Transcript Document

Mission
Linking Faith and Service
Vision
A 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
Reports/Open Communication
The 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.
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)
EMG consists of EMT, EPT, and EST. The implementation and leadership of the Continuous Quality Improvement
initiatives is the responsibility of the EMG.
EMT: Oversees program excellence and strategic growth
EPT: Implements the strategic goals established by the EMT while ensuring program excellence and compliance
EST: Provides support for the EMT and EPT to achieve program excellence and strategic growth
Program Excellence Through Lifelong Learning
Quality Initiatives Impact Statement; The end result of the Quality Initiative
Life Long Learning: Staff,
families/individuals and
other professionals gain
knowledge and
competence through
training and skill
attainment
Family Partnership:
Families feel empowered
in the decision making
process and express a
sense of connectedness
to supportive networks
Academic Excellence:
The learning environment
at St. Stephen’s Lutheran
Academy reflects academic
excellence and an
Accountable, Safe and Kind
environment
Individualization/
Generalization:
families/individuals
learn and practice skills
that will transfer to their
unique home and
community
settings
Goals and Action Steps to Achieve Outcome/Impact
Quality Initiative Measurement Tools
Quarterly Summary/Follow-up
Evidence Based
Practices: Program
excellence is achieved
with the training and
utilization of evidence
based practices
Lifelong Learning
Champion Nickole Pribozie
Staff, families/individuals and other professionals gain knowledge and competence through
training and skill attainment
Goals and Action steps to Achieve Outcome/Impact
Quality Initiative Measurement Tools.
Develop career tracks for all job classifications
Training records will identify the completion of career track
trainings.
Assess, prioritize and evaluate training needs for staff,
individuals families and other professionals
Quarterly training effectiveness survey’s
New hire surveys initial and at first quarter
Educate and train employees and supervisors regarding
career tracks.
Design web-based trainings
Develop professional skill evaluation checklists
Establishment of learning goals for employees
Google analytics will be used to evaluate utilization of webbased 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
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 up
Life 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
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.
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.”
Training Survey’s
Q1
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%
New Hire Campus Orientation Survey
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%
Community New Hire Orientation survey
1st Q
Agree
Strongly
Agree
2nd Q
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%
Agree
Strongly
Agree
Family Partnership
Champion Leslie Walter
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
Grow the Glade Run Family network data base
Review the number and percentage of active participants in the
Glade Run Family Network Database
Increase decision making and participation of families in
agency events/activities
Review family participation/voice in treatment plans, progress
notes and ISPT and treatment plan signature pages
family partnership support will increase visibility and continue
communicating their role in glade run culture
Training records
Review advisory counsel minutes.
Family advisory counsel continues to grow and become
involved in decision making and planning.
3, 6, 9 month aftercare calls
Family satisfaction surveys
Database communication form.
Summary/follow up
Family 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.
Family Satisfaction Survey
1. I fe e l Gla d e R un s ta ff a re we lc o ming .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
1
1
12
65
Stro ng ly
Ag re e
R a ting
Av e ra g e
107
4.48
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
186
186
0
2. I a m a s k e d fo r my inp ut a b o ut the s tre ng ths a nd ne e d s o f my fa mily .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
1
4
12
67
Stro ng ly
Ag re e
R a ting
Av e ra g e
102
4.42
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
186
186
0
3. I he lp e d to c re a te the c urre nt g o a ls .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
Stro ng ly
Ag re e
1
4
16
75
89
R a ting
Av e ra g e
4.34
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
185
185
1
4. Gla d e R un s ta ff a re frie nd ly a nd p o lite .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
1
1
6
61
Stro ng ly
Ag re e
R a ting
Av e ra g e
115
4.57
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
184
184
2
5. I re c e iv e up d a te s o n p ro g re s s to wa rd s g o a ls .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
