MECKLENBURG COUNTY
PROVIDED SERVICES ORGANIZATION
ANNUAL
PERFORMANCE IMPROVEMENT
PROGRAM EVALUATION
Assessment of Fiscal Year 2015
PSO Performance Improvement Program Evaluation for FY15
INTRODUCTION
The Provided Services Organization (PSO) became a Mecklenburg County Department on July 1, 2012. The PSO
was previously part of Area Mental Health (AMH). On October 7, 2014 the County Manager announced plans to
divest some substance abuse services and reorganize others within the County. The substance abuse treatment
programs were redistributed as follows: the jail and shelter programs began operating under the Community
Support Services Department as of July 1, 2015 and the detox and residential programs were contracted out to
The Anuvia Prevention and Recovery Center, a local non-profit provider effective September 2, 2015.
In the 1990’s AMH operated a number of programs including a free-standing psychiatric hospital. AMH partnered
with other providers in the area; with AMH continuing to provide case management services for children,
adolescents and adults, substance abuse services, developmental disabilities, and some mental health programs.
The NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services announced a plan for
Mental Health Reform in 2001. In compliance with this plan, Mecklenburg County divested more services over the
next three years. Two distinct business lines were developed. As outlined in the Reform Plan, AMH restructured
operations to create a Local Management Entity (LME) which was responsible for managing a network of
providers, conducting utilization management, and other activities delegated by the NC Department of Health and
Human Services. A second business line of provided services continued. With permission from the NC DHHS
Secretary, Mecklenburg County operated a number of programs for Mecklenburg County residents with the
greatest needs and least financial resources. Those programs comprised the Provided Services Organization
(PSO). This report includes performance improvement information regarding the PSO Substance Abuse Services
programs that were accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) first October
2008, August 2011, and again October 2014.
The PSO conducts an ongoing Performance Improvement (PI) program and an annual evaluation of the PI
Program to measure progress, highlight the activities that resulted in meaningful improvement and identify activities
that need ongoing attention. The assessment looks at the fiscal year twelve month period (July through June) and
summarizes progress toward meeting performance goals.
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PSO Performance Improvement Program Evaluation for FY15
PSO Operations Management under the direction of Jonathan Myers, MHA prepared the FY15 Performance
Improvement Program Evaluation. The evaluation was reviewed and approved by the Community Support Services
Performance Improvement Council (PIC) on September 23, 2015. The findings are provided below.
This Performance Improvement Program Evaluation reflects the continuing commitment of the PSO to quality care.
The evaluation includes a review of completed and ongoing quality activities, trended data, and an assessment of
barriers to improved performance when performance goals are not met. Conclusions about the overall effectiveness
of the program, including assessments of the adequacy of resources and the appropriateness of committee
structure, are integrated into the program evaluation.
COMMITTEE STRUCTURE AND EFFECTIVENESS
In 2005, the PSO initiated a Performance Improvement Council structure to support the development,
implementation, and evaluation of the PI Program. The Mecklenburg County Board of County
Commissioners serves as the governing body for the agency and is ultimately responsible for oversight of
the PI Program. A copy of the PSO Committee organizational chart is below.
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PSO Performance Improvement Program Evaluation for FY15
Board of County
Commissioners
County Manager
Assistant Manager
PSO Director
Client Rights
Committee
Performance Improvement
Council
Health Information
Management
Committee
Qualification
Decision Team
Provided Services
Leadership Team
Safety
Committee
Risk Management
Committee
PSO Management Team
Training
Committee
Cultural
Competence
Committee
Information
Technology
Advisory Group
The PIC solicits input from its many subcommittees to identify issues, suggest strategies for improvement,
and to implement activities. The PSO’s Client Rights Committee, a consumer-led group, advises the PSO
on Performance Improvement (PI) activities including customer satisfaction, accessibility, incident
management, complaint management and readability and usefulness of the department’s website and some
PSO publications.
This section of the PI evaluation examines the effectiveness of services provided.
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PSO Performance Improvement Program Evaluation for FY15
Table 1. Effectiveness of Consumer Services
Program
Measurement
Target
CY07 FY14
FY15
Day Tx –SA Program
# program grads returning to jail w/in
<55%
53%
46%
at Jail Central
12 months of release
≥60%
*46% *42% *47%
≥60%
*40% *54% *50%
41%
(decreasing measure)
Day Tx-SA Program
% Successfully Completing Program
Men’s Shelter
during the entire month
Day Tx-SA Program
% Successfully Completing Program
Women’s Shelter
during the entire month
Detox SA
% Successful program completion
≥80%
91%
96%
94%
Residential SA
% Successful program completion
≥75%
75%
79%
82%
* Target not met.
