one hope united 2013 cqir annual report - hudelson region

7/27/2019 One Hope United 2013 CQIR Annual Report - Hudelson Region

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CQIRANNUAL REPORT

2013HUDELSON REGION

ANALYSIS

REPORT PREPARED BY KIMBERLY D.CLARK

CQIRSYSTEMS ANALYST

PLEASE DIRECT INQUIRIES TO:[email protected]

Primary Office Location

Area of Service Impact

1

4

5

67

8

2

3

Illinois

Missouri

Report Snapshot

Hudelson Regionserved 1,790 clients

and families in

FY13.

91% of Hudelson

Outcome Goals

were met.

The Hudelson

Region Compliance& Quality rating on

Peer Record

Reviews was 93%.

4 out of 5 program

categories scored

an A in overall

client satisfaction.


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Table of Contents

LETTER FROM THE EDITORS ................................................................................................................ 2

CQIR TEAM & HIGHLIGHTS .................................................................................................................... 3

HUDELSON LEADERSHIP ...................................................................................................................... 5

EXECUTIVE SUMMARY .......................................................................................................................... 6

CLIENTS SERVED ................................................................................................................................... 9

OUTCOME MANAGMENT ..................................................................................................................... 10

PEER RECORD REVIEWS .................................................................................................................... 12

CLIENT SATISFACTION ........................................................................................................................ 15

INCIDENT REPORTS ............................................................................................................................. 16

OFFICE SYSTEMS REVIEWS ............................................................................................................... 17

SUPERVISORY SYSTEMS REVIEWS ................................................................................................... 18

PRIORITY REVIEWS ............................................................................................................................. 19

EMPLOYEE RECOGNITION .................................................................................................................. 20

QUALITY IMPROVEMENT TEAMS ........................................................................................................ 21

APPENDIX.............................................................................................................................................. 22

Appendix A: Counseling Highlights ...................... .......................... ...................... ......................... ......................... 22

Appendix B: Family Preservation Highlights ........... ......................... ......................... ....................... ...................... 25

Appendix C: Placement Highlights........................ ........................ ....................... ......................... ......................... 28

Appendix D: Prevention Highlights ...................... .......................... ...................... ......................... ......................... 32

Appendix E: Youth Services Highlights ......................... ...................... ......................... ......................... ................. 34


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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 services

in order to see what sticks from our service and genuinely changes lives. This work will help us ensure that

One 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, PhDExecutive 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 HonakerCQIR Director

Katurah RobyCQIR Coordinator

Ron CulbertsonCQIR Coordinator

Linda WeissCQIR Medicaid

Coordinator

Ryan Counihan

CQIR Technician

Stan GrimesCQIR Coordinator

Elizabeth HopkinsCQIR Medicaid

Coordinator

Jackie SchedinCQIR 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 Hudelson Region annual report is organized by these CQIR 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, OfficeReviews, and Supervisory Reviews which has made the data entry process more efficient. A pilot

for 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 ITthat 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 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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Hudelson Leadership

The Hudelson Region is led by an Executive Director and an Associate Executive Director. Additionally,

there are 5 Directors of Programs who assist in the leadership of specific programs. The Hudelson

Region offers services in 5 program categories: Counseling, Family Preservation, Placement,

Prevention, and Youth Services.

Patricia Griffith Executive Director

Associate

Executive Director

Ann Pearcy

Directors ofPrograms

Rachel Gubbins Becky Newcomer Nikki QuandtShannon Stokes Melissa Webster


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Executive Summary

This year, OHU programs in the Hudelson Region served 1,790 clients and families a 14% decreasefrom last year. The Compliance & Quality of service and record documentation overall was 93%. The

efforts of Hudelson programs overall resulted in 91% of all outcome goals being met.

OUTCOME MANAGEMENT PEER RECORD REVIEWS

Across all programs, 91% of Outcome goals weremet in FY13.

Out of 340 files reviewed in FY13, the HudelsonRegion Compliance & Quality rating on servicedocumentation was at 93%.

CLIENT SATISFACTION INCIDENT REPORTS

Hudelson Region Overall satisfaction score hasremained above 4.50 (A) for the past three years.

In the Hudelson Region, the number of incidentsdecreased about 4% across most incident types.Incidents involving Client/Caregiver Property(-89%), Sexually Problematic Behaviors (-42%),and Education Incidents (-32%) had the largestdecreases from FY12 to FY13.

OFFICEREVIEWS

SUPERVISORYREVIEWS

PRIORITY REVIEWS

In the Hudelson Region, 94% of Office Reviewsand 97% of Supervisory reviews were compliant.

There were 3 priority reviews conducted in FY13: 2Level III, 0 Level IIand 1 Case Consultation.

EMPLOYEE RECOGNITION QUALITY IMPROVEMENT TEAMS

There were 15 STAR awards and 5 GALAXYawards distributed this year.

There was an average QIT attendance rate of 98%in the Hudelson region.


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In reviewing each area assessed in this report, the following actions are recommended in FY14 based on

Outcomes and Peer Record Reviews in FY13.

Program ReviewedRisk Management Topics for FY14 QITs:

Recommended Areas to Develop Action Plans

Counseling

Counseling programs did not achieve the outcome of clients meetingtreatment goals at discharge; it was within 4% of the target.

In Peer Record Review the following programs did not achieve the agencystarget: Foster Care Counseling did not achieve the 90% target in Intake (82%). SOC-Collinsville did not achieve the 90% target in Intake (87%) or

Treatment Planning (73%). SOC-Effingham did not achieve the 90% target in Assessment (85%),

Treatment Planning (86%), and Closing (80%).

