Quality Enhancement Plan - The Arc Baltimore · 19-07-2016 · Quality Enhancement Plan Annual...

Quality Enhancement Plan Annual Report

2016-2017

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: 7-19-16

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TABLE OF CONTENT

Human Rights Committee (standing committee) and Remarks .......................................... 3

Adult Services and Family Living ....................................................................................... 4

Foster Care Department ..................................................................................................... 21

Family Living Department ................................................................................................ 32

Outreach/Intake Department ............................................................................................. 33

Employment and Day Services Division .......................................................................... 34

Training Department.......................................................................................................... 46

Human Resources Department .......................................................................................... 47

Nursing Department .......................................................................................................... 49

Community Living Division .............................................................................................. 51

2017-2018 Quality Enhancement Plan .............................................................................. 59

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Human Rights/ Standing Committee Bob Davidson, Chair, Community Member, [email protected]

Richard Weih, Community Member, [email protected]

Pat Rosner, Community Member, [email protected]

Daphni Steffin, Employee, [email protected]

Yolanda Dorchy, Employee, [email protected]

Dawn Davis-Brodeur, [email protected]

2016-2017 Annual Quality Enhancement Plan

The 2016-2017 Annual Quality Enhancement Plan includes four quarters worth of

data. Each category of measure found in the 2016-2017 annual report has both quarterly

results and annual results. The results describe whether goals have been achieved, or not,

along with supporting data. When a goal is not achieved an action plan is developed that

is then implemented, and prior actions are tracked. Whether a goal is achieved or not, the

results are thoroughly reviewed, and the information gained from the analysis is then

used to improve services.

2017-2018 Quality Enhancement Plan Development The Arc Baltimore’s (The Arc) 2017-2018 Quality Enhancement Plan was

developed with input from across the agency. The result is a plan with meaningful

measures and goals that promote the mission and vision of The Arc. Additionally,

measures and goals were added to align with the updated Home and Community Based

Services (HCBS) Waivers (Section 1915 (c) under the Medicaid program. These ensure

individuals receive services in integrated settings that support full access to the

community. This includes opportunities to seek employment in competitive and

integrated settings and engage in community life. Lastly, the 2017-2018 Quality

Enhancement Plan has a new and improved design.

The measures and goals in the 2017-2018 Quality Enhancement Plan reflect The

Arc’s commitment to enhancing services that will have a positive impact on the people

receiving services from The Arc. The underlying theme of the Plan is a person-centered

approach and community based integrated services; the individuals guide their services.

Included in the Plan are exciting categories of measure, along with corresponding goals

that will continue to ensure that individuals receiving services have choices, are able to

express their preferences and have those preferences met, and that they receive services

in the most integrated community based setting possible.

mailto:[email protected]





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Adult Services and Family Living

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

assistive technology

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

referrals.

Status :

o Annual: Achieved

o Annual summary: There were a total of 73 referrals.

o Q4: Achieved

o Q4 summary: There were 15 referrals in quarter four.

o Q4 action plan: None needed

o Q4 actions taken: None needed

o Q3: Achieved

o Q3 summary: There were 20 referrals in quarter three.



o Q2: Achieved

o Q2 summary: There were 18 referrals in quarter two.



o Q1: Achieved

o Q1 summary: There were 20 referrals in quarter one.



Goal Two: To complete one random review of device utilization per month.

Status:

o Annual: Achieved

o Annual summary: Random reviews of device utilization was conducted once per

month.

o Q4: Achieved

o Q4 summary: Random reviews of device utilization were conducted in April,

May, and June. Two of the three individuals selected were using their devices at

the time of the review. The barrier to regular use was that the staff was not

trained. This issue was addressed at the time of review.


o Q4 actions taken: Addressed with staff at the time of the review

o Q3: Achieved

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o Q3 summary: A random review of device utilization was conducted in January,

February, and March. None of the three individuals selected were using their

communication devices at the time of the review. Some of the barriers to regular

use included lack of Individual Plan specific training for staff, lack of Individual

Plan goals integrating AT to achieve meaningful outcomes, and devices not

coming into day program regularly. These issues were addressed at the time of

review.


o Q3 actions taken: Addressed with staff at the time of the review

o Q2: Achieved

o Q2 summary: A random review of device utilization was conducted in October,

November, and December. Two of the three devices reviewed were being utilized

and had Individual Plan goals related to use of the devices. For the device that

was not being utilized, the device was onsite, but the staff was not properly

trained, and there was no Individual Plan documentation.

o Q2 action plan: Additional training and management to follow up to ensure that

the device is utilized.

o Q2 actions taken: Director of Assistive Technology met with the staff at the

location and talked to them about utilization.

o Q1: Achieved

o Q1 summary: A random review of device utilization was conducted in July,

August, and September. Two of the individuals reviewed had their devices with

them and were using them. One of the individuals did not have their device and

the team is exploring having the individual assessed for a new device. One out of

three individuals reviewed had an assistive technology goal in their Individual

Plan, which helps monitor progress.