Analysis of Performance:
In FY15, the Day Treatment – Men’s Shelter SA Program and the Day Treatment– Women’s Shelter SA
Program did not meet the effectiveness measure of program completion. Because Day Treatment is
provided at the homeless shelters and only to those consumers that actually live on-site, the programs have
little to no control over how many consumers are referred for services, complete treatment, or continue to
live at the shelters. Housing, rather than treatment is the reason our consumers are at the
shelter. Obviously, since the base portions of Maslow’s Hierarchy of Needs is a priority for the majority of
our consumers, the need for housing comes before treatment. In addition to other reasons, once housing is
obtained, consumers leave the Shelter and are discharged from our Shelter Program before treatment is
completed.
What also comes into play is that if a consumer breaks a shelter rule and is discharged they are
automatically discharged from treatment and cannot complete the program. Shelter staff members do what
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PSO Performance Improvement Program Evaluation for FY15
they can to work with the shelter’s leadership but, because we are a “guest in their house”, they make the
final decision on who stays or who goes.
In May of 2014 Mecklenburg County initiated a single portal Coordinated Assessment process. This has
slowed the flow of consumers to the shelter programs.
Table 1.1 Effectiveness of Consumer Services –Plans for FY16
Program
Measurement
Target
FY15
Action Plans
Day Tx-
Successfully
60%
47%
Program Leadership continues to work with
Substance
Completing
leadership of Shelter to increase the likelihood
Abuse
Program during
that consumers will stay with the program on a
Program
the entire month
contiguous basis. Leadership is also optimistic
Men’s
regarding meeting the goal of fully staffing the
Shelter
program early in the year. PSO Leadership is
reassessing services provided at the shelters to
determine what will be most effective and plans
to implement integrated behavioral healthcare
in programs that serve the homeless.
Day Tx-
Successfully
60%
50%
Program Leadership continues to work with
Substance
Completing
leadership of Shelter to increase the likelihood
Abuse
Program during
that consumers will stay with the program on a
Program
the entire month
contiguous basis. Leadership is also optimistic
Women’s
regarding meeting the goal of fully staffing the
Shelter
program early in the year. PSO Leadership is
reassessing services provided at the shelters to
determine what will be most effective and plans
to implement integrated behavioral healthcare
in programs that serve the homeless.
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PSO Performance Improvement Program Evaluation for FY15
This section of the PI evaluation examines the efficiency of services provided.
Table 2. Efficiency of Consumer Services
Program
Measurement
Target
Actual
Actual
Actual
CY07
FY14
FY15
Day Tx –SA Program in Jail
% occupancy
≥95%
*94%
*79%
*87%
Day Tx-SA Program Men’s Shelter
% occupancy
≥75%
*77%
*66%
*65%
Day Tx-SA Program Women’s Shelter
% occupancy
≥75%
*67%
*40%
*48%
Detox
% occupancy
≥50%
79%
69%
76%
Residential Substance Abuse Program
% occupancy
≥50%
82%
82%
59%
Analysis of Performance:
In FY15, the Jail Central Substance Abuse Treatment Program did not meet the efficiency measure of
occupancy. Several factors contributed to the decreased occupancy in the Jail Men’s and Women’s
Substance Abuse programs this year. They include: refusal of inmates to remain in the program, transition
of County Sheriff’s Office (MCSO) Program Officers, frequent removal of consumers from the program by
the criminal justice system, and staffing shortages.
Upcoming improvements include better training for new MCSO Detention Officers to maintain the therapeutic
POD and we continue to seek opportunities for collaboration with MCSO Jail Program Staff to provide
incentives for inmates to remain in the program
In FY15, the Day Tx-SA Program at the Men’s’ Shelter did not meet the efficiency measure of occupancy.
Program Leadership continues to work with leadership of Shelter to increase the likelihood that consumers
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PSO Performance Improvement Program Evaluation for FY15
will stay with the program on a contiguous basis. Leadership is also optimistic regarding meeting the goal
of maintaining full staffing of the program throughout the year.
In FY15, the Day Tx-SA Program at the Women’s’ Shelter did not meet the efficiency measure of
occupancy. Each winter the policy of the Women’s Shelter is that women with young children are priority
for placement at the shelter main site while women with no children are referred to alternate shelter beds at
churches. This decreases referrals to the Shelter Program due to the limited availability of child care and
more appropriate referral to other providers such as CASCADE.