Family Preservation

Intact Family Counseling did not achieve the outcome of not havingconfirmed abuse or neglect reports during the service period; it was

within 5% of the target. Visitation Transportation did not achieve the outcome of cases being

successfully returned home or achieving permanency; it was within 33%of the target.

In Peer Record Review the following programs did not achieve the agencystarget: Intact Families Eastern did not achieve the 90% target in Intake (88%),

Assessment (82%), Treatment Planning (69%), and Service Delivery(76%).

Intact Families Southern did not achieve the 90% target in Closing(86%).

Visitation Transportation did not achieve the 90% target in Intake (89%).

Placement

Specialized Foster Care did not achieve the outcome of childrenachieving permanency during the fiscal year or children experiencingtwo or fewer placement settings within 12 months; they were within 3-5% of the target.

The Residential Program did not reach the outcome related to clientsbeing available for treatment; it was within 2.47% of the target.

In Peer Record Review the following programs did not achieve the agencystarget: Foster Care did not achieve the 90% target in Intake (80%), Assessment

(81%), Treatment Planning (89%), and Service Delivery (82%). Specialized Foster Care did not achieve the 90% target in Intake (68%),

Treatment Planning (73%), Service Delivery (73%, and Closing (0%).

Residential did not achieve the 90% target in Closing (46%).

Prevention

FSS did not achieve 4 of its outcomes. Improving in the domains ofParenting Capabilities, Family Interactions, Safety, and Child-Well-Beingas measured by the NCFAS were within 20% of the target.

Foster Grandparent-Mt. Vernon did not achieve the outcome ofvolunteers scoring a 5 or below on the Mood Assessment scale; it waswithin 1% of the target.

Youth Services

FTS-FFT did not achieve the outcome of youth remaining in a home likesetting; it was within 13% of the target.

FFT-Madison did not achieve the outcome of youth remaining in a homelike setting or being deflected from further involvement in the juvenile

justice system; they were within 9-23% of the target.

FTS-MST did not achieve any of its outcome goals. All outcome goals


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were within 20-40% of the target.In Peer Record Review the following programs did not achieve the agencystarget: CCBYS-Mt. Vernon did not achieve the 90% target in Closing (80%). CCBYS-Olney did not achieve the 90% target in Treatment Planning

(83%). Youth Diversion Program did not achieve the 90% target in Closing

(83%). SASS-Effingham and Mt. Vernon did not achieve the 90% target in

Closing (81% and 70%, respectively).


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Clients Served

In fiscal year 2013, One Hope United served 1,790 clients and families in the Hudelson Region a

decrease of 14% from FY12.

# of Clients Served by Fiscal Year

FY13 FY12 FY11

Counseling 173 179 254Family Preservation 347 414 295

Placement 133 150 134Prevention 375 535 535

Youth Services 762 802 896

TOTAL 1,790 2,080 2,114

The main influences contributing to the decrease in clients served occurred in Family Preservation(-16%), Prevention (-30%), and Placement (-11%).

In Family Preservation, the closing of the Differential Response program contributed to the

decrease. Additionally, the Circle of Hope program closed operations at the end of the first

quarter of FY13.

Prevention programs had 3 programs close at the end of FY12 (Supporting Student Stability and

2 Education Works programs) that attributed to some of the decrease. There were also less

DCFS referrals to the Family Support Services (FSS) program due to the privatization of the

Intact Families programs.

Placement had less Foster Care referrals from DCFS which caused the decrease in the number

of clients served.

The Youth Services programs continue to be the largest source of clients for the Hudelson Region,

accounting for 43% of their client population. The next largest program category is Prevention services,

accounting for 21% of Hudelsons client population.

10%

19%

7%

21%

43%

Clients Served: Hudelson

Counseling Family Preservation Placement Prevention Youth Services


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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.

Percentage of Outcome Goal Achievement: Hudelson

FY13 FY12 FY11OVERALL TOTAL 91% 90% 95%

Safety 100% 90% 89%

Permanency 84% 90% 90%

Well-Being 92% 90% 100%

This year, the Hudelson Region achieved 91% of its outcome goals.

The Hudelson Region holds itself to 53 outcome goals across the 5 program categories. Below is the

outcome goal achievement by program category for FY13. For further outcome achievement information

please see Appendices A-E.

Percentage of Outcome Goal Achievement: Program Category

Counseling % AchievedFamily

Preservation% Achieved Placement % Achieved

Safety100%(1/1)

Safety100%(2/2)

Safety100%(3/3)

Permanency100%(3/3)

Permanency100%(1/1)

Permanency67%(6/9)

Well-Being67%(2/3)

Well-Being50%(1/2)

Well-Being100%(2/2)

TOTAL86%(6/7)

TOTAL80%(4/5)

TOTAL79%

(11/14)

Prevention % AchievedYouth

Services% Achieved

Safety100%(2/2)

Safety100%(1/1)

Permanency100%

(2/2)Permanency

100%

(4/4)

Well-Being100%

(10/10)Well-Being

100%(8/8)

TOTAL100%

(14/14)TOTAL

100%(13/13)

CQIR monitors contract and agency

outcome goals established by federal

and state standards and OHU values.


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ADDITIONAL PERMANENCY ACHIEVEMENT OUTCOMES FOR FOSTER CARE

Foster Care programs in Illinois measure permanency achievement each Fiscal Year. Below are the

permanency outcomes for both Specialized Foster Care and Traditional & Relative Foster Care for the

Hudelson Region.