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:

o Annual: Partially achieved

o Annual summary: Outcomes were reviewed each quarter with the exception of

quarter four, in which no outcomes were reviewed.

o Q4: Not achieved

o Q4 summary: No outcomes were reviewed in quarter four.

o Q4 action plan: Review other ways to ensure outcome attainment.

o Q4 actions taken: None taken

o Q3: Achieved

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o Q3 summary: Two individuals’ outcomes were reviewed in quarter three. Both

individuals chose their outcomes and there was evidence that the outcome, goals,

and strategies were being worked on. Both individuals reported that they enjoy

working towards their goals, enjoy their home and work, and are participating in

the community.

o Q3 action plan:

Work to have more staff at The Arc Baltimore participate in quarterly

reviews.

Explore creating an annual, or every two year, Individual Plan refresher

training for case managers.

o Q3 actions taken:

The Arc Baltimore has identified a new database and the roll is being

developed.

o Q2: Achieved

o Q2 summary: Two individuals’ outcomes were reviewed in quarter two. Both

individuals chose their outcomes and there was evidence that the outcome, goals,

and strategies were being worked on. Both individuals reported that they enjoy

working towards their goals, enjoy their home and work, and are participating in

the community.

o Q2 action plan:

Work to have more staff at The Arc Baltimore participate in quarterly

reviews.



The Arc Baltimore is demoing new databases that have enriched outcome,

goal, and strategy review elements. The plan is to choose a new database

and begin implementation late 2017.

o Q2 actions taken: None yet

o Q1: Achieved

o Q1 summary: Two individuals outcomes were reviewed in quarter one. One

individual reported wanting a new job and that was not reflected in the

individual’s outcomes or goals. The second individual’s outcomes and goals were

service oriented and did not appear to be chosen by the individual.

o Q1 action plan:



The Arc Baltimore is demoing new databases that have enriched outcome,

goal, and strategy review elements. The plan is to choose a new database

and begin implementation late 2017.

o Q1 actions taken:

Quality Enhancement site visit form updated to emphasize the Individual

Plan and outcomes, goals, and strategies.

Outcome, goal, and strategy training at case manager meetings.

Individual Plan training for new hires and staff who need refreshers.

Individualized training with case managers who are struggling with

outcome, goal, and strategy writing.

Routine reviews of Individual Plans by management.

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3) Category of Measure: The number of Meaningful Life Surveys completed

Goal: 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:

o Annual: Not achieved

o Annual summary: Board Members completed two Meaningful Life Surveys in

quarter one.

o Q4: Not achieved

o Q4 summary: No meaningful life surveys were completed by Board Members.

o Q4 action plan: This measure is being removed from the 2017-2018 Quality

Enhancement Plan.

o Q4 actions taken:

Chair of the Quality Enhancement Committee made an appeal to Board

Members about the positive impact completing surveys has for the

individuals who receive services.

An email was sent to Board Members asking for their participation in

quarter two.

o Q3: Not achieved


o Q3 action plan:

Explore whether to continue this measure or not.

o Q3 actions taken:





quarter two.

o Q2: Not achieved


o Q2 action plan:

Send an email to Board Members asking for their participation in quarter

three.

o Q2 actions taken:





quarter two.

o Q1: Not achieved

o Q1 summary: Two meaningful life surveys were completed by Board Members.

o Q1 action plan:

Chair of the Quality Enhancement Committee will make an appeal to

Board Members about the positive impact completing surveys has for the


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Send an email to Board Members asking for their participation in quarter

two.

o Q1 actions taken:

Assistant executive director of the Quality Enhancement Division met

with two emeritus Board Members, and the Chair of Quality Enhancement

Committee, and revamped the survey to make more user friendly.

The Chair of the Quality Enhancement Committee has encouraged Board

Members to complete surveys.

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 Annual: Achieved

o Annual summary: Individuals interviewed reported a combined average of

95.25% satisfaction with services.

Employment: 88 out of 99 individuals, or 89% of individuals were

satisfied with services.

Day Services: 168 out of 171 individuals, or 98% of individuals were


Community Living: 62 out of 66 individuals, or 94% of individuals were


Family Living: 3 out of 3 individuals, or 100% of individuals were


Parent-Provider: None received.

o Q4: Achieved

o Q4 summary: Individuals interviewed reported a combined average of 96.25%

satisfaction with services.



