QUALITY ASSURANCE / IMPROVEMENT PLAN Guidelines

Modified on Tue, 25 Apr, 2023 at 3:35 PM

The written Quality Assurance/Improvement Plan has been developed to govern the system of competency based service delivery and insure that treatment is uniform and of high quality. The ongoing process of improvement, evaluation and the implementation of approved recommendations for these services will be governed by this plan. Implementation of the plan will be the responsibility of the Quality Assurance/Improvement Committee (hereafter referred to as the QAIC).

This written plan was developed to meet the requirements of the Rules for MH/DD/SA Facilities and Services, 10A NCAC (subchapter 27G). These standards require a Quality Assurance/Quality Improvement Plan, a Quality Assurance Committee, methods to evaluate quality and appropriateness of client care including the gathering and evaluation of outcome data. Also included is a plan for clinical supervision, strategies for the improvement of client care, and a review of all fatalities for active clients being served by The Ship Group Community Services , LLC.

The Quality Assurance/Improvement Plan will be reviewed by the QAIC for annual approval, or sooner as

revision, amendment, or addition warrants.

Membership and Activities of the Quality Assurance/Improvement Committee:

The QAIC shall be a multidisciplinary committee comprised of, but not limited or restricted to, the following: Representation of Professional Clinical staff including Social Work, Psychology, Psychiatry as available; Representation of Health Information Management staff as available; and Representation of Case Management staff as available. One member shall be the Clinical Director and/or the Program Director and at least one member shall be a Qualified Mental Health Professional. Other staff or company personnel may join as full or ad hoc members as deemed appropriate.

I. QAIC Officer Appointment / Selection:

The QAIC Chairperson shall be appointed by vote. The QAIC Chairperson shall in turn appoint members. Appointments shall be reviewed in a yearly basis or more frequently as needed. The Secretary will take the written minutes for the meeting and shall be identified by the QAIC Chairperson at the time of each meeting.

II. QAIC Voting Requirement:

The QAIC meetings are governed as follows. The chairperson shall oversee the discussion. The Chairperson as deemed may call other meetings appropriate.

In the absence of the Chairperson, the Clinical Director or the Medical Director will serve as the Chairperson. Votes shall not be binding unless participated in by a quorum of the members of the QAIC.

III. Quality Assurance Plan Meeting Times and Chair

A. Quarterly: Full QAIC Meeting at 11 am.

All issues including clients, employees, forms and company policy addressed.

QAIC Chairperson: QM Director or Clinical Director

B. Client’s Rights Subcommittee Meeting at 10 am, Quarterly.

Issues regarding client’s rights

Chair Person: QP

C. Recruitment and Orientation Subcommittee Meeting at 10 am, Third Tuesday each month.

Issues regarding recruitment and orientation

Chair Person: Personnel Officer

D. HIPAA Committee Meeting at 9 am, Third Tuesday each month.

Issues regarding protected health information and privacy

Chair Person: Health Information Management Officer

E. Human Resources Subcommittee Meeting at 9 am, Fourth Tuesday of each month.

Issues regarding human resources

Chair Person: Personnel Officer

F. Medical Records Subcommittee Meeting at 9 am, Fourth Tuesday of each month.

Issues regarding medical records

Chair Person: Medical Records Officer

IV. Records of the QAIC

Minutes of the meeting shall be recorded by the appointee of the Chairperson and will include the meeting

date, time, attendance, absentees, and a summary of the business that was conducted. Minutes shall be provided to all members of the QAIC. Minutes may include the consumer’s medical records number but no

other identifying information.

V. Subcommittee Responsibility

A. Human Resource / Clinical Privileging Subcommittee

The Human Resource/Clinical Privileging subcommittee ensures all staff providing clinical services to clients of The Ship Group Community Services are completely, valid, and appropriately privileged to perform those services. In collaboration with the Recruitment, Orientation, and Training subcommittee, this committee will revoke the privilege of any staff person who fails to meet mandatory qualifications for training, experience, licensure, certification, or education necessary for performance of the staff person’s assigned job tasks.

