beconnected accreditation and you version 20.15 working together to maintain a successful...

BeConnected ACCREDITATION and YOU

Version 20.15

Working Together to Maintain a Successful Accreditation

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What is Accreditation?

• Accreditation is an ongoing process of improving services and supports to BeConnected’s “persons served.”

• Accreditation means meeting and exceeding international standards determined by CARF International.

• Accreditation means that BeConnected maintains contracts with Government Ministries and we all keep our jobs.

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Who is CARF?

• CARF is an international society located in Tucson, Arizona, with offices in both Edmonton and Ottawa.

• They research and write standards for various programs and services and then conduct site surveys at agencies like ours to check to see if we are meeting the standards.

• We selected them because they are user friendly and a good fit for our organization.

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Who is CARF?

Quiz:“CARF” stands for:(a) Capable Aardvarks Repairing Fences(b) Caring And Responsible Friendships(c) Commission on Accreditation of Rehabilitation Facilities(d) Canadian Accreditation of Residential Facilities

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How Does BeConnected Get Accredited?

• BeConnected maintains its accreditation as the result of a SURVEY visit by 2 or 3 trained CARF surveyors;

• Surveyors issue a report to CARF based on their visit to BeConnected Admin Offices (2!) and homes where they observe, review documentation, and interview persons served, families, employees and professionals about the quality of services being provided;

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How Does BeConnected Get Accredited?

• *Surveyors also provide consultation to BeConnected personnel.

• CARF reviews the survey findings and renders their decision. The decision can be either a three-year, a one-year, a provisional, or a non-accreditation.

• BeConnected earned a 1 year accreditation in 2005, a 3 year accreditation in 2006, 2009, and 2012; and is being revisited in May or June of 2015 for a fifth time. 6

CARF Survey 2012• BeConnected’s official CARF SURVEY REPORT

confirmed that we received NO RECOMMENDATIONS;

• We were surprised and delighted to read that CARF awarded BSS EXEMPLARY CONFORMANCE in the area of RIGHTS OF PERSONS SERVED;

• A letter addressed to Rhonda, from Brian Boon, President/CEO of CARF, stated in part, “Ms. Connell, please also be advised that the CARF surveyors made no recommendations… This is an extraordinary accomplishment, as only 3 percent of CARF surveys result in no recommendations.”

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CARF Survey 2012Some of BeConnected’s “STRENGTHS” as identified

in our 2012 CARF Survey Report include: • “BSS has an extremely passionate and deep commitment to

its mission, vision, purpose, and core values; to providing quality services; and to quality improvement. “

• “BSS has an extremely positive image and reputation in its service delivery area and is a respected and valued member of the community. “

• “Stakeholders express very high satisfaction with the organization’s performance and quality of services. BSS is held in very high regard by resource people in the community.”

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CARF Survey 2012

• “BSS is recognized for its outstanding services to a very difficult population.”

• “Families consistently expressed appreciation for the opportunities afforded through the services provided.”

• “Throughout the organization the sense of teamwork is strong and evident in ways such as interaction, respect, communication, and dedication.”

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CARF Survey 2012

• “Staff members are competent, motivated, responsive, passionate, and enthusiastic about the services delivered.”

• “This organization is dedicated to conforming to CARF standards and has worked very hard to prepare for this survey. The organization demonstrates substantial conformance to CARF standards, and the residents benefit.”

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What Can I Do to be Part of Accreditation?

You Can Do Many Things!A few ideas…. • Attend staff meetings regularly;• Offer your ideas to better improve delivery of services to

residents by talking to your Coordinator; • Ask questions about standards BeConnected is following;• Know and follow BeConnected’ Mission, Vision, and Values

Statements, Codes of Ethics, and Guidelines for Practice;• Read past Accreditation Bulletins and Quizzes (

www.BeConnectedsupport.ca);• Read BeConnected’s annual reports; 11

http://www.beconsupport.ca/

What Can I Do to be Part of Accreditation?

• Know the policies and procedures that BeConnected expects everyone to know and follow;

• Set a goal to improve your job performance as part of your Annual Performance Appraisal ;

• Attend in-service and training sessions offered by BeConnected ;

• Attend out-service optional workshops offered by BeConnected;

• Join a committee – Have a voice!• Be prepared to talk to the surveyors and answer their

questions honestly and openly• Help prepare the folks we support for survey What else?

