One Hope United 2013 CQIR Annual Report - Northern Region

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CQIR ANNUAL REPORT

2013 NORTHERN REGION ANALYSIS

REPORT PREPARED BY KIMBERLY D. CLARK CQIR SYSTEMS ANALYST

� PLEASE DIRECT INQUIRIES TO: [email protected]

Report Snapshot

� Northern Region

served 5,486 clients

and families in

FY13.

� 73% of Northern

Outcome Goals

were met.

� The Northern

Region Compliance

& Quality rating on

Peer Record

Reviews was 88%.

� 5 out of 6 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

NORTHERN 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 .................................................................................................................. 21

QUALITY IMPROVEMENT TEAMS ........................................................................................................ 22

APPENDIX.............................................................................................................................................. 23

Appendix A: Child Development Highlights ............................................................................................................ 23

Appendix B: Counseling Highlights ........................................................................................................................ 24

Appendix C: Family Preservation Highlights .......................................................................................................... 31

Appendix D: Placement Highlights......................................................................................................................... 33

Appendix E: Prevention Highlights......................................................................................................................... 40

Appendix F: Youth Services Highlights .................................................................................................................. 42

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

Kimberly D. Clark CQIR Systems Analyst

Fotena A. Zirps, PhD

Executive Vice President

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Continuous Quality Improvement & Research Team

To support direct service providers and ensure best practice quality of service throughout the agency, the Continuous Quality Improvement and Research (CQIR) team at One Hope United guides the organization in 14 core tasks (PQI Standards) that are aligned with internal OHU principles and external accreditation standards.

Dr. Fotena Zirps – Executive Vice President Tina McLeod – Assistant to the EVP

Florida Region Hudelson Region Northern Region Research Team

Ruann Barrack Senior Vice President

Jeffrey Honaker CQIR Director

Katurah Roby

CQIR Coordinator

Ron Culbertson CQIR Coordinator

Linda Weiss

CQIR Medicaid Coordinator

Ryan Counihan CQIR Technician

Stan Grimes

CQIR Coordinator

Elizabeth Hopkins CQIR Medicaid

Coordinator

Jackie Schedin CQIR Coordinator

Sarah Tunning Director of Research

Kimberly Clark

Systems Analyst

Special thanks to Katrina Brewsaugh of the CQIR team who left in FY13.

Information presented in the Northern 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 been categorized in line with the OHU promises of Innovation, Collaboration, Leadership, Results, and Hope. Innovation

• The CQIR team has been utilizing Survey Monkey technology to enter Incident Reports, Office Reviews, and Supervisory Reviews which has made the data entry process more efficient. A pilot for utilizing Survey Monkey for Peer Record Reviews is planned for FY14 using Tablet technology.

• The CQIR team has taken a Risk Management focus which included a pilot and a full implementation of the OHU Risk Management Report in Local, Service, and Regional Quality Improvement Teams.

• Under the direction of Fotena Zirps, PhD. and Sarah Tunning; Ruann Barack, Jeffrey Honaker and Kimberly Clark are members of Team Data which is looking at the current and future data needs of the organization in alignment with the agency’s strategic plan. In addition, there are

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many members from Operations (including the Team Excellence Outcomes committee) and IT that are collaborating on this project.

• Peer Record Review Training has been developed and placed on the Essential Learning Website.

Collaboration • Stan Grimes, Jackie Schedin, and Elizabeth Hopkins have all participated as volunteers with the

Council on Accreditation to re-accredit 3 organizations. • In collaboration with the Department of Children and Family Services, all OHU CQIR staff have

access to SACWIS which will assist with electronic review of case files. • The CQIR team participated in a WorkSmart training facilitated by Larry Kujovich from Executive

Partners. • Jackie Schedin was a presenter at a CANS training in collaboration with the Casey Foundation. • Linda Weiss and Elizabeth Hopkins continued to collaborate to ensure consistency across

Regions with the Medicaid Rule Changes. This included monthly meetings with program leaders to ensure all involved participated in the process of change.

• Jackie Schedin and Ron Culbertson collaborated with operations in the Northern and Hudelson Regions in revising the “Intact Operating Procedures” for the Agency Operating Manual based upon Rule changes. The group also collaborated in the revision of the Intact Quality Review Tool.

• Linda Weiss worked with operations in the revision of the SASS Model for service delivery to achieve a team approach to provide more efficient and effective service delivery.

• Ron Culbertson provided technical assistance with Missouri Leadership to assist the Missouri office in maintaining their Licensing as a Child Placement Agency.

Leadership • Linda Weiss from Hudelson and Elizabeth Hopkins from Northern have led the process of

implementing the new Medicaid Rule to ensure all Medicaid programs are in compliance. They have also consolidated forms to one Mental Health Assessment and two Individualized Treatment Plans so that there is more consistency amongst the Northern and Hudelson regions.

• Stan Grimes, Jeffrey Honaker, and Kimberly Clark are participants in the 2013 Leadership Academy facilitated by CEO Bill Gillis and Executive Vice President Fotena Zirps PhD.

• Ruann Barack was awarded the Promise Award for Leadership. • Jackie Schedin was awarded a STAR Award for exemplary service during the 4th quarter of FY13.

Results • The CQIR team in Florida has launched a weekly data reporting process that takes a proactive

stance in addressing programmatic concerns. • The Medicaid Team in Hudelson achieved a 97% rating and Northern achieved a 94% rating (a

19 point increase) on their Post Payment Reviews for FY13 services. • The CQIR team participated in a CQI Capacity Assessment administered by the Department of

Children and Family Services and received a 19 out of 20 rating. The assessment focused on Foster Care Programs in Illinois.

• Members of the CQIR team completed a Program Evaluation of the Circle of Hope program in Springfield, MO.

• Members of the CQIR Team completed a 100% file review of the Tampa program.

Hope • Katurah Roby joined the CQIR team in Tampa, FL. • Sarah Tunning has taken on the Director of Research role for the Federation.

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Northern Leadership

The Northern Region is led by an Executive Director, 2 Associate Executive Directors, and 4 Senior Vice Presidents. Additionally, there are 5 Directors of Programs who assist in the leadership of specific program categories/programs. The Northern Region offers services in 6 program categories: Child Development, Counseling, Family Preservation, Placement, Prevention, and Youth Services.

Mark McHugh – Executive Director David Fox – Associate Executive Director

Beth Lakier – Associate Executive Director

Senior Vice Presidents Josie Disterhoft � Laura Franz � Joyce Heneberry � Timothy Snowden

Directors of Programs

Christina Czech � Rosanne DeGregorio � Jill Novacek Karen Powell � John Zupancic

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Executive Summary

This year OHU programs in the Northern Region served 5,486 clients and families – a 2.16% decrease from last year. The Compliance & Quality of service and record documentation overall was 88%. The efforts of Northern programs resulted in 73% of all outcome goals being met.

OUTCOME MANAGEMENT

PEER RECORD REVIEWS

Across all programs, 73% of Outcome goals were met in FY13.

Out of 896 files reviewed in FY13, the Northern Region Compliance & Quality rating on service documention was at 88%.