0
13
22
58
90
4.23
183
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
183
3
6. I re c e iv e info rma tio n a b o ut the s e rv ic e s a v a ila b le a t Gla d e R un.
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
2
7
24
78
72
4.15
183
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
183
3
7. Gla d e R un s ta ff s ho w c o nc e rn fo r my fa mily ' s imp ro v e me nt.
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
1
4
21
60
95
4.35
181
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
181
5
8. I ha v e a v o ic e re g a rd ing d e c is io ns inv o lv ing c a re , tre a tme nt a nd s e rv ic e s .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
2
3
9
67
102
4.44
183
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
183
3
9. My ne e d s a re b e ing a d d re s s e d .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
4
4
23
74
79
4.20
184
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
184
2
10. I re c e iv e info rma tio n o n re s o urc e s /e v e nts tha t a re re le v a nt a nd b e ne fic ia l to me .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
Stro ng ly
Ag re e
4
9
32
71
68
R a ting
Av e ra g e
4.03
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
184
184
2
11. Gla d e R un s ta ff a re he lp ing /ha v e he lp e d me b uild a s up p o rtiv e ne two rk in my c o mmunity (fa mily , frie nd s , re s o urc e s , e tc .).
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
Stro ng ly
Ag re e
4
16
48
54
62
R a ting
Av e ra g e
3.84
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
184
184
2
Summary/follow up
Family 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 Achievement
Champion Amy Williams
The learning environment at St. Stephens’ Lutheran Academy reflects academic excellence
and an Accountable, Safe and Kind environment
Goals and Action steps to Achieve Outcome/Impact
Quality Initiative Measurement Tools
85% attendance Rate
Attendance Records
Grades will improve school wide
School wide grade reports
Major incidents will decrease (Acts of violence, self injurious
behavior, AWOL, restraint, police involvement, psychiatric
hospitalization)
Positive Behavior Support Assessment; Incident Report review; ASK
points
Students will demonstrate increased proficiency in reading
comprehension and math
Aims-WEB reports
Implement the CBITS
Classroom Engagement
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
Frequency
Attendance 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 up
Academic 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
Student
Engagement
11/46 24%
19/46 41%
16/46 35%
0
Teacher
Engagement
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 Kind
Points 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/Generalization
Champion Beth Hines
Families/individuals learn and practice skills that will transfer to their unique home and
community settings.
Goals and Action steps to Achieve Outcome/Impact
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
Quality Initiative Measurement Tools
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
Summary/follow up
Individualization/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.
Family Sat isf act ion Survey - G eneralizat ion
1. I he lp e d to c re a te the c urre nt g o a ls .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
1
4
16
75
89
4.34
185
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
185
1
2. I ha v e a v o ic e re g a rd ing d e c is io ns inv o lv ing c a re , tre a tme nt a nd s e rv ic e s .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
2
3
9
67
102
4.44
183
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
183
3
3. I re c e iv e info rma tio n o n re s o urc e s / e v e nts tha t a re re le v a nt a nd b e ne fic ia l to me .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
4
9
32
71
68
4.03
184
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
184
2
4. Gla d e R un s ta ff a re he lp ing / ha v e he lp e d me b uild a s up p o rtiv e ne two rk in my c o mmunity (fa mily , frie nd s , re s o urc e s , e tc .).
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
4
16
48
54
62
3.84
184
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
184
2
5. I fe e l c o nfid e nt the s k ills I ha v e le a rne d c a n b e us e d in my ho me , c o mmunity a nd / o r the s c ho o l.
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
2
3
34
67
77
4.17
183
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
183
3
Family Satisfaction Survey - Individualization
1. I a m a s k e d fo r my inp ut a b o ut the s tre ng ths a nd ne e d s o f my fa mily .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
