one hope united 2013 cqir annual report - hudelson region
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CQIRANNUAL REPORT
2013HUDELSON REGION
ANALYSIS
REPORT PREPARED BY KIMBERLY D.CLARK
CQIRSYSTEMS ANALYST
PLEASE DIRECT INQUIRIES TO:KCLARK@ONEHOPEUNITED.ORG
Primary Office Location
Area of Service Impact
1
4
5
67
8
2
3
Illinois
Missouri
Report Snapshot
Hudelson Regionserved 1,790 clients
and families in
FY13.
91% of Hudelson
Outcome Goals
were met.
The Hudelson
Region Compliance& Quality rating on
Peer Record
Reviews was 93%.
4 out of 5 program
categories scored
an A in overall
client satisfaction.
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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 makingsure 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 couldmake the report better in the future. Thank you for your support.
Kimberly D. ClarkCQIR Systems Analyst
Fotena A. Zirps, PhDExecutive 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 theorganization in 14 core tasks (PQI Standards) that are aligned with internal OHU principles and external
accreditation standards.
Dr. Fotena Zirps Executive Vice PresidentTina McLeod Assistant to the EVP
Florida Region Hudelson Region Northern Region Research Team
Ruann BarrackSenior Vice President
Jeffrey HonakerCQIR Director
Katurah RobyCQIR Coordinator
Ron CulbertsonCQIR Coordinator
Linda WeissCQIR Medicaid
Coordinator
Ryan Counihan
CQIR Technician
Stan GrimesCQIR Coordinator
Elizabeth HopkinsCQIR Medicaid
Coordinator
Jackie SchedinCQIR Coordinator
Sarah TunningDirector of Research
Kimberly ClarkSystems Analyst
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 Incident Reports Priority Reviews Peer Record Reviews Office Reviews Employee Recognition Client Satisfaction Supervisory Reviews Quality Improvement Teams
The CQIR Team achieved the following accomplishments in FY13. Accomplishments have beencategorized 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, OfficeReviews, 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 ITthat 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 theCouncil 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 TreatmentPlans 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 4 th 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
Ann Pearcy
Directors ofPrograms
Rachel Gubbins Becky Newcomer Nikki QuandtShannon 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% decreasefrom 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 weremet in FY13.
Out of 340 files reviewed in FY13, the HudelsonRegion Compliance & Quality rating on servicedocumentation was at 93%.
CLIENT SATISFACTION INCIDENT REPORTS
Hudelson Region Overall satisfaction score hasremained above 4.50 (A) for the past three years.
In the Hudelson Region, the number of incidentsdecreased about 4% across most incident types.Incidents involving Client/Caregiver Property(-89%), Sexually Problematic Behaviors (-42%),and Education Incidents (-32%) had the largestdecreases from FY12 to FY13.
OFFICEREVIEWS
SUPERVISORYREVIEWS
PRIORITY REVIEWS
In the Hudelson Region, 94% of Office Reviewsand 97% of Supervisory reviews were compliant.
There were 3 priority reviews conducted in FY13: 2Level III, 0 Level IIand 1 Case Consultation.
EMPLOYEE RECOGNITION QUALITY IMPROVEMENT TEAMS
There were 15 STAR awards and 5 GALAXYawards distributed this year.
There was an average QIT attendance rate of 98%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 ReviewedRisk Management Topics for FY14 QITs:
Recommended Areas to Develop Action Plans
Counseling
Counseling programs did not achieve the outcome of clients meetingtreatment goals at discharge; it was within 4% of the target.
In Peer Record Review the following programs did not achieve the agencystarget: 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%).
Family Preservation
Intact Family Counseling did not achieve the outcome of not havingconfirmed 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 agencystarget: 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%).
Placement
Specialized Foster Care did not achieve the outcome of childrenachieving permanency during the fiscal year or children experiencingtwo or fewer placement settings within 12 months; they were within 3-5% of the target.
