Client Signature Present:

Yes

BHRS/Strengths Based/Brief Treatment - 30 Day Review Audit

Answer Options

Paper

No

answered question

Answer Options

NoUnknown

EMR

IF NO, List Missing Dates:

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1. Psychosocial Health Assessment - sections asking for "in their own words" are completed with quotes/comments from client/family:

Yes

Both

Unknown

answered question

2. Preliminary Treatment Plan - Present: (BHRS & VBH = 30 days) (BHRS & CCBH = 5 days) (SBT = 5 weeks) (Brief Tx = 5 weeks)

Response Percent

Response Count

80.0% 40.0% 020.0% 1

57

Response Percent

Response Count

58.3% 733.3% 48.3% 1

120

Answer Options

NoUnknown

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Answer Options

No

Yes

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4. Preliminary Treatment Plan - Identifies Client/Family strengths and prioritized needs:

answered question

5. Preliminary Treatment Plan - Identifies goals and interventions that include natural and informal supports:

Yes

Unknown

Response Percent

Response Count

44.4% 411.1% 144.4% 4

94


No

FBMHS - 30 Day Review

Unknown

Answer Options

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Yes

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Response Percent

Response Count

46.2% 60.0% 00.0% 053.8% 70.0% 0

130

Response Percent

Response Count

66.7% 633.3% 30.0% 0

94

Response Percent

Response Count

55.6% 544.4% 40.0% 0

94

Yes

Unknown

No

No

answered question

Answer Options

Unknown

3. Preliminary Treatment Plan - Identifies Client/Family strengths and prioritized needs:

No

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EMR

4. Preliminary Treatment Plan - Identifies goals and interventions that include natural and informal supports:

Answer Options

answered questionUnknown

answered question

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Answer Options

2. Preliminary Treatment Plan - Parent or Guardian/Client Signature Present:

BothPaper

Yes

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Response Percent

Response Count

66.7% 633.3% 30.0% 0

94

No


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Answer Options

5. Preliminary Treatment Plan - Documentation of Skill Transfer to Parent/Guardian:

Yes

OP - 30-Day Review

Response Percent

Response Count

11.1% 177.8% 70.0% 011.1% 1

91

Response Percent

Response Count

0.0% 00.0% 00.0% 033.3% 133.3% 133.3% 1

37


Yes

Answer Options

NoN/A

Both

Yes

Unknown

3. Initial Treatment Plan - parent/client signature present:

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Answer Options

No

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N/A

4. Initial Treatment Plan - Identifies goals and interventions that include natural and informal supports:

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Paper

Response Percent

Response Count

0.0% 00.0% 00.0% 033.3% 133.3% 133.3% 1

37

No

5. Initial Treatment Plan - Documentation of Skill Transfer to Parent/Guardian:

Answer Options

Both

N/AUnknown

YesPaper

answered questionskipped question

Response Percent

Response Count

33.3% 10.0% 00.0% 00.0% 00.0% 066.7% 2

37

UnknownN/A

answered question

Paper

Answer Options


skipped question

BothNo

Yes

RTF - 30 Day Review Audit

Response Percent

Response Count

88.9% 80.0% 011.1% 1

90

No

3. Master Treatment Plan - Identifies Client/Family strengths and prioritized needs:

Yes

Answer Options


skipped question

Response Percent

Response Count

88.9% 80.0% 011.1% 1

90

Response Percent

Response Count

88.9% 80.0% 011.1% 1

90

Response Percent

Response Count

88.9% 80.0% 011.1% 1

90

Response Percent

Response Count

22.2% 266.7% 611.1% 1

90

Yes

Unknown

No

5. Master Treatment Plan - Documentation of Skill Transfer to Parent/Guardian:

Yes

Answer Options

skipped question

Answer Options

Unknown

skipped questionanswered question

7. Master Treatment Plan - Signature Page - Parent/Guardian Signature Present:

Answer Options

No

answered question

4. Master Treatment Plan - Identifies goals and interventions that include natural and informal supports:

Yes

answered question

Answer Options

Unknown

skipped question

Unknown

skipped question

No

answered question

No

6. Master Treatment Plan - Signature Page - Client Signature

Yes

Evidence Based PracticesChampion Beth Hines

Program excellence is achieved with the training and utilization of evidence based practices

