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TARRY HOUSE, INC.2019

Quality Improvement and Management Report

Tarry House, Inc.564 Diagonal RoadAkron, Ohio, 44320

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IntroductionThe annual Quality Improvement and Management Report is generally written and disseminated after the first quarter each year outlining Tarry House’s successes and opportunities for improvement when looking at data from the previous year. This 2018 Management Report is a summary of Tarry House’s purpose, mission, vision, goals, objectives, accomplishments, outcomes, and financial performance for the previous year. The results are analyzed as part of Tarry House’s continuous quality and performance improvement process. This process gives us the opportunity to address the needs of the people we serve, modify and/or develop programs, build upon our strengths, and correct problems. In order to give important stakeholders the opportunity to review our performance, printed and/or electronic copies will be provided to the Board of Trustees, Tarry House Staff, the County of Summit, Alcohol, Drug Addiction and Mental Health Services Board, NAMI of Summit County and Ohio, Community Support Services, Inc., consumers of mental health services, funders, licensers, volunteers, and other interested parties.

Tarry House’s Purpose and Brief Service Descriptions: Tarry House, Inc. serves Summit County residents who are over the age of 18 and who have been diagnosed with a severe mental illness. In 2018 the agency offered a 16-bed residential recovery/treatment program at 564 Diagonal Road, a 12-bed respite facility at 4635 Manchester Road, an 8-unit apartment building for supported housing at 914 Copley Road, and finally Mental Health Assessment, Counseling and Community Psychiatric and Supportive Treatment services. A core belief of Tarry House is that mental health recovery services, provided through collaboration and partnerships within Summit County, enable all persons served to receive care within the least restrictive setting. Tarry House is dedicated to eliminating barriers based on race, gender, ethnicity, religion, age, national origin, marital status, disability and sexual orientation.

The Residential Recovery/Treatment Program offers 24-hour supervision, the monitoring of the persons served self-administration of medication, meals and individual and group skills training to help people regain or maintain their recovery and prepare for living in the community. Tarry House embraces the recovery model and encourages all persons served to set goals to increase their independence and improve the quality of their lives. Staff and volunteers have created and continue to maintain an atmosphere in which the persons served are treated with dignity and respect while they participate in behavioral health recovery services.

Tarry House’s residential recovery/treatment program has also filled a need in the Summit County community by providing housing for persons with severe mental illness who would otherwise may be homeless. Of the 27 people served by the Tarry House Recovery Home in 2019, 27 were considered homeless at admission. Tarry House also works closely with CSS’s forensic services team and mental health court teams, serving 7 individuals in 2019.

The large, multi-bedroom home is located a block away from public transportation and the persons served enjoy central dining, laundry, and recreational facilities. People are referred to the Tarry House residential behavioral health recovery program through Community Support Services, Inc. the agency in Summit County that provides multi-disciplinary services to persons with severe and persistent mental illness. A recovery specialist (generally a licensed social worker) helps each person served in the development of an Individualized Recovery Service Plan (IRSP) when he or she is admitted, and the plans are updated quarterly. The IRSP’s reflect each person’s needs, strengths, and preferences and vary in the level of structure, support and training. Services are planned and delivered to promote recovery and improve quality of life, as well as increasing skills in maintaining a home, budgeting, travel, use of community resources, and symptom recognition. Tarry House staff monitors the person served self-administration of medications and encourages the persons served to take responsibility for their continued recovery. People served in the residential program are invited to attend a weekly “house council” meeting facilitated by the staff. Issues that affect the people living in the home are discussed and their input is solicited. In most cases, Tarry House supports the transition plans developed by the referring agencies and provides housing to the persons served until they are able to obtain a subsidized apartment or other less-restrictive living situation. However, Tarry House will ask the referring agency to remove a person if his/her behavior is violating the rights of other people living at Tarry House. The 12-bed Tarry House Respite Program provides up to 13 days of emergency transitional housing “shelter” service including living quarters and support to people who are mentally ill and homeless or at risk for homelessness. The Respite Program is open to serve persons who are being discharged from hospitals and need further support. In addition, the program offers Summit County families a respite, freeing family members or other care givers to attend to other responsibilities. Treatment services are not offered at the Respite facility. In 2019, 151 different people were served.

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The 8-unit Belvedere Apartment Building was purchased in August, 2005. In 2019, Tarry House provided supportive housing services to 7 individuals with severe and persistent mental illnesses. The tenants are generally referred to The Belvidere following a stay at one of the CSS or Tarry House Treatment group homes. In 2007, due to security issues as well as the needs of the tenants served, it was decided to hire a live-in apartment manager. The apartment manager provides security, liaisons with the tenant’s community recovery specialist and assists the tenants as needed. Security cameras were installed in 2009 to add one more layer of improved security.

The Tarry House Community Psychiatric Supportive Treatment Team provided CPST services to 1 individuals in 2019. Tarry House bills third party payers directly for these individuals.

The Tarry House Counseling Services was added to the menu of services in July, 2014. Two staff members are licensed and qualified to provide this service. Tarry House staff providing Counseling Services use evidenced based interventions such as Motivation Interviewing and Cognitive Behavioral Therapy in providing services for persons with thought disorders. Tarry House bills third party payers for these services.

Tarry House is dedicated to eliminating barriers based on race, gender, ethnicity, religion, age, national origin, marital status, disability and sexual orientation.

Mission StatementTarry House, Inc. will provide quality client-driven, family-supported and evidenced based residential recovery services to assist persons with severe mental illness and/or addictions to maximize independence.

Vision StatementTarry House will be recognized as a model in treating all people with dignity, compassion and respect in its on-going efforts to reduce the stigma of mental illnesses and addictions. Tarry House will be acknowledged as a leader in recovery, fostering client resiliency and choice, while promoting family advocacy.

Admission Criteria & Referral Process: Tarry House serves Summit County residents, 18 years of age or older, who have a serious mental illness as a primary diagnosis. Admission to the Tarry House programs is voluntary, although in some cases there is usually no alternative available. Also, sometime the courts require some individuals to go through residential treatment, counseling or case management services as part as one’s outpatient commitment. People seeking admission to the Tarry House Residential Recovery Program are referred by ADM-affiliated agencies charged with serving persons with severe and persistent mental illnesses such as Community Support Services (CSS). Admission takes place after the referring agency determines that an applicant meets the admission criteria set forth by the ADM Board. Referrals to the Respite Facility are received in a variety of ways. Agencies, families, caregivers or the individual served can access this service by completing the Tarry House Respite Program Referral Form. The referral form can be found at all the Summit County Behavior Health Centers as well as state and private behavioral health hospitals and consumer run organizations such as Choices Recreation Center. The referral form can be hand delivered or faxed to Respite at 330.645.9602.