The Residential Program did not reach the outcome related to clientsbeing available for treatment; it was within 2.47% of the target.
In Peer Record Review the following programs did not achieve the agencystarget: 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%).
Prevention
FSS did not achieve 4 of its outcomes. Improving in the domains ofParenting Capabilities, Family Interactions, Safety, and Child-Well-Beingas measured by the NCFAS were within 20% of the target.
Foster Grandparent-Mt. Vernon did not achieve the outcome ofvolunteers scoring a 5 or below on the Mood Assessment scale; it waswithin 1% of the target.
Youth Services
FTS-FFT did not achieve the outcome of youth remaining in a home likesetting; it was within 13% of the target.
FFT-Madison did not achieve the outcome of youth remaining in a homelike 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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were within 20-40% of the target.In Peer Record Review the following programs did not achieve the agencystarget: 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
FY13 FY12 FY11
Counseling 173 179 254Family Preservation 347 414 295
Placement 133 150 134Prevention 375 535 535
Youth Services 762 802 896
TOTAL 1,790 2,080 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.
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.
10%
19%
7%
21%
43%
Clients Served: Hudelson
Counseling Family Preservation Placement Prevention Youth Services
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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 havevalue to the goals of the agency. Outcome
goals are important to establish because they
provide purpose for the work with children and
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 FY11OVERALL 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 Outcome Goal Achievement: Program Category
Counseling % AchievedFamily
Preservation% Achieved Placement % Achieved
Safety100%(1/1)
Safety100%(2/2)
Safety100%(3/3)
Permanency100%(3/3)
Permanency100%(1/1)
Permanency67%(6/9)
Well-Being67%(2/3)
Well-Being50%(1/2)
Well-Being100%(2/2)
TOTAL86%(6/7)
TOTAL80%(4/5)
TOTAL79%
(11/14)
Prevention % AchievedYouth
Services% Achieved
Safety100%(2/2)
Safety100%(1/1)
Permanency100%
(2/2)Permanency
100%
(4/4)
Well-Being100%
(10/10)Well-Being
100%(8/8)
TOTAL100%
(14/14)TOTAL
100%(13/13)
CQIR monitors contract and agency
outcome goals established by federal
and state standards and OHU values.
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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
RegionStarting
Caseload
TotalPermanencies(measured by
points)
FY13Permanency
RateFY13 Goal
Hudelson 6 1 17% 20%
Specialized Foster Care Actual Children
Region AdoptionReturnHome
Guardianship Other Total
Hudelson 0 0 1 0 1
Illinois Traditional & Relative Foster Care Permanency Outcomes
RegionStarting
Caseload
TotalPermanencies(measured by
points)
FY13Permanency
RateFY13 Goal
Hudelson Downstate 44 21 48% 33%
Illinois Traditional & Relative Foster Care Actual Children
Region AdoptionReturnHome
Guardianship Other Total
Hudelson Downstate 4 6 0 0 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.
CQIR Coordinators conduct file reviews for
each program every quarter and the results are
communicated via a report for each review
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 TOTALCounseling 7 7 9 8 31
Family Preservation 8 6 15 18 47
Placement 13 13 14 11 51Prevention 25 24 24 23 96
Youth Services 27 28 28 32 115TOTAL 80 78 90 92 340
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.
COA standards require OHU to
randomly select a sample of records to
review for all programs.
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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.
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 toproduce the following graph.
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.