B. Client Rights Subcommittee

The Client Rights Subcommittee responsibilities are to ensure that the rights of the clients of The Ship Group Community Services are respected, valued, and fully extended. These rights include but are not restricted to;

Confidentiality

Informed

Consent Right of Refusal Treatment,

Treatment with Respect and Dignity

The subcommittee is granted the liberty to review the use of all physical interventions, timeouts, or other forms of approved consequence/intervention utilized by staff or agents of the company to determine the adherence of the practice to Policy and Procedure regarding Client Rights. The subcommittee is also responsible to ensure that a system of reporting, information gathering, and investigation is consistently implemented with guaranteed access to all clients, family members of clients, concerned others, or staff of The Ship Group Community Services or referring agencies and that such reports may be made with anonymity and without fear of reprisal. This subcommittee will provide review and investigation of referred incident reports that are found to pose additional client rights concerns by the Critical Incident/Risk Management Subcommittee.

C. Recruitment, Orientation, and Training Subcommittee

The Recruitment, Orientation, and Training subcommittee is responsible for guiding and tailoring the recruitment of new staff with an emphasis on the maintenance of the high expectations of quality and performance of The Ship Group Community Services staff. The primary focus of this committee is to:

1. To develop, assess, and revise the orientation curriculum used to introduce new and prospective

employees to the The Ship Group Community Services Care way of service provision and impart to them the concepts, philosophies, and expectations that are critical to service provision.

2. To ensure the timely and effective access and valid completion of training, both mandatory and

supplementary, to enable the staff person to perform their job tasks and to enhance the quality of

performance. This committee monitors the attendance of the trainings, authorizes use of tools to assess the effectiveness of the training, and oversees the maintenance of training records and requests for individual staff persons.

3. The HR/Personnel Director is responsible for notifying the staff person and management team of

impending lapse and, if necessary, the revocation of mandatory training, experience, licensure, certification, or education necessary for privileges performance of the staff person’s assigned job tasks.

4. The tools that will be used to gauge the overall effectiveness and on-going maintenance of the training program include the development of a new hire orientation training manual, clinical supervision tracking form that includes attendees and topics, personnel training records and database that tracks certificate expiration

dates.

D. Risk Management/Incident Report Subcommittee

The Risk Management/Incident Report Subcommittee will examine events, reports and policy regarding issues of risk and safety. The committee will employ proactive efforts to reduce client risk and incident through the evaluation and study real events, as documented through incident reports, progress notes and clinical discussion, thereby identifying and reducing the contributing conditions precipitating such events. A risk assessment database will be created from information received from incident reporting. All incidents falling under the following categories will be closely scrutinized for data trends:

Restrictive Interventions lasting longer than 15 minutes

Client injury

Client grievance

More than three incidents involving same client in a 30 day period.

More than three incidents involving same staff in a 30 day period.

The Client’s Rights Advisory Panel findings will be available to the Risk Management/Incident Report Committee.

E. Medical Records Subcommittee

The Medical Records Subcommittee will review and set policy regarding all aspects of the Medical Records to ensure compliance with medical standards and The Ship Group Community Services Care policy. Areas of concern include reviews of changing state requirements, peer review, chart contents, security, HIPAA and the transportation and storage of non-active of charts.

VI. Monitoring Appropriateness of Care, Delineation of Outcomes and Utilization of Services

A. The appropriateness of the level of care offered by The Ship Group Community Services shall be determined by review of the packet by the Clinical Director/Program Director prior to admission to include the client’s most recent Comprehensive Clinical Assessment.

B. Clients who are mental health area program referrals to The Ship Group Community Services shall have a PCP/current order for services for the treatment to which the client is being admitted. The order for services shall be reviewed annually or as the need arises and re-authorized if deemed appropriate.

C. Treatment teams will be scheduled every 30 days and will include the attendance of the client when applicable and appropriate, his/her guardian, caseworker, and any other appropriate parties. The team shall review client’s treatment and recommendations may be made for consideration and/or implementation.

VII. Consumer Rights Review

Evidence of Goal Achievement

A. 100% consistency between the current PCP and the recommended level of care or documented justification authorized by the referring agency as to the continued need for consumer to receive treatment as indicated by Clinical Review and 100% congruence between order for service authorization and the client’s current level of care as demonstrated by Clinical Review.

B. Consumer’s rights to receive appropriate treatment evidenced by on-going review of consumer’s progress (or lack of) as measured by participation in therapy, participation in outcome study and his/her negotiation of behavioral level system.