Referrals for CPST and Counseling Services can be made by calling 330-253-6689

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Highlights of 2019

Celebrated 52 years of providing services to Summit County constituents. Provided residential treatment/recovery services to 27 different people at Tarry House. 4944 Bed Day Units of Service. Provided respite services to 151 different people at Tarry House Respite. 3259 Bed days. Provide permanent Supported Housing for 7 tenants at the Belvedere Apartments. Provided CPST services to 1 individual. Provided Counseling Services for 1 individual. Provided 8212 total unit bed days billed of service for our Tarry House and Tarry House Respite Homes. Over 22 people served per day. Maintained conformance to a 3-Year CARF Accreditation to provide Out-Patient Behavioral Health Services, Case Management, Assessment

and Referral Services, Respite Services and Residential Treatment Services. Tarry House Treatment Facility participated in ODMHAS Residential Licensure Renewal. Some recommendations for improvement we

addressed and as of early 2020, still waiting for Licensure Approval. Tarry House maintained its 3-Year OhioMHAS Certification to continue to operate as a behavioral health organization in Ohio. Completed most of the tasks, objectives and goals as outlined in the Tarry House 2017-19 Organization Strategic Plan. Participated in the 2019 Akron Marathon to spread word about Tarry House and to hopefully help reduce stigma toward persons with

behavioral health diseases. Received 2 fundraising group donations from two Facebook fundraisers totaling over $1500. New concrete steps poured for Tarry House’s front entry way, replacing broken steps that had been there. Tarry House had nearly 60 staff members, clients, friends and family members participate in the ADM Recovery Challenge. Executive

Director, Mike Bullock was the race director for its 7th year. Tarry House won two awards: Most Participants and Fastest Team. Tarry House had its annual fundraiser in 2019, a golf fundraiser, in October. About 100 people enjoyed golf or putt-putt golf, a nice meal and

chance to win many fabulous prizes. About $7000 was raised and will be used to match other capital improvement grants. Tarry House built and installed raised garden beds for Tarry House’s garden in the spring of 2019 from monies collected from the 2018 Golf

Fundraiser. By the end of 2019, three staff Members celebrated 15 years with the organization.

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Tarry House Treatment Home – (564 Diagonal Road): 2019 Demographic Information:

Number of People Served on 1/1/19: 10Number of Admissions 17Number of Discharges 10Number on 12/31/19: 15

2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009Number of People Served 27 36 32 37 37 28 39 28 32 31 33

Gender: Ethnicity:Male 13 African American 15 Latino 1

Female 14 Asian American 1Caucasian 10 Other 1

Challenges and Concerns Other Than Severe Mental IllnessDiabetes 6 Mental Health Court/Forensic/ Probation/Parole 9

Other Medical Problems* 27 Physically Disabled – Ambulatory Issues 6Cigarette Smoking 16 Co-occurring Alcohol and or Substance Abuse 10

Homeless prior to admission 26 Veterans 1Victims of abuse 3

Note: each person served might be counted in more than one category

* COPD, traumatic brain injury, HIV/AIDS and other communicable diseases, kidney failure, hypertension, etc.

Served 9 fewer people at Tarry House in 2019 compared to 2018. The severity of symptoms for those served has remained steady the last couple years. In 2019, all 27 people served had “other medical problems”. This is the most recorded over the past 10 years. This number needs to be explored and see if there have been trends among the mentally ill where medical problems have increased. 59% of the people served by Tarry House in 2019 smoke cigarettes and many of them have medical problems, such as COPD or hypertension, that are exacerbated by smoking. Tarry House continues providing options for those served to attend a smoking cessation program, training to the cook to prepare healthy meals and training to all staff related to the care and prevention of diabetes. 37% of the people served had co-occurring substance abuse issues, in 2018 the percentage was 28%. So a bit of an increase. 26% of the people served were involved with the court system and the percentage remained about the same fomr last year. Tarry House continues to work closely with the person’s community recovery specialist to ensure the whole team is following court orders and expectations for treatment. Almost all of the 27 individuals served at Tarry House were considered homeless at admission.

Analysis: 1. The County of Summit, the mental health community in general and Summit 2020 has set goals to improve the physical health of persons with severe and persistent

mental illnesses. Tarry House should set some goals related to improving physical health of those served. Helping folks quit smoking would be a good start as a high percentage of the folks served, smoke. Also, healthy eating should be encouraged. Tarry House is exploring grants to fund the provision of fresh vegetables and fruits. Other medical problems have increased steadily over the past 10 years. This should also be addressed via agency goals.

2. Served 1 military veterans in 2019. Services for veterans, especially around homelessness and housing has really increased in Summit County over the past couple years, thanks to the VA and other housing programs serving military veterans.

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3. A high percentage of folks (96%) served were homeless prior to admission. Tarry House continues to set goals to make sure everyone works hard to help folks move to independent apartments when persons “graduate” from Tarry House.

4. Tarry House began to track how many individuals served had a history of being victims of abuse in 2018. Of the 36 people served in 2019 only 3 (compared to 18 in 2018) have a documented history of abuse. This number needs to be reevaluated. This might be an interrater reliability error. Perhaps Tarry House needs to look for documentation related to victimization when completing clinical records reviews. Tarry House will continue to track this and make adjustments as needed to track this and to make sure people are given options to help recover.

5. 10 individuals (28%) served had diagnosed addiction issue. This has been the norm the last several years.

Utilization of Services in 2019Tarry House Treatment/Recovery Home (specifications based on 85% of 14 beds)

Units of Service expected: 4343 Average length of stay – days - of those discharged in 2019 219 daysCY 2019 Billed Units of Service (“bed days”): 4944 Median Length of Stay 79 days

Percentage of Goal: 114%“Unduplicated Persons Served” 27

Analysis and comments about Tarry House Treatment/Recovery Home’ utilization of services: In 2019, the Tarry House Residential Treatment program provided 4944 “bed days” of service. In 2018, this program provided 4137 units (bed days) of service, thus increasing the number of treatment days by 807 days. The expectation was to provide 4343 units of service, so this program greatly exceeded that goal. The 4137 “bed days” reflects days when the person served slept at the recovery home or in an acute hospital stay. Tarry House does not bill for therapeutic leaves which are generally when the person visits family or friends’ over-night or had left the home and had not returned without notice. When a person leaves the program without notice, the “bed” is held as long as ADM, Tarry House, CSS and the referring entity think it is appropriate.

The target for length of stay at the Tarry House Treatment/Recovery Home is 270 days. Clients at Tarry House averaged 219 days, so the goal was met. This is probably due to the fact that to end homelessness, Summit County has worked very hard the last 2 decades to secure Federal and State funding for affordable housing. In the past, many stayed at Tarry House even after they essentially met their goals but due to lack of housing, many stayed longer than probably needed. Two individuals stayed 963 and 682 days respectively thus eschewing the numbers a bit as did the 3 folks who stayed less than 30 days each. Serving just 27 people at the Tarry House Recovery Home in 2019 was statistically lower than the norm when compared to the previous 10 years, as averaging the amount of people per year the past 10 years is 34 people served per year.

It should be noted that the Tarry House Residential Treatment Home has not received State funding for many years but thankfully the County of Summit ADM Board provides the per diem rate.

Level of Care Following Treatment in the Tarry House Recovery Home in 2019 (N= 10)

Apartment or own home 4 Hospital 0Family, friend or significant other 2 Nursing home 1

Board and care group home 0 Shelter 1

jail 1 Drug Rehab inpatient 0lateral transfer (treatment group home) 1 TOTAL Discharges 10 people

Analysis: Of the 10 people who transitioned/discharged from the Recovery Home in 2019, 7 (70%) went to a setting that was an equal to or less restrictive environment such as an apartment, a home, board and care group home, or a friend or family member’s home. 4 people transitioned to independent apartments or homes for a total of 40%, missing the goal of 50%. Although Tarry House did not meet this goal, Tarry House is serving people with dual diagnoses (addiction issues) so the organization will take this in consideration as it analyses outcomes and may set goals to change programming to improve outcomes.

