This is an Outcome Measurement and Management Report. It has been prepared by the members of the Quality Services Department with input received from each division of the organization, those who use us for services and a variety of other stakeholders. In year’s past, this document was titled the Administrative Program Review. The topic list for review was derived from those reports and from the 2010 CARF Standards Manual. This report will seek to define the following objectives:

  1. What progress has been made on the 2009 quality improvement plan, the CARF QIP, and the 2009 Accessibility Plan?
  2. Determine the 2010 Accessibility Plan.
  3. Devise a plan of correction for any areas that can be addressed by continuous quality improvement.

 

Much of the data for this report came to light toward the latter half of 2009 when the organization experienced a change in leadership. During the last five months of that year and the first six months of this year, we have had to concentrate on that transition at the same time that we were experiencing numerous financial constraints being imposed on us by OMRDD, now referred to as OPWDD. A number of our internal procedures such as trending family and individual complaints lapsed but are now back on track for monitoring. Despite the difficulties of managing the JRC, the reader will glean that we have continued to achieve much progress towards better service.

Report Format

As raw data was gathered, it was analyzed into an Update that was sent to each member of the Management Team. Each update represented one of the topics. A large amount of data has been collected but will not be duplicated again in this report. Anyone who wishes to view an update can make such a request to Quality Services.

Positive Practices

  1. Seamless transition from one Executive Director to the next at a critical time in New York State as the economic conditions tightens.
  2. The organization continues to receive much state-wide recognition for our self advocacy efforts. As the Executive Assistant to SANYS says “the JRC gets it when it comes to bringing in those being served to facilitate the management of the organization.”
  3. MHLS comes on site to inspect our Non-Incident Process, an audit of 50 cases. The JRC is described as “You are the A-team for following agency procedure and follow-up.”
  4. Human Resources/Staff Development hold a first ever Staff Development Day on post for the Ft. Drum contact employees. This allowed them to catch up past due trainings and made better use of their time, instead of trying to schedule via the in-service calendar.
  5. More sites are linked up electronically to the agency as we make progress on our system. This improves communication by making it quicker and serves to eliminate problems associated with the inter-agency mail system. This also allows us to move closer to a paperless operation.
  6. Another JRC individual was elected as a representative of the Northern Region of SANYS.
  7. The North Country Self Advocates has grown to approximately 37 members as a result of the support provided by the JRC. This group is not only participants from agency programs but includes those from other provider agencies and at-large. Their agenda is their own, not one designed by the JRC.
  8. Obtained the Day Care license which creates more opportunities for staff and the organization, as well as meets on-going needs in the larger community for affordable child care.
  9. Finding new ways to recognize staff such as the coins, PRIDE campaign, and the newsletter. This is an outcome of the recent Strategic Plan and is viewed as a retention strategy.
  10. Added new persons (7) to the EDD rotation as a way to recognize their dedication to the organization and to bring them into the “fold” of the Management Team. This is a retention strategy.

 

Self-Advocacy: “one of the best self advocates that I know”

Self Advocacy at the JRC is presented on a continuum that allows for as much involvement as the program participant can effectively use or want. It begins on the treatment team level, moves on to an Advisory Board, and extends beyond the confines of the JRC to the North Country Self Advocates, a non-affiliated and independent group located in Watertown, that receives logistical support from the agency to operate. This sponsorship includes support for transportation (driver and vehicle) and the use of a liaison, who is a staff member from Quality Services. Additional supports are provided for medication administration, preparing them to speak publically, and how to conduct themselves in such a way as to be received favorably. The JRC has received a great deal of state-wide recognition for this area. It is resulting in the appointment of a person with disabilities to the agency’s Board of Directors in the fall of 2010. The quote above appeared in a state-wide brochure from NYSARC as a description of this man who is being asked to join our Board.

There are no recommendations for this area.

Outcome Measurement and Summary

We are using two primary means to evaluate agency performance, improvement planning and departmental objectives. There are a number of quality improvement plans (QIP) that are managed throughout the year by departments and by the Management, with a measurement that indicates if the objectives met the stated purpose.

¨      CARF QIP: 22 objectives, 78% met.

¨      2009 Performance Analysis QIP: 17 objectives, 82% met.

¨      Individualized Residential Alternative QIP: 5 objectives, 60% met.