Also, during the year, the number of appropriate referrals from the Women’s Shelter declined as those in the
shelter did not meet dependency diagnosis guidelines.
Table 2.1 Efficiency of Consumer Services-Plans for FY16
Program
Measurement
Target
Actual FY
Action Plans
2015
Day Tx-SA
% occupancy
95%
87%
The program will work with Sheriff’s Office
Program in
staff to include better training for MCSO
Jail
Detention officers to maintain the therapeutic
POD, seek incentives for inmates to remain in
the program, and return to staffing goals.
Day Tx-SA
% occupancy
75%
65%
Program Leadership continues to work with
Program
leadership of Shelter to increase the likelihood
Men’s Shelter
that consumers will stay with the program on
a contiguous basis. Leadership is also
optimistic regarding meeting the goal of fully
staffing the program early in the year. PSO
Leadership is reassessing services provided at
the shelters to determine what will be most
effective and plans to implement integrated
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PSO Performance Improvement Program Evaluation for FY15
behavioral healthcare in programs that serve
the homeless.
Day Tx-SA
% occupancy
75%
48%
Program Leadership continue to work with
Program
leadership of Shelter to decrease the
Women’s
likelihood that consumers are discharged with
Shelter
the Shelter for rules violations and to increase
likelihood that the Shelter Program staff can
meet with consumers prior to these discharges
to provide assistance with SA issues.
Although they have had limited success, we
will continue to utilize perks and incentives to
encourage the consumers to stay (weekly bus
passes if treatment is completed, perfect
attendance certificates, etc.). PSO Leadership
is reassessing services provided at the
shelters to determine what will be most
effective and plans to implement integrated
behavioral healthcare in programs that serve
the homeless.
This section of the PI evaluation examines the accessibility of services provided to our consumers.
Table 3. Accessibility of Consumer Services
Program
Measurement
Target
Day Tx –SA
Average # Days Consumers are on the
Program Jail
Waiting List
Central
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≤5
Actual Actual Actual
CY07
FY14
FY15
*7.05
2.75
1.25
PSO Performance Improvement Program Evaluation for FY15
Program
Day Tx-SA
Measurement
Target
Actual Actual Actual
CY07
FY14
FY15
Average days to complete admission
≤2
*6
1.0
1.5
Average days to complete admission
≤2
1
2.0
0.8
Detox
Consumers screened within 2 hours
100%
100%
100%
100%
Residential SA
Average number of consumers per month
0
*2.2
*0.5
0
Program Men’s
Shelter
Day Tx-SA
Program Women’s
Shelter
waiting more than 7 days for admission
* Target not met.
Analysis of Performance:
In FY15, all the SA Programs met the goal for Accessibility of Consumer Services.
This section of the PI evaluation examines satisfaction among consumers and stakeholders with the services
provided.
Table 4. Consumer and Family Satisfaction with Consumer Services
Program
Target
Actual
Actual
Actual
CY07
FY14
FY15
Day Tx –SA Program in Jail
85%
92%
95.3%
97.3%
Day Tx-SA Program Men’s Shelter
85%
92%
94.8%
94.8%
Day Tx-SA Program Women’s
85%
93%
95.8%
94.8%
85%
87%
96.3%
94.0%
Shelter
Detox
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PSO Performance Improvement Program Evaluation for FY15
Residential SA
85%
95%
96.8%
96.8%
* Target not met
Analysis of Performance:
The FY15 results for the programs exceed the target for consumer satisfaction.
Table 5. Stakeholder Satisfaction Survey:
Analysis:
The comparison grid below reflects survey results from 2012 to present. This year’s analysis will however
focus on 2014 compared to 2013.
The response rate for 2014 was 8% (5 of 60 respondents). This is a vast decline over 2013 which had a
46% (19 of 41 respondents). The drastic drop in participation may be due to a new survey process that was
used this year, called Qualtrics, which is a County system. With this new process, surveys were not
distributed manually in addition to electronically. Also, in using Qualtrics, the survey email and link to the
survey did not come directly from the program managers, and they had the two previous years, but rather
came from the QI Department. In addition to the above, Management changed this year in all three
programs.
In analyzing the data, the PSO uses the percentage of 85% as successful. Our goal is to reach 85% when
combining the two responses of “Always” and “Most of the time”. The table below reflects the above
mentioned calculations with the areas in the “successful” range highlighted in green.
