Florida Coalition Florida Coalition Against Domestic Against Domestic

ViolenceViolence Quality Assurance TrainingQuality Assurance Training

FY 09-10FY 09-10

March 24, 2010March 24, 2010

Quality Assurance AgendaQuality Assurance Agenda

IntroductionIntroduction

Incident ReportingIncident Reporting

Fiscal CloseoutFiscal Closeout

Budget AmendmentsBudget Amendments

Quarterly DeliverablesQuarterly Deliverables

ADA Compliance (ADA Compliance (Support to the Deaf or Hard of Support to the Deaf or Hard of Hearing) Hearing)

FCADV Upcoming TrainingsFCADV Upcoming Trainings

AdjournmentAdjournment

Quality Assurance Quality Assurance Organizational ChartOrganizational Chart

Lauri WildgooseDirector of Contracts

and Grant Administration

Henry BetseyContract Manager

Brenda PeckContract Manager

Chelsea Massey Grants Specialist

Jill WingContract Monitor

Fiscal & Administrative

Tiffany CarrCEO

Incident ReportingIncident Reporting

QAOP 700-002 QAOP 700-002

Incident Reporting ProceduresIncident Reporting Procedures

Timelines for submissionTimelines for submission

PurposePurpose

Establishes procedures and Establishes procedures and guidelines for identifying guidelines for identifying and reporting information and reporting information related to incidents that related to incidents that may be defined as may be defined as majormajor or or criticalcritical..

PurposePurposeA major or critical incident shall be any A major or critical incident shall be any unplanned event resulting in or having unplanned event resulting in or having the distinct potential of seriously or the distinct potential of seriously or negatively impacting the program negatively impacting the program participant, staff, volunteer, a visitor, or participant, staff, volunteer, a visitor, or center facility in the following areas:center facility in the following areas:

HealthHealthSafetySafetyWelfareWelfarePublic trust or media coverage of a certified Public trust or media coverage of a certified center center

ScopeScopeThis operating procedure applies to all This operating procedure applies to all incident reporting and risk prevention incident reporting and risk prevention in certified domestic violence centers in certified domestic violence centers under contract with FCADV. under contract with FCADV.

Please note:Please note: It is the responsibility of It is the responsibility of all certified domestic violence center all certified domestic violence center staff paid or unpaid to promptly report staff paid or unpaid to promptly report all incidents in accordance with the all incidents in accordance with the requirements of these procedures.requirements of these procedures.

ScopeScopeThis reporting procedure does not replace This reporting procedure does not replace the abuse, neglect and exploitation the abuse, neglect and exploitation reporting system as required by reporting system as required by Chapter Chapter 39 and 415, F.S.39 and 415, F.S.

Regardless of the determination based on Regardless of the determination based on the guidelines any allegations of abuse, the guidelines any allegations of abuse, neglect or exploitation shall always be neglect or exploitation shall always be reported immediately to the Florida Abuse reported immediately to the Florida Abuse Hotline on the statewide toll-free Hotline on the statewide toll-free telephone number telephone number (1-800-96ABUSE)(1-800-96ABUSE). .

Reportable IncidentsReportable Incidents

AltercationAltercationAny incident resulting in a serious Any incident resulting in a serious injury that requires medical injury that requires medical treatment by a licensed health treatment by a licensed health care professional due to a physical care professional due to a physical altercation between two or more altercation between two or more participants, or their dependents; participants, or their dependents; or between one or more or between one or more participant, their dependent, an participant, their dependent, an employee, or a volunteer.employee, or a volunteer.

Sexual BatterySexual BatteryAny incident resulting in a Any incident resulting in a participant alleging sexual participant alleging sexual battery by another battery by another participant, employee, or participant, employee, or volunteer while residing at volunteer while residing at the shelter facility or while the shelter facility or while receiving outreach services.receiving outreach services.

Serious Serious Injury/IllnessInjury/Illness

Any incident resulting in a serious Any incident resulting in a serious injury or illness that requires the injury or illness that requires the response of law enforcement, response of law enforcement, emergency medical services, emergency medical services, paramedics, or firefighters and is paramedics, or firefighters and is a result of conditions at the a result of conditions at the center that pose a serious risk of center that pose a serious risk of imminent harm to the health or imminent harm to the health or safety of participants.safety of participants.

EmbezzlementEmbezzlement

Theft/larceny of center assets Theft/larceny of center assets (money or property)(money or property) by any by any staff member or volunteer. staff member or volunteer. (Seek the advise of your CPA)(Seek the advise of your CPA)

Immediate ReportingImmediate Reporting

What is immediate What is immediate notification?notification?