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Tarry House Respite: Demographic Data: CY 2019Calendar Year 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008

Number of Persons Served 151 149 178 195 175 178 185 142 182 167 171 190Total Admissions 308 340 351 378 371 409 393 367 388 348 386 383

Gender and Ethnicity:Women 58 African American 54 Multi-racial or other 2

Men 93 Caucasian 95Transgender 0

Challenges and Concerns Other Than Severe Mental IllnessDiabetes 6 Mental Health Court/Forensic/ Probation/Parole 11 Co-Occurring Drug and Alcohol 60

Other Medical Problems * 10 Physically Disabled – Ambulatory Issues 1 Developmentally Disabled 0Cigarette Smoking 61 History or current Alcohol abuse 56 Communicable Disease 0

Homeless prior to admission 147 History or current Drug Abuse 28 Veterans 4Note: each person served might be counted in more than one category. *includes COPD, traumatic brain injury, HIV/AIDS, kidney disease, hypertension, etc.

In 2019, Tarry House Respite served 151 people and of those people served, 147 or 97% were homeless prior to admission. This was one of the primary reasons the Tarry House Respite Program was established 28 years ago. In 2019, 61 of the people served at Respite were smokers, 40%, which has been the approximate percentage the last few years. This is still an area for which the community needs to set goals to help people quit smoking. Although there were 308 admissions, only 151 different people were served. As has been the norm since the inception of Tarry House Respite, many people were served at least 2 times throughout 2019. People may stay up to 13 days but can be “re-referred” immediately after discharge if necessary and many do.

Analysis: 1. Tarry House Respite is serving more people who have co-occurring mental illness and drug and alcohol addiction issues over the past year although the number in 2019

were similar by percentage to the calendar 2018 numbers. 2. People suffering from addictions and/or mental illness and who are smokers has decreased a bit over the years. Some of the community interventions may be working.

Will continue to track and monitor this.

Tarry House Respite. Utilization of Service in 2019: Tarry House Respite: (specifications based on 85% of 11 beds): Units of Service Goal (bed days): 3412 Utilized Service 4 times 4Units Provided 3259 Utilized Service 5 times 6Percentage of Goal: 95% Utilized Service 6 times 3“Unduplicated” Persons Served 151 Utilized Service 7 times 4Total Admissions 308 Utilized Service 8 times 2Average Length of Stay 9 days Utilized Service 9 times 1Utilized Service 1 time 93 Utilized Service 10 times 1Utilized Service 2 times 24 Utilized Service 14 times 14Utilized Service 3 times 12

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Tarry House Respite: comments and analysis about utilization of services: Tarry House Respite had the goal to provide 3412 units of service and provided 3259 days of service, or 96% of the goal. Tarry House Respite would have moved closer to this goal had everyone referred and accepted to Respite actually showed up for admission. “No call, no shows” occurred on an average of 10 times monthly in 2019. The documented explanation for these no shows was a lack of follow-through of the person served, and/or the person’s Community Recovery Specialist (CRS). Procedurally, the first thing in the morning a Respite employee phones the persons on the waiting list and/or the person’s CRS is notified that there is a vacancy. The vacancy is reserved for that person for approximately four hours the day of the vacancy. Often the person and/or CRS would not return calls or show up, thus potentially contributing to a vacancy.

Of the 151 different people served at Respite, 93 individuals utilized the program just one time. 40 individuals used the program two, three or four times. There were also several individuals who stayed at the Respite facility more than four times. One individual used the Respite program 14 times in 2019. The primary reason for multiple admissions for these individuals was due to chronic homelessness, poor tenant histories and multiple addiction issues coupled with a long waiting list for subsidized housing.

Although individuals may stay at Respite for up to 13 days, people stayed an average of 9 days for each admission in 2019. This is the same as in 2018. As was the case the last couple years and probably through the history of Respite, the main reason the census was not higher is due to “beds” being held for people who never arrive to utilize the facility and many who go in to town for the day but do not return. See 2019 Major and Minor Incident Reports – absence without notice in pages to come.

Supported Housing – The Belvidere ApartmentsPeople Served Male Female Caucasian AA Smoker Alcohol - Drug Jailed Hospitalized in

2019Incidents of

HomelessnessOther Medical

Supported Housing 7 4 3 2 5 5 5 0 1 0 3

Tarry House CPST and Counseling Services: 2017 Demographic and Utilization DataPeople Served Male Female Caucasian AA Smoker Alcohol - Drug Jailed Hospitalized in

2019Incidents of

HomelessnessOther Medical

CPST Services: 1 1 1 1 0 0 0 0 1Counseling: 1 1 1 1 0 0 0 0 1

Tarry House Supported Housing, CPST and Counseling: comments and analysis: By the end of 2018, almost all of persons served in these programs were transferred to other providers. Tarry House struggled to break even financially due to struggles in billing health insurance providers. In addition, Tarry House had difficulty hiring a competent case manager. So Tarry House, with the approval of the Board of Trustees ended providing these services for 2019. As far as counseling, the Executive Director and Manager of Programs are licensed and hope to free up some time to provide this service by the end of 2019.

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Board of Trustees and Human Resources

All Staff Breakdown (as of 12/31/19):Executive/Clinical Director 1 FTE Team Leader 1 FTE Recovery Specialist 1. FTE

Contract Accountant .125 FTE Maintenance Technician 1 FTE Recovery Aides 10 FTEBookkeeper .5 FTE Administrative Assistant .7 FTE Contract Apartment Manager .15 FTE

Manager of Programs 1 FTE Contract Clinical Nurse Specialist .013 Total FTE’s 17 FTE

Staff Diversity Chart in CY 2019 (on the last day of the year: 12/31/19):African American 12 African American Men 2 African American Women 14

Caucasian 13 Caucasian Men 3 Caucasian Women 7Total Staff 25 Total Men 5 Total Women 21

• Total staff budgeted positions: 17 FTE• Direct services staff (12 FTE) to persons served (up to 28). Ratio: .42 FTE to 1 Person Served

Board of Trustees: 10 Board Members on 12/31/19Male Female Caucasian AA Primary consumers of BH

ServicesSecondary consumers of BH

Services4 6 8 2 2 4

Analysis and Comments for Personal and Board Diversity: Tarry House, Inc. strives to hire and employ a culturally diverse work force that is representative of the persons served. By the end of 2019 according to the staff to person served statistics, about 52% of the staff was Caucasian and the other 48% were African American. Of the 186 different people served in 2019, 108 or 58% were Caucasians and 76 or 40% were African Americans and just 1% was “other” race. Tarry House has a goal that staff’s ethnicity should “resemble” persons served. This goal for diversity as the ethnicity of the employees moderately resembles the ethnicity of those served. Few men apply for work at Tarry House. Perhaps a goal to pursue, but it is hard to find qualitied staff in general, especially with low rates of unemployment and a tight budget where we struggle to compete with the private sector who can generally afford higher rates of pay.

