Quality Enhancement Plan - The Arc Baltimore · and the analysis is used to determine the proper...

Quality Enhancement Plan 2014-2015

Annual Report

Mission The Arc Baltimore provides advocacy and high quality, life-changing

supports to individuals with intellectual and developmental

disabilities and their families.

Vision

People with intellectual and developmental disabilities and their

families THRIVE in the community.

Table of Contents

Opening Remarks

Committees

Annual Goal Status

2015-2016 Proposed Quality Enhancement Plan

Opening Remarks

The Arc Baltimore’s vision is that “individuals with intellectual and

developmental disabilities thrive in their communities”. The Quality Enhancement

Plan (the plan) is a key component in reaching that vision. The plan acts as a guide

post, ensuring that The Arc Baltimore provides individuals with intellectual and

developmental disabilities cutting edge, high quality supports and services. Here at

The Arc Baltimore, we believe that such supports are essential in assisting

individuals in reaching their life goals and flourishing within their respective

communities. The plan lays the foundation of accountability to the individuals we

support and the community at large.

The 2014-2015 Annual Quality Enhancement Plan includes four quarters

worth of data. Each Category of Measure found in the 2014-2015 annual report has

both annual and quarterly results. These results describe whether goals have been

achieved, or not, along with supporting data. Each result is thoroughly analyzed

and the analysis is used to determine the proper response.

The Arc Baltimore’s proposed 2015-2016 Quality Enhancement Plan, was

created through a collaborative effort, with final approval coming from the Human

Rights Committee (Standing Committee). Several months in the making, the plan

reflects input from a large cross section of The Arc Baltimore stakeholders and

feedback was gathered through several brainstorming sessions. The key focus of

the plan development process was to conceive and articulate progressive, forward

thinking goals and garner buy in from all stakeholders.

Included in the proposed 2015-2016 Quality Enhancement Plan are exciting

categories of measure, along with corresponding goals, that will help The Arc

Baltimore ensure that individuals’ choices, preferences, and overall satisfaction

with services are being fulfilled.

Committees

Human Rights/ Standing Committee

Bob Davidson, Chair, Community

Member

Daphni Steffin, Staff, Assistive Technology

& LifePrint

Richard Weih, Community Member Pat Rosner, Board Member

Karyn Harvey, Staff Liaison, Quality

Supports (non-voting member)

Aaron Atkinson, Staff Liaison, Quality

Supports (non-voting member)

Quality Enhancement Committee

Danielle Ford, Board Member, Chair Shontae Jones, Staff, Human Resources

Sean O’Connor, Volunteer Jonathan Ferrell, Staff, Safety

Sylvester Bieler, Staff, Day Services Karyn Harvey, Staff, Quality Supports

Kathleen Durkin, Staff, Executive Kimberly Longford, Board Member

Douglas McQuade, Staff, Employment

and Day Services

Liz Moag, Board Member, Family Advocate

Carla Murphy, Board Member, President Ronald Christian, Staff, Community Living

Shanna Strickland, Staff, Employment

and Day Services

Nellie Power, Staff, Outreach & Family

Services

Aaron Atkinson, Staff Liaison, Quality

Supports

Janet Mayer, Board Member, Family

Advocate

Joseph Ward, Board Member, Family

Advocate

Crystal Stephens, Board Member, Self-

Advocate

Risk Management Committee

Jonathan Ferrell, Chair, Operations Don Watts, Employment and Day Services

Brent Davidson, Employment and Day

Services

Kathleen Durkin, Deputy Executive

Director

Kimberly Becker, Operations Sheena Johnson, Human Resources

Terri Spurrier, Employment and Day

Services

David Higgs, Employment and Day

Services

Florence Ndi, Nursing Susan Spallone, Operations

Lori Miller, Community Living Mike Pollutra, Operations

Shontae Jones, Human Resources Tracy Pruitt, Finance and Accounting

Aaron Atkinson, Quality Supports Kelly Bell, Family Living

Karyn Harvey, Quality Supports Doug McQuade, Employment & Day

Services

Individual Plan Committee

Aaron Atkinson, Chair, Quality Supports Kate Owen, Community Living

Michelle Smith, Community Living Ron Christian, Community Living

Karyn Harvey, Quality Supports Esther Ford, Family Living

Stephanie Helfman, Quality Supports Mathew Piercey, Quality Supports

Nancy Brown, Employment and Day

Services

Daphni Steffin, Assistive Technology &

LifePrint

Adam Deitz, Employment and Day

Services

Amanda Maier, LifePrint

Root Cause Analysis Committee

Aaron Atkinson, Chair, Quality Supports Lori Miller, Community Living

Karyn Harvey, Quality Supports Kelly Bell, Family Living

Stephanie Helfman, Quality Supports Allegra Hild, Community Living

Doug McQuade, Employment and Day

Services

Cathy Otterbein, Employment and Day

Services

Jonathan Ferrell, Safety

CARF Leadership Team

Aaron Atkinson, Chair, Quality Supports Kim Becker, Operations

Lori Miller, Community Living Ron Christian, Community Living

Jonathan Ferrell, Operations Shontae Jones, Human Resources

Karyn Harvey, Quality Supports Florence Ndi, Quality Supports

Nellie Power, Outreach and Family

Services

Allis Kensing, Employment and Day

Services

Sylvester Bieler, Employment and Day

Services

Douglas McQuade, Employment and Day

Services

Donald Watts, Employment and Day

Services

QA Interviewers

Sean O’Connor, Board Member Jim List, Board Member, President

Don Himelfarb, Board Member Carla Murphy, Board Member

Janet Mayer, Board Member Kimberly Longford, Board Member

Liz Moag, Board Member Mike Jones, Self-Advocate

Tara Lilley, Self-Advocate Rene Schuekhardt, Self-Advocate

Neil MacDonald, Board Member

Adult Services and Family Living

1.) Category of Measure: Individuals are maximizing independence through the use of

assistive technology (AT)

Goal: 10 individuals using assistive technology will be reviewed, 100% of the time each

quarter, to ensure that devices are being utilized

Status:

o Annual Results: Achieved. 40 individuals using AT were reviewed. The majority

of individuals reviewed utilized their AT devices regularly. Not having AT as a

goal was the main reason several individuals did not utilize their device, so

additional training was done with case managers. This was a new measure in FY

15, so there is no FY 14 data to compare.

o Q4: Achieved. 10 individuals using AT were reviewed. 90% of individuals

reviewed utilized their AT devices regularly. The individuals’ devices were

present for 100% of reviews and 100% of staff had been trained. In the instance

where the individual was not using his device regularly, there was no IP goal

which identified AT as a strategy toward achieving a meaningful outcome. 40%

of the individuals reviewed had AT as a Goal in their Individual Plan, which is a

slight decrease since last quarter.


reviewed utilized their AT devices regularly. The individuals’ devices were

present for 90% of reviews and 100% of staff had been trained. In the instance

where the device was not used regularly, the device was not present, so measures

are being taken to assure the individual has access to the device. 50% of the

individuals reviewed had AT as a Goal in their Individual Plan. This increase over

last quarter is most likely due to ongoing training efforts.


reviewed utilized their AT devices regularly. The individuals’ device were present

for 100% of reviews and 100% of staff had been trained. 30% of the individuals

reviewed had AT as a Goal in their Individual Plan. In each instance where a

device was not being utilized regularly, there was no AT Goal in the Individual

Plan.

o Q1: Achieved. 10 individuals using AT were reviewed. 80% of people reviewed

utilized their AT device regularly. Barriers to regular utilization included device

malfunction and the persons need for encouragement from team members to

utilize their communication device, on an ongoing and regular basis. 60% of

people reviewed had AT as a part of their Individual Plan goals. The Arc

Baltimore would like to see this percentage increase, to ensure that assistive

technology is effective in helping an individual achieve greater independence, in

both their personal and career goals.

Explanation: The Arc Baltimore recognizes a person often needs ongoing support to

facilitate the use of assistive technology in order to achieve greater independence. A

sample of The Arc Baltimore participants, who have obtained assistive technology

devices, will be reviewed each quarter to ensure that they are being supported with the

ongoing use of the devices. The Arc Baltimore was successful linking individuals with

assistive technology and recognizes that utilization is a key component.