Any iAny incident which the center is ncident which the center is required to report to the Executive required to report to the Executive Director and FCADV Director and FCADV within 5 hours within 5 hours by telephoneby telephone. .

Please note:Please note: Regardless of the Regardless of the perceived severity of the issue, all perceived severity of the issue, all incidents of death, communicable incidents of death, communicable disease or negative media coverage disease or negative media coverage should be reported to FCADV should be reported to FCADV immediately by telephone.immediately by telephone.

What’s next?What’s next?During normal business hours telephone During normal business hours telephone reporting to FCADV shall be made by reporting to FCADV shall be made by contacting the FCADV Contract contacting the FCADV Contract Administrator or Contract Manager at Administrator or Contract Manager at the main phone line the main phone line (850) 425-2749(850) 425-2749. . Incident reporting after normal business Incident reporting after normal business hours may be made to the Quality hours may be made to the Quality Assurance Department at Assurance Department at (850) 284-(850) 284-02860286 or to the President/CEO at or to the President/CEO at (850) (850) 510-8168510-8168..

Timelines for Timelines for SubmissionsSubmissions

All incidents requiring All incidents requiring immediate notification by immediate notification by telephone shall be followed-up telephone shall be followed-up with the completion of the with the completion of the incident reporting form within incident reporting form within 24 hours of the incident to the 24 hours of the incident to the FCADV Contract Manager.FCADV Contract Manager.

Closure of Facility, Outreach Closure of Facility, Outreach Office or Hotline FailureOffice or Hotline Failure

Any act in which the facility Any act in which the facility must close or there is hotline must close or there is hotline failure of five hours duration failure of five hours duration or longer. FCADV may assist or longer. FCADV may assist with the coordination of with the coordination of relocation for residents and relocation for residents and the transfer of hotline calls to the transfer of hotline calls to another center.another center.

Communicable Communicable DiseaseDisease

Any outbreak of a Any outbreak of a communicable disease in the communicable disease in the shelter facility that requires shelter facility that requires implementation of control implementation of control procedures or a quarantine procedures or a quarantine order issued by the State Health order issued by the State Health Officer or county health Officer or county health department.department.

OtherOtherAny action by a program Any action by a program participant, their dependent, participant, their dependent, an employee, or a volunteer, an employee, or a volunteer, that results in an that results in an adverse/negative inquiry by adverse/negative inquiry by public media, the Legislature, public media, the Legislature, or the Office of the Governor. or the Office of the Governor.

DeathDeathAny incident that involves the Any incident that involves the death of participant or their death of participant or their dependent which occurs while dependent which occurs while residing at the shelter facility residing at the shelter facility or while receiving outreach or while receiving outreach services, or any incident that services, or any incident that involves the death of an involves the death of an employee or a volunteer while employee or a volunteer while working or on center property.working or on center property.

FCADV- INCIDENT REPORTINGFCADV- INCIDENT REPORTING

Example 1Example 1You witness Participant X13 slap You witness Participant X13 slap participant YZ56 in the face. You participant YZ56 in the face. You immediately step in to keep this immediately step in to keep this incident from escalating. Law incident from escalating. Law enforcement is called and enforcement is called and participant X13 is arrested. participant X13 is arrested. Participant YZ56 is upset but states Participant YZ56 is upset but states she will be okay. she will be okay. Is this reportable?Is this reportable?

Answer 1Answer 1

Not ReportableNot Reportable

Example 2Example 2Approximately 12 noon participant Approximately 12 noon participant 123xyz’s abuser approached the gate of 123xyz’s abuser approached the gate of the shelter, rang the bell, and asked for the shelter, rang the bell, and asked for the participant by name. He was the participant by name. He was immediately instructed to leave the immediately instructed to leave the premises by staff. The Sheriffs office was premises by staff. The Sheriffs office was contacted and located him down the contacted and located him down the street from the shelter. Upon asking him street from the shelter. Upon asking him a few question he becomes belligerent a few question he becomes belligerent and gets arrested.and gets arrested.

Answer 2Answer 2

Not ReportableNot Reportable

Example 3Example 3Participant 123X’s completes her Participant 123X’s completes her safety plan and has decided it’s time safety plan and has decided it’s time to relocate and find a place of her to relocate and find a place of her own. She moves two counties away to own. She moves two counties away to start a new life with her child. After 3 start a new life with her child. After 3 years of doing very well and living on years of doing very well and living on her own, your center is notified that her own, your center is notified that participant 123X’s body was found at participant 123X’s body was found at her residence. her residence. Is this reportable?Is this reportable?

