one hope united 2013 cqir annual report - florida region
TRANSCRIPT
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CQIRANNUAL REPORT
2013FLORIDA REGION
ANALYSIS
REPORT PREPARED BY KIMBERLY D.CLARK
CQIRSYSTEMS ANALYST
PLEASE DIRECT INQUIRIES TO:[email protected]
Report Snapshot Florida region
served 3,178 clients
in FY13.
90% of Florida
Outcome Goals
were met.
The Florida Region
Compliance &Quality rating on
Peer Record
Reviews was 76%.
For the past three
years, Florida
scored an A in
overall client.
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Table of Contents
Letter from the Editors .............................................................................................................................. 2
CQIR Team & Highlights ........................................................................................................................... 3
Florida Leadership .................................................................................................................................... 5
Executive Summary .................................................................................................................................. 6
Clients Served .......................................................................................................................................... 8
Outcome Management.............................................................................................................................. 9
Peer Record Reviews ............................................................................................................................. 11
Client Satisfaction ................................................................................................................................... 16
Incident Reports ...................................................................................................................................... 17
Office Systems Reviews ......................................................................................................................... 18
Supervisory Systems Reviews ................................................................................................................ 19
Priority Reviews ...................................................................................................................................... 20
Employee Recognition ............................................................................................................................ 21
Quality Improvement Teams ................................................................................................................... 22
Appendix ................................................................................................................................................. 23
Appendix A: Circuit 9 Highlights .......................................................................................................... 23
Appendix B: Circuit 10 Highlights ........................................................................................................ 26
Appendix C: Circuit 13 Highlights ........................................................................................................ 28
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Letter from the Editors
October 19, 2013
To Our Readers:
This is our 13th year of providing the Continuous Quality Improvement and Research (CQIR) annual report on
the agencys outcomes and other quality improvement activities and results. The CQIR team takes great pride
in preparing and presenting this report to you, our valued stakeholders.
In Fiscal Year 2013, the CQIR team has adopted a Risk Management orientation in the processes and
functions we facilitate. This shift was made at the request of staff so that we could ensure that we are spotting
and addressing small problems before they become larger problems. Therefore, this type of orientation is meant
to be proactive rather than reactive in order to alleviate risks and ideally prevent them before they occur. With
this orientation, the CQIR team has begun using a new Risk Management report during Quality Improvement
Teams (QITs). This type of approach requires participation at all levels; therefore, during this process, all staff
(from direct service staff to program and agency leadership) are looking at current CQIR data to identify areas
for improvement and develop action plans to meet and/or exceed best practice. Staff members have reported
that this approach is better for them as they are able to see the data from their programs more regularly and
develop solutions to areas of concern.
In the human services field, organizations are constantly being asked to, do more with less while at the same
time being asked to perform at higher levels than ever before. In these economic times many programs are
being scaled back or eliminated for not reaching outcomes and targets set by funders. Now more than ever,
One Hope United needs to look at each program, even those that consistently perform at high levels, and use
creativity, research, and innovation to become even better. Each and every program can improve upon
something. If One Hope United becomes stagnant, we will fall behind.
Ultimately, at the end of the day, this constant attention to data and program improvement is for the clients we
serve. By asking ourselves, what can we do even better we are investing our time and energy into makingsure that our clients become healthy and productive adults when they leave One Hope United. In the next year,the CQIR team will spend time developing methods to learn what happens to our clients after leaving servicesin order to see what sticks from our service and genuinely changes lives. This work will help us ensure thatOne Hope United is here for our future clients.
We hope that you find this report informative and that you will let us know what you think and how we couldmake the report better in the future. Thank you for your support.
Kimberly D. ClarkCQIR Systems Analyst
Fotena A. Zirps, PhD
Executive Vice President
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Continuous Quality Improvement & Research Team
To support direct service providers and ensure best practice quality of service throughout the agency, the
Continuous Quality Improvement and Research (CQIR) team at One Hope United guides theorganization in 14 core tasks (PQI Standards) that are aligned with internal OHU principles and external
accreditation standards.
Dr. Fotena Zirps Executive Vice PresidentTina McLeod Assistant to the EVP
Florida Region Hudelson Region Northern Region Research Team
Ruann BarrackSenior Vice President
Jeffrey HonakerCQI Director
Katurah RobyCQI Coordinator
Ron CulbertsonCQI Coordinator
Linda WeissCQI MedicaidCoordinator
Ryan CounihanCQI Technician
Stan GrimesCQI Coordinator
Elizabeth HopkinsCQI MedicaidCoordinator
Jackie SchedinCQI Coordinator
Sarah TunningDirector of Research
Kimberly ClarkSystems Analyst
Special thanks to Katrina Brewsaugh of the CQIR team who left in FY13.
Information presented in the Florida region annual report is organized by these CQI Core Tasks:
Outcome Management Incident Reports Priority Reviews Peer Record Reviews Office Reviews Employee Recognition Client Satisfaction Supervisory Reviews Quality Improvement Teams
The CQIR Team achieved the following accomplishments in FY13. Accomplishments have beencategorized in line with the OHU promises of Innovation, Collaboration, Leadership, Results, and Hope.
Innovation
The CQIR team has been utilizing Survey Monkey technology to enter Incident Reports, Office
Reviews, and Supervisory Reviews which has made the data entry process more efficient. A pilotfor utilizing Survey Monkey for Peer Record Reviews is planned for FY14 using Tablet
technology.
The CQIR team has taken a Risk Management focus which included a pilot and a full
implementation of the OHU Risk Management Report in Local, Service, and Regional Quality
Improvement Teams.
