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Report Snapshot

CQIR ANNUAL REPORT 2013 HUDELSON REGION ANALYSIS


Primary Office Location Area of Service Impact

Hudelson Region served 1,790 clients and families in FY13. 91% of Hudelson Outcome Goals were met. The Hudelson Region Compliance

Illinois

& Quality rating on Peer Record Reviews was 93%. 4 out of 5 program
1 2 5 4 7 8 6

Missouri

categories scored an A in overall client satisfaction.

REPORT PREPARED BY KIMBERLY D. CLARK CQIR SYSTEMS ANALYST PLEASE DIRECT INQUIRIES TO: KCLARK@ONEHOPEUNITED.ORG
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Table of Contents
LETTER FROM THE EDITORS ................................................................................................................2 CQIR TEAM & HIGHLIGHTS ....................................................................................................................3 HUDELSON LEADERSHIP ......................................................................................................................5 EXECUTIVE SUMMARY ..........................................................................................................................6 CLIENTS SERVED ...................................................................................................................................9 OUTCOME MANAGMENT .....................................................................................................................10 PEER RECORD REVIEWS ....................................................................................................................12 CLIENT SATISFACTION ........................................................................................................................15 INCIDENT REPORTS .............................................................................................................................16 OFFICE SYSTEMS REVIEWS ...............................................................................................................17 SUPERVISORY SYSTEMS REVIEWS ...................................................................................................18 PRIORITY REVIEWS .............................................................................................................................19 EMPLOYEE RECOGNITION ..................................................................................................................20 QUALITY IMPROVEMENT TEAMS ........................................................................................................21 APPENDIX..............................................................................................................................................22
Appendix A: Counseling Highlights ........................................................................................................................ 22 Appendix B: Family Preservation Highlights .......................................................................................................... 25 Appendix C: Placement Highlights......................................................................................................................... 28 Appendix D: Prevention Highlights ........................................................................................................................ 32 Appendix E: Youth Services Highlights .................................................................................................................. 34

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Letter from the Editors

October 19, 2013 To Our Readers: This is our 13th year of providing the Continuous Quality Improvement and Research (CQIR) annual report on the agencys outcomes and other quality improvement activities and results. The CQIR team takes great pride in preparing and presenting this report to you, our valued stakeholders. In Fiscal Year 2013, the CQIR team has adopted a Risk Management orientation in the processes and functions we facilitate. This shift was made at the request of staff so that we could ensure that we are spotting and addressing small problems before they become larger problems. Therefore, this type of orientation is meant to be proactive rather than reactive in order to alleviate risks and ideally prevent them before they occur. With this orientation, the CQIR team has begun using a new Risk Management report during Quality Improvement Teams (QITs). This type of approach requires participation at all levels; therefore, during this process, all staff (from direct service staff to program and agency leadership) are looking at current CQIR data to identify areas for improvement and develop action plans to meet and/or exceed best practice. Staff members have reported that this approach is better for them as they are able to see the data from their programs more regularly and develop solutions to areas of concern. In the human services field, organizations are constantly being asked to, do more with less while at the same time being asked to perform at higher levels than ever before. In these economic times many programs are being scaled back or eliminated for not reaching outcomes and targets set by funders. Now more than ever, One Hope United needs to look at each program, even those that consistently perform at high levels, and use creativity, research, and innovation to become even better. Each and every program can improve upon something. If One Hope United becomes stagnant, we will fall behind. Ultimately, at the end of the day, this constant attention to data and program improvement is for the clients we serve. By asking ourselves, what can we do even better we are investing our time and energy into making sure that our clients become healthy and productive adults when they leave One Hope United. In the next year, the CQIR team will spend time developing methods to learn what happens to our clients after leaving services in order to see what sticks from our service and genuinely changes lives. This work will help us ensure that One Hope United is here for our future clients. We hope that you find this report informative and that you will let us know what you think and how we could make the report better in the future. Thank you for your support.
Kimberly D. Clark CQIR Systems Analyst Fotena A. Zirps, PhD Executive Vice President

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Continuous Quality Improvement & Research Team


To support direct service providers and ensure best practice quality of service throughout the agency, the Continuous Quality Improvement and Research (CQIR) team at One Hope United guides the organization in 14 core tasks (PQI Standards) that are aligned with internal OHU principles and external accreditation standards. Dr. Fotena Zirps Executive Vice President Tina McLeod Assistant to the EVP Florida Region Hudelson Region Northern Region Research Team Ruann Barrack Senior Vice President Ryan Counihan CQIR Technician Jeffrey Honaker CQIR Director Katurah Roby CQIR Coordinator Ron Culbertson CQIR Coordinator Linda Weiss CQIR Medicaid Coordinator Stan Grimes CQIR Coordinator Elizabeth Hopkins CQIR Medicaid Coordinator Jackie Schedin CQIR Coordinator Special thanks to Katrina Brewsaugh of the CQIR team who left in FY13. Information presented in the Hudelson Region annual report is organized by these CQIR Core Tasks: Outcome Management Peer Record Reviews Client Satisfaction Incident Reports Office Reviews Supervisory Reviews Priority Reviews Employee Recognition Quality Improvement Teams Sarah Tunning Director of Research Kimberly Clark Systems Analyst

The CQIR Team achieved the following accomplishments in FY13. Accomplishments have been categorized in line with the OHU promises of Innovation, Collaboration, Leadership, Results, and Hope. Innovation The CQIR team has been utilizing Survey Monkey technology to enter Incident Reports, Office Reviews, and Supervisory Reviews which has made the data entry process more efficient. A pilot for utilizing Survey Monkey for Peer Record Reviews is planned for FY14 using Tablet technology. The CQIR team has taken a Risk Management focus which included a pilot and a full implementation of the OHU Risk Management Report in Local, Service, and Regional Quality Improvement Teams. Under the direction of Fotena Zirps, PhD. and Sarah Tunning; Ruann Barack, Jeffrey Honaker and Kimberly Clark are members of Team Data which is looking at the current and future data needs of the organization in alignment with the agencys strategic plan. In addition, there are many members from Operations (including the Team Excellence Outcomes committee) and IT that are collaborating on this project.
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Peer Record Review Training has been developed and placed on the Essential Learning Website.