2.) Category of Measure: Individuals and families connected with The Arc Baltimore are

well informed of available assistive technology services

Goal: To increase the number of annual fair attendees

Status:

o Annual Results: Achieved. 200 people attended the annual fair in May of

2015. 160 people attended the annual fair in FY 14, which is a 25% increase in attendance in FY 15. Attendees had the opportunity to meet with 18 vendors

and try out AT devices and to learn how the devices can be used for greater

independence. This was a new measure in FY 15.

o Q4: Achieved. 200 people attended the annual fair in May of 2015. 160 people

attended the annual fair in 2014, so there was a 25% increase in attendance this year. Attendees had the opportunity to meet with 18 vendors and try out AT

devices and to learn how the devices could be used as a tool for greater

independence.

o Q3: The annual fair is held once per year in May.

o Q2: No results. The annual fair is held once per year in May.

o Q1: No results. The annual fair is held once per year in May.

3.) Category of Measure: Individuals have meaningful Outcomes, along with high quality

Goals and Strategies, which are in alignment with their life vision

Goal: Outcomes, along with their supporting Goals and Strategies, will be reviewed each

quarter to ensure that they are of the highest quality

Status:

o Annual Results: Achieved.

o Annual Summary: Quality Enhancement reviewed 24 individuals Outcomes,

Goals, and Strategies. The majority of the Outcomes were meaningful and in

alignment with the individuals life visions. However, many of the Goals and

Strategies reviewed were not easily measured, so training efforts and case

manager meetings focused, and will continue to emphasize, the writing of

measurable Goals and Strategies that are meaningful to the individuals. This

measure was slightly changed in FY 15, so there is no FY 14 data to compare.

o Q4: Achieved

o Q4 Summary: Quality Enhancement reviewed six individuals Outcomes, Goals,

and Strategies. The majority of Outcomes, Goals, and Strategies reviewed were

meaningful and were in alignment with their life vision. Four of the six Outcomes

reviewed did not have measureable Goals and Strategies, so training and case

managers meetings will continue to focus on the development of meaningful and

measurable Outcomes, Goals, and Strategies.

o Q3: Achieved


and Strategies. The Outcomes reviewed were meaningful and created a solid

foundation to build the Goals and Strategies on. However, the Strategies, and

some of the goals, lacked detail and did not provide good direction for

implementation. Ongoing training is occurring in this area and there are procedure

changes in the works that will continue to increase the quality of the Outcomes,

Goals, and Strategies.

o Q2: Achieved


and Strategies. Most of the individuals whose Outcomes, Goals, and Strategies

were chosen for review were unable to communicate with Quality Enhancement

staff verbally, with the assistance of technology, or with assistance of other

supports. Therefore, it was difficult to determine if the Outcomes, Goals, and

Strategies were meaningful to the individuals based on their own reporting.

However, the Outcomes, Goals, and Strategies reviewed were agreed upon by the

involved teams, the agreements of which were based on the teams’ beliefs that the

Outcomes, Goals, and Strategies were meaningful to the individuals. That said,

the Outcomes, Goals, and Strategies reviewed had a generic quality to them and

did not appear to capture what the individuals really wanted in their life. Quality

Enhancement staff met with the case managers who wrote the Outcomes, Goals,

and Strategies and talked about ways to improve meaningfulness and

measurability of the Outcomes.

o Q1: Achieved

o Q1 Summary: Quality Enhancement reviewed six supported individuals

Outcomes, Goals, and Strategies. All six individuals stated that they were

involved in their Individual Planning process, the creation of their Outcomes,

Goals, and Strategies, and that their Outcomes were meaningful and in alignment

with their life.

Explanation: Each Quarter, staff from Quality Enhancement will read Outcomes that are

selected for review, along with their supporting Goals, Strategies and Progress Notes.

Quality Enhancement staff will then meet with the supported individuals whose

Outcomes were chosen for review, to ensure that they chose their Outcomes, and that

progress was made towards the achievement of their Outcomes. Quality Enhancement

staff will then meet with the case managers who wrote the plans, offering them feedback

about the quality of the Outcomes, Goals, and Strategies.

4.) Category of Measure: Individuals are connected with their favorite people, connected

with their community, are happy with their lives, and are thriving in their lives

Goal: Randomly completed Meaningful Life Surveys completed each quarter

demonstrate:

o All individuals surveyed are 85% satisfied with their connection to their favorite

people

o All individuals surveyed are 85% satisfied with their connection to their

community

o All individuals surveyed are 85% satisfied with their level of happiness

o All individuals surveyed are 85% satisfied with the level at which they are

thriving

Status:

o Annual Results: Not achieved

o Annual Summary:

Individuals reported being 94.3% satisfied with their connections to their

favorite people in FY 15. Individuals reported being 88% satisfied with

their connections to their favorite people in FY 14.

Individuals reported being 83.3% satisfied with their connections to their

communities in FY 15. Individuals reported being 84% satisfied with their

connections to their communities in FY 14.

Individuals reported being 93.3% satisfied with their level of happiness in

FY 15. Individuals reported being 97% satisfied with their level of

happiness in FY 14.

Individuals reported being 93.3% satisfied with the level at which they are

thriving in FY 15. Individuals reported being 89% satisfied with the level

at which they are thriving in FY 14.

o Q4: Unable to measure

o Q4 Summary based on 0 completed surveys

o Q3: Not achieved

o Q3 Summary based on 3 completed surveys

Individuals reported being 83% satisfied with their connections to their

favorite people.


communities.

Individuals reported being 80% satisfied with their level of happiness.

Individuals reported being 80% satisfied with the level at which they are

thriving.

o Q2: Achieved

o Q2 Summary based on two completed surveys


favorite people.


communities.



thriving.

o Q1: Achieved

o Q1 Summary based on two completed surveys:


favorite people.


communities.



thriving.

Explanation: Each survey will be reviewed and the findings will help improve the quality

of services, specifically in the areas of supported individuals happiness and connectivity

to their community. Having board members complete Meaningful Life Surveys is unique

to The Arc of Baltimore; CARF noted in its recent reaccreditation of The Arc Baltimore

that, “The board members demonstrate availability to the stakeholders visiting programs

and sites [meeting with individuals].” This process helps ensure customer satisfaction,

while at the same time, enhances board members connection to the agency and the

supported individuals.

5.) Category of Measure: Individuals interviewed are satisfied with their services

Goal: 95% satisfaction with services as indicated by answering 2 or 3 on question 10,

“How would you rate your overall satisfaction with the level of service provided by the

department?”

Status:

o Annual Results: Achieved. 392 out of 405 individuals, or 97% of individuals were

satisfied with services in FY 15. 360 out of 373 individuals, or 97% of individuals

were satisfied with services in FY 14.

Employment: 327 out of 340 individuals, or 96% of individuals were

satisfied with services in FY 15. 308 out of 318 individuals, or 97% of

individuals were satisfied with services in FY 14.

Community Living: 34 out of 34 individuals, or 100% of individuals were

satisfied with services in FY 15. 27 out of 30, or 90% of individuals were

satisfied with services in FY 14.

Family Living: 11 out of 11, or 100% of individuals were satisfied with

services. Not measured in FY 14.

Parent-Provider: 20 out of 20, or 100% of parents-providers were satisfied

with services in FY 15. 25 out of 25, or 100% of individuals were satisfied

with services in FY 14.

o Q4: Achieved

Employment: 172 out of 182 individuals, or 95% of individuals were

satisfied with services.

Community Living: 18 out of 18 individuals, or 100% of individuals were

satisfied with services.


services.

Parent-Provider: No surveys

o Q3: This goal is completed twice per year. Results will be posted with Q4 of the

2013-2014 QE Plan.

o Q2: Achieved

Day: 123 out of 126 individuals, or 98% of individuals were satisfied with

services.

Employment: 32 out of 32, or 100% of individuals were satisfied with

services.

Community Living: 16 out of 16, or 100% of individuals were satisfied

with services.


services.

Parent-Provider: 20 out of 20, or 100% of parents-providers were satisfied

with services.

o Q1: This goal is completed twice per year. Results will be posted with Q2 and Q4

of the 2013-2014 QE Plan.

