QUALITY ASSURANCE AND QUALITY IMPROVEMENT

QUALITY ASSURANCE AND QUALITY IMPROVEMENT

COMPOSITION OF THE QUALITY ASSURANCE AND QUALITY IMPROVEMENT COMMITTEE:

The committee may be composed of, but is not limited to Owner(s), Clinical Director, Quality Management & Training Director, a Qualified Professional, a Staff Educator, Consumer Advocate, and Human Resources Assistant/Director.

The purpose of the Quality Assurance and Quality Improvement committee is as follows:

• Written quality assurance and quality improvement plan

• Methods for monitoring and evaluating the quality and appropriateness of client care, including delineation of client outcomes and utilization of services

• Professional or clinical supervision, including a requirement that staff who are not qualified professionals and provide paraprofessional services shall be supervised by a qualified professional in that area of service

• To ensure that all services are of the highest possible quality within the agency

• Review of individualized service plan procedures: to review goals and signatures and to assure plans are measurable, objective and reasonable

• Utilization and peer review of client’s records to assure the appropriateness and effectiveness of services and quality care

• Record review: to establish criteria for utilization and peer review, and to establish medical record policies, procedures, and forms in compliance with applicable laws, standards and guidelines

• Supervision: Processes to assure that the QP, Program Director, and Para-Professional/Associate Professional staff have the proper credentials to perform treatment and provide services

• Client Outcome Measures: Assess, modify, and improve goals in order to assure that the best interest of the client, their families, the community, and our supporters are served

• Standards, guidelines, and law review: To assure that treatment services and procedures are in compliance and that the QP, Program Director, and Para-professional/Associate Professional staff are informed

• Review of all fatalities of active clients in the agency’s programs and all possible right restrictions

• Grievances: Client’s rights to express concerns about services rendered

• Adoption of standards that assure operational and programmatic performance meeting applicable standards of practice. For this purpose, “applicable standards of practice” means a level of competence established with reference to the degree of knowledge, skills and care exercised by other practitioners in the field.

• Use of medications by clients in accordance with the rules in this section

• Reporting of any incident, unusual occurrence, or medication error

• Services of interns/volunteers, when applicable, including supervision and requirements for maintaining client confidentiality

• Areas in which staff, including nonprofessional staff, receive training and continuing education

• Safety precautions and requirements for agency areas including special client activity areas

• Monitor Human Resources Management: In order to assure that the QP, Program Director, and Paraprofessional staff stays current in all certifications and training (in collaboration with the Training Director)

• Committee will meet quarterly

To assure proper training, personnel records are reviewed quarterly for compliance.

To assure proper utilization of services, the committee will review attendance logs on an annual basis.

The committee will also be responsible for assuring that proper education, credentialing, and documented experience with the target population or area of work is completed and on file for each individual prior to beginning work. A criminal background check must have been conducted prior to hire. The individual must be able to read, write, and understand and follow directions, and must have no known history of abuse, neglect, or exploitation of children or vulnerable adults. In order to administer medication, implement restrictive interventions, or to administer First Aid/CPR, proof of current certification must be provided. Other service implementation and/or planning are approved based on the individual’s level of education and training. In order to be credentialed to be a QMHP, the individual must have a four-year degree in a human service field and four years of clinically supervised experience or an advanced degree in a Human Service field and two years of clinically supervised experience.

Every employee who is not credentialed as a Qualified Professional (QP) will follow a supervision plan.

METHODS FOR MONITORING AND EVALUATING QUALITY AND APPROPRIATENESS OF CLIENT CARE

A.     Method:        Client records and progress notes are completed daily and evaluated by the qualified professional to assure that direct-care staff and paraprofessionals are providing the most therapeutic interventions to facilitate progress towards goals, independence, and self-maintenance for clients.

The QP reviews all documentation and ensures that staff are completing notes accurately, promptly, and interventions are facilitating client progress toward meeting goals and discharge.

B.         Method:         Annual Treatment Team meetings are conducted that involve the client and family, along with clinical staff including therapists, psychologists, case managers, associate/qualified professionals, and other healthcare professionals, as appropriate, to ascertain goals that are realistic and attainable in meeting therapeutic needs of the client and rehabilitation of the family. The treatment team will discuss the appropriateness of client specific care. Every effort is made to directly involve the client in goal setting and evaluation of therapeutic needs of the client.

STAFF CREDENTIALING / PRIVILEGING

All staff will be considered fully privileged to perform duties contained in their job descriptions once they have provided proof of sufficient professional clinical experience relative to the target population (professional resume for review, copy of degree/certifications/licensure, college transcript, training certificates, etc.) and acquired the necessary training from Qualified Professionals, in-services and staff development trainings, as well as continuing education. Staff must at minimum have:

• High School Graduate or GED

• First Aid/CPR (Certificate / Course Completion Card)

• NCI (Certificate)

• General Organizational Orientation (Certificate of Completion/Other Approved Proof of Training Participation and Completion)

• Client Rights (Certificate of Completion/Other Approved Proof of Training Participation and Completion)

• Medication Administration Education (Certificate of Completion/Other Approved Proof of Training Participation and Completion)

• Blood-Borne Pathogens (Certificate of Completion/Other Approved Proof of Training Participation and Completion)

• Confidentiality Training (Certificate of Completion/Other Approved Proof of Training Participation and Completion

• Person-Centered Thinking (Certificate of Completion/Other Approved Proof of Training Participation and Completion)

• Training related to specific population served (Certificate of Completion/Other Approved Proof of Training Participation and Completion)

STRATEGIES FOR IMPROVING CLIENT CARE

A. Semi-annual review of client’s goals and review of said goals, by referring agency and QP: This will be done by reviewing client’s previous treatment plans every six months, evaluating progress of goals and making necessary modifications of treatment plans if needed.

B. Review of staff qualifications and determination made to grant treatment by the Program Director, Qualified Professionals, and when appropriate, the referring agency.

C. The Qualified Professionals, the referring agency, and the Program Director of The Ship Group Community Services will monitor current certifications and recommend in-service trainings for improving treatment, coordination of care, and clinical competency of staff.