Collaboration Stan Grimes, Jackie Schedin, and Elizabeth Hopkins have all participated as volunteers with the Council on Accreditation to re-accredit 3 organizations. In collaboration with the Department of Children and Family Services, all OHU CQIR staff have access to SACWIS which will assist with electronic review of case files. The CQIR team participated in a WorkSmart training facilitated by Larry Kujovich from Executive Partners. Jackie Schedin was a presenter at a CANS training in collaboration with the Casey Foundation. Linda Weiss and Elizabeth Hopkins continued to collaborate to ensure consistency across Regions with the Medicaid Rule Changes. This included monthly meetings with program leaders to ensure all involved participated in the process of change. Jackie Schedin and Ron Culbertson collaborated with operations in the Northern and Hudelson Regions in revising the Intact Operating Procedures for the Agency Operating Manual based upon Rule changes. The group also collaborated in the revision of the Intact Quality Review Tool. Linda Weiss worked with operations in the revision of the SASS Model for service delivery to achieve a team approach to provide more efficient and effective service delivery. Ron Culbertson provided technical assistance with Missouri Leadership to assist the Missouri office in maintaining their Licensing as a Child Placement Agency. Leadership Linda Weiss from Hudelson and Elizabeth Hopkins from Northern have led the process of implementing the new Medicaid Rule to ensure all Medicaid programs are in compliance. They have also consolidated forms to one Mental Health Assessment and two Individualized Treatment Plans so that there is more consistency amongst the Northern and Hudelson regions. Stan Grimes, Jeffrey Honaker, and Kimberly Clark are participants in the 2013 Leadership Academy facilitated by CEO Bill Gillis and Executive Vice President Fotena Zirps PhD. Ruann Barack was awarded the Promise Award for Leadership. Jackie Schedin was awarded a STAR Award for exemplary service during the 4th quarter of FY13. Results The CQIR team in Florida has launched a weekly data reporting process that takes a proactive stance in addressing programmatic concerns. The Medicaid Team in Hudelson achieved a 97% rating and Northern achieved a 94% rating (a 19 point increase) on their Post Payment Reviews for FY13 services. The CQIR team participated in a CQI Capacity Assessment administered by the Department of Children and Family Services and received a 19 out of 20 rating. The assessment focused on Foster Care Programs in Illinois. Members of the CQIR team completed a Program Evaluation of the Circle of Hope program in Springfield, MO. Members of the CQIR Team completed a 100% file review of the Tampa program. Hope Katurah Roby joined the CQIR team in Tampa, FL. Sarah Tunning has taken on the Director of Research role for the Federation.
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Hudelson Leadership
The Hudelson Region is led by an Executive Director and an Associate Executive Director. Additionally, there are 5 Directors of Programs who assist in the leadership of specific programs. The Hudelson Region offers services in 5 program categories: Counseling, Family Preservation, Placement, Prevention, and Youth Services.

Patricia Griffith Executive Director

Associate Executive Director Directors of Programs

Ann Pearcy Rachel Gubbins Becky Newcomer Nikki Quandt Shannon Stokes Melissa Webster

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Executive Summary
This year, OHU programs in the Hudelson Region served 1,790 clients and families a 14% decrease from last year. The Compliance & Quality of service and record documentation overall was 93%. The efforts of Hudelson programs overall resulted in 91% of all outcome goals being met.

OUTCOME MANAGEMENT

PEER RECORD REVIEWS

Across all programs, 91% of Outcome goals were Out of 340 files reviewed in FY13, the Hudelson met in FY13. Region Compliance & Quality rating on service documentation was at 93%. CLIENT SATISFACTION INCIDENT REPORTS

Hudelson Region Overall satisfaction score has In the Hudelson Region, the number of incidents remained above 4.50 (A) for the past three years. decreased about 4% across most incident types. Incidents involving Client/Caregiver Property (-89%), Sexually Problematic Behaviors (-42%), and Education Incidents (-32%) had the largest decreases from FY12 to FY13. OFFICE REVIEWS SUPERVISORY REVIEWS PRIORITY REVIEWS

In the Hudelson Region, 94% of Office Reviews There were 3 priority reviews conducted in FY13: 2 Level III, 0 Level II and 1 Case Consultation. and 97% of Supervisory reviews were compliant. EMPLOYEE RECOGNITION QUALITY IMPROVEMENT TEAMS

There were 15 STAR awards and 5 GALAXY There was an average QIT attendance rate of 98% awards distributed this year. in the Hudelson region.

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In reviewing each area assessed in this report, the following actions are recommended in FY14 based on Outcomes and Peer Record Reviews in FY13. Program Reviewed Risk Management Topics for FY14 QITs: Recommended Areas to Develop Action Plans Counseling programs did not achieve the outcome of clients meeting treatment goals at discharge; it was within 4% of the target. In Peer Record Review the following programs did not achieve the agencys target: Foster Care Counseling did not achieve the 90% target in Intake (82%). SOC-Collinsville did not achieve the 90% target in Intake (87%) or Treatment Planning (73%). SOC-Effingham did not achieve the 90% target in Assessment (85%), Treatment Planning (86%), and Closing (80%). Intact Family Counseling did not achieve the outcome of not having confirmed abuse or neglect reports during the service period; it was within 5% of the target. Visitation Transportation did not achieve the outcome of cases being successfully returned home or achieving permanency; it was within 33% of the target. In Peer Record Review the following programs did not achieve the agencys target: Intact Families Eastern did not achieve the 90% target in Intake (88%), Assessment (82%), Treatment Planning (69%), and Service Delivery (76%). Intact Families Southern did not achieve the 90% target in Closing (86%). Visitation Transportation did not achieve the 90% target in Intake (89%). Specialized Foster Care did not achieve the outcome of children achieving permanency during the fiscal year or children experiencing two or fewer placement settings within 12 months; they were within 35% of the target. The Residential Program did not reach the outcome related to clients being available for treatment; it was within 2.47% of the target. In Peer Record Review the following programs did not achieve the agencys target: Foster Care did not achieve the 90% target in Intake (80%), Assessment (81%), Treatment Planning (89%), and Service Delivery (82%). Specialized Foster Care did not achieve the 90% target in Intake (68%), Treatment Planning (73%), Service Delivery (73%, and Closing (0%). Residential did not achieve the 90% target in Closing (46%). FSS did not achieve 4 of its outcomes. Improving in the domains of Parenting Capabilities, Family Interactions, Safety, and Child-Well-Being as measured by the NCFAS were within 20% of the target. Foster Grandparent-Mt. Vernon did not achieve the outcome of volunteers scoring a 5 or below on the Mood Assessment scale; it was within 1% of the target. FTS-FFT did not achieve the outcome of youth remaining in a home like setting; it was within 13% of the target. FFT-Madison did not achieve the outcome of youth remaining in a home like setting or being deflected from further involvement in the juvenile justice system; they were within 9-23% of the target. FTS-MST did not achieve any of its outcome goals. All outcome goals
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Counseling

Family Preservation

Placement

Prevention

Youth Services

were within 20-40% of the target. In Peer Record Review the following programs did not achieve the agencys target: CCBYS-Mt. Vernon did not achieve the 90% target in Closing (80%). CCBYS-Olney did not achieve the 90% target in Treatment Planning (83%). Youth Diversion Program did not achieve the 90% target in Closing (83%). SASS-Effingham and Mt. Vernon did not achieve the 90% target in Closing (81% and 70%, respectively).