Intake AssessmentTreatment
Plan
Service
DeliveryClosing Overall
Actual 96% 94% 92% 92% 85% 93%
Target 90% 90% 90% 90% 90% 90%
Cross-Region 90% 85% 84% 84% 83% 86%
0%
20%
40%
60%
80%
100%
Compliance & Quality - Overall: Hudelson Programs
CounselingFamily
PreservationPlacement Prevention
Youth
Services
Program Category 94% 90% 90% 98% 93%
Target 90% 90% 90% 90% 90%
0%
20%
40%
60%
80%
100%
Overall Compliance & Quality - Across All Program Categories
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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 ReviewersEmily Blackburn
Stephanie BowdlerKendra Schuler
Mindy MillerJayme Godoyo
Jim WebsterTawnya HacklerDeb PackmanDawn WhiteNikki Quandt
Brionne RhodesHoward Coon
Colleen LareauBrigette Spelbring
Lisa RankinChanta Love
Jennifer WetzelSophia Ruffin
LaNette HeseltonHeather Kelly
Joy Loyd
Jen MaleeJoe Berry
Michelle TroyerPenny Hanks
Kristy HardwickRachel GubbinsDarren Dunahee
Lauren Kessler-SchottMelissa Webster
Becca Smith
Kara LowryChristy BrownHolly CottonKatie Klass
Afthan ReentsJennifer Shook
Kristi ZettlerTyler Moor
Becky NewcomerShannon StokesAmy 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 ofthe services provided. After all surveys have
been received, regional and program reports
are compiled to provide stakeholders with a
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.
Counseling
Family
Preservation Placement Prevention Youth ServicesFY13 4.77
(N=32)4.64
(N=168)4.19
(N=83)4.90
(N=139)4.91
(N=143)
FY12 Did not reachvalidity
4.72(N=119)
3.85(N=65)
4.83(N=187)
4.81(N=112)
FY11 4.80
(N=44)
4.78
(N=102)
4.23
(N=77)
4.82
(N=193)
4.76
(N=209)
Across Region and fiscal year, all programs except Placement scored in the fine tuning range. Twoprogram 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 FY13Overall 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 forCounseling program from FY12, since the program did not reach validity; however there was a slightdecrease when comparing to FY11.
2013 2012 2011
4.69(N= 558)
4.67(N=500)
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.
3.60
3.80
4.00
4.20
4.40
4.60
4.80
5.00
Counseling Family Preservation Placement Prevention Youth Services
Overall OHU Client Satisfaction: Hudelson Region
Client Satisfaction Surveys monitor
clients impressions of the services OHU
rovides.
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Incident ReportsAn incident is any occurrence that may have
the potential for increased risk for our clientsand the liability of our agency. Reportable
incidents also include situations that raise
risk to staff or agency property, such as a
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.
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.
0
200
400
600
800
1000
Incident Types by Year: Hudelson Region Programs
FY13 FY12 FY11
Incident reports track situations that may
have the potential for increased risk for our
clients and the liability of our agency.
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Office Systems Reviews
The Office Systems Review is a process to determine if an office is meeting agency standards. Thisincludes professional appearance, staff response to answering telephone calls, maintaining client
confidentiality and safety and risk management. CQIR coordinators conduct OHU office systems reviews
annually.
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.
94%
2% 4%
Office Systems Compliance: Hudelson
Compliant Not Compliant Partially Compliant
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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.
Twenty-two Supervisory Systems Reviews were completed in the Hudelson Region. As a Region,
supervisors were 97% compliant with items measured a 1% decrease from FY12.
97%
1%2%
Supervisory Systems Compliance: Hudelson
Compliant Not Compliant Partially Compliant
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Priority review is a process that examines
the quality of services provided to a client or
family.
Priority Reviews
A priority review is a process that
examines the quality of services providedto a client or family and compliance with
program policies and procedures. There
are three levels of priority reviews: The
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
Program CategoryCase
ConsultationsLevel 2 Level 3 TOTAL
Counseling 0 0 0 0
Family Preservation 0 0 1 1
Placement 1 0 0 1
Prevention 0 0 1 1
Youth Services 0 0 0 0
TOTAL 1 0 2 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, itwould be in the families best interest for OHU to provide aftercare services (up to 3 months) tohelp the family cope, even if the funder (such as DCFS) has closed the case. This would be agood practice for all OHU services.
It is important for external reviewers to be able to read case notes and be aware of familialrelationships 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 medicaltreatment.