Under the direction of Fotena Zirps, PhD. and Sarah Tunning; Ruann Barack, Jeffrey Honaker
and Kimberly Clark are members of Team Data which is looking at the current and future data
needs of the organization in alignment with the agencys strategic plan. In addition, there are
many members from Operations (including the Team Excellence Outcomes committee) and IT
that are collaborating on this project.
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Peer Record Review Training has been developed and placed on the Essential Learning
Website.
Collaboration
Stan Grimes, Jackie Schedin, and Elizabeth Hopkins have all participated as volunteers with theCouncil on Accreditation to re-accredit 3 organizations.
In collaboration with the Department of Children and Family Services, all Illinois OHU CQIR staff
have access to SACWIS which will assist with electronic review of case files.
The CQIR team participated in a WorkSmart training facilitated by Larry Kujovich from Executive
Partners.
Jackie Schedin was a presenter at a CANS training in collaboration with the Casey Foundation.
Linda Weiss and Elizabeth Hopkins continued to collaborate to ensure consistency across
Regions with the Medicaid Rule Changes. This included monthly meetings with program leaders
to ensure all involved participated in the process of change.
Jackie Schedin and Ron Culbertson collaborated with operations in the Northern and Hudelson
Regions in revising the Intact Operating Procedures for the Agency Operating Manual based
upon Rule changes. The group also collaborated in the revision of the Intact Quality Review Tool.
Linda Weiss worked with operations in the revision of the SASS Model for service delivery to
achieve a team approach to provide more efficient and effective service delivery.
Ron Culbertson provided technical assistance with Missouri Leadership to assist the Missouri
office in maintaining their Licensing as a Child Placement Agency.
Leadership
Linda Weiss from Hudelson and Elizabeth Hopkins from Northern have led the process of
implementing the new Medicaid Rule to ensure all Medicaid programs are in compliance. They
have also consolidated forms to one Mental Health Assessment and two Individualized TreatmentPlans so that there is more consistency amongst the Northern and Hudelson regions.
Stan Grimes, Jeffrey Honaker, and Kimberly Clark are participants in the 2013 Leadership
Academy facilitated by CEO Bill Gillis and Executive Vice President Fotena Zirps PhD.
Ruann Barack was awarded the Promise Award for Leadership.
Jackie Schedin was awarded a STAR Award for exemplary service during the 4 th quarter of FY13.
Results
The CQIR team in Florida has launched a weekly data reporting process that takes a proactive
stance in addressing programmatic concerns.
The Medicaid Team in Hudelson achieved a 97% rating and Northern achieved a 94% rating (a
19 point increase) on their Post Payment Reviews for FY13 services.
The CQIR team participated in a CQI Capacity Assessment administered by the Department of
Children and Family Services and received a 19 out of 20 rating. The assessment focused on
Foster Care Programs in Illinois.
Members of the CQIR team completed a Program Evaluation of the Circle of Hope program in
Springfield, MO.
Members of the CQIR Team completed a 100% file review of the Tampa program.
Hope
Katurah Roby joined the CQIR team in Tampa, FL.
Sarah Tunning has taken on the Director of Research role for the Federation.
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Florida Leadership
The Florida Region is divided into three Circuits (Circuit 9 Orlando, Circuit 10 Sebring/Wauchula, and
Circuit 13 Tampa). The region is led by an Executive Director and a Senior Vice President. Additionally,each Circuit has a Director of Programs (DOP).
Barbara Moss Executive Director
Neika Berry Senior Vice President
Circuit 9(Orlando)
Circuit 10(Sebring/Wauchula)
C13(Tampa)
Brigitte Brown DOP Michelle Ramirez DOP LaSonja Houston DOP
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Executive Summary
This year, OHU programs in the Florida region served 3,178 clients and families an 8.4% increase from
last year. The Compliance & Quality of service documentation overall was 76%. The efforts of Floridaprograms overall resulted in 90% of all outcome goals being met.
OUTCOME MANAGEMENT PEER RECORD REVIEWS
Across all programs, 90% of Outcome goals weremet in FY13.
Out of 444 files reviewed in FY13, the Floridaregion Compliance & Quality rating on servicedocumentation was at 76%.
CLIENT SATISFACTION INCIDENT REPORTS
Florida region Overall satisfaction score hasremained above 4.50 (A) for the past three years.
In the Florida region, the number of incidentsincreased 25% across most incident types.Incidents classified as Other andMedical/Psychiatric incidents had the largestincreases, up by over 274% and 94%, respectively,from FY12 to FY13.
OFFICEREVIEWS
SUPERVISORYREVIEWS
PRIORITY REVIEWS
In the Florida region, 89% of Office Reviews and78% of Supervisory reviews were compliant.
There were 3 priority reviews conducted in FY13: 1Level III, 1 Level IIand 1 Case Consultation.
EMPLOYEE RECOGNITION QUALITY IMPROVEMENT TEAMS
There were 36 STAR awards and 2 GALAXYawards distributed this year.
There was an average QIT attendance rate of 94%in the Florida region.
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In reviewing each area assessed in this report, the following actions are recommended in FY14 based on
Outcomes, Peer Record Reviews, Office Reviews, and Supervisory Reviews in FY13.
Circuit ReviewedRisk Management Topics for FY14 QITs:
Recommended Areas to Develop Action Plans
Circuit 9
Circuit 9 did not achieve the outcome of children remaining reunified fora period of 6 months without re-entry into foster care; it was within 3% ofthe outcome. Adoptions finalized within 24 months of the latest removaldid not reach its target; it was within 18%.
