The following Review was performed by The State of Montana Developmental Disabilities Program (Department of Public Health & Human Services)
COR Enterprises Quality Assurance Review
Fiscal Year 2009
November 17th, 2008
Scope of Review:
This Quality Assurance Review covers the period of October 1, 2007 through September 30, 2008. The review includes a desk review of COR’s policies, personnel records, evacuation drills, accreditation, and a review of program records and interviews with staff during visits to COR and the Career Guidance Center. The review includes both the community supports and the 0208 waiver and includes the following services: work (both facility based and supported employment), supported living and transportation.
General Areas:
A. ADMINISTRATIVE
Significant Events from the agency:
· Since the last review COR has added more clients to many of the service areas they offer.
· They have sold off the excess land that surrounds the new building site, for a small profit.
· COR has hired a part time person to lead fund raising efforts, this person also does grant writing and marketing for the production areas; she has increased COR’s presence in the community by doing presentations at various locations.
· COR held an open house this last year to kick off their fund raising campaign.
· COR has had several other fund raising events; they have done a “shredding party”; which has resulted in many new shredding contracts. They did a mailing called “growing strong with COR”; and this last year was the 3rd annual Art Auction fund raiser which netted the most money yet and the 4th annual is already planned for January of 2009.
· This last year the Accessibility Plan and the Strategic Plan for COR were updated.
· COR is currently working on updating their website.
Agency internal communication systems:
COR facility based staff meet weekly and twice a month the entire organization has a meeting. The Career Guidance Center also has bi-monthly staff meetings that include the supported employment and supported living staff. When completing quarterly reports to the case managers the direct supervisor meets one on one with the staff and goes through each case and talks with the staff to determine if there are any concerns or issues. This is an excellent process for internally monitoring PSP outcome and action progress.
Email access is given to all employees, this helps with quick and efficient communication between supervisors and employees. It also gives them the ability to communicate changes to the agency as a whole when it is needed. Email access continues to be a preferred way of communication with the implementation of the PSP’s. Thanks for assisting us with this process.
In addition to the in facility communication they also have seven cell phones that are available to staff going on crews and outings, walkie-talkies for when they need to communicate within an area or from one area to another. COR has a policy where they reimburse an employee that uses their personal cell phone for the benefit of the job, the employee agrees to have the number posted and available to all other staff in order to get reimbursed.
Fiscal:
COR submits the required fiscal information to this office in a timely manner.
This office and COR work closely to set up and correctly process invoices for payment. This has been continued to be challenging with the addition of the transportation funds this fiscal year. We would like to again request that if an item is not correct to not invoice it so that it doesn't become a payback situation.
DPHHS preformed an internal audit of COR for the fiscal year that ended June 30, 2007. The audit showed that during this time period the amount paid by the state was covering the costs for day and supported living services with small gains for both programs. COR has a defensive interval of 5.69 months which was considered excellent. Nine other contract areas were reviewed. The auditors had recommendations for 2 of the areas reviewed. One was in regards to the role of representative payee and how funds are distributed and receipts collected. The other was that COR increase the employee dishonesty coverage to 10%. All of the auditor’s recommendations have been implemented.
Appendix I:
There were no negotiated Appendix I’s to review for the last fiscal year.
Specific Services Reviewed:
A. Residential
Accomplishments:
· The Supported Living program has continued to increase the amount of clients they serve in the last year. Since the last review this program has increased from 12 clients to 20, with more coming in from Severely Disabling Mental Illness Waiver and continued porting.
· They are proud of their ability to retain staff, this has been the reason they can provide quality services and ensure that client hours are met.
· Supported Living has made a lot of ICP changes to meet the needs of the clients they serve. They modified a cost plan to provide a client with environmental modifications. They recently got the okay to purchase a lift for one of the clients, through one time money.
· The Supported Living Program has shown great flexibility to meet individual needs.
· Michelle has drafted a new payee policy for the SL program.
i. SERVICE PLANNING AND DELIVERY
Individual program books were reviewed for people receiving supported living services. Program books were found to be organized and the data was easily located. All actions were being implemented as stated in the IP/PSP. Assessments for supported living were individualized based on the needs of the person. Quarterly progress reports were completed and clearly show the status of objectives, quarterlies are being put on the PSP forms to meet the new requirement. The files were found to be more organized this review then the last, COR has done an excellent job of updating the filing system to be more effective and efficient, thanks for your work on this. Clients also have a choice of staff, which is a policy implemented by COR last year.
The clients in Supported Living are getting out to a variety of activities. Supported Living staff have done many community outings in the last year and continue to be creative with coming up with activities to do with the clients.
ii. STAFFING
See below under “Work/Day”
iii. INCIDENT MANAGEMENT
See below in “work/day”
B. Work/Day/Community Employment
Accomplishments
· Increased number of clients served in both facility based and supported employment
· COR has worked to increase their presence in the community which has increased the public’s knowledge of person’s with disabilities
· The facility has added one additional full time employee this last year, and another staff has moved to the front office
i. SERVICE PLANNING AND DELIVERY
Individual Program books were reviewed for two individuals in Supported Employment and six individuals at the workshop.