Specialized Foster Care Permanency Outcomes

RegionStarting

Caseload

TotalPermanencies(measured by

points)

FY13Permanency

RateFY13 Goal

Hudelson 6 1 17% 20%

Specialized Foster Care Actual Children

Region AdoptionReturnHome

Guardianship Other Total

Hudelson 0 0 1 0 1

Illinois Traditional & Relative Foster Care Permanency Outcomes

RegionStarting

Caseload

TotalPermanencies(measured by

points)

FY13Permanency

RateFY13 Goal

Hudelson Downstate 44 21 48% 33%

Illinois Traditional & Relative Foster Care Actual Children

Region AdoptionReturnHome

Guardianship Other Total

Hudelson Downstate 4 6 0 0 10


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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.

CQIR Coordinators conduct file reviews for

each program every quarter and the results are

communicated via a report for each review

date, as well as Risk Management reports that

show individual program results and results by

program category. 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 Hudelson Region in this report

are: Counseling, Family Preservation, Placement, Prevention, and Youth Services.

# of Hudeslon Region File Reviews by Quarter

Program Category Q1 Q2 Q3 Q4 TOTALCounseling 7 7 9 8 31

Family Preservation 8 6 15 18 47

Placement 13 13 14 11 51Prevention 25 24 24 23 96

Youth Services 27 28 28 32 115TOTAL 80 78 90 92 340

In FY13, 340 files were reviewed across all five program categories.

There are 9 tools utilized in the Hudelson Region that assess Compliance & Quality. There are some

tools that are used that assess only compliance and then another tools that assess quality (Ex. Foster

Care utilizes a Standard Compliance Tool and then a Foster Care Quality Tool). There are other

programs that use one tool that assesses both Compliance and Quality (Ex. Foster Grandparent).

Results were combined across all tools to produce the following graph which looks at how the Region

performed as a whole.

COA standards require OHU to

randomly select a sample of records to

review for all programs.


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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.

In FY13, the Hudelson Region met the 90% Compliance & Quality target in all areas with the exception

of Closing, which was within 5% of the target. Overall, the Hudelson Region is the only region to meet or

exceed the agencys 90% target across all program categories. Hudelson achieved a 93% Compliance &

Quality rating, which is a 1% increase from FY12.

Compliance & Quality performance for the Hudelson Region was also analyzed by program category toproduce the following graph.

All program categories are meeting or exceeding the agencys 90% target for Compliance and Quality.

Prevention programs are within 2% of a 100% Compliance & Quality rating. Each program category is

analyzed more closely in Appendices A-E to identify additional trends and areas of improvement.

Intake AssessmentTreatment

Plan

Service

DeliveryClosing Overall

Actual 96% 94% 92% 92% 85% 93%

Target 90% 90% 90% 90% 90% 90%

Cross-Region 90% 85% 84% 84% 83% 86%

0%

20%

40%

60%

80%

100%

Compliance & Quality - Overall: Hudelson Programs

CounselingFamily

PreservationPlacement Prevention

Youth

Services

Program Category 94% 90% 90% 98% 93%

Target 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Overall Compliance & Quality - Across All Program Categories


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During fiscal year 2013 there were 42 case managers, therapists, supervisors, and directors who

assisted in reviewing 340 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.

Hudelson Peer Record ReviewersEmily Blackburn

Stephanie BowdlerKendra Schuler

Mindy MillerJayme Godoyo

Jim WebsterTawnya HacklerDeb PackmanDawn WhiteNikki Quandt

Brionne RhodesHoward Coon

Colleen LareauBrigette Spelbring

Lisa RankinChanta Love

Jennifer WetzelSophia Ruffin

LaNette HeseltonHeather Kelly

Joy Loyd

Jen MaleeJoe Berry

Michelle TroyerPenny Hanks

Kristy HardwickRachel GubbinsDarren Dunahee

Lauren Kessler-SchottMelissa Webster

Becca Smith

Kara LowryChristy BrownHolly CottonKatie Klass

Afthan ReentsJennifer Shook

Kristi ZettlerTyler Moor

Becky NewcomerShannon StokesAmy Overmyer

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, regional 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.

Counseling

Family

Preservation Placement Prevention Youth ServicesFY13 4.77

(N=32)4.64

(N=168)4.19

(N=83)4.90

(N=139)4.91

(N=143)

FY12 Did not reachvalidity

4.72(N=119)

3.85(N=65)

4.83(N=187)

4.81(N=112)

FY11 4.80

(N=44)

4.78

(N=102)

4.23

(N=77)

4.82

(N=193)

4.76

(N=209)

Across Region and fiscal year, all programs except Placement scored in the fine tuning range. Twoprogram categories (Prevention and Youth Services) saw an increase in Overall satisfaction with OHU.Placement has scored in the needs improvement range for the past three years; however in FY13Overall satisfaction with OHU increased from FY12. Overall satisfaction in Family Preservation also

decreased; however, this program is still in the fine tuning range. There is no comparative data forCounseling program from FY12, since the program did not reach validity; however there was a slightdecrease when comparing to FY11.

2013 2012 2011

4.69(N= 558)

4.67(N=500)

4.72(N=625)

In the Hudelson Region, overall client satisfaction with OHU has remained above 4.50 (A) for the past

three years. This year, there were 558 surveys returned for the Hudelson Region, an 11.6% increase

from the 500 surveys collected in 2012.