Day Services: 71 out of 73 individuals, or 97% of individuals were







o Q4 action plan: Additional surveys will be sent parents and providers next year.

o Q4 actions taken: None

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

2016-2017 QE Plan.

Employment: N/A

Day Services: N/A

Community Living: N/A

Family Living: N/A

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Parent-Provider: N/A

o Q3 action plan: None need


o Q2: Achieved

o Q2 summary: Individuals interviewed reported a combined average of 99.75%

satisfaction with services.



Day Services: 97out of 98 individuals, or 99% of individuals were







o Q2 action plan: Additional surveys will be sent parents and providers.


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

of the 2016-2017 QE Plan.

Employment: N/A

Day Services: N/A

Community Living: N/A

Family Living: N/A

Parent-Provider: N/A



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:


o Annual summary: 67 of 107, or 63% of individuals started services on the

effective funded date.

o Q4: Not achieved

o Q4 summary: 16 of 32, or 50% of individuals started services on the effective

funded date.

100% of Community Living individuals started on time.

100% of Employment/Day individuals started on time.

43% of Family Living individuals started on time.

o Q4 action plan: The Arc Baltimore is working to streamline and improve its

hiring process; the delays in Family Living were due to not having hired staff

ready at the time of effective start date.

o Q4 actions taken:

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For Personal Support hours, in Family Living, enhancements to the hiring

process include requesting as standing day of week & time of day for the

individual/family home visits in advance, to avoid the delays which arise

from needing to coordinate The Arc Baltimore and family schedules.

Family Living has also collaborated with families to choose start dates as

far out as feasible to ensure staff can be hired in time.

Family Living has hosted multiple job fairs. This helps reduce vacancies

and build a pool of prospective candidates for ‘new’ plans.

Day Services began listing vacant positions as soon as the commitment

letter from DDA was generated, rather than waiting for the approval to be

posted in PCIS, which has helped with some hiring delays.

Day Service staff are expected to complete their training within two weeks

of attending orientation.

o Q3: Not achieved

o Q3 summary: 5 of 18, or 28% of individuals started services on the effective date.

100% of Community Living individuals started on time.

50% of Employment/Day individuals started on time.

0% of Family Living started on time.

o Q3 action plan:

The agency as a whole is working to streamline and improve our hiring

process (the lack of hired staff being a primary contributor to delays- in

this quarter, representing 100% of delays). Strategies listed below

Family Living delays re: staffing will be addressed through assessment of

and implementation of improvement opportunities related to position

postings, the scheduling of job interviews and family visits and the

collection of documents required for pre-employment.

o Q3 actions taken:

In the Family Living department, enhancements to the hiring process

include requesting as standing day of week & time of day for the

individual/family home visits in advance, to avoid the delays which arise

from needing to coordinate Arc Baltimore & family schedules.

Family Living has also collaborated with families to choose start dates as

far out as is feasible to ensure staff can be hired in time.

FL has hosted 7 job fairs so far, which helps reduce vacancies and build a

pool of prospective candidates for ‘new’ plans.

Day program team began listing vacant positions as soon as the

commitment letter from DDA was generated, rather than waiting for the

approval to be posted in PCIS, which has helped with some hiring delays.

In addition, new Day program staff are expected to complete their training

within the first two weeks it is offered (rather than spreading it out over

more weeks).

o Q2: Not achieved


funded date.

o Q2 action plan:

Efforts would be made to complete new staff training in the most efficient

way possible through listing the position upon the commitment letter from

DDA rather than waiting for PCIS posting.

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Family Living delays re: staffing will be addressed through assessment of

and implementation of improvement opportunities related to position

postings, the scheduling of job interviews and family visits and the

collection of documents required for pre-employment.

o Q2 actions taken: All strategies outlined in the action plan have been

implemented.

o Q1: Not achieved


funded date.

o Q1 action plan:

Continue to work with staff to complete new staff training as quickly as

possible.

Explore obtaining an approval to hire new staff upon receiving the

commitment letter from the Developmental Disability Administration,

rather than waiting until funding is in place in PCIS - sometime take a few

weeks to be entered.

o Q1 actions taken:

None

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

of direct support professionals

Goal: Quality Enhancement facilitators (direct support professionals) complete a

combined total of 6 Roundings with direct support professionals per quarter.

Status:


o Annual summary: Roundings were completed in quarter one. The rounding

process changed midway through the Quality Enhancement Plan year and will be

done during direct support professional meetings going forward.

o Q4: Not achieved

o Q4 summary: The Roundings will now be completed at quarterly direct support

professional meetings.

o Q4 action plan: Schedule director support professional meeting.

o Q4 actions taken:

Trained the new director of Quality Enhancement on the Rounding

process.