Circuit 9 Family Preservation programs did not achieve the 90% targeton peer record reviews in Intake (86%), Assessment (86%), ServiceDelivery (83%), and Closing (38%).
Circuit 9 Placement programs did not achieve the 90% target on peerrecord reviews in Intake (78%), Assessment (86%), Treatment Planning(87%), Service Delivery (86%), and Closing (0%).
The Office Review in Circuit 9 did not achieve the 90% target, which is
mainly attributed to the office moving locations.
Circuit 10
Circuit 10 did not achieve the outcome of children remaining reunifiedfor a period of 6 months without re-entry into foster care; it was within11% of the target. Children experiencing no more than two placementsettings within 12 months did not reach its target; it was within 3%.
Circuit 10 Family Preservation programs did not achieve the 90% targeton peer record reviews in Intake (81%), Assessment (85%), TreatmentPlanning (77%), Service Delivery (80%), and Closing (50%).
Circuit 10 Placement programs did not achieve the 90% target on peerrecord reviews in Intake (69%), Assessment (85%), Treatment Planning(79%), Service Delivery (78%), and Closing (45%).
The Office Reviews in Circuit 10 did not achieve the 90% target, it was
within 1%.
Circuit 13
Circuit 13 did not achieve 5 of its outcomes. No substantiated reports ofabuse or neglect while in out of home care, children will remain reunifiedfor a period of 6 months without re-entry into foster care, and childrenwere not removed with 12 months of a prior reunification (re-entry) werewithin 1% of the target. Adoptions finalized within 24 months of thelatest removal was within 3% of the target and sibling visitation waswithin 6% of the target.
Circuit 13 Family Preservation programs did not achieve the 90% targeton peer record reviews in Intake (68%), Assessment (76%), TreatmentPlanning (65%), Service Delivery (67%), and Closing (20%).
Circuit 13 Placement programs did not achieve the 90% target on peer
record reviews in Intake (68%), Assessment (69%), Treatment Planning(73%), Service Delivery (65%), and Closing (29%). The Supervisory Reviews in Circuit 13 did not achieve the 90% target,
they were within 50%.
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Clients Served
In fiscal year 2013, One Hope United served 3,128 clients and families in the Florida Region an
increase of 8.4% from FY12. The increase can be attributed to the programs in C13 which operated theentire fiscal year. (In FY12 the C13 program only operated for the last half of the fiscal year).
# of Clients Served by Fiscal Year
FY13 FY12 FY11
Counseling N/A N/A 109Family Preservation 932 573 809
Placement 2,246 1,686 1,863C131 N/A 673 N/A
TOTAL 3,178 2,932 2,781
The Placement programs continue to be the largest source of clients for the Florida Region, accountingfor 71% of their client population. Family Preservation programs account for 29% of the client population.
Circuit 9 continues to serve the most clients in the Florida region accounting for 44% of clients served.
Circuit 13 serves 36% of Floridas clients and Circuit 10 serves 20%.
1C13 began services in FY12. In this year client numbers could not be separated by Program Category. In FY13 client
numbers were tracked by Program Category and are accounted for in the Family Preservation and Placement rows.
29%
71%
Clients Served: Florida
Family Preservation Placement
44%
20%
36%
Clients Served: By Circuit
C9 C10 C13
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Outcome Management
An outcome or accomplishment can be defined as the result of efforts or outputs (interventions by an
individual or team) within an agency that havevalue to the goals of the agency. Outcome
goals are important to establish because they
provide purpose for the work with children and
families and should tie either directly or
indirectly to the mission of the agency.
Additionally, outcome goals create a culture of accountability and also provide an evaluation of Child
Welfare Measures (referring to a clients safety, permanency and well-being). CQIR monitors contract
and agency outcome goals established by federal and state standards and OHU values.
Outcome Goal Achievement: Florida RegionFY13 FY12 FY11
OVERALL TOTAL 90% 90% 80%
Safety 100% 100% 100%Permanency 86% 83% 67%Well-Being 100% 100% 100%
This year, the Florida region achieved 90% of its outcome goals.
The Florida region holds itself to ten outcome goals. Two outcome goals pertain to Family Preservation
programs and the remaining 8 outcome goals refer to Placement programs. Below is an analysis of how
each Circuit performed.
Outcome Goal Achievement: By Circuit
Circuit 9%
AchievedCircuit 10
%Achieved
Circuit 13%
Achieved
Safety100%(2/2)
Safety100%(2/2)
Safety50%(1/2)
Permanency71%(5/7)
Permanency71%(5/7)
Permanency57%(4/7)
Well-Being100%(1/1)
Well-Being100%(1/1)
Well-Being0%
(0/1)
TOTAL80%
(8/10)
TOTAL80%
(8/10)
TOTAL50%
(5/10)
SAFETY ACHIEVEMENT
Outcome Goals Target C9 C10 C13 Region1. No Substantiated abuse or neglect while in
out of home care.99% 99% 99% 98% 99%
2. Children not abused or neglected during in-home services.
95% 98% 98% 98% 98%
CQIR monitors contract and agency
outcome goals established by federal
and state standards and OHU values.