Answer 3Answer 3Reportable- If the file is openReportable- If the file is open

DeathDeath - Any incident that involves - Any incident that involves the death of participant or their the death of participant or their dependent which occurs while dependent which occurs while residing at the shelter facility or residing at the shelter facility or while receiving outreach services, or while receiving outreach services, or any incident that involves the death any incident that involves the death of an employee or a volunteer while of an employee or a volunteer while working or on center property.working or on center property.

Answer 3Answer 3

If the file is closedIf the file is closed

Not ReportableNot Reportable

Incident Reporting Incident Reporting FormsForms

There are two incident reporting forms:There are two incident reporting forms:

Domestic Violence Center Domestic Violence Center GeneralGeneral Incident Report Incident Report formform

Domestic Violence Center Domestic Violence Center DeathDeath Incident Report Incident Report formform

Centers may use these forms as part of their own Centers may use these forms as part of their own internal incident reporting policy and procedure, internal incident reporting policy and procedure, even if the incident does not rise to the level of even if the incident does not rise to the level of requiring a report to FCADV.requiring a report to FCADV.

Incident Reporting Incident Reporting FormsForms

The Domestic Violence Center Incident The Domestic Violence Center Incident Report Form and the Domestic Violence Report Form and the Domestic Violence Center Death Incident Report form shall Center Death Incident Report form shall be filled out by the staff person having be filled out by the staff person having witnessed the incident or having first witnessed the incident or having first hand knowledge of the issue. Hand hand knowledge of the issue. Hand written documentation and written documentation and documentation that is not 100% perfect documentation that is not 100% perfect English is completely acceptable. English is completely acceptable. Clarification or more detailed information Clarification or more detailed information can always be obtained later if necessary.can always be obtained later if necessary.

Reporting Reporting ProceduresProcedures

For incidents that involve participants or For incidents that involve participants or their dependents, their dependents, the actual names the actual names shall notshall not be included in the report be included in the report, , only participant case numbers shall be only participant case numbers shall be used for identification.used for identification.

Incident reporting forms shall be Incident reporting forms shall be completed fully and provide a detailed completed fully and provide a detailed summary of the incident including summary of the incident including specifics as to who, what, where, how specifics as to who, what, where, how and when.and when.

Reporting Reporting ProceduresProcedures

Incident reports are to be submitted Incident reports are to be submitted to FCADV utilizing the following to FCADV utilizing the following email address: email address:

IncidentReporting@fcadv.orgIncidentReporting@fcadv.org

QuestionsQuestions

FY 2009/2010 Close OutFY 2009/2010 Close Out

Programmatic CloseoutProgrammatic Closeout

Includes, but is not limited to, Includes, but is not limited to, determining and documenting that:determining and documenting that:

All deliverables (i.e. primary All deliverables (i.e. primary prevention, rural, ARRA, etc. and prevention, rural, ARRA, etc. and reports were received and approved reports were received and approved in writingin writing

Program objectives were met Program objectives were met

Remedies have been assessed for Remedies have been assessed for non-performance/non-compliancenon-performance/non-compliance

Fiscal Closeout Cont.Fiscal Closeout Cont.

Disallowed costs and unused grant Disallowed costs and unused grant funds have been recoveredfunds have been recoveredFinal payment to provider is made Final payment to provider is made onlyonly after all programmatic and fiscal after all programmatic and fiscal steps have been completedsteps have been completedAll financial reports has been All financial reports has been reviewed and approved in writingreviewed and approved in writingExpenditure review has been Expenditure review has been performedperformedMatch requirements have been metMatch requirements have been met

Fiscal CloseoutFiscal CloseoutUnexpended FundsUnexpended Funds

All funds disbursed under contract with FCADV All funds disbursed under contract with FCADV shall be fully expended on costs authorized by shall be fully expended on costs authorized by and in accordance with, the terms of the and in accordance with, the terms of the contract. contract. Within 90 days following the end of Within 90 days following the end of FCADV’s fiscal year of this contract, the provider FCADV’s fiscal year of this contract, the provider shall return any unexpended funds to FCADVshall return any unexpended funds to FCADV..