CLIENT SATISFACTION

INCIDENT REPORTS

Northern Region Overall satisfaction score has remained above 4.50 (‘A’) for the past three years.

In the Northern Region, the number of incidents decreased about 12% across most incident types. Incidents involving Client/Caregiver Property (-93%), Education incidents (-50%), and Client Deaths (-30%) had the largest decreases from FY12 to FY13.

OFFICE REVIEWS

SUPERVISORY REVIEWS

PRIORITY REVIEWS

In the Northern Region, 94% of Office Reviews and 79% of Supervisory reviews were compliant.

There were 16 priority reviews conducted in FY13: 5 Level III, 3 Level II and 8 Case Consultations.

EMPLOYEE RECOGNITION

QUALITY IMPROVEMENT TEAMS

There were 13 STAR awards and 4 GALAXY awards distributed this year.

There was an average QIT attendance rate of 96% in the Northern 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.

Programs Reviewed Risk Management Topics for FY14 QITs: Recommended Areas to Develop Action Plans

Child Development � Supervisory Reviews did not achieve the 90% target specifically in areas of individual supervision/team meetings and on-time performance reviews.

Counseling

� Counseling programs did not achieve the following outcomes: 1. Client treatment goals will be met at discharge did not reach the target in

DCFS Counseling, Foster Care Counseling-Cook, Foster Care/Comprehensive Counseling Downstate, and Intact Counseling.

2. Clients discharged will show an overall improvement between initial and closing CANS ratings did not reach the target in Foster Care Counseling-Cook, Foster Care/Comprehensive Counseling Downstate, and Intact Counseling.

3. Clients who reside in foster care or other out of home placement will remain in that placement or achieve permanency did not reach the target in Foster Care/Comprehensive Counseling-Downstate.

4. Clients who reside in the home of a parent at the time of referral will remain in the home did not reach the target in Intact Counseling.

5. Clients will demonstrate improved well-being did not reach the target in Community Counseling-Gurnee,

� Sexual Abuse Counseling Programs did not achieve the following outcomes: 1. Clients who reside in the home of a parent will remain in the home at the

time of discharge did not achieve the target in Adolescents with Sexual Behavior Problems-Gurnee/Kenosha and in St. Charles.

2. Clients will have a reduced level of sexual re-offense was not achieved by Adolescents with Sexual Behavior Problems-Gurnee/Kenosha.

3. Clients will have achieved at least 90% of their treatment plan goals at planned discharge did not reach the target in Adolescents with Sexual Behavior Problems-Gurnee/Kenosha.

4. Clients discharged will show an overall improvement between initial and Closing CANS did not reach the target in Adolescents with Sexual Behavior Problems-Gurnee/Kenosha.

� In Peer Record Review the following areas of service documentation did not achieve the agency’s target: 1. Intake was not achieved in Foster Care Counseling-Cook, DCFS

Counseling, Intact Counseling OHU, Foster Care Counseling-Downstate, Children with Sexual Behavior Problems-St. Charles, and CARE Day Treatment.

2. Assessment was not achieved in DCFS Counseling, Intact Counseling-OHU, Comprehensive Counseling-Downstate, Anger Management, Sexual Abuse Treatment Program-Adults, Adolescents with Sexual Behavior Problems-St. Charles, Adolescents with Sexual Behavior Problems-Gurnee, CARE Day Treatment.

3. Treatment Planning was not achieved in DCFS Counseling, Intact Counseling, Intact Counseling-OHU, Comprehensive Counseling-Downstate, Anger Management, Sexual Abuse Treatment Program-Adults, Adolescents with Sexual Behavior Problems-St. Charles & Gurnee, Children with Sexual Behavior Problems-St. Charles, and CARE Day Treatment.

4. Service Delivery was not achieved in Intact Counseling-OHU, Anger Management, and CARE Day Treatment.

5. Closing was not achieved in Intact Counseling and Anger Management.

Family Preservation

� In Peer Record Review the following areas of service documentation did not achieve the agency’s target: 1. Intake was not achieved in Intact Family-Cook Team A. 2. Assessment was not achieved in Intact Family-Waukegan and Intact

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Family-Cook Team A. 3. Treatment Planning was not achieved in Intact Family-Waukegan and

Intact Family Cook Team A. 4. Service Delivery was not achieved in Intact Family Waukegan.

Placement

� Foster Care-Cook did not achieve 2 outcomes. Children will achieve permanency within 24 months of the child coming and children who are reunified with their families will be reunited within12 months of the child coming into care did not achieve their targets.

� Foster Care-Downstate did not achieve 2 outcomes. Children will not be abused and/or neglected by a substitute caregiver while in foster care and children will remain reunified for a period of 6 months without re-entry into foster care did not achieve their targets.

� Specialized Foster Care did not achieve 3 outcomes. Children will achieve permanency during the fiscal year, children discharged will show improvement between initial and closing CANS and children will not require a higher level of care did not reach their designated targets.

� Rebound did not achieve 4 outcomes. Youth will be discharged into the community in a planned manner, treatment clients will have received their GED at the time of discharge, youth will be employed while enrolled in the program, and youth will improve their life skills did not achieve their targets.

� In Peer Record Review the following areas of service documentation did not achieve the agency’s target: 1. Intake was not achieved in Foster Care-Cook, Foster Care-Downstate,

Specialized Foster Care, and CARE Residential. 2. Assessment was not achieved in Licensing-Cook, Foster Care-Cook,

Foster Care Downstate, Specialized Foster Care, and CARE Residential. 3. Treatment Planning was not achieved in Foster Care-Cook, Foster Care

Downstate, and CARE Residential. 4. Service Delivery was not achieved in Foster Care-Cook, Foster Care-

Downstate, Specialized Foster Care, and CARE Residential. 5. Closing was not achieved in Foster Care-Cook, Foster Care-Downstate,

and Rebound.

Prevention

� In Peer Record Review the following areas of service documentation did not achieve the agency’s target: 1. Intake was not achieved in Wings-CPS. 2. Assessment was not achieved in Wings and Wings-CPS. 3. Treatment Planning was not achieved in Healthy Families and Wings-CPS. 4. Closing was not achieved in Wings.

Youth Services

� MST Probation, MST Kane, and MST Re-Entry did not achieve 3 outcomes. Youth will be maintained in a home like setting, youth will be deflected form further involvement in the juvenile justice system and youth will remain in school, alternative education, vocational training or employed did not achieve their targets.

In Peer Record Review the following areas of service documentation did not achieve the agency’s target:

1. Intake was not achieved in MST Re-Entry and MST Probation. 2. Assessment was not achieved in CCBYS, MST Re-Entry, and MST

Probation. 3. Treatment Planning was not achieved in CCBYS and MST Re-Entry, 4. Service Delivery was not achieved in CCBYS. 5. Closing was not achieved in MST Probation.

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Clients Served

In fiscal year 2013, One Hope United served 5,486 clients and families in the Northern Region – a decrease of 2.2% from FY12.

# of Clients Served by Fiscal Year FY13 FY12 FY11

Child Development 2,180 2,137 2,045 Counseling 1,049 1,136 938

Family Preservation 355 466 256 Placement 701 830 923 Prevention 965 800 7001

Youth Services 236 238 207 TOTAL 5,486 5,607 5,069

The main influences contributing to the decrease in clients served occurred in Family Preservation and Placement.