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PERMANENCY ACHIEVEMENT
Outcome Goals Target C9 C10 C13 Region
1. Children reunified within 12 months of thelatest removal.
46% 81% 64% 61% 68%
2. Children will achieve permanency within 24months of latest removal.
32% 80% 94% 49% 70%
3. Children will remain reunified for a period of6 months without re-entry into foster care.
91% 88% 80% 90% 88%
4. Children were not removed within 12months of a prior reunification (re-entry).
91% 93% 96% 90% 91%
5. Adoptions finalized within 24 months of thelatest removal.
32% 14% 83% 29% 36%
6. No more than two placement setting within12 months.
85% 89% 82% 85% 86%
7. Children served in Family Preservation willremain intact during services.
95% 98% 99% 99% 99%
WELL-BEING ACHIEVEMENT
Outcome Goals Target C9 C10 C13 Region1. Sibling Visitation: There will be documented
visitations occurring for children separatedin out of home care.
50% 97% 87% 44% 77%
Circuit 9 achieved 80% of its outcome goals. The outcome goal pertaining to children remaining reunified
for a period of 6 months without re-entry into foster care was within 3% of meeting the target. Theoutcome referring to adoptions finalized in 6 months was more than 10% away from the target.
Circuit 10 achieved 80% of its outcome goals. The outcome pertaining to clients having no more than two
placement settings within 12 months was within 3% of meeting the target. The outcome referring to
children remaining reunified for a period of 6 months without re-entry into foster care was more than 10%
away from the target.
Circuit 13 achieved 50% of its outcome goals. All outcome goals that did not achieve the target were
within 1%-6% of achieving the target.
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Peer Record Reviews
A Peer Record Review is the process by which CQIR internally examines records in depth for timely
completion of required activities (a Compliance Review) and for quality of services (a Quality Review).COA standards require OHU to randomly select
a sample of records to review for all programs.
CQI Coordinators conduct file reviews for each
program every quarter and the results are
communicated via a report for each review
date, as well as a Risk Management report that
rolls up all units by program category in a
particular circuit. For the annual report, peer reviews are looked at for the fiscal year beginning July 1st,
2012 through June 30th, 2013. The program categories reviewed for the Florida Region in this report are:
Family Preservation, and Placement.
# of Florida Region File Reviews by QuarterPRR Review Tool Q1 Q2 Q3 Q4 TOTAL
Compliance & QualityFamily Preservation In-Home 36 22 22 30 110
Placement Adoption 5 4 4 5 18Placement Foster Care 83 76 89 68 316
TOTAL 124 102 115 103 444
In FY13, 444 files were reviewed across Family Preservation (110) and Placement (334) Programs.
There are 3 tools utilized in the Florida region that assess Compliance & Quality. Results were combinedacross all tools to produce the following graph which looks at overall Region performance.
The goal for each phase of client services is 90%, represented by the black dashed line on the chart
below. The purple solid line represents how each phase of client services scored cross-regionally.
COA standards require OHU to
randomly select a sample of records to
review for all programs.
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In FY13, the Florida region achieved a 76% Compliance & Quality rating on service documentation. All
areas measured were below the agencys 90% target. Closing (38%) is significantly below the agencys
target. Closing decreased significantly from FY12 where it scored 84%. It is recommended that
supervisors pay close attention to Closing activities to ensure that documentation is completed. It may
also be useful to review more closed files to see whether this is a larger trend than seen in the Record
Review process. (Only 8% of the 444 files reviewed was a closed record).
Compliance & Quality performance for the Florida region was also analyzed by Program Category and
by Circuit to produce the following three graphs. Further analysis can be found in Appendices A-C.
Family Preservation programs are performing slightly better than Placement programs; however, no
areas are achieving the 90% target on Compliance & Quality measures. Across all phases of client
services Family Preservation achieved an 80% Compliance & Quality rating and Placement achieved a
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Region 73% 78% 79% 75% 38% 76%
Target 90% 90% 90% 90% 90% 90%
Cross-Region 90% 85% 84% 84% 83% 86%
0%
20%
40%
60%
80%
100%
Compliance & Quality - Florida Region
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Family Preservation 79% 83% 80% 78% 38% 80%
Placement 71% 77% 79% 74% 39% 75%
Target 90% 90% 90% 90% 90% 90%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Program Category
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75% Compliance & Quality rating. With the exception of Closing, all areas are performing similarly to as
they did in FY12.
Family Preservation programs in Circuit 9 (86%) are outperforming Circuits 10 (81%) and 13 (70%) as
well as the Cross Regional rate (85%); however, they are below the 90% target (-4%). Circuit 10 is within
9% of the target, whereas Circuit 13 is within 20% of the target. Circuit 9 is achieving the 90% target in
Treatment Planning.
Placement programs in Circuit 9 (85%) are outperforming Circuits 10 (79%) and 13 (69%) as well as the
Cross Regional rate (79%). Circuit 10 is meeting the Cross Regional rate. Across all Circuits no phases
of client services are achieving the 90% target.
To improve in FY14, programs should focus on the areas missed most on reviews throughout the year.
Below is a full item analysis for each review conducted in FY13 by program category. The percentage
indicates the percent of files in compliance. The number in parentheses at the end of each statement
indicates the number missed out of the total for each review, excluding those items marked N/A.