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Clients Served
In fiscal year 2013, One Hope United served 1,790 clients and families in the Hudelson Region a decrease of 14% from FY12.

# of Clients Served by Fiscal Year


Counseling Family Preservation Placement Prevention Youth Services TOTAL FY13 173 347 133 375 762 1,790 FY12 179 414 150 535 802 2,080 FY11 254 295 134 535 896 2,114

The main influences contributing to the decrease in clients served occurred in Family Preservation (-16%), Prevention (-30%), and Placement (-11%). In Family Preservation, the closing of the Differential Response program contributed to the decrease. Additionally, the Circle of Hope program closed operations at the end of the first quarter of FY13. Prevention programs had 3 programs close at the end of FY12 (Supporting Student Stability and 2 Education Works programs) that attributed to some of the decrease. There were also less DCFS referrals to the Family Support Services (FSS) program due to the privatization of the Intact Families programs. Placement had less Foster Care referrals from DCFS which caused the decrease in the number of clients served.

Clients Served: Hudelson

10% 43% 19%

7% 21%
Counseling Family Preservation Placement Prevention Youth Services

The Youth Services programs continue to be the largest source of clients for the Hudelson Region, accounting for 43% of their client population. The next largest program category is Prevention services, accounting for 21% of Hudelsons client population.

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Outcome Management
An outcome or accomplishment can be defined as the result of efforts or outputs (interventions by an individual or team) within an agency that have value to the goals of the agency. Outcome CQIR monitors contract and agency goals are important to establish because they outcome goals established by federal provide purpose for the work with children and and state standards and OHU values. families and should tie either directly or indirectly to the mission of the agency. Additionally, outcome goals create a culture of accountability and also provide an evaluation of Child Welfare Measures (referring to a clients safety, permanency and well-being). CQIR monitors contract and agency outcome goals established by federal and state standards and OHU values.
Percentage of Outcome Goal Achievement: Hudelson FY13 FY12 FY11 OVERALL TOTAL 91% 90% 95% Safety 100% 90% 89% Permanency 84% 90% 90% Well-Being 92% 90% 100%

This year, the Hudelson Region achieved 91% of its outcome goals. The Hudelson Region holds itself to 53 outcome goals across the 5 program categories. Below is the outcome goal achievement by program category for FY13. For further outcome achievement information please see Appendices A-E.
Percentage of Out come Goal Achievement: Program Categor y Family % Achieved % Achieved Placement Preservation 100% 100% Safety Safety (1/1) (2/2) 100% 100% Permanency Permanency (3/3) (1/1) 67% 50% Well-Being Well-Being (2/3) (1/2) 86% 80% TOTAL TOTAL (6/7) (4/5) % Achieved 100% (2/2) 100% (2/2) 100% (10/10) 100% (14/14) Youth Services Safety Permanency Well-Being TOTAL

Counseling Safety Permanency Well-Being TOTAL

% Achieved 100% (3/3) 67% (6/9) 100% (2/2) 79% (11/14) % Achieved 100% (1/1) 100% (4/4) 100% (8/8) 100% (13/13)

Prevention Safety Permanency Well-Being TOTAL

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ADDITIONAL PERMANENCY ACHIEVEMENT OUTCOMES FOR FOSTER CARE

Foster Care programs in Illinois measure permanency achievement each Fiscal Year. Below are the permanency outcomes for both Specialized Foster Care and Traditional & Relative Foster Care for the Hudelson Region. Specialized Foster Care Permanency Outcomes Region Hudelson Starting Caseload 6 Total Permanencies (measured by points) 1 FY13 Permanency Rate 17% FY13 Goal 20%

Specialized Foster Care Actual Children Region Hudelson Adoption 0 Return Home 0 Guardianship 1 Other 0 Total 1

Illinois Traditional & Relative Foster Care Permanency Outcomes Total FY13 Starting Permanencies Region Permanency Caseload (measured by Rate points) Hudelson Downstate 48% 44 21 Illinois Traditional & Relative Foster Care Actual Children Return Region Adoption Guardianship Home Hudelson Downstate 4 6 0

FY13 Goal 33%

Other 0

Total 10

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Peer Record Reviews


A Peer Record Review is the process by which CQIR internally examines records in depth for timely completion of required activities (a Compliance Review) and for quality of services (a Quality Review). COA standards require OHU to randomly select a sample of records to review for all programs. COA standards require OHU to CQIR Coordinators conduct file reviews for randomly select a sample of records to each program every quarter and the results are communicated via a report for each review review for all programs. date, as well as Risk Management reports that show individual program results and results by program category. For the annual report, peer reviews are looked at for the fiscal year beginning July 1st, 2012 through June 30th, 2013. The program categories reviewed for the Hudelson Region in this report are: Counseling, Family Preservation, Placement, Prevention, and Youth Services. # of Hudeslon Region File Reviews by Quarter Program Category Q1 Q2 Q3 Q4 Counseling 7 7 9 8 Family Preservation 8 6 15 18 Placement 13 13 14 11 Prevention 25 24 24 23 Youth Services 27 28 28 32 TOTAL 80 78 90 92 In FY13, 340 files were reviewed across all five program categories. There are 9 tools utilized in the Hudelson Region that assess Compliance & Quality. There are some tools that are used that assess only compliance and then another tools that assess quality (Ex. Foster Care utilizes a Standard Compliance Tool and then a Foster Care Quality Tool). There are other programs that use one tool that assesses both Compliance and Quality (Ex. Foster Grandparent). Results were combined across all tools to produce the following graph which looks at how the Region performed as a whole.

TOTAL 31 47 51 96 115 340

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The goal for each phase of client services is 90%, represented by the black dashed line on the chart below. The purple solid line represents how each phase of client services scored cross-regionally.