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 forindividual 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 Quarter 3
Residential Specialist Team (Centralia, IL) Intact Family Services Team (Hudelson) Baker Home (Centralia, IL) 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 onimproving 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 Service Center Regional
Givers of HopeNoble IntendersCasenote QueensGibb Baker HeroesWilson Hick Heroes
BlissRG and the Sunshine Band
Behavior BustersBig 10Win3
The SupportersYouth Empowerment Program
Clinical HeroesSuper Glue Sticks
Youth Encouragers and StabilizersChain LinksNight Owls
Exceptional EightASAP
Missouri Service CenterLeaders 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
1. Clients served will not be subjects ofindicated reports of abuse or neglectduring the service period.
90% 92%
2. Clients who reside in the home of aparent at the time of referral willremain in the home.
90% 100%
3. Clients who reside in foster care orother out of home placement willremain in that placement or achievepermanency.
90% 100%
4. Clients discharged will show anoverall improvement between initial
and closing CANS ratings.
80% 92%
5. Client treatment goals having beensubstantially met at discharge.
80% 76%
SOC
Goals Target Charleston Collinsville Effingham
1. Clients will maintain their initialplacement at the time of discharge.
70% 100% 77% 82%
2. Clients discharged will show animprovement between initial and closingCANS ratings.
80% 100% 96% 88%
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Peer Record Reviews are reported below.
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 andclosing (OHU400)? (3/8)
Treatment Plan (73%)
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Comprehensive Counseling 90% 100% 95% 100% 100% 97%
Foster Care Counseling 82% 96% 100% 100% 100% 96%
Specialized Foster CareCounseling 91% 100% 92% 95% 96%
SOC-Charleston 100% 95% 100% 100% 100% 99%
SOC-Collinsville 87% 93% 73% 94% 100% 88%
SOC-Effingham 100% 85% 86% 100% 80% 91%
Target 90% 90% 90% 90% 90% 90%
All Programs 90% 94% 89% 98% 94% 94%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Counseling
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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-EffinghamAssessment (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 TargetIntactFamily
Counseling
IntactFamiliesEastern
IntactFamiliesSouthern
A
IntactFamiliesSouthern
B
1. Families will not have aconfirmed abuse or neglectreport during the serviceperiod
85% 80% 94% 87% 90%
2. Families remain togetherduring service period.
90% 95% 96% 93% 90%
3. Families discharged from theFamily Preservation programwill show an overallimprovement between initialand closing CANS.
80% 90% 89% N/A N/A
Visitation TransportationGoals Target % Achieved
1. Families will not have additionalindicated reports of abuse or neglectduring the service period.
90% 100%
2. Cases shall be terminatedsuccessfully when returned home ormeets permanency.
85% 52%
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Peer Record Reviews are reported below.
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 anoverall 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)
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Intact Family Counseling 94% 95% 100% 93% 100% 95%
Intact Families Eastern 88% 82% 69% 76% 78%Intact Families Southern 92% 91% 92% 93% 86% 92%
Visitation Transportation 89% 100% 100% 100% 96%
Target 90% 90% 90% 90% 90% 90%
All Programs 91% 90% 88% 90% 89% 90%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Family Preservation
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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 SouthernClosing (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 an11% 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 Target % Achieved
1. Children will not be abused and/or neglected(an indicated report) by a substitutecaregiver while in foster care.
99.6% 100%
2. Children will achieve permanency within 24months of the child coming into care (allother permanencies outside of reunification).
32% 80%
3. Children will experience two or fewerplacement settings within a 12 month period.
95% 100%
4. Children who are reunified with their familieswill be reunified within 12 months of the childcoming into care.
46% 100%
5. Children will remain unified for a period of 6months without re-entry into foster care.
91% 100%
6. Clients discharged from the foster careprogram will show an overall improvement
between the initial and the closing CANSratings.
