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Title: Reports/Open Communication


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Mission Linking Faith and Service
Vision A bridge to a brighter future through
lifelong learning
  • Core Values
  • Learning as a focus across all Glade Runs
    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.
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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
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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
Family Partnership Families feel empowered in
the decision making process and express a sense
of connectedness to supportive networks
Evidence Based Practices Program excellence is
achieved with the training and utilization of
evidence based practices
Life Long Learning Staff, families/individuals
and other professionals gain knowledge and
competence through training and skill attainment

Academic Excellence The learning environment at
St. Stephens Lutheran Academy reflects academic
excellence and an Accountable, Safe and Kind
environment
Individualization/ Generalization families/indivi
duals 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
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Lifelong LearningChampion 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
  • 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 checklists
  • Establishment of learning goals for employees

Training records will identify the completion of
career track trainings. Quarterly training
effectiveness surveys 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
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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)




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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, MHWs, Teaching
    Assistants, Adventures staff
  • Therapist MHP, BSC, Mobile therapists
  • Clinical Supervision
  • Leadership
  • Support Staff
  • Case Management

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  • 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.

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Training Surveys
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
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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
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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
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Family PartnershipChampion 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
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.
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
records Review advisory counsel minutes. 3, 6, 9
month aftercare calls Family satisfaction
surveys Database communication form.
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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
    surveys 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.

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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.
  • Marthens 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.

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Academic AchievementChampion 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
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
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
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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
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  • 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. Stephens. 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
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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. Stephens 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

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  • POSITIVE BEHAVIOR SUPPORT
  • St. Stephens 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
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Individualization/GeneralizationChampion Beth
Hines
  • Families/individuals learn and practice skills
    that will transfer to their unique home and
    community settings.

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

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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 surveys 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.

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  • 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 communitys. 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.

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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
  • 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)

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 QuestionnaireModified
(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) AssessmentStaff survey Teacher
Surveys Training Records Review Supervision
records 3, 6, 9 month aftercare calls Treatment
retention
Quarterly Summary/Follow up

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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.

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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.
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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 agencys 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 Agencys 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
Organizations 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.
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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.
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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 Runs 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.
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