6.) Category of Measure: The time between the funded date and effective date

Goal: 90% of referred individuals will start services on the effective date

Status:

o Annual Results: Not achieved. 68 out of 107 individuals, or 64% started receiving

services on the effective start date in FY 15. 51 out of 86, or 59% of individuals

started receiving services on the effective date in FY 14.

o Q4: Not achieved. 6 out of 15 individuals, or 40% started receiving services on

the effective start date. 3 out of 15 late starts were considered The Arc

Baltimore’s fault and the reason for the late starts were not having a home ready

at service start and not having staff members ready to provide services at start

date.

o Q3: Status: Not achieved. 15 out of 21 individuals, or 71.5% started receiving

services on the effective start date. Of the late starts, three occurrences were

avoidable, and were the result of The Arc Baltimore not having supports in place

at the time of the effective start date. The other three occurrences were not within

The Arc Baltimore’s control.

o Q2: Not achieved. 7 out of 14 individuals, or 50% started receiving services on

the effective start date. The primary reasons for delayed start dates were due to

The Arc Baltimore not receiving required documentation from stakeholders,

individuals being sick at the time of effective start date, and staff not hired by

effective start date.

o Q1: Not achieved. 40 out of 57 individuals, or 70%, started receiving services on

their effective start date. Some of the reasons for the delays included difficulty

getting required paperwork, difficulty finding enhanced support staff, one

individual being on vacation at the time of the effective start date, and one

individual did not have the required work boots needed for their job.

7.) Category of Measure: The quality of departmental services will improve with input of

direct support professionals

Goal: Quality enhancement groups in each division, comprised of direct support

professionals, meet quarterly

Status:

o Annual Results: Not achieved.

o Annual Summary: Workgroups met in Q1, Q2, and Q3, but some did not meet in

Q 4. The workgroups had a positive impact on the agency in FY 15, as

demonstrated by now having: direct support professional membership on

committees; quarterly direct support professional meetings; direct support

professionals more involved in the individual planning process; and improved

communication between direct support professionals and management.

o Q4: Not achieved.

o Q4 Summary: Quarter 4 saw a lot of membership changes due to resignations and

promotions of facilitators and workgroup members. Quality Enhancement met

with the new facilitators in early July and provided an overview of the purpose

and goals of the workgroups.

o Q3: Achieved

o Q3 Summary: Workgroups continue to meet and the quality enhancement director

met with most of the workgroups in quarter three. Part of the reason the director

met with the workgroups was to help reinvigorate the workgroups, because many

of the staff members in the workgroups expressed the belief that no changes were

occurring as a result of the workgroups. The director shared with each workgroup

all of the great changes that have already occurred as a result of their work; which

helped reenergize the staff members. Additionally, the leadership of each program

area have helped to identify new facilitators and staff members as needed. Shanna

Strickland was identified as the new direct support professional member of the

Quality Enhancement Committee and Meagan Craig was identified as the new

direct support professional member of the Individual Plan Committee.

o Q2: Achieved

o Q2 Summary: The first agency wide direct support professionals meeting was

held on October 16, 2014 and there were approximately 30 staff present. The

topic of the discussion was the Individual Plan process and how direct support

professionals would like to have input into the creation of Outcome, Goals, and

Strategies and to be invited to the Individual Planning meetings. Additionally, a

panel of direct support professionals presented at The Arc Baltimore’s

Administrative Staff meeting on December 10, 2014 that sparked a great

discussion, the content of which will help The Arc Baltimore find ways to

improve communication and the quality of supports.

o Q1: Achieved

o Q2 Summary: One recommendation made by the workgroups was to improve

how information is disseminated to direct support professionals. In response,

Quality Enhancement is now hosting quarterly direct support professional

meetings, to which all direct support professionals are invited, and the first

meeting is being held on October 16, 2014.

Explanation: The purpose of this measure is to empower direct support professionals.

Each group will take meeting minutes, a copy of which will be provided to the director of

quality enhancement for review. The director of Quality Enhancement will serve as a

liaison to the groups, ensuring that their feedback is heard and responded to in a timely

manner. Additionally, information provided by the groups will be used to help improve

services.

8.) Category of Measure: The number of Therapeutic Interactions between Psychology

Associates and individuals

Goal: To complete 350 therapeutic interactions per quarter

Status:

o Annual Results: Achieved. 1,757 therapeutic interactions were completed in FY

15, or 26% more than the goal of 1,400. In FY 14, 1,667 therapeutic interactions

were completed.

o Q4: Achieved. 470 therapeutic interactions were completed.




9.) Category of Measure: The number of restrictive procedures in Behavior Support Plans

Goal: To reduce the number of restrictive procedures

Status:

o

o Annual Results: Not achieved. There were 15 restrictive procedures in Behavior

Support Plans in Q4 of FY 15. There were 11 restrictive procedures in Behavior

Support Plans in Q4 of FY 14.

o Q4: Not achieved. There were 15 restrictive Behavior Plans in Q4 and there were

14 restrictive Behavior Plans in Q3.

Current Restrictions:

Door Alarms: 3

Vehicle safety locks: 3

Seat belt guard: 0

Use of protective glove: 1

Reimbursement for property damage: 4

Search of a person: 1

Lock up knives: 2

Physical escorts: 1

o Q3: Not Achieved. There were 14 restrictive Behavior Plans in Q3 and there were



Door Alarms: 3


Seat belt guard: 0




Lock up knives: 2

Physical escorts: 0




Door Alarms: 1


Seat belt guard: 1




Lock up knives: 2

Physical escorts: 1




Door Alarms: 1


Seat belt guard: 1




Lock up knives: 2

Physical escorts: 1

10.) Category of Measure: The percentage of Internal Incidents

Goal: 10% decrease in Internal Incidents

Status:

o Annual Results: Not achieved. There were 454 internal incidents in FY 15, which

is a 38% increase compared to FY 14. There were 328 internal incidents in FY 14.

Summary:

Internal Incident Types:

o Reporting history of unsubstantiated abuse: 5 (3)

o Physical aggression: 37 (26)

o Hospital Treatment Chronic Condition: 18 (20)

o ER visit: 217 (165)

o Injury: 26 (40)

o Medication error: 106 (50)

o Choking: 2 (3)

o Police with no report taken: 23 (10)

o Theft < $50: 5 (1)

o Unexpected or risky absence: 3 (2)

o Other: 12 (8)

*( ) = FY 14 numbers

o Q4: Not achieved. There were 108 Internal Incidents in Q4, which is a 2%

decrease from Q3. There were 110 Internal Incidents reported in Q3.

Summary:


o Reporting history of unsubstantiated abuse: 1

o Physical aggression: 10

o Hospital Treatment Chronic Condition: 3

o ER visit: 55

o Injury: 7

o Medication error: 20

o Choking: 0

o Police with no report taken: 7

o Theft < $50: 0

o Unexpected or risky absence: 2

o Other: 3



Summary:





o ER visit: 61

o Injury: 4


o Choking: 0


o Theft < $50: 1


o Other: 2



Summary:





o ER visit: 52

o Injury: 3


o Choking: 1


o Theft < $50: 0


o Other: 3

o Q1: Not Achieved. There were 121 Internal Incidents in Q1, which is a 27%

increase from Q4. There were 95 Internal Incidents reported in Q4.

Summary:





o ER visit: 49

o Injury: 12


o Choking: 1


o Theft < $50: 4


o Other: 4

11.) Category of Measure: The percentage of Reportable Incidents

Goal: 10% decrease in Reportable Incidents

Status:

o Annual Results: Not achieved. There were 201 Reportable Incidents in FY 15,

which is a 1% decrease from FY 14. There were 203 Reportable Incidents

reported in FY 14 (not including abuse and neglect)

Summary:

Reportable Incident Types:

o Death: 13 (6)

o Hospital admission: 111 (107)

o Injury: 6 (13)

o Medication error: 5 (7)

o Choking: 0 (0)

o Police with report taken: 16 (9)

o Fire department: 4 (16)

o Theft > $50: 1 (4)

o Unexpected or risky absence: 0 (1)

o Unauthorized/inappropriate use of restraints: 4 (1)

o Other: 41 (39)

*( ) = FY 14 numbers

o Q4:

Summary: Not achieved. There were 49 Reportable Incidents in Q4, which

is a 4% decrease from Q3. There were 51 Reportable Incidents reported in

Q3 (not including abuse and neglect)


o Death: 5

o Hospital admission: 26

o Injury: 1


o Choking: 0

o Police with report taken: 4

o Fire department: 0

o Theft > $50: 0


o Unauthorized/inappropriate use of restraints: 2

o Other: 9

o Q3: Not achieved. There were 51 Reportable Incidents in Q3, which is a 5%

increase from Q2. There were 49 Reportable Incidents reported in Q2 (not

including abuse and neglect)