� In Family Preservation, the closing of the Differential Response program contributed to the decrease.

� In Placement, there was a decrease in the number of referrals which attributes to the decrease in the number of clients served.

Prevention programs saw an increase in the number of clients served due to an increase in the number of clients served in Parenting Groups.

The Child Development programs continue to be the largest source of clients for the Northern Region, accounting for 40% of their client population. The next largest program categories are Counseling, accounting for 19% of Northern’s client population and Placement, accounting for 13% of the client population.

1 In FY11 the Prevention client’s served number was originally reported at 1,135. Due to turnover and lack of documentation this number could not be confirmed. Therefore, the number was changed to 700 which was confirmed in documentation.

40%

19%

6%

13%

18%4%

Clients Served: Northern

Child Development 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 have value 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 client’s 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: Northern Re gion FY13 FY12 FY11

OVERALL TOTAL 73% 83% 83% Safety 90% 80% 100%

Permanency 55% 68% 74% Well-Being 76% 90% 80%

This year, the Northern Region achieved 73% of its outcome goals. The Northern Region holds itself to a number of outcome goals depending on the program category. Below is the outcome goal achievement by Child Welfare Measures by program category for FY13. For further outcome achievement information please see Appendices A-F.

Percentage of Outcome Goal Achievement: Program Cat egory Child

Development % Achieved

Counseling % Achieved

/

Family Preservation % Achieved

Safety 100% (1/1)

Safety 100% (3/3)

Safety 100% (1/1)

Well-Being 100% (4/4)

Permanency 83% (5/6)


TOTAL 100% (5/5)



TOTAL 72% (13/18)

TOTAL 100% (3/3)

Placement % Achieved Prevention %

Achieved Youth Services % Achieved

Safety 67% (2/3) Safety

100% (1/1) Safety

100% (1/1)

Permanency 40%

(4/10) Well-Being

100% (22/22)



TOTAL 100% (23/23)


TOTAL 48% (10/21)

TOTAL 40% (4/10)

“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 Northern Region. Specialized Foster Care Permanency Outcomes

Region Starting Caseload

Total Permanencies (measured by

points)

FY13 Permanency

Rate FY13 Goal

Northern 16 2 13% 20% Specialized Foster Care Actual Children

Region Adoption Return Home Guardianship Other Total

Northern 1 0 0 0 1 Illinois Traditional & Relative Foster Care Perman ency Outcomes

Region Starting Caseload

Total Permanencies (measured by

points)

FY13 Permanency

Rate FY13 Goal

Northern – Cook 158 50 32% 29% Northern – Downstate 209 73.5 35% 33%

Illinois Traditional & Relative Foster Care Actual Children

Region Adoption Return Home Guardianship Other Total

Northern – Cook 8 14 16 0 38 Northern-Downstate 22 19 8 1 50

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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 Northern Region in this report are: Child Development, Counseling, Family Preservation, Placement, Prevention, and Youth Services.

# of Northern Region File Reviews by Quarter Program Category Q1 Q2 Q3 Q4 TOTAL Child Development 95 97 91 89 372

Counseling 47 47 50 49 193 Family Preservation 12 11 11 12 46

Placement 51 51 45 46 193 Prevention 12 13 13 12 50

Youth Services 9 10 12 11 42 TOTAL 226 229 222 219 896

In FY13, 896 files were reviewed across all six program categories. There are 11 tools utilized in the Northern Region that assess Compliance & Quality. There are some tools that are used that assess only compliance and then other 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 assess both compliance and quality (Ex. Child Development). Results were combined across all tools to produce the following graph which looks at how the Region performed as a whole.

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.

“COA standards require OHU to

randomly select a sample of records to

review for all programs.”

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In FY13, the Northern Region met the 90% Compliance & Quality target in Intake and Closing. The Region is performing at or above the Cross-Regional rates in all areas measured and achieved an 88% Compliance & Quality overall rating – this was an increase of 5% from FY12.

Compliance & Quality performance for the Northern region was also analyzed by program category to produce the following graph.

Child Development Centers, Prevention programs, and Youth Services are all meeting or exceeding the agency’s 90% target for Compliance & Quality across all areas measured. Counseling and Family Preservation programs are within 1% of the target. Placement programs are within 10% of the target. Each program category is analyzed more closely in Appendices A-F to identify additional trends and areas of growth.

Intake AssessmentTreatment

PlanServiceDelivery

Closing Overall

Actual 94% 86% 84% 85% 91% 88%Target 90% 90% 90% 90% 90% 90%Cross-Region 90% 85% 84% 84% 83% 86%

0%

20%

40%

60%

80%

100%

Compliance & Quality - Across All Northern Programs

Child

DevelopmentCounseling

Family

PreservationPlacement Prevention

Youth

Services

Program Category 96% 89% 89% 80% 93% 90%

Target 90% 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Overall Compliance & Quality - Across All Program Ca tegories

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During fiscal year 2013 there were 73 case managers, therapists, supervisors, and directors who assisted in reviewing 896 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.

Peer Record Reviewers Jennifer Woods Jennifer Riha

Jennifer Hedrich Margaret Vergamini

Terri Cummings Brian McConville Brandy Kukurba

Bessie Whitehurst-Smith Bobbie Weiner

Sue Olson Keith Wheeler Cindy Rotman

Mary Mann Shirica Flowers Jennifer Keith Sarah Martin Noell Juola

Kahdijah Hakeem Danielle Sines

Katie Jackson Denny Clouse Lisa Wiemhoff Lorena Duran

Jim Ogle Carleen Otto

Cindy Peterson Dennis Delgado

Beth Tuthill Joi LaMon

June Galinski Karen Felix

Samella Taylor Devin Dittrich Karen Powell Terry Kean Jane Lough

Beth Ericksen Dana Torres

George Husick Shantina Griffin

Deborah Holmes-Thomas Andrea Gray-Strutzenberg

Freya Gorenstein Brian McGannon Shirley Hawkins

Cortney Rhadigan Kristin Patten Denise Herron Jennifer Forbes Diana Guzman

Carolina Rodriguez Julius Benjamin Andrew Hamlyn Latrina Presley Megan Sullivan Cecilia Rivas

Lakiethia Butler

Adrienne Patterson-Green Marlice Waddy Felicia Foster

Liza Simon-Roper Joanna Zakhem Jill Bulakowski Tammy Ambre Brenda Gossett

Amy Collins Brigette Davis

Lois Aliotta Mindy Kwoh

Brenda Gossett Ann O’Malley

Cindy Paladino Ron Smith

TOTAL: 73

Thank you for your time, efforts, and commitment to quality service delivery.

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Client Satisfaction

CQIR conducts an annual Client Satisfaction Survey to monitor OHU clients’ impressions of the 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.