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What Happens During the Survey? Day Minus-One, aka the-day-before

• BeConnected is responsible for picking up each surveyor as they arrive at the airport and seeing them safely to their hotel.

• We will have dropped off a “welcome package” including boxes full of non-confidential information for them to review prior to Day One (policies, procedures, handbooks, reports for the last three years, etc.). The surveyors will review all of these materials PRIOR TO commencing survey in the morning.

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What Happens During the Survey? Day One

• 8:00am – Introduction of Surveyors to BeConnected at Orientation Conference… Leadership, Admin, HC’s and stakeholders.

• 9:00am – Survey Begins (Admin Offices and Program Locations)

• 5:00pm – The survey team returns to their hotel to review findings relative to conformance to the standards. *Because BeConnected provides residential services, it may be the case that the program surveyors choose to visit some homes into the evening.

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What Happens During the Survey? Day Two

• …more of the same…

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What Happens During the Survey? Day Three

• 8:00am: The survey team returns to head office to make specific requests for evidence of conformance to standards – things they haven’t already noted conformance to.

• 11:00’ish – The survey team meets to compile its findings. A “pre-exit meeting” is an option with BeConnected Leadership and surveyors if we request it.

• 2:00’ish – The Exit Conference, which is approximately one hour in length, is conducted by the survey team with those invited by BeConnected (we open this one up). Exiting conference consists of…

• Celebrate! 16

What the Surveyors will ask to see?

• Care Plans and Person Centred Plans; GOALS and goal boards

• Program Emergency Information

• Resident binders and files (home and at admin offices)

• Household Comm Books

• Emergency and First Aid Kits

• Van Safety Kit and Documentation

• Accessibility Issues (getting around the site safely – entrances and exits)

• Health and Safety Minutes and Staff Meeting Minutes 17

What the Surveyors will ask to see?• A safe and clean environment – a well cared for home• Personalized rooms showing the residents choice,

interests and culture• Policy and Procedure Binder and all Manuals• Personnel Files • Financial Records • Confidentiality of resident and personnel records

(locked filing cabinets, office doors, etc) • Medications are kept in a secured and locked cabinet • Access to cleaning products are kept under lock and key What else? 18

What Happens After the Survey?

• 2 months after survey we will receive our final report including recommendations and the official status of BeConnected’s 2015 accreditation result (1 or 3 years, no accreditation…).

• Then, Kristen submits to CARF a Quality Improvement Plan (QIP) outlining the actions that have been or will be taken in response to the recommendations made in the survey report.

• Ongoing quality improvements to services offered to persons served and our systems.

• Assuming we are accredited for another three years, we issue an annual report to CARF of conformance to new standards on the anniversary date of our accreditation survey… and continue preparation for next survey…2018!

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…and Finally

Congratulate……personnel, persons served, families,

stakeholders, YOU!...on a job well done!

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BUT…?

If we met standards enough to receive the highest award in 2012, and we are doing the same things now as we were then, wouldn’t we get the same award in 2015 as we did in 2012???

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No.The whole point of accreditation is CONTINUOUS QUALITY IMPROVEMENT. If we’re the same, then we haven’t improved. If we haven’t improved, then we will not be successful at meeting the standards. We need to DEMONSTRATE improvements across all categories of standards. If we do not, BeConnected is at risk because our funders (CLBC and MCFD) require us to be accredited in order to do business. 22

What else is really really important?...

This.“…where the agency has multiple

programs being surveyed (I.E., our group homes), the accreditation decision reflects conformance at the weakest program, site or service.”

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The…

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The Standards: SECTION 1 – BUSINESS PRACTICES

1A) Leadership (just examples, non-exclusive)

• leadership structure • responsibilities• vision/mission…• code of ethics and what happens when one

violates the Code…• cultural competency• contractual relationships

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1C) Strategic Integrated Planning

• “the loop, “the machine:” _____• strategic planning/strategic plan

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1D) Input from Persons Served

• “…input is obtained…on an ongoing basis…from all stakeholders…using a variety of mechanisms…”

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1E) Legal Requirements

• complies with legal and regulatory requirements for:– rights (HR, LL)– privacy and confidentiality – contractual requirements (what we are contractually

required to abide by)– licensing– employment practices (CA)– “all others as applicable” 28


1F) Financial Planning and Management

1G) Risk Management

• individual and agency risk• insurances

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1H) Health and Safety

• OHS; H&S; EP

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1I) Human Resources

• cascade of in-hire requirements• recruitment activities• retention activities• trending (internal re. turnover and external)• competency-based training• performance evals and goal-setting• students & volunteers• personnel policies 31


1J) Technology

• plans and report

1L) Accessibility

• plans and report; RA32


1K) RIGHTS of Person Served

• “…communicated in a way that is meaningful…prior to the beginning of service delivery…at least annually thereafter…available at all times.”