Long has the goal been to have a Board that also “resembles” the people we serve. It is difficult to recruit Board Members to volunteer many hours each year in general but to find primary consumers of mental health services to join the Board has been especially difficult. Although just 2 members of the Board identifies him or herself as a primary consumer 4 others identify themselves as family members of a loved one who struggles with mental illness. The Membership Committee on the Board will continue to reach out to potential board members who share Tarry House’s mission.

Community Needs AssessmentTarry House, Inc. staff addresses the need for residential services in the following manner. The Respite Program Manager and the Tarry House Recovery Specialist and/or the Program Manager attend the weekly residential placement meeting held at Community Support Services. This group includes the funding agency, liaisons from the many CSS Treatment Teams to present and discuss referrals, representatives from the residential treatment facilities and group homes. The group reviews key information for each person served in need of housing and determines the appropriate placement referral.

Tarry House contracts to provide about 7756 bed days per calendar year, based on 25 total beds between Respite and Tarry House at 85% occupancy. In the calendar year 2018, the agency provided 7366 bed days short of the goal but still supporting the “The Housing Plan,” at 95% of the goal. This indicates a continued need for the services that Tarry House, Inc. offers.

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2019 Major and Minor Incident Reports:

Major Incident Reports Minor Incident ReportsIncident Reported # T. H. R Incident Reported # T. H. RSelf Inflicted Injuries 0 0 0 Medical Emergencies 0 0 0Attempted Suicide 0 0 0 Missing Persons 0 0 0Physical Assault 0 0 0 Away without Notice 28 0 28Sexual Boundary Issue 0 0 1 Threat of Suicide 0 0 0Adverse Reaction 0 0 0 Assault of Staff Person 0 0 0Death 0 0 0 Under the influence of drugs/alcohol 3 1 2

Totals 0 0 1 Medication not taken by person served found 0 0 0Non-Medical Attention – Self Injury 0 0 0Self Inflicted Injury, requiring med. attention 0 0 0Accidental Injury no medical attention required

3 2 1

Accidental Injury requiring med. attention 2 2 0Illegal Contraband Found 3 0 3Wrong meds consumed by person served 0 0 0Threats/Threatening Behavior 16 11 5Person Served Assault on Person Served. 0 0 0Exposure to Hazardous Waste 0 0 0Illness not requiring Medical attention 6 2 4Illness requiring Medical attention 10 5 5Property Damage 2 1 1Theft 3 0 3Other 27 19 8 Totals 103 43 60

Historical Major and Minor Incidents2019 2018 2017 2016 2015 2014 2013

Major Incidents 1 0 0 0 3 0 3Minor Incidents 103 97 102 169 150 143 161

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Comments and analysis about the 2019 Incident Reports: (see charts above) As an organization, there was 1 Major Unusual Incident Reports in 2019 as defined by the Ohio Department of Mental Health and Addictive Services. Tarry House has averaged just 1 major incident per year for the past 10 years. A very positive accomplishment.

Tarry House also tracks “Minor Incident Reports” as outlined in the Tarry House Policy and Procedures for quality improvement purposes. In 2019, there were 103 minor incidents. This is a 5 more than 2018, where 97 minor incidents were documented. Looking at the past 7 years, Tarry House has averaged 132 minor incidents. But looking at the last three, incidents are down to 101 per year. Time will tell if this trend continues, but Tarry House has continued to run safe and healthy operations, perhaps reflected by these numbers.

A common reported incident in 2019, as has been the case since Tarry House Respite opened, remains folk’s failure to return to the Respite Home by those served at the end of the day. This occurred a total of 28 times, an average number over the years. The reason for so many “absence without notice” continues to be the location of the Respite Facility. There is only one stop by public transportation to and from the residential area where the Respite Facility is located, persons served are unable to return after appointments in the city. Discussed over the years has been to have staff take a “second run” into town but there is only one staff after 3:00 at Respite and adding a second staff member, coupled with the cost of fuel, this remains cost prohibitive. Persons served at Respite are reminded everyday they go to CSS that they must be available to return at 12:30 p.m. to return by Respite van; otherwise they need to secure their own transportation. Tarry House has seen an increase of residents under the influence of drugs and alcohol. Statistically, Tarry House is serving more people with a co-occurring addiction disorder so the increase in this minor incident is not too surprising.

Tarry House, Inc.Summary of Grievances

Calendar Year: 1/01/2019- 12/31/2019

Types of Grievances/Complaints

by Clients Rights Categories

Number of grievances received Resolution status of grievance, ,i.e. Number of Grievances Resolved to the

Satisfaction of the ConsumerRight to Dignity and Respect 2 2

Right to Informed Choice and Treatment

0 0

Right to Freedom 0 0Right to Personal Liberties 0 0

Right to Freely Exercise All Rights

0 0

Other (i.e. Housing, employment, custody)

0 0

Service Improvement and Environment

0 0

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There were a total of 2 grievances at Tarry House, Inc., Recovery and Respite facilities, in the calendar year - 2019. The primary source of grievances stemmed from staff and clients residing at Tarry House’s Recovery and Respite facilities. The grievances are explained as follows:

1) 5/21/2020 (Grievance 1): A client wrote a grievance alleging that two clients were being loud during the night and that the staff on shift did not do anything until 3:00 in the morning. a) Outcome: The Client Rights Officer met with client who filed the grievance. His/her concerns were discussed in detail. The client did not report incident to

the staff. The client was encouraged to do so, if there was a next time. The Client Rights Officer spoke with the clients named in grievance in regard to respecting the rights of others. Staff was asked to ensure rounds were being completed and remind clients of guidelines.

b) The matter was resolved to their satisfaction.

A copy was not requested to be sent to the Client Rights Coordinator at the Summit County ADM Board.i) The Mental Health, Client Right, that this grievance falls into category with is, The Clients’ Right to Dignity and Respect. Right #1.

2) 6/14/2019 (Grievance 2): A client wrote a grievance alleging a client’s rights violation by a staff member. a) Outcome: The Client Rights Officer met with the client who filed the grievance. His/her concerns were discussed in detail. Met with the Team Leader,

Executive Director and staff member named in the grievance. Staff denied allegations. However, it was determined that some of the allegations were substantiated. The client was informed of options and the staff member was terminated.

b) The matter was resolved to the Client’s satisfaction. A copy was not requested to be sent to the Client Rights Coordinator at the Summit County ADM Board.i) The Mental Health, Client Rights, that this grievance falls into category with is, The Clients’ Right to Dignity and Respect.

Comparing Grievances over the last 10 years:

Types of Grievances/Complaints by Clients Rights Categories

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Right to Dignity and Respect 3 4 2 3 5 1 12 9 3 2Right to Informed Choice and Treatment 0 0 0 0 0 0 0 0 0 0Right to Freedom 0 0 0 0 0 0 1 0 0 0Right to Personal Liberties 0 0 0 0 0 0 1 0 0 0Right to Freely Exercise All Rights 0 0 0 0 0 0 0 0 0 0Other (i.e. Housing, employment, custody) 0 0 0 0 1 0 0 0 0 0Service Improvement and Environment 0 1 0 0 0 0 0 0 0 0

Totals: 3 5 2 3 5 1 14 9 3 2

Comments and Analysis related to the 2019 Client Grievances and/or Complaints: 1. Tarry House continues to educate clients at admission and throughout services with Tarry House education related to client rights, and grievances and how to get along

with others. 2. 2019 had only 2 grievances, much less than 2016 and 2017 when Tarry House had higher amounts of complaints/grievances compared to the years before. This could

mean several things. The hope is that Tarry House, through staff training and good supervision will keep grievances in the single digits.