1
4
12
67
Stro ng ly
Ag re e
R a ting
Av e ra g e
102
4.42
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
186
186
0
2. I he lp e d to c re a te the c urre nt g o a ls .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
Stro ng ly
Ag re e
1
4
16
75
89
R a ting
Av e ra g e
4.34
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
185
185
1
3. Gla d e R un s ta ff ro utine ly c o mmunic a te with me .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
Stro ng ly
Ag re e
1
9
12
62
99
R a ting
Av e ra g e
4.36
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
183
183
3
4. I re c e iv e up d a te s o n p ro g re s s to wa rd s g o a ls .
Ans we r Op tio ns
Stro ng ly
D is a g re e
D is a g re e
N e utra l
Ag re e
Stro ng ly
Ag re e
0
13
22
58
90
R a ting
Av e ra g e
4.23
a nswe re d q ue stio n
skip p e d q ue stio n
R e s p o ns e
Co unt
183
183
3
5. I re c e iv e info rma tio n a b o ut the s e rv ic e s a v a ila b le a t Gla d e R un.
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
2
7
24
78
72
4.15
183
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
183
3
6. Gla d e R un s ta ff s ho w c o nc e rn fo r my fa mily ' s imp ro v e me nt.
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
1
4
21
60
95
4.35
181
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
181
5
7. I ha v e a v o ic e re g a rd ing d e c is io ns inv o lv ing c a re , tre a tme nt a nd s e rv ic e s .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
2
3
9
67
102
4.44
183
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
183
3
8. T he p ro g ra m is he lp ing my fa mily .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
3
7
25
55
94
4.25
184
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
184
2
9. My ne e d s a re b e ing a d d re s s e d .
A ns we r Op tio ns
S tro ng ly
D is a g re e
D is a g re e
N e utra l
A g re e
S tro ng ly
A g re e
R a ting
A v e ra g e
R e s p o ns e
Co unt
4
4
23
74
79
4.20
184
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
184
2
10. I re ce ive info rma tio n o n re so urce s/e ve nts tha t a re re le va nt a nd b e ne ficia l to me .
Answe r Op tio ns
Stro ng ly
Disa g re e
Disa g re e
Ne utra l
Ag re e
Stro ng ly
Ag re e
4
9
32
71
68
Ra ting
Ave ra g e
4.03
a nswe re d q ue stio n
skip p e d q ue stio n
Re sp o nse
Co unt
184
184
2
11. Gla d e Run sta ff a re he lp ing /ha ve he lp e d me b uild a sup p o rtive ne two rk in my co mmunity (fa mily, frie nd s, re so urce s, e tc.).
Answe r Op tio ns
Stro ng ly
Disa g re e
Disa g re e
Ne utra l
Ag re e
Stro ng ly
Ag re e
4
16
48
54
62
Ra ting
Ave ra g e
3.84
a nswe re d q ue stio n
skip p e d q ue stio n
Re sp o nse
Co unt
184
184
2
Summary/follow up
Individualization/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.
Co mmu n it y Pro g ra ms A f t e rca re ca lls
5. P ro g ra m :
A ns we r O p ti o ns
BCM - Beaver
BCM - Butler
BHRS- Beaver
BHRS - Butler
BHRS - Pittsburgh
Family Based - Beaver
Family Based - Butler
Family Preservation-Reunification
Family Focused Solution Based
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
12.2%
14.1%
12.6%
9.3%
30.4%
6.6%
6.3%
1.4%
7.1%
81
94
84
62
202
44
42
9
47
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
665
0
6. A re y o u c urre ntl y l i v i ng i n the s a m e ho m e a s whe n y o u we re
d i s c ha rg e d ?
A ns we r O p ti o ns
Yes
No
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
88.2%
11.8%
157
21
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
178
487
7. H a v e y o u b e e n a rre s te d s i nc e d i s c ha rg e ?
A ns we r O p ti o ns
Yes
No
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
2.8%
97.2%
5
172
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
177
488
8. H a v e y o u e xp e ri e nc e d a c ri s i s tha t re s ul te d i n a p s y c hi a tri c
ho p s i ta l i za ti o n?
A ns we r O p ti o ns
Yes
No
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
6.8%
93.2%
12
165
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
177
488
9. H a v e y o u b e e n v o l unta ri l y ho s p i ta l i ze d ?
A ns we r O p ti o ns
Yes
No
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
8.0%
92.0%
14
161
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
175
490
10. A re y o u c urre ntly ta k ing y o ur p re s c rib e d m e d ic a tio n?
A ns we r Op tio ns
Yes
No
N/A (No medications prescribed)
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
62.3%
14.9%
22.9%
109
26
40
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
175
490
11. A re y o u c urre ntly inv o lv e d with o r re c e iv ing s e rv ic e s fro m CY F
(Child re n, Y o uth, a nd F a m ilie s )?