Child

Development Counseling Family

Preservation Placement Prevention Youth

Services � FY13 4.81

(N=619) 4.67

(N=349) 4.79

(N=108) 4.28

(N=343) 4.93

(N=189) 4.53

(N=59) � FY12 4.70

(N=597) 4.54

(N=351) 4.63

(N=131) 4.34

(N=345) 4.83

(N=169) 4.68

(N=97) � FY11 4.74

(N=547) 4.63

(N=351) 4.78

(N=137) 4.29

(N=334) 4.89

(N=165) 4.79

(N=86) Across Region and fiscal year, all programs except Placement scored in the ‘fine tuning’ range. Four program categories saw an increase in “Overall satisfaction with OHU”. Placement has scored in the ‘needs improvement’ range for the past three years, and in FY13 “Overall satisfaction with OHU” decreased from FY12. Overall satisfaction in Youth Services also decreased; however, this program is still in the ‘fine tuning’ range

2013 2012 2011 4.67

(N=1,667) 4.60

(N=1,690) 4.64

(N=1,620) In the Northern Region, overall client satisfaction with OHU has remained above 4.50 (‘A’) for the past three years. This year, there were 1,677 surveys returned for Northern Region, a 1.36% decrease from the 1,690 surveys collected in 2012.

3.60

3.80

4.00

4.20

4.40

4.60

4.80

5.00

ChildDevelopment

Counseling FamilyPreservation

Placement Prevention Youth Services

Overall OHU Client Satisfaction: Northern Region

“Client Satisfaction Surveys monitor

clients’ impressions of the services OHU

provides.”

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Incident Reports

An incident is any occurrence that may have the potential for increased risk for our clients and 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 and circuit over three fiscal years.

In the Northern Region, there was an 11.8% decrease in the number of incident types in FY13 compared to FY12. There was only one incident type that increased and that was Behavioral Issues, which increased by 4.4% in FY13. All other incident categories saw a decrease. The most significant decreases were in Client Caregiver Property (-92.9%), Education (-50%), Deaths (-30%), Behavior Management (-27.5%), and Sexually Problematic Behaviors (-22%). It is important to note that the number of Behavior Management incidents (incidents involving a restraint) in the CARE Day Treatment (DTx) and Residential (RTx) programs decreased for the first time since FY10. In FY12, 34% of all incidents in the Northern Region involved a restraint. In FY13, out of the 1,475 incidents, 28% involved a restraint, a 6% decrease.

0

200

400

600

800

Incident Types by Year: Northern 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. This includes professional appearance, staff response to answering telephone calls, maintaining client confidentiality and safety and risk management. CQIR coordinators conduct OHU office systems reviews annually.

Seventeen Office Systems Reviews were conducted in the Northern Region (9 Child Development Centers and 8 Program Offices). As a Region, 94% of all office system reviews were compliant – a 2% decrease from FY12. Both Child Development Centers and Program Offices are exceeding the agency’s 90% target.

93% 95% 94%

0%

20%

40%

60%

80%

100%

Child DevelomentCenters

Program Offices Region

Office Systems Compliance: Northern Region

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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.

Fifty-seven Supervisory Systems Reviews were completed in the Northern Region (37 from Child Development Centers and 20 from Program Offices). As a Region, supervisors were 79% compliant with items measured – a 2% increase from FY12. Both Program Offices (85%) and Child Development Centers (73%) are below the agency’s 90% target.

Items missed most on Supervisory Systems Reviews at Child Development Centers were: • Supervision occurs monthly (Management Team Meetings and/or Individual). • Annual performance reviews are completed within 30 days of review date.

Items missed most on Supervisory Systems Reviews at Program Offices were:

• Individual supervision occurs. • The supervisor completes annual staff performance reviews within the month they are due.

73%85% 79%

0%

20%

40%

60%

80%

100%

Child Development Program Offices Region

Supervisory Systems Compliance: Northern Region

Page 19 of 43

“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 provided to 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 are 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 Category Case Consultations Level 2 Level 3 TOTAL

Child Development 0 0 0 0 Counseling 1 0 2 3

Family Preservation 2 0 0 2 Placement 5 3 1 8 Prevention 0 0 1 1

Youth Services 0 0 2 2

TOTAL 8 3 5 (see footnote)

162 (unduplicated)

There were 16 priority reviews conducted in FY13 (down 10 from FY12). The decrease can be attributed to a decrease in the number of Case Consultations and Level 3 Reviews.

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. Northern conducted 3 less Case Consultations in FY13 compared to FY12. There were three Level 2 Priority Reviews conducted in FY13 (up 1 from FY12). One was due to the abduction of a child from Foster Care, one was due to inappropriate behavior between 2 clients, and one was at the request of program leadership. There were five Level 3 Priority Reviews conducted in FY13 (down 7 from FY12) (one review was for a client that was enrolled in 2 OHU programs). Four reviews were due to suicide attempts made by clients and one was due to a client death. Below are some highlights of lessons learned throughout the year:

• When there is a significant safety issue or history of abduction with a natural parent, that case needs to be staffed immediately with the Director of Programs to devise a plan for visitation and services with the supervisor moving forward.

2 The Level 3 review that took place in Counseling and Prevention involved a client that was enrolled in Intact Family Counseling and the Wings – CPS program. In the total column this review was only counted once.

Page 20 of 43

• Based on the dynamics of the case, the location of the visits needs to be assessed to identify safety concerns.

• Case aids need to be updated on the history and dynamics of each case in which they are supervising parent-child visits.

• Transportation requests need to be signed by the case manager as well as the supervisor to ensure the case aid has all the important case information needed for safety and security reasons.

• The history of the case needs to be shared with everyone involved in the case. • Transitional programming for clients who have finished high school would provide increased

structure and might help prevent boredom and some acting out behavior. • Good communication on shared cases between programs is essential and aides in ongoing

assessment and treatment planning. This was done effectively on this case. • The importance of having the proper training and completion of an Eco-map to understand

the family, strengths and resources. • For non-traditional families that we work with, we need to look for non-traditional ways to

engage them. • The review was reminder to obtain consents within the agency for different programs that

have the same client in order to communicate with each other. • Continue to try to engage client even though they may be resistant.

Additional information can be found by contacting a member of the CQIR team.

Page 21 of 43

Employee Recognition

Two methods of awarding staff excellence are supported by CQIR. The first is the STAR Award for individual excellence, and the second is the GALAXY Award for team excellence. The awards recognize staff that have gone above and beyond “normal” work duties, exhibited exemplary performance and done their job under circumstances that are “out of the ordinary.” – There were 13 Star awards and 4 Galaxy awards distributed in the Northern Region this year. In FY13 we were proud to recognize these Northern employees with a STAR Award.

Quarter 1 � Patty Diaz – Eligibility Specialist (Aurora, IL) � Andrew Rozanski – Youth Care Worker

(Lake Villa, IL) � Delores Momen – Case Manager

(Kankakee, IL) � Blanca Figueroa – Payroll Manager (Lake

Villa, IL) � Ginny Kowalski – Office Manager

(Waukegan, IL/Busy Bee) � Amy Hirsh – Child Development Director

(Wilmette, IL) � Susan Spjuth – Child Development

Specialist (Des Plaines, IL)

Quarter 2 � Nicole Apolo – Donor Database

Administrator/Accountant I (Lake Villa, IL)

Quarter 3 � Yudelca Romano – Counselor/Therapist

(Gurnee, IL) � Bonita Porter – Therapist (Chicago, IL) � Francine Williams – Case Manager

(Chicago, IL)

Quarter 4 � Jackie Schedin – CQIR Coordinator

(Chicago, IL) � Devin Gazelle – Supervisor (Joliet, IL)

The following teams were presented with a GALAXY Award this year.