Summary:


o Death: 3


o Injury: 1


o Choking: 0



o Theft > $50: 0



o Other: 10

o Q2: Not achieved. There were 49 Reportable Incidents in Q2, which is a 6%

decrease from Q1. There were 52 Reportable Incidents reported in Q1 (not


Summary:


o Death: 3


o Injury: 1


o Choking: 0



o Theft > $50: 0



o Other: 12

o Q1: Achieved. There were 52 Reportable Incidents in Q1, which is a 17%

decrease from Q4. There were 63 Reportable Incidents reported in Q4 (not


Summary:


o Death: 2


o Injury: 3


o Choking: 0



o Theft > $50: 1



o Other: 10

12.) Category of Measure: The number of abuse and neglect allegations

Goal 1: No substantiated allegations of abuse by staff

Status/Abuse:

o Annual Results:

Community living:

Between staff and individual: 23

o Substantiated: 7

o Unsubstantiated: 16

Between supported individuals: 4

o Substantiated: 2


Between community member/family member and individual: 1

o Substantiated: 0


Employment:


o Substantiated: 4



o Substantiated: 6



o Substantiated:2


o Unknown Outcome: 2

Family Living:


o Substantiated: 0



o Substantiated: 0



o Substantiated: 0


o Q4: Not Achieved. There was 2 substantiated abuse allegation between staff

members and individuals in Q4.

Community living:

Between staff and individual: 4 allegations involving 4 individuals

o Substantiated: 1


Between supported individuals: 3 allegations involving 6

individuals

o Substantiated: 1



allegations involving 0 individuals

o Substantiated: 0


Employment:


o Substantiated: 1


Between supported individuals: 3 allegation involving 3

individuals

o Substantiated: 2




o Substantiated: 1


o Unknown Outcome: 2

Family Living:


o Substantiated: 0


Between supported individuals: 0 allegations involving 0

individuals

o Substantiated: 0




o Substantiated: 0


o Q3: Not Achieved. There were 2 substantiated abuse allegations between staff and

individuals in Q3.

Community living:


o Substantiated: 1



o Substantiated: 0



o Substantiated: 0


Employment:


o Substantiated: 1



individuals

o Substantiated: 2




o Substantiated: 1


Family Living: 0


o Substantiated: 0



o Substantiated: 0



o Substantiated: 0



individuals in Q2.

Community living:


o Substantiated: 2



o Substantiated: 0



o Substantiated: 0


Employment:

Between staff and individual: 1 allegation involving 3 individuals

o Substantiated: 1



individuals

o Substantiated: 1



o Substantiated: 0


Family Living:


o Substantiated: 0



o Substantiated: 0


Between community member/family member and individual:

o Substantiated: 0



individuals in Q1.

Community living:


o Substantiated: 4



o Substantiated: 1



o Substantiated: 0


Employment:


o Substantiated: 1



o Substantiated: 2



o Substantiated: 1


Family Living:


o Substantiated: 0



o Substantiated: 0



o Substantiated: 0


Goal 2: No substantiated allegations of neglect by staff

Status/Neglect:

o Annual Results: Not Achieved. There were 14 substantiated neglect allegations

between staff and individuals in FY 15.

Community living:


o Substantiated: 9



o Substantiated: 1


Employment:


o Substantiated: 4



o Substantiated: 0


Family Living:


o Substantiated: 1



o Substantiated: 1


o Q4: Not Achieved. There were 2 substantiated neglect allegations between staff

and individuals in Q4.

Community living:


o Substantiated: 2




o Substantiated: 0


Employment:


o Substantiated: 0




o Substantiated: 0


Family Living:

Between staff and individual: 0 allegations involving 0 individual

o Substantiated: 0




o Substantiated: 0




Community living:


o Substantiated: 2



o Substantiated: 0


Employment:


o Substantiated: 2



o Substantiated: 0


Family Living:

Between staff and individual: 1 allegations involving 1 individual

o Substantiated: 1



o Substantiated: 0




Community living:


o Substantiated: 2



o Substantiated: 0


Employment:


o Substantiated: 1

o Unsubstantiated:


o Substantiated: 0


Family Living:


o Substantiated: 0



o Substantiated: 1




Community living:


o Substantiated: 3



o Substantiated: 1


Employment:


o Substantiated:1



o Substantiated: 0


Family Living:


o Substantiated: 0



o Substantiated: 0


Adult Services

1.) Category of Measure: Percentage of site visits completed

Goal: To complete 90% of site visits

Status:

o Annual Results: Not achieved. 1,155 out of 1,385 site visits, or 84.4% were

completed by Community living and Employment. This was a new measure in FY

15, so there is no FY 14 data to compare.

o Q4: Achieved. 309 out of 336 site visits, or 92% of site visits were completed by

Community Living. 6 out of 6, or 100% of site visits for day programs were

completed by Employment.

o Q3: Not achieved. 307 out of 346 site visits, or 89% of site visits were completed

by Community Living. 6 out of 6, or 100% of site visits for day programs were


o Q2: Not achieved. 287 out of 340 site visits, or 84% of site visits were completed

by Community Living. O out of 6, or 0% of site visits for day programs were


o Q1: Not achieved. 240 out of 339, or 71% of site visits were completed by

Community Living. O out of 6, or 0% of site visits for day programs were


Foster Care

1.) Category of Measure: Percentage of Reportable Incidents that are preventable

Goal: To investigate and assess all Reportable Incidents for preventability and develop a

response plan for each preventable incident

Annual Results: Achieved. A total of 66 incidents were assessed for preventability in FY

15. This was a new measure in FY 15, so there is no FY 14 data to compare.

Q4: Achieved. There were 16 incidents and each was assessed for preventability.

o Reportable Incidents: 16

Elopement : 4

Preventable: 4

Not Preventable: 0

Emergency hospitalization medical: 1

Preventable: 0

Not Preventable: 1

Emergency hospitalization psychiatric: 1

Preventable: 0

Not Preventable: 1

Emergency medical treatment: 1

Preventable: 0

Not Preventable: 1

Illness: 0

Preventable: 0

Not Preventable: 0

Injury to other youth: 0

Preventable: 0

Not Preventable: 0

Injury to youth subject to incident: 2

Preventable: 0

Not Preventable: 2

Medical event: 0

Preventable: 0

Not Preventable: 0

School expulsion: 0

Preventable: 0

Not Preventable: 0

Theft : 0

Preventable: 0

Not Preventable: 0

Property damage : 0

Preventable: 0

Not Preventable: 0

Substance use : 1

Preventable: 1

Not Preventable: 0

Assault: 0

Preventable: 0

Not Preventable: 0

Death: 0

Preventable: 0

Not Preventable: 0

Possible violation of rights: 0

Preventable: 0

Not Preventable: 0

Behavioral issue: 0

Preventable: 0

Not Preventable: 0

Other : 6

Preventable: 3

Not Preventable: 3

Summation: There were 3 less incidents in Q4 than in Q3. Additionally,

historically elopement is the highest reportable category and it was reduced in Q4

from 9 to 4, or a 44% reduction. Foster Care has been more proactive with parents

in regards to elopement. Furthermore, Foster Care has worked to empower the

individuals receiving services to communicate more effectively with their

treatment team. It is believed that these action steps have helped reduce the

number of elopements.

Q3: Achieved. There were 18 incidents and each was assessed for preventability.


Elopement : 9

Preventable: 7 (Elopement is being coded as preventable unless

there is a specific reason not to.)

Not Preventable: 2 (In this situation Foster Care tried everything to

work with the foster child to prevent the elopement from

occurring. This was not successful, so Foster Care had to discharge

the foster child.)


Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 1


Preventable: 0

Not Preventable: 5

Illness: 0

Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 1 (This youth has already been captured in the

emergency medical treatment)

Medical event: 3

Preventable: 0

Not Preventable: 3

School expulsion: 0

Preventable: 0

Not Preventable: 0

Theft : 0

Preventable: 0

Not Preventable: 0

Property damage : 0

Preventable: 0

Not Preventable: 0

Substance use : 0

Preventable: 0

Not Preventable: 0

Assault: 0

Preventable: 0

Not Preventable: 0

Death: 0

Preventable: 0

Not Preventable: 0

Possible violation of rights: 0

Preventable: 0

Not Preventable: 0

Behavioral issue: 0

Preventable: 0

Not Preventable: 0

Other : 0

Preventable: 0

Not Preventable: 0

Summation: There were a total of 18 incidents in the third quarter, 9 of which were in

the category of elopement. To further assist foster parents with the management of

elopement, Foster Care is developing an elopement training for foster parents.

o Q2: Achieved. There were 28 incidents and each was assessed for preventability.


