Three-Year Accreditation. CARF Survey Report for Hamilton County Developmental Disabilities Services

Transcription

1 Three-Year Accreditation CARF Survey Report for Hamilton County Developmental Disabilities Services

2 Organization Hamilton County Developmental Disabilities Services (HCDDS) 1520 Madison Road Cincinnati, OH Organizational Leadership Alice Pavey, M.S.W., LSW, Superintendent Survey Dates March 25-27, 2015 Three-Year Accreditation Survey Team Linda K. Rimmer, M.A., CRC, CVE, PVE, Administrative Surveyor Donna M. Conte-Ennis, Program Surveyor Programs/Services Surveyed Community Integration Services Coordination Transition Services Previous Survey March 26-28, 2012 Three-Year Accreditation Survey Outcome Three-Year Accreditation Expiration: April 2018

3 SURVEY SUMMARY Hamilton County Developmental Disabilities Services (HCDDS) has strengths in many areas. HCDDS is congratulated for its dedicated, passionate, well-experienced staff members, with forward-thinking departmental leadership. It also has exceptionally strong leadership in its board and superintendent. All of these components of human capital drive the organization to consistently higher levels of service to persons served. The organization is extremely proud of its very meaningful community involvement, including its nurturing leadership of other community partners. Significantly low staff turnover assists with maintaining a stable and well-experienced staff with a broad base of knowledge and expertise. As federal guidelines may dictate changes in the ways services and supports can be provided through county boards in the future, HCDDS is recognized for its focus on inclusion and community integration. The leadership team of HCDDS is positioning the organization for future initiatives, is continually communicating to stakeholders regarding this issue, and is transparent about the potential impact that changes in the delivery of services could have for persons served. By doing so, HCDDS hopes to accomplish a smooth transition to any new service options, resulting in increased opportunities for inclusion and integrated services for persons with disabilities. HCDDS is acknowledged for the inclusion of behavioral supports into the individual planning process and for its proactive and positive approach toward supporting persons with behavioral challenges. Very skilled staff members employed on the behavioral support team are passionate about the use of positive behavioral approaches and about supporting staff members throughout the organization in their training in this area. There is excellent communication and collaboration throughout the organization. Persons served, staff members, and other stakeholders are consistent in their understanding of the strategic plan of the organization and of current challenges and opportunities. The organization is complimented for the use of social media in also communicating its mission and values. Persons served, guardians, families, and referral sources express considerable satisfaction with the services and supports provided by HCDDS. The organization appears to be extremely well regarded in the community, the county, and the state of Ohio. Across all services areas, there is evidence of extensive partnership and collaboration with internal and external stakeholders. Community partners are unabashed in their praise for the organization. Transition staff members are skilled and knowledgeable about resources for external stakeholders in the areas of transition and employment. New initiatives in transition services reflect best practices, resulting in increased meaningful outcomes for persons served. The transition team is creative with options and committed to employment outcomes for persons transitioning from school settings. Staff members also network with stakeholders throughout the state of Ohio in developing transition services for young adults. Page 2

4 Significant attention is given to the development of person-centered plans. Extensive discovery and assessment instruments are utilized in the development of the plans. Recognition is given for the development by one of the service and support administrator (SSA) staff members of a site-developed instrument to assist in the planning process. This instrument is now also being used outside of HCDDS. HCDDS is complimented for its efforts in the inclusion of persons served in the staff selection process. The facilities of HCDDS are cheerful, well maintained, safe, and accessible and include beautiful artwork created by persons served. Rehabilitation engineering staff members have contributed significantly to the opportunities for participation for persons throughout the organization. There is also significant usage of assistive technology throughout all of the programs. Ancillary therapy services in the areas of physical therapy, occupational therapy, nursing, and speech services are also available to persons served. Persons served in the adult centers have access to a variety of activities and experiences, including a number of opportunities for paid work experience and work available on a consistent basis. Several curricula are utilized to support persons served in the areas of mindfulness, being safe in the community, later-life planning, domestic abuse, and health and wellness. The SSA staff members are very knowledgeable about the services available to persons with disabilities and take a holistic approach in addressing the needs, choices, and preferences of persons served. Staff members in this area demonstrate meaningful relationships with persons served and their families and are compassionate in their service delivery. There are additional supports available within the organization to assist in benefits management and housing options. Specialization of the SSA staff members appears to also have assisted in addressing the concerns of specific populations with disabilities, such as children, adults, and those with multi-system needs. HCDDS is acknowledged for its work to convert its records into an electronic data management system. There has been considerable effort to enhance the skills of staff members in the use of electronic recordkeeping, including access to software and hardware. HCDDS is recognized for creative ways in which it encourages staff members from throughout the integrated services team to embrace community access for persons served. One example is putting objectives in staff performance appraisals to include working with at least one person served in a community inclusion activity. HCDDS is commended for its review of services needed to support both aging caregivers and aging adults with disabilities. HCDDS shines as a proactive, rather than just reactive, entity. It leads, instead of lags, among its peers in the field of services and advocacy on behalf of persons with disabilities. It is fearless, wrapped in solid experience, creative innovation, and a large degree of dedication. Page 3