Quarter 1 Quarter 3 � CARE Day Treatment (Lake Villa, IL) � Kenwood Support Staff (Chicago, IL) � Des Plaines Child Development Center (Des Plaines, IL) Quarter 4 � Bridgeport II Child Development Center Classroom 2 (Chicago, IL)

Page 22 of 43

Quality Improvement Teams

Everyone in the agency participates in at least one Quality Improvement Team (QIT). This allows each employee the power to implement improvement within their own QIT. The QIT is focused on improving the quality of service at the local level using data, effective problem solving and action planning. Across the agency, there was an overall attendance rate of 96% in FY13. – The attendance rate in the Northern Region was 96%. The following local, service center and regional Quality Improvement Teams were assembled three times this year in the Northern Region.

QIT Names Local Service Center Regional

Wonder Women The River Valley Responders KFC – Kenwood Foster Care

Whatever it Takes MST on The Prairie

Super Crew Top Performing Butterflies

OHU Advocates Social Workers for Justice

The Guardian Angels Bridgeport II

Edgewater Educators O’Hare CDC

The Inspirations The Eclectics

The Facilitators CLC

Seeds of Change 24-7 Crew

Team Extreme EBT The Rainbow – Team Teach

The 4 Runners Old School Rebounders

Cheers Connect 6

Team Unity All Stars Educaneers

The Show Must Go On Wilmette/Glenview CDC

Eternal Optimists The Pilots

The B.R.A.T.S.

Energizers To Infinity & Beyond

Mission Movers CARE Leadership The Wanderers

Prevention Supervisors

Community Transformers

Page 23 of 43

Appendix A – Child Development Highlights

The Northern Region operates 11 Child Development Centers throughout the Chicagoland area. Across the 11 centers, 2,180 clients were served in FY13 which is a 2% increase from FY12. � Outcomes

Goals Target % Achieved 1. Children served will not be subjects of

abuse or neglect while physically present in the child development program.

90% 100%

2. Children in the center will meet or exceed widely held expectation for social and emotional development.

80% 94%

3. Children in the center will meet or exceed widely held expectations for physical development.

80% 94%

4. Children in the center will meet or exceed widely held expectations for cognitive development.

80% 93%

5. Children in the center will meet or exceed widely held expectations for language development.

80% 90%

� Peer Reviews

Overall, Child Development Centers achieved a 96% Compliance & Quality rating on all areas measured across all centers. Intake, Assessment, and Service Delivery were within 3-5% of a 100% Compliance & Quality rating. When looking at each of the 11 centers individually, all centers across all phases of the case life-cycle were above the 90% target.

Intake AssessmentServiceDelivery

Overall

Child Development 97% 97% 95% 96%Target 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Child Development Centers

Page 24 of 43

Appendix B – Counseling Highlights

The Northern Region operates Counseling programs throughout the Chicagoland area. Across all programs, 1,049 clients were served in FY13 which is a 7.7% decrease from FY12. � Outcomes are reported below. For ease of analysis, results were condensed across specific types

of Counseling Programs. 1. DCFS Counseling, ECHO, Foster Care (FC) Counseling Cook, Foster Care (FC) &

Comprehensive (Comp) Counseling – Downstate (program offices were combined), and Intact Counseling

2. Community Counseling 3. System of Care (SOC) 4. Sex Offender Counseling Programs 5. CARE Day Treatment

DCFS Medicaid Counseling, ECHO, Foster Care Counsel ing,

Comprehensive Counseling & Intact Counseling

Goals Target DCFS Counseling ECHO

FC Counseling

Cook

FC/Comp Counseling Downstate

Intact Counseling

1. Clients served will not be subjects of indicated reports of abuse or neglect during the service period.

90% 100% 100% 100% 98% 91%

2. Clients who reside in the home of a parent at the time of referral will remain in the home.

90% N/A 100% N/A 100% 80%

3. Clients who reside in foster care or other out of home placement will remain in that placement or achieve permanency.

90% 100% N/A 92% 87% N/A

4. Clients discharged will show an overall improvement between initial and closing CANS ratings.

80% 86% N/A 70% 78% 50%

5. Client treatment goals having been substantially met at discharge.

80% 76% 87.2% 65% 72% 29%

Page 25 of 43

Community Counseling Goals Target Gurnee St. Charles

1. Clients will achieve at least 75% of the treatment plan goals at discharge

70% 100% 100%

2. Clients will demonstrate improved well-being as measured by a standardized instrument, pre and post service (measured at discharge).

75% 50% 100%

SOC

Goals Target % Achieved 6. Clients will maintain their initial placement at

the time of discharge. 70% 94%

7. Clients discharged will show an improvement between initial and closing CANS ratings.

80% 94%

Sex Offender Counseling Programs

Goals Target SATP ASBP – Gurnee/Kenosha

ASBP – St. Charles

1. Client has reduced level of risk for sexual re-offense as measured by the ERASOR and JSOAP (adolescents) and Static 99 and Vermont (adults).

75% 87% 71% 90%

2. Clients who reside in the home of a parent will remain in the home at time of discharge

90% N/A 71% 64%

3. Client has achieved at least 90% of their treatment plan goals at planned discharge or completion of treatment.

80% 96% 60% 100%

4. Clients discharged will show an overall improvement between initial and closing CANS ratings.

80% N/A 73% 100%

CARE Day Treatment 3

Goals Target % Achieved 1. Youth will remain in the community while

enrolled in the program. 90% 100%

2. Youth will maintain their less restrictive placement for 6 months after being discharged from the CARE program.

80% 100%

3. Youth shall experience an increase in one academic grade during the academic year, based on the results of the MAP testing.

80% 100%

4. Parents shall indicate program satisfaction 80% 100%

3 The final two outcomes are contract-based satisfaction outcomes. They are not included in the agency’s overall outcome performance.

Page 26 of 43

at the time of termination. 5. Referral Sources shall indicate program

satisfaction at the time of termination. 80% 100%

� Peer Record Reviews are reported below. For ease of analysis, results were condensed across

specific types of Counseling Programs. 1. Cook County Counseling Reviews 2. Downstate Counseling including: Foster Care, Comprehensive, Community, & Anger

Management Counseling Reviews (results were combined across offices) 3. Sexual Offender Counseling Program Reviews 4. CARE Day Treatment Reviews

Overall, Counseling Programs in Cook County achieved a 93% Compliance & Quality rating. DCFS Counseling (77%), Intact Counseling (89%), and Intact Counseling-OHU (84%) are the only programs that did not achieve the 90% target. ECHO and SOC exceeded the target in all areas measured. Foster Care Counseling met or exceeded the target in Assessment, Treatment Planning and Service Delivery, and was within 5% of the target in Intake.