Compliance & Quality - Overall: Hudelson Programs


100% 80% 60% 40% 20% 0% Intake Actual Target Cross-Region 96% 90% 90% Assessment 94% 90% 85% Treatment Plan 92% 90% 84% Service Delivery 92% 90% 84%

Closing 85% 90% 83%

Overall 93% 90% 86%

In FY13, the Hudelson Region met the 90% Compliance & Quality target in all areas with the exception of Closing, which was within 5% of the target. Overall, the Hudelson Region is the only region to meet or exceed the agencys 90% target across all program categories. Hudelson achieved a 93% Compliance & Quality rating, which is a 1% increase from FY12. Compliance & Quality performance for the Hudelson Region was also analyzed by program category to produce the following graph. Overall Compliance & Quality - Across All Program Categories
100% 80% 60% 40% 20% 0% Counseling Program Category Target 94% 90% Family Preservation 90% 90% Youth Services 93% 90%

Placement 90% 90%

Prevention 98% 90%

All program categories are meeting or exceeding the agencys 90% target for Compliance and Quality. Prevention programs are within 2% of a 100% Compliance & Quality rating. Each program category is analyzed more closely in Appendices A-E to identify additional trends and areas of improvement.
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During fiscal year 2013 there were 42 case managers, therapists, supervisors, and directors who assisted in reviewing 340 files as a part of the CQI peer record review process. These champions of quality serve as an integral part of the continual process of assessing the quality of our files, providing feedback on how to improve, and ensuring that plans of correction are being completed on time. Hudelson Peer Record Reviewers Emily Blackburn Jen Malee Stephanie Bowdler Joe Berry Kendra Schuler Michelle Troyer Mindy Miller Penny Hanks Jayme Godoyo Kristy Hardwick Jim Webster Rachel Gubbins Tawnya Hackler Darren Dunahee Deb Packman Lauren Kessler-Schott Dawn White Melissa Webster Nikki Quandt Becca Smith Brionne Rhodes Kara Lowry Howard Coon Christy Brown Colleen Lareau Holly Cotton Brigette Spelbring Katie Klass Lisa Rankin Afthan Reents Chanta Love Jennifer Shook Jennifer Wetzel Kristi Zettler Sophia Ruffin Tyler Moor LaNette Heselton Becky Newcomer Heather Kelly Shannon Stokes Joy Loyd Amy Overmyer Total Reviewers: 42 Thank you for your time, efforts, and commitment to quality service delivery.

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Client Satisfaction
CQIR conducts an annual Client Satisfaction Survey to monitor OHU clients impressions of Client Satisfaction Surveys monitor the services provided. After all surveys have clients impressions of the services OHU been received, regional and program reports are compiled to provide stakeholders with a provides. Consumer Report Card that compares their program to the programs in their program category and to regions as a whole. Please contact Sarah Tunning, Director of Research for One Hope United, for a report card on any program or region.

Overall OHU Client Satisfaction: Hudelson Region


5.00 4.80 4.60 4.40 4.20 4.00 3.80 3.60 Counseling Counseling 4.77 (N=32) Did not reach validity 4.80 (N=44) Family Preservation Family Preservation 4.64 (N=168) 4.72 (N=119) 4.78 (N=102) Placement Placement 4.19 (N=83) 3.85 (N=65) 4.23 (N=77) Prevention Prevention 4.90 (N=139) 4.83 (N=187) 4.82 (N=193) Youth Services Youth Services 4.91 (N=143) 4.81 (N=112) 4.76 (N=209)

FY13 FY12 FY11

Across Region and fiscal year, all programs except Placement scored in the fine tuning range. Two program categories (Prevention and Youth Services) saw an increase in Overall satisfaction with OHU. Placement has scored in the needs improvement range for the past three years; however in FY13 Overall satisfaction with OHU increased from FY12. Overall satisfaction in Family Preservation also decreased; however, this program is still in the fine tuning range. There is no comparative data for Counseling program from FY12, since the program did not reach validity; however there was a slight decrease when comparing to FY11. 2013 4.69 (N= 558) 2012 4.67 (N=500) 2011 4.72 (N=625)

In the Hudelson Region, overall client satisfaction with OHU has remained above 4.50 (A) for the past three years. This year, there were 558 surveys returned for the Hudelson Region, an 11.6% increase from the 500 surveys collected in 2012.

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Incident Reports
An incident is any occurrence that may have the potential for increased risk for our clients Incident reports track situations that may and the liability of our agency. Reportable incidents also include situations that raise have the potential for increased risk for our risk to staff or agency property, such as a clients and the liability of our agency. theft or natural disaster. CQIR provides monthly reports on incident trends and correlations. Annually, this report rolls up data for the fiscal year and presents incident trends by region over three fiscal years.

Incident Types by Year: Hudelson Region Programs


1000 800 600 400 200 0

FY13

FY12

FY11

In the Hudelson Region, there was a 3.7% decrease in the number of incident types in FY13 compared to FY12. There were only two incident type that increased, Medical/Psychiatric Incidents increased by 25.6% and Behavioral Issues increased by 3.4% in FY13. All other incident categories saw a decrease. The most significant decreases were in Client Caregiver Property (-88.9%), Sexually Problematic Behaviors (-42.1%), Education (-32.1%), and Client Injuries (-21.8%). It is important to note that the number of Behavior Management incidents (incidents involving a restraint) in the Residential (RTx) program decreased for the first time since FY10. In FY12, 19.9% of all incidents in the Hudelson Region involved a restraint. In FY13, out of the 1,455 incidents, 17.1% involved a restraint, a 2.8% decrease.

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Office Systems Reviews


The Office Systems Review is a process to determine if an office is meeting agency standards. This includes professional appearance, staff response to answering telephone calls, maintaining client confidentiality and safety and risk management. CQIR coordinators conduct OHU office systems reviews annually.

Office Systems Compliance: Hudelson

2%

4%

94%

Compliant

Not Compliant

Partially Compliant

Seven Office Systems Reviews were conducted in the Hudelson Region. As a Region, 94% of all office system reviews were compliant a 4% decrease from FY12.

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Supervisory Systems Reviews


On an annual basis CQIR conducts an assessment of supervision provided by each direct service supervisor in the organization. The review uses a standardized form and involves a check of a number of supervision tasks. Although there are several items addressed, there is a concentration on the frequency of supervision and quality documentation of supervisory activities.

Supervisory Systems Compliance: Hudelson

1% 2%

97%

Compliant

Not Compliant

Partially Compliant

Twenty-two Supervisory Systems Reviews were completed in the Hudelson Region. supervisors were 97% compliant with items measured a 1% decrease from FY12.