VIII. Professional and Clinical Supervision

A. Evidence of Goal Achievement

The privileging of staff will be the responsibility of the Clinical and Training Directors using the guidelines set forth in 10 NCAC 27G .0104 .0202 .0203 and reviewed on a monthly basis by the Human Resource Committee. Staff will be privileged through the use of the Clinical Supervision form, review of competency, and in-service training documentation. Expiring certificates and other deficiencies will be reported to supervising QP and the management team.

The staff person’s supervisor or that supervisor’s assigned agent shall review the performance of each staff person. Such reviews shall take place for employees working directly with the consumers no less than annually. Periodic updates, amendments, or alterations of the plans require the participation of the staff person and the direct supervisor.Clinical records shall be reviewed at the time of the employee’s performance review by the staff person’s supervisor, or that supervisor’s assigned agent. Periodic updates, amendments, or alterations of the plans require the participation of the staff person and the direct supervisor.

Oversight of the quality and delivery of training will be conducted by the Clinical Director/Program Director/Administrative Director and/or QP with recommendations being reported to the QAIC Recruitment, Orientation, and Training Subcommittee.

Conforming to present Medicaid guidelines ensuring that all Paraprofessionals receive not less than one hour of supervision monthly, by a Qualified Mental Health Professional, in the form of individual or group supervision, and that such supervision is documented in writing.

Conforming to present Medicaid guidelines ensuring that all Qualified Mental Health Professionals receive not less than one hour of supervision monthly, by the Clinical Director/Program Director, in the form of individual or group supervision, and that such supervision is documented in writing.

B. Improving Consumer Care

Consumer treatment will be evaluated and improved through the use of trended data obtained through outcome studies, incident report studies, client’s rights infringements and consumer/guardian satisfaction questionnaires. All branches of the QAIC subcommittees will have access to this trended data and will use it to make recommendations to policy.

The formation of the QA team, who provide random agency checks to monitor the consistency of consumer care. The QA team will inspect all facets of the community support service including but not limited to monitoring therapeutic interactions between staff and consumer as shift work is provided, verifying safe and secure treatment environments, reviewing documentation of HRI notes and double checking medication administrations for dosage and time.

The following meetings will be established to facilitate the on-going review of and changes to existing consumer care:

a. Monthly Communication Council Meetings

b. Clinical Supervision

c. Weekly Clinical Team Meetings

C. Evidence of Successful Implementation of Consumer Care Improvement

Data will be input into various databases and trended history will be produced as a reference for study.

• Outcome studies will be managed by the Clinical Department and will include interviews with consumers a minimum of twice a year with data capture including consumer preferences, motivators, rewards and satisfaction of treatment and environment.

• Incident report studies will be managed by the QP and will be produced a minimum of monthly with data capture including but not limited to consumer, staff, event type, precipitating events, injury, medical treatment and resolution.

• Consumer’s rights infringement studies will be managed by the QP and will be investigated and reviewed within 24 hours with an internal finding within 72 hours with data capture including but not limited to consumer, staff, event type, precipitating events, injury, medical treatment and resolution.

• Consumer and guardian satisfaction studies will be managed by the Program Director and will be produced a minimum of twice a year with data capture including but not limited to treatment, safety, staff competence, cultural awareness, program integrity and satisfaction.

D. Evidence of Successful Implementation of Consumer Care Improvement

Data will be input into various databases and trended history will be produced as a reference for study.

E. Staff Qualifications for Treatment and Habilitation Privileges:

Assurance of the Professional Skill and Ongoing Development of the Staff

Implementation Activities: Accurate, Complete, Appropriate Privileging/Credentialing. The hiring administrator shall verify records and experience prior to the hiring of any staff person to ensure the prospective staff person’s eligibility for temporary privileges. Regular privileges will be granted or temporary privileges within (90) days by a review of the Personnel Director.

Access to Provision of Mandatory Staff Training: Each Program Director shall arrange for the provision or accessibility to any training required for the continued privileging of staff persons within their service area to perform the duties of their assigned job title.

Clinical Supervision: Clinical supervision that meets or exceeds requirements of the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse and Medicaid shall be provided for any staff person providing direct client services.

A Supervision Plan is developed collaboratively by the staff person, the direct supervisor, the assigned clinical supervisor, and individualized to the specific needs of the staff person as indicated. As related to Clinical Staff, the program director/clinical director shall maintain topics and content of supervision.