Intake Assessment TreatmentPlan

ServiceDelivery

Closing Overall

FC Counseling Cook 85% 90% 91% 95% 91%ECHO 98% 91% 92% 94% 97% 95%DCFS Counseling 82% 81% 39% 93% 100% 77%SOC 96% 99% 100% 100% 96% 99%Intact Counseling 95% 100% 89% 91% 33% 89%Intact Counseling-OHU 88% 74% 79% 88% 100% 84%Target 90% 90% 90% 90% 90% 90%All Programs 93% 92% 90% 95% 93% 93%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Counseling - Cook

Page 27 of 43

Overall, Downstate Counseling Programs achieved a 93% Compliance & Quality rating. Comprehensive Counseling (88%) and Anger Management (36%) are the only programs that did not achieve the 90% target. Community Counseling achieved a 100% Compliance & Quality rating. Foster Care Counseling exceeded the target in all areas measured with the exception of Intake, which was within 2% of the target.

Overall, Sex Offender Counseling Programs achieved a 93% Compliance & Quality rating. Children with Sexual Behavior Problems – St. Charles (83%) and Adolescents with Sexual Behavior Problems – Gurnee (89%) are the only programs that did not achieve the 90% target. Adolescents with Sexual Behavior Programs – Kenosha and Children with Sexual Behavior Problems – Gurnee achieved a 100% Compliance & Quality rating.


PlanServiceDelivery

Closing Overall

Foster Care Counseling 88% 95% 97% 98% 100% 96%Comprehensive Counseling 93% 89% 71% 98% 88%Community Counseling 100% 100% 100% 100% 100% 100%Anger Management 92% 33% 22% 23% 30% 36%Target 90% 90% 90% 90% 90% 90%All Programs 91% 94% 91% 95% 65% 93%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Counseling - Downstate


ServiceDelivery

Closing Overall

SATP - Adults 99% 83% 88% 95% 100% 93%ASBP St. Charles 97% 89% 81% 98% 92%CSBP - St. Charles 87% 100% 62% 93% 83%ASBP - Kenosha 100% 100% 100% 100% 100% 100%ASBP - Gurnee 100% 86% 63% 96% 100% 89%CSBP - Gurnee 100% 100% 100% 100% 100%Target 90% 90% 90% 90% 90% 90%All Programs 98% 88% 84% 96% 100% 93%

0%20%40%60%80%

100%

Compliance & Quality: Counseling - Sex Offender Prog rams

Page 28 of 43

Overall, CARE Day Treatment scored an overall Compliance & Quality Rating of 49%. Closing is the only category that met the agency’s 90% target with a 100% 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. Foster Care Counseling-Cook Intake (85%)

• Are Releases of Information completed, signed and current? (4/8) DCFS Counseling Intake (82%)

• Are the Client’s Rights and Responsibilities in the record & signed by all relevant parties? (2/6) • Are the Release of Information Forms current (within 1 year) for correspondence with ALL

entities outside of the agency? (2/6) Assessment (81%)

• Was the updated assessment report completed within the required timeframe of the program contract? (2/2)

Treatment Plan (39%) • Is the current copy of the service plan/treatment plan/case plan in the file (Per Program

Contract/Plan)? (3/5) Intact Counseling Treatment Plan (89%)

• 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? (3/4)


PlanServiceDelivery

Closing Overall

CARE DTx 69% 49% 50% 28% 100% 49%Target 90% 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Counseling - CARE Day Treatmen t

Page 29 of 43

Closing (33%) • Is the Closing Summary in the record? (1/1) • If follow-up services were recommended were appropriate referrals and linkages made? (1/1)

Intact Counseling-OHU Assessment (74%)

• Was the Initial Assessment Report completed within the required timeframe of the program contract? (3/5)

Treatment Plan (79%) • 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? (3/4) Service Delivery (88%)

• Does the record confirm sufficient contacts according to program requirements with the client/family to accomplish the goals? (2/5)

Foster Care Counseling-Downstate Intake (88%)

• Are Releases of Information completed, signed and current? (5/20)

Comprehensive Counseling Assessment (89%)

• Is a copy of the Initial Assessment Report in the record? (1/9) • Was sufficient information recorded to understand the presenting problem? (1/9)

Treatment Plan (71%) • Is the current service/treatment/case plan signed and dated by the client and parent/guardian?

(4/9) • Is there evidence in the record that the family participated in the development of the

service/treatment plan? (4/9)

Anger Management Assessment (33%)

• Is a copy of the Initial Assessment Report in the record? (2/3) Treatment Plan (22%)

• Is the current copy of the service plan/treatment plan/case plan in the file (Per Program Contract/Plan)? (2/3)

Service Delivery (23%) • Is there required documentation of current client progress (or lack there of) towards their

service goals in the case record? (2/3) Closing (30%)

• Is the Closing Summary in the record? (1/2)

SATP-Adults Assessment (83%)


Treatment Plan (88%)

Page 30 of 43


ASBP-St. Charles Assessment (89%)



Manager/therapist and supervisor within the required timeframe of the program contract? (2/6)

CSBP-St. Charles Intake (87%)


entities outside of the agency? (1/3) Treatment Plan (81%)


ASBP-Gurnee Assessment (86%)



CARE Day Treatment Intake (69%)

• Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (16/24)

Assessment (33%) • Is a copy of the Initial Assessment Report in the record? (9/28)

Treatment Plan (22%) • Is the current copy of the service plan/treatment plan/case plan in the file (Per Program

Contract/Plan)? (12/28) Service Delivery (23%)

• Is there required documentation of current client progress (or lack there of) towards their service goals in the case record? (20/28)

Page 31 of 43

Appendix C – Family Preservation Highlights

The Northern Region operates two Family Preservation programs: one located in Waukegan, IL and the other one located in Cook County, IL, which is divided into 2 teams. Across the programs, 355 clients were served in FY13 which is a 23.8% decrease from FY12 which is attributed to the closing of the Differential Response program. � Outcomes

Family Preservation Goals Target Cook Waukegan

1. Families will not have a confirmed abuse or neglect report during the service period

85% 97% 93%

2. Families remain together during service period.

90% 97% 97%

3. Families discharged from the Family Preservation program will show an overall improvement between initial and closing CANS.

80% 91% N/A

� Peer Reviews

Across all programs and all areas measured, the Family Preservation programs achieved an 89% Compliance & Quality Rating, which is just below the 90% target. Across all programs, Intake, Service Delivery and Closing exceeded the 90% target. When looking at individual programs, Intact Family-Cook B exceeded the 90% target in all areas measured and received a 95% Compliance & Quality rating overall. Cook A achieved the target in Service Delivery and Closing and was within 2% of the agency’s target. Waukegan achieved the target in Intake.