As a Region,

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Priority Reviews
A priority review is a process that examines the quality of services provided Priority review is a process that examines to a client or family and compliance with program policies and procedures. There the quality of services provided to a client or are three levels of priority reviews: The family. Level 1 Priority Review also called a case consultation is voluntary and can be conducted on any case upon the request of the supervisor. The Level 2 Priority Review is conducted in the event of a serious injury to a client or a crime. Level 3 Priority Reviews are held when there is a client death, suicide attempt, or felony. # Priority Reviews in FY13 Case Program Category Level 2 Level 3 Consultations Counseling 0 0 0 Family Preservation 0 0 1 Placement 1 0 0 Prevention 0 0 1 Youth Services 0 0 0 TOTAL 1 0 2

TOTAL 0 1 1 1 0 3

There were 3 priority reviews conducted in FY13 (down 1 from FY12). There was a decrease is the number of Level 2 Priority Reviews from FY12 (2 less) and an increase in the number of Level 3 reviews (1 more). Case Consultations are preventative in nature and are meant to be used as a method to share thoughts and ideas about a case that may be challenging. Hudelson conducted one Case Consultation in FY13. There were two Level 3 Priority Reviews conducted in FY13. One was due to the suicide of a former client from the Education Works Program and the other involved the death of a client from the Intact Family Program. Below are some highlights of lessons learned throughout the year: When a family OHU is serving experiences a death or significant change, such as moving, it would be in the families best interest for OHU to provide aftercare services (up to 3 months) to help the family cope, even if the funder (such as DCFS) has closed the case. This would be a good practice for all OHU services. It is important for external reviewers to be able to read case notes and be aware of familial relationships when there are multiple family members involved with families being served. Ensure consents are completed accurately, correctly, and for appropriate contacts. There needs to be clarification on the requirements of incident reporting for emergency medical treatment.

A complete list of lessons learned from reviews can be obtained by contacting a member of the CQIR team.
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Employee Recognition
Two methods of awarding staff excellence are supported by CQIR. The first is the STAR Award for individual excellence, and the second is the GALAXY Award for team excellence. The awards recognize staff that have gone above and beyond normal work duties, exhibited exemplary performance and done their job under circumstances that are out of the ordinary. There were 15 Star awards and 5 Galaxy awards distributed in the Hudelson Region this year. In FY13 we were proud to recognize these Hudelson employees with a STAR Award. Quarter 1 Shawn Lux Youth Care Worker I (Centralia, IL) Stacey Garner Lead Youth Care Worker (Centralia, IL) Gregory Phoenix Residential Specialist (Centralia, IL) Kayla Dunahee Residential Specialist (Centralia, IL) Shannon Stokes Director of Programs (Jefferson City, MO) Quarter 2 Jessica Perry Therapist (Centralia, IL) Brooke Lopez Administrative Assistant (Centralia, IL) Guy Janic Maintenance (Centralia, IL) Quarter 3 Jim Webster Coordinator (Centralia, IL) Brenda Perry Family Support Specialist (Olney, IL) Josh Smith Youth Care Worker (Centralia, IL) Jayme Godoyo Fund Development Officer (Centralia, IL) Tina Schrage Youth Care Worker (Centralia, IL) Quarter 4 Cindy Smith Youth Care Worker (Centralia, IL) Gabriel King Lead Youth Care Worker (Centralia, IL)

The following teams were presented with a GALAXY Award this year. Quarter 1 Residential Specialist Team (Centralia, IL) Baker Home (Centralia, IL) Quarter 3 Intact Family Services Team (Hudelson) Family Support Services and Visitation Team (Collinsville, IL) Gibb Home (Centralia, IL)

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Quality Improvement Teams


Everyone in the agency participates in at least one Quality Improvement Team (QIT). This allows each employee the power to implement improvement within their own QIT. The QIT is focused on improving the quality of service at the local level using data, effective problem solving and action planning. Across the agency, there was an overall attendance rate of 96% in FY13. The attendance rate in Hudelson was 98%. The following local, service center and regional Quality Improvement Teams were assembled three times a year in the Hudelson Region. QIT Names Local Givers of Hope Noble Intenders Casenote Queens Gibb Baker Heroes Wilson Hick Heroes Bliss RG and the Sunshine Band Behavior Busters Big 10 Win3 The Supporters Youth Empowerment Program Clinical Heroes Super Glue Sticks Youth Encouragers and Stabilizers Chain Links Night Owls Service Center Regional

Exceptional Eight ASAP Missouri Service Center Leaders of the Pack

Destination Excellence

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Appendix A Counseling Highlights


The Hudelson Region operates Counseling programs throughout Southern Illinois. Across all programs, 173 clients were served in FY13 which is a 3.4% decrease from FY12. Outcomes are reported below. For ease of analysis, results were condensed across specific types of Counseling Programs. 1. Comprehensive Counseling, which also includes Foster Care Counseling and Specialized Foster Care Counseling. 2. SOC Counseling, which provides results for all three offices. Foster Care/Specialized Foster Care/ Comprehensive Counseling Goals Target % Achieved Clients served will not be subjects of 90% 92% indicated reports of abuse or neglect during the service period. Clients who reside in the home of a 90% 100% parent at the time of referral will remain in the home. Clients who reside in foster care or other out of home placement will 90% 100% remain in that placement or achieve permanency. Clients discharged will show an 80% 92% overall improvement between initial and closing CANS ratings. Client treatment goals having been 80% 76% substantially met at discharge. SOC Target 70% 80%

1.

2.

3.

4.

5.

Goals 1. Clients will maintain their initial placement at the time of discharge. 2. Clients discharged will show an improvement between initial and closing CANS ratings.

Charleston 100% 100%

Collinsville 77% 96%

Effingham 82% 88%

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Peer Record Reviews are reported below. Compliance & Quality: Counseling
100% 80% 60% 40% 20% 0% Intake Comprehensive Counseling Foster Care Counseling Specialized Foster Care Counseling SOC-Charleston SOC-Collinsville SOC-Effingham Target All Programs 90% 82% 91% 100% 87% 100% 90% 90% Assessment 100% 96% 100% 95% 93% 85% 90% 94% Treatment Plan 95% 100% 92% 100% 73% 86% 90% 89% Service Delivery 100% 100% 95% 100% 94% 100% 90% 98% 100% 100% 80% 90% 94% Closing 100% 100% Overall 97% 96% 96% 99% 88% 91% 90% 94%