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Financial The financial status of Tarry House, Inc. is presented by the Board’s Finance Committee to the Board of Trustees quarterly and the financials are shared with the full-Board monthly, This financial schedules shared are quite comprehensive that include a Balance Sheet and monthly Statements that compare spending to a budget and also compares to spending the previous year and shows monthly and year to date spending. On an annual basis, a financial audit is performed by a certified accounting firm. Tarry House ended 2019 spending more money than it brought in. However, with positive investment activity, Tarry House end the calendar year 2019 with revenue exceeding expenses. The cost of doing business has gets more expensive every year and over the last 10 years, Tarry house has received very few increases from the ADM Board, its main funder. Tarry House has continued to offer competitive staff wages and employee health insurance to retain its personnel. Another high cost the last couple of years, is the City of Akron water and sewer utilities which have gone up substantially.

Criminal Background Checks/Drug and Alcohol ScreeningTarry House, Inc. has a policy of performing pre-employment criminal background checks and drug and alcohol screenings as part of the decision-making process. Per State of Ohio statutes, the agency cannot hire individuals who have been convicted of violent crimes. OhioMHAS also requires that all personnel get an updated criminal background check every five year. Yet another unfunded mandate but completed.

Fire/Disaster/Emergency DrillsThe Tarry House Recovery Facility and Tarry House Respite conducted monthly fire drills, covering each shift, once per quarter in 2018. In analyzing the results of the fire drills, there were no significant findings necessitating a change in how these fire drills are conducted. Response from staff and persons served were generally within acceptable limits for the drills. These sites also conducted many required disaster/ emergency evacuation drills during 2018. The drills conducted were as follows: tornado, power failure, workplace violence, handling psychiatric emergencies and medical emergencies. Again, in reviewing the documented data related to these drills, there were no significant findings. Having a small administrative team, the “safety committee” meets as part of the Administrative Staff Meeting were safety issues are discussed almost monthly.

Technological Systems Review The organization’s information systems technology had some improvements and changes in 2019. Tarry House continues to work with Probe Technologies to handle its information technology needs and increased the contract with Probe to improve the Tarry House Website. The website is updated on an ongoing basis. Both facilities have wireless internet access with a secure router and software. While Tarry House, Inc. continues to use Microsoft Windows as its operating system, many computers have been upgraded with the most current Window’s operating system. The majority of management staff is fairly skilled in using computers. A goal in the area of technology over the next couple years will be an effort to move to more electronic records and documents. Tarry House, Inc. is trying to become more “green” as far too much paper is being used.

All staff now have Gmail accounts and administrative staff now can save documents into the “cloud”. Although under-utilized, the Admin Staff may save documents into the “Team Drive”. More information will be given to admin staff as to how to utilize this tool. And the idea is to use emails for memos and training and the like. The Tarry House Management Team will look at setting some goals over the next couple years to improve the work environment through technology and to improve the agency web-site. Tarry House joined Face Book in 2017. A policy was written and approved by the Board of Trustees to clarify policies and procedures around social media.

Cultural Competency PlanPer CARF Standards, Tarry House added yet another plan in 2017; The Tarry House Cultural Competency Plan. Goals in 2020 will include continuing to assess Tarry House’s needs as an agency to improve our cultural competency. This will occur via polling staff’s, board member’s and client’s knowledge related to understanding culture, race and ethnicity and using that data to develop appropriate goals to better serve our clients.

Risk Management PlanUpdated for 2019. No significant changes.

Quality Records Reviews:

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No clinical Record Reviews in 2019.

Tarry House, 2018 Clinical Record Reviews and Analysis: A total of 12 clinical records (out of 32) were reviewed by a qualified clinician. 27 elements were reviewed in each file (see chart below). The process includes a quality review as well as making sure all elements were in place per funders, licensure, and certification and accreditation guidelines. In all the clinical records received an average score of 97%. Most issues was related to failure for filing to take place in a timely manner as when the initial findings outlining missing items were presented to staff, more times than not, the document just hadn’t been filed.

Tarry House Clinical Records Review2018

Key: Yes or N/A = 1 1st 2nd 3rd 4th

Record Reviewed: CA CT PF CW JNCH-S TC GB SH JH IB JM Totals

D/C D/C D/C D/C 1 The person served was provided with a complete orientation. 1 1 1 1 1 1 1 1 1 1 1 1 12

2The person served was actively involved in making informed choices regarding the services they received. 1 1 1 1 1 1 1 1 1 1 1 1 12

3 Confidential information was released according to applicable laws/regulations 1 1 1 1 1 1 1 1 1 1 1 1 124 Release of information forms is complete, dated appropriately, signed and up-to-date. 1 1 1 1 1 1 1 1 1 1 1 1 125 The assessment of the person served was thorough. 0 1 1 1 1 0 1 1 1 1 1 1 106 The assessment of the person served was complete. 0 1 1 1 1 1 1 1 1 1 1 1 117 The assessment of the person served was timely (within 12 days) 0 0 1 0 1 0 0 0 1 1 0 1 5

8A psychosocial history prepared by the referring agency is present in the file and within one year of admission. 1 1 1 1 1 1 1 1 1 1 1 1 12

9A psychiatric evaluation or mental health assessment is present in the file completed by a qualified clinician. 1 1 1 1 1 1 1 1 1 1 1 1 12

10 Is it dated within one year of admission? 1 1 1 1 1 1 1 1 1 1 1 1 1211 The treatment plan of the referring agency is in the file. 1 1 1 1 1 1 1 1 1 1 1 1 1212 The goals and objectives in the IRSP were based on the assessment. 1 1 1 1 1 1 1 1 1 1 1 1 1213 The goals and objectives in the IRSP were based on input of the person served 1 1 1 1 1 1 1 1 1 1 1 1 1214 Goals and service treatment objectives were revised when necessary or requested. 1 1 1 1 1 1 1 1 1 1 1 1 1215 The actual services provided were related to the goals and objectives in the person’s plan. 1 1 1 1 1 1 1 1 1 1 1 1 1216 The actual services reflect appropriate level of care 1 1 1 1 1 1 1 1 1 1 1 1 1217 The actual services reflect reasonable duration 1 1 1 1 1 1 1 1 1 1 1 1 1218 The person-centered plan was reviewed and updated in accordance with the organization’s policy 1 1 1 1 1 1 1 1 1 1 1 1 1219 The functioning of the person served was re-assessed after 180 days. 1 1 1 1 1 1 1 1 1 1 1 1 1220 The IRSP was updated after 180 days. 1 1 1 1 1 1 1 1 1 1 1 1 1221 The functioning of the person served was re-assessed after 270 days. 1 1 1 1 1 1 1 1 1 1 1 1 1222 The IRSP was updated after 270 days. 1 1 1 1 1 1 1 1 1 1 1 1 1223 When applicable, the following have been completed: Transition Plan. 1 1 1 1 1 1 1 1 1 1 1 1 1224 When applicable, the following have been completed: Discharge/Transition summary. 1 1 1 1 1 1 1 1 1 1 1 1 1225 Services were documented in accordance with the organization’s policy. 1 1 1 1 1 1 1 1 1 1 1 1 12