FY 2010-11 Contract FY 2010-11 Contract OverviewOverview

New contracts will be emailed to centers New contracts will be emailed to centers by the tentative date of June 15by the tentative date of June 15thth

An executed copy must be submitted to An executed copy must be submitted to FCADV by June 30FCADV by June 30thth

All contracts shall be fully executed by All contracts shall be fully executed by July 1July 1stst

Once the contract has been fully executed Once the contract has been fully executed a copy shall be mailed to centersa copy shall be mailed to centersPost Award Notices will be sent 60 days Post Award Notices will be sent 60 days after executionafter execution

QuestionsQuestions

Budget Budget AmendmentsAmendments

Budget AmendmentsBudget Amendments

The deadline to submit final budget The deadline to submit final budget amendments is March 31, 2010.amendments is March 31, 2010.

Budget amendment forms are accessible on Budget amendment forms are accessible on the FCADV website using the following link: the FCADV website using the following link:

http://www.fcadv.org/quality-http://www.fcadv.org/quality-contract_forms.phpcontract_forms.php

Submit all budget amendments to the Submit all budget amendments to the following email address: following email address: Contract_manager@fcadv.orgContract_manager@fcadv.org

Quarterly Quarterly DeliverablesDeliverables(4(4thth Quarter Quarter

Requirements)Requirements)

44thth Quarter Reporting Quarter Reporting RequirementsRequirements

During the 4During the 4thth quarter of this fiscal year quarter of this fiscal year centers are required to submit the centers are required to submit the Exhibit Exhibit FF (Monthly Financial Report)(Monthly Financial Report) along with a along with a profit and loss (P&L) statement generated profit and loss (P&L) statement generated from the center’s accounting system. The from the center’s accounting system. The Exhibit F, accompanied with the P&L Exhibit F, accompanied with the P&L statements, must be submitted to FCADV statements, must be submitted to FCADV with each invoice.with each invoice.

Note:Note: Centers on a cost reimbursement Centers on a cost reimbursement contract are not required to submit the contract are not required to submit the Exhibit F form however the P&L report is Exhibit F form however the P&L report is required.required.

Quarterly DeliverablesQuarterly Deliverables

Board meeting minutesBoard meeting minutes

Quarterly Financial ReportQuarterly Financial Report Must be accompanied by Profit & Loss Must be accompanied by Profit & Loss financial report generated from the financial report generated from the accounting system (FCADV Funding accounting system (FCADV Funding Only)Only)

Prior quarters can not be adjustedPrior quarters can not be adjusted

ADA ComplianceADA Compliance(Support to the Deaf or Hard of Hearing)(Support to the Deaf or Hard of Hearing)

OverviewOverview

As a directive from the Department of Children and As a directive from the Department of Children and Families, and to ensure all centers comply with Families, and to ensure all centers comply with requirements/guidelines of the CDA 10-10,  requirements/guidelines of the CDA 10-10,  this directive this directive was released in response to the Department of Children was released in response to the Department of Children and Families (DCF) entering into a Settlement Agreement and Families (DCF) entering into a Settlement Agreement with the U.S. Department of Health and Human Services, with the U.S. Department of Health and Human Services, Office of Civil Rights (OCR), Region IV.  Office of Civil Rights (OCR), Region IV. 

The focus of this directive is to provide grant and contract The focus of this directive is to provide grant and contract provisions pertaining to accommodating the special needs provisions pertaining to accommodating the special needs of the deaf or hard -of-hearing.   The provisions shall apply of the deaf or hard -of-hearing.   The provisions shall apply to grant recipients and contracted providers, as well as to grant recipients and contracted providers, as well as their partners, subcontractors, and agents, who provide their partners, subcontractors, and agents, who provide direct client services and employ 15 or more employees.direct client services and employ 15 or more employees.

Time Sensitive RequirementsTime Sensitive Requirements

The provider shall, if the provider or any of its The provider shall, if the provider or any of its partners, subcontractors, or agents employs 15 partners, subcontractors, or agents employs 15 or more employees, or more employees, designate a Single-Point-designate a Single-Point-of-Contactof-Contact (one per firm) to ensure effective (one per firm) to ensure effective communication with deaf or hard-of-hearing communication with deaf or hard-of-hearing customers or companions in accordance with customers or companions in accordance with Section 504 and the ADA. The name and Section 504 and the ADA. The name and contact information for the provider’s Single-contact information for the provider’s Single-Point-of-Contact shall be furnished to Point-of-Contact shall be furnished to the FCADV Contract Manager within the FCADV Contract Manager within 14 14 calendar dayscalendar days of the effective date of this of the effective date of this requirement. requirement.