¨      Intermediate Care Facilities QIP: 5 objectives, 60% met.

¨      Case Management QIP: 5 objectives, 89% met.

¨      Day Treatment QIP: 4 objectives, 64% met.

¨      Day Habilitation QIP: 12 objectives, 89% met.

¨      EI/Preschool QIP: 4 objectives, 75% met.

¨      Work Training QIP: 10 objectives, 84% met.

¨      Career Connections QIP: 5 objectives, 80% met.

Total average of departmental measurements: 75%

¨      2009 Accessibility Plan: 17 objectives, 82% met.

¨      Quality Services Corporate Compliance Work Plan: 23 objectives, 96% met.

¨      Departmental Objectives: 34 objectives, 56% met or exceeded the desired measurement.

            Note: separate reports on the agency’s performance to the departmental objectives are       sent annually to the Jefferson County Community Services Board, a report is posted on       our web site, and copies are sent to the Advisory Boards.

Total average of all measures: 78%

There are no recommendations in this area.

Health and Safety Planning

There were two primary areas of concern in this topic that we have addressed very well.

A. Fire Prevention:

A fire at a residential facility in Wells, NY, that resulted in a number of deaths, prompted OPWDD to engage providers in a number of initiatives that fell outside of the traditional regulations and are listed as recommendations that are citable. We met these initiatives in this manner:

  • Have begun to invite “in” Fire Departments to inspect and review our procedures. As an example, we have moved a number of the points of safety.
  • All fire drill forms have been revised to include new data points such as when did the last person arrive at the point of safety.
  • A survey was conducted with the Residential Sites to solicit their concerns, detail problems, and ask for input to make fire evacuation better.
  • Had all of our sites that had sprinklers in the attic inspected for antifreeze.
  • Have increased staff training and awareness in the programs.
  • Implemented a building-wide fire drill evacuation from and dismissal of the main Gaffney Drive building in June. This drill was implemented with the Watertown City Fire Department on hand and included the first ever dismissal of a large number of individuals from the Preschool program home.
  • Have responded to citations from OPWDD by adding these issues to either the Quality Services Quarterly Site Visit form or the Pre-OPWDD Process forms to ensure that we are maintaining the changes to fire protection.

 

B. The ‘flu’:

With concerns over the impact of the H1N1 virus, the Nursing Department created the first ever Pandemic Influenza Plan, designed to control the spread of these diseases, safeguard persons served and staff in our programs, and maximize our funding streams against the loss of units of service due to participant absences. The Plan included regular updates to the staff, clinics for vaccines, installation of hand sanitizers in all buildings, and training. The results exceeded our expectations. Very few persons contracted the disease, or were hospitalized, and we were able to capture most of the lost funding by creating a plan to send day program staff to residences to provide as many of the day services as possible, typically in Day Treatment or Day Habilitation; this plan involved an understanding with Medicaid for the concept of exceptions to where day services are typically provided. We were able to capture in excess of $5,000 that other wise would have been lost.

C:  “Slip and Fall”

This year marked a departure from our past performance when we were challenged to create a plan to deal with our loss-time accidents of the employees. As a result, an Accident Reduction Plan was created by the Human Resources Department and Quality Services that included two in-service trainings, one for all staff and another for supervisors, daily inspections of all sites, and monthly trending of all accidents. It took six months to have all supervisors participate and we were never able to have everyone using the most current inspection form (revised in January 2010), but the goal to reduce time-loss accidents by 10% was achieved.

Recommendation:

v  The slip and fall form should be revised for implementation in January 2011 based on the total accident report of 2010.

Outside Inspections

Throughout the year, various sites were inspected by an ‘outside’ source. These included insurance companies, Dept. of Health, a sprinkler company, local fire departments, etc. Findings were forward to Quality Services for monitoring and were incorporated into operations as needed.

There are no recommendations in this area.

Responding to Input

This is another of the CARF Standards that over time, we have embraced rather well and it has produced many results throughout the organization.  Our primary venue for input has been the persons served either at a treatment team level or from their Advisory Boards. Our staff is continuously solicited to express their views on all agency matters. The Employee Advisory Committee, made up of elected representatives, is their main spokesperson. Over the years, this group has earned much respect and creditability for how well they conduct their meetings and themselves. Below are a few examples of how the agency has responded to input.