26After your review of this file, would you say that the information is organized, clear, complete, current and legible? 1 1 1 1 1 1 1 1 1 1 1 1 12

27 When billing for services occurs, the clinical documentation is consistent with billing records. 1 1 1 1 1 1 1 1 1 1 1 1 12 score when compared to 27 elements 24 26 27 26 27 25 26 26 27 27 26 27 26.17 Percent of elements found through the review: 89% 96% 100% 96% 100% 93% 96% 96% 100% 100% 96% 100% 97%

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Analysis for Tarry House clinical records: Although Tarry House has received high marks from the ADM Board, OhioMHAS and CARF, the amount of paperwork is required is daunting. The files are large, full and cumbersome. In 2018 and maybe into 2019, the Tarry House Clinical Team will review all regulatory requirements, see what can be done electronically and see if we can free staff up to have more time to work directly with the persons we serve. Tarry House Respite Records Review:A total of 20 records were reviewed at the Tarry House Respite Home. It was primarily a review to make sure all required documents were present in the record, however quality was reviewed as well related to a few documents. In all the records had 97% of the required elements in place. All records reflected appropriate billing to the ADM Board.

Analysis: The Respite staff do a very good job documenting. As is the case with Tarry House, a goal remains to move some of this documentation to electronic, secure formats.

Tarry House Respite

Records Review

Year: 2018 Quarter: 4th 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Client vb ji jw se pj ow jk jt rr sb jc sw th gr mh lk sc hp rs rr Totals Ave

1 Person served has a thoroughly completed referral form. Client has signed the form. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

2 The Closure form is completely filled out. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

3 Person served has signed the HMIS Client Informed Consent Authorization for Release of Info. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

4 MACSIS Form completed? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

5 Is Social Security number included? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

6 Privacy Practices (HIPPA) signed? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

7 Respite Rules signed? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

8 The person served signed a Client’s Rights Acknowledgment? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

9 Person served has signed consent to release confidential information? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

10 Residential Agreement? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

11 Is there a complete admission note? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

12 Does it include age, race, height and weight? 0 0 1 0 0 0 0 1 1 1 0 0 1 0 0 0 0 1 1 1 8 40%

13 Does it include whether the person served signed all required paperwork? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

14 Does it include whether the person served was given supplies and a lock? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

15 Are there progress notes for the person served? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

16 If so, was it an unusual incident? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

17 If so, does the note include what occurred, how it was handled, and if an incident report was needed? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

18 Is there a complete discharge note? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

19 Does it include where the person went and whether the person served items were returned to him/her? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

20 Person Served has signed Voting form? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

21 Is there a completed and signed Valuables Record? 0 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 18 90%

22 Is there a completed and signed Clothing List? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

Billing 97%

23 According to census sheet submitted for billing, does it show that this person

received services during this time period? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 100%

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Quality Improvement and Satisfaction Survey Information Tarry House, Inc. has several methods to receive data from people who are served, staff members and external stakeholders. This includes written surveys, house council and client health and safety meetings and suggestion boxes. This data is reviewed, analyzed and utilized to effect change. For moderate and long term goals, this information is utilized as an organization in its development in its organizational strategic and accessibility plans. Data and its analysis, is also discussed as part of the monthly administrative staff meetings to effect immediate change as well. In addition to survey data, incident reports and client rights are discussed as needed at the administrative staff meeting to effect immediate change when it is appropriate.

Quality Improvement Indicators Report – 2019

1. Performance IndicatorWhat Program?

Description Person Responsible

Supporting Documents/Source

When Measured

Targeted Expectancies

Results

Effectiveness: All ProgramsMaximize the percent of people served who report that the services received have helped in their recovery.

Report and track responses regarding whether the persons

served perceive the services they receive have helped in their

recovery. Increase the scores by encouraging staff to use outcomes

focused on persons served recovery goals and other evidenced based

measures

Program Managers, Executive Director

MHSIP Consumer Satisfaction

Surveys

Annually 80% Satisfaction

rating

Goal met: Tarry House at 92% in the area of satisfaction.

Compared to similar agencies: National score 88% Ohio score: 84%

Comments about indicator above Goal met. The second year utilizing the MIHSIP rating system.




When Measured


Results

Effectiveness: All ProgramsThe MHSIP looked at other areas as well: See MHSIP Tables at the end of this document.

20 Individuals completed the MHSIP Survey and addition to satisfaction, the tool also rated Tarry House in the following areas: Access, quality, outcomes, improved functioning, Social connectedness and participation.

Program Managers, Executive Director

MIHSIP Consumer Satisfaction Surveys

Annually 80% Satisfaction

rating

Goal met: Tarry House at 94% in the area of satisfaction.

Compared to similar agencies: National score 88% Ohio score: 84%

Comments about indicator above Goal met. Tarry House now administers the survey throughout all of April each year, thus improving the sample size.

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When Measured Targeted Expectancies

Results

Effectiveness: Tarry House and CPST ProgramsMinimize the amount of times those served are in need of inpatient hospital stays or treatment group home treatment.

CPST Program suspended at this time.

Report and track the amount of times individuals served need

inpatient care. Provide interventions to assist the

individual in learning techniques to maintain recovery in the

community. Utilize the clinical meetings to develop strategies to

help individuals avoid the need for inpatient care.

Program Managers,& CPST Specialist

Billing reports, staff supervision and group case

discussions. Maintain a daily census sheet that

tracks where those served are living.

Monthly Hospital admissions will

not exceed .05%

Tarry House: Clients living at Tarry House needed

hospitalization for a total of 127 days out of 4137

possible days or 3%. In 2018, it was 183 days out of 4799 possible days or 3%.

Goal Met

CPST: No data. CPST Services not provided in

2019. Comments about indicator above Goals met for Tarry House.




When Measured


Results

Effectiveness: Tarry House and CPSTMinimize the amount of times those served are arrested/incarcerated.

Report and track the amount of times individuals served are

arrested. Provide interventions to assist the individual in learning

techniques to avoid behaviors that lead to arrests and possible

incarceration. Utilize the clinical meetings to develop strategies to help individuals avoid troubles

with the law.

Program Managers,Recovery Specialist,& CPST Specialist

Billing reports, staff supervision and group case

discussions.

Monthly Arrests and/or incarcerations will not exceed

5% of those served

Tarry House: 1 incarcerations out of 27

people served = 4% Goal Met

CPST: No information

Comments about indicator above Goal met.

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Results

Effectiveness: Tarry House Recovery Home GroupsCurrently Tarry House offers at least 4 hours a day of individual and group programming at the recovery home. There could be an improvement in attendance to this programming (groups and individual) and activities scheduled.

Track attendance to these groups by looking at data from attendance sheets. Add to monthly report

percentages of group attendance.

Program Manager, Recovery Specialist,

Student Interns

Clinical records, Program

Manager’s Monthly Report

Monthly Goal = 50% attendance.

Goal not Met

Attendance to Tarry House groups for year 2019

remained around 40%.