3.60

3.80

4.00

4.20

4.40

4.60

4.80

5.00

Counseling Family Preservation Placement Prevention Youth Services

Overall OHU Client Satisfaction: Hudelson Region

Client Satisfaction Surveys monitor

clients impressions of the services OHU

rovides.


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Incident ReportsAn incident is any occurrence that may have

the potential for increased risk for our clientsand the liability of our agency. Reportable

incidents also include 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

over three fiscal years.

In the Hudelson Region, there was a 3.7% decrease in the number of incident types in FY13 compared

to FY12.

There were only two incident type that increased, Medical/Psychiatric Incidents increased by 25.6% and

Behavioral Issues increased by 3.4% in FY13.

All other incident categories saw a decrease. The most significant decreases were in Client Caregiver

Property (-88.9%), Sexually Problematic Behaviors (-42.1%), Education (-32.1%), and Client Injuries

(-21.8%).

It is important to note that the number of Behavior Management incidents (incidents involving a restraint)

in the Residential (RTx) program decreased for the first time since FY10. In FY12, 19.9% of all incidents

in the Hudelson Region involved a restraint. In FY13, out of the 1,455 incidents, 17.1% involved a

restraint, a 2.8% decrease.

0

200

400

600

800

1000

Incident Types by Year: Hudelson 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. Thisincludes professional appearance, staff response to answering telephone calls, maintaining client

confidentiality and safety and risk management. CQIR coordinators conduct OHU office systems reviews

annually.

Seven Office Systems Reviews were conducted in the Hudelson Region. As a Region, 94% of all office

system reviews were compliant a 4% decrease from FY12.

94%

2% 4%

Office Systems Compliance: Hudelson

Compliant Not Compliant Partially Compliant


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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 of

supervision tasks. Although there are several items addressed, there is a concentration on the frequency

of supervision and quality documentation of supervisory activities.

Twenty-two Supervisory Systems Reviews were completed in the Hudelson Region. As a Region,

supervisors were 97% compliant with items measured a 1% decrease from FY12.

97%

1%2%

Supervisory Systems Compliance: Hudelson

Compliant Not Compliant Partially Compliant


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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 providedto a client or family and compliance with

program policies and procedures. 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

Counseling 0 0 0 0

Family Preservation 0 0 1 1

Placement 1 0 0 1

Prevention 0 0 1 1

Youth Services 0 0 0 0

TOTAL 1 0 2 3

There were 3 priority reviews conducted in FY13 (down 1 from FY12). There was a decrease is the

number of Level 2 Priority Reviews from FY12 (2 less) and an increase in the number of Level 3 reviews

(1 more).

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. Hudelson conducted one Case Consultation in FY13.

There were two Level 3 Priority Reviews conducted in FY13. One was due to the suicide of a former

client from the Education Works Program and the other involved the death of a client from the Intact

Family Program.

Below are some highlights of lessons learned throughout the year:

When a family OHU is serving experiences a death or significant change, such as moving, itwould be in the families best interest for OHU to provide aftercare services (up to 3 months) tohelp the family cope, even if the funder (such as DCFS) has closed the case. This would be agood practice for all OHU services.

It is important for external reviewers to be able to read case notes and be aware of familialrelationships when there are multiple family members involved with families being served.

Ensure consents are completed accurately, correctly, and for appropriate contacts.

There needs to be clarification on the requirements of incident reporting for emergency medicaltreatment.

A complete list of lessons learned from reviews can be obtained 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 forindividual 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 15 Star awards and 5 Galaxy awards distributed

in the Hudelson Region this year.

In FY13 we were proud to recognize these Hudelson employees with a STAR Award.

Quarter 1

Shawn Lux Youth Care Worker I

(Centralia, IL) Stacey Garner Lead Youth Care Worker

(Centralia, IL) Gregory Phoenix Residential Specialist

(Centralia, IL) Kayla Dunahee Residential Specialist

(Centralia, IL) Shannon Stokes Director of Programs

(Jefferson City, MO)Quarter 2

Jessica Perry Therapist (Centralia, IL) Brooke Lopez Administrative Assistant

(Centralia, IL) Guy Janic Maintenance (Centralia, IL)

Quarter 3

Jim Webster Coordinator (Centralia, IL)

Brenda Perry Family Support Specialist(Olney, IL)

Josh Smith Youth Care Worker (Centralia,IL)

Jayme Godoyo Fund Development Officer(Centralia, IL)

Tina Schrage Youth Care Worker(Centralia, IL)

Quarter 4

Cindy Smith Youth Care Worker (Centralia,IL)

Gabriel King Lead Youth Care Worker(Centralia, IL)

The following teams were presented with a GALAXY Award this year.

Quarter 1 Quarter 3

Residential Specialist Team (Centralia, IL) Intact Family Services Team (Hudelson) Baker Home (Centralia, IL) Family Support Services and Visitation

Team (Collinsville, IL)

Gibb Home (Centralia, IL)


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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 is focused onimproving 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 in

Hudelson was 98%. The following local, service center and regional Quality Improvement Teams

were assembled three times a year in the Hudelson Region.

QIT Names

Local Service Center Regional

Givers of HopeNoble IntendersCasenote QueensGibb Baker HeroesWilson Hick Heroes

BlissRG and the Sunshine Band

Behavior BustersBig 10Win3

The SupportersYouth Empowerment Program

Clinical HeroesSuper Glue Sticks

Youth Encouragers and StabilizersChain LinksNight Owls

Exceptional EightASAP

Missouri Service CenterLeaders of the Pack

Destination Excellence


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Appendix A Counseling Highlights

The Hudelson Region operates Counseling programs throughout Southern Illinois. Across all

programs, 173 clients were served in FY13 which is a 3.4% decrease from FY12.