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
C9 86% 86% 90% 83% 38% 86%
C10 81% 85% 77% 80% 50% 81%
C13 68% 76% 65% 67% 20% 70%Target 90% 90% 90% 90% 90% 90%
Cross Regionally 85% 85% 82% 89% 75% 85%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Family Preservation by Circuit
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
C9 78% 86% 87% 86% 0% 85%
C10 69% 85% 79% 78% 45% 79%
C13 68% 69% 73% 65% 29% 69%
Target 90% 90% 90% 90% 90% 90%
Cross Regionally 83% 79% 80% 76% 47% 79%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Placement by Circuit
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Family Preservation
Intake (79%)
Are the Release of Information Forms current (within checked timeframes) for correspondence
with ALL entities outside of the agency? (44/109)
Is the Clients Rights and Responsibilities (current within 1 year) receipt in the record & signed byall clients involved in the service? (41/108)
Assessment (83%)
Was the Initial Family Assessment completed within 15 business days of intake staffing? (50/98)
Has the Family Assessment been updated every 6 months? (41/73)
Treatment Plan (80%)
Is the current Service/Treatment Plan/Case Plan signed and dated by the client, parent/guardian,
caseworker and supervisor? (39/86)
Is the current copy of the case plan in the record? (31/105)
Service Delivery (78%)
Is there current dental records for the child(ren) contained in the file if medical concerns are thereasons for service involvement? (24/42)
Closing (46%)
Does the record contain a case closure letter to the family regarding additional resources for
continued assistance? (15/21)
Placement
Intake (71%)
Is the Clients Rights and Responsibilities (current within 1 year) receipt in the record & signed by
all clients involved in the service? (181/300)
Are the Release of Information Forms current (within checked timeframes) for correspondence
with ALL entities outside of the agency? (167/307)
Assessment (77%)
Was the Initial Family Assessment completed within 15 business days of intake staffing?
(159/275)
Has the Family Assessment been updated every 6 months? (128/220)
Were recommended services of the Comprehensive Behavioral Health Assessment initiated
within 30 days of the report completion date? (97/214)
Is the Comprehensive Behavioral Health Assessment in the record? (91/281)
Treatment Plan (79%)
Is the current Service/Treatment Plan/Case Plan signed and dated by the client, parent/guardian,
caseworker and supervisor? (118/241) Is the current copy of the case plan in the record? (85/299)
Service Delivery (74%)
Is there documentation in FSFN that the Case Manager visited or attempted face to face contact
with biological parents every 30 days when the goal of the case was reunification?
o For Mother? (94/233)
o For Father? (104/199)
Closing (39%)
Does the record contain a case closure letter to the family regarding additional resources for
continued assistance? (9/13)
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During fiscal year 2013 there were 42 case managers and supervisors who assisted in reviewing 444
files as a part of the CQI peer record review process. These champions of quality serve as an
integral part of the continual process of assessing the quality of our files, providing feedback on how
to improve, and ensuring that plans of correction are being completed on time.
Florida
C9 C10 C13
Lauren Prekop
Melanie Rivera
MaryAnn Miller
Dhaima Chin
Elliot Vegas
Brandy Davis
April Campbell
Shawna Sweetman
Natheena Soto
Miguelina Jorge
Carmen Lott
Carissa Arena
Emily Gustafson
Ebonie Hopkins
Laurie Stern
Yolanda Walker
Vanessa Hyden
Bernadine West
Barbara Hester
Monica Sanders
Darby Barwick
Veronica Bell
Andre Davis
Becka KampmanMuriah Davis Deuth
Ayana Alexander
Danielle Day
Robin Sherwood
Ashley Vaughn
Jeannine Powell
Pam Evans
Candace Fraser
Anna Beyea
Justin Wilkins
Nyla Williams
Laurie VincentAmy Clarke
Kristy Swift
Anne Marie Johnson
Myra Singleton
Renante Demezier
Stacey Singleton
Total Reviewers: 42
Thank you for your time, efforts, and commitment to quality service delivery.
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Client Satisfaction
CQIR conducts an annual Client Satisfaction
Survey to monitor OHU clients impressions ofthe services provided. After all surveys have
been received, region and program reports are
compiled to provide stakeholders with a
Consumer Report Card that compares their
program to the programs in their program
category and to regions as a whole. Please contact Sarah Tunning, Director of Research for One Hope
United, for a report card on any program or region.
C9 C10 C13-OHU C13-Transfer
FY13 4.64
(N=259)
4.67
(N=162)
4.40
(N=201)N/A
FY12 4.64
(N=302)
4.76
(N=196)
4.81
(N=69)
4.37
(N=218)
FY11 4.57
(N=248)
4.62
(N=138)N/A N/A
In the Florida region, C9, and C10 scored in the fine tuning (A) range. C13 scored in the needs
improvement (B) range. Overall client satisfaction in C9 remained unchanged in FY13; whereas C10experienced a slight decrease. In FY12, C13 separated client surveys due to the inheritance of casesfrom a different Case Management Organization. In FY13, this was not the case. Although there wasdecrease in Overall Client Satisfaction in FY13, a true comparison cannot be made.
2013 2012 20114.57
(N=622)4.61
(N=785)4.59
(N=435)
In the Florida region, overall client satisfaction with OHU has remained above 4.50 (A) for the past threeyears. This year, there were 622 surveys returned for Florida Region, a 20.76% decrease from the 785surveys collected in 2012.
3.80
4.00
4.20
4.40
4.60
4.80
5.00
C9 C10 C13-OHU C13-Transfer
Overall OHU Client Satisfaction: Florida Region
Client Satisfaction Surveys monitor
clients impressions of the services OHU
provides.
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Incident Reports
An incident is any occurrence that may have the potential for increased risk for our clients and the liability
of our agency. Reportable incidents alsoinclude situations that raise risk to staff or
agency property, such as a theft or natural
disaster. CQIR provides monthly reports on
incident trends and correlations. Annually,
this report rolls up data for the fiscal year and
presents incident trends by region and circuit
over three fiscal years.
In the Florida region, there was a 25% increase in the number of incident types in FY13 compared to
FY12.