A ns we r Op tio ns
Yes
No
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
7.0%
93.0%
12
160
a ns we re d q ue s tio n
s k ip p e d q ue s tio n
172
493
12. A re y o u c urre ntly e m p lo y e d ?
A ns we r Op tio ns
Yes
No
N/A (Consumer is a child)
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
7.4%
36.6%
56.0%
13
64
98
a ns we re d q ue s tio n
175
RT F A fte rc are Calls
3 . Cl i e n t wa s d i s c h a rg e d to :
A n s we r O p ti o n s
Ho me
Gro up Ho me
Fo ste r Ca re
Ind e p e nd e nt Living
CRR
CYS
De te ntio n
She lte r
Othe r (p le a se sp e cify)
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
89.3%
4.9%
2.9%
1.0%
1.0%
0.0%
0.0%
1.0%
92
5
3
1
1
0
0
1
2
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
103
0
4 . T y p e o f In te rv e i w
A n s we r O p ti o n s
30 Da ys
60 Da ys
90 Da ys
180 Da ys
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
30.1%
19.4%
21.4%
29.1%
31
20
22
30
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
103
0
5 . If s u rv e y c a n n o t b e c o m p l e te d , i n d i c a te wh y .
A n s we r O p ti o n s
No Re sp o nse (fa mily d id no t re turn ca ll o r a nswe r
Clie nt Re -Ad mitte d to Pro g ra m/T re a tme nt
No Co nta ct Info rma tio n (p ho ne numb e r is no lo ng e r in
Clie nt/Fa mily Re fuse d to Answe r Que stio ns
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
79.1%
0.0%
20.9%
0.0%
34
0
9
0
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
43
60
6 . W h e re i s y o u r c h i l d c u rre n tl y ? (P l e a s e i n d i c a te wh e re th i s c h i l d i s o n th e
d a y o f th e s u rv e y , i .e h o m e , h o s p i ta l i ze d , ru n a wa y , u n k n o wn )
A n s we r O p ti o n s
Ho me
Gro up Ho me
Fo ste r Ca re
Ind e p e nd e nt Living
CRR
CYS
De te ntio n
RT F
Ho sp ita lize d
Runa wa y
She lte r
Unkno wn
Othe r (p le a se sp e cify)
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
71.2%
6.8%
3.4%
0.0%
3.4%
1.7%
1.7%
5.1%
1.7%
0.0%
1.7%
3.4%
42
4
2
0
2
1
1
3
1
0
1
2
0
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
7 . S ta ff Q u e s ti o n -
59
44
Is th i s c h i l d CU R R E N T L Y i n a L e s s R e s tri c ti v e S e tti n g ?
A n s we r O p ti o n s
Ye s
No
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
85.0%
15.0%
51
9
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
60
43
8 . D i d y o u r c h i l d g o to h i s / h e r fi rs t a fte rc a re a p p o i n tm e n t a fte r l e a v i n g
Gl a d e R un?
A n s we r O p ti o n s
Ye s
No
Do n't Kno w
Othe r (p le a se sp e cify)
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
86.7%
10.0%
3.3%
52
6
2
2
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
60
43
9. Is y o ur c hi l d s ti l l fo l l o wi ng hi s / he r a fte rc a re p l a n?
A ns we r Op ti o ns
Yes
No
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
78.3%
20.0%
1.7%
47
12
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
60
43
10. S i nc e y o ur c hi l d wa s d i s c ha rg e d , d o y o u thi nk he / s he i s d o i ng b e tte r,
the s a m e , o r wo rs e ?
A ns we r Op ti o ns
Better
Same
Worse
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
55.0%
21.7%
23.3%
33
13
14
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
60
43
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.