The Supported Employment files reviewed both
had a completed Career Plan that the individual, case manager and the job
coach have signed. The tiers assigned were looked at and compared to
contact notes, the contact notes reflected the number of visits required by
the career plans. It is suggested to the Supported Employment program that in
the contacts they make it clear when it is a face to face contact as the
career plans make it clear that a certain number of face to face contacts must
be done in order to support that particular tier. I was able to discern face
to face contacts with the two clients I reviewed; however it would be helpful
to have it clearly written in the contacts.
One Supported Employment site was visited, JY works at Albertson’s; I met him,
his case manager and his SE follow along staff at the site. JY answered all
my questions and explained that he is happy at his job and with his staff
person from CGC. JY appeared happy and content with his job, his staff and
the supports in his life.
Program books were reviewed for a 10% sample of clients in work/day; data was easy to locate and interpret. All actions were documented throughout the year and plans were monitored, quarterly reports were submitted to case management on time. Quarterly reports have been found to clearly state progress on actions and outcomes, thank you for doing these in an efficient and effective manner.
ii. STAFFING
Screening/Hiring
Five staff files were reviewed for background checks and DOJ checks. All staff files reviewed contained the proper criminal background checks required. DOJ checks appear to have been returned in a timely fashion.
Orientation/training
The five staff files reviewed was cross referenced with the report of current learners on the CDS system, all of those staff were enrolled and current with CDS. The staff files also all had training documentation for: Mandt, CPR/1st Aid, Medication Certification, and driver orientation.
Staff Surveys
COR currently does not have staff complete surveys. However, they encourage feedback from staff in a variety of ways and staff meet quarterly one on one with the supervisor to complete quarterly reports, at this time they are asked how things are going and what is working and what is not working. The supervisors in each service area are present often and staff is given many opportunities to express dissatisfaction. It is not evident that any health and safety or quality of life issues exist due to no staff surveys.
iii. INCIDENT MANAGEMENT
APS
COR had seven APS reported events this review year. Six of the seven reports were reported about an outside community members or family members allegedly abusing clients that also go to COR; one report involved an incident on the COR van during transportation. This event was an allegation of potential sexual abuse by one client toward another client. None of these reports to APS indicated that abuse occurred and at this time there are no pending actions or recommendations from APS to COR.
Incident Reporting
COR continues to train staff on incident reporting. Incident management meets weekly; where they review incidents from the workshop, supported employment, community supports, and supported living. COR’s incident management committee includes management staff from all the services COR offers either in person or via phone. COR’s incident management has given a lot of good feedback and recommendations regarding incidents that have occurred. This committee is proactive in trouble shooting and preventing reoccurrences of incidents.
Critical Incident Investigations
During the course of the review period COR had 26 Critical Incidents, which required follow up staffing or investigation. All investigations were done in the time frames required by the policy. COR did have one issue of an employee in Hardin not notifying the appropriate people when he found out that an individual was hospitalized. The person was taken to the hospital by her father and staff was notified later. It is noted that Michelle Sheedy; the coordinator of SL and CS has put out guidelines to all of her staff and has made sure they are all now aware of reporting guidelines and IR policies.
C. Community Supports
COR serves 33 people in Community Supports in Yellowstone County and the surrounding counties. Services provided include residential habilitation, transportation, work, recreation and education.
i. SERVICE PLANNING AND DELIVERY
This report reviewed five consumer files in Community Supports in Billings and Hardin. The people in the sample receive a variety of services including work, transportation, residential habilitation, education, recreation and medical. One of the consumers reviewed uses Community Supports to attend COR’s work/day services in Billings. The files were found to be up to date and contained all the necessary documents required. All CSA’s were present and current; changes in plans were done accurately and effectively.
During the course of the review I visited with one client receiving CS through COR. She expressed a high level of satisfaction with COR, her only complaint was that her Case Manager (who is through another agency) has changed a lot in the last year and that is frustrating, so she stated it is nice to have stable staff at COR.
ii. STAFFING
See above in “work/day”
iii. INCIDENT MANAGEMENT
See above in “work/day”
D. Transportation:
Accomplishments:
· COR’s transportation program has again expanded from 10 clients to 19. These are the clients that COR provides a commute ride for
· COR has been awarded another van through an Montana Department of Transportation grant
· COR also sold one of the Para transit vans this last year
Checklist:
During this review, the Transportation QA checklist was completed. Using the same sample that was used for the staffing sample I checked for driver’s licenses COR continues to check staff driver’s licenses and has staff complete a driver orientation program. Three of the vehicles COR uses were checked for emergency supplies, fire extinguishers and logs, all were present in the vehicles checked. One of the vehicles had wheelchair tie downs present. The maintenance checks were reviewed and found to be up to date; the repairs noted as being needed were completed in a timely manner. All MDT inspection forms were on file and no deficiencies were found.
Conclusion
Findings Open: NONE
Findings Closed: I would like to thank all the employees of COR for all their time and assistance in completing this report. This is the first year of a brief review and COR is the first corporation to have this done in Region 3. The brief review can be done for two consecutive years and then a full QA review must be done. COR continues to adjust to changes in the system, provide quality services and emphasize staff development.
There were no deficiencies found during this review or since the last review