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Nova
House Association, Inc.
Fourth
Quarter 2007
Quality
Assurance/Quality Improvement
Prepared
by: Jeannie
Motley BS, LICDC, NCAC 11
Clinical
Director
Introduction:
Per
the Board of Trustees were made aware of the
following performance improvement information as
per ODADA Standards the following report is being
submitted. Copies
will be sent to those funding boards, which
require reporting QA and QI activities.
This report represents quality assurance
for the months of April, May, and up to the 15th
day of June 2006.
Completeness of
Records
Fourth
quarter Findings:
The
Quality Assurance Trainer reviews 100% if all open
charts each quarter in all units.
The unit supervisors and trainers reviewed
100% of the charts weekly.
All in-house audits are evaluated on the
standards by ODADAS in all areas.
The areas evaluated were:
Accurate Documentation,
Appropriate
TX
plan, and Services Authorized in the Outpatient
Unit.
Accurate
Documentation:
Quality Assurance found this area to be in
100% compliance.
Appropriate
TX Plan:
Quality Assurance found this area to be in
100% compliance.
Services
Authorized:
Quality Assurance found this area to be in
100% compliance.
Compliance:
The internal audit resulted in an average
of 100% compliance in all the above
areas.
The peer review team review 5% of the
complete audit and found the unit to be in 100% of
compliance in these areas also.
Plan
of Action/Correction:
Reports are given to counselors and unit
supervisors. Staff
is to correct areas within 30 days and have
supervisors sign off on review sheets from both
audits.
Clinical
Director is made aware of any area that is below
the 80% compliance goal by peer review and Quality
Assurance auditor.
Independent
Peer Review:
4th
Quarter Findings:
Reviewer:
Willie Scales, LICDC
Findings:
Five charts are randomly chosen from units
each month of the quarter.
The completed peer review forms were
evaluated after peer review to calculate the
percentage of quality factors, which met ODADAS
standards.
April:
100% of charts reviewed were in compliance.
May:
100% of charts reviewed were in compliance.
June:
This review has not taken because
scheduling is usually at the last week in the month.
Recommendations
from the previous independent peer review:
No recommendations were noted.
Plan of
Action: Review
will be presented to Board of Trustees during
annual meeting.
Utilization
Review:
Per
ODADAS utilization review must include a review of
the appropriateness of admission, continued stay,
waiting list, discharge and trend and patterns of
the use of the program services.
Ninety
percent of referrals to Nova House come from
Montgomery
County
’s, central intake and screening facility Crisis
Care. The
determination of appropriateness for referrals to
any of Nova House unit is determined by agency’s
appropriate staff/supervisor review with a
signature and with a confirmations interview prior
to admittance.
SOP
productivity level out to 77% from second quarter
of 85% and 129% in third quarter.
The Residential Units requests dropped
within the fourth quarter to making only 1 request
pasted the 90 days stay.
There was a drastic decline in referrals to
Halfway house.
Waiting
List:
Residential
Programs involving identification of pregnant
women, intravenous drug users, and non-emergency
status clients and clients with medical and/or
psychiatric emergencies as per ODADAS 3793:
2-01-04
is maintained at the front as a referral logbook.
Maintaining contact, removal from waiting
list and procedures for notifying referral sources
of client’s waiting list status is given
verbally to clients during sign in.
Signature denotes information received with
authorization of release, if applicable.
The
waiting list served 88 unduplicated individuals
from January until June 15th.
Out of these unduplicated individuals 53%
were admitted to the residential programs.
This amount is possible higher since it
does not take into account individuals that
received a bed date and no showed for entrance.
Trends
and Patterns:
Chart
below addresses trend and pattern of initial
contact for SOP.
The plateau of productivity
for outpatient appears to have leveled off
to 77% from 2nd and 3rd
quarter. IDDT approvals for continued stay showed
a trend from 3 days to a maximum 30 days.
The most drastic trend noted was the
referrals to the Halfway House during the 2nd
and 3rd quarter from referral source
that shows a direct effect on productivity.