Outcomes are reported below. For ease of analysis, results were condensed across specific types

of Counseling Programs.

1. Comprehensive Counseling, which also includes Foster Care Counseling and Specialized

Foster Care Counseling.

2. SOC Counseling, which provides results for all three offices.

Foster Care/Specialized Foster Care/

Comprehensive Counseling

Goals Target % Achieved

1. Clients served will not be subjects ofindicated reports of abuse or neglectduring the service period.

90% 92%

2. Clients who reside in the home of aparent at the time of referral willremain in the home.

90% 100%

3. Clients who reside in foster care orother out of home placement willremain in that placement or achievepermanency.

90% 100%

4. Clients discharged will show anoverall improvement between initial

and closing CANS ratings.

80% 92%

5. Client treatment goals having beensubstantially met at discharge.

80% 76%

SOC

Goals Target Charleston Collinsville Effingham

1. Clients will maintain their initialplacement at the time of discharge.

70% 100% 77% 82%

2. Clients discharged will show animprovement between initial and closingCANS ratings.

80% 100% 96% 88%


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Peer Record Reviews are reported below.

Overall, Counseling Programs in Hudelson achieved a 94% Compliance & Quality rating. SOC

Collinsville (88%) is the only programs that did not achieve the overall 90% target. SOC Collinsville

was below the target in Intake (87%) and Treatment Planning (73%). Comprehensive Counseling,Specialized Foster Care Counseling, and SOC Charleston met or exceeded the target across all

phases of the case life cycle. Foster Care Counseling did not achieve the target in Intake (82%) and

SOC Effingham did not achieve the target in Assessment (85%), Treatment Planning (86%), and

Closing (80%).

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 (only those

programs that did not achieve 90% in an area were analyzed). 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.

Foster Care Counseling

Intake (82%)

Are Releases of Information completed, signed and current? (4/7)

SOC-Collinsville

Intake (87%)

Is there a Case Action Form in the record documenting date of opening, transitions andclosing (OHU400)? (3/8)

Treatment Plan (73%)


PlanServiceDelivery

Closing Overall

Comprehensive Counseling 90% 100% 95% 100% 100% 97%

Foster Care Counseling 82% 96% 100% 100% 100% 96%

Specialized Foster CareCounseling 91% 100% 92% 95% 96%

SOC-Charleston 100% 95% 100% 100% 100% 99%

SOC-Collinsville 87% 93% 73% 94% 100% 88%

SOC-Effingham 100% 85% 86% 100% 80% 91%

Target 90% 90% 90% 90% 90% 90%

All Programs 90% 94% 89% 98% 94% 94%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Counseling


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Was the current service plan/treatment plan/case plan written, signed and dated by the Case

Manager/therapist and supervisor within the required timeframe of the program contract? (4/8)

SOC-EffinghamAssessment (85%)

Was a Child & Family Team meeting conducted within 30 calendar days of accepting the

referral? (2/4)




Closing (80%)

Was a Child and Family team meeting conducted within 10 working days of a verbal request

for discharge? (1/1)


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Appendix B Family Preservation Highlights

The Hudelson Region operates four Family Preservation programs: three programs provide Intact

Family Services and one provides Visitation Transportation services. Across the 4 programs, 347

clients were served in FY13, which is a 16% decrease from FY12. This decrease can be attributed to

the closing of the Differential Response and Circle of Hope programs.

Outcomes are provided below for Intact Family Services and for Visitation Transportation.

Family Preservation

Goals TargetIntactFamily

Counseling

IntactFamiliesEastern

IntactFamiliesSouthern

A

IntactFamiliesSouthern

B

1. Families will not have aconfirmed abuse or neglectreport during the serviceperiod

85% 80% 94% 87% 90%

2. Families remain togetherduring service period.

90% 95% 96% 93% 90%

3. Families discharged from theFamily Preservation programwill show an overallimprovement between initialand closing CANS.

80% 90% 89% N/A N/A

Visitation TransportationGoals Target % Achieved

1. Families will not have additionalindicated reports of abuse or neglectduring the service period.

90% 100%

2. Cases shall be terminatedsuccessfully when returned home ormeets permanency.

85% 52%


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Across all programs and all areas measured, the Family Preservation programs achieved a 90%

Compliance & Quality Rating, which meets the agencys target. Intact Family Counseling and

Visitation Transportation exceeded the target in all areas measured and scored overall Compliance &

Quality ratings of 95% and 96%, respectively. Intact Families Southern did not achieve the target in

Closing (86%); however all other areas measured exceeded the target and the program scored anoverall Compliance & Quality rating of 92%. Intact Families Eastern is the only program that did not

achieve the agencys 90% target. All areas measured were below the agencys target. Overall, the

program scored a 78% Compliance & Quality rating.






