Quality Enhancement Plan Annual Report
2016-2017
Mission The Arc Baltimore provides advocacy and high quality, life-changing
supports to individuals with intellectual and developmental disabilities
and their families.
Vision People with intellectual and developmental disabilities and their
families THRIVE in the community.
Human Rights Committee Approval: 7-19-16
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TABLE OF CONTENT
Human Rights Committee (standing committee) and Remarks .......................................... 3
Adult Services and Family Living ....................................................................................... 4
Foster Care Department ..................................................................................................... 21
Family Living Department ................................................................................................ 32
Outreach/Intake Department ............................................................................................. 33
Employment and Day Services Division .......................................................................... 34
Training Department.......................................................................................................... 46
Human Resources Department .......................................................................................... 47
Nursing Department .......................................................................................................... 49
Community Living Division .............................................................................................. 51
2017-2018 Quality Enhancement Plan .............................................................................. 59
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Human Rights/ Standing Committee Bob Davidson, Chair, Community Member, [email protected]
Richard Weih, Community Member, [email protected]
Pat Rosner, Community Member, [email protected]
Daphni Steffin, Employee, [email protected]
Yolanda Dorchy, Employee, [email protected]
Dawn Davis-Brodeur, [email protected]
2016-2017 Annual Quality Enhancement Plan
The 2016-2017 Annual Quality Enhancement Plan includes four quarters worth of
data. Each category of measure found in the 2016-2017 annual report has both quarterly
results and annual results. The results describe whether goals have been achieved, or not,
along with supporting data. When a goal is not achieved an action plan is developed that
is then implemented, and prior actions are tracked. Whether a goal is achieved or not, the
results are thoroughly reviewed, and the information gained from the analysis is then
used to improve services.
2017-2018 Quality Enhancement Plan Development The Arc Baltimore’s (The Arc) 2017-2018 Quality Enhancement Plan was
developed with input from across the agency. The result is a plan with meaningful
measures and goals that promote the mission and vision of The Arc. Additionally,
measures and goals were added to align with the updated Home and Community Based
Services (HCBS) Waivers (Section 1915 (c) under the Medicaid program. These ensure
individuals receive services in integrated settings that support full access to the
community. This includes opportunities to seek employment in competitive and
integrated settings and engage in community life. Lastly, the 2017-2018 Quality
Enhancement Plan has a new and improved design.
The measures and goals in the 2017-2018 Quality Enhancement Plan reflect The
Arc’s commitment to enhancing services that will have a positive impact on the people
receiving services from The Arc. The underlying theme of the Plan is a person-centered
approach and community based integrated services; the individuals guide their services.
Included in the Plan are exciting categories of measure, along with corresponding goals
that will continue to ensure that individuals receiving services have choices, are able to
express their preferences and have those preferences met, and that they receive services
in the most integrated community based setting possible.
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Adult Services and Family Living
1) Category of Measure: Individuals are maximizing independence through the use of
assistive technology
Goal One: To increase the number of referrals each quarter from the baseline of twelve
referrals.
Status :
o Annual: Achieved
o Annual summary: There were a total of 73 referrals.
o Q4: Achieved
o Q4 summary: There were 15 referrals in quarter four.
o Q4 action plan: None needed
o Q4 actions taken: None needed
o Q3: Achieved
o Q3 summary: There were 20 referrals in quarter three.
o Q3 action plan: None needed
o Q3 actions taken: None needed
o Q2: Achieved
o Q2 summary: There were 18 referrals in quarter two.
o Q2 action plan: None needed
o Q2 actions taken: None needed
o Q1: Achieved
o Q1 summary: There were 20 referrals in quarter one.
o Q1 action plan: None needed
o Q1 actions taken: None needed
Goal Two: To complete one random review of device utilization per month.
Status:
o Annual: Achieved
o Annual summary: Random reviews of device utilization was conducted once per
month.
o Q4: Achieved
o Q4 summary: Random reviews of device utilization were conducted in April,
May, and June. Two of the three individuals selected were using their devices at
the time of the review. The barrier to regular use was that the staff was not
trained. This issue was addressed at the time of review.
o Q4 action plan: None needed
o Q4 actions taken: Addressed with staff at the time of the review
o Q3: Achieved
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o Q3 summary: A random review of device utilization was conducted in January,
February, and March. None of the three individuals selected were using their
communication devices at the time of the review. Some of the barriers to regular
use included lack of Individual Plan specific training for staff, lack of Individual
Plan goals integrating AT to achieve meaningful outcomes, and devices not
coming into day program regularly. These issues were addressed at the time of
review.
o Q3 action plan: None needed
o Q3 actions taken: Addressed with staff at the time of the review
o Q2: Achieved
o Q2 summary: A random review of device utilization was conducted in October,
November, and December. Two of the three devices reviewed were being utilized
and had Individual Plan goals related to use of the devices. For the device that
was not being utilized, the device was onsite, but the staff was not properly
trained, and there was no Individual Plan documentation.
o Q2 action plan: Additional training and management to follow up to ensure that
the device is utilized.
o Q2 actions taken: Director of Assistive Technology met with the staff at the
location and talked to them about utilization.
o Q1: Achieved
o Q1 summary: A random review of device utilization was conducted in July,
August, and September. Two of the individuals reviewed had their devices with
them and were using them. One of the individuals did not have their device and
the team is exploring having the individual assessed for a new device. One out of
three individuals reviewed had an assistive technology goal in their Individual
Plan, which helps monitor progress.
o Q1 action plan: None needed
o Q1 actions taken: None needed
2) Category of Measure: Individuals have outcomes of their choosing, along with goals
and strategies that provide clear instruction on outcome attainment.
Goal: A sampling of outcomes, along with their supporting goals and strategies, will be
reviewed each quarter to ensure individuals chose their outcomes, and that the goals and
strategies provide clear instruction on outcome attainment.
Status:
o Annual: Partially achieved
o Annual summary: Outcomes were reviewed each quarter with the exception of
quarter four, in which no outcomes were reviewed.
o Q4: Not achieved
o Q4 summary: No outcomes were reviewed in quarter four.
o Q4 action plan: Review other ways to ensure outcome attainment.
o Q4 actions taken: None taken
o Q3: Achieved
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o Q3 summary: Two individuals’ outcomes were reviewed in quarter three. Both
individuals chose their outcomes and there was evidence that the outcome, goals,
and strategies were being worked on. Both individuals reported that they enjoy
working towards their goals, enjoy their home and work, and are participating in
the community.
o Q3 action plan:
Work to have more staff at The Arc Baltimore participate in quarterly
reviews.
Explore creating an annual, or every two year, Individual Plan refresher
training for case managers.
o Q3 actions taken:
The Arc Baltimore has identified a new database and the roll is being
developed.
o Q2: Achieved
o Q2 summary: Two individuals’ outcomes were reviewed in quarter two. Both
individuals chose their outcomes and there was evidence that the outcome, goals,
and strategies were being worked on. Both individuals reported that they enjoy
working towards their goals, enjoy their home and work, and are participating in
the community.
o Q2 action plan:
Work to have more staff at The Arc Baltimore participate in quarterly
reviews.
Explore creating an annual, or every two year, Individual Plan refresher
training for case managers.
The Arc Baltimore is demoing new databases that have enriched outcome,
goal, and strategy review elements. The plan is to choose a new database
and begin implementation late 2017.
o Q2 actions taken: None yet
o Q1: Achieved
o Q1 summary: Two individuals outcomes were reviewed in quarter one. One
individual reported wanting a new job and that was not reflected in the
individual’s outcomes or goals. The second individual’s outcomes and goals were
service oriented and did not appear to be chosen by the individual.
o Q1 action plan:
Explore creating an annual, or every two year, Individual Plan refresher
training for case managers.
The Arc Baltimore is demoing new databases that have enriched outcome,
goal, and strategy review elements. The plan is to choose a new database
and begin implementation late 2017.
o Q1 actions taken:
Quality Enhancement site visit form updated to emphasize the Individual
Plan and outcomes, goals, and strategies.
Outcome, goal, and strategy training at case manager meetings.
Individual Plan training for new hires and staff who need refreshers.
Individualized training with case managers who are struggling with
outcome, goal, and strategy writing.
Routine reviews of Individual Plans by management.
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3) Category of Measure: The number of Meaningful Life Surveys completed
Goal: Board Members are engaged with the individuals receiving services as evidenced
by the completion of a combined total of six Meaningful Life Surveys per quarter.
Status:
o Annual: Not achieved
o Annual summary: Board Members completed two Meaningful Life Surveys in
quarter one.
o Q4: Not achieved
o Q4 summary: No meaningful life surveys were completed by Board Members.
o Q4 action plan: This measure is being removed from the 2017-2018 Quality
Enhancement Plan.
o Q4 actions taken:
Chair of the Quality Enhancement Committee made an appeal to Board
Members about the positive impact completing surveys has for the
individuals who receive services.
An email was sent to Board Members asking for their participation in
quarter two.
o Q3: Not achieved
o Q3 summary: No meaningful life surveys were completed by Board Members.
o Q3 action plan:
Explore whether to continue this measure or not.
o Q3 actions taken:
Chair of the Quality Enhancement Committee made an appeal to Board
Members about the positive impact completing surveys has for the
individuals who receive services.
An email was sent to Board Members asking for their participation in
quarter two.
o Q2: Not achieved
o Q2 summary: No meaningful life surveys were completed by Board Members.
o Q2 action plan:
Send an email to Board Members asking for their participation in quarter
three.
o Q2 actions taken:
Chair of the Quality Enhancement Committee made an appeal to Board
Members about the positive impact completing surveys has for the
individuals who receive services.
An email was sent to Board Members asking for their participation in
quarter two.
o Q1: Not achieved
o Q1 summary: Two meaningful life surveys were completed by Board Members.
o Q1 action plan:
Chair of the Quality Enhancement Committee will make an appeal to
Board Members about the positive impact completing surveys has for the
individuals who receive services.
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Send an email to Board Members asking for their participation in quarter
two.
o Q1 actions taken:
Assistant executive director of the Quality Enhancement Division met
with two emeritus Board Members, and the Chair of Quality Enhancement
Committee, and revamped the survey to make more user friendly.
The Chair of the Quality Enhancement Committee has encouraged Board
Members to complete surveys.
4) Category of Measure: Individuals interviewed are satisfied with their services
Goal: 95% satisfaction with services as indicated by answering 2 or 3 on question 10,
“How would you rate your overall satisfaction with the level of service provided by the
department?”
Status:
o Annual: Achieved
o Annual summary: Individuals interviewed reported a combined average of
95.25% satisfaction with services.
Employment: 88 out of 99 individuals, or 89% of individuals were
satisfied with services.
Day Services: 168 out of 171 individuals, or 98% of individuals were
satisfied with services.
Community Living: 62 out of 66 individuals, or 94% of individuals were
satisfied with services.
Family Living: 3 out of 3 individuals, or 100% of individuals were
satisfied with services.
Parent-Provider: None received.
o Q4: Achieved
o Q4 summary: Individuals interviewed reported a combined average of 96.25%
satisfaction with services.
Employment: 39 out of 50 individuals, or 98% of individuals were
satisfied with services.
Day Services: 71 out of 73 individuals, or 97% of individuals were
satisfied with services.