5 In the following areas HCDDS demonstrates exemplary conformance to the standards. The organization shows exemplary conformance with its wonderful Leaders in Action group, an advocacy team composed of persons with disabilities and an agenda of inclusion. The team is very active on local and state levels and also has an excellent advisory entity to assist it when needed. The team has been impactful on multiple levels, and the organization is commended for the manner in which it has assisted in the creation of this extremely effective advocacy group. It is amazing to hear all that the Leaders in Action group has been able to accomplish, either together or singularly, on behalf of persons with disabilities. The organization demonstrates exemplary conformance with its format and technique for representing the rights of persons with disabilities and others. The artwork representing basic human rights is creative and easily understandable and created entirely by persons served. HCDDS should seek improvement in the areas identified by the recommendations in the report. Consultation given does not indicate nonconformance to standards but is offered as a suggestion for further quality improvement. On balance, HCDDS is an outstanding organization providing solid, cutting-edge services to persons with disabilities in the Hamilton County area. This county organization is passionate about the persons it serves, and strong advocacy is an essential part of what the organization does throughout the greater community and the state of Ohio. As a funding entity for services in Hamilton County, the organization is viewed as a solid partner that is willing to provide creative services to assist the persons served. The services provided by the organization are excellent, caring, innovative, focused services that assist a large number of individuals with disabilities. The organization cares deeply about the persons it serves, and its staff members are on a constant quest for more effective services with ever higher levels of excellence. HCDDS is congratulated for its strong stance on advocacy for persons with disabilities and its development of the Leaders in Action group, which is well recognized throughout the local area and the state of Ohio. HCDDS demonstrates substantial conformance to the CARF standards and to quality improvement. It is encouraged to use its resources to address the opportunities for improvement noted in this report. Hamilton County Developmental Disabilities Services has earned a Three-Year Accreditation. The organization, its leadership, and its staff members are complimented for the quality services and advocacy efforts at multiple levels that are provided throughout the Cincinnati and Hamilton County area. Persons served are the focal point for this organization and are provided with innovative services. The organization is encouraged to continue to use the CARF standards as it pursues additional programs and services in the area it serves. Page 4

6 SECTION 1. ASPIRE TO EXCELLENCE A. Leadership CARF-accredited organizations identify leadership that embraces the values of accountability and responsibility to the individual organization s stated mission. The leadership demonstrates corporate social responsibility. Leadership structure Leadership guidance Commitment to diversity Corporate responsibility Corporate compliance Exemplary Conformance A.6.d. Corporate responsibility efforts clearly include advocacy efforts for the persons served, and HCDDS is dedicated to advocacy on behalf of persons with severe disabilities. The Leaders in Action group is a prime example of how dedicated the organization is to ongoing advocacy efforts. The Leaders in Action group is an organized group of persons with disabilities that is willing to take on the advocacy role for the greater community of persons with disabilities. It is astounding that the group was able to convince the Mental Retardation and Developmental Disabilities Board to remove Mental Retardation from its official state agency name and all state signage. One of its goals has also been to eradicate the word handicapped off of accessible parking signage. The organization provides the group with guidance in the quest to eradicate archaic terms from phrases and titles of objects that are considered offensive, as well as to challenge common stereotypes of persons with disabilities. The group is focused and has great determination, and the organization models exemplary conformance to the CARF standard on advocacy efforts for persons served. The client councils throughout the adult centers also offer wonderful opportunities for persons served to participate in advocacy and leadership activities. Participants on the councils also collaborate with the Leaders in Action group. Page 5