Overall, Counseling Programs in Hudelson achieved a 94% Compliance & Quality rating. SOC Collinsville (88%) is the only programs that did not achieve the overall 90% target. SOC Collinsville was below the target in Intake (87%) and Treatment Planning (73%). Comprehensive Counseling, Specialized Foster Care Counseling, and SOC Charleston met or exceeded the target across all phases of the case life cycle. Foster Care Counseling did not achieve the target in Intake (82%) and SOC Effingham did not achieve the target in Assessment (85%), Treatment Planning (86%), and Closing (80%). To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. Foster Care Counseling Intake (82%) Are Releases of Information completed, signed and current? (4/7) SOC-Collinsville Intake (87%) Is there a Case Action Form in the record documenting date of opening, transitions and closing (OHU400)? (3/8) Treatment Plan (73%)

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Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (4/8)

SOC-Effingham Assessment (85%) Was a Child & Family Team meeting conducted within 30 calendar days of accepting the referral? (2/4) Treatment Plan (86%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (2/4) Closing (80%) Was a Child and Family team meeting conducted within 10 working days of a verbal request for discharge? (1/1)

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Appendix B Family Preservation Highlights


The Hudelson Region operates four Family Preservation programs: three programs provide Intact Family Services and one provides Visitation Transportation services. Across the 4 programs, 347 clients were served in FY13, which is a 16% decrease from FY12. This decrease can be attributed to the closing of the Differential Response and Circle of Hope programs. Outcomes are provided below for Intact Family Services and for Visitation Transportation. Family Preservation Goals 1. Families will not have a confirmed abuse or neglect report during the service period 2. Families remain together during service period. 3. Families discharged from the Family Preservation program will show an overall improvement between initial and closing CANS. Target Intact Family Counseling Intact Families Eastern Intact Families Southern A 87% Intact Families Southern B 90%

85%

80%

94%

90%

95%

96%

93%

90%

80%

90%

89%

N/A

N/A

Visitation Transportation Goals Target 1. Families will not have additional 90% indicated reports of abuse or neglect during the service period. 2. Cases shall be terminated 85% successfully when returned home or meets permanency.

% Achieved 100%

52%

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Peer Record Reviews are reported below. Compliance & Quality: Family Preservation
100% 80% 60% 40% 20% 0% Intake Intact Family Counseling Intact Families Eastern Intact Families Southern Visitation Transportation Target All Programs 94% 88% 92% 89% 90% 91% Assessment 95% 82% 91% 100% 90% 90% Treatment Plan 100% 69% 92% 90% 88% Service Delivery 93% 76% 93% 100% 90% 90% Closing 100% 86% 100% 90% 89% Overall 95% 78% 92% 96% 90% 90%

Across all programs and all areas measured, the Family Preservation programs achieved a 90% Compliance & Quality Rating, which meets the agencys target. Intact Family Counseling and Visitation Transportation exceeded the target in all areas measured and scored overall Compliance & Quality ratings of 95% and 96%, respectively. Intact Families Southern did not achieve the target in Closing (86%); however all other areas measured exceeded the target and the program scored an overall Compliance & Quality rating of 92%. Intact Families Eastern is the only program that did not achieve the agencys 90% target. All areas measured were below the agencys target. Overall, the program scored a 78% Compliance & Quality rating. To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. Intact Families Eastern Intake (88%) Are the Clients' Rights and Responsibilities in the record signed by all relevant parties? (2/11) Is there a Case Action Form in the record documenting date of opening, transitions and closing? (2/11) Assessment (82%) DASA Screen on all relevant household members (2/3) Was the Initial Assessment Report completed within the required timeframe of the program contract? (3/11) Was a CERAP completed within 5 working days of case opening? (2/6) Was the Home Safety Checklist completed within 30 days of case opening? (2/6)
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Treatment Plan (69%) Was the familys comprehensive service plan completed within 30 days of case opening? (3/6) Is there evidence that the initial CANS was completed? (2/3) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (4/11) Is the current service/treatment/case plan signed and dated by the client and parent/guardian? (4/11) Service Delivery (76%) Did the caseworker visit the child (ren) in the intact family home weekly during the first 45 days after the case was opened? (3/3) Did the Intact Family Case Manager maintain the required in-home face-to-face contacts with the family? (2/6) Intact Families Southern Closing (86%) Was a CANTS/LEADS check completed for all adult members of the household, youth age 13 and older, and all adults that are frequently in the home, prior to case closing? (1/1) Was a Child/Family Team Meeting held for case closure? (1/1) Visitation Transportation Intake (89%) Are the Clients' Rights and Responsibilities in the record signed by all relevant parties? (2/5)

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Appendix C Placement Highlights


The Hudelson Region operates three Placement programs including Foster Care, Specialized Foster Care, and Residential services. Across the programs, 133 clients were served in FY13 which is an 11% decrease from FY12. This decrease is primarily attributed to a decrease in the number of referrals in Foster Care. Outcomes are reported below by program. Foster Care Goals Children will not be abused and/or neglected (an indicated report) by a substitute caregiver while in foster care. Children will achieve permanency within 24 months of the child coming into care (all other permanencies outside of reunification). Children will experience two or fewer placement settings within a 12 month period. Children who are reunified with their families will be reunified within 12 months of the child coming into care. Children will remain unified for a period of 6 months without re-entry into foster care. Clients discharged from the foster care program will show an overall improvement between the initial and the closing CANS ratings.

Target 99.6%

% Achieved 100%

1.

2.

32% 95% 46% 91%

80% 100% 100% 100%

3. 4.

5. 6.

80%

100%

1.

2. 3. 4. 5.

6.

Specialized Foster Care Goals Target Children will not be abused and/or neglected 99.6% (an indicated report) by a substitute caregiver while in foster care. Children will achieve permanency during the 20% fiscal year. Children will experience two or fewer 85% placement settings within a 12 month period. Children will remain unified for a period of 6 91% months without re-entry into foster care. Clients discharged from the foster care program will show an overall improvement 80% between the initial and the closing CANS ratings. Children will not require a higher level of 85% care (i.e. psychiatric hospitalization or residential care).

% Achieved 100% 17% 80% N/A

100%

92%

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Hudelson Residential Goals Target 1. Youth served will not be subjects of indicated reports of abuse or neglect while 95% physically present in the residential treatment program. 2. Youth served will achieve and sustain a 21.73% positive or neutral discharge placement for a period of 90 days following discharge 3. The treatment opportunity rates will be 94.49% achieved.