From Individuals:

  • The Self Advocacy Consultant met with the DT/DH Administrator to ask for support with eliminating the “R” word. She agrees to change the job title of QMRP to Human Service Professional.
  • The North Country Self Advocates were asked to meet and draft their input for the upcoming Strategic Planning Process. They did so on 3/31/10 with 27 persons in attendance. They mentioned such items as not having staff react too quickly with ‘hands on’, that staff lack patience, and that they do not understand how to report poor staff behavior such as smoking in vans. The Liaison conveyed this in a memorandum to the Executive Director.
  • Individuals from the Day Treatment and Day Habilitation Advisory Boards requested additional agency support in the form of more vehicles for inclusion. The agency has responded by applying for a grant to purchase new buses and more mini-vans have been purchased.

 

From Families:

  • The Program Coordinator created a new satisfaction survey for their input to ask them to evaluate their satisfaction with the Medicaid Service Coordinators.
  • The Director of Administrative Services creates a questionnaire mailing this to 140 families for their input. The results will be used to create a Family Support Group.

 

From Staff:

The Employee Advisory Committee was asked to respond to changes in the following issues:

  • Dress code. Nose studs approved but not tongue piercings.
  • Bereavement Policy. New policy.
  • Combining Floating Holidays with Personal into Vacation. Being studied by HR.
  • Parking in main Gaffney. Supported changes to the slots being set aside for parents.
  • Sick bank policy. A policy is being developed by Human Resources.
  • Cell phone use. New policy however staff can use cell phones when on break or lunch.
  • On Call pay:  The first team of investigators was getting paid for their week of on call. Now both teams receive this pay.

 

There are no recommendations.

Critical Events

Data was collected on three areas of concern that are typical to the field of disability services, one defined by CARF (sentinel), one by the JRC (non-reportable), and one by OPWDD (incidents). At the JRC, all of these concerns are processed on the same form, the Written Preliminary Findings Form. One of the reasons for this form is to make it easier to capture this data at year-end. Many of the categories that appear on the top of the form are required for monitoring by CARF.

Sentinel Events are defined in the CARF Standards manual as an “unexpected occurrence that results in death or serious physical or psychological injury.” Therefore, we had no events that met this criterion. There were 5 events, all fires that did possess the potential to meet this definition.

  • In May 2009, fire broke out in the kitchen of ICF 1 when a glass container with a cake inside of it was placed on a hot stove burner. No Written Prelim was completed until the following September.
  • In June 2009, the Breen Ave. IRA had 3 fires: on separate occasions a doughnut box, a lunch box, and a dish cloth were left on a hot stove burner. These events should have been reported as separate events.
  • In June 2009, a fire was reported at the Adams IRA and the process was followed; however it was subsequently determined that no fire actually took place, but rather, the cause of the smoke was from an outside source. The alarms were activated but the house did not evacuate.

 

Non-reportable Events are those events that do not initially appear to be serious enough to be classified as incidents. Both the form and this process have been revised several times to make the process easier to understand and to complete. Often, staff “read” too much into this and provide far more details than are necessary to explain the event. Or, they fail to “close the loop” on documenting the event with a follow-up memo to the Executive Director’s office when all facts are known by the 15th day. In 2009, there were 95 events processed in this manner, up less than 4% from the year before. Upon further investigation, 5 events were reclassified as allegations of abuse (2) or reportable incidents (3). In 2010 the category of ‘negative x-ray’ was removed. This should reduce the number of these events. This change was in fact prompted by OPWDD. Many issues that were previously reported on as either a non-reportable or even an incident can now remain on the Minor Injury Logs. See below however….

Incidents can be either a reportable, serious reportable, or an allegation of abuse. These are trended for an OPWDD regulation. We did not complete that process for the 2008 incidents as timely as in the past; it was competed on 9/17/09 with a copy forwarded to the Management Team and the Board of Directors. The 2009 incidents were trended in a report issued on 2/24/10. Due to a number of changes to the SRC and how data is being sorted it is difficult to make comparisons to previous years. These are the noteworthy trends:

  • The number of incidents fell (8%) from 2008 to 2009.
  • The number of allegations of abuse fell by 31%.
  • There were 31% fewer falls.
  • Anyone assigned to a rotation as an Investigator, Administrator-on-Call, or Executive Director Designee were provided with several in-service trainings. These included changes to the Part 624 regulations, recent trends in our reporting, and recent changes to our procedures.
  • Whenever staff turn-over of the Investigators or the EDD took place, new hires were trained on these duties and assigned to a co-worker with experience for mentoring.