Community Living: 35 out of 39 individuals, or 90% of individuals were
satisfied with services.
Family Living: 1 out of 1 individuals, or 100% of individuals were
satisfied with services.
Parent-Provider: None received.
o Q4 action plan: Additional surveys will be sent parents and providers next year.
o Q4 actions taken: None
o Q3: This goal is completed twice per year. Results will be posted with Q4 of the
2016-2017 QE Plan.
Employment: N/A
Day Services: N/A
Community Living: N/A
Family Living: N/A
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Parent-Provider: N/A
o Q3 action plan: None need
o Q3 actions taken: None needed
o Q2: Achieved
o Q2 summary: Individuals interviewed reported a combined average of 99.75%
satisfaction with services.
Employment: 49 out of 49 individuals, or 100% of individuals were
satisfied with services.
Day Services: 97out of 98 individuals, or 99% of individuals were
satisfied with services.
Community Living: 27 out of 27 individuals, or 100% of individuals were
satisfied with services.
Family Living: 2 out of 2 individuals, or 100% of individuals were
satisfied with services.
Parent-Provider: None received.
o Q2 action plan: Additional surveys will be sent parents and providers.
o Q2 actions taken: None needed
o Q1: This goal is completed twice per year. Results will be posted with Q2 and Q4
of the 2016-2017 QE Plan.
Employment: N/A
Day Services: N/A
Community Living: N/A
Family Living: N/A
Parent-Provider: N/A
o Q1 action plan: None need
o Q1 actions taken: None needed
5) Category of Measure: The time between the funded date and effective date
Goal: The Arc Baltimore is prepared to start services on the effective funded date for
90% of funded individuals.
Status:
o Annual: Not achieved
o Annual summary: 67 of 107, or 63% of individuals started services on the
effective funded date.
o Q4: Not achieved
o Q4 summary: 16 of 32, or 50% of individuals started services on the effective
funded date.
100% of Community Living individuals started on time.
100% of Employment/Day individuals started on time.
43% of Family Living individuals started on time.
o Q4 action plan: The Arc Baltimore is working to streamline and improve its
hiring process; the delays in Family Living were due to not having hired staff
ready at the time of effective start date.
o Q4 actions taken:
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For Personal Support hours, in Family Living, enhancements to the hiring
process include requesting as standing day of week & time of day for the
individual/family home visits in advance, to avoid the delays which arise
from needing to coordinate The Arc Baltimore and family schedules.
Family Living has also collaborated with families to choose start dates as
far out as feasible to ensure staff can be hired in time.
Family Living has hosted multiple job fairs. This helps reduce vacancies
and build a pool of prospective candidates for ‘new’ plans.
Day Services began listing vacant positions as soon as the commitment
letter from DDA was generated, rather than waiting for the approval to be
posted in PCIS, which has helped with some hiring delays.
Day Service staff are expected to complete their training within two weeks
of attending orientation.
o Q3: Not achieved
o Q3 summary: 5 of 18, or 28% of individuals started services on the effective date.
100% of Community Living individuals started on time.
50% of Employment/Day individuals started on time.
0% of Family Living started on time.
o Q3 action plan:
The agency as a whole is working to streamline and improve our hiring
process (the lack of hired staff being a primary contributor to delays- in
this quarter, representing 100% of delays). Strategies listed below
Family Living delays re: staffing will be addressed through assessment of
and implementation of improvement opportunities related to position
postings, the scheduling of job interviews and family visits and the
collection of documents required for pre-employment.
o Q3 actions taken:
In the Family Living department, enhancements to the hiring process
include requesting as standing day of week & time of day for the
individual/family home visits in advance, to avoid the delays which arise
from needing to coordinate Arc Baltimore & family schedules.
Family Living has also collaborated with families to choose start dates as
far out as is feasible to ensure staff can be hired in time.
FL has hosted 7 job fairs so far, which helps reduce vacancies and build a
pool of prospective candidates for ‘new’ plans.
Day program team began listing vacant positions as soon as the
commitment letter from DDA was generated, rather than waiting for the
approval to be posted in PCIS, which has helped with some hiring delays.
In addition, new Day program staff are expected to complete their training
within the first two weeks it is offered (rather than spreading it out over
more weeks).
o Q2: Not achieved
o Q2 summary: 7 of 12, or 60% of individuals started services on the effective
funded date.
o Q2 action plan:
Efforts would be made to complete new staff training in the most efficient
way possible through listing the position upon the commitment letter from
DDA rather than waiting for PCIS posting.
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Family Living delays re: staffing will be addressed through assessment of
and implementation of improvement opportunities related to position
postings, the scheduling of job interviews and family visits and the
collection of documents required for pre-employment.
o Q2 actions taken: All strategies outlined in the action plan have been
implemented.
o Q1: Not achieved
o Q1 summary: 39 of 45, or 87% of individuals started services on the effective
funded date.
o Q1 action plan:
Continue to work with staff to complete new staff training as quickly as
possible.
Explore obtaining an approval to hire new staff upon receiving the
commitment letter from the Developmental Disability Administration,
rather than waiting until funding is in place in PCIS - sometime take a few
weeks to be entered.
o Q1 actions taken:
None
6) Category of Measure: The quality of departmental services will improve with input
of direct support professionals
Goal: Quality Enhancement facilitators (direct support professionals) complete a
combined total of 6 Roundings with direct support professionals per quarter.
Status:
o Annual: Not achieved
o Annual summary: Roundings were completed in quarter one. The rounding
process changed midway through the Quality Enhancement Plan year and will be
done during direct support professional meetings going forward.
o Q4: Not achieved
o Q4 summary: The Roundings will now be completed at quarterly direct support
professional meetings.
o Q4 action plan: Schedule director support professional meeting.
o Q4 actions taken:
Trained the new director of Quality Enhancement on the Rounding
process.
Reevaluated how the Roundings were being completed and decided to
complete the Roundings at the quarterly director support professional
meetings.
o Q3: Not achieved
o Q3 summary: The Roundings will now be completed at quarterly direct support
professional meetings.
o Q3 action plan:
Train the new director of Quality Enhancement on the Rounding process.
Schedule a direct support professional all meeting.
o Q3 actions taken:
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Reevaluated how the Roundings were being completed and decided to
complete the Roundings at the quarterly director support professional
meetings.
o Q2: Not achieved
o Q2 summary: The Roundings will now be completed at quarterly direct support
professional meetings.
o Q2 action plan:
Train the new Director of Quality Enhancement on the Rounding process.
o Q2 actions taken:
Reevaluated how the Rounds are being completed and begin completing
the Roundings at the quarterly director support professional meetings.
o Q1: Not achieved
o Q1 summary: Quality Enhancement facilitators completed a combined total of
three Roundings.
o Q1 action plan:
Explore new ways of empowering, and improving communication, for
direct support professionals.
o Q1 actions taken:
The structure of the measure was changed in 2015, with the intent of
encouraging direct support professional increased participation.
The coordinator of Quality Enhancement took over the role of
coordinating the rounding with the direct support professionals.
7) Category of Measure: The number of Therapeutic Interactions between Psychology
Associates and individuals
Goal: To complete 350 therapeutic interactions per quarter.
Status:
o Annual: Achieved
o Annual summary: There were 2,507 therapeutic interactions.
o Q4: Achieved
o Q4 summary: There were 1,014 therapeutic interactions.
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Achieved
o Q3 summary: There were 510 therapeutic interactions.
o Q3 action plan: None needed
o Q3 actions taken: None needed
o Q2: Achieved
o Q2 summary: There were 498 therapeutic interactions.
o Q2 action plan: None needed
o Q2 actions taken: None needed
o Q1: Achieved
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o Q1 summary: There were 485 therapeutic interactions.
o Q1 action plan: None need
o Q1 actions taken: None needed
8) Category of Measure: The number of group therapy sessions
Goal: To complete 20 group therapy sessions per quarter.
Status:
o Annual: Achieved
o Annual summary: There were 124 group sessions.
o Q4: Achieved
o Q4 summary: There were 33 group sessions.
o Q4 action plan: None needed
o Q4 actions taken: Groups were expanded to several centers.
o Q3: Achieved
o Q3 summary: There were 40 group sessions.
o Q3 action plan: None needed
o Q3 actions taken: Groups were expanded to several centers.
o Q2: Achieved
o Q2 summary: There were 43 group sessions.
o Q2 action plan: None needed
o Q2 actions taken: Groups were expanded to several centers.
o Q1: Not achieved
o Q1 summary: There were 8 group sessions.
o Q1 action plan: Groups will be implemented at Dundalk Day.
o Q1 actions taken: None
9) Category of Measure: The number of restrictive procedures in Behavior Support
Plans
Goal: To reduce the number of restrictive procedures.
Status:
o Annual: Not achieved
o Annual summary: There were 25 restrictions in quarter four. There were 15
restrictions in quarter four of the 2015-2016 Quality Enhancement Plan.
o Q4: Not achieved
o Q4 summary: There were 25 restrictions in quarter four. There were 21
restrictions last quarter.
Current Restrictions:
Door Alarms: 6
Vehicle safety locks: 4
Seatbelt guard: 0
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Reimbursement for property damage: 4
Locked cabinet for cleaning supplies: 0
Search of a person: 0
Use of protective helmet: 0
Use of proactive glove: 1
Lock up knives: 7
Physical blocking: 1
Physical escorts: 0
Bed exit alarm: 0
No smart phone: 1
No lighters: 1
o Q4 action plan: Quality supports will continue to monitor behavior plan data and
work closely with the staff who support the individual, to ensure that the plans are
being implemented, and faded when possible.
o Q4 actions taken: The Arc Baltimore is supporting individuals with increased
support needs, some of which require restrictive behavior plans. Quality Supports
monitors individuals’ behavior data and works closely with the staff supporting
the individuals, to ensure that the plans are being implemented, and faded when
possible.
o Q3: Not achieved. There were 21 restrictions in quarter three. There were 21
restrictions last quarter.
o Q3 summary:
Current Restrictions:
Door Alarms: 5
Vehicle safety locks: 3
Seatbelt guard: 0
Reimbursement for property damage: 4
Locked cabinet for cleaning supplies: 0
Search of a person: 0
Use of protective helmet: 0
Use of proactive glove: 1
Lock up knives: 7
Physical blocking: 1
Physical escorts: 0
Bed exit alarm: 0
o Q3 action plan: Quality supports will continue to monitor behavior plan data and
work closely with the staff who support the individual, to ensure that the plans are
being implemented, and faded when possible.
o Q3 actions taken: The Arc Baltimore is supporting individuals with increased
support needs, some of which require restrictive behavior plans. Quality Supports
monitors individuals’ behavior data and works closely with the staff supporting
the individuals, to ensure that the plans are being implemented, and faded when
possible.
o Q2: Achieved. There were 21 restrictions in quarter two. There were 23
restrictions last quarter.
o Q2 summary:
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Current Restrictions:
Door Alarms: 5
Vehicle safety locks: 3
Seatbelt guard: 0
Reimbursement for property damage: 4
Locked cabinet for cleaning supplies: 0
Search of a person: 0
Use of protective helmet: 0
Use of proactive glove: 1
Lock up knives: 7
Physical blocking: 1
Physical escorts: 0
Bed exit alarm: 0
o Q2 action plan: Quality supports will continue to monitor behavior plan data and
work closely with the staff who support the individual, to ensure that the plans are
being implemented, and faded when possible.
o Q2 actions taken: The Arc Baltimore is supporting individuals with increased
support needs, some of which require restrictive behavior plans. Quality Supports
monitors individuals’ behavior data and works closely with the staff supporting
the individuals, to ensure that the plans are being implemented, and faded when
possible.
o Q1: Not achieved
o Q1 summary of restrictions: There were 23 restrictions in quarter one. There were
15 restrictions last quarter.