Intact Families Eastern

Intake (88%)

Are the Clients' Rights and Responsibilities in the record signed by all relevant parties? (2/11) Is there a Case Action Form in the record documenting date of opening, transitions and

closing? (2/11)

Assessment (82%)

DASA Screen on all relevant household members (2/3)

Was the Initial Assessment Report completed within the required timeframe of the program

contract? (3/11)

Was a CERAP completed within 5 working days of case opening? (2/6)

Was the Home Safety Checklist completed within 30 days of case opening? (2/6)


PlanServiceDelivery

Closing Overall

Intact Family Counseling 94% 95% 100% 93% 100% 95%

Intact Families Eastern 88% 82% 69% 76% 78%Intact Families Southern 92% 91% 92% 93% 86% 92%

Visitation Transportation 89% 100% 100% 100% 96%

Target 90% 90% 90% 90% 90% 90%

All Programs 91% 90% 88% 90% 89% 90%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Family Preservation


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Was the familys comprehensive service plan completed within 30 days of case opening? (3/6)

Is there evidence that the initial CANS was completed? (2/3)


Manager/therapist and supervisor within the required timeframe of the program contract?(4/11)

Is the current service/treatment/case plan signed and dated by the client and parent/guardian?

(4/11)

Service Delivery (76%)

Did the caseworker visit the child (ren) in the intact family home weekly during the first 45

days after the case was opened? (3/3)

Did the Intact Family Case Manager maintain the required in-home face-to-face contacts with

the family? (2/6)

Intact Families SouthernClosing (86%)

Was a CANTS/LEADS check completed for all adult members of the household, youth age 13

and older, and all adults that are frequently in the home, prior to case closing? (1/1)

Was a Child/Family Team Meeting held for case closure? (1/1)

Visitation Transportation

Intake (89%)

Are the Clients' Rights and Responsibilities in the record signed by all relevant parties? (2/5)


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Appendix C Placement Highlights

The Hudelson Region operates three Placement programs including Foster Care, Specialized Foster

Care, and Residential services. Across the programs, 133 clients were served in FY13 which is an11% decrease from FY12. This decrease is primarily attributed to a decrease in the number of

referrals in Foster Care.

Outcomes are reported below by program.

Foster Care


1. Children will not be abused and/or neglected(an indicated report) by a substitutecaregiver while in foster care.

99.6% 100%

2. Children will achieve permanency within 24months of the child coming into care (allother permanencies outside of reunification).

32% 80%

3. Children will experience two or fewerplacement settings within a 12 month period.

95% 100%

4. Children who are reunified with their familieswill be reunified within 12 months of the childcoming into care.

46% 100%

5. Children will remain unified for a period of 6months without re-entry into foster care.

91% 100%

6. Clients discharged from the foster careprogram will show an overall improvement

between the initial and the closing CANSratings.

80% 100%

Specialized Foster Care


1. Children will not be abused and/or neglected(an indicated report) by a substitutecaregiver while in foster care.

99.6% 100%

2. Children will achieve permanency during thefiscal year.

20% 17%

3. Children will experience two or fewer

placement settings within a 12 month period.

85% 80%

4. Children will remain unified for a period of 6months without re-entry into foster care.

91% N/A

5. Clients discharged from the foster careprogram will show an overall improvementbetween the initial and the closing CANSratings.

80% 100%

6. Children will not require a higher level ofcare (i.e. psychiatric hospitalization orresidential care).

85% 92%


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Hudelson Residential


1. Youth served will not be subjects of

indicated reports of abuse or neglect whilephysically present in the residentialtreatment program.

95% 100%

2. Youth served will achieve and sustain apositive or neutral discharge placement for aperiod of 90 days following discharge

21.73% 33.33%

3. The treatment opportunity rates will beachieved.

94.49% 92.02%

Peer Record Reviews are reported below for Foster Care Services and the Residential program.

Across all programs and all areas measured, Foster Care services achieved an 87% Compliance &

Quality Rating, which is below the agencys 90% target. Specifically, across all programs Treatment

Planning (86%), Service Delivery (81%), and Closing (0%) were below the agencys target

(Specialized Foster Care is the only program that reviewed a Closed case). Foster Care Licensing is

the only program that exceeded the agencys target in all areas measured. Overall, Foster Care

Licensing achieved a 99% Compliance & Quality rating. Foster Care achieved an overall Compliance

& Quality rating of 82%. Treatment Planning was within 1% of the agencys target. Specialized Foster

Care achieved an overall Compliance & Quality rating of 72% with Assessment (95%) exceeding the

agencys 90% target.


PlanServiceDelivery Closing Overall

Foster Care 80% 81% 89% 82% 82%

Foster Care Licensing 99% 100% 100% 99%

Specialized Foster Care 68% 95% 78% 73% 0% 72%

Target 90% 90% 90% 90% 90% 90%

All Programs 95% 95% 86% 81% 0% 87%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Placement - Foster Care Services


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Overall, the Hudelson Residential program achieved a 94% Compliance & Quality rating. All areas,

with the exception of Closing, exceeded the agencys target. Closing is an area of opportunity for the

Residential program in FY14.






Foster Care

Intake (80%)

Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (3/8)

Assessment (81%)

Was the Initial Assessment Report completed within the required timeframe of the program

contract? (3/8)



(5/8)Service Delivery (82%)

Did the initial Family Meeting occur within 48 hours of case assignment (with Supervisor

present)? (5/8)

Did the current Case Manager achieve or attempt face to face contact with the biological

family within five working days after case assignment? (3/8)

Did the Case Manager meet weekly with the child in substitute care for the first month

following initial placement or change in placement? (3/8)

For the past 6 months: Are there monthly supervision notes in the case record? (3/8)


PlanServiceDelivery

Closing Overall

RTx 96% 95% 96% 94% 46% 94%

Target 90% 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Placement - Residential


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Specialized Foster Care

Intake (68%)

Is there a Case Action Form in the record documenting date of opening, transitions and

closing? (2/5) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (2/5)