Elopement: 5

Preventable: 5

Not Preventable: 0


Preventable: 0

Not Preventable: 1


Preventable: 0

Not Preventable: 2


Preventable: 1

Not Preventable: 5

Illness: 0

Preventable: N/A

Not Preventable: N/A


Preventable: 0

Not Preventable: 2


Preventable: 0

Not Preventable: 1

Medical event: 3

Preventable: 0

Not Preventable: 3

School expulsion: 0

Preventable: N/A


Theft: 0

Preventable: N/A


Property damage: 1

Preventable: 1

Not Preventable: 0

Substance use: 0

Preventable: N/A


Other: 7

Preventable: 3

Not Preventable: 4

Q2 Summation: There were 28 total incidents reported in Q2. The area Foster Care

will be focusing on in the upcoming year is elopement. While Foster Care cannot

physically prevent a child from leaving a home, it can take additional steps to ensure

that children feel equipped to communicate their needs appropriately, and to ensure

that foster parents have the support and skills needed to assist a child during the

process.

o Q1: Achieved. There were three incidents and each was assessed for

preventability.

Reportable Incidents: 3

Elopement: 0

o Preventable: N/A

o Not Preventable: N/A


o Preventable: N/A



o Preventable: N/A



o Preventable: 0

o Not Preventable: 2

Illness: 0

o Preventable: N/A



o Preventable: N/A



o Preventable: N/A


Medical event: 0

o Preventable: N/A


School expulsion: 0

o Preventable: N/A


Theft: 0

o Preventable: N/A


Property damage: 0

o Preventable: N/A


Substance use: 0

o Preventable: N/A


Other: 1

o Preventable: 1

o Not Preventable: 0

o Q1 Summation: One out of three incidents were deemed preventable and

appropriate training and actions were taken to avoid a similar incident in the

future.

Explanation: Every incident is both an opportunity to explore what could have prevented

the incident, as well as an opportunity to address the root cause of the incident, which

will decrease the likelihood of future incidents occurring.

2.) Category of Measure: Percentage of Annual Assessments completed on time

Goal: 100% compliance with completing Annual Assessments

Status:

o Annual Results: Not achieved. 34 out of 37, or 92% of Annual Assessments were

completed on time in FY 15. 39 out of 43, or 91% of Annual Assessments were

completed on time in FY 14.

o Q4: Not achieved. 13 out of 15, or 87% of Annual Assessments were completed

on time.

o Q3: Achieved. 7 out of 7, or 100% of the Annual Assessments were completed on

time.

o Q2: Not achieved. 6 out of 7 or 86% of the Annual Assessments were completed

on time.

o Q1: Achieved. 8 out of 8, or 100% of the Annual Assessments were completed on

time.

3.) Category of Measure: CANS and Ansell Casey Assessments will be completed on time

each quarter

Goal: 100% compliance with completion of CANS Assessments

Status:

o Annual Results: Not achieved. 129 out of 133, or 97% of the CANS and Ansell

Casey Assessments were completed on time in FY 15. 132 out of 137, 96% of the

CANS and Ansell Casey Assessments were completed on time in FY 14.

o Q4: Achieved. 32 out of 32, or 100% of the CANS and Ansell Casey Assessments

were completed on time.

o Q3: Achieved. 32 out of 32, or 100% of the CANS and Ansell Casey Assessments

were completed on time.

o Q2: Not achieved. 31 out of 32, or 97% of the CANS and Ansell Casey

Assessments were completed on time.

o Q1: Not achieved. 34 out of 37, or 92% of the CANS and Ansell Casey

Assessments were completed on time.

4.) Category of Measure: Foster children will experience placement stability and avoid

disruption by matching children with the best fitting placements

Goal: Upon discharge, 90% of foster children will have stayed in their initial placement

for the entirety of their involvement in the Foster Care program

Status:

o Annual Results: Not achieved. 20 out of 23 children, or 87% remained with their

initial foster family for the entirety of their stay in Foster Care in FY 15. 10 out of

13 children, or 77% remained with their initial foster family for the entirety of

their stay in Foster Care in FY 14.

o Q4: Not achieved. 4 out of 5 children, or 80% remained with their initial foster

family for the entirety of their stay in Foster Care.

o Q3: Achieved. 5 out of 5 children, or 100% remained with their initial foster






5.) Category of Measure: Foster parents will report overall satisfaction with the services

provided by The Arc Baltimore

Goal: 90% satisfaction based on a five point Likert Scale

Status:

o Annual Results: Achieved. 12 out of 12, or 100% of foster parents surveyed

reported overall satisfaction with serviced provided by The Arc Baltimore in FY

15. In FY 14, 14 out of 15, or 93% of foster parents surveyed reported overall

satisfaction with serviced provided by The Arc Baltimore.

o Q4: No results. Surveys completed one time per year in January.

o Q3: Achieved. 12 out of 12, or 100% satisfaction reported based on a five point

Likert Scale.



Family Living

1.) Category of Measure: Family education topics will appeal to a broad and widening

range of community members. Audience members will report that topics are meaningful

and helpful

Goal 1: Yearly attendees will exceed 320 individuals. New attendees each session will

exceed 10% of the total participants

Status:

o Annual Results: Achieved. There were 470 attendees in FY 15. An average of

20.4% were new attendees each quarter. There were 335 attendees in FY 14, of

which 17 or 10% were new attendees.

o Q4: Achieved. There were 220 attendees this quarter for a total of 470 attendees

to date. 60 of the 200 attendees, or 27.3% were new attendees.

o Q3: Achieved. There have been 250 attendees to date. 38, or 15.2 % were new

attendees.

o Q2: Achieved. There have been 195 attendees to date. 35, or 18% were new

attendees.

o Q1: Achieved. There have been 143 attendees to date. 6 out of 29, or 21%, of

attendees at the last session were new.

Goal 2: 80% satisfaction with the topics presented

Status:

o Annual Results: Achieved. In FY 15, an average of 89% were satisfied with the

relevance of the topics presented. In FY 14, an average of 96% were satisfied with

the relevance of the topics presented.

o Q4: Achieved. 89% of attendees were satisfied with the relevance of the topics

presented.


presented.


presented.


presented.

Outreach/Intake

1.) Category of Measure: Individuals and families seeking resources and/or intake

information will receive prompt responses

Goal: 90% of calls will be returned within one business day

Status:

o Annual Results: Achieved. Outreach/Intake received 5,213 calls inquiring about

resources and intake information in FY 15. 5,017, or 96.2% of the calls were

returned within one business day. Outreach/Intake received 3,246 calls inquiring

about resources and intake information in FY 14. 3,232, or 99.6% of the calls

were returned within one business day in FY 14.

o Q4: Achieved. Outreach/Intake received 1,476 calls inquiring about resources and

intake information. 1,363, or 92.3% of the calls were returned within one business

day.


intake information. 1,272, or 97% of the calls were returned within one business

day.


intake information. 1,153, or 99.5% of the calls were returned within one business

day.


intake information. 1,229, or 97% of the calls were returned within one business

day.

2.) Category of Measure: Individuals and families are satisfied with the intake process

Goal: 95% satisfaction with the intake process

Status:

o Annual Results: Achieved. 7 out of 7 individuals and families, or 100% were

satisfied with the intake process in FY 15. This was a new measure in FY 15, so

there is no FY 14 data to compare.

o Q4: Achieved. 7 out of 7 individuals and families, or 100% were satisfied with the

intake process.

o Q3: The satisfaction survey for Outreach has been developed and is at the

printers. Surveys will begin being collected in Q4.

o Q2: The satisfaction survey for Outreach has been developed and is under review.

Surveys will begin being collected in Q3.

o Q1: The survey is in the development process. No results for this quarter.

Employment

1.) Category of Measure: Number of individual placements

Goal: To increase the total number of competitive employer paid individual placements

to 110

Status:

o Annual Results: Achieved. There was a monthly average of 121 individuals were

working in competitive employer paid placements in FY 15. There was a monthly

average of 100 employer paid individual placements in FY 14.

o Q4: Achieved. 131 individuals were working in competitive employer paid

placements.


placements.


placements.


placements.