An increase is noted in the number of questions that scored in the “successful” range. This increased from
three to five areas at 85% or better, resulting in 55% of our questions meeting criteria, an increase over 33%
in 2013. Question 9 (Staff demonstrate initiative and flexibility in responding to my needs) has historically
been an area needing improvement.
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PSO Performance Improvement Program Evaluation for FY15
Comparison Grid
SA Services Only
Response Rates
2012
2013
2014
11/41
19/41
5/60
27%
46%
8%
Q1. Staff respond to calls/emails no later than the next business day
91%
79%
80%
Q2. I am able to connect with the person who can best respond to my needs
91%
89%
80%
Q3. I am treated with courtesy and respect
82%
84%
100%
Q4. Staff accept responsibility
82%
79%
100%
Q5. Information provided to me is useful
100%
90%
100%
Q6. Staff act in a professional manner
91%
89%
100%
Q7. Staff follow proper channels for communication
73%
74%
60%
Q8. There is appropriate follow-through
91%
84%
100%
Q9. Staff demonstrate initiative and flexibility in responding to my needs
73%
68%
80%
A. Through which service do you have primary contact with PSO staff?
SASC Detox
3
Jail North Treatment
2
SASC Residential
3
PSO Administration
1
Adult SA Diag. Assess.
2
PSO Medical Records
1
Men's Shelter
2
PSO Consumer Advocate
0
Women's Shelter
3
Other (UM)
0
Jail Central Treatment
4
B. Which of these best describe you? Check all that apply.
Vocational
0
LME Employee
0
Other SA Treatment Provider
1
Regulatory/Licensing
0
Mental Health Services
0
Board Member
0
Other County Department
1
Community Member/Organization
0
Advocate/Family
0
Criminal Justice
4
Consumer Guardian
0
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PSO Performance Improvement Program Evaluation for FY15
C. What is your relationship to the PSO? Check all that apply.
I refer people to the PSO
2
Our agency hosts a PSO program
2
I receive referrals from the PSO
2
Other
0
We share consumers with the PSO
4
D. How often do you come into contact with the PSO?
Daily
1
Weekly
2
Monthly
2
F. If you made a referral to the PSO, your referral was:
Accepted, and services started promptly
100% Not processed to your
0%
satisfaction
Declined, but PSO staff were helpful in making
0
Question was skipped
0
alternative referral(s)
Action Plan:
During the 2015/2016 FY, QI staff will meet with Program Managers to review survey questions to assure
these areas are addressed during orientation of new hires as well as during the supervision of current staff.
Managers will solicit ideas/methods from staff as to strategies on how to improve areas scoring 85% or less
(questions 1, 7 & 9). Although the return results are not statistically reliable due to the low response, these
same areas were identified during the two previous surveys.
Table 6. Consumer Complaints: FY 13/14
Time
# of
Frame
Complaints Resolution %
1st
Timely
1
100%
Systematic improvement & Actions Needed
None noted
Quarter
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PSO Performance Improvement Program Evaluation for FY15
2nd
3
100%
None noted
0
100%
NA
3
100%
Two of these incidents were sent back to supervisors to
Quarter
3rd
Quarter
4th
Quarter
gather additional detail regarding all actions taken.
Process Measure
Goal
Results
Action Plan
Timeliness
100%
100%
None noted
For this reporting year, the PSO served 5,088 consumers in Substance Abuse Services. Of these
consumers, the total number of enrollments even greater. For each enrollment, there is the potential for
complaints to occur. The PSO received seven complaints this year, and each was resolved within the time
frame identified our policy (within 10 calendar days from receipt of complaint). One consistent theme
mentioned in a few of the complaints was customer service. This is an area that has been an ongoing topic
during group staff meetings as well as individual coaching.
Table 7. Accessibility
The following serves as the Mecklenburg County Provided Service Organization’s (PSO) Accessibility Plan
Assessment for fiscal year 2014-15. The purpose of this document is to provide a means to facilitate continual quality
improvement in the area of accessibility.
The PSO is committed to providing an organizational setting that seeks to accommodate the needs of all consumers,
employees, and stakeholders. Central to this commitment is the removal of architectural, attitudinal, employment,
and other barriers that may impede full access to the services and programs of the organization.
This Accessibility Plan is developed in response to the PSO’s internal evaluation of barriers through the use of
facility inspections, assessments of need, and feedback from consumers, employees, and other stakeholders.