B H R S /S t re n g t h s B a s e d /B rie f Tre a t me n t - 3 0 D a y R e vie w A u d it
1 . P s y c h o s o c i a l H e a l th A s s e s s m e n t - s e c ti o n s a s k i n g fo r " i n th e i r o w n
w o r d s " a r e c o m p l e te d w i th q u o te s / c o m m e n ts fr o m c l i e n t/ fa m i l y :
A n s w e r O p ti o n s
Ye s
Pa p e r
Bo th
No
U nkno wn
IF N O, list inco mp le te se ctio ns:
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
40.0%
0.0%
0.0%
40.0%
20.0%
2
0
0
2
1
4
a n s we re d q u e s ti o n
s k i p p e d q u e s ti o n
5
7
2 . P r e l i m i n a r y T r e a tm e n t P l a n - P r e s e n t: ( B H R S & V B H = 3 0 d a y s ) ( B H R S
& CCB H = 5 d a y s ) (S B T = 5 we e k s ) (B ri e f T x = 5 we e k s )
A n s w e r O p ti o n s
EMR
No
IF N O, List Missing D a te s:
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
83.3%
16.7%
10
2
3
a n s we re d q u e s ti o n
s k i p p e d q u e s ti o n
12
0
3 . P r e l i m i n a r y T r e a tm e n t P l a n - P a r e n t/ G u a r d i a n / C l i e n t S i g n a tu r e P r e s e n t:
A n s w e r O p ti o n s
Ye s
No
U nkno wn
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
75.0%
16.7%
8.3%
9
2
1
a n s we re d q u e s ti o n
s k i p p e d q u e s ti o n
12
0
4. P re l i m i na ry T re a tm e nt P l a n - Id e nti fi e s Cl i e nt/ F a m i l y s tre ng ths a nd
p ri o ri ti ze d ne e d s :
A ns we r O p ti o ns
Yes
No
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
80.0%
0.0%
20.0%
4
0
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
5
7
5. P re l i m i na ry T re a tm e nt P l a n - Id e nti fi e s g o a l s a nd i nte rv e nti o ns tha t
i nc l ud e na tura l a nd i nfo rm a l s up p o rts :
A ns we r O p ti o ns
Yes
No
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
58.3%
33.3%
8.3%
7
4
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
12
0
F B MH S - 3 0 D a y R e vie w
1 . P s y c h o s o c i a l H e a l th A s s e s s m e n t - s e c ti o n s a s k i n g fo r " i n th e i r o wn
wo rd s " a re c o m p l e te d wi th q u o te s / c o m m e n ts fro m c l i e n t/ fa m i l y :
A n s we r O p ti o n s
Ye s
No
Unkno wn
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
44.4%
11.1%
44.4%
4
1
4
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
4
2. P re l i m i na ry T re a tm e nt P l a n - P a re nt o r G ua rd i a n/ Cl i e nt S i g na ture
P re s e nt:
A ns we r O p ti o ns
EMR
Paper
Both
No
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
46.2%
0.0%
0.0%
53.8%
0.0%
6
0
0
7
0
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
13
0
3. P re l i m i na ry T re a tm e nt P l a n - Id e nti fi e s Cl i e nt/ F a m i l y s tre ng ths a nd
p ri o ri ti ze d ne e d s :
A ns we r O p ti o ns
Yes
No
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
66.7%
33.3%
0.0%
6
3
0
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
4
4. P re l i m i na ry T re a tm e nt P l a n - Id e nti fi e s g o a l s a nd i nte rv e nti o ns tha t
i nc l ud e na tura l a nd i nfo rm a l s up p o rts :
A ns we r O p ti o ns
Yes
No
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
55.6%
44.4%
0.0%
5
4
0
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
4
5. P re l i m i na ry T re a tm e nt P l a n - D o c um e nta ti o n o f S k i l l T ra ns fe r to
P a re nt/ G ua rd i a n:
A ns we r O p ti o ns
Yes
No
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
66.7%
33.3%
0.0%
6
3
0
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
4
OP - 30-D ay R eview
3 . In i ti a l T re a tm e n t P l a n - p a re n t/ c l i e n t s i g n a tu re p re s e n t:
A n s we r O p ti o n s
Ye s
No
N/A
Unkno wn
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
11.1%
77.8%
0.0%
11.1%
1
7
0
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
1
4 . In i ti a l T re a tm e n t P l a n - Id e n ti fi e s g o a l s a n d i n te rv e n ti o n s th a t i n c l u d e
n a tu ra l a n d i n fo rm a l s u p p o rts :
A n s we r O p ti o n s
Ye s
Pa p e r
Bo th