Current Restrictions:
Door Alarms: 6
Vehicle safety locks: 3
Seatbelt guard: 0
Reimbursement for property damage: 4
Locked cabinet for cleaning supplies: 0
Search of a person: 0
Use of protective helmet: 0
Use of proactive glove: 1
Lock up knives: 7
Physical blocking: 1
Physical escorts: 0
Bed exit alarm: 1
o Q1 action plan: Quality supports will continue to monitor behavior plan data and
work closely with the staff who support the individual, to ensure that the plans are
being implemented, and faded when possible.
o Q1 actions taken: The Arc Baltimore is supporting individuals with increased
support needs, some of which require restrictive behavior plans. Quality Supports
monitors individuals’ behavior data and works closely with the staff supporting
the individuals, to ensure that the plans are being implemented, and faded when
possible.
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10) Category of Measure: Review all Internal Incidents
Goal: To review Internal Incidents for trends.
Status:
o Annual: Achieved
o Annual summary: The Human Rights Committee and Quality Enhancement
Department reviewed incidents for trends.
o Internal Incident Types: 412
Abuse allegations: 32
o Reporting history of unsubstantiated abuse: 5
o Physical aggression: 27
Hospital admission/ER visit: 217
Hospital Admission Chronic Condition: 1
Injury: 53
Medication error: 47
Choking: 4
Police with no report taken: 25
Theft < $50: 0
Unexpected or risky absence: 3
Other: 29
o Q4: Achieved
o Q4 summary: The Human Rights Committee and Quality Enhancement
Department reviewed incidents for trends.
o Internal Incident Types: 81
Abuse allegations: 8
o Reporting history of unsubstantiated abuse: 2
o Physical aggression: 6
Hospital admission/ER visit: 42
Hospital Admission Chronic Condition: 0
Injury: 10
Medication error: 11
Choking: 2
Police with no report taken: 2
Theft < $50: 0
Unexpected or risky absence: 1
Other: 5
o Q4 action plan: The Human Rights Committee and Quality Enhancement
Department will continue to review incidents for trends.
o Q4 actions taken: None needed
o Q3: Achieved
o Q3 summary: The Human Rights Committee, Abuse and Neglect Workgroup, and
Quality Enhancement Department reviewed incidents for trends.
o Internal Incident Types: 118
Abuse allegations: 6
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o Reporting history of unsubstantiated abuse: 0
o Physical aggression: 6
Hospital admission/ER visit: 60
Hospital Admission Chronic Condition: 0
Injury: 14
Medication error: 15
Choking: 0
Police with no report taken: 4
Theft < $50: 0
Unexpected or risky absence: 0
Other: 19
o Q3 action plan: The Human Rights Committee, Abuse and Neglect Workgroup,
and Quality Enhancement Department will continue to review incidents for
trends.
o Q3 actions taken: None needed
o Q2: Achieved
o Q2 summary: The Human Rights Committee, Abuse and Neglect Workgroup, and
Quality Enhancement Department reviewed incidents for trends.
o Internal Incident Types: 99
Abuse allegations: 7
o Reporting history of unsubstantiated abuse: 2
o Physical aggression: 5
Hospital admission/ER visit: 55
Hospital Admission Chronic Condition: 0
Injury: 14
Medication error: 10
Choking: 1
Police with no report taken: 9
Theft < $50: 0
Unexpected or risky absence: 1
Other: 2
o Q2 action plan: The Human Rights Committee, Abuse and Neglect Workgroup,
and Quality Enhancement Department will continue to review incidents for
trends.
o Q2 actions taken: None needed
o Q1: Achieved
o Summary: The Human Rights Committee, Abuse and Neglect Workgroup, and
Quality Enhancement Department reviewed incidents for trends.
o Internal Incident Types: 113
Abuse allegations:11
o Reporting history of unsubstantiated abuse: 1
o Physical aggression: 10
Hospital admission/ER visit: 60
Hospital Admission Chronic Condition: 1
Injury: 15
Medication error: 11
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Choking: 1
Police with no report taken: 10
Theft < $50: 0
Unexpected or risky absence: 1
Other: 3
o Q1 action plan: To continue to review incidents for trends.
o Q1 actions taken: The Human Rights Committee, Abuse and Neglect Workgroup,
and Quality Enhancement Department reviewed incidents for trends in quarter
one, and in prior quarters.
11) Category of Measure: Review all Reportable Incidents
Goal: To review Reportable Incidents for trends.
Status:
o Annual: Achieved
o Annual summary: The Human Rights Committee and Quality Enhancement
Department reviewed incidents for trends.
o Reportable Incident Types: 293
Death: 15
Abuse allegations: 56
o Individual/Staff: 36
o Individual/Individual: 12
o Individual/Community Member: 8
Neglect allegations: 19
o Individual/Staff: 18
o Individual/Community Member: 1
Hospital admission: 115
o Non-Psychiatric: 100
o Psychiatric:15
Injury: 7
Medication error: 5
Choking: 0
Police with report taken: 23
Fire department: 3
Theft > $50: 4
Unexpected or risky absence: 2
Unauthorized/inappropriate use of restraints: 1
Other outbreak of communicable diseases: 34
Other Suicide Attempt: 3
Other Suicide Threat: 3
Other- Three of a kind: 4
o Q4: Achieved
o Q4 summary: The Human Rights Committee and Quality Enhancement
Department reviewed incidents for trends.
o Reportable Incident Types: 53
Death: 5
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Abuse allegations: 17
o Individual/staff: 15
o Individual/individual: 0
o Individual/community member: 2
Neglect allegations: 5
o Individual/staff: 5
o Individual/community member: 0
Hospital admission: 19
o Non-Psychiatric: 18
o Psychiatric: 1
Injury: 2
Medication error: 0
Choking: 0
Police with report taken: 2
Fire Department: 0
Theft > $50: 1
Unexpected or risky absence: 1
Unauthorized/inappropriate use of restraints: 0
Other outbreak of communicable diseases: 0
Other suicide attempt: 0
Other suicide threat: 1
Other three of a kind: 0
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Achieved
o Q3 summary: The Human Rights Committee, Abuse and Neglect Workgroup, and
Quality Enhancement Department reviewed incidents for trends.
o Reportable Incident Types:78
Death: 1
Abuse allegations: 13
o Individual/staff: 10
o Individual/individual: 1
o Individual/community member: 2
Neglect allegations: 8
o Individual/staff: 8
o Individual/community member: 0
Hospital admission: 30
o Non-Psychiatric: 28
o Psychiatric: 2
Injury: 4
Medication error: 1
Choking: 0
Other- Outbreak of communicable diseases: 5
Police with report taken: 10
Fire Department: 3
Theft > $50: 0
20
Unexpected or risky absence: 1
Unauthorized/inappropriate use of restraints: 0
Other suicide attempt: 0
Other suicide threat: 0
Other three of a kind: 2
o Q3 action plan: None needed
o Q3 actions taken: None taken
o Q2: Achieved
o Q2 summary: The Human Rights Committee, Abuse and Neglect Workgroup, and
Quality Enhancement Department reviewed incidents for trends.
o Reportable Incident Types: 64
Death: 6
Abuse allegations: 14
o Individual/staff: 3
o Individual/individual: 9 allegations involving 5 individuals
o Individual/community Member: 2
Neglect allegations: 2
o Individual/staff: 2
o Individual/community member: 0
Hospital admission: 26
o Non-psychiatric: 21
o Psychiatric: 5
Injury: 0
Medication error: 3
Choking: 0
Police with report taken: 4
Fire department: 0
Theft > $50: 1
Unexpected or risky absence: 0
Unauthorized/inappropriate use of restraints: 0
Other communicable disease: 5
Other suicide attempt: 1
Other suicide threat: 1
Other three of a kind: 1
o Q2 action plan: None needed
o Q2 actions taken: None taken
o Q1: Achieved
o Summary: The Human Rights Committee, Abuse and Neglect Workgroup, and
Quality Enhancement Department reviewed incidents for trends.
o Reportable Incident Types: 98
Death: 3
Abuse allegations: 12
o Individual/staff: 8
o Individual/individual: 2
o Individual/community member: 2
21
Neglect allegations: 4
o Individual/Staff: 3
o Individual/community member: 1
Hospital admission: 40
o Non-psychiatric: 33
o Psychiatric: 7
Injury: 1
Medication error: 1
Choking: 0
Police with report taken: 7
Fire department: 0
Theft > $50: 2
Unexpected or risky absence: 0
Unauthorized/inappropriate use of restraints: 1
Other communicable disease: 24
Other suicide attempt: 2
Other suicide threat: 1
Other three of a kind: 1
o Q1 action plan: None needed
o Q1 actions taken: None taken
Foster Care
1) Category of Measure: Percentage of Reportable Incidents that are preventable
Goal: To investigate and assess all Reportable Incidents for preventability and develop a
response plan for each preventable incident.
Status:
o Annual: Achieved
o Annual summary: There were 57 incidents in quarter three. All were assessed
for preventability. 2 were deemed preventable and response plans were
developed.
Elopement: 13
Preventable: 2
Not Preventable: 11
Emergency hospitalization medical: 1
Preventable: 0
Not Preventable: 1
Emergency hospitalization psychiatric: 7
Preventable: 0
Not Preventable: 7
Emergency medical treatment: 9
Preventable: 0
Not Preventable: 9
Illness: 0
Preventable: 0
22
Not Preventable: 0
Injury to other youth: 1
Preventable: 1
Not Preventable: 0
Injury to youth subject to incident: 3
Preventable: 0
Not Preventable: 3
Medical event: 4
Preventable: 0
Not Preventable: 4
School expulsion: 0
Preventable: 0
Not Preventable: 0
Theft: 0
Preventable: 0
Not Preventable: 0
Property damage: 2
Preventable: 0
Not Preventable: 2
Substance use: 0
Preventable: 0
Not Preventable: 0
Other: Auto accident: 2
Preventable: 0
Not Preventable: 2
Other: School suspension:
Preventable:
Not Preventable:
Other: Assault on foster parent: 0
Preventable: 0
Not Preventable: 0
Other: Assault on other adult:
Preventable:
Not Preventable:
Other: Fire Setting: 1
Preventable: 0
Not Preventable: 1
Other: Suspected Abuse: 1
Preventable: 0
Not Preventable: 1
Other: Assault on other staff: 1
Preventable: 0
Not Preventable: 1
Other: Emergency psychiatric evaluation: 2
Preventable: 0
Not Preventable: 2
23
o Q4:
o Q4 summary: There were 18 incidents in quarter four. All were assessed for
preventability. One was deemed preventable and a response plan was
developed.