PlanServiceDelivery Closing Overall

Intact Family-Waukegan 91% 73% 55% 75% 72%Intact Family-Cook A 89% 82% 79% 98% 100% 88%Intact Family-Cook B 92% 94% 93% 99% 100% 95%Target 90% 90% 90% 90% 90% 90%All Programs 90% 85% 80% 95% 100% 89%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Family Preservation

Page 32 of 43

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 Family - Waukegan Assessment (73%)


• Was the Home Safety Checklists for Intact and Permanency Workers updated every six months during the life of the case? (2/2)

• Were the Home Safety Checklists updated every 90 days during the life of the case? (2/2) Treatment Plan (55%)


• Was the family’s comprehensive service plan completed within 30 days of case opening? (2/2) Service Delivery (75%)

• Is there evidence of quarterly case supervision in which the case is reviewed at least quarterly and includes an evaluation of the client’s progress toward achieving his/her service goals? (3/8)

Intact Family – Cook A Intake (89%)

• Is there documentation in the record of written correspondence with the funding/referral source indicating the actual date of case opening and/or case closing? (4/19)

• Did the transitional visit occur within two business days of receiving the intact case referral? (4/12)

Assessment (82%) • Was the Initial Assessment Report completed within the required timeframe of the program

contract? (7/19) • Was a CERAP completed within 5 working days of case opening? (3/6) • Was a SACWIS Risk Assessment completed every 90 days? (2/3) • Is there evidence that the initial CANS was completed? (2/6) • Was the Home Safety Checklist for Intact and Permanency Workers completed within 30 days

of case opening?(2/6) Treatment Plan (79%)


• Did the initial Child and Family Team meeting occur within 45 days of the transitional visit? (4/6)

• Was the family’s comprehensive service plan completed within 30 days of case opening? (5/6)

Page 33 of 43

Appendix D – Placement Highlights

The Northern Region operates a number of different Placement programs including CARE Residential Treatment, Rebound, Foster Care services in Cook County, Downstate Foster Care services, and Specialized Foster Care. Across the programs, 701 clients were served in FY13 which is a 15.5% decrease from FY12 which is primarily attributed to a decrease in the number of referrals in Foster Care. � Outcomes are reported below by program and/or by program contract.

Foster Care Goals Target Cook Downstate

1. Children will not be abused and/or neglected (an indicated report) by a substitute caregiver while in foster care.

99.6% 99.7% 99.4%

2. Children will achieve permanency within 24 months of the child coming into care (all other permanencies outside of reunification).

32% 10% 35%

3. Children will experience two or fewer placement settings within a 12 month period.

95% 98% 99%

4. Children who are reunified with their families will be reunified within 12 months of the child coming into care.

46% 14% 61%

5. Children will remain unified for a period of 6 months without re-entry into foster care.

91% 100% 85%

6. Clients discharged from the foster care program will show an overall improvement between the initial and the closing CANS ratings.

80% 100% 99%

Specialized Foster Care

Goals Target % Achieved 1. Children will not be abused and/or neglected

(an indicated report) by a substitute caregiver while in foster care.

99.6% 100%

2. Children will achieve permanency during the fiscal year.

20% 5%

3. Children will experience two or fewer placement settings within a 12 month period.

85% 100%

4. Children will remain unified for a period of 6 months without re-entry into foster care.

91% N/A

5. Clients discharged from the foster care program will show an overall improvement between the initial and the closing CANS ratings.

80% 50%

6. Children will not require a higher level of care (i.e. psychiatric hospitalization or residential care).

85% 76%

Page 34 of 43

Rebound

Goals Target % Achieved 1. Youth will be discharged into the community

in a planned manner. 25% 8 %

2. Diagnostic clients will be participating in the GED assessment and courses.

70% 100%

3. Treatment clients will have completed and received their GED at time of discharge.

50% 17%

4. Youth will participate in initial job searching skill development.

90% 100%

5. Youth will be employed while enrolled in the Rebound program.

50% 13%

6. Youth will reconnect with family members as visiting resources.

80% 100%

7. Youth will improve their life skills as measured by the Ansell-Casey Life Skills Assessment.

80% 30%

CARE Residential

Goals Target % Achieved 1. Youth served will not be subjects of

indicated reports of abuse or neglect while physically present in the residential treatment program.

95% 100%

2. Youth served will achieve and sustain a positive or neutral discharge placement for a period of 90 days following discharge

22.49% 23.53%

3. The treatment opportunity rates will be achieved.

95.32% 96.24%

� Peer Record Reviews are reported below by program and/or by program contract.


ServiceDelivery

Closing Overall

Licensing 94% 81% 90% 91%FC - Cook 71% 64% 74% 71% 78% 71%Target 90% 90% 90% 90% 90% 90%All Programs 89% 72% 74% 73% 78% 77%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Placement - Cook

Page 35 of 43

Across all programs and all areas measured, the Foster Care programs in Cook County achieved a 77% Compliance & Quality Rating, which is below the agency’s 90% target. All phases of the case life cycle were below the 90% target. When looking at individual programs, Licensing met or exceeded the 90% target in Intake and Service Delivery and received a 91% Compliance & Quality rating overall. Foster Care Cook achieved an overall Compliance & Quality rating of 71% and did not achieve the target in any areas measured. .

Across all programs and all areas measured, the Downstate Foster Care programs achieved an 84% Compliance & Quality Rating, which is below the agency’s 90% target. Intake was the only area, across all programs to meet/exceed the agency’s target. When looking at individual programs, Licensing – Downstate achieved an overall Compliance & Quality rating of 94% and exceeded the target in all areas measured. Foster Care – Downstate achieved an overall Compliance & Quality rating of 76% and did not achieve the target in any areas measures.


PlanServiceDelivery

Closing Overall

Licensing - Downstate 93% 99% 93% 94%FC-Downstate 77% 73% 82% 75% 67% 76%Target 90% 90% 90% 90% 90% 90%All Programs 91% 88% 82% 77% 67% 84%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Placement - Downstate

Page 36 of 43

Overall, Specialized Foster Care achieved an 83% Compliance & Quality Rating. Treatment Planning is the only area that met the agency’s 90% target.

Overall, CARE Residential achieved 70% Compliance & Quality Rating. Closing is the only area that exceeded the agency’s target.



Specialized FC 79% 73% 90% 84% 83%Target 90% 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Placement - Specialized Foster Care



CARE 74% 72% 70% 70% 100% 70%Target 90% 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Placement - CARE Residential

Page 37 of 43

Overall, Rebound achieved a 97% Compliance & Quality Rating. Closing is the only area that did not achieve the 90% target; however it was within 1% of the goal. All other areas measured exceeded the 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. Licensing - Cook Assessment (81%)

• Initial Home Study: Physical environment of the home, both inside and outside. (7/22) • Initial Home Study: Knowledge and skill of foster parents such as, understanding of child

development, attitude toward natural parents, educational level, communication skills, etc. (7/22)

Foster Care - Cook Intake (71%)

• Are the Client’s Rights and Responsibilities in the record & signed by all relevant parties? (20/32)

Assessment (64%) • Was the Initial Assessment Report completed within the required timeframe of the program

contract? (11/26) • Substance Abuse Screen (For all cases). (14/29) • Child/Caregiver Matching Tool. (5/7)


(23/31) Service Delivery (71%)


PlanServiceDelivery

Closing Overall

Rebound 97% 99% 93% 97% 89% 97%Target 90% 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Placement - Rebound

Page 38 of 43

• Fingerprints for all children age 6 months or older. (27/29) • Did the initial Family Meeting occur within 48 hours of case assignment (with Supervisor

present)? (21/29) • Consent for Ordinary/Routine Medical and Dental Care. (17/29) • Child Identification Form. (15/29)