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PSO Performance Improvement Program Evaluation for FY15
The Elements of the Accessibility Plan are as follows:
1. ARCHITECTURAL:
Architectural barriers have been identified through internal and external inspections, assessments of need,
and employee, stakeholder and consumer feedback. Mecklenburg County Asset and Facilities Management
and the Safety Committee provide ongoing monitoring of conditions within the organization that serves to
improve access. The organization’s leadership conducts long and short range planning meetings that
routinely include assessment of architectural needs and related costs analysis.
2. ENVIRONMENTAL:
The PSO believes that the environment in which services are provided reflect the culture and cultural customs of
the consumers, and in addition are conducive to providing a comfortable and confidential setting for consumers
and employees to achieve their highest potential.
3. ATTITUDINAL:
The organization seeks to reduce the stigma associated with persons who have mental illness, and
substance abuse problems, and to promote their inclusion within the community.
4. FINANCIAL:
The PSO, within in the structure of Mecklenburg County, seeks to support appropriate programming to
provide support and resources to those consumers most in need.
5. EMPLOYMENT:
The PSO strives to maintain a diverse workforce sensitive to the unique needs of consumers and
representative of the community it serves. In addition, the PSO strives to hire and maintain the highest of
quality of employees available in the labor market.
6. COMMUNICATION:
The PSO seeks to provide open channels of communication that allow consumers, employees, and stakeholders
to access information that accurately represents the status of the organization’s systems and outcomes. The
Mecklenburg County Balanced Scorecard System is used by the PSO to provide information regarding the PSO to
the Mecklenburg County Board of County Commissioners. In addition, the PSO seeks to facilitate communication
among consumers and employees, providing a basis for personal and professional growth, and well-being.
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PSO Performance Improvement Program Evaluation for FY15
7. TECHNOLOGY
The PSO seeks to utilize technology to gain efficiency, communicate information, and market the Department’s
services to staff, consumers and other stakeholders. The annual Technology and Systems Plan and assessment of
the plan detail goals and progress made toward them.
8. TRANSPORTATION:
The PSO seeks to ensure that consumers are not limited by a lack of personal transportation options or by options
that may not accommodate their disabilities, and that transportation systems fully accommodate any community
member seeking to access services.
9. OTHER AREAS:
In addition to the above specific accessibility goals and objectives, the PSO is involved in many ongoing activities
and procedures that enhance the accessibility of consumers, employees, and members of the community.
Examples include personnel policies (employee climate survey, balanced scorecard measures, and exit interview
process), ongoing outreach activities in all program areas, the utilization of consumer feedback/input processes
such as satisfaction surveys, psychosocial assessments, and individual planning, participation in consumer
advocacy groups, outcome studies, cultural competency education, and a multitude of other activities that directly
facilitate the enhancement of accessibility.
ANNUAL REVIEW:
The Provided Services Organization Performance Improvement Council develops and approves a revised
Accessibility Plan each year. The plan is reviewed and approved by the PSO Director, and is made available to
consumers, employees, and stakeholders on the PSO website.
1. ARCHITECTURAL:
Goal
Objectives
Measure
Responsible
Cost/Source
Staff are relocated County Asset
Target/Status Date
Potential PSO
Centrally locate PSO
relocation
administration staff at
and Facility
August
the Sam Billings Center
Management,
2014
PSO and
Project was
County
terminated
leadership
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TBD/TBD
Target
PSO Performance Improvement Program Evaluation for FY15
Update Watkins Egress
Update and replace
Signs are
Mark Hahn,
Cost: TBD
Target June
Route Signage
current old exit route
replaced
Asset and
Source –AFM
30, 2014
signs with new current
Facilities
Completed
versions
Management
August
2014
Install Restroom in
Provide safe access for
Restroom is
Gustavo
Part of
Target Sept
Admissions Area and
pre-admitted individuals
installed and
Mibelli and
$200,000 in
1, 2014
Update Existing
and for accomplishing
updates are
Jay Rhodes
capital
Project was
Restrooms at the
drug screening.
completed
improvement
terminated
Substance Abuse
Replace existing
Services Center
countertops and mirrors
projects
in the bathrooms.