% Achieved 100%

33.33% 92.02%

Peer Record Reviews are reported below for Foster Care Services and the Residential program. Compliance & Quality: Placement - Foster Care Services
100% 80% 60% 40% 20% 0% Intake Foster Care Foster Care Licensing Specialized Foster Care Target All Programs 80% 99% 68% 90% 95% Assessment 81% 100% 95% 90% 95% Treatment Plan 89% 78% 90% 86% Service Delivery 82% 100% 73% 90% 81%

Closing

Overall 82% 99% 72% 90% 87%

0% 90% 0%

Across all programs and all areas measured, Foster Care services achieved an 87% Compliance & Quality Rating, which is below the agencys 90% target. Specifically, across all programs Treatment Planning (86%), Service Delivery (81%), and Closing (0%) were below the agencys target (Specialized Foster Care is the only program that reviewed a Closed case). Foster Care Licensing is the only program that exceeded the agencys target in all areas measured. Overall, Foster Care Licensing achieved a 99% Compliance & Quality rating. Foster Care achieved an overall Compliance & Quality rating of 82%. Treatment Planning was within 1% of the agencys target. Specialized Foster Care achieved an overall Compliance & Quality rating of 72% with Assessment (95%) exceeding the agencys 90% target.

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Compliance & Quality: Placement - Residential


100% 80% 60% 40% 20% 0% Intake RTx Target 96% 90% Assessment 95% 90%

Treatment Plan 96% 90%

Service Delivery 94% 90%

Closing 46% 90%

Overall 94% 90%

Overall, the Hudelson Residential program achieved a 94% Compliance & Quality rating. All areas, with the exception of Closing, exceeded the agencys target. Closing is an area of opportunity for the Residential program in FY14. To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. Foster Care Intake (80%) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (3/8) Assessment (81%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (3/8) Treatment Plan (89%) Is the current service/treatment/case plan signed and dated by the client and parent/guardian? (5/8) Service Delivery (82%) Did the initial Family Meeting occur within 48 hours of case assignment (with Supervisor present)? (5/8) Did the current Case Manager achieve or attempt face to face contact with the biological family within five working days after case assignment? (3/8) Did the Case Manager meet weekly with the child in substitute care for the first month following initial placement or change in placement? (3/8) For the past 6 months: Are there monthly supervision notes in the case record? (3/8)

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Specialized Foster Care Intake (68%) Is there a Case Action Form in the record documenting date of opening, transitions and closing? (2/5) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (2/5) Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (2/5) Treatment Plan (78%) Is the current service/treatment/case plan signed and dated by the client and parent/guardian? (3/4) Service Delivery (73%) Case note documentation reflects the level of client contact per program requirements? (3/5) Did the current Case Manager achieve or attempt face to face contact with the biological family within five working days after case assignment? (3/4) Did the second Family Meeting occur during the first 35 days of case assignment? (3/4) Did Child and Family Team meetings occur quarterly? (3/4) Closing (0%) Is the Closing Summary in the record? (1/1) Residential Closing (46%) Does the record contain documentation of an aftercare plan completed with and signed by the client or a reason why an aftercare plan was not needed? (2/2) If follow-up services were necessary, did the Closing Summary contain a formalized After Care Plan (when appropriate), signed by the client, parent/guardian, Case Manager and supervisor? (2/2)

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Appendix D Prevention Highlights


The Hudelson Region operates five Prevention programs. Across the 5 programs, 375 clients were served in FY13 which is a 30% decrease from FY12. The decrease can be attributed to the closing of the Supporting Student Stability Program, and 2 Education Works programs. There was also a decrease in the number of clients served in the Family Support Services program. Outcomes for Prevention Programs are shown below by program. Adoptive Family Support Goals Target 90% 1. No substantiated reports of abuse or neglect 2. Families will remain intact during the service 95% period. 3. Families served will show an improvement in perceived stress at completion of services as 90% measured by the Caregiver Strain Questionnaire. Family Support & Supplemental Services Goals 1. No reports of abuse or neglect during the service period 2. Families will remain intact. 3. Families will maintain stability or show improvement in the domain of overall environment as measured by the NCFAS. 4. Families will maintain stability or show improvement in the domain of overall parenting capabilities as measured by the NCFAS. 5. Families will maintain stability or show improvement in the domain of overall family interactions as measured by the NCFAS. 6. Families will maintain stability or show improvement in the domain of overall safety as measured by the NCFAS. 7. Families will maintain stability or show improvement in the domain of overall childwell-being as measured by the NCFAS. Target 90% 90% 70% FSS 95% 95% 75% Supplemental Services 100% 100% 96%

% Achieved 100% 100%

100%

70%

50%

96%

70%

50%

96%

70%

50%

96%

70%

50%

96%

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1.

2.

3.

4.

Foster Grandparent Goals Target Foster Grandparent Volunteers will score a 5 90% or below on the Mood Assessment Scale (short form) on a bi-annual basis. Foster Grandparent Volunteers who respond to the survey will report that participating in 90% the program has improved the overall quality of their life as surveyed on an annual basis. Foster Grandparent volunteer sites will report that they are satisfied with Foster Grandparent Volunteers over-all ability to 70% perform tasks with individual children and/or groups of children as assigned by the site supervisor. Children receiving one on one mentoring and/or tutoring by a Foster Grandparent 70% Volunteer will achieve academic, social, and behavioral goal(s) indicated on the individual childcare plans.

Mt. Vernon 89%

Springfield 97%

100%

100%

94%

100%

94%

100%

Peer Record Reviews are reported below. Compliance & Quality: Prevention
100% 80% 60% 40% 20% 0% Intake Adoptitve Family Support Foster Grandparent-Mt.Vernon Foster Grandparent-Springfield FSS Supplemental Services Target All Programs 95% 99% 100% 94% 94% 90% 99% Assessment 100% 100% 100% 91% 100% 90% 99% Treatment Plan 100% 90% 100% 100% 100% 90% 98% Service Delivery 100% 100% 100% 96% 100% 90% 98%

Closing 100%

Overall 99% 99% 100% 95% 99% 90% 98%

96% 100% 90% 97%

Across all programs and all areas measured, Prevention programs achieved a 98% Compliance & Quality rating, while exceeding the agencys target in all phases of the case life cycle.

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Appendix E Youth Services Highlights


The Hudelson Region operates several Youth Services programs throughout the region; including CCBYS, FFT, MST, SASS, and the Youth Diversion Program (YDP). Across all programs, 762 clients were served in FY13 which is a 5% decrease from FY12. Youth Services accounts for 43% of clients served in the region. Outcomes are reported below by program. Youth Services: CCBYS Goals 1. Youth served will not be subjects of indicated reports of abuse or neglect during the service period. 2. Youth will be maintained in a home like setting. 3. Youth will be deflected from further involvement in the juvenile justice system 4. Youth will remain in school, alternative education, vocational training or employed Target CCBYS (All) 97%

90%

90% 90%

93% 99%

90%

94%

1.

2. 3.

4.