 

A review of how long it takes each department to have their packets ‘closed’ by the SRC indicates that the average range is 17-62 days. Days-to-Close:

            IRA     58                    ICF      17                    Case Management       35

            DT       21                    DH      34                    Preschool                     27

            Wk.Tr. 25                    Career  62

 

Departmental average: 34

Recommendation:

v  Reduce the average number of days to close the 2011 incidents by 15%. Using the SRC Monitoring Chart, a report will be developed to highlight how a packet is being held up from closure.

Service Access and Characteristics of those served

Those with developmental disabilities continue to be the primary focus of our service delivery system. It is Mission-based. During this past year, the program administrators have attempted to manage their units of service by filling openings as quickly as possible. These openings are discussed often in the Management Team process. The majority of openings is in Waiver service models and has come under increasing constraints by OPWDD on a state-wide level or at the Sunmount-level as a means of limiting access to Medicaid-based services. Additionally, in our state, residential openings are subject to a 5-county search in an attempt to provide placement to those in a most critical need, such as having no residence or in an abusive situation. Many individuals and their families can also exercise the right of refusal to placement. Whenever possible, we attempt to meet an existing need from a participant already receiving services from us. Those placements are the result of problems associated with their health or their ability to self-evacuate in the event of a fire.

During 2009, the Admission and Discharge Committee processed 112 referrals for service. Of these, 17 were accepted; 56 had needs that we could not meet. Mild MR was the most common referral. The largest group of referrals came from an age group of 0-21 years old.

There are no recommendations in this area.

Business Functions

  • Accounting has made additional progress on creating efficiencies for reporting on hours worked with E-time.
  • The IT Group has been very busy this year with the continuation of linking up all sites, securing a new telephone system, and moving towards an electronic casefile system.
  • Purchasing created a very successful Freight Quote Review process that has saved much money. In 2008 these costs were $68,000 and to-date in 2010 these are $18,000.

 

There are no recommendations in this area.

Strategic Planning

A new plan was developed in the beginning of 2010. Areas of concentration include becoming the employer of choice, increase community awareness of who the JRC is, responding to a changing service environment, and promoting new efficiencies as a means of maximizing our resources. This management technique involves a wide variety of stakeholders including those who use services and the community. A review of the Mission and Values indicated that no changes were necessary. Two areas of concern are a lack of measurable objectives by each work group and that the group fails to met/work consistently to the end of the plan.

 

Recommendation:

v  The revisions to the old emergency plan were never finalized in the recent Strategic Plan. This remains an outstanding need from the CARF QIP. Staff and program participants have not been trained on it and there have not been annual tests of the process.

Satisfaction Surveys

These surveys include models for the visually impaired, Spanish speaking, persons who respond to symbols better than words, and models whereby the staff who know the person best assist them to answer. Surveys are typically done once a year at a team meeting. Other surveys are sent to family members, those who have been discharged, and groups in the community that the individuals access. Results of all of these are incorporated into the respective Program Review. Beginning in 2009, Quality Services returned to an old format of conducting a separate survey to validate the data collected in these other avenues. Satisfaction remains very high in all service models.

There are no recommendations.

Safety Committee

This was an area of concern from the previous CARF QIP in that our efforts were not maintained by involving those being served in the inspection process or in the area of conducting inspections on all shifts, especially on the over-night shift in the residences. Turnover in the Human Resources Department had impaired this process. By the end of 2010, our process should become realized and be able to produce more timely trending reports.

There are no recommendations.

Closing

Despite the on-going pressures of the economic conditions within the state and on the federal level, the evidence indicates that the Jefferson Rehabilitation Center was able to make progress on a number of areas as indicated by this report. We remain true to our Mission. We have saved money in a number of areas that can be used elsewhere for service enhancement and for the staff who seek what is best and what has become the ‘norm’ at this agency. We are ready for what comes next.