Remove Office
Increase Day Room
Cubicles are
Gustavo
Part of
Sept 1,
Cubicles from the Day
space, provide safe
removed
Mibelli and
$200,000 in
2014
Room at the Substance
meeting space for staff
Jay Rhodes
capital
Project was
Abuse Services Center
and consumers
improvement
terminated
projects
Improve Access to the
Install wheelchair
Door is installed
Gustavo
Part of
Sept 1,
Courtyard at the
accessible door for staff
and landscaping
Mibelli and
$200,000 in
2014
Substance Abuse
and consumers and
is completed
Jay Rhodes
capital
Project was
Services Center
landscape the area
improvement
terminated
projects
Replace Fire panels
Update and upgrade fire
Fire panels and
Installation
throughout the Sam
panels
related equipment
Company and
2014
are installed and
John Horton
Completed
Billings Center
functional
County funds
Nov. 1,
November
2014
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PSO Performance Improvement Program Evaluation for FY15
2. ENVIRONMENTAL:
Goal
Objectives
Measure
Responsible
Mecklenburg County
Set up processes to
A system is in
Cultural
Land Use and
meet LUESA
place to
Competency
Environmental
Balanced Scorecard
capture data
Committee
Services Agency
Goals for the PSO
and report it
(LUESA) Goals
Department
to LUESA
Cost/Source
Target/Status Date
none
July 1, 2014
ongoing
3. ATTITUDINAL:
Goal
Objectives
Measure
Responsible
Mental Health Task
Respond to
Improvement in
Force
Mecklenburg County’s
Services for MH
Cost/Source
Connie Mele
Target/Status Date
N/A
Fall 2014
Ongoing
2014 Community Health
meetings
Assessment Findings
occur
~monthly
Involve consumers in
Include annual review of
PSO Client Rights
accessibility planning
the PSO accessibility
plan on the PSO Client
Connie Mele
$50
Fall 2014
minutes indicate the
PSO
ongoing
members reviewed
Admin
Rights Committee (CRC) the accessibility
agenda
Budget
plan
4. FINANCIAL:
Goal
Medicaid Billing
Objectives
Measure
Responsible
Cost/Source
Target/Status Date
Set up and maintain
Billing occurs timely
Christopher
Utilize existing
June 1,
contract, credentialed
and completely-
Stowe and
PSO SASC and
2014
staff and access to
Medicaid or IPRS
Christine
VARS staff
In progress
systems
funding per
Payseur
successful event
Page 18 of 26
as of 4/15
PSO Performance Improvement Program Evaluation for FY15
Expand Substance
Research and identify
Contracts are in
Christopher
Abuse Treatment
Affordable Care Act
place with private
Stowe for
2014
health insurers
SAS
(CDSA in
insurance such as
covering Substance
Will Snell for
Progress)
Tri-care and Blue
Abuse treatment
CDSA
Billing Opportunities and other private
N/A
December
Cross & Blue Shield
5. EMPLOYMENT:
Goal
Objectives
Measure
Responsible
Cost/Source
Employ the
Locate qualified people,
On average during
best staff
have the ability to afford
the year have 90%
90% of
them, maintain staffing
of positions filled
positions
Employee
Connie Mele
Target/Status Date
TBD
Average
that is representative of
filled during
the persons served
FY14
Improve staff morale
Hold at least one
Longevity
recognition event
Recognition
annually
Connie Mele
TBD
October
2014
Event
6. COMMUNICATION:
Goal
Objectives
Measure
Responsible
Cost/Source
Target/Status Date
Give consumers
Publish BSC
BSC report in the
Jonathan
$200
Fall 2014
access to the
outcomes for
newsletter and on
Myers
PSO Admin
Newsletters
PSO’s county
Substance Abuse
the PSO Website
Budget
Published
balanced scorecard
Services in the PSO
Fall and
(BSC) outcomes
Consumer newsletter
Spring 2015
when it is published
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PSO Performance Improvement Program Evaluation for FY15
7. TECHNOLOGY:
Goal
Objectives
Measure
Responsible
Cost/Source
Target/Status Date
Replace PSO
Acquire and install faster 70 PC’s are
Christine
$16,000
June 30,
staff PC’s that
and more reliable
replaced with newer
Payseur, IST
County Funds
2014
are over 5 years
machines
models
staff
Completed
old
July 2014
8. TRANSPORTATION:
Goal
Objectives
Measure
Responsible
Cost/Source
none
Target/Status Date
Remove Fuelman Meet County Policy
Fuelman cards are
David
June 15, 2014
cards from
regarding location and
no longer retained
Brinkerhoff,
Completed
County Fleet
handling of Fuelman
in vehicles
AFM and
June 2014
Vehicles
cards
PSO Admin
assigned to PSO
staff
9. OTHER AREAS:
Goal
Objectives
GPS in County
Safety, locate vehicles
Vehicles
easily, track usage
Measure
Responsible
GPS installed
Cost/Source
County AFM
Unknown
Target/Status Date
May, 15,
2014
Completed
June 2014
Status updated 4/13/15
The Accessibility Plan has a number of incomplete projects. These are rolled into the plan for FY16.