Are the Release of Information Forms current (within 1 year) for correspondence with ALL

entities outside of the agency? (2/5)



(3/4)

Service Delivery (73%)

Case note documentation reflects the level of client contact per program requirements? (3/5)

Did the current Case Manager achieve or attempt face to face contact with the biological

family within five working days after case assignment? (3/4) Did the second Family Meeting occur during the first 35 days of case assignment? (3/4)

Did Child and Family Team meetings occur quarterly? (3/4)

Closing (0%)

Is the Closing Summary in the record? (1/1)

Residential

Closing (46%)

Does the record contain documentation of an aftercare plan completed with and signed by the

client or a reason why an aftercare plan was not needed? (2/2)

If follow-up services were necessary, did the Closing Summary contain a formalized After

Care Plan (when appropriate), signed by the client, parent/guardian, Case Manager and

supervisor? (2/2)


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Appendix D Prevention Highlights

The Hudelson Region operates five Prevention programs. Across the 5 programs, 375 clients were

served in FY13 which is a 30% decrease from FY12. The decrease can be attributed to the closing ofthe Supporting Student Stability Program, and 2 Education Works programs. There was also a

decrease in the number of clients served in the Family Support Services program.

Outcomes for Prevention Programs are shown below by program.

Adoptive Family Support


1. No substantiated reports of abuse or neglect 90% 100%

2. Families will remain intact during the serviceperiod.

95% 100%

3. Families served will show an improvement inperceived stress at completion of services asmeasured by the Caregiver StrainQuestionnaire.

90% 100%

Family Support & Supplemental Services

Goals Target FSSSupplemental

Services

1. No reports of abuse or neglect during theservice period

90% 95% 100%

2. Families will remain intact. 90% 95% 100%

3. Families will maintain stability or showimprovement in the domain of overallenvironment as measured by the NCFAS.

70% 75% 96%

4. Families will maintain stability or showimprovement in the domain of overallparenting capabilities as measured by theNCFAS.

70% 50% 96%5. Families will maintain stability or show

improvement in the domain of overall familyinteractions as measured by the NCFAS.


improvement in the domain of overall safety

as measured by the NCFAS.


improvement in the domain of overall child-well-being as measured by the NCFAS.

70% 50% 96%


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Foster Grandparent

Goals Target Mt. Vernon Springfield

1. Foster Grandparent Volunteers will score a 5or below on the Mood Assessment Scale

(short form) on a bi-annual basis.

90% 89% 97%

2. Foster Grandparent Volunteers who respondto the survey will report that participating inthe program has improved the overall qualityof their life as surveyed on an annual basis.

90% 100% 100%

3. Foster Grandparent volunteer sites willreport that they are satisfied with FosterGrandparent Volunteers over-all ability toperform tasks with individual children and/orgroups of children as assigned by the sitesupervisor.

70% 94% 100%

4. Children receiving one on one mentoring

and/or tutoring by a Foster GrandparentVolunteer will achieve academic, social, andbehavioral goal(s) indicated on the individualchildcare plans.

70% 94% 100%


Across all programs and all areas measured, Prevention programs achieved a 98% Compliance &

Quality rating, while exceeding the agencys target in all phases of the case life cycle.


PlanServiceDelivery

Closing Overall

Adoptitve Family Support 95% 100% 100% 100% 100% 99%

Foster Grandparent-Mt.Vernon 99% 100% 90% 100% 99%

Foster Grandparent-Springfield 100% 100% 100% 100% 100%

FSS 94% 91% 100% 96% 96% 95%Supplemental Services 94% 100% 100% 100% 100% 99%

Target 90% 90% 90% 90% 90% 90%

All Programs 99% 99% 98% 98% 97% 98%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Prevention


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Appendix E Youth Services Highlights

The Hudelson Region operates several Youth Services programs throughout the region; including

CCBYS, FFT, MST, SASS, and the Youth Diversion Program (YDP). Across all programs, 762 clientswere served in FY13 which is a 5% decrease from FY12. Youth Services accounts for 43% of clients

served in the region.

Outcomes are reported below by program.

Youth Services: CCBYS

Goals TargetCCBYS

(All)

1. Youth served will not besubjects of indicated reports of

abuse or neglect during theservice period.

90% 97%

2. Youth will be maintained in ahome like setting.

90% 93%

3. Youth will be deflected fromfurther involvement in the

juvenile justice system90% 99%

4. Youth will remain in school,alternative education,vocational training or employed

90% 94%

Youth Services: FFT

Goals TargetFTS FFT

FFT -Madison

FFT -Missouri

1. Youth served will not besubjects of indicated reportsof abuse or neglect duringthe service period.

90% 100% 100% 100%

2. Youth will be maintained ina home like setting.

80% 67% 71% 84%

3. Youth will be deflected fromfurther involvement in the

juvenile justice system

80% 100% 57% 88%

4. Youth will remain in school,alternative education,vocational training oremployed

80% 100% 86% 92%


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Youth Services: MST & YDP

Goals TargetFTS MST

MST 4thCircuit

MST Redeploy

YDP

1. Youth served will not besubjects of indicatedreports of abuse orneglect during the serviceperiod.

90% 50% 100% 100% 100%

2. Youth will be maintainedin a home like setting.

70% 50% 71% 95% 100%

3. Youth will be deflectedfrom further involvementin the juvenile justicesystem

70% 50% 71% 95% 92%

4. Youth will remain in

school, alternativeeducation, vocationaltraining or employed

70% 50% 71% 90% 96%

Youth Services: SASS


1. Youth will remain in a homelike setting or least restrictivesetting at time of discharge.

90% 98%

2. Youth who completed serviceswill improve or maintain theirCSPI score from initial screento closing scree.

85% 92%

3. Youth will decrease their riskbehaviors as evidenced by areduction in the risk behaviordomain on the CSPI at thetime of discharge.