80% 100%
Specialized Foster Care
Goals Target % Achieved
1. Children will not be abused and/or neglected(an indicated report) by a substitutecaregiver while in foster care.
99.6% 100%
2. Children will achieve permanency during thefiscal year.
20% 17%
3. Children will experience two or fewer
placement settings within a 12 month period.
85% 80%
4. Children will remain unified for a period of 6months without re-entry into foster care.
91% N/A
5. Clients discharged from the foster careprogram will show an overall improvementbetween the initial and the closing CANSratings.
80% 100%
6. Children will not require a higher level ofcare (i.e. psychiatric hospitalization orresidential care).
85% 92%
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Hudelson Residential
Goals Target % Achieved
1. Youth served will not be subjects of
indicated reports of abuse or neglect whilephysically present in the residentialtreatment program.
95% 100%
2. Youth served will achieve and sustain apositive or neutral discharge placement for aperiod of 90 days following discharge
21.73% 33.33%
3. The treatment opportunity rates will beachieved.
94.49% 92.02%
Peer Record Reviews are reported below for Foster Care Services and the Residential program.
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.
Intake AssessmentTreatment
PlanServiceDelivery Closing Overall
Foster Care 80% 81% 89% 82% 82%
Foster Care Licensing 99% 100% 100% 99%
Specialized Foster Care 68% 95% 78% 73% 0% 72%
Target 90% 90% 90% 90% 90% 90%
All Programs 95% 95% 86% 81% 0% 87%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Placement - Foster Care Services
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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)
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
RTx 96% 95% 96% 94% 46% 94%
Target 90% 90% 90% 90% 90% 90%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Placement - Residential
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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 ofthe 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 % Achieved
1. No substantiated reports of abuse or neglect 90% 100%
2. Families will remain intact during the serviceperiod.
95% 100%
3. Families served will show an improvement inperceived stress at completion of services asmeasured by the Caregiver StrainQuestionnaire.
90% 100%
Family Support & Supplemental Services
Goals Target FSSSupplemental
Services
1. No reports of abuse or neglect during theservice period
90% 95% 100%
2. Families will remain intact. 90% 95% 100%
3. Families will maintain stability or showimprovement in the domain of overallenvironment as measured by the NCFAS.
70% 75% 96%
4. Families will maintain stability or showimprovement in the domain of overallparenting capabilities as measured by theNCFAS.
70% 50% 96%5. Families will maintain stability or show
improvement in the domain of overall familyinteractions as measured by the NCFAS.
70% 50% 96%6. Families will maintain stability or show
improvement in the domain of overall safety
as measured by the NCFAS.
70% 50% 96%7. Families will maintain stability or show
improvement in the domain of overall child-well-being as measured by the NCFAS.
70% 50% 96%
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Foster Grandparent
Goals Target Mt. Vernon Springfield
1. Foster Grandparent Volunteers will score a 5or below on the Mood Assessment Scale
(short form) on a bi-annual basis.
90% 89% 97%
2. Foster Grandparent Volunteers who respondto the survey will report that participating inthe program has improved the overall qualityof their life as surveyed on an annual basis.
90% 100% 100%
3. Foster Grandparent volunteer sites willreport that they are satisfied with FosterGrandparent Volunteers over-all ability toperform tasks with individual children and/orgroups of children as assigned by the sitesupervisor.
70% 94% 100%
4. Children receiving one on one mentoring
and/or tutoring by a Foster GrandparentVolunteer will achieve academic, social, andbehavioral goal(s) indicated on the individualchildcare plans.
70% 94% 100%
Peer Record Reviews are reported below.
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.
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
Adoptitve Family Support 95% 100% 100% 100% 100% 99%
Foster Grandparent-Mt.Vernon 99% 100% 90% 100% 99%
Foster Grandparent-Springfield 100% 100% 100% 100% 100%
FSS 94% 91% 100% 96% 96% 95%Supplemental Services 94% 100% 100% 100% 100% 99%
Target 90% 90% 90% 90% 90% 90%
All Programs 99% 99% 98% 98% 97% 98%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Prevention
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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 clientswere 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 TargetCCBYS
(All)
1. Youth served will not besubjects of indicated reports of
abuse or neglect during theservice period.