Elopement: 4
Preventable: 0
Not Preventable: 4
Emergency hospitalization medical: 0
Preventable: 0
Not Preventable: 0
Emergency hospitalization psychiatric: 1
Preventable: 0
Not Preventable: 1
Emergency medical treatment: 1
Preventable: 0
Not Preventable: 1
Illness: 0
Preventable: 0
Not Preventable: 0
Injury to other youth: 1
Preventable: 1
Not Preventable: 0
Injury to youth subject to incident: 2
Preventable: 0
Not Preventable: 2
Medical event: 3
Preventable: 0
Not Preventable: 3
School expulsion: 0
Preventable: 0
Not Preventable: 0
Theft: 0
Preventable: 0
Not Preventable: 0
Property damage: 0
Preventable: 0
Not Preventable: 0
Substance use: 1
Preventable: 0
Not Preventable: 1
Other: Auto accident: 0
Preventable: 0
Not Preventable: 0
Other: School suspension: 0
Preventable: 0
Not Preventable: 0
Other: Assault on foster parent: 0
24
Preventable: 0
Not Preventable: 0
Other: Assault on other adult: 0
Preventable: 0
Not Preventable: 0
Other: Fire Setting: 1
Preventable: 0
Not Preventable: 1
Other: Suspected Abuse: 1
Preventable: 0
Not Preventable: 1
Other: Assault on other staff: 1
Preventable: 0
Not Preventable: 1
Other: Emergency psychiatric evaluation: 2
Preventable: 0
Not Preventable: 2
o Q4 action plan: A certain degree of incidents can be expected and DHR reporting
requirements result in a report for even normal and expected childhood injuries.
o Q4 actions taken: None needed
o Q3: Achieved
o Q3: Summary:
o Reportable Incidents: There were 15 incidents in quarter three. All were
assessed for preventability. One was deemed preventable and a response plan
was developed.
Elopement: 6
Preventable: 1
Not Preventable: 5
Emergency hospitalization medical: 1
Preventable: 0
Not Preventable: 1
Emergency hospitalization psychiatric: 3
Preventable: 0
Not Preventable: 3
Emergency medical treatment: 1
Preventable: 0
Not Preventable: 1
Illness: 0
Preventable: 0
Not Preventable: 0
Injury to other youth: 0
Preventable: 0
Not Preventable: 0
Injury to youth subject to incident: 0
Preventable: 0
25
Not Preventable: 0
Medical event: 0
Preventable: 0
Not Preventable: 0
School expulsion: 0
Preventable: 0
Not Preventable: 0
Theft: 0
Preventable: 0
Not Preventable: 0
Property damage: 1
Preventable: 0
Not Preventable: 1
Substance use: 0
Preventable: 0
Not Preventable: 0
Other: Auto accident: 1
Preventable: 0
Not Preventable: 1
Other: School suspension: 1
Preventable: 0
Not Preventable: 1
Other: Assault on foster parent: 2
Preventable: 0
Not Preventable: 2
Other: Assault on other adult: 1
Preventable: 0
Not Preventable: 1
Q3 action plan: Overall, we had 15 incidents in Q3. The increaser in
elopement was mostly comprised of the same two youth. We instituted
additional support as a result.
Q3 actions taken: To address elopement, we instituted and recommended
higher levels of care and supervision and collaborated with foster parents
and external providers to ensure that the youth are getting the services
needed.
o Q2: Achieved
o Q2 summary:
o Reportable Incidents: There were 15 incidents in quarter two and each was
deemed not preventable. The increase in medical treatment and psychiatric
hospitalizations is mostly comprised of several youth. Foster Care will
continue to be mindful of, and focus on, how to best prepare youth and
families to respond during incidents.
Elopement: 2
Preventable: 1
Not Preventable: 1
Emergency hospitalization medical: 0
Preventable: 0
26
Not Preventable: 0
Emergency hospitalization psychiatric: 3
Preventable: 0
Not Preventable: 3
Emergency medical treatment: 5
Preventable: 0
Not Preventable: 5
Illness: 0
Preventable: 0
Not Preventable: 0
Injury to other youth: 0
Preventable: 0
Not Preventable: 0
Injury to youth subject to incident: 0
Preventable: 0
Not Preventable: 0
Medical event: 0
Preventable: 0
Not Preventable: 0
School expulsion: 0
Preventable: 0
Not Preventable: 0
Theft: 0
Preventable: 0
Not Preventable: 0
Property damage: 1
Preventable: 0
Not Preventable: 1
Substance use: 0
Preventable: 0
Not Preventable: 0
Other: Auto accident: 1
Preventable: 0
Not Preventable: 1
Other: School refusal: 1
Preventable: 0
Not Preventable: 1
Other: Assault on foster parent: 2
Preventable: 0
Not Preventable: 2
o Q2 action plan: In order to support youth with higher acuity needs, Foster Care
may see an increase in overall incidents. Foster Care will continue to be mindful
of, and focus on, how to best prepare youth and families to respond during
incidents.
o Q2 actions taken:
Foster Care has a responsive on call process, which in some incidents
results in an in-person staff response, especially for hospitalizations.
27
Foster Care increased its support to the children and families and has
collaborated with its foster parents, and external providers, to ensure that
the youth are getting needed services.
o Q1: Achieved
o Q1 summary: There were 9 incidents in quarter one and each was deemed not
preventable. However, Foster Care continues to examine each incident closely to
ensure the safety of its youth, foster parents, and staff.
o Reportable Incidents: 9
Elopement: 1
Preventable: 0
Not Preventable: 1
Emergency hospitalization medical: 0
Preventable: 0
Not Preventable: 0
Emergency hospitalization psychiatric: 0
Preventable: 0
Not Preventable: 0
Emergency medical treatment: 2
Preventable: 0
Not Preventable: 2
Illness: 0
Preventable: 0
Not Preventable: 0
Injury to other youth: 0
Preventable: 0
Not Preventable: 0
Injury to youth subject to incident: 1
Preventable: 0
Not Preventable: 1
Medical event: 1
Preventable: 0
Not Preventable: 1
School expulsion: 0
Preventable: 0
Not Preventable: 0
Theft: 0
Preventable: 0
Not Preventable: 0
Property damage: 0
Preventable: 0
Not Preventable: 0
Substance use: 0
Preventable: 0
Not Preventable: 0
o Q1 action plan: None needed
o Q1 actions taken: None needed
28
2) Category of Measure: Percentage of Annual Assessments completed on time
Goal: 100% compliance with completing Annual Assessments.
Status:
o Annual: Not achieved
o Annual summary: 29 out of 30, or 97% of the Annual Assessments were
completed on time.
o Q4: Achieved
o Q4 summary: 14 out of 14, or 100% of the Annual Assessments were completed
on time.
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Achieved
o Q3 summary: 5 out of 5, or 100% of the Annual Assessments were completed on
time.
o Q3 action plan: None needed
o Q3 actions taken: None taken
o Q2: Achieved
o Q2 summary: 6 out of 6, or 100% of the Annual Assessments were completed on
time.
o Q2 action plan: None needed
o Q2 actions taken:
Foster parents were reminded a month prior to the due date that the
assessments were coming due.
When possible, the assessments were scheduled two weeks prior to the
due date.
o Q1: Not achieved
o Q1 summary: 4 out of 5, or 80% of the Annual Assessments were completed on
time.
o Q1 action plan:
For all annual assessments, foster parents are reminded a month prior to
the due date that the assessments are coming due.
Attempts are made to schedule the assessment two weeks prior to the due
date.
The late assessment in quarter one, was due to a parent having a medical
emergency that resulted in the meeting to complete the assessment
needing to be cancelled.
o Q1 actions taken:
Per policy and keeping with regulation, the parent was suspended from
taking new placements until the assessment was complete.
29
3) Category of Measure: CANS Assessments will be completed on time each quarter
Goal: 100% compliance with completion of CANS Assessments Ansell Casey
Assessments.
Status:
o Annual: Not achieved
o Annual summary: 113 out of 115, or 98% of the CANS and Ansell Casey
Assessments were completed on time.
o Q4: Not achieved
o Q4 summary: 25 out of 26, or 96% of the CANS and Ansell Casey Assessments
were completed on time.
o Q4 action plan: All staff currently maintain a tracking system to ensure the due
dates are met.
o Q4 actions taken: The supervisor began sending monthly reminders and reiterate
due dates in supervision.
o Assessments are scheduled with some time to spare, incase rescheduling is
needed.
o Q3: Achieved
o Q3 summary: 32 out of 32, or 100% of the CANS and Ansell Casey Assessments
were completed on time.
o Q3 action plan: None needed
o Q3 actions taken:
o Q2: Not achieved
o Q2 summary: 29 out of 30, or 97% of the CANS and Ansell Casey Assessments
were completed on time.
o Q2 action plan:
For all annual assessments, parents are notified a month in advance that
assessments will be due.
Attempts are made to schedule the meeting at least 2 weeks prior to the
due date, to allow for cancellations, emergencies, and other happenings.
o Q2 actions taken: None
o Q1:Achievd
o Q1 summary: 27 out of 27, or 100% of the CANS and Ansell Casey Assessments
were completed on time.
o Q1 action plan: None needed
o Q1 actions taken: None needed
4) Category of Measure: Foster children will experience placement stability and avoid
disruption by matching children with the best fitting placements
Goal: Upon discharge, 90% of foster children will have stayed in their initial placement
for the entirety of their involvement in the Foster Care program.
Status:
30
o Annual: Not achieved
o Annual summary: 21 out of the 24 youth, or 88% remained with their initial foster
family for the entirety of their stay in Foster Care.
o Q4: Not achieved
o Q4 summary: 0 out of the 1 youth, or 0% remained with their initial foster family
for the entirety of their stay in Foster Care.
o Q4 action plan: Throughout the youth’s stay in foster care, all efforts were made
to be proactive and observant such that issues did not result in a crisis or
placement disruption.
o Q4 actions taken: None needed
o Q3: Achieved
o Q3 summary: 6 out of the 6 youth, or 100% remained with their initial foster
family for the entirety of their stay in Foster Care.
o Q3 action plan: None needed
o Q3 actions taken: None taken
o Q2: Not achieved
o Q2 summary: 8 out of 9 children, or 89% remained with their initial foster family
for the entirety of their stay in Foster Care.
o Q2 action plan: The youth who did not remain in her original placement achieved
permanence through adoption in Q2. Since her original placement disruption
occurred in 2003, an action plan would most likely not have prevented the
disruption.
o Q2 actions taken: None
o Q1: Not achieved
o Q1 summary: 7 out of 8 children, or 88% remained with their initial foster family
for the entirety of their stay in Foster Care.
o Q1 action plan:
None needed. The child who did not remain with original foster family,
was moved to a foster home within The Arc Baltimore, where his brother
was lives; this was a move towards permanence and stability.
o Q1 actions taken: None needed
5) Category of Measure: Stakeholder will report overall satisfaction with the services
provided by The Arc Baltimore
Goal: 90% satisfaction based on five point Likert Scale.