2.) Category of Measure: Number of integrated community activities

Goal: Each center will have at least six community integrated events/activities per month

Status:

o Annual Results: Not achieved. Two out of four quarters in FY 15 had at least six

community integrated events/activities per month. Three out of four quarters had

at least six community integrated events/activities per month in FY 14.

o Q4: Not achieved

o Q4 Summary

Dundalk: 8 in April, 5 in May, 10 in June

Loch Ridge: 6 in April, 9 in May, 11 in June

Seton: 12 in April, 10 in May, 12 in June

Woodlawn: 30 in April, 28 in May, 21in June

Towson: 22 in April, 11 in May, 12 in June

Homeland: 5 in April, 5 in May, 6 in June

CLS: 12 in April, 38 in May, 38 in June

o Q3: Achieved

o Q3 Summary:

Day Services community activities:

Dundalk: 6 in January, 8 in February, 9 in March

Loch Ridge: 13 in January, 17 in February, 21 in March

Seton: 10 in January, 7 in February, 9 in March

Woodlawn: 29 in January, 37 in February, 37 in March

Towson: 13 in January, 27 in February, 27 in March

Homeland: 7 in January, 6 in February, 6 in March

CLS: 53 in January, 44 in February, 37 in March

o Q2: Not achieved

o Q2 Summary:


Dundalk: 10 in October, 3 in November, 4 in December

Loch Ridge: 9 in October, 2 in November, 5 in December

Seton: 18 in October, 15 in November, 17 in December

Woodlawn: 8 in October, 10 in November, 8 in December

Towson: 16 in October, 11 in November, 10 in December

Homeland: 3 in October, 6 in November, 6 in December

o Q1: Achieved

o Q1 Summary:


Dundalk: 17 in July, 8 in August, 8 in September

Loch Ridge: 28 in July, 12 in August, 8 in September

Seton: 18 in July, 18 in August, 13 in September

Woodlawn: 34 in July, 24 in August, 25 in September

Towson: 8 in July, 17 in August, 15 in September

Homeland: 8 in July, 8 in August, 8 in September

3.) Category of Measure: Number of individuals in community based employment

Goal: To provide community based paid employment to 30% of individuals attending day

centers

Status:

o Annual Results: Not achieved. On average, 28% of individuals attending day

centers were provided community based paid employment throughout FY 15.

This measure was slightly changed in FY 15, so there is no FY 14 data to

compare.

o Q4: No achieved. 134 out of 512, or 26% of individuals attending day programs

participated in community based paid employment.

o Q3: Data not captured for this quarter. Data will be provided in quarter four.

o Q2: No achieved. 150 out of 530, or 28% of individuals attending day programs


o Q1: Achieved. 160 out of 516, or 31% of individuals attending day programs


Nursing

1.) Category of Measure: Individuals in Community Living, who receive nursing supports,

and are prescribed 10 or more medications

Goal: To review and address all unnecessary medications

Status:

o Annual Results: Achieved. Although individuals on 10 or more medications

increased comparing Q1 to Q4, nursing was able to identify individual’s

prescribed unneeded medications each quarter, and helped advocate for the

superfluous medications to be removed from the list of prescribed medications in

FY 15. This measure was slightly changed in FY 15, so there is no FY 14 data to

compare.

o Q4: Achieved. There were 71 individuals identified who were prescribed 10 or

more medications. Combined, the identified individuals were prescribed 1,035

medications, or an average of 14.6 medications per individual. At the end of Q4,

12 individuals were added to the list of individuals on 10 or more medications. At

the end of Q4, the total amount of prescribed medications was increased from 958

to 1,112.


more medications. Combined, the identified individuals were prescribed 1035


nine individuals were able to be removed from the list of individuals on ten or

more medications. At the end of Q3, the total amount of prescribed medications

was reduced from 1,035 to 958.



medications, or an average of 14 medications per individual. At the end of Q2,

five individuals were able to be removed from the list of individuals on 10 or

more medications and four individuals were added. At the end of Q2, the total

amount of prescribed medications was reduced from 1,119 to 1,094.




one individual was removed from the list of individuals on 10 or more

medications, and the total amount of prescribed medications was reduced from

1,072 to 1,062.

Explanation: Many medications prescribed are necessary for the health and well-being of

supported individuals. However, individuals with intellectual disabilities are often

prescribed an excessive amount of medications. The intent of this measure is to ensure

that individuals who are prescribed high quantities of medications are not being

superfluously medicated.

2.) Category of Measure: The percentage of nursing reviews completed on time

Goal: 90% of nursing reviews are completed on time

Status:

o Annual Results: Achieved. 1,890 out of 1,998, or 95% of nursing reviews were

completed on time in FY 15. This was a new measure in FY 15, so there is no FY

14 data to compare.

o Q4: Achieved. 544 out of 557, or 98% of nursing reviews were completed on

time.


time.

o Q2: Achieved. 331 out of 339, or 97.5% of nursing reviews were completed on

time.


time.

Community Living

1.) Category of Measure: Satisfaction with relationships (not including housemates and

paid staff) as measured through visits with friends and family, activities in the community,

phone calls, cards and letters, email and social media communication, and participation in

community groups

Goal: 25% percent increase in satisfaction with meaningful relationships

Status:

o Annual Results: Achieved. On a scale of 1 through 5, 5 being the highest

satisfaction with relationships, individuals surveyed reported a 91% increase in

satisfaction with meaningful relationships compared to the baseline of 2.3. This

was a new measure in FY 15, so there is no FY 14 data to compare.

o Q4: Achieved. On a scale of 1 through 5, 5 being the highest satisfaction with

relationships, individuals surveyed reported 4.4 satisfaction with their meaningful

relationships, which is a 91% increase in satisfaction with meaningful

relationships compared to the baseline of 2.3.

o Q3: This goal is completed twice per year. Results will be posted with Q4 of the

2014-2015 QE Plan.

o Q2: Achieved. On a scale of 1 through 5, 5 being the highest satisfaction with

relationships, individuals surveyed reported 4.3 satisfaction with their meaningful

relationships, which is an 87% increase in satisfaction with meaningful

relationships compared to the baseline of 2.3.

o Q1: This goal is completed twice per year. Results will be posted with Q2 and Q4

of the 2014-2015 QE Plan.

2.) Category of Measure: The percentage of medical appointments completed on time

Goal: 80% of appointments are completed on time (within The Arc Baltimore’s control)

Status:

o Annual Results: 4,870 appointments were due, of which 3,262 or 67% were

completed on time in FY 15. This was a new measure in FY 15, so there is no FY

14 data to compare.

o Q4: Not achieved

o Q4 Summary:

Community Living East:

401 appointments were due, of which 244 or 61% were completed

on time

34 appointments were completed late

123 appointments were delinquent

Community Living West:


on time



Late Reasons:

Community Living East: 9 out of 34 appointments completed late

within The Arc Baltimore’s control:

o Did not know about appointment: 3

o Forgot appointment: 1

o Individual refused: 0

o Lack of staff: 3

o Lack of transportation:

o Staff/transportation got lost: 2

o When called, no appointment available: 0

Community Living West: 18 out of 60 appointments completed

late within The Arc Baltimore’s control:




o Lack of staff: 1

o Lack of transportation: 0



o Q3: Not achieved

o Q3 Summary:



on time





on time



Late Reasons:

Community Living East: 24 out of 89 appointments completed late





o Lack of staff: 0









o Lack of staff: 1




o Q2: Not achieved

o Q2 Summary:



on time





on time



Late Reasons:

Community Living East:10 out of 49 appointments completed late





o Lack of staff: 0









o Lack of staff: 5




o Q1: Not achieved

Q1 Summary:


o 525 appointments were due, of which 347 or 66% were

completed on time

o 78 appointments were completed late

o 100 appointment were delinquent


o 454 appointments were due, of which 260 or 57% were

completed on time

o 60 appointments were completed late

o 134 appointments were delinquent

Late Reasons:

Community Living East:18 late out of 78 appointments completed





o Lack of staff: 0




Community Living West: 14 late out of 60 appointments

completed late within The Arc Baltimore’s control:




o Lack of staff: 3




3.) Category of Measure: A decrease in the number of overdue medical appointments

Goal: To decrease the number of overdue medical appointments

Status:

o Annual Results: There were a total of 238 overdue medical appointments at the

end of Q4 in FY 15. This was a new measure in FY 15, so there is no FY 14 data

to compare.

o Q4: Not achieved


There were 123 overdue medical appointments in Q4, which was a

19% increase in overdue medical appointments compared to Q3.