7 C. Strategic Planning CARF-accredited organizations establish a foundation for success through strategic planning focused on taking advantage of strengths and opportunities and addressing weaknesses and threats. Strategic planning considers stakeholder expectations and environmental impacts Written strategic plan sets goals Plan is implemented, shared, and kept relevant D. Input from Persons Served and Other Stakeholders CARF-accredited organizations continually focus on the expectations of the persons served and other stakeholders. The standards in this subsection direct the organization s focus to soliciting, collecting, analyzing, and using input from all stakeholders to create services that meet or exceed the expectations of the persons served, the community, and other stakeholders. Ongoing collection of information from a variety of sources Analysis and integration into business practices Leadership response to information collected E. Legal Requirements CARF-accredited organizations comply with all legal and regulatory requirements. Page 6

8 Compliance with all legal/regulatory requirements F. Financial Planning and Management CARF-accredited organizations strive to be financially responsible and solvent, conducting fiscal management in a manner that supports their mission, values, and annual performance objectives. Fiscal practices adhere to established accounting principles and business practices. Fiscal management covers daily operational cost management and incorporates plans for long-term solvency. Budget(s) prepared, shared, and reflective of strategic planning Financial results reported/compared to budgeted performance Organization review Fiscal policies and procedures Review of service billing records and fee structure Financial review/audit Safeguarding funds of persons served G. Risk Management CARF-accredited organizations engage in a coordinated set of activities designed to control threats to their people, property, income, goodwill, and ability to accomplish goals. Page 7

9 Identification of loss exposures Development of risk management plan Adequate insurance coverage Consultation The risk management plan is comprehensive and updated annually. However, it could be more effective if newly discovered issues were incorporated into the risk management plan as soon as possible, rather than waiting until the annual update to do so. H. Health and Safety CARF-accredited organizations maintain healthy, safe, and clean environments that support quality services and minimize risk of harm to persons served, personnel, and other stakeholders. Inspections Emergency procedures Access to emergency first aid Competency of personnel in safety procedures Reporting/reviewing critical incidents Infection control H.12.l.(1) Although HCDDS communicates in an ongoing manner with the transportation contractor, there is not an annual review of the elements of the contract regarding the specific needs to be included in the transportation service. The organization should ensure an annual review of the contract that includes evidence of appropriate licensing of all drivers, regular review of driving records of all drivers on an ongoing basis, insurance covering vehicles and passengers, safety features in vehicle(s), safety equipment, accessibility, training of drivers in the organization s transportation requirements, Page 8

10 written emergency procedures available in the vehicle, communication devices available in the vehicle, first aid supplies available in the vehicle, and maintenance of vehicles owned or operated by the organization according to manufacturers recommendations. I. Human Resources CARF-accredited organizations demonstrate that they value their human resources. It should be evident that personnel are involved and engaged in the success of the organization and the persons they serve. Adequate staffing Verification of background/credentials Recruitment/retention efforts Personnel skills/characteristics Annual review of job descriptions/performance Policies regarding students/volunteers, if applicable I.6.c.(1) through I.6.c.(4) Although HCDDS continuously communicates with contracted personnel, a formal assessment of the contractors performance is not done at least annually. Annual reviews of all contract personnel utilized by the organization should be conducted to assess performance of their contracts, ensure that they follow all applicable policies and procedures of the organization, and ensure that they conform to the CARF standards applicable to the services they provide. J. Technology CARF-accredited organizations plan for the use of technology to support and advance effective and efficient service and business practices. Written technology and system plan Page 9