Status:
o Annual: Partially achieved
o Annual Summary:
Foster Families: 95.6% reported satisfaction. Response rate of 50% (18/36
responses)
Birth Families: 62.5% reported satisfaction. Response rate of 22% (4/18)
DSS Workers: 95.2 % reported satisfaction. Response rate of 20% (7/35)
Placement Unit Workers: 87% reported satisfaction. Response rate of 22%
(4/18)
31
o Q4: N/A
o Q4 summary: This is an annual goal and results were posted with quarter three’s
results.
o Q4 action plan: N/A
o Q4 actions taken: N/A
o Q3: Not Achieved
o Q3 Summary:
Foster Families: 95.6% reported satisfaction. Response rate of 50% (18/36
responses)
Birth Families: 62.5% reported satisfaction. Response rate of 22% (4/18)
DSS Workers: 95.2 % reported satisfaction. Response rate of 20% (7/35)
Placement Unit Workers: 87% reported satisfaction. Response rate of 22%
(4/18)
o Q3 action plan: No action plan needed for Foster Families and DSS workers. For
Birth Families, the FC program will analyze and ensure that survey questions get
at the root of the information we want to measure and determine the appropriate
recipients for those surveys.
o Q3 actions taken: No action needed for Foster Families and DSS workers. The
staff person responsible for placements has been designed to, regularly, speak to
DSS Placement workers at the time of placement to identify any unmet needs and
check in about the working relationship. Social workers, when working with Birth
Families will provide additional information/education about roles and
responsibilities of DSS, the court system and The Arc Baltimore Survey questions
for Birth Families will be tweaked to ensure families provide information about
their satisfaction with the Arc Baltimore rather than another entity Biological
Families who lack legal permission/autonomy to engage with their children
independent of court oversight may get another survey version, or be removed
from the survey pool, as they are inherently dissatisfied.
o Q2: This is an annual goal and results will be posted with quarter three’s results.
o Q2 action plan: N/A
o Q2 actions taken: N/A
o Q1: This is an annual goal and results will be posted with quarter three’s results.
o Q1 action plan: N/A
o Q1 actions taken: N/A
Family Living
1) Category of Measure: Education series topics will appeal to a broad and widening
range of community members. Audience members will report that topics are
meaningful and helpful
Goal 1: Yearly attendees will exceed 350 individuals.
Status:
o Annual: Not achieved
32
o Annual summary: 344 people have attended the educational series to date.
o Q4: Not achieved
o Q4 summary: 344 people have attended the educational series to date.
o Q4 action plan: Targets were almost met this year and successful strategies used
to increase the number of new attendees.
o Q4 actions taken: None needed
o Q3: Annual goal
o Q3 summary: 139 people have attended the educational series to date
o Q3 action plan: None needed
o Q3 actions taken: None taken. We expect Q4 to have the highest number of
attendees based on prior year data.
o Q2: Annual goal
o Q2 summary: 33 people have attended the educational series to date.
o Q2 action plan: N/A
o Q2 actions taken: N/A
o Q1: Annual goal
o Q1 summary: 27 people have attended the educational series to date.
o Q1 action plan: N/A
o Q1 actions taken: N/A
Goal 2: New attendees will exceed 10% of the yearly attendees.
Status:
o Annual: Achieved
o Annual summary: 141 of the 344, or 41% of the attendees were new attendees.
o Q4: Achieved
o Q4 summary: 83 of the 205, or 41% of the attendees were new attendees.
o Q4 action plan: None needed
o Q4 actions taken: None needed
o Q3: Annual goal
o Q3 summary: 40 of the 79, or 51% of the attendees were new attendees.
o Q3 action plan: None needed
o Q3 actions taken: None taken
o Q2: Annual goal
o Q2 summary: 6 of the 33, or 18% of the attendees were new attendees.
o Q2 action plan: N/A
o Q2 actions taken: N/A
o Q1: Annual goal
o Q1 summary: 12 of the 27, or 44% of the attendees were new attendees.
o Q1 action plan: None needed
o Q1 actions taken: None needed
33
Goal 3: 80% satisfaction with the topics presented.
Status:
o Annual: Achieved
o Annual summary: 88% of the attendees YTD report satisfaction with the topics
presented.
o Q4: Annual aggregate goal
o Q4 summary: 94% of the attendees YTD report satisfaction with the topics
presented.
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Annual aggregate goal
o Q3 summary: 87% of the attendees YTD report satisfaction with the topics
presented.
o Q3 action plan: None needed
o Q3 actions taken: None taken
o Q2: Annual goal
o Q2 summary: 83% of the attendees reported satisfaction with the topics presented.
o Q2 action plan: None needed
o Q2 actions taken: None taken
o Q1: Annual goal
o Q1 summary: 87% of the attendees reported satisfaction with the topics presented.
o Q1 action plan: None needed
o Q1 actions taken: None taken
Outreach/Intake
1) Category of Measure: Individuals and families are satisfied with the intake process
Goal: 95% satisfaction with the intake process.
Status:
o Annual: Achieved
o Annual summary: 14 of the 14 survey respondents, or 100% reported satisfaction
with the intake process.
o Q4: Achieved
o Q4 summary: 1 of the 1 survey respondents, or 100% reported satisfaction with
the intake process.
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Achieved
o Q3 summary: 3 of the 3 survey respondents, or 100% reported satisfaction with
the intake process.
34
o Q3 action plan: None needed
o Q3 actions taken: None taken
o Q2: Achieved
o Q2 summary: 3 of the 3 survey respondents, or 100% reported satisfaction with
o Q2 action plan: None needed
o Q2 actions taken: None needed
o Q1: Achieved
o Q1 summary: 7 of the 7 survey respondents, or 100% reported satisfaction with
the intake process.
o Q1 action plan: None needed
o Q1 actions taken: None needed
Employment and Day Services
1) Category of Measure: Number of individual competitive jobs (full time or part time
on a community business’ payroll)
Goal: To increase the total number of individual competitive jobs from 92 to 132.
Status:
o Annual: Not achieved
o Annual summary: At the end of quarter four, 122, or 92% of the target goal of 132
had competitive jobs.
o Q4: Not achieved
o Q4 summary: The total number of competitive employer paid individual
placements in quarter three was 122, or 92% of the target goal of 132 competitive
jobs.
o Q4 action plan:
Increase job development activities throughout FY18
Build job competency through job shadowing, internships, and Career
Catalyst.
Explore the possibility of expanding our Career Catalyst program
Institute a new highbred position of job developer/community integrator
housed out of the Day Program. The hope being to provide a majority of
our day programs with this staffing. The new job developer/community
integrator will concentrate on individuals served at their assigned center
and will seek to individually assess each person’s need while helping them
obtain employment or meaningful community activities.
o Q4 actions taken:
Attended 66 Networking events throughout the year (with 14 of these
events occurring in the 4th quarter).
Added a 4th Job Developer to department in the last quarter.
Started our first mobile Career Catalyst in quarter 4 (2 individuals were
hired after this intensive training and 1 more is in the interview process).
4th Workforce Development Specialist (Job Developer) hired – should be
starting in April. Position is being posted again this month with the hope
35
of hiring 1 more. WDS’s will be developing relationships with individuals
on crews and at centers to foster interest in competitive employment
Continued attendance at networking events. Hosted a general meeting of
the Baltimore City Chamber of Commerce that featured Diversity
employment.
Developed relationship with Marshall’s in Towson to host first Part 1 of
new career catalyst model beginning in mid-April
Project SEARCH programs continue to focus on job development for
current interns with a goal of having a 50% placement rate before
graduation.
The process of downsizing the large ACE and UniFirst enclaves continues
with some individuals being referred to Business Services for individual
placements. Some will hopefully find employment with a new partnership
that is being developed with UP To Date Laundry where we plan to
implement our new supported employment model Approximately 10
people initi8ally will be hired directly by Up To Date in individual
placements throughout the business on 2 shifts and in different locations,
and we will provide a coach on site for support of those individuals.
A Job Coach Training Program is in the development process that will
reinforce an Employment First focus.
o Q3: Not achieved
o Q3 summary: The total number of competitive employer paid individual
placements in quarter three was118, or 89% of the target goal of 132 competitive
jobs.
o Q3 action plan:
Expand Business Services Department
Increase number of business relationships/partnerships and overall
presence in the business community (Across all depts.: SE, PS & CC)
Encourage individuals and their families to consider individual
employment in the community
Retrain and set new expectations for staff of work crews, etc. to encourage
individuals to consider individual employment in the community
Downsize ACE and Unifirst enclaves and move as many people into
individual placements as possible.
o Q3 actions taken:
4th Workforce Development Specialist (Job Developer) hired – should be
starting in April. Position is being posted again this month with the hope
of hiring 1 more. WDS’s will be developing relationships with individuals
on crews and at centers to foster interest in competitive employment
Continued attendance at networking events. Hosted a general meeting of
the Baltimore City Chamber of Commerce that featured Diversity
employment.
Developed relationship with Marshall’s in Towson to host first Part 1 of
new career catalyst model beginning in mid-April
Project SEARCH programs continue to focus on job development for
current interns with a goal of having a 50% placement rate before
graduation.
The process of downsizing the large ACE and UniFirst enclaves continues
with some individuals being referred to Business Services for individual
36
placements. Some will hopefully find employment with a new partnership
that is being developed with UP To Date Laundry where we plan to
implement our new supported employment model Approximately 10
people initi8ally will be hired directly by Up To Date in individual
placements throughout the business on 2 shifts and in different locations,
and we will provide a coach on site for support of those individuals.
A Job Coach Training Program is in the development process that will
reinforce an Employment First focus.
o Q2: Annual goal
o Q2 summary: The total number of competitive employer paid individual
placements in quarter two was 121, or 92% of the target goal of 132 competitive
jobs.
o Q2 action plan:
Expand Business Services Department
Increase number of business relationships/partnerships and overall
presence in the business community (Across all depts.: SE, PS & CC)
Implement Employment Discovery and Customization practices
Encourage individuals and their families to consider individual
employment in the community
Retrain and set new expectations for staff of work crews, etc. to encourage
individuals to consider individual employment in the community
o Q2 actions taken:
3rd Workforce Development Specialist (Job Developer) hired – started in
October. Position is being posted again this month with the hope of hiring
2 more. WDS’s will begin to develop relationships with individuals on
crews and at centers to foster interest in competitive employment
“Networking Group” met with Andrew Rose on 11/17 for networking
training and advice
Continue to have targeted staff attend networking events
Exploring other avenues to promote The Arc as workforce solution. For
example, hosting a general meeting of the Baltimore City Chamber of
Commerce.
In the process of freeing up select ESA’s from some current
responsibilities so they can focus on Employment Discovery &
Customization (under Nancy)
Project SEARCH programs are beginning now to focus on job
development for current interns; any LY graduates who are not employed
goal is for them to be placed by spring
o Q1: Annual goal
o Q1 summary: The total number of competitive employer paid individual
placements in quarter one was 113, or 86% of the target goal of 132 competitive
jobs.
o Q1 action plan:
Expand Business Services Department.
Increase number of business relationships/partnerships and overall
presence in the business community (Across all depts.: SE, PS & CC).
Implement Employment Discovery and Customization practices.
37
Encourage individuals and their families to consider individual
employment in the community.
Retrain and set new expectations for staff of work crews, etc. to encourage
individuals to consider individual employment in the community.
o Q1 actions taken:
Hired second Account Manager/Job Developer to start in October.
Planning to hire third Account Manager/Job Developer in next few
months.
Create “Networking Group” of staff across departments to clarify and
make uniform employment message to employers and train staff on
networking.