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PSO Performance Improvement Program Evaluation for FY15
PSO Annual Incident Analyses
FY 2013 / 2014
This year’s report for the Provided Services Organization (PSO) is comparing Incident reporting from FY
12/13 to 13/14.
For this reporting year, the PSO served 5,088 consumers in Substance Abuse Services. Of these
consumers, the total number of enrollments even greater. For each enrollment, there is the potential for
incidents to occur. The number of reported incidents for this fiscal year was 53 across all SAS programs, a
decrease from last year of 70 incidents. This reflects a continued trend of declining incidents over the past
five years. Hypothesis for the decreases are indicated below in each area identified.
Of the 53 incidents, 34% were categorized as level I, 458% as level II and 8% level III’s. These percentages
were similar to last year’s. The Substance Abuse Services Center (SASC) reported 44 (83%) of the
incidents. This is not unusual due to the population served and the fact this is a residential facility that
operates 24 hours a day, 7 days a week. The Men’s and Women’s Shelter each reported 5 incidents (10%)
of the total number. Jail reported 0 incidents. The remainder of this report will focus on the five categories
having the highest number of incidents.
1. Suspensions: This area comprised of 40% of the incidents, a 5% increase over last year resulting
in an increase for four consecutive years 57% of the suspensions were at SASC, and the remainder
at the Shelters. This is a decrease percentage wise for SASC and an increase for the Shelters.
Analyses, Trends, Patterns: Consumers have a variety of rules that are explained to them upon
entry into the programs and are reminded of throughout services. Consumers are discharged when
there are multiple infractions of these rules, or if the event is serious enough to disrupt or endanger
other consumers. For each consumer suspended, there was documented evidence that these
individuals were discharged due to misconduct. Two primary reasons for suspensions are due to
aggressive behavior or having positive drug tests at the shelter.
Action Plan: At all locations, staff will continue to review the center’s rules frequently with
consumers.
2. Behavior: In this broad area, SASC had 3 inappropriate/sexual behavior acts, 1 illegal act and five
aggressive acts, which totaled 17% of the incidents.
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PSO Performance Improvement Program Evaluation for FY15
Analyses, Trends, Patterns: Due to the populations served, these numbers are not out of the
ordinary and no trends were noted.
Action Plan: Staff will continue to be diligent in monitoring consumers and behaviors, and will
address issues as identified. Staff stress to consumers that their time in treatment is critical, and
they should be focusing on their recovery, and that this is not the time to develop romantic
relationships while at SASC.
3. Absence greater than 3 hours: These events only occur at the SASC due to the fact that
individuals can be petitioned to services, and thus are considered involuntary admissions. Of the 52
involuntary admissions, only six (13%) were reported to have left against medical advice. This is an
increase from last year, with 5% of 58 consumers.
Analyses, Trends, Patterns: No trends were noted this year, and 13% of involuntary admissions
leaving against medical advice is considered low given many of the individuals initially do not want
to be in treatment.
Action Plan: As individuals are admitted on an involuntary basis and are not receptive to treatment,
staff will continue to explain the benefits of choosing treatment and the ramification of leaving
against medical advice.
4. Suicidal Behavior: There were 5 consumers who expressed suicidal ideation, resulting in only 9% of
this year’s incidents. This in a 21% decrease.
Analyses, Trends, Patterns: 100% of the suicidal ideations were level 1, meaning the consumer
expressed a suicidal threat or verbalization that indicates new or different behaviors or an increase in
the number of these behaviors. It is believed that the decrease in incidents is due to a through
screening prior to admission, and recommending a higher level of care for these individuals, prior to
being admitted to SASC. There were no actual suicide attempts.
Action Plan: The PSO will continue the practice as identified above.
The remaining 23% of incidents were split between various categories, which can be seen below. Again, no
trends or patterns were noted and no action plan is warranted, other than to continue to monitor.