There were five incident categories that increased from FY12:
Incidents classified as Other increased by 274% Medical/Psychiatric related incidents increased by 94%. Client Injuries increased by 50%. Hospitalizations increased by 42%.
Abuse and neglect increased by 7%.
Circuits 9 and 10 both saw decreases in the number of incident types in FY13 compared to FY12, 15.9%and 6.7% respectively. Circuit 13 experienced a 415% increase primarily attributed to being in fulloperation the entire fiscal year. Further information on Incident Reports can be found in Appendices A-C.
0100200300400500600
Incident Types by Year: Florida Region Programs
FY13 FY12 FY11
Incident reports track situations that may
have the potential for increased risk for our
clients and the liability of our agency.
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Office Systems Reviews
The Office Systems Review is a process to determine if an office is meeting agency standards. This
includes professional appearance, staff response to answering telephone calls, maintaining clientconfidentiality and safety and risk management. CQIR coordinators conduct OHU office systems reviews
annually.
Four Office Systems Reviews were conducted in the Florida Region (1 in both C9 and C13 and 2 in
C10). As a region, 89% of all office system reviews were compliant an 8% decrease from FY12. Circuits 9 and 10 were just below the agencys 90% target (represented by the black dashed line)whereas C13 slightly exceeded the target.
The items that were missed most on Office Systems Reviews were:
The agencys Mission and Values statements are posted in the reception area.
Safety evacuation plans are visibly posted in the office.
The office is convenient to public transportation.
86%89% 91% 89%
0%
20%
40%
60%
80%
100%
C9 C10 C13 Region
Office Systems Complinace : Florida Region
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Supervisory Systems Reviews
On an annual basis CQIR conducts an assessment of supervision provided by each direct service
supervisor in the organization. The review uses a standardized form and involves a check of a number ofsupervision tasks. Although there are several items addressed, there is a concentration on the frequency
of supervision and quality documentation of supervisory activities.
Fifteen Supervisory Systems Reviews were completed in the Florida Region (C9 = 6, C10 = 4, C13 = 5).
As a region, supervisors were 78% compliant with items measured a 13% decrease from FY12.Circuits 9 and 10 were above the agencys 90% target (represented by the black dashed line) with C9
achieving 100% compliance. Circuit 13 is significantly below the target, achieving a 40% compliance
rating.
The items that were missed most on Supervisory Systems Reviews were:
Individual supervision occurs.
The supervisor maintains supervision notes.
It is possible to determine the purpose and outcome of the supervisory meetings documented.
100%
93%
40%
78%
0%
20%
40%
60%
80%
100%
C9 C10 C13 Region
Supervisory Systems Compliance: Florida Region
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Priority review is a process that examines
the quality of services provided to a client or
family.
Priority Reviews
A priority review is a process that examines the quality of services provided to a client or family and
compliance with program policies andprocedures. There are three levels of
priority reviews: The Level 1 Priority
Review also called a case consultation
is voluntary and can be conducted on
any case upon the request of the
supervisor. The Level 2 Priority Review is conducted in the event of a serious injury to a client or a crime.
Level 3 Priority Reviews are held when there is a client death, suicide attempt or felony.
# Priority Reviews in FY13
Program CategoryCase
ConsultationsLevel 2 Level 3 TOTAL
Family Preservation 0 0 0 0
Placement 1 1 1 3
TOTAL 1 1 1 3
There were 3 priority reviews conducted in FY13 (down 6 from FY12). The decrease in Priority Reviews
in the Florida region can be attributed to a decrease in Case Consultations and Level 2 reviews.
Case Consultations are preventative in nature and are meant to be used as a method to share thoughts
and ideas about a case that may be challenging. Florida conducted 5 less Case Consultations in FY13.
There was one Level 2 Priority Reviews in FY13 (down 1 from FY12). The review was conducted due tothe medical neglect of a youth in placement by their caregiver, which resulted in a permanent injury.
There was one Level 3 Priority Review in FY13 (no change from FY12). This review was due to the
death of a client while at an outside providers child care facility.
Below are some highlights of lessons learned throughout the year:
In cases of medical neglect, it is important that supervisors have an ongoing discussion withcase managers to address any medical concerns during monthly supervision.
Collateral contacts with service providers are vital in monitoring client progress and followingup if concerns are identified.
Medical neglect cases warrant an increased level of vigilance to make certain that medicalneeds are addressed.
We make assumptions that licensed providers, in this case, child care, are consistentlymeeting licensing requirements. When visiting such providers, we should focus our attentionon seeing where the child sleeps, feeding log, etc. Possibly enlist the assistance of leadagencies in this effort for extra oversight.
Possibly interviewing a new child care provider prior to placing the child in the service anddetermine the quality and licensing compliance.
A complete list of lessons learned from reviews can be found by contacting a member of the CQIR team.
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Employee Recognition
Two methods of awarding staff excellence are supported by CQIR. The first is the STAR Award for
individual excellence, and the second is the GALAXY Award for team excellence.The awards recognize staff that have gone above and beyond normal work duties,
exhibited exemplary performance and done their job under circumstances that are
out of the ordinary. There were 36 Star awards and 2 Galaxy awards distributed
in the Florida region this year.
In FY13 we were proud to recognize these Florida employees with a STAR Award.