11 K. Rights of Persons Served CARF-accredited organizations protect and promote the rights of all persons served. This commitment guides the delivery of services and ongoing interactions with the persons served. Communication of rights Policies that promote rights Complaint, grievance, and appeals policy Annual review of complaints Exemplary Conformance K.1.a.(1) The rights of the persons served are clearly communicated to the persons served in a way that is understandable. HCDDS has an excellent format and technique for representing the rights of persons served. The pictorial representation of each right is beautifully represented in a framed piece of art, hanging on a very conspicuous wall in the entry area of the main offices. Each representation was designed and executed by persons served, with the overall effect of a beautiful and very meaningful collage on the wall. The organization did not influence the way in which the persons served represented their rights. Rather, the persons served, through their drawings and artistry, demonstrated to the organization what their rights meant to them. The talent represented in the artwork is striking. HCDDS has many examples of phenomenal artwork created by persons with disabilities throughout its building. L. Accessibility CARF-accredited organizations promote accessibility and the removal of barriers for the persons served and other stakeholders. Page 10

12 Written accessibility plan(s) Requests for reasonable accommodations M. Performance Measurement and Management CARF-accredited organizations are committed to continually improving their organizations and service delivery to the persons served. Data are collected and analyzed, and information is used to manage and improve service delivery. Information collection, use, and management Setting and measuring performance indicators Consultation Although HCDDS has designed and promulgated a new cutting-edge, blended method of quantifying and evaluating its diverse, multifaceted outcomes as both a government entity and a service provider, it might consider also bringing together the salient information regarding its specific programs, such as those being offered for CARF accreditation, so that the ongoing efficacy of those specific programs could more easily be evaluated. N. Performance Improvement The dynamic nature of continuous improvement in a CARF-accredited organization sets it apart from other organizations providing similar services. CARF-accredited organizations share and provide the persons served and other interested stakeholders with ongoing information about their actual performance as a business entity and their ability to achieve optimal outcomes for the persons served through their programs and services. Page 11

13 Proactive performance improvement Performance information shared with all stakeholders SECTION 2. QUALITY INDIVIDUALIZED SERVICES AND SUPPORTS A. Program/Service Structure A fundamental responsibility of the organization is to provide a comprehensive program structure. The staffing is designed to maximize opportunities for the persons served to obtain and participate in the services provided. Services are person centered and individualized Persons are given information about the organization s purposes and ability to address desired outcomes Documented scope of services shared with stakeholders Service delivery based on accepted field practices Communication for effective service delivery Entrance/exit/transition criteria Consultation HCDDS is encouraged to complete the conversion of the clinical records into an electronic data management system. Page 12

14 B. Individual-Centered Service Planning, Design, and Delivery Improvement of the quality of an individual s services/supports requires a focus on the person and/or family served and their identified strengths, abilities, needs, and preferences. The organization s services are designed around the identified needs and desires of the persons served, are responsive to their expectations and desired outcomes from services, and are relevant to their maximum participation in the environments of their choice. The person served participates in decision making, directing, and planning that affects his or her life. Efforts to include the person served in the direction or delivery of those services/supports are evident. Services are person-centered and individualized Persons are given information about the organization s purposes and ability to address desired outcomes C. Medication Monitoring and Management Current, complete records of medications used by persons served Written procedures for storage and safe handling of medications Educational resources and advocacy for persons served in decision making Physician review of medication use Training and education for persons served regarding medications C.1.g.(1) It is recommended that the individual record of all prescription medications used by the person served include the prescribing professional s phone number. Page 13

15 Consultation Although the medication policy and procedures reference that medications will be safely disposed of, HCDDS is encouraged to include additional information in this area regarding specific arrangements for disposal. F. Community Services Principle Standards Access to community resources and services Enhanced quality of life Community inclusion Community participation SECTION 3. EMPLOYMENT AND COMMUNITY SERVICES An organization seeking CARF accreditation in the area of employment and community services assists the persons served through an individualized person-centered process to obtain access to the services, supports, and resources of their choice to achieve their desired outcomes. This may be accomplished by direct service provision, linkages to existing generic opportunities and natural supports in the community, or any combination of these. The persons served are included in their communities to the degree they desire. The organization provides the persons served with information so that they may make informed choices and decisions. Although we use the phrase person served, this may also include family served, as appropriate to the service and the individual. The services and supports are arranged and changed as necessary to meet the identified desires of the persons served. Service designs address identified individual, family, socioeconomic, and cultural preferences. Page 14

