Performance and Quality Improvement Annual Report

Corry Counseling Services

Performance and Quality Improvement

Annual Report

FY 2016/2017

Corry Counseling formally established the Quality Assurance Committee in January 2008 with members representing various areas of the agency. In late 2016, the decision was made to expand the mission and scope of the committee. The initial meeting of the Performance and Quality Improvement (PQI) Committee was 12/12/16.

Membership in the PQI Committee now includes all program directors and the Executive Director:

Karen Croyle, Executive Director

Ann Hippely, Corporate Compliance Director

Laurie Holthouse, BCM and Mobile Medication Director

Jennifer Malone, OP Director

Tammy Messinger, Fiscal Director

Renee Parker-Mitchell, FBMH and FPS Director

Denise Seib, Human Resources, Group Home manager

Overview of 2016/2017 agency performance accomplishments and quality improvements:

· Successful licensure and funder visits

· Client survey in January 2017

· Staff survey in April 2017

· Outcome measurement for all programs

· Annual program reports initiated

· Emergency Response (Disaster) Plan updated

· Revised Corporate Compliance Policy and planned staff training

· Staff retention data collected for the first time.

· Exposure Control Plan updated

· Initiation of recycling

· Training plans and process formalized

The PQI Committee is structured to play the central organizing role in quality improvement at the agency. The Committee regularly reviews significant components of agency services and operation. Data is collected prior to each PQI Committee meeting on the areas to be reviewed at that meeting. An assigned committee member is responsible presentation of each area. The Committee reviews each area, notes changes and trends, and makes recommendations.

Areas reviewed: Behavior Management Intervention, Case Record Review , Client Grievances, Client Satisfaction, Emergency Response System, Incident Reports, Licensure/Funder visits, Outcomes, Corporate Compliance, Risk Prevention, Training, Performance Evaluations, Staff grievances, Staff Retention, Staff Satisfaction

The attached PQI Review Schedule indicates the frequency and month(s) each area is reviewed as well as the staff member responsible for leading the discussion. This fiscal year, the PQI Committee met on the following 6 dates: 12/12/16, 1/20/17, 2/27/17, 3/20/17, 5/1/17 and 6/26/17. Due to scheduling difficulty, the April and May meetings were combined.

Behavioral Management Intervention: At PQI Committee meetings there was discussion of behavior support and management in the group homes, currently the only agency department in which such interventions occur. Restraint is rarely used, although on occasion a resident may need to be escorted to their room. No use of restraints was reported.

Case Record Review: Quarterly record reviews are being completed in accordance with COA recommendations. Full reports are available in the PQI Audit and CRR binder. For the first time in March, group home records were reviewed.

Case record review findings were addressed at 3 PQI Committee meetings. There was discussion of improvements observed as programs addressed areas of concern (e.g. OP improvements in percentage of signed treatment plans and BCM improvements in the percentage of timely service plans) as well as areas of continued need. Programs managers offered feedback about the structure of case record review reports and areas for focus in the future. June reviews focused in part on the timeliness of documentation; this will continue to be explored in future reviews.

Over the course of the fiscal year, 4 audits were completed related to specific concerns or topics; e.g. the presence of safety assessments for clients with specific diagnoses.

Client grievances: A grievance in November related to BHRS closure was resolved with no plan.

Client Satisfaction: Client satisfaction surveys for counseling center clients were developed and used for the first time. The first 5 questions inquired about general satisfaction with the agency and were the same for all surveys. The final 2 questions were program specific and were developed with the input of program staff. The results indicated a high level of satisfaction; for example, 98% of 257 respondents from the mental health center agreed or strongly agreed they were treated with respect. Group living services has utilized services for some time; their results were also positive.

Corporate Compliance: In early 2017, the Pennsylvania Department of Human Services and Managed Care Organizations (CCBH, VBH) announced enhanced requirements for Corporate Compliance plans, procedures and training. The board approved and the committee reviewed revisions to the agency Corporate Compliance policy and plans for training both new and current staff.

Related to the above, in the coming year, the Corporate Compliance Director will complete case record review focused on variables related to billing, such as the presence of encounter forms.

Emergency Response System: The Emergency Response (Disaster) Plan was reviewed in Feb. Updates were made by program managers to their key contacts. Updates related to general procedures were later made by the Corporate Compliance Director. Staff will be trained on the updates.