Youth Services: FFT FTS Goals Target FFT Youth served will not be subjects of indicated reports 90% 100% of abuse or neglect during the service period. Youth will be maintained in 80% 67% a home like setting. Youth will be deflected from 80% 100% further involvement in the juvenile justice system Youth will remain in school, alternative education, 80% 100% vocational training or employed

FFT Madison 100%

FFT Missouri 100%

71% 57%

84% 88%

86%

92%

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Goals 1. Youth served will not be subjects of indicated reports of abuse or neglect during the service period. 2. Youth will be maintained in a home like setting. 3. Youth will be deflected from further involvement in the juvenile justice system 4. Youth will remain in school, alternative education, vocational training or employed

Youth Services: MST & YDP FTS MST 4th Target MST Circuit

MST Redeploy

YDP

90%

50%

100%

100%

100%

70%

50%

71%

95%

100%

70%

50%

71%

95%

92%

70%

50%

71%

90%

96%

Youth Services: SASS Goals Target 1. Youth will remain in a home 90% like setting or least restrictive setting at time of discharge. 2. Youth who completed services will improve or maintain their 85% CSPI score from initial screen to closing scree. 3. Youth will decrease their risk behaviors as evidenced by a 85% reduction in the risk behavior domain on the CSPI at the time of discharge.

% Achieved 98%

92%

92%

Peer Reviews are reported in the four graphs below based on program level and/or program.

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Compliance & Quality: Youth Services - CCBYS


100% 80% 60% 40% 20% 0% Intake CCBYS-Effingham CCBYS-Mt.Vernon CCBYS-Olney Target All Programs 100% 100% 93% 90% 97% Assessment 90% 95% 91% 90% 93% Treatment Plan 96% 93% 83% 90% 90% Service Delivery 100% 96% 100% 90% 98% Closing 100% 80% 100% 90% 90% Overall 98% 95% 93% 90% 95%

There are three offices that implement CCBYS services. Across all offices a 95% Compliance & Quality rating was achieved. All areas across the case life cycle met or exceeded the agencys 90% target. CCBYS Effingham achieved a 98% Compliance & Quality rating and met or exceeded the target across all areas measured. CCBYS Mt. Vernon achieved a 95% Compliance & Quality rating, with Closing (80%) being the only area to not meet the agencys target. CBBYS Olney achieved a 93% Compliance & Quality rating with Treatment Planning (83%) being the only are to not meet the target.

Compliance & Quality: Youth Services - FFT


100% 80% 60% 40% 20% 0% Intake FFT-Madison Co Redeploy FFT-Missouri FTS-FFT Target All Programs 100% 90% 100% 90% 96% Assessment 91% 100% 100% 90% 97% Treatment Plan 100% 100% 100% 90% 100% Service Delivery 100% 95% 100% 90% 98% Closing 100% 100% 100% 90% 100% Overall 99% 95% 100% 90% 98%

There are three FFT programs in Hudelson. Across all three programs a 98% Compliance & Quality rating was achieved. All areas across the case life cycle exceeded the agencys 90% target. FTS FFT achieved a 100% Compliance & Quality rating. FFT Madison Co Redeploy achieved a 99% Compliance & Quality rating. All areas measured exceeded the agencys target with Intake, Treatment Planning, Service Delivery, and Closing all achieving a 100% Compliance & Quality rating. FFT Missouri achieved a 95% Compliance & Quality rating with all areas measured meeting or
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exceeding the agencys target. Assessment, Treatment Planning, and Closing all achieved a 100% Compliance & Quality rating. Compliance & Quality: Youth Services: MST & YDP
100% 80% 60% 40% 20% 0% Intake FTS-MST MST-4th Circuit Redeploy MST-Redeploy YDP Target All Programs 100% 92% 95% 95% 90% 95% Assessment 100% 100% 100% 100% 90% 100% Treatment Plan 100% 100% 100% 97% 90% 99% Service Delivery 100% 100% 100% 96% 90% 98% Closing 100% 100% 100% 83% 90% 91% Overall 100% 98% 99% 96% 90% 98%

There are three MST programs and 1 Youth Diversion program in Hudelson. Across all four programs a 98% Compliance & Quality rating was achieved. All areas across the case life cycle exceeded the agencys 90% target. FTS MST achieved a 100% Compliance & Quality rating. MST Redeploy achieved a 99% Compliance & Quality rating. All areas measured exceeded the agencys target with Assessment, Treatment Planning, Service Delivery, and Closing all achieving a 100% Compliance & Quality rating. MST 4th Circuit Redeploy achieved a 98% Compliance & Quality rating with all areas measured meeting or exceeding the agencys target. Assessment, Treatment Planning Service Delivery, and Closing all achieved a 100% Compliance & Quality rating. The Youth Diversion Program achieved a 96% Compliance & Quality rating. Closing (83%) is the only area that is below the agencys target.

Compliance & Quality: Youth Services - SASS


100% 80% 60% 40% 20% 0% Intake SASS-Effingham SASS-Mt.Vernon Target All Programs 97% 91% 90% 94% Assessment 92% 93% 90% 93% Treatment Plan 95% 91% 90% 93% Service Delivery 93% 90% 90% 91% Closing 81% 70% 90% 75% Overall 93% 91% 90% 92% Page 37 of 38

There are two offices that implement SASS services. Combined, both offices achieved a 92% Compliance & Quality rating. All areas across the case life cycle, with the exception of Closing (75%), exceeded the agencys 90% target. SASS Effingham achieved a 93% Compliance & Quality rating. Closing (81%) was within 9% of the agencys target. SASS Mt. Vernon achieved a 91% Compliance & Quality rating. Closing (70%) was within 20% of the agencys target. To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. CCBYS-Mt. Vernon Closing (80%) Did the Case Manager participate with the client/family in determining if any follow-up services were necessary? (1/2) If follow-up services were necessary, did the Closing Summary contain a formalized After Care Plan (when appropriate), signed by the client, parent/guardian, caseworker and supervisor? (1/2) CCBYS-Olney Treatment Plan (83%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (5/8) YDP Closing (83%) Does the record contain documentation of an aftercare plan completed with and signed by the client or a reason why an aftercare plan was not needed? (1/2) If follow-up services were necessary, did the Closing Summary contain a formalized After Care Plan (when appropriate), signed by the client, parent/guardian, caseworker and supervisor? (1/1) SASS-Effingham Closing (81%) In preparing for termination, was the need for follow up/aftercare services determined with the client/family? (3/7) SASS-Mt. Vernon Closing (70%) Is the Closing Summary in the record? (2/4)

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