16 Depending on the program s scope of services, expected results from these services/supports may include: Increased inclusion in community activities. Increased or maintained ability to perform activities of daily living. Increased self-direction, self-determination, and self-reliance. Self-esteem. Housing opportunities. Increased independence. Meaningful activities. Increased employment options. Employment obtained and maintained. Competitive employment. Economic self-sufficiency. Employment with benefits. Career advancement. N. Services Coordination Services coordination programs provide goal-oriented and individualized supports focusing on improved self-sufficiency for the persons served through assessment, planning, linkage, advocacy, coordination, and monitoring activities. Successful services coordination results in community opportunities and increased independence for the persons served. Programs may provide occasional supportive counseling and crisis intervention services, when allowed by regulatory or funding authorities. Services coordination may be provided by an organization as part of its individual service planning and delivery, by a department or division within the organization that works with individuals who are internal and/or external to the organization, or by an organization with the sole purpose of providing community services coordination. Such programs are typically provided by qualified services coordinators or by case management teams. Organizations performing services coordination as a routine function of other services or programs are not required to apply these standards unless they are specifically seeking accreditation for this program. Page 15

17 Goal-oriented and systematic process of advocacy Coordination of services Formation of linkages with community resources and services O. Transition Services Transition services are integrated, community-oriented, systematic services for students and their families provided through a jointly planned approach, involving broad-based community collaboration, linkages, advocacy, and natural supports. Transition services/supports are planned and coordinated for multiple outcomes for youths leaving school, including post-secondary education, supported education, vocational training, employment (including supported employment and volunteer placement), independent or supported living, and community participation. The organization demonstrates early active outreach to and connection and partnership with school districts to address the transition needs of students and their families. The purpose of this collaboration and early planning is focused on ensuring children are not missed as they move from one system to another. Integrated services for students and their families Jointly planned approach with community collaboration and linkages Outcomes such as postsecondary education, vocational training, and integrated employment Page 16

18 P. Community Integration Community integration is designed to help persons to optimize their personal, social, and vocational competency to live successfully in the community. Persons served are active partners in determining the activities they desire to participate in. Therefore, the settings can be informal to reduce barriers between staff members and persons served. An activity center, a day program, a clubhouse, and a drop-in center are examples of community integration services. Consumer-run programs are also included. Community integration provides opportunities for the community participation of the persons served. The organization defines the scope of these services and supports based on the identified needs and desires of the persons served. This may include services for persons who without this option are at risk of receiving services full-time in more restrictive environments with intensive levels of supports such as hospitalization or nursing home care. A person may participate in a variety of community life experiences or interactions that may include, but are not limited to: Leisure or recreational activities. Communication activities. Spiritual activities. Cultural activities. Pre-vocational experiences. Vocational pursuits. Development of work attitudes. Employment activities. Volunteerism in the community. Educational and training activities. Development of living skills. Health and wellness promotion. Orientation, mobility, and destination training. Access and utilization of public transportation. Interacting with volunteers from the community in program activities. Community collaborations and social connections developed by the program (partnerships with community entities such as senior centers, arts councils, etc.). Page 17

19 Opportunities for community participation Consultation HCDDS may want to consider pursuit of accreditation for a special population designation in older adult services as the number of persons served who are older increases and as specialization increases in this area. It is suggested that HCDDS consider expanding the employment assessment to include how the person s disability affects his or her productivity. Page 18

20 PROGRAMS/SERVICES BY LOCATION Hamilton County Developmental Disabilities Services 1520 Madison Road Cincinnati, OH Administrative Location Only Bobbie B. Fairfax School 4999 Kingsley Drive Cincinnati, OH Transition Services Margaret B. Rost School 5858 Bridgetown Road Cincinnati, OH Transition Services Elmer P. Beckman Adult Center 2600 Civic Center Drive Cincinnati, OH Community Integration Thomas H. Kidd Adult Center 9910 Reading Road Cincinnati, OH Community Integration Robert W. Franks Adult Center 5884 Bridgetown Road Cincinnati, OH Community Integration Roger Jackson Adult Center 5093 Kingsley Drive Cincinnati, OH Community Integration Queensgate 801A West Eighth Street, Suite 300 Cincinnati, OH Services Coordination Page 19