Goals and Action steps to Achieve Outcome/Impact Measurement Tools

Quarterly Summary/Follow up

Research and obtain information on the following Evidenced Based Practices:

•Cognitive Behavioral Therapy (CBT)

•Dialectical Behavior Therapy (DBT)

•Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

•Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

•Parent-Child Interaction Therapy (PCIT)

•Safe and Civil Schools Positive Behavioral Interventions and Supports Model (PBIS)

Identify and develop who will become trained trainers in the above mentioned modalities

Train employees in the above mentioned modalities

Develop clinical coaching supervision model to ensure fidelity to the modalities

Measurement tools associated with each modality if indicated/available:

Suicide Attempt Self Injury Interview (SASII); Nonsuicidal self-injury (NSSI)

Child Behavior checklists; child depression inventory; Weekly Behavior report; Parent Emotional Reaction Questionnaire ; Parenting Practices Questionnaire (PPQ); Parent Support Questionnaire (PSQ)

Child PTSD symptom Scale (CPSS); Pediatric Symptom Checklist (PSC);

Dyadic Parent-Child Interaction Coding System (DPIS); Parenting Scale (PS); Eyberg Child Behavior Inventory (ECBI); Child Behavior Checklist;

Home Situations Questionnaire—Modified (HSQM); Parenting Stress Index (PSI); Parent Locus of Control Scale (PLOC); Parent Sense of Competence Scale (PSOC);

An Academic Index Kentucky Core Content Tests; California Standards Test in Mathematics; Positive Behavior Support (PBS) Assessment—Staff survey; Teacher Surveys

Training Records

Review Supervision records

3, 6, 9 month aftercare calls

Treatment retention

Summary/follow upEvidenced Based Practices

The following Evidenced Based Practices are currently being utilized with the Glade Run Continuum.

Aggression Replacement Therapy (ART) * ART is a cognitive behavioral intervention program to help children and adolescents improve social skill competence and moral reasoning, better manage anger, and reduce aggressive behavior.

Dialectical Behavioral Therapy (DBT) *DBT is a cognitive-behavioral treatment approach with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes.

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) *CBITS program is a school-based group and individual intervention designed to reduce symptoms of posttraumatic stress disorder (PTSD), depression, and behavioral problems; improve peer and parent support; and enhance coping skills among students exposed to traumatic life events, such as community and school violence, physical abuse, domestic violence, accidents, and natural disasters.

Parent-Child Interaction Therapy (PCIT) *Parent-Child Interaction Therapy (PCIT) is a treatment program for young children with conduct disorders that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) *TF-CBT is a psychosocial treatment model designed to treat posttraumatic stress and related emotional and behavioral problems in children and adolescents. Initially developed to address the psychological trauma associated with child sexual abuse, the model has been adapted for use with children who have a wide array of traumatic experiences, including domestic violence, traumatic loss, and the often multiple psychological traumas experienced by children prior to foster care placement.

Positive Behavioral Interventions and Supports (PBIS) **One of the foremost advances in school-wide discipline is the emphasis on school-wide systems of support that include proactive strategies for defining, teaching, and supporting appropriate student behaviors to create positive school environments. Instead of using a piecemeal approach of individual behavioral management plans, a continuum of positive behavior support for all students within a school is implemented in areas including the classroom and non-classroom settings (such as hallways, buses, and restrooms)

Executive Program Team is currently evaluating the above Evidenced Based Practices to identify what programs we want to use them for. The group has identified currently employees who are trained in these modalities. Once these decisions are made than identification of measurement tools will be developed.

The importance of a Compliance program is to ensure that our agency meets the highest possible standards for all relevant federal, state and local regulations, laws and guidelines. The compliance plan helps establish a culture within the organization that promotes prevention, detection, and resolution of any activities that do not conform to federal and state laws as well as our agency’s own business and ethical policies. A compliance program provides a framework for disseminating information and establishes mechanisms for investigation potential noncompliance. An effective compliance program sends an important message to employees. Having an Agency wide Compliance Program in place encourages an environment of quality and continuous improvement. As an agency we are continuing our efforts toward a solid compliance program. Value Behavioral Health provided Glade Run with an audit tool for Provider Compliance Program Checklist. This is just anther example of the attention that is continuing to be placed upon Agency’s to operationalize their compliance policies and procedures.