Incident Reports There were 10 reports for the group homes and 21 for the mental health center for the time period Nov. 2016 – June 30, 2107. 10 of the mental health center reports were Childline reports. No critical incidents occurred.

Licensure/Funders: The Blended Case Management Program reported receipt of program approval based on a successful 4/18/17 site visit by a Human Services Program Representative.

The OP and FBMH Programs were found to be in full compliance with all requirements at their 2017 licensing visits by PA DHS.

Outcomes: The BCM Program measured client improvements in functioning after one year of service as indicated by Combined Strengths Assessment Scale (CSAS) scores. The target was improvement of at least 10% by 85% of new clients. The results were that 61% of adults showed improved scores with 39% of scores improving more than 10%. With the children and adolescents, there were 38% with improved scores and 25% with scores that improved over 10%. While the defined target was not met, based on the outcomes the program director identified variables related to lack of improvement: for adults, housing instability, drug and alcohol related issues, medical issues, jail, and the death of a family member; for children and youth, housing instability and a mentally ill parent. Target expectations may not have been realistic; next year the program outcome measurement will be a target of 70% improvement in CSAS scores after a year of service, with 50% being over 10% higher.

FPS program outcomes are measured by the Mercyhurst Civic Institute as part of the agency’s contract with the Erie County Office of Children and Youth. The desired outcomes are improvements in parenting and child safety as measured by pre- and post-service administration of the North Carolina Family Assessment Scale (NCFAS) and the Index of Parental Attitudes (IPA). Data was submitted to Mercyhurst at the end of the fiscal year; a report is expected by October 2017.

The FBMH program measured improvements in family functioning and goal achievement. The data source was the client satisfaction survey completed at the close of services. The indicator was agreement or strong agreement to the questions 6, 7, 8, 9, 10 on the survey. The target was at least 85% agreement. Of the 25 clients who completed surveys (of 39 who were discharged) 90% expressed agreement or strong agreement with questions 6, 7, 8, 9, 10.

Group home outcomes focused on resident involvement in community activities. The target was that each individual would have at least 2 individual and 2 group activities per month 85% of the time. The individual goal was met at 100%; the group goal was close to being met at 81.25%. In one home, the group goal was met. As increased emphasis is being placed system wide on community activity, the overall goal will continue for 2017/2018.

Outpatient is measuring decreased depression as measured by the Patient Health Questionnaire (PHQ-9) and the PHQ-A (for children ages 11-17). The target was defined as a 25% reduction after treatment in score of clients who are identified as depressed at initial assessment. Initially, the plan was to measure improvements after 6 months of treatment, but this was later changed to one year. Administration of the PHQ-9 and the PHQ-A started in February. By the close of the fiscal year, there were no available results. OP will continue with this outcome measure.

Risk Prevention: Safety Committee reports included results of monthly safety checks. The committee addressed concerns related to sidewalks being adequately shoveled and unaccompanied guests in the building. The committee continues to explore options for a visitor sign-in process.

Training: Prompted by COA preparations, the agency has worked to develop more formal training schedules and to describe training processes. The following documents were reviewed by the committee and it was agreed to proceed with their use.

Annual assessment of training needs

Annual training and development plan 2017/18

Outline of required training, procedures for tracking training

Table of contents for orientation and training curricula

Annual training schedule 2017/18

Procedures for tracking staff training

Performance Evaluation: Not reviewed this fiscal year.

Staff grievances: None

Staff retention: Retention data was gathered for the first time. The period reviewed was for FY 2015-2016. In the future, this data will be reviewed in August, closer to the end of the fiscal year.

Staff Satisfaction Surveys: Staff satisfaction surveys were completed for the first time in April. At the June PQI Committee meeting, the Executive Director distributed summarized results of the surveys and led the related discussion. There will be continued discussion by the management team of areas of concern to staff. It is noted that 100% of respondents agreed or strongly agreed with the statement, “When something unexpected comes up, I know who to ask for help.” Over 95% of respondents agreed or strongly agreed with the statement, “I have the authority to carry out the responsibility assigned to me.”

Other: The committee discussed quality concerns related to preparations for COA, initiation of recycling at the agency, the need to update the Exposure Control Plan and had the opportunity to offer feedback on the new vision statement.

PQI Review Schedule

The PQI Committee meets on the 3rd Monday of the month at 1:00 pm.