Continue to have targeted staff attend networking events.
Moved Employment Discovery & Customization under Business Services.
2) Category of Measure: Non-disability specific community based engagement
Goal: To increase the number of community partnerships with associations, classes,
leagues, organizations, and community groups by two each quarter.
Status:
o Annual: Achieved
o Annual summary: The number of community partnerships with associations,
classes, leagues, organizations, and community groups increased by two each
quarter (see quarter summations below).
o Q4: Achieved
o Q4 summary:
o Dundalk:10
o Miniature golf
o Added 3 more people to the senior center for a total of 5 individuals 2 x
week
o Hair Salon- in community
o Nail Salon- in community
o Clown Troop performed at 1 school Glenn Mar School
o Art Museum tour
o Movies- weekly
o Health Fair
o Aunt Anne’s White Marsh- working and making pretzels
o Using services in the community, snowballs, ice cream, Rita’s
o Loch Ridge: 3
o Local movie club at Cinemax
o Healthy Weights weekly classes at Towson University
o Minimally twice monthly visits to Baltimore City Department of
Recreation
o Seton: 8
o My Sisters Place volunteered 2x@month passing out food to the homeless
o Twice Monty walk Montebello Lake where individuals socialize with
other walkers
o Church spaghetti day lunch
o Visited Social Security for snowball day
38
o Visited several museums
o Visited Safety City at Druid Hill park
o Tour of Turkey Hill Ice Cream
o Strawberry Farm to pick organic foods
o Woodlawn: 5
o Meals on Wheels
o Peep Show (Howard Co. Fairgrounds)
o Universal Circus
o Woodlawn Library
o Glynn Taff Nursing Home
o Towson: 5
o Meals on Wheels volunteering
o Visits to Inner Harbor
o Shopping visits to Five Below
o Several small group visits to Golden Corral
o Shopping visits to
o Wal-Mart,
o Lowe’s,
o Home Depot
o Homeland: 7
o M Meals on Wheels
o Visited 3 local museums
o Participated in Healthy Weights weekly
o Attended local movies
o Visited local parks and had picnics
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Achieved
o Q3 summary:
o Dundalk:9
Community Center- voice, drama, dance—working on a play that will
be offered to the community,
Battle Monument students visited the center,
Senior center- Tuesday/ Thursday added one more senior to our group,
Delivering food- to people in the community,
Bags of Hope – delivered to office for use in the community
Meals on Wheels- 3 runs 5 days a week,
Bowling- weekly,
Book Club- on going at Beanies Ice Cream Store,
Clay works-6 individuals are in the community
o Loch Ridge: 2
Glen Meadows Nursing Homes,
Towson movie club 2x in quarter
o Seton: 5
Evans Temple Church the last Friday of each month passing out food
Columbia Mall Walkers,
Charity Christian Church pass out food,
39
My Sisters Place,
MOW
o Woodlawn: 2
Baltimore Clayworks
Woodlawn Library
o Towson: 2
Individuals delivered Meals on Wheels 12 days a month for this
quarter
Walters Art Gallery for in depth tour
o Homeland: 4
MOW,
Local movies,
Healthy weighs,
ACC group at Towson Wellness center
o Q3 action plan: None needed
o Q3 actions taken: None needed
o Q2: Achieved
o Q2 summary:
Dundalk: 4
Delivered bags of Hope to a church and Keepers of the Green-
connection
Individuals went shopping in the community to purchase
Christmas gifts for others
Visited local train garden
Valley View for holiday shopping
Play at the Government Center, “Sky’s the limit”
Loch Ridge: 2
Glen Meadows Nursing Homes
Site services-neighborhood business
Seton: 2
Evans Temple Church, the last Friday of each month passing out
food
Columbia Mall Walkers-weekly
Woodlawn: 4
Senior Expo at Timonium Fairgrounds
Cherry Hill Aquatic Center
Liberty Senior Center
Goucher College- 2 Separate shows
Towson: 4
Meals on Wheels
Developed friendship with local retailer
o Amish Market
o Golden Corral
o Towson Cinema
o Valley View Farms
Homeland: 4
Meals on Wheels
Local movies
40
Horse farm
Healthy Weights
o Q2 action plan: None needed
o Q2 actions taken: None needed
o Q1: Achieved
o Q1 summary:
Dundalk: 3
Local hair salon
Nail salon
Walters Art
Loch Ridge: 2
Local movie club Cinemax
Baltimore city rec department water aerobics
Seton: 2
Participated in a twice weekly program to learn about horticulture
Partnership with equine farm
Woodlawn: 2
Liberty Senior Center
Meals on Wheels
Towson: 2
Meals on Wheels
CCBC Math class at Essex Community College
Homeland: 2
Developed friendship with local retailer
Meals on Wheels
o Q1 action plan: None needed
o Q1 actions taken: Goal was discussed with center managers to ensure that they
understand the expectations of the goal.
3) Category of Measure: Opportunities for individuals who attend day centers to learn
about employment
Goal: To offer six employment related experiences every quarter.
Status:
o Annual: Achieved
o Annual summary: At least six employment related experiences were offered every
quarter (see quarter summations below).
o Q4: Achieved
o Q4 summary:
Dundalk: 6
CCBC at the college- hygiene and personal care- job readiness
weekly
Visiting Restaurants in the local area, Chick-Fil-A, Pizza Hut 2x’s,
Sweet Frogs, Mc Donald’s to discuss employment possibilities
41
Individual is Volunteering at Nursing Home down the street from
the center Future Care 2 x week
Simulated interviews with individuals—done weekly
Classes discussing proper dress for employment—done weekly
Discussions about safe lawn mowing with the lawn care crews
Loch Ridge: 8
Mock interviews
Discussions about employment in contract area
Filled out 4 applications; Dollar Tree, Big Lots, Savers and the
BCPL Library.
Also worked at TUNES Music and DVDs store for information
volunteer purpose.
Seton: 8
Gave 5 individuals job trial at Chase Brexton putting together
patient information packets for a month.
Began work preparedness classes – about 10 individuals attend
weekly classes—classes occurred 6 time so far
Submitted DORS application for individual to obtain
funding/training for cosmetology
Woodlawn: 6
AMF Woodlawn - inquired about job opportunities/ application
Woodlawn Library – inquired about job opportunities/ application
Group discussion about attendance and punctuality
Mock interviews weekly
Group discussion on what is needed for a job application 1x week
Towson: 2
Two individuals went filled out job applications at the work site
Three individuals filled out on-line job applications
Talked about best choices for each supported worker
Had group discussions regarding employment related skills needed
Met with 2 supported individuals regarding specific and individual
job interests
Two work groups had discussions concerning on the job behavior
Homeland: 2
Individuals went to apply for jobs at Walmart, Dollar General, and
Giant.
Discussed proper hygiene for job interviews.
Discussed completing resumes.
Discussed filling out job applications
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Achieved
o Q3 summary:
Dundalk: 7
Tenax- several (3) individuals tried out for jobs,
Tenax- one on going job for individual at Tenax,
Tenax- 3 contractual jobs,
42
Ladies group visited a store and talked about jobs in that store,
One individual asked about volunteering or working at the North
Point Library after visiting,
Ladies group went to restaurant and talked jobs the type of jobs in
the restaurant,
Talked to several individuals about the landscaping group as part
of lawn mowing.
Loch Ridge: 4
Mock interviews held,
3 actual interview occurred,
Regular discussions about employment with contract area,
2 individuals worked at community job for employment experience
Seton: 3
4 individuals were given a trial experience at Chase Brexton.
o 2 individuals were hired to work at Chase Brexton 4 hrs a
day/for 2 days a week.
6 individuals went down the see if the subway job would be a good
fit;
2 of those people are waiting to do some job sampling at the
subway.
Woodlawn: 4
Session on getting along with co-workers,
Discussion on utilizing MTA Mobility to gain independence,
Job opportunities frequently available and general duties
associated (janitorial, landscaping, clerical)
Importance of learning new skills to increase employment
possibilities
Towson: 2
Staff had supported workers speak with workers at the
following businesses in an effort to build a relationship and
discuss jobs:
o Home Depot
o Rita’s
o Gold Gym
o Goodyear Tire
Regular (usually weekly) discussions about employment with
supported individuals.
Homeland: 2
Individuals went out to apply for jobs at Family Dollar store,
Discussed:
o Proper hygiene for job interviews,
o How to complete a resume and an application,
o Proper attire,
o Proper attendance, and
o Looked for jobs openings on line.
o Q3 action plan: None needed
o Q3 actions taken: None needed
43
o Q2: Achieved
o Q2 summary:
Dundalk: 7
Ladies group talked about:
o Daily hygiene
o Dream jobs
o Visiting new job sites
o Grocery shopping
o Three individuals had jobs in a community setting- two
were successful
Loch Ridge: 6
Mock interviews
Actual interview
Discussions about employment with contract area
Completed two online applications- Walmart & Rugged
Warehouse
Seton: 8
Job trails for 8 individuals for the Peat Log job. 4 were successful
in obtaining employment
Reviewed appropriate work behavior and appearance for work
Assisted individual in getting fingerprinted for a job at Chatsworth
School
Completed an application of another individual to work at the
Woodmoor school as a cafeteria aid
Woodlawn: 5
Answering incoming calls (receptionist desk)
Stocking supplies
Mock interview
Enhancing reading skills/word recognition
Enhancing writing skills
Towson: 8
Held Group Sessions
o Job as day care worker
o Cashier at a grocery store
o McDonalds
o Discuss job choices
o Strengths/abilities on a job
o Goals/interests in jobs
Homeland: 8
Completed applications for
o Dollar Store
o Giants
Discussed proper hygiene for job interviews
Discussed how to complete a resume
o Q2 action plan: None needed
o Q2 actions taken: None needed
o Q1: Achieved
o Q1 summary:
44
Dundalk: 7
Discussed employment with individuals
Moved several individuals to PS
One individual tried 2 possible jobs
Filled out applications online
Added job at school
Loch Ridge: 7
Mock interviews
Resume building
Actual interview
Discussions about employment with PWS
Seton: 6
Went to school to fill out application to become cafeteria aid
Several individuals filled out applications
Discussed job expectations with individuals
Woodlawn: 6
Good work skills
How to find a job
Computer job search
Personal information on job application
Hygiene and proper attire on interview
Towson: 6
Assisted with application and transportation to Camden Yards
Individual was assisted with resume for job as office clerk
Individuals were assisted with filling out application for Walmart
Individual was assisted with application to apply for job at AMC
theater for ticket holder job
Towson CEC had a job session on august 13, 2016 on attitude and
appearance at the work place
Towson CEC had a work session on getting along with co-workers
Homeland: 8
Discussed employment with individuals
Filled out applications online
Went to local retailers inquiring about jobs
o Q1 action plan: None needed
o Q1 actions taken: None needed
4) Category of Measure: Number of individuals in community based group integrated
jobs
Goal: To provide group integrated jobs to 30% of individuals attending day centers.