85% 92%

Peer Reviews are reported in the four graphs below based on program level and/or program.


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There are three offices that implement CCBYS services. Across all offices a 95% Compliance &

Quality rating was achieved. All areas across the case life cycle met or exceeded the agencys 90%

target. CCBYS Effingham achieved a 98% Compliance & Quality rating and met or exceeded the

target across all areas measured. CCBYS Mt. Vernon achieved a 95% Compliance & Quality rating,

with Closing (80%) being the only area to not meet the agencys target. CBBYS Olney achieved a

93% Compliance & Quality rating with Treatment Planning (83%) being the only are to not meet the

target.

There are three FFT programs in Hudelson. Across all three programs a 98% Compliance & Quality

rating was achieved. All areas across the case life cycle exceeded the agencys 90% target.

FTS FFT achieved a 100% Compliance & Quality rating. FFT Madison Co Redeploy achieved a

99% Compliance & Quality rating. All areas measured exceeded the agencys target with Intake,

Treatment Planning, Service Delivery, and Closing all achieving a 100% Compliance & Quality rating.

FFT Missouri achieved a 95% Compliance & Quality rating with all areas measured meeting or


PlanServiceDelivery

Closing Overall

CCBYS-Effingham 100% 90% 96% 100% 100% 98%

CCBYS-Mt.Vernon 100% 95% 93% 96% 80% 95%

CCBYS-Olney 93% 91% 83% 100% 100% 93%

Target 90% 90% 90% 90% 90% 90%

All Programs 97% 93% 90% 98% 90% 95%

0%

20%

40%60%

80%

100%

Compliance & Quality: Youth Services - CCBYS


PlanServiceDelivery

Closing Overall

FFT-Madison Co Redeploy 100% 91% 100% 100% 100% 99%

FFT-Missouri 90% 100% 100% 95% 100% 95%FTS-FFT 100% 100% 100% 100% 100% 100%

Target 90% 90% 90% 90% 90% 90%

All Programs 96% 97% 100% 98% 100% 98%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Youth Services - FFT


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exceeding the agencys target. Assessment, Treatment Planning, and Closing all achieved a 100%

Compliance & Quality rating.

There are three MST programs and 1 Youth Diversion program in Hudelson. Across all four programs

a 98% Compliance & Quality rating was achieved. All areas across the case life cycle exceeded the

agencys 90% target. FTS MST achieved a 100% Compliance & Quality rating. MST Redeploy

achieved a 99% Compliance & Quality rating. All areas measured exceeded the agencys target with

Assessment, Treatment Planning, Service Delivery, and Closing all achieving a 100% Compliance &

Quality rating. MST 4th Circuit Redeploy achieved a 98% Compliance & Quality rating with all areasmeasured meeting or exceeding the agencys target. Assessment, Treatment Planning Service

Delivery, and Closing all achieved a 100% Compliance & Quality rating. The Youth Diversion

Program achieved a 96% Compliance & Quality rating. Closing (83%) is the only area that is below

the agencys target.


PlanServiceDelivery

Closing Overall

FTS-MST 100% 100% 100% 100% 100% 100%

MST-4th Circuit Redeploy 92% 100% 100% 100% 100% 98%

MST-Redeploy 95% 100% 100% 100% 100% 99%YDP 95% 100% 97% 96% 83% 96%

Target 90% 90% 90% 90% 90% 90%

All Programs 95% 100% 99% 98% 91% 98%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Youth Services: MST & YDP


PlanServiceDelivery

Closing Overall

SASS-Effingham 97% 92% 95% 93% 81% 93%

SASS-Mt.Vernon 91% 93% 91% 90% 70% 91%

Target 90% 90% 90% 90% 90% 90%

All Programs 94% 93% 93% 91% 75% 92%

0%

20%

40%

60%80%

100%

Compliance & Quality: Youth Services - SASS


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There are two offices that implement SASS services. Combined, both offices achieved a 92%

Compliance & Quality rating. All areas across the case life cycle, with the exception of Closing (75%),

exceeded the agencys 90% target. SASS Effingham achieved a 93% Compliance & Quality rating.

Closing (81%) was within 9% of the agencys target. SASS Mt. Vernon achieved a 91% Compliance& Quality rating. Closing (70%) was within 20% of the agencys target.






CCBYS-Mt. Vernon

Closing (80%)

Did the Case Manager participate with the client/family in determining if any follow-up services

were necessary? (1/2)


Care Plan (when appropriate), signed by the client, parent/guardian, caseworker and

supervisor? (1/2)

CCBYS-Olney




YDP

Closing (83%)

Does the record contain documentation of an aftercare plan completed with and signed by the

client or a reason why an aftercare plan was not needed? (1/2)


Care Plan (when appropriate), signed by the client, parent/guardian, caseworker and

supervisor? (1/1)

SASS-Effingham

Closing (81%) In preparing for termination, was the need for follow up/aftercare services determined with the

client/family? (3/7)

SASS-Mt. Vernon

Closing (70%)

Is the Closing Summary in the record? (2/4)

one hope united 2013 cqir annual report - hudelson region

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