Quarter 1
Myra Singleton Program Specialist(Tampa, FL)
Amanda Boley Family Support Specialist(Tampa, FL)
Stacey Singleton Permanency Specialist(Tampa, FL)
Christina Doty Office Manager (Tampa,FL)
Melissa Gabriel Office Manager (Tampa,FL)
Quarter 2
Amanda Birge Case Manager(Sebring/Wauchula, FL)
Daniel Cook Life Coach
(Sebring/Wauchula, FL) Rebecca Kampan Case Manager
(Sebring/Wauchula, FL) Bobbie Colvin Family Support Worker
(Sebring/Wauchula, FL) Beverly Mitchell Case Manager (Orlando,
FL) Dhaima Chin Family Case Manager
(Orlando, FL) Vanessa Hayden-Johnson Family Case
Manager (Orlando, FL) Lucie Memorie Case Manager (Orlando,
FL) Alan Blackmon-Case Manager (Orlando, FL) Brandy Davis Family Case Manager
(Orlando, FL) Lauren Prekop Case Manager (Orlando,
FL) Lauren Loffert Case Manager (Orlando,
FL)
April Campbell Family Case Manager(Orlando, FL)
Fiona Simmons Records ManagementSpecialist (Orlando, FL)
Ebonie Hopkins Supervisor (Orlando, FL) Yolanda Walker Supervisor (Orlando, FL) Laurie Stern Supervisory (Orlando, FL) Ferdinand Medina Family Support Worker
(Orlando, FL) Jennifer Carmin Case Manager (Orlando,
FL) Emily Gustafson Case Manager (Orlando,
FL) Jolene Palazzo Business Manager
(Orlando, FL)Quarter 3
Mileidy Daniel Case Manager (Orlando,FL)
Therese Hartwell Family Case Manager(Orlando, FL)
Shawna Lambert Supervisor (Sebring, FL) Claudia Gonzalez Adoption Specialist
(Tampa, FL) Ana Cruz Case Manger I (Wauchula, FL) Lindsay Bass Case Manager (Wauchula,
FL) Robin Sherwood Lead Case Manager
(Wachula, FL) Nancy Baker-Guerin Case Manager I
(Wachula, FL)Quarter 4
Courtney Hall Family Case Manager(Sebring, FL)
Natheena Soto Family Case Manager(Orlando, FL)
The following teams were presented with a GALAXY Award this year.
Quarter 2
OHU Licensing Team (Orlando, FL
Quarter 3
C10 Leadership Team (Sebring/Wauchula, FL)
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Quality Improvement Teams
Everyone in the agency participates in at least one Quality Improvement Team (QIT). This
allows each employee the power to implement improvement within their own QIT. The QIT isfocused on improving the quality of service at the local level using data, effective problem
solving and action planning.
Across the agency, there was an overall attendance rate of 96% in FY13. The attendance rate
for the Florida region was 94%. The following local, service center and regional Quality
Improvement Teams were assembled three times this year in the Florida region.
QIT Names
Local
Sassy Soldiers
Stellar Seven
Elite 6
Advocates
Unit 206 The A Team
Team Terrific
Mighty Helpers
Everyday Heroes
Unit 853 The A Team
Best & Brightest
Team Focus
Perfect StarsOHU Angles
Rescue Rangers
Excellence Trackers
Q2 Quality Queens
Improvement Seekers
Quality Avengers
Mighty Women of Quality
ServiceCenter
C9 Supervisors Super Sups
C10 Supervisors No WorriesC13 Supervisors Quality Angels
Regional Hopes Heroes
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Appendix A: Circuit 9 Highlights
Peer Record Reviews are shown below by Program Category with a break-down by Unit.
Overall, Family Preservation programs in Circuit 9 achieved an overall Compliance & Quality
rating of 86%. Treatment Planning is the only area measured that achieved the target. Unit 206
is the only Unit that achieved an overall Compliance & Quality rating that met the agencys
target. Assessment, Treatment Planning, and Closing achieved the target. Unit 205 was within2% of the target, achieving an overall Compliance & Quality rating of 88%. Intake and
Treatment Planning both exceeded the agencys target. Unit 204 was within 4% of the agencys
target, achieving an overall Compliance & Quality rating of 86%. Assessment achieved the
agencys target. Unit 202 achieved an overall Compliance & Quality rating of 84%, with
Treatment Planning exceeding the agencys target. Unit 201 achieved an overall Compliance &
Quality rating of 80%.
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Unit 201 73% 84% 81% 83% 33% 80%
Unit 202 85% 79% 93% 86% 33% 84%Unit 204 82% 91% 88% 76% 33% 86%
Unit 205 100% 83% 94% 79% 38% 88%
Unit 206 87% 93% 90% 86% 100% 90%
Target 90% 90% 90% 90% 90% 90%
All Programs 86% 86% 90% 83% 38% 86%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Family Preservation - Circuit 9
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Overall, Placement programs in Circuit 9 achieved an overall Compliance & Quality rating of
85%. Unit 206 is the only Unit that exceeded the agencys target with an overall Compliance &
Quality rating of 91%. Assessment, Treatment Planning, and Closing all exceeded the target.
Unit 205 was within 4% of the target, achieving an overall Compliance & Quality rating of 86%.
Unit 204 was within 7% of the agencys target, achieving an overall Compliance & Quality rating
of 83%. Units 201, 202, and Adoption 209 all achieved an overall Compliance & Quality rating of
82%.
Incident Reports by incident type are reported below for Circuit 9.
In Circuit 9 there was a 15.9% decrease in the number of incident types in FY13 compared to
FY12. Over the past three fiscal years the number of incidents have decreased by over 15%
each year.
There were significant decreases in six incident categories.