90% 97%
2. Youth will be maintained in ahome like setting.
90% 93%
3. Youth will be deflected fromfurther involvement in the
juvenile justice system90% 99%
4. Youth will remain in school,alternative education,vocational training or employed
90% 94%
Youth Services: FFT
Goals TargetFTS FFT
FFT -Madison
FFT -Missouri
1. Youth served will not besubjects of indicated reportsof abuse or neglect duringthe service period.
90% 100% 100% 100%
2. Youth will be maintained ina home like setting.
80% 67% 71% 84%
3. Youth will be deflected fromfurther involvement in the
juvenile justice system
80% 100% 57% 88%
4. Youth will remain in school,alternative education,vocational training oremployed
80% 100% 86% 92%
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Youth Services: MST & YDP
Goals TargetFTS MST
MST 4thCircuit
MST Redeploy
YDP
1. Youth served will not besubjects of indicatedreports of abuse orneglect during the serviceperiod.
90% 50% 100% 100% 100%
2. Youth will be maintainedin a home like setting.
70% 50% 71% 95% 100%
3. Youth will be deflectedfrom further involvementin the juvenile justicesystem
70% 50% 71% 95% 92%
4. Youth will remain in
school, alternativeeducation, vocationaltraining or employed
70% 50% 71% 90% 96%
Youth Services: SASS
Goals Target % Achieved
1. Youth will remain in a homelike setting or least restrictivesetting at time of discharge.
90% 98%
2. Youth who completed serviceswill improve or maintain theirCSPI score from initial screento closing scree.
85% 92%
3. Youth will decrease their riskbehaviors as evidenced by areduction in the risk behaviordomain on the CSPI at thetime of discharge.
85% 92%
Peer Reviews are reported in the four graphs below based on program level and/or program.
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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.
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
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
CCBYS-Effingham 100% 90% 96% 100% 100% 98%
CCBYS-Mt.Vernon 100% 95% 93% 96% 80% 95%
CCBYS-Olney 93% 91% 83% 100% 100% 93%
Target 90% 90% 90% 90% 90% 90%
All Programs 97% 93% 90% 98% 90% 95%
0%
20%
40%60%
80%
100%
Compliance & Quality: Youth Services - CCBYS
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
FFT-Madison Co Redeploy 100% 91% 100% 100% 100% 99%
FFT-Missouri 90% 100% 100% 95% 100% 95%FTS-FFT 100% 100% 100% 100% 100% 100%
Target 90% 90% 90% 90% 90% 90%
All Programs 96% 97% 100% 98% 100% 98%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Youth Services - FFT
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exceeding the agencys target. Assessment, Treatment Planning, and Closing all achieved a 100%
Compliance & Quality rating.
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 areasmeasured 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.
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
FTS-MST 100% 100% 100% 100% 100% 100%
MST-4th Circuit Redeploy 92% 100% 100% 100% 100% 98%
MST-Redeploy 95% 100% 100% 100% 100% 99%YDP 95% 100% 97% 96% 83% 96%
Target 90% 90% 90% 90% 90% 90%
All Programs 95% 100% 99% 98% 91% 98%
0%
20%
40%
60%
80%
100%
Compliance & Quality: Youth Services: MST & YDP
Intake AssessmentTreatment
PlanServiceDelivery
Closing Overall
SASS-Effingham 97% 92% 95% 93% 81% 93%
SASS-Mt.Vernon 91% 93% 91% 90% 70% 91%
Target 90% 90% 90% 90% 90% 90%
All Programs 94% 93% 93% 91% 75% 92%
0%
20%
40%
60%80%
100%
Compliance & Quality: Youth Services - SASS
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7/27/2019 One Hope United 2013 CQIR Annual Report - Hudelson Region
39/39
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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