Comments about indicator above Goal not met. Best attendance remains for cook’s helper, laundry skills groups and social activities in the community. An emphasis was placed on this via staff training and on-going reminders to persons served and staff. Another ongoing issue is staffing turnover in and difficulty hiring new staff in a timely manner.





Results

Efficiency: CPSTMinimize no show rates when meeting with CPST Worker.

Develop strategies to minimize no shows. Improve engagement;

evaluate scheduling practices on an on-going basis. Enforce scheduling

policies for those served who frequently no show.

Program Managers,

Team Leader, Quality

Improvement Manager

Scheduling data base, billing

reports and other reports from CPST Staff.

Annually - although

discussed at weekly clinical

meetings.

Less than 15% no shows

CPST not provided in 2019

Comments about indicator: Hope to start some CPST in 2020




When Measured


Results

Access to Service: Tarry House and CPST Services.Minimize the average number of days between when person starts treatment to when they are assessed into service.

Report and track the average number of days between the move-in dates of

the initial assessment.

Program Managers,

CPST Worker

Reviewing clinical records/notes

Semi-Annually Intake assessment

occurs within 12 business days of the

referral 90% of the time

Goals met: No CPST information

Tarry House goal is to complete assessment within 12 business days, and that goal was not met. 2 of 17

clinical record reviews found that the deadline date was

missed. Comments about indicator above Goal not met - 85%. Will continue to work and support the Recovery Specialist to improve this number.

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When Measured


Results

Satisfaction – those served: All ProgramsMaximize the percent of clients who report that the quality of care, satisfaction and services they received is/was somewhat to very satisfied. At least 85% on the MHSIP.

Track and report responses to whether or not the person served believe they

received an excellent quality of care in the services they received. Maximize this percentage by providing ongoing

training and supervision to support and equip all employees to provide outcomes focuses interventions, friendly, accurate

administrative procedures and timely responses to concerns.

Program Managers,Recovery Specialist,

CPST Specialist

MHSIP and/or other Satisfaction

Survey

Quarterly At least 85% on the MSHIP

Goal Met:94% on Satisfaction Scale.

Better than Ohio and National ratings.

Comments about indicator above Using the new MHSIP has shown good results of satisfaction when compared to other State organizations and Nationally. However, it has been difficult to get clients to complete the survey due to its length. Also, it does not give Tarry House results from different services or departments. Will work with ADM to see if this can be done.




When Measured


Results

Satisfaction & Efficiency - Funders & Referral Sources. Maximize the satisfaction scores reported by referral and funding sources regarding Tarry House’s referral and intake procedures for service.

Survey referral and funding sources regarding their satisfaction of Tarry

House’s referral process considering timely response and

ease in making referrals. Maximize the score by considering and implanting survey results as

possible.

Executive Director

Satisfaction Survey: Tarry House Design - Survey Monkey

Annually 92% Strongly Agree or Agree

ratings

Goal met:Strongly Agree: 44%

Agree: 48% Total = 93%

Comments about indicator above Scoring between 90 and 94% has been the norm the past several years. Tarry House Admin and the Board are happy with these numbers and will strive to continue to obtain these numbers.




When Measured


Results

Satisfaction – Other Stakeholders: (Clients, Family and Friends)Maximize the scores reported by stakeholders when surveyed regarding their satisfaction with Tarry House Services.

Survey other stakeholders regarding their impression of Tarry House’s

delivery practices. Maximize these scores by considering and

implementing survey results as applicable.

Executive Director

Satisfaction Survey: Tarry House Survey


ratings

Goal not measured.

Comments about indicator above Will continue to use a survey tool developed by Tarry House in 2020, after taking a year off.

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When Measured


Results

Satisfaction – Staff Members (including student interns and volunteers)Maximize the scores reported by staff Members when surveyed regarding their satisfaction with Tarry House Services.

Survey staff members regarding their impression of Tarry House’s

delivery practices. Maximize these scores by considering and

implementing survey results as applicable.

Executive Director

Satisfaction Survey: survey Monkey


ratings

Goal Met:Strongly Agree: 67%

Agree: 32%

Average score: 3.15 out of 4.

Comments about indicator above Goal met. A total of 30 questions were asked. The focus ranged from evaluation administration, the benefits and work environment at Tarry House, client service and Tarry House’s place in the community. A robust response with the vast majority of staff members answering “strongly agree or agree”.




When Measured


Results

Efficiency and accuracy – Clinical Record Review of the Persons Served. Tarry House Treatment Home.Minimize the amount of missing items in the records of the person served.

All records via accreditation standards and as mandated by ADM and OhioMHAS have standards for what is to be included in the records

for the persons served.

Executive Director

Records review Quarterly 95% of the 33 elements to be in place as and

meeting the standards of

quality.

Goal Met:N = 1297%

Comments about indicator above Goal Met. Scored 97%, the same as last year. As was the case in 2016, there were several incidents where filing had not taken place leading to items being marked as “not there” but most items were complete but just not filed and credit was given. Need to address this in 2018 to make sure filing is completed on-going. Also, there are a lot of elements that are not applicable. May need to review this while doing the statistical analysis.




When Measured


Results

Efficiency and accuracy– Records of the Persons Served. Tarry House Respite.Minimize the amount of missing items in the records of the person served.

All records via accreditation standards and as mandated by ADM and ODMHAS have standards for

what is to be included in the records for the persons served.

Executive Director

Records review Quarterly 95% items to be in place and meeting the standards of quality as required.

Goal met:N = 2097%

Comments about indicator above Met the goal. Demographic info related to the person in the initial progress note was the only cause for this as the note missed elements per Tarry House Respite policy.

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Behavioral Health Outcome Surveys - MIHSIP

The ADM Board switched to a valid and quantifiable clinical and satisfaction outcome tool called MISHIP in late 2016 and this tool has been used since. The results of these surveys are below:

Tarry House MHSIP Consumer Satisfaction Surveys

N = 14

Results: Tarry House National Ohio Satisfaction 97 88 84Access 80 83 76Quality 96 88 80Outcomes 89 74 54Improved Functioning 86 75 56Social Connectedness 95 74 57Participation 100 82 70Totals 643 564 477Average 92 81 68

Comments and Analysis related to the MHSIP Surveys:

This was the second year looking at this data results. Overall, the results are positive, with Tarry House scoring higher than nation and Ohio averages in almost all categories. Will need to continue to review. The biggest issue is that Tarry House sample size is small. Since this survey is conducted in just a two week window in time, there are only about

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30 - 35 people served max during that time and to get the recommended 30 surveys complete is difficult. Difficult because it is a voluntary survey and is a bit long and challenging to complete.

Another issue is that since this is managed by ADM, although appreciated, different Tarry House programs are not compared to each other and using this tool at admission, at a point while a person is being served, at discharge and at a point following discharge, isn’t completed as recommended by CARF. Tarry House will need to develop or purchase another valid instrument to use for this purpose. We have discussed using the LOCUS tool or one’s GAF scores.