Community Living East had an all quarter total of 220 overdue

medical appointments.



6% decrease in overdue medical appointments when compared to

Q3.

Community Living West had an all quarter total of 230 overdue


o Q3: Achieved



51% decrease in overdue medical appointments compared to Q2.





37% decrease in overdue medical appointments when compared to

Q2.



o Q2: Not achieved



110% increase in overdue medical appointments compared to Q1.




There were 174 overdue medical appointments in Q2 which was a

30% increase in overdue medical appointments when compared to

Q1.



o Q1: Overdue medical events were not measured last quarter, so this goal was

neither achieved nor not achieved.


There were 100 overdue medical appointments in Q1. This is the

first quarter this is being measured, so the following information is

not yet known: which is a #% increase/decrease from last quarter.

There were # overdue medical appointments last quarter.


There were 134 overdue medical appointments in Q1. This is the

first quarter this is being measured, so the following information is

not yet known: which is a #% increase/decrease from last quarter.

There were # overdue medical appointments last quarter.

Graphs

Category of Measure: The number of Therapeutic Interactions between Psychology


Category of Measure: The number of restrictive procedures in Behavior Support Plans

363433

491 470

1,7571,667

Q1: 2014-2015 Q2: 2014-2015 Q3: 2014-2015 Q4: 2014-2015 Annual Results FY15Annual Results FY14

Therapeutic Interactions

12

12

01

01

21

11

12

12

01

01

21

11

3 3

0

4

01

01

2

0

14

3 3

0

4

01

01

21

15

0

2

4

6

8

10

12

14

16

Restrictive Behavior Plans Adult Services and Family Living

Q1: 2014-2015 Q2:2014-2015 Q3: 2014-2015 Q4: 2014-2015

Category of Measure: The percentage of Internal Incidents

3 3

0

4

01

01

21

15

12

12

01

01

21

11

0

2

4

6

8

10

12

14

16

Restrictive Behavior PlansAdult Servcies and Family Living

Annual FY 15 Annual FY 14

537

18

217

26

106

223 5 3 12

454

326 20

165

40 50

3 10 1 2 8

328

0

50

100

150

200

250

300

350

400

450

500

Internal Incidents Adult Services and Family Living

Annual Result FY 15 Annual Result FY 14

Category of Measure: The percentage of Reportable Incidents

Category of Measure: The number of abuse and neglect

13

111

6 5 016

4 1 0 4

41

201

6

107

13 7 0 9 164 1 1

39

203

0

50

100

150

200

250

Reportable IncidentsAdult Services and Family Living

Annual Result FY 15 Annual Result FY 14

23

8

15

42 2 1 0 1

20

8

12

0 0 0 0 0 00

5

10

15

20

25

Community LivingAbuse


4

10

8

6

2

8

3

5

21

4

1 10

5

23

00

2

4

6

8

10

12

Employment Abuse


1

0

1

0 0 0 0 0 00 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0

1

0

1

0 0 0 0 0 00

0.2

0.4

0.6

0.8

1

1.2

Family LivingAbuse

Q1:2014-2015 Q2:2014-2015 Q3:2014-2015 Q4:2014-2015 Annual FY 15

12

9

31 1

0

20

15

5

1 10

0

5

10

15

20

25

Allegations staffand individual-CL

Substantiated Unsubstantiated Allegationscommunity/familyand individual-CL

Substantiated Unsubstantiated

Community Living Neglect


5

4

1

0 0 0

3 3

0

2

1 1

0

1

2

3

4

5

6

EmploymentNeglect


Category of Measure: Percentage of Reportable Incidents that are preventable

0 0 0 0 0 00 0 0

1 1

0

1 1

0 0 0 00 0 0 0 0 0

1 1

0

1 1

00

0.2

0.4

0.6

0.8

1

1.2

Family LivingNeglect

Q1: 2014-2015 Q2: 2014-2015 Q3: 2014-2015 Q4: 2014-2015 Annual FY 15

Category of Measure: Individuals in Community Living, who receive nursing supports,

and are prescribed 10 or more medications

Category of Measure: The percentage of medical appointments completed on time

1094 1062 9581,112

4,226

Q1: 2014-2015 Q2: 2014-2015 Q3: 2014-2015 Q4: 2014-2015 ANNUAL RESULTS FY15

Number of Medications Individuals On 10 or More Medications

979

607

138234

1,428

929

115

384

1,232

858

162212

845

513

94

238

0

200

400

600

800

1000

1200

1400

1600

Appointments Due Appointments Completed onTime

Appointments CompletedLate

Appointments Delinquent

Community Living Medical Appointments

Q1: 2014-2015 Community Living Q2: 2014-2015 Community Living

Q3: 2014-2015 Community Living Q4: 2014-2015 Community Living

Category of Measure: A decrease in the number of overdue medical appointments

224

356

210

315

212

507

238

450

OVERDUE WITHIN Q1: 2014-2015

TOTAL OVERDUE Q1:

2014-2015


TOTAL OVERDUE Q2:

2014-2015


TOTAL OVERDUE Q3:

2014-2015


TOTAL OVERDUE Q4:

2014-2015

Community Living Overdue Medical Events

Quality Enhancement Plan 2015-2016

Mission The Arc Baltimore provides advocacy and high quality, life-changing

supports to individuals with intellectual and developmental disabilities

and their families.

Vision People with intellectual and developmental disabilities and their

families THRIVE in the community.

Human Rights Committee Approval: 6-30-15

Adult Services and Family Living

1) Category of Measure: Individuals are maximizing independence through the use of

assistive technology

Goal: To increase the number of referrals each quarter from the baseline of ten referrals

Status: Explanation: The Arc Baltimore recognizes that assistive technology can help individuals

achieve greater independence.

2) Category of Measure: Individuals have outcomes of their choosing, along with goals

and strategies that provide clear instruction on outcome attainment

Goal: A sampling of outcomes, along with their supporting goals and strategies, will

be reviewed each quarter to ensure individuals chose their outcomes, and that the

goals and strategies provide clear instruction on outcome attainment.

Status:

Summary:

Explanation: Each quarter, staff members will review a sampling of outcomes, along

with the supporting goals, strategies and progress notes. Staff members will then meet

with the supported individuals whose outcomes were chosen for review, to ensure

that they chose their outcomes, and that progress has been made towards the

achievement of their outcomes. Staff members will then provide feedback to Quality

Enhancement regarding the quality of the outcomes, goals, and strategies. This

information will be used to guide Individual Planning training and clinics on outcome

writing and implementation.

3) Category of Measure: Individuals are connected with their favorite people, connected

with their community, are happy with their lives, and are thriving in their lives

Goal One: Randomly completed Meaningful Life Surveys completed each quarter

demonstrate:


favorite people


community

o All individuals surveyed are 85% satisfied with their level of happiness

o All individuals surveyed are 85% satisfied with the level at which they are

thriving

Status:

Goal Two: Board Members are engaged with the individuals receiving services as

evidenced by the completion of a combined total of six Meaningful Life Surveys per

quarter

Status:

Explanation for goals one and two: Surveys are reviewed and the findings help

improve the quality of services, specifically in the areas of supported individuals

happiness and connectivity to their community. This process helps ensure customer

satisfaction, while at the same time, enhances board members connection to the

agency and the supported individuals.

4) Category of Measure: Individuals interviewed are satisfied with their services

Goal: 95% satisfaction with services as indicated by answering 2 or 3 on question 10,

“How would you rate your overall satisfaction with the level of service provided by the

department?”

Status:

o Employment:

o Community Living:

o Family Living

o Parent-Provider:

5) Category of Measure: The time between the funded date and effective date

Goal: The Arc Baltimore is prepared to start services on the effective funded date for

90% of funded individuals

Status:

Summary:

6) Category of Measure: The quality of departmental services will improve with input

of direct support professionals

Goal: Quality enhancement groups in each division, comprised of direct support

professionals, meet quarterly

Status:

Summary:

Explanation: The purpose of this measure is to empower direct support professionals.