F.Fatality Review for Active Clients: Critical Incident/Risk Management Subcommittees

The Critical Incident/Risk Management subcommittee is responsible to review all incident reports generated within the company or involving staff or clients. This includes, but is not restricted to, the review of all client deaths occurring while the deceased client was in the care of The Ship Group Community Services The driving force of this subcommittee shall be the continued increase in quality care, the reduction of such events, the recognition of trends related to such events, and determination of the need for referral of reports to the Client Rights Subcommittee for further investigation and review.

G. Standards of Practice:

Review of Operations and Programmatic Performance Implementation Activities

Evaluation of Facilities

Evaluation of Staff

Evaluation of Consumer, Comments, Critique

Evaluation of Outcome

H. Goals

The QAIC Chairperson shall appoint informal committees as the need arises. These subcommittees shall report back to the main committee for the final approval of recommendations.

The QAIC chairperson will appoint all subcommittee chairpersons.

The subcommittee chair and the QAIC chairperson shall be responsible to appoint subcommittee members.

All meetings of a subcommittee shall record attendance and have minutes taken and turned into the QAIC secretary.

The QAIC will have certain standing subcommittees that meet in a monthly basis and report to the main committee.

I. Protocol for the Gathering, Use and Distribution of Clinical Information to Line Staff

Gathering And Use Of Clinical Information

As a part of Quality Improvement (QI), the systematic gathering, use and distribution of all general and

client specific clinical information will be managed by the Clinical Director or Medical Director. The Clinical Director will have access to all data generated by the QAIC and all of its subcommittees as described in sections D and E and will process such data, including QI project results, consumer outcomes, consumer satisfaction surveys and treatment team evaluations for trend analysis, with specific regards to appropriateness of care and comparison of consumer outcomes. Trend evaluations will be published quarterly and will be reported to the LME.

Trended data will include at a minimum the study of consumer’s ages, sex, length of stay, diagnosis and presenting problems relating to treatment strategy and outcomes (such as Step-down, AWOL,

hospitalization etc.), six month recidivism rate, client’s rights issues, uses of restrictive interventions and

consumer satisfaction and/or complaint issues. Trended will be used to strengthen desired clinical

outcomes and shorten treatment time. The use of trended data, policy change and treatment strategy

modifications as a function of QI system reform will be documented in writing and be kept in the QAIC log book.

The Clinical Director will review and provide input into the final approval of policy changes recommended by the QAIC and all of its subcommittees as described in sections D and E.

Distribution of Clinical Information to Line Staff

Policy changes, system changes, QI project outcomes and trended data approved for treatment and/or

program modification by the Board of Directors will be distributed to all line and direct care staff through the following delivery system:

The Clinical Director or Administrative Director will assemble the written materials or policies necessary

to convey the information and present it to the Program Directors/QPs during clinical supervision and staff meetings. The Program Directors/QPs will in turn, present the same training to their employees at the next weekly all staff supervision. Employee participation in these weekly trainings and reviews is mandatory and participation will be documented in writing and kept on-site in the employees’ training/staff meeting folder.

J.Employee Training Programs

Training Topics and Testing During Clinical Supervision

The Program Director/Clinical Director will address with the agency QPs during clinical supervision each week, specific concerns for specific consumer’s treatment strategy as specified in the consumer’s treatment plan. Additionally, the Clinical Director will address concerns on client’s rights, confidentiality, treatment free of exploitation and abuse and infectious diseases / blood-borne pathogens as specific concerns arise.

In addition to consumer specific training, the Clinical Director shall develop a curriculum of program wide training topics to be presented to the QPs at clinical supervision. The Clinical Director or his choice of qualified designee will present to the QPs, various timely topics that will be of aid to all staff in improving therapeutic effectiveness. Trainings materials will include handouts and will be presented to the direct-care staff by the agency QPs at the weekly all-staff meeting.

K. HIPAA Sub-committees:

Policy and Procedures Committee: monitor the creation of policy, insuring that the created policy is QAIC reviewed and placed in all existing HIPAA policy manuals.

Security Committee: monitor the safe keeping of all information, to include the storage of PHI behind double locks, transportation of PHI and security.

Compliance Committee: monitor the program’s on-going ability in the implementation of the policies as set forth by the HIPAA committee.

Privacy Committee: monitor all areas of client and staff PHI rights.

Training Committee: facilitate training as needed to ensure all staff are supportive of and understanding of established HIPAA policy. The Chair Person will oversee the functioning of all committees and will lead the Monthly HIPAA meetings.