CY 2019 Stakeholder Surveys Results and Analysis: Tarry House, Inc. Satisfaction Survey Staff Members (N=20) “All programs rated but received 7 from Respite staff and 13 from Admin and/or Tarry House

AverageStrong Agree

score Totals: Possible: Percent1 Employees treat the clients, family members, community professionals and all visitors with dignity and respect. 3.55 71 80 89%2 Tarry House's Leadership is involved in the community and partners with other agencies when appropriate. 3.3 66 76 87%3 Tarry House's referral and intake procedures are efficient. 3.1 62 76 82%4 Tarry House provides person and family centered services to the people it serves. 3.25 65 76 86%5 Tarry House's facilities are clean, safe, comfortable and welcoming. 3.55 71 80 89%6 Tarry House programs and services provide adequate support for clients and families. 3.1 62 76 82%7 I would recommend employment at Tarry House to someone who is looking for a job. 3.45 69 80 86%8 I would feel comfortable recommending the Tarry House programs to a loved one who needed services. 3.5 70 80 88%9 When I contact Tarry House there is always a response in a reasonable amount of time. 3.5 70 80 88%

10 When a report or document is needed and appropriate for release, Tarry House responds quickly. 3.45 69 80 86%11 Tarry House staff help me understand the services in Summit County available to clients and their families. 3.3 66 76 87%12 Tarry House, Inc. provides a valuable service to the Summit County community. 3.55 71 80 89%13 The Tarry House administration and staff are advocates for those with mental health illnesses. 3.45 69 80 86%14 Tarry House provides effective education on the needs of those with mental illnesses. 3.25 65 76 86%1 Staff Members are treated fairly and respectfully by their supervisor(s). 2.8 68 80 85%2 Tarry House provides a safe and healthy environment for people it serves and also for staff members. 3.5 70 80 88%3 Tarry House's policies and procedures are followed consistently. 2.85 57 76 75%4 Tarry House has effective training regimen for all staff members 3.4 68 80 85%5 Tarry House's pay and benefit package is fair and comprehensive. 3.2 64 76 84%6 Tarry House's administration, staff members and board members employ cultural competency techniques. 3.4 68 80 85%7 I understand well, Tarry House's Corporate Compliance and Ethics Policies. 3.25 65 76 86%8 Mission statement appropriately states Tarry Houses’ purpose, given the current needs of those we serve. 3.45 69 80 86%9 Team work is encouraged and rewarded. 3 60 72 83%10 My work drives me to go the extra mile. 3.5 70 80 88%

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11 I am proud to work for this organization. 3.35 69 80 86%12 At work, I have the opportunity to do what I do best every day. 3.35 69 80 86%13 In the last six months, someone at work has talked to me about my progress. 2.95 59 76 78%14 In the last year, I have had opportunities to learn and grow. 3.4 68 80 85%15 I feel adequately informed about the performance outcomes of Tarry House programs and services. 3.35 67 80 84%16 Performance outcomes are used to guide future programming and service decisions. 2.9 58 68 85%

Totals 3.05 1995 2340 85%

Tarry House, Inc. Satisfaction Survey – Board Members - December 2019 (N=5) All programs Ave1 The Tarry House Leadership and employees are professional, courteous and helpful. 4 4 4 4 4 20 42 Agency leadership and personnel involved in community and partnerships 4 4 4 4 4 20 43 Tarry House's referral and intake procedures are efficient & employees are helpful in the process. n 4 4 n 4 12 4

4When I make a special request(s) on behalf of the person served, it is honored by Tarry House if it is reasonable. 4 4 n 4 n 12 4

5 The people served by Tarry House have favorable comments about the services they've received. 4 4 4 4 4 20 46 Tarry House's facilities are clean, safe, comfortable and welcoming. 4 4 4 4 4 20 47 Tarry House, Inc. provides a valuable service to the Summit County Community 4 4 4 4 4 20 48 Individuals receiving Tarry House services improve in their recovery 4 4 4 4 4 20 49 The Tarry House fees and rates are fair and competitive 4 4 4 4 4 20 4

10 People served follow their recovery plan and maintain their recovery following discharge for more than 90 days. 4 n 4 4 n 12 4

11 I would feel comfortable referring a loved one for Tarry House services. 4 4 4 4 4 20 4 Totals 40 40 40 40 36 196

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Comments and analysis related to Staff and Board Member surveys. The results of the staff and Board surveys were similar in ratings compared to 2018’s scores. Overall staff rated most categories with “agree or strongly agree” most areas with “strong agreement. Staff are generally very satisfied with the services provided and with the work environment. However, there are 3 areas that received just average scores (below 3 out of 4) so these areas might need to be addressed to see if we can improve that staff ratings a bit.

Those served at the Tarry House Treatment/Recovery Facility – Treatment Goals and Objectives reached before discharge: In completing a random sample of the records of the clients discharged in 2019, when reviewing the goals and objectives completed by the client, of the 6 records reviewed, 5 individuals showed improvement in meeting the goals of their individual recovery service plan, so 83%. Most people who transitioned into the community had a better understanding about how to maintain their recovery. 83% was higher than 2018 where a 75% score was reached.

Also reviewed was the LOCUS Assessments (level of care utilization system) that were completed by a qualified person before, during and at discharge. With the ADM Board no longer sponsoring the BHOS Survey and going to MHSIP, Tarry House no longer captures data comparing one’s satisfaction and functioning before, during and after services. Tarry House is considering using the LOCUS Assessment tool and comparing those scores. However, there is poor interrater reliability with this tool. Tarry House will continue to look at alternatives and discuss with other organizations and CARF to find a valid and reliable tool to use. Final Thoughts:

Tarry House remains financially solvent as the organization even through Tarry House ended the year with expenses exceeding income by a relatively large amount. The last couple years the only reason Tarry House showed a “profit” was due to a good return on Tarry House’s money invested in the Market. The biggest financial capital improvement expense in 2019 was replacing the boiler at the Belvidere Apartments and having new concrete steps installed at Tarry House. Overall, 2019 was another challenging year for providers in the mental health system with budgets remaining mostly flat.

Information collected throughout CY 2019 will be analyzed and was utilized in the formation of the SFY 2020 budget. Administration also took into consideration new health insurance plans as well as liability, property and auto for 2019, expecting the usual rate increases. At the last Board Meeting in 2019, the Board also took into consideration the difficulty hiring and retaining qualified staff and Tarry House began a plan to increase hourly rates. Also considered were needed equipment and renovations and the likelihood of unscheduled repairs. Due to difficulty filling positions and billing 3rd-party insurance companies, counseling and CPST services have been put on hold. Tarry House hopes to start them up again in 2020.

Tarry House continues to hire employees who treat those served with dignity and respect. Overall, employees are generally very satisfied with employment at Tarry House, Inc. as based on employee comments in supervision and staff meetings and in staff surveys. Employees have also complimented the management staff and Board Members on informative and enjoyable staff retreats every year as well as the annual holiday party.

Tarry House served nearly 220 different people in 2019 and a little over 22 people per day. Based on satisfaction surveys, Tarry House continues to receive high ratings from those served.

2019 was overall a very good year highlighted by Tarry House’s first signature fundraiser. The second annual golf outing brought in $7000 to be used to be used for capital improvements. Tarry House also took part successful fundraising for the ADM Levy Support Committee via the ADM Recovery Challenge 5K which raises monies annually for the ADM Board Renewal Levy. Tarry House employees and Board Members were very involved in these fund-raising activities.

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Tarry House has been an important provider of behavioral health services to persons with severe and persistent mental illness for 52 years. Tarry House looks forward to continuing its role in helping the constituents of Summit County live more productive and fulfilling lives regardless of challenges.

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