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PSO Performance Improvement Program Evaluation for FY15
Calendar Year Comparisons
FY
FY
FY
12/13
13/14
14/15
Injury-Aggressive Behavior
1
1
0
Self-Injury
0
0
0
Trip or Fall
6
2
1
Auto Accident
0
0
0
Injury - Other
3
5
1
Alleged abuse
1
0
2
Alleged neglect
0
0
0
Alleged exploitation
0
0
1
Wrong dose administered
2
0
0
Wrong med administered
0
1
1
Wrong time administered
0
0
0
Refused Medication
6
0
4
Med Error – Other
1
1
0
Missed dosage
0
0
0
Suicidal Behavior
16
22
5
Inappropriate/Illegal/Sexual Behavior
0
2
3
Illegal acts
1
0
1
Aggressive acts
6
5
5
Other Consumer Behavior
0
0
0
Diversion of Drugs
0
0
0
Suspension
19
24
21
Expulsion
0
0
0
Fire
0
0
0
Absence > 3 hrs (ACA)
8
3
6
Category
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PSO Performance Improvement Program Evaluation for FY15
Absence > 3 hrs (AWOL)
7
0
0
Search & Seizure
0
0
0
Conf. breach
1
0
1
Death
2
4
1
Restrictive Intervention
0
0
0
180
70
53
Totals
Table 9. Risk Analysis
In June 2015, the Substance Abuse Services leadership conducted a risk assessment. What follows are the
items in each area given the highest score and strategies to mitigate issues identified.
1.
Focus Area
Weakness, Threat
Reduction Strategy
Information
Connectivity at Jail
Substance Abuse Services leadership indicated that Jail
Technology
and Shelter Program
and Shelter staff attempting to utilize ECHO for
Locations
documentation and billing as well as accessing
Department and County drives, folders and websites
often experience very slow load times and system
crashes. When this topic was reviewed at the June
PSO Management Team meeting it was announced by
Information Technology staff that the Shelter
Supervisor’s CPU is in the process of being upgraded.
It was also recommended that staff experiencing these
issues submit work requests (clearly indicating when
ECHO is involved) through the online MeckSupport IT
Customer Support Center available on MeckWeb.
2.
Financial
Impact of the change
Challenges have included new software to implement,
Stability
4/1/14 from
new processes with shorter timelines, lack of provider
MeckLINK to Cardinal
information during conversion of data from MeckLink to
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PSO Performance Improvement Program Evaluation for FY15
Innovations as the
Cardinal and additional steps to process a claim. Also
Managed Care
impactful were the staff learning curve and staff
Organization for the
shortages.
PSO
3.
Health & Safety
Injuries and close
As a County Department, the PSO has one of the
calls: cars & drivers,
lowest incidents per person/vehicle compared with
workers comp, slips,
other departments. As necessary the Safety Committee
trips & falls
follows up regarding any trends with the individual(s)
involved, reviewing policies for update, and/or with
focused training for individuals and/or at team
meetings.
4.
Buildings &
Exterior lighting, staff
The annual County Employee Climate Survey and the
Grounds
comfort, safety and
Risk Survey both indicate concern for staff safety in the
security
parking lots after dark. While anyone can request a
security guard escort at any time, staff tend to be
reticent to do so. In following up with County Asset and
Facilities leadership regarding this concern here is an
update to the current status of the project: to upgrade
the Watkins Center parking lot lamps will require an
expensive upgrade to the main power line coming to
the facility. This line item has been included in the
capital improvements list at the County level for at least
two years.
5.
Staff Conduct
Following Policy,
and
Rules and Regulations themselves for familiarity and application and to review
Performance
Supervision has been reminded to review polices
updates and new policies with staff as the policies are
distributed following approval.
6.
Succession
Lack of a clear annual Make succession plan development part of annual EPR
Planning for
succession plan
for senior leadership.
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PSO Performance Improvement Program Evaluation for FY15
Senior
indicating the
Leadership
development of the
person who would
lead the Department if
the current Director
were incapacitated
7.
Stakeholder
Too few resources to
Identify gaps in services, seek funding for them.
Input
address the needs of
“Advertise” the good work of the PSO. Continue
too many consumers
utilization of the PSO Client Rights Committee for input
regarding resource utilization. Utilize updated PSO
Website to both provide and receive communication
with stakeholders.
SUMMARY of PERFORMANCE IMPROVEMENT PROGRAM
Throughout the year, the staff implemented a number of improvement projects and activities. Some were
clearly successful and some did not result in expected level of performance. For FY16, renewed emphasis
will be applied to important activities that have not yet reached the targeted level of performance. In cases
where performance levels meet the goals, ongoing monitoring will continue.
The PSO Quality Improvement staff continues to work closely with SAS Leadership, Managers and Staff to
prepare for triennial accreditation surveys by the Commission on the Accreditation of Rehabilitation Facilities
(CARF).
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