The following will provide a brief overview of the compliance activities conducted during the past fiscal year.

HIPAA: The HIPAA privacy and HIPAA security meetings have been combined. This committee is chaired by the Director of Information Management and the Director of Quality and Compliance. The committee reviewed 6 reported HIPAA privacy violations. Two reported violations were not determined to be violations. However, there were 4 violations during the past year that resulted in retraining and progressive discipline for employees. The agency also provided Identify Theft Protection to three families as a result of the HIPAA violation. The HIPAA security officer with the assistance of the training director developed a new HIPAA security training to address potential risks and vulnerabilities related to the advances in the use of electronic devices and technology and the agency use of the Electronic Medical record. The HIPAA privacy officer will developing an updated course on HIPAA privacy.

Fraud Waste and Abuse: Glade Run conducted a self audit of an allegation of potential fraud. After a thorough review of this allegation, it was determined that Glade Run did not believe that the allegation rose to the level of Medicaid Fraud, however Glade Run elected to self report to the Managed Care Organization’s Fraud, Waste and Abuse department. Glade Run did however, identified several performance improvement areas and other personnel issues that led to the termination of employment for one employee and a voluntary resignation of the other.

Glade Run was asked to participate in an Fraud, Waste and Abuse investigation with CCBHO regarding the questioning of the staffing credentials of an employee delivering BHRS services. After several months of investigation the MCO did rule that the employee did not meet the qualifications of the position and requested a payback of revenues generated during services rendered by this employee.

Glade Run did not limit the scope of the investigation to just this one employee we conducted a full self audit of all employees providing master level services and made employment decisions accordingly. We also improved on several areas of the on-boarding process.

Streamlining external audits/complaints/grievances: Significant efforts have been made to ensure that the Director of Quality and Compliance is notified of any external audits, grievances and complaints. This is a major culture shift as program personnel have relied on their own internal structure to coordinate these activities in the past. We believe that this will provide uniformity and greater systemic approaches to problem solving and opportunities for continued compliance with regulations and enhance quality service delivery.

Internal Audits: The Quality and Compliance team with the collaboration of program personnel have developed program specific audit tools that incorporate both qualitative and quantitative reviews of medical records. The teams have developed an admission, quarterly and discharge audit. During fiscal year 2012-2013 were 382 recorded medical record/chart audits. The first quarter of this fiscal year has already seen an increase as 408 audits have been recorded.

Results of these audits are forwarded to program managers to use a supervision tool with employees but also for them to evaluate their processes and their compliance with standards. This continues to be an evolving system to ensure full effectiveness.

The Joint Commission Accreditation: There continues to be a steady volume of audit activities related to the Joint Commission standards. Historically the results of Joint Commission surveys became the foundation of our quality improvement activities and focused very heavily on the RTF program.

As you can see, from the extensive work reported in this report, significant movement has been made to develop audit activities that go across all of Glade Run’s Continuum of services. With that being said, there is still a significant amount of audit activity associated with compliance with The Joint Commission Standards. Over 1000 audits have been conducted in several difference areas ranging from infection control to Utilization Reviews in response to previous Joint Commission findings.

Communication: There is a clear culture shift occurring regarding the importance of compliance. The agency has always strived and provided quality of service delivery, however with the increased emphasis at a national level for increased enforcement of Fraud, Waste and Abuse initiatives, the seriousness of compliance has reached the awareness of providers. We have seen an increase in external audit activity and an increase in requests for paybacks. There is on-going meetings and consultation between Executive Program Team and the Quality and Compliance Department.

Next Steps: The focus for 2013-2014 will remain on imbedding a culture of compliance and quality service delivery. We need to develop a concrete compliance plan, educate staff and ensure implementation of that plan occurs.

Reports/Open Communication The Director of Quality and Compliance is a direct link to the Quality...

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Transcript of Reports/Open Communication The Director of Quality and Compliance is a direct link to the Quality...