Status:
o Annual: Achieved
o Annual summary: On average, group integrated jobs were provided to 34% of
individuals attending day centers.
o Q4: Not achieved
45
o Q4 summary: 127 out of 449, or 28% of individuals attending day programs
participated in community based paid employment.
o Q4 action plan: The decline in quarter four is likely due to the fact that several
people working 5 hours or less were taken off The Arc Baltimore’s payroll on
April 1, 2017; they were working outside of the center performing such tasks as
policing and even contract work but may have been on bloated contracts.
o Q4 actions taken: None taken
o Q3: Achieved
o Q3 summary: 174 out of 533, or 33% of individuals attending day programs
participated in community based paid employment.
o Q3 action plan: None needed
o Q3 actions taken: None taken
o Q2: Achieved
o Q2 summary: 236 out of 532, or 44% of individuals attending day programs
participated in community based paid employment.
o Q2 action plan: None needed
o Q2 actions taken: None needed
o Q1: Achieved
o Q1 summary: 160 out of 533, or 30% of individuals attending day programs
participated in community based paid employment.
o Q1 action plan: None needed
o Q1 actions taken: None needed
5) Category of Measure: Percentage of individuals with employment related goals in
their Individual Plans.
Goal: To increase the percentage of individuals with employment related goals in
Individual Plan from baseline to 3% to 25%.
Status:
o Annual: Achieved
o Annual summary: The percentage of individuals with employment related goals
in their Individual Plans increased from the baseline of 3% to an annual average
of 47%.
o Q4: Annual goal
o Q4 summary: 160 out of 259, or 62% of individuals have employment related
goals in their Individual Plans.
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Annual goal
o Q3 summary: 120 out of 248, or 48% of individuals have employment related
goals in their Individual Plans.
o Q3 action plan: None taken
o Q3 actions taken: None needed
46
o Q2: Annual goal
o Q2 summary: 113 out of 260 or 43% of individuals have employment related
goals in their Individual Plans.
o Q2 action plan: None needed
o Q2 actions taken: None needed
o Q1: Annual goal
o Q1 summary: 396 out of 1,145 or 35% of individuals have employment related
goals in their Individual Plans.
o Q1 action plan: None needed
o Q1 actions taken: None needed
Training
1) Category of Measure: Employees receive specialized Autism training.
Goal: 20 employees will participate and graduate from the Autism Certification
Program.
Status:
o Annual: Not achieved
o Annual summary: 11 participants in total are expected to have completed the
Autism Certification training.
o Q4: Annual goal
o Q4 summary: A class of seven participants began the program in March of 2017.
All are progressing through the program, and should complete the program on
August 1, 2017.
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Annual goal
o Q3 summary: Applications were accepted for the Spring/Summer 2017 session
and 10 applicants applied and were accepted into the program. The first class was
held on March 28, 2017.
o Q3 action plan: None needed
o Q3 actions taken: None taken
o Q2: Annual goal
o Q2 summary: 4 of the 9 trainees enrolled in the Fall Autism Certification Program
completed the session.
o Q2 action plan: None needed
o Q2 actions taken: None taken
o Q1: Annual goal
o Q1 action plan: None needed
o Q1 actions taken: None taken
47
Human Resources
1) Category of Measure: The applicant onboarding process
Goal: To decrease the number of days between when a potential employee submits their
job application and attends orientation to 35 days or less.
Status:
o Annual: Achieved
o Annual summary: There were 322 applicants hired and 235, or 73% started
orientation within 35 days of submitting their application.
o Q4: Achieved
o Q4 summary: There were 128 applicants hired in quarter four and 100, or 78%
started orientation within 35 days of submitting their application.
o Q4 action plan: None needed
o Q4 actions taken:
Once a position is posted managers start interviewing.
The time between interview date and the pre-employment date should be
three or four days. Managers schedule applicants for pre-employment
immediately after they make an offer. Pre-employment is offered twice a
week.
Managers make sure they communicate clearly with applicants what they
need to bring to pre-employment. This helps eliminate confusion, errors,
and reduce the time between pre-employment and orientation
Human Resources continues to schedule interviews for Community Living
managers to help reduce the time between phone screens and interviews.
Human Resources continues to sends out reminder text messages to
applicants before pre-employment to ensure they bring all the required
documents.
Human Resources held a Career Open House on March 17th, 2017 to
increase applicant’s traffic.
o Q3: Achieved
o Q3 summary: There were 69 applicants hired in quarter three and 55, or 80%
started orientation within 35 days of submitting their application.
o Q3 action plan:
Once a position is posted managers need to be ready to start interviewing.
The time between interview date and the pre-employment date should be
three or four days. Managers need to schedule applicants for pre-
employment immediately after they make an offer. Pre-employment is
offered twice a week.
Managers need to make sure they communicate clearly with applicants
what they need to bring to pre-employment. This helps eliminate
confusion, errors, and reduce the time between pre-employment and
orientation
o Q3 actions taken:
Human Resources continues to schedule interviews for Community Living
managers to help reduce the time between phone screens and interviews.
48
Human Resources continues to sends out reminder text messages to
applicants before pre-employment to ensure they bring all the required
documents.
Human Resources held a Career Open House on March 17th, 2017 to
increase applicant’s traffic.
o Q2: Achieved
o Q2 summary: There were 59 applicants hired in quarter one and 47, or 80%
started orientation within 35 days of submitting their application.
o Q2 action plan:
None needed
o Q2 actions taken:
Once a position is posted managers need to be ready to start interviewing.
The time between interview date and the pre-employment date should be
three or four days. Managers need to schedule applicants for pre-
employment immediately after they make an offer. Pre-employment is
offered twice a week.
Managers need to make sure they communicate clearly with applicants
what they need to bring to pre-employment. This helps eliminate
confusion, errors, and reduce the time between pre-employment and
orientation
o Q1: Not achieved
o Q1 summary: There were 66 applicants hired in quarter one and 33, or 50%
started orientation within 35 days of submitting their application.
o Q1 action plan:
Once a position is posted managers need to be ready to start interviewing.
Managers need to block off more times on their calendar to help reduce
the time between the phone screen and the interview date. The time
between phone screens and interviews should be three or four days.
The time between interview date and the pre-employment date should be
three or four days, and pre-employment is offered twice a week. Managers
need to schedule applicants for pre-employment immediately after they
make an offer.
Managers need to make sure they communicate clearly with applicants
what they need to bring to pre-employment. This helps eliminate
confusion, errors, and reduce the time between pre-employment and
orientation
o Q1 actions taken:
Automated the recruitment and onboarding process that helped streamline
the hiring process. The onboarding implementation was complete in July
of 2016.
Human Resources continues to schedule interviews for Community Living
managers to help reduce the time between phone screens and interviews.
Human Resources sends out reminder text messages to applicants before
pre-employment to ensure they bring all the required documents.
Recruitment Coordinator was hired in May of 2015 to increase phone
screens, and reduce the time between when an applicant submits his/her
application, and receives a call from Human Resources.
Human Resources attended several job fairs.
49
Nursing
1) Category of Measure: Individuals in Community Living, who receive nursing
supports, and are prescribed 10 or more medications
Goal: To review and address all duplicated PO medications.
Status:
o Annual: Achieved
o Annual summary: At the beginning of the Quality Enhancement Plan year, there
were 77 individuals prescribed 10 or more medications. Combined the individuals
were prescribed 1,090 medications. The review process resulted in a reduction
from 77 to 73 individuals prescribed 10 or more medications, or a 5% reduction,
and a reduction from 1,090 to 827 prescribed medications, or a 24% reduction.
o Q4: Achieved
o Q4 summary: 69 individuals prescribed 10 or more medications were identified.
Combined the individuals were prescribed 979 medications. The review process
did not result in a reduction of total individuals on 10 or more medications (at the
end of the quarter there were 73 individuals), but there was a reduction from 979
to 827 prescribed medications, or a 16% reduction.
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Achieved
o Q3 summary: 74 individuals prescribed 10 or more medications were identified.
Combined the individuals were prescribed 1,058 medications. The review process
resulted in a reduction from 74 to 69 individuals prescribed 10 or more
medications, or a 7% reduction, and a reduction from 1,058 to 979 prescribed
medications, or an 8% reduction.
o Q3 action plan: None needed
o Q3 actions taken: None needed
o Q2: Achieved
o Q2 summary: 75 individuals prescribed 10 or more medications were identified.
Combined the individuals were prescribed 1,070 medications. The review
processes resulted in a reduction from 75 to 74 individuals prescribed 10 or more
medications, or a 1% reduction, and a reduction from 1,070 to 1,058 prescribed
medications, or a 1% reduction.
o Q2 action plan: None needed
o Q2 actions taken: None needed
o Q1: Achieved
o Q1 summary: 77 individuals prescribed 10 or more medications were identified.
Combined the individuals were prescribed 1,090 medications. The review
processes resulted in a reduction from 77 to 75 individuals prescribed 10 or more
medications, or a 3% reduction, and a reduction from 1,090 to 1,070 prescribed
medications, or a 6% reduction.
50
o Q1 action plan: None needed
o Q1 actions taken: None needed
2) Category of Measure: The percentage of nursing reviews completed on time
Goal: 100% of nursing reviews are completed on time.
Status:
o Annual: Not achieved
o Annual summary: 1,585 out of 2,000 or 79% of nursing reviews were completed
on time.
o Q4:
o Q4 summary: Out of 488 nursing reviews completed this quarter between CL, FL
and Day Services, 397 were completed on time. 31 nursing reviews were
identified as late and 60 are pending. At the end of the quarter, 81% of nursing
reviews were completed on time.
o Q4 action plan:
The Nursing Department director will encourage nurses to be more
diligent about completing the nursing reviews
o Q4 actions taken:
The Nursing Department director encouraged nurses to be more diligent
about completing the nursing reviews
Nurses continue to enter comments in LP to indicate the reason for nursing
reviews could not be completed. A list of individuals’ not receiving
nursing assessments at the day program has been sent to LP for updating.
The director of nursing will check LP monthly to ensure that nursing
events are entered and are current.
o Q3: Not achieved
o Q3 summary: Out of 461 nursing reviews completed this quarter between CL, FL
and Day Services, 359 were completed on time. 24 nursing reviews were
identified as late and 78 are pending. At the end of the quarter, 78% of nursing
reviews were completed on time.
o Q3 action plan:
The Nursing Department director will encourage nurses to be more
diligent about completing the nursing reviews
o Q3 actions taken:
Nurses continue to enter comments in LP to indicate the reason for nursing
reviews could not be completed. A list of individuals’ not receiving
nursing assessments at the day program has been sent to LP for updating.
The director of nursing will check LP monthly to ensure that nursing
events are entered and are current.
o Q2: Not achieved
o Q2 summary: 319 out of 481, or 66% of nursing reviews were completed on time.
o Q2 action plan:
The Nursing Department director will encourage nurses to be more
diligent about completing the nursing reviews
o Q2 actions taken:
51
Nurses continue to enter comments in LP to indicate the reason the
nursing review could not be completed.
A list of individuals’ not requiring nursing assessments at the day program
has been sent to LP for update.
Newly hired nurses have signed up for LP training scheduled for January
24th, 2017.
o Q1: 510 out of 570, or 89% of nursing reviews were completed on time.
o Q1 action plan:
The Nursing Department director will encourage nurses to be more
diligent about completing the nursing reviews.
o Q1 actions taken:
Nurses enter comments into Life print when an individual’s nursing
review cannot be completed due hospital admission, rehabilitation
admission, decline in health (for day services), etc.