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Unit 201 78% 83% 82% 83% 82%
Unit 202 74% 78% 90% 83% 82%
Unit 204 70% 85% 86% 85% 83%
Unit 205 86% 87% 85% 85% 0% 86%
Unit 206 80% 95% 92% 93% 91%
Adoption 209 71% 78% 86% 84% 82%
Target 90% 90% 90% 90% 90% 90%All Programs 78% 86% 87% 86% 0% 85%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Placement - Circuit 9
0
50
100
150
200
250
Incident Types: Circuit 9
FY13 FY12 FY11
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Education related incidents decreased by 100%. Client injuries decreased by 66.7%. Criminal Acts decreased by 59%. Sexually Problematic Behaviors decreased by 46.2% Abuse and neglect decreased by 41.3%.
Behavioral issues decreased by 28.6%.
There were large increases in 2 incident categories. Incidents classified as Other increased by over 200%. Medical/Psychiatric injuries increased by 18.8%.
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Appendix B: Circuit 10 Highlights
Peer Record Reviews are shown below by Program Category with a break-down by Unit.
Overall, Family Preservation programs in Circuit 10 achieved an overall Compliance & Quality
rating of 81%. Unit 853 achieved an 85% overall Compliance & Quality rating, with Service
Delivery meeting the agencys target. Unit 854 achieved an overall Compliance & Quality rating
of 85%, with Assessment exceeding the agencys target. Unit 855 achieved an overallCompliance & Quality rating of 78%, with Assessment meeting the agencys target and Closing
receiving a 100% on Compliance & Quality items. Unit 849 achieved an overall Compliance and
Quality rating of 75%, with Closing receiving 100% on Compliance & Quality items.
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Unit 849 83% 69% 86% 64% 100% 75%Unit 853 88% 85% 86% 90% 25% 85%
Unit 854 81% 93% 81% 82% 33% 84%
Unit 855 73% 90% 57% 86% 100% 78%
Target 90% 90% 90% 90% 90% 90%
All Programs 81% 85% 77% 80% 50% 81%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Family Preservation - Circuit 10
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Unit 121 92% 85% 91% 91% 75% 90%
Unit 849 67% 85% 89% 83% 80% 82%
Unit 853 61% 92% 77% 76% 0% 80%
Unit 854 68% 79% 70% 70% 50% 72%
Unit 855 68% 84% 67% 75% 0% 75%
Target 90% 90% 90% 90% 90% 90%
All Programs 69% 85% 79% 78% 45% 79%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Placement - Circuit 10
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Overall, Placement programs in Circuit 10 achieved an overall Compliance & Quality rating of
79%. Unit 121 is the only Unit to meet the agencys target with an overall Compliance & Quality
rating of 90%. Intake, Treatment Planning, and Service Delivery exceeded the agencys target.
Unit 849 achieved an 82% overall Compliance & Quality rating. Unit 853 achieved an overallCompliance & Quality rating of 80%, with Assessment exceeding the agencys target. Unit 855
achieved an overall Compliance & Quality rating of 75%. Unit 854 achieved an overall
Compliance and Quality rating of 72%.
Incident Reports by incident type are reported below for Circuit 10.
In Circuit 10 there was a 6.7% decrease in the number of incident types in FY13 compared toFY12.
There were large decreases in 4 incident categories.
Deaths decreased by 100%. Medical/Psychiatric incidents decreased by 26.7%. Criminal Acts decreased by 21.9%. Abuse and Neglect decreased by 14.5%.
There were large increases in 4 incident categories. Client injuries increased by 200%.
Education related incidents increased by 150%. Hospitalizations increased by 50%. Incidents classified as Other increased by 50%.
0
25
50
75
Incident Reports: Circuit 10
FY13 FY12 FY11
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Appendix C: Circuit 13 Highlights
Peer Record Reviews are shown below by Program Category with a break-down by Unit.
Overall, Family Preservation programs in Circuit 13 achieved an overall Compliance & Quality
rating of 70%. Unit 660 achieved the highest rating with an overall Compliance & Quality rating
of 74%, followed by Unit 650 (71%), Unit 910 (70%), and Units 640 and 910 (66%).
Overall, Placement programs in Circuit 13 achieved an overall Compliance & Quality rating of
69%. Unit 650 achieved the highest rating with an overall Compliance & Quality rating of 73%,
followed by Unit 660 (70%), Unit 720 (69%), Unit 640 (66%), and Unit 910 (63%).
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Unit 640 61% 72% 66% 64% 0% 66%
Unit 650 70% 82% 56% 69% 50% 71%
Unit 660 73% 86% 63% 72% 74%
Unit 720 63% 64% 73% 70% 0% 66%
Unit 910 72% 75% 72% 58% 25% 70%
Target 90% 90% 90% 90% 90% 90%
All Programs 68% 76% 65% 67% 20% 70%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Family Preservation - Circuit 13
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Unit 640 64% 67% 64% 66% 66%
Unit 650 70% 74% 80% 67% 0% 73%
Unit 660 71% 71% 76% 66% 70%
Unit 720 75% 65% 75% 66% 0% 69%
Unit 910 61% 64% 68% 61% 50% 63%
Target 90% 90% 90% 90% 90% 90%
All Programs 68% 69% 73% 65% 29% 69%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Placement - Circuit 13
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Incident Reports by incident type are reported below for Circuit 13.
In Circuit 13 there was an increase in the number of all incident types in FY13 compared toFY12. This increase is due to the fact that C13 was not operational until the second half of thefiscal year and Incident Reporting to CQIR did not begin until the 4 th quarter of FY12. A moredetailed year to year analysis will be completed in FY14 when there are 2 complete fiscal yearsof data available.
0102030405060708090
Incident Reports: Circuit 13
FY13 FY12