No
N/A
Unkno wn
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
0.0%
0.0%
0.0%
33.3%
33.3%
33.3%
0
0
0
1
1
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
3
7
5. Ini ti a l T re a tm e nt P l a n - D o c um e nta ti o n o f S k i l l T ra ns fe r to
P a re nt/ G ua rd i a n:
A ns we r O p ti o ns
Yes
Paper
Both
No
N/A
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
0.0%
0.0%
0.0%
33.3%
33.3%
33.3%
0
0
0
1
1
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
3
7
8. P s y c ho s o c i a l H e a l th A s s e s s m e nt - s e c ti o ns a s k i ng fo r " i n the i r o wn
wo rd s " a re c o m p l e te d wi th q uo te s / c o m m e nts fro m c l i e nt/ fa m i l y :
A ns we r O p ti o ns
Yes
Paper
Both
No
N/A
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
33.3%
0.0%
0.0%
0.0%
0.0%
66.7%
1
0
0
0
0
2
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
3
7
R TF - 3 0 D a y R e vie w A u d it
3. M a s te r T re a tm e nt P l a n - Id e nti fi e s Cl i e nt/ F a m i l y s tre ng ths a nd p ri o ri ti ze d
ne e d s :
A ns we r O p ti o ns
Yes
No
Unknown
R e s p o ns e
P e rc e nt
R e s p o ns e
Co unt
88.9%
0.0%
11.1%
8
0
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
0
4 . M a s te r T re a tm e n t P l a n - Id e n ti fi e s g o a l s a n d i n te rv e n ti o n s th a t i n c l u d e
n a tu ra l a n d i n fo rm a l s u p p o rts :
A n s we r O p ti o n s
Ye s
No
Unkno wn
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
88.9%
0.0%
11.1%
8
0
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
0
5 . M a s te r T re a tm e n t P l a n - D o c u m e n ta ti o n o f S k i l l T ra n s fe r to
P a re n t/ G u a rd i a n :
A n s we r O p ti o n s
Ye s
No
Unkno wn
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
88.9%
0.0%
11.1%
8
0
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
0
6 . M a s te r T re a tm e n t P l a n - S i g n a tu re P a g e - Cl i e n t S i g n a tu re
A n s we r O p ti o n s
Ye s
No
Unkno wn
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
88.9%
0.0%
11.1%
8
0
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
0
7 . M a s te r T re a tm e n t P l a n - S i g n a tu re P a g e - P a re n t/ G u a rd i a n S i g n a tu re
P re s e n t:
A n s we r O p ti o n s
Ye s
No
Unkno wn
R e s p o ns e
P e rc e n t
R e s p o ns e
Co u n t
22.2%
66.7%
11.1%
2
6
1
a ns we re d q ue s ti o n
s k i p p e d q ue s ti o n
9
0
Evidence Based Practices
Champion 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
Research and obtain information on the following Evidenced Based Practices:
•
Cognitive Behavioral Therapy (CBT)
Measurement tools associated with each modality if indicated/available:
•
Dialectical Behavior Therapy (DBT)
Suicide Attempt Self Injury Interview (SASII); Nonsuicidal self-injury (NSSI)
•
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Child Behavior checklists; child depression inventory; Weekly Behavior report;
Parent Emotional Reaction Questionnaire ; Parenting Practices Questionnaire
(PPQ); Parent Support Questionnaire (PSQ)
•
Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
Child PTSD symptom Scale (CPSS); Pediatric Symptom Checklist (PSC);
•
Parent-Child Interaction Therapy (PCIT)
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);
•
Safe and Civil Schools Positive Behavioral Interventions and Supports
Model (PBIS)
An Academic Index Kentucky Core Content Tests; California Standards Test in
Mathematics; Positive Behavior Support (PBS) Assessment—Staff survey;
Teacher Surveys
Quarterly Summary/Follow up
Identify and develop who will become trained trainers in the above mentioned
modalities
Training Records
Review Supervision records
Train employees in the above mentioned modalities
3, 6, 9 month aftercare calls
Develop clinical coaching supervision model to ensure fidelity to the modalities
Treatment retention
Summary/follow up
Evidenced 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 20122013 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.