Community Living
1) Category of Measure: The percentage of medical appointments completed on time
Goal: 80% of appointments are completed on time.
Status:
o Annual: Not achieved
o Annual summary: 80% of medical appointments were not completed on time (see
quarter summation below).
o Q4: Not achieved
o Q4 summary: 608 appointments were completed, of which 519 or 67% were
completed on time
o Q4 action plan:
Assistant executive director of Community Living will review medical
events with the directors during their supervision meetings.
Use the information gained from the coordinator job duty survey to better
emphasize what job areas should be prioritized.
o Q4 actions taken:
Coordinator job duty survey was completed by coordinators to better
determine how coordinators are spending their time.
Medical events are review during supervision meetings completed with
coordinators.
o Q3: Not Achieved
o Q3 summary:
Community Living
739 appointments were completed, of which 395 or 58% were
completed on time
o Q3 action plan:
52
Assistant executive director of Community Living will incorporate
medical event review into the supervision meetings completed with
coordinators, by directors.
Assistant executive director of Community Living will review medical
events with the directors during their supervision meetings.
o Q3 actions taken:
None
o Q2: Achieved
o Q2 summary:
Community Living East
273 appointments were completed, of which 233 or 85% were
completed on time
Community Living West
196 appointments were completed, of which 151 or 77% were
completed on time
o Q2 action plan: None needed, but Community Living will continue to work on
completing all medical events on time.
o Q2 actions taken: None needed, but Community Living will continue to work on
completing all medical events on time.
o Q1: Achieved
o Q1 summary:
o Community Living East:
251 appointments were completed, of which 219 or 87% were
completed on time
o Community Living West:
277 appointments were completed, of which 221 or 80% were
completed on time
o Q1 action plan: None needed, but Community Living will continue to work on
completing all medical events on time.
o Q1 actions taken: None needed, but Community Living will continue to work on
completing all medical events on time.
o Late Reasons:
Q4 CL: 14 late at fault out of 89:
Did not know about appointment: 3
Forgot appointment: 3
Individual refused: 2
Lack of staff: 5
Lack of transportation: 0
Staff/transportation got lost: 0
When called, no appointment available: 1
Q3 CL: 17 late at fault out of 98:
Did not know about appointment: 2
Forgot appointment: 4
Individual refused: 2
Lack of staff: 5
53
Lack of transportation: 2
Staff/transportation got lost: 0
When called, no appointment available: 2
Q2:
CL East: 11 late at fault out of 40:
o Did not know about appointment: 2
o Forgot appointment: 1
o Individual refused: 3
o Lack of staff: 4
o Lack of transportation: 0
o Staff/transportation got lost: 1
o When called, no appointment available: 0
CL West: 7 late at fault out of 45:
o Did not know about appointment: 5
o Forgot appointment: 0
o Individual refused: 1
o Lack of staff: 1
o Lack of transportation: 0
o Staff/transportation got lost: 0
o When called, no appointment available: 0
Q1:
CL East: 1 late at fault out of 32:
o Did not know about appointment: 0
o Forgot appointment: 0
o Individual refused: 0
o Lack of staff: 0
o Lack of transportation: 0
o Staff/transportation got lost: 1
o When called, no appointment available: 0
CL West: 15 late at fault out of 56:
o Did not know about appointment: 8
o Forgot appointment: 3
o Individual refused: 2
o Lack of staff: 0
o Lack of transportation: 0
o Staff/transportation got lost: 0
o When called, no appointment available: 2
2) Category of Measure: A decrease in the number of overdue medical appointments
Goal: To decrease the number of overdue medical appointments.
Status:
o Annual: Achieved
54
o Annual summary: There were 340 overdue medical appointments at the end of
this quarter, which is a 24% decrease from last year’s quarter four. There were
423 overdue medical appointments in quarter four of last year.
o Q4: Achieved
o Q4 summary: There were 340 overdue medical appointments this quarter, which
is a 34% decrease from last quarter. There were 512 overdue medical
appointments last quarter.
o Q4 action plan: None needed
o Q4 actions taken: None taken
o Q3: Annual goal
o Q3 summary:
There were 512 overdue medical appointments this quarter, which is a
35% increase from last quarter. There were 379 overdue medical
appointments last quarter.
o Q3 action plan:
Assistant executive director of Community Living will meet with the
directors of Community Living to review all overdue medical events and
create an action plan for completing those appointment.
o Q3 actions taken:
Assistant executive director of Community Living will incorporate
medical event review into the supervision meetings completed with
coordinators, by directors.
Assistant executive director of Community Living will review medical
events with the directors during their supervision meetings.
o Q3 actions taken:
None
o Q2: Annual goal
o Q2 summary:
o Community Living East:
There were 135 overdue medical appointments this quarter, which is a
21% decrease from last quarter. There were 170 overdue medical
appointments last quarter.
o Community Living West:
There were 254 overdue medical appointments this quarter, which is a
22% increase from last quarter. There were 209 overdue medical
appointments last quarter.
o Q2 action plan:
Assistant executive director of Community Living will meet with the
director of Community Living West to review all overdue medical events
and create an action plan for completing those appointment.
o Q2 actions taken: None
o Q1: Annual goal
o Q1 summary:
o Community Living East:
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There were 170 overdue medical appointments this quarter, which is
an 11% decrease from last quarter. There were 191 overdue medical
appointments last quarter.
o Community Living West:
There were 209 overdue medical appointments this quarter, which is a
2% decrease from last quarter. There were 214 overdue medical
appointments last quarter.
o Q1 action plan: None needed
o Q1 actions taken: None needed
3) Category of Measure: To increase the number of director support professionals who
attend individual planning meetings
Goal: Direct support professionals attend 70% of individual planning meetings.
Status:
o Annual: Achieved
o Annual summary: On average, direct support professionals attended 70% of
individual planning meetings that occurred this year.
o Q4: Not achieved
o Q4 summary: Direct support professionals attended 65% of individual planning
meetings.
o Q4 action plan:
Continue to invite direct support professionals to Individual Planning
meetings.
o Q4 actions taken:
Community Living continues to encourage attendance and promote value
of DSP’s input/attending. CL is working to ensure DSP’s who cannot
attend provide input prior to the meeting.
Many Individual Planning meetings are held during day hours when
Community Living direct support professionals are not available.
Community Living coordinators will be reminded to always extend an
invitation to direct support professionals to the Individual Planning
meetings.
Community Living will also work to schedule meetings at non-traditional
hours.
o Q3: Not Achieved
o Q3 summary: Direct support professionals attended 62% of individual planning
meetings.
o Q3 action plan :
Many Individual Planning meetings are held during day hours when
Community Living direct support professionals are not available.
Community Living coordinators will be reminded to always extend an
invitation to direct support professionals to the Individual Planning
meetings.
Community Living will also work to schedule meetings at non-traditional
hours.
o Q3 actions taken:
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CL encourages attendance and promotes value of DSP’s input/attending.
CL is working to ensure DSP’s who cannot attend provide input prior to
the meeting.
o Q2: Achieved
o Q2 summary: Direct support professionals attended 71% of individual planning
meetings.
o Q2 action plan:
Although the goal was met, some direct support professionals were not
available for when the individual plan meetings were scheduled.
o Q2 actions taken:
CL will continue to encourage attendance and promote value of DSP’s
input/attending. CL is working to ensure DSP’s who cannot attend provide
input prior to the meeting.
o Q1: Achieved
o Q1 summary: Direct support professionals attended 80% of individual planning
meetings.
o Q1 action plan: None needed
o Q1 actions taken: None needed
4.) Category of Measure: Direct support professionals meet with their supervisor
individually and in groups
Goal one: 95% of house meetings occur on a monthly basis.
Status:
o Annual: Not achieved
o Annual summary: On average, monthly house meetings occurred 76% of the time.
o Q4: Not achieved
o Q4 summary: 91% of house meeting occurred on a monthly basis.
o Q4 action plan:
Continue to emphasize the importance of house meeting during
supervision meetings.
o Q4 actions taken:
Coordinator positions were filled.
Coordinators will be reminded that house meetings must occur on a
monthly basis.
Coordinators will be offered more parameters regarding how house
meetings can be done e.g., pulling houses together for a large meeting,
utilizing technology like Skype for employees who are unable to attend
the meeting physically, but could call in etc.
o Q3: Not achieved
o Q3 summary: 75% of house meeting occurred on a monthly basis.
o Q3 action plan:
Coordinators will be reminded that house meetings must occur on a
monthly basis.
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Coordinators will be offered more parameters regarding how house
meetings can be done e.g., pulling houses together for a large meeting,
utilizing technology like Skype for employees who are unable to attend
the meeting physically, but could call in etc.
o Q3 actions taken:
Coordinator positions were filled.
o Q2: Not achieved
o Q2 summary: 74% of house meeting occurred on a monthly basis.
o Q2 action plan:
Ensure that coordinators know the expectation that they hold monthly
house meetings.
o Q2 actions taken:
Coordinator positions were filled.
o Q1: Not achieved
o Q1 summary: 62% of house meetings occurred on a monthly basis.
o Action Plan: Community Living management will clarify expectations with the
coordinators regarding the house meetings needing to be held on a monthly basis.
Community Living is restructuring in October of 2016, which should help ensure
that the meetings occur.
o Actions Taken: Community Living is working to fill open coordinator positions.
Goal two: 90% of supervision meetings occur between managers and the direct support
professionals they supervise (in Q3 supervision changed to quarterly).
Status
o Annual: Not measurable
o Annual summary: The supervision requirements changed from monthly to
quarterly in quarter three. See quarterly summation below.
o Q4: Achieved
o Q4 summary: 96% of supervision meetings occurred between managers and the
direct support professionals they support.
o Q4 action plan: None needed
o Q4 actions taken:
Assistant executive director of Community Living changed the
requirement from monthly to quarterly.
Ensured that coordinators know the expectation that they meeting with
their staff at least once per quarter.
Coordinators are aware of the supervision requirements and adjustments
were made to better enable the coordinators to meet with their employees.
Coordinators will be reminded of the expectations and held accountable to
meeting the expectations.
o Q3: Not Achieved
o Q3 summary: 50% of supervision meetings occurred on a quarterly basis.
o Q3 action plan:
Coordinators are aware of the supervision requirements and adjustments
were made to better enable the coordinators to meet with their employees.
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Coordinators will be reminded of the expectations and held accountable to
meeting the expectations.
o Q3 actions taken:
Assistant executive director of Community Living changed the
requirement from monthly to quarterly.
Ensured that coordinators know the expectation that they meeting with
their staff at least once per quarter.
o Q2: Not Achieved
o Q2 summary: 43% of supervision meetings occurred on a monthly basis.
o Q2 action plan:
Ensure that coordinators know the expectation that they meeting with their
staff at least once per quarter.
o Q2 actions taken:
Assistant executive director of Community Living changed the
requirement from monthly to quarterly.
o Q1: Not achieved
o Q1 summary: 65% of supervision meetings occurred on a monthly basis.
o Q1 action plan: Community Living management will clarify expectations with the
coordinators regarding the supervision meetings needing to be held on a monthly
basis. Community Living is restructuring in October of 2016, which should help
ensure that the meetings occur.
o Q1 actions taken: Community Living is working to fill open coordinator
positions.
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o
o
o
o
o
o
o
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o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
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