Each group takes meeting minutes, a copy of which is provided to the director of

quality enhancement for review. The director of Quality Enhancement serves as a

liaison to the groups, ensuring that their feedback is heard and responded to in a

timely manner. Additionally, information provided by the groups is used to help

improve services.

7) Category of Measure: The number of Therapeutic Interactions between Psychology


Goal: To complete 350 therapeutic interactions per quarter

Status:

8) Category of Measure: The number of restrictive procedures in Behavior Support

Plans

Goal: To reduce the number of restrictive procedures

Status: There are currently # restrictions. There were # restrictions last quarter

o Current Restrictions:

Door Alarms: #

Vehicle safety locks: #

Reimbursement for property damage: #

Locked cabinet for cleaning supplies: #

Search of a person: #

Use of protective helmet: #

Lock up knives: #

Physical escorts: #

9) Category of Measure: The percentage of Internal Incidents

Goal: 10% decrease in Internal Incidents

Status: There were # Internal Incidents this quarter, which is a #% increase/decrease from

last quarter. There were # Internal Incidents reported last quarter

Summary:

o Internal Incident Types:

Abuse:#

o Reporting history of unsubstantiated abuse:#

o Physical aggression:#

Hospital admission/ER visit: #

Injury:#

Medication error: #

Choking:#

Police with no report taken: #

Theft < $50: #

Unexpected or risky absence: #

Other: #

10) Category of Measure: The percentage of Reportable Incidents

Goal: 10% decrease in Reportable Incidents

Status: There were # Reportable Incidents this quarter, which is a #% increase/decrease

from last quarter. There were # Reportable Incidents reported last quarter (not including

abuse and neglect)

Summary:

o Reportable Incident Types:

Death: #

Hospital admission: #

Injury: #

Medication error: #

Choking:#

Police with report taken: #

Fire department: #

Theft > $50: #

Unexpected or risky absence: #

Unauthorized/inappropriate use of restraints: #

Other: #

11) Category of Measure: The number of abuse and neglect allegations

Goal 1: No substantiated allegations of abuse by staff

Status/Abuse: There were # abuse allegations involving # individuals

o Community living:

Abuse:

Between staff and individual: #

o Substantiated:

o Unsubstantiated:

Between supported individuals: #

o Substantiated:

o Unsubstantiated:

Between community member/family member and individual: #

o Substantiated:

o Unsubstantiated:

o Employment:

Abuse:


o Substantiated:

o Unsubstantiated:


o Substantiated:

o Unsubstantiated:


o Substantiated:

o Unsubstantiated:

o Family Living:

Abuse:


o Substantiated:

o Unsubstantiated:


o Substantiated:

o Unsubstantiated:


o Substantiated:

o Unsubstantiated:

Summary:

Goal 2: No substantiated allegations of neglect by staff

Status/Neglect: There were # neglect allegations involving # individuals

o Community living:

Neglect:#


o Substantiated:

o Unsubstantiated:


o Substantiated:

o Unsubstantiated:

o Employment:

Neglect:#


o Substantiated:

o Unsubstantiated:


o Substantiated:

o Unsubstantiated:

o Family Living:

Neglect:#


o Substantiated:

o Unsubstantiated:


o Substantiated:

o Unsubstantiated:

Summary:

Adult Services

1) Category of Measure: Percentage of site visits completed

Goal: To complete 100% of semiannual site visits on each shift

Status:

2) Category of Measure: The percentage of emergency drills completed

Goal: 100% of sites owned or operated by The Arc Baltimore will conduct CARF

required emergency drills on each shift once per year.

Status:

Explanation: This measure is reported biannually. Fire drills are completed monthly per

COMAR, but only the CARF fire drill is tracked in this measure.

Foster Care

1) Category of Measure: Percentage of Reportable Incidents that are preventable

Goal: To investigate and assess all Reportable Incidents for preventability and develop a

response plan for each preventable incident

Status:

o Reportable Incidents:

Elopement:#

Preventable:

Not Preventable:

Emergency hospitalization medical: #

Preventable:

Not Preventable:

Emergency hospitalization psychiatric: #

Preventable:

Not Preventable:

Emergency medical treatment: #

Preventable:

Not Preventable:

Illness: #

Preventable:

Not Preventable:

Injury to other youth: #

Preventable:

Not Preventable:

Injury to youth subject to incident: #

Preventable:

Not Preventable:

Medical event: #

Preventable:

Not Preventable:

School expulsion: #

Preventable:

Not Preventable:

Theft: #

Preventable:

Not Preventable:

Property damage: #

Preventable:

Not Preventable:

Substance use:#

Preventable:

Not Preventable:

Summation:

Explanation: Every incident is both an opportunity to explore what could have

prevented the incident, as well as an opportunity to address the root cause of the

incident, which will decrease the likelihood of future incidents occurring.

2) Category of Measure: Percentage of Annual Assessments completed on time

Goal: 100% compliance with completing Annual Assessments

Status:

3) Category of Measure: CANS Assessments will be completed on time each quarter

Goal: 100% compliance with completion of CANS Assessments

Status:

4) Category of Measure: Foster children will experience placement stability and avoid

disruption by matching children with the best fitting placements

Goal: Upon discharge, 90% of foster children will have stayed in their initial placement

for the entirety of their involvement in the Foster Care program

Status:

5) Category of Measure: Stakeholder will report overall satisfaction with the services

provided by The Arc Baltimore

Goal: 90% satisfaction based on five point Likert Scale

Status:

Family Living

1) Category of Measure: Education series topics will appeal to a broad and widening

range of community members. Audience members will report that topics are

meaningful and helpful

Goal 1: Yearly attendees will exceed 320 individuals

Status:

Goal 2: New attendees will exceed 10% of the yearly attendees

Status:

Goal 3: 80% satisfaction with the topics presented

Status:

Outreach/Intake

1) Category of Measure: Individuals and families are satisfied with the intake process

Goal: 95% satisfaction with the intake process

Status:

Employment Services

1) Category of Measure: Number of individual placements

Goal: To increase the total number of competitive employer paid individual placements

to 150

Status:

2) Category of Measure: Number of integrated community activities

Goal One: Goal: Each center will have at least eight community based events/activities

per month

Status:

o Day Services community activities

Dundalk:

Loch Ridge:

Seton:

Woodlawn:

Towson:

Homeland

Goal Two: Each center will have at least two community inclusive events/activities that

are solely geared towards friendship and/or connection building.

3) Category of Measure: Number of individuals in community based employment

Goal: To provide community based paid employment to 30% of individuals attending day

centers

Status:

Human Resources

1) Category of Measure: The applicant onboarding process

Goal: To decrease the number of days between when a potential employee submits their

job application and attends orientation to 25 days or less.

Status:

Nursing

1) Category of Measure: Individuals in Community Living, who receive nursing

supports, and are prescribed 10 or more medications

Goal: To review and address all unnecessary medications

Status:

Explanation: Many medications prescribed are necessary for the health and well-being of

supported individuals. However, individuals with intellectual disabilities are often

prescribed an excessive amount of medications. The intent of this measure is to ensure

that individuals who are prescribed high quantities of medications are not being

superfluously medicated.

2) Category of Measure: The percentage of nursing reviews completed on time

Goal: 90% of nursing reviews are completed on time

Community Living

1) Category of Measure: The percentage of medical appointments completed on time

Goal: 80% of appointments are completed on time

Status:

o Community Living East:

# appointments were completed, of which # or #% were completed on

time

o Community Living West:

# appointments were completed, of which # or #% were completed on

time

Late Reasons:

o CL East: # late at fault out of #:

Did not know about appointment:

Forgot appointment:

Individual refused:

Lack of staff:

Lack of transportation:

Staff/transportation got lost:

When called, no appointment available:

o CL West: # late at fault out of #:

Did not know about appointment:

Forgot appointment:

Individual refused:

Lack of staff:

Lack of transportation:

Staff/transportation got lost:

When called, no appointment available:

2) Category of Measure: A decrease in the number of overdue medical appointments

Goal: To decrease the number of overdue medical appointments

Status:

o Community Living East:

There were # overdue medical appointments this quarter, which is a #%

increase/decrease from last quarter. There were # overdue medical

appointments last quarter

o Community Living West:

There were # overdue medical appointments this quarter, which is a #%

increase/decrease from last quarter. There were # overdue medical

appointments last quarter

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