• freedom from _____ and right to _____• complaints procedure and review• informed consent

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1M) Information Measurement and Management

• “outcomes” (…that individuals are supported to achieve their goals)

• Reliability, validity, completeness, accuracy• demographics

*1N) Performance Improvement

• just the loop. this is what it’s all about. 34

The Standards: SECTION 2 – QUALITY INDIVIDUALIZED SERVICES AND SUPPORTS

2A) Program/Service Structure• service delivery model/map (intake)• transition and exit• records of persons• informed consent• behaviour planning (positive, restrictive)• rights restrictions

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2B) Individual-Centred Service Planning, Design, Delivery

• PCP and Goals!• SNAP and culture• resident files• assistive technology and RA’s• risk assessment• referrals• exit and exit summary

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2C) Medication Monitoring and Management

• …storage…safe handling…labeling…training… documentation…disposal…and a whole lot more.

• DROPPED PILL!

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2F) Community Services Principle Standards• matching/input into support persons• community inclusion• social networks• “the organization is a proactive force in their

community…”

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2G) Children and Adolescents Specific Population Designation

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The Standards: SECTION 3 – COMMUNITY SERVICES

3K) Community Housing (aka our group homes)

• privacy & security; personalized setting• meals and snacks• community activities, integration• spiritual, cultural, social, recreational,

employment, self advocacy, self-help activities & transportation to get there

• visitors & guests40

The Standards: SECTION 3 – COMMUNITY

SERVICES3K) Community Housing (continued)• risk• Abuse + neglect• opportunities to make changes in living environment• transitioning• skill development• Personnel are trained• 24/7 emerg response• Transportation• Maintenance of residence during temp leaves 41

The Standards: SECTION 3 – COMMUNITY SERVICES

3J) Host Family Services (HFS)

3L) Supported Living (SL/SIL)

3M) Respite Services (RS)• SNAP of family and of person served• medications• communication

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Questions?

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Let’s Play…

Surveyor Says!44

Surveyor Says!(1) Proper handling procedures for a “dropped pill”

include (choose all that apply):a) 5 second ruleb) Flush itc) A replacement dose should be ordered from the

Pharmacyd) Tape it back into the bubble packe) A dose from the highest numbered pouch

containing medication should be used until the replacement dose is received from pharmacy

f) The medication must be returned to the dispensing pharmacy for proper disposal 45

Surveyor Says!(2) BSS’s Abuse and Reporting Abuse Policies state that “…All

employees and volunteers are responsible and obligated to reporting any/all situations of abuse or neglect, observed or suspected, without delay or hesitation; with no time intervening, to their Coordinator.” In the event personnel suspects, or it is reported to him or her, a situation of possible neglect or abuse, he or she must:

a) Sleep on itb) Talk about it with other staff members, practicum

students, residents, parents of residents, neighbours, anyone who listen, to get their opinion

c) Report the situation, without delay or hesitation; with no time intervening, to their Coordinator

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Surveyor Says!

(3) The term “stakeholder” refers to (choose all that apply):(a) Persons served and their family members(b) CLBC social workers(c) Dan at the dance(d) Employees and Contractors of BeConnected(e) Community partners [Such as DDMHT](f) Keg Steakhouse kitchen staff

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Surveyor Says!

(4) A person’s Planning is based upon his or her SNAP. What does SNAP refer to?(a) Social Night Away Partying(b) Strengths Needs Abilities Preferences(c) Silly Neurosis Affecting Personality(d) Supplying Needs And Personal Care

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Surveyor Says!

(5) BeConnected’s Vision states:(a) “The sky is the limit!”(b) “Over 50 billion served”(c) “Where everybody knows your name”

(d):_____________________________________________________________________________________________________________

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