Initial
contact for SOP:
|
|
March
|
April
|
May
|
|
Referrals
|
43
|
41
|
55
|
|
|
|
|
|
|
Within
7 days
|
21
|
10
|
15
|
|
Percentage
|
49%
|
24%
|
27%
|
|
|
|
|
|
|
No
shows
|
22
|
21
|
20
|
|
Percentage
|
51%
|
51%
|
36%
|
Halfway
House Referrals
|
|
JUL
|
AUG
|
SEP
|
OCT
|
NOV
|
DEC
|
JAN
|
FEB
|
MAR
|
APR
|
|
REF
|
12
|
8
|
5
|
16
|
6
|
13
|
13
|
12
|
6
|
4
|
Program
Evaluation:
The AOD
programs of Nova House have implemented the
evidence-based practices of cognitive behavior
approaches within treatment.
This treatment approach will be monitored
by the peer review of documentation in charts. AOD
has entry, mid-treatment, and exit survey for
persons served and SASSI.
Per
ODMH 5122-23-03 (C) (1) the IDDT unit has
implemented evidence-based practices of cognitive
behavior approaches.
The SAMI CCOE consultant will monitor the
IDDT model to meet fidelity and quality
improvement of model.
IDDT model will use the Ohio Scale Survey
and Stages of Change Readiness and Treatment
Eagerness Scale to monitor performance.
Agency
sent out annual survey to consumers.
Responses were reviewed and analyzed by
Performance Improvement committee and presented to
agency Directors and Executive Director.
MUI:
Agency
reported no major unusual incidents report this
quarter.
Risk
Management:
Per ODADDS meetings are held with members of the
governing body (Board of Trustees).
Financial by (Brad Wainwright), Internal
Quality Assurance, Hazardous Working/Safety
Conditions by (Lynette Davis); Major/unusual
Incidents, Sexual/Physical Abuse, and Death/Injury
to client or staff, by (Shelia Morgan
(nurse)/Jeannie Motley/Dr. David Long).
Risk
Management
Plan
Agency
financial status
Agency’s financial status was presented
to the Board of Directors.
Plan
of Action/correction
Board of Directors had Executive Director,
Financial Director, and Clinical
Director meet with
ADAMHSB for proposal for assistance.
Quality
Improvement: AOD/MH
A.
Access to care:
Initial
contact for SOP:
The trend stay consistent with initial
contact for SOP in March and April and dropped in
May with a lower count of no shows.
Residential
Waiting List:
Residential had 53% of waiting list to
enter treatment.
Possible higher since unduplicated names
did not reflect individuals that were given a bed
date and no showed.
IDDT
model: The
allotted time for continued stay will determine
access to treatment.
Peer
Review:
Will
serve as monitor for maintaining ODDADS
regulations for compliance for AOD and monitoring
documentation for cognitive behavioral approaches.
The
CPST team for IDDT model with the CCOE consultant
will monitor the IDDT model for meeting fidelity.
Utilization
Review:
The
quality improvement committee determined that
appropriateness of referrals drastically effected
entrance into the Halfway House.
Extenuating factors were determined to be
referrals and the criteria/diagnosis present on
assessment, no show, and inability to have
community linkage for medication, if applicable.
Nova House supervisors attended the
staffing for Crisis Care and presented all needed
information and criteria in January so as to keep
staff aware of changes.
Informed staff of no longer a 90 day
waiting period before returning for admittance, it
is now 30 days unless otherwise being reviewed by
supervision. IDDT
CPST noticed continued stay allotment dropped in 3rd
quarter to minimum 3 to 30 days.
Continuity
of Care:
AOD
The
peer review/supervisors/clinical director
will monitor the AOD programs for
continuity of care.
MH
The
IDDT CPST team within Nova House and CCOE
consultant will monitor the continuity of care for
the IDDT model and
fidelity.
Report will be submitted to the Executive
director.
Major
Unusual Incidents:
None
noted. Implementation
of the 333-COPS helped defrayed any financial cost
to agency for calling a ambulance.
Involuntary
Terminations:
Were
at 15%. Extenuating
factors were client choice/ability to delay beyond
threshold and inappropriate
referrals.
All
quality improvements will be done in the PDCA
format under the Performance Improvement Plan of
CARF. Nova
House will electronically submit quarterly reports
to ADAMHS and submit hard copy within 5 days.
This submission is coming in hard copy
first due to computer problems.
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