Reevaluated how the Roundings were being completed and decided to

complete the Roundings at the quarterly director support professional

meetings.

o Q3: Not achieved



o Q3 action plan:

Train the new director of Quality Enhancement on the Rounding process.

Schedule a direct support professional all meeting.

o Q3 actions taken:

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Reevaluated how the Roundings were being completed and decided to

complete the Roundings at the quarterly director support professional

meetings.

o Q2: Not achieved



o Q2 action plan:

Train the new Director of Quality Enhancement on the Rounding process.

o Q2 actions taken:

Reevaluated how the Rounds are being completed and begin completing

the Roundings at the quarterly director support professional meetings.

o Q1: Not achieved

o Q1 summary: Quality Enhancement facilitators completed a combined total of

three Roundings.

o Q1 action plan:

Explore new ways of empowering, and improving communication, for

direct support professionals.

o Q1 actions taken:

The structure of the measure was changed in 2015, with the intent of

encouraging direct support professional increased participation.

The coordinator of Quality Enhancement took over the role of

coordinating the rounding with the direct support professionals.

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

Associates and individuals

Goal: To complete 350 therapeutic interactions per quarter.

Status:

o Annual: Achieved

o Annual summary: There were 2,507 therapeutic interactions.

o Q4: Achieved

o Q4 summary: There were 1,014 therapeutic interactions.



o Q3: Achieved

o Q3 summary: There were 510 therapeutic interactions.



o Q2: Achieved




o Q1: Achieved

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8) Category of Measure: The number of group therapy sessions

Goal: To complete 20 group therapy sessions per quarter.

Status:

o Annual: Achieved

o Annual summary: There were 124 group sessions.

o Q4: Achieved

o Q4 summary: There were 33 group sessions.


o Q4 actions taken: Groups were expanded to several centers.

o Q3: Achieved




o Q2: Achieved




o Q1: Not achieved


o Q1 action plan: Groups will be implemented at Dundalk Day.


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

Plans

Goal: To reduce the number of restrictive procedures.

Status:


o Annual summary: There were 25 restrictions in quarter four. There were 15

restrictions in quarter four of the 2015-2016 Quality Enhancement Plan.

o Q4: Not achieved

o Q4 summary: There were 25 restrictions in quarter four. There were 21

restrictions last quarter.

Current Restrictions:

Door Alarms: 6

Vehicle safety locks: 4

Seatbelt guard: 0

14

Reimbursement for property damage: 4

Locked cabinet for cleaning supplies: 0

Search of a person: 0

Use of protective helmet: 0

Use of proactive glove: 1

Lock up knives: 7

Physical blocking: 1

Physical escorts: 0

Bed exit alarm: 0

No smart phone: 1

No lighters: 1

o Q4 action plan: Quality supports will continue to monitor behavior plan data and

work closely with the staff who support the individual, to ensure that the plans are

being implemented, and faded when possible.

o Q4 actions taken: The Arc Baltimore is supporting individuals with increased

support needs, some of which require restrictive behavior plans. Quality Supports

monitors individuals’ behavior data and works closely with the staff supporting

the individuals, to ensure that the plans are being implemented, and faded when

possible.

o Q3: Not achieved. There were 21 restrictions in quarter three. There were 21


o Q3 summary:


Door Alarms: 5


Seatbelt guard: 0






Lock up knives: 7


Physical escorts: 0

Bed exit alarm: 0








possible.

o Q2: Achieved. There were 21 restrictions in quarter two. There were 23


o Q2 summary:

15


Door Alarms: 5


Seatbelt guard: 0






Lock up knives: 7


Physical escorts: 0

Bed exit alarm: 0








possible.

o Q1: Not achieved

o Q1 summary of restrictions: There were 23 restrictions in quarter one. There were

15 restrictions last quarter.


Door Alarms: 6


Seatbelt guard: 0






Lock up knives: 7


Physical escorts: 0

Bed exit alarm: 1








possible.

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10) Category of Measure: Review all Internal Incidents

Goal: To review Internal Incidents for trends.

Status:

o Annual: Achieved

o Annual summary: The Human Rights Committee and Quality Enhancement

Department reviewed incidents for trends.

o Internal Incident Types: 412

Abuse allegations: 32

o Reporting history of unsubstantiated abuse: 5

o Physical aggression: 27

Hospital admission/ER visit: 217

Hospital Admission Chronic Condition: 1

Injury: 53

Medication error: 47