Closing (78%) • Was the evaluation of the service plan completed? (1/1)

Foster Care - Downstate Intake (77%)


• Is the Family Face Sheet/Case Cover Sheet in the record? (16/49) • Are the Release of Information Forms current (within 1 year) for correspondence with ALL


• Is a copy of the Initial Assessment Report in the record? (10/49) • Was the Initial Assessment Report completed within the required timeframe of the program

contract? (12/40) • Substance Abuse Screen. (14/35) • Child/Caregiver Matching Tool. (4/9)


(22/41) Service Delivery (75%)

• For the past 6 months: Are there monthly supervision notes in the case record? (20/36) • Did the initial Family Meeting occur within 48 hours of case assignment (with Supervisor

present)? (22/36) • Fingerprints for all children age 6 months or older. (25/31) • A photograph of the child annually (the photograph needs to be labeled on the back with the

child’s name, birth date, DCFS ID # and the date on which the photo was taken) (23/35) Closing (67%)

• 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)

Specialized Foster Care Intake (79%)

• Are the Client’s Rights and Responsibilities in the record & signed by all relevant parties? (2/3) Assessment (73%)

• Is a copy of the Initial Assessment Report in the record? (1/4) • Substance Abuse Screen. (3/4)

Service Delivery (84%) • Did Child and Family Team meetings occur quarterly? (3/3)

CARE-Residential Intake (74%)

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• A letter to the funding source documenting the date of case acceptance and case closure. (5/8)


Assessment (72%) • Is there a Children's Global Assessment Scale (CGAS) completed with assessment and

quarterly reports? (5/8) • Does the current Mental Health Assessment include: General physical health. (5/8)


(10/20) • Does the record contain the most current 497? (4/8) • Has a current written visiting plan (in the 497) been developed for all siblings in substitute

care? (5/6) Service Delivery (70%)

• Did the record contain a minimum of one service provided and documented every day during the past 30 day sample period? (8/8)

• Case note documentation reflects the level of client contact per program requirements? (8/12) • If sibling visitation is not occurring per the 497, has a plan been developed to attempt to

achieve compliance with visitation? (6/6) Rebound Closing (89%)

• 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)

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Appendix E – Prevention Highlights

The Northern Region operates four Prevention programs. Across the 4 programs, 965 clients were served in FY13 which is a 20.6% increase from FY12 which is attributed to an increase in the number of clients enrolled in the Parent Group. � Outcomes for the Prevention Programs have been condensed to show the number of outcomes

achieved by outcome category (i.e. Safety and Well-Being). For a full listing of Prevention outcomes please contact Kimberly Clark.

% of Safety Outcomes Achieved

% of Well -Being Outcomes Achieved

Healthy Families 100% (1/1)

100% (10/10)

Wings 100% (1/1)

100% (10/10)

Parent Group N/A 100%

(10/10)

Wings – CPS 100% (1/1)

100% (10/10)

Success by 6 100% (1/1)

100% (12/12)

� Peer Reviews

Across all programs and all areas measured, Prevention programs achieved a 93% Compliance & Quality rating, which exceeds the 90% target. Across all programs, Assessment (88%) is the only area that was below the target. The Success by 6 program achieved an overall Compliance & Quality rating of 99%, with three areas (Assessment, Treatment Planning, and Closing) achieving a 100% rating. Healthy Families and Wings both achieved a 93% overall Compliance & Quality rating. Healthy Families exceeded the target in Intake, Assessment, and Service Delivery and Wings exceeded the target in Treatment Planning and Service Delivery. The Wings-CPS program achieved an overall


ServiceDelivery

Closing Overall

Healthy Families 93% 94% 89% 100% 93%Wings 89% 86% 97% 97% 60% 93%Wings-CPS 96% 74% 82% 93% 100% 88%Success by 6 98% 100% 100% 99% 100% 99%Target 90% 90% 90% 90% 90% 90%All Programs 93% 88% 91% 98% 93% 93%

0%

20%

40%

60%

80%

100%

Compliance & Quality: Prevention

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Compliance & Quality rating of 88%, within 2% of the target. Intake, Service Delivery, and Closing all exceeded the 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. Healthy Families Treatment Plan (87%)


Wings Intake (89%)


Assessment (86%) • Was the updated assessment report completed within the required timeframe of the program

contract? (3/5) Closing (60%)

• Is the Closing Summary in the record? (1/1) Wings-CPS Assessment (74%)


• Was the child screened within 45 days of starting the program? (2/4) • Is the Curriculum Checklist complete and up to date within the last 30 days? (2/5)




• Does the IFSP address developmental goals of children, objectives and expected outcome(s) for the specific service(s) provided to the client and/or family? (2/5)

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Appendix F – Youth Services Highlights

The Northern Region operates four Youth Services programs. Across the 4 programs, 236 clients were served in FY13 which is a 0.8% decrease from FY12. � Outcomes

Youth Services

Goals Target CCBYS Target MST Probation

MST Kane Target MST

Re-Entry 1. Youth served will not be

subjects of indicated reports of abuse or neglect during the service period.

90% 100% 90% 98% 100% 90% 100%

2. Youth will be maintained in a home like setting.

90% 96% 70% 46% 65% 50% 35%

3. Youth will be deflected from further involvement in the juvenile justice system

90% 95% 70% 67% 27% 50% 35%

4. Youth will remain in school, alternative education, vocational training or employed

90% 96% 70% 33% 54% 55% 35%

� Peer Reviews

Across all programs and all areas measured, Youth Services programs achieved a 90% Compliance & Quality rating, which meets the agency’s target. Across all programs, Assessment (82%) and Treatment Planning (87%) are the only areas that were below the target. The MST 16th Circuit program achieved an overall Compliance & Quality rating of 97%, with all areas meeting or exceeding the target. CCBYS and MST Probation both achieved an 86% overall Compliance & Quality rating. CCBYS exceeded the target in Intake and Closing and MST Probation exceeded the target in


PlanServiceDelivery

Closing Overall

CCBYS 92% 89% 71% 89% 100% 86%MST Re-Entry 80% 50% 77% 95% 100% 82%MST Probation 86% 69% 98% 93% 53% 86%MST 16th Circuit 97% 90% 98% 99% 100% 97%Target 90% 90% 90% 90% 90% 90%All Programs 91% 82% 87% 94% 92% 90%

0%20%40%60%80%

100%

Compliance & Quality: Youth Services

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Treatment Planning and Service Delivery. The MST Re-Entry program achieved an overall Compliance & Quality rating of 82%. Service Delivery and Closing exceeded the 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 Assessment (89%)




Service Delivery (89%) • Is there evidence of quarterly case supervision in which the case is reviewed at least quarterly

and includes an evaluation of the client’s progress toward achieving his/her service goals? (3/15)

• Case note documentation reflects the level of client contact per program requirements? (3/17) MST Re-Entry Intake (80%)






MST Probation Intake (86%)


Assessment (69%) • Is a copy of the Initial Assessment Report in the record? (3/8) • Was the Initial Assessment Report completed within the required timeframe of the program

contract? (6/9) Closing (53%)

• 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? (2/2)

Documents

One Hope United 2013 CQIR Annual Report - Northern Region