Time Sensitive RequirementsTime Sensitive Requirements

The provider’s Single-Point-of-Contact will ensure that The provider’s Single-Point-of-Contact will ensure that conspicuous Notices which provide information about the conspicuous Notices which provide information about the availability of appropriate auxiliary aids and services at availability of appropriate auxiliary aids and services at no-cost to the deaf or hard-of-hearing customers or no-cost to the deaf or hard-of-hearing customers or companions are posted near where people enter or are companions are posted near where people enter or are admitted within the agent locations. admitted within the agent locations. Such Notices must Such Notices must be posted immediately, but not later than March 12, be posted immediately, but not later than March 12, 20102010, with respect to current providers (partners, , with respect to current providers (partners, subcontractors, and agents). The approved Notice can subcontractors, and agents). The approved Notice can be downloaded through the Internet at: be downloaded through the Internet at:

http://www.dcf.state.fl.us/admin/ig/civilrights.shtmlhttp://www.dcf.state.fl.us/admin/ig/civilrights.shtml

Time Sensitive RequirementsTime Sensitive Requirements

The provider shall, within 30 days of the The provider shall, within 30 days of the effective date of this requirement, contractually effective date of this requirement, contractually require that its partners, subcontractors and require that its partners, subcontractors and agents comply with section 504 and the ADA. agents comply with section 504 and the ADA. A Single-Point-of-Contact shall be required for A Single-Point-of-Contact shall be required for each partner, subcontractor or agent that each partner, subcontractor or agent that employs 15 or more employees. This Single-employs 15 or more employees. This Single-Point-of-Contact will ensure effective Point-of-Contact will ensure effective communication with deaf or hard-of-hearing communication with deaf or hard-of-hearing customers or companions in accordance with customers or companions in accordance with Section 504 and the ADA and coordinate Section 504 and the ADA and coordinate activities and reports with the provider’s activities and reports with the provider’s Single-Point-of-Contact.Single-Point-of-Contact.

Time Sensitive RequirementsTime Sensitive RequirementsThe provider and its partners, subcontractors, and agents shall The provider and its partners, subcontractors, and agents shall document the customer’s or companion’s preferred method of document the customer’s or companion’s preferred method of communication and any requested auxiliary aids/services communication and any requested auxiliary aids/services provided in the customer’s record. Documentation, with provided in the customer’s record. Documentation, with supporting justification, must also be made if any request was not supporting justification, must also be made if any request was not honored. The provider shall submit Compliance Reports monthly, honored. The provider shall submit Compliance Reports monthly, not later than the 15th day of each month, to the FCADV Contract not later than the 15th day of each month, to the FCADV Contract Manager. The provider shall distribute Customer Feedback forms Manager. The provider shall distribute Customer Feedback forms to customers or companions, and provide assistance in to customers or companions, and provide assistance in completing the forms as requested by the customer or completing the forms as requested by the customer or companion.companion.

Please Note: Please Note: A start date has not been established for submitting A start date has not been established for submitting the compliance monthly reports.  The Department of Children the compliance monthly reports.  The Department of Children and Families will notify FCADV when this activity is to start. and Families will notify FCADV when this activity is to start. FCADV in turn will notify each center.FCADV in turn will notify each center.

Kim Wiley, Domestic Violence and Disability Trainer Kim Wiley, Domestic Violence and Disability Trainer

wiley_kim@fcadv.orgwiley_kim@fcadv.org

FCADV Upcoming FCADV Upcoming TrainingsTrainings

Contracts and Quality Contracts and Quality Assurance UnitAssurance Unit

FCADV Contracts & FCADV Contracts & Standards TrainingStandards Training

When: May 18-19, 2010When: May 18-19, 2010Where: Swan & Dolphin Hotel – Orlando, FLWhere: Swan & Dolphin Hotel – Orlando, FL

Time: 9:00 – 4:00 pm DailyTime: 9:00 – 4:00 pm DailyRegistration Fees: NoneRegistration Fees: None

Scholarships are available on a first come, first Scholarships are available on a first come, first service basisservice basis

Please register TODAY!Please register TODAY!

AdjournmentAdjournmentIf at anytime you have questions or concerns If at anytime you have questions or concerns please contact us directly using the following:please contact us directly using the following:

Contract_manager@fcadv.orContract_manager@fcadv.orgg

FCADVFCADV425 Office Plaza Dr.425 Office Plaza Dr.

Tallahassee, FL 32301Tallahassee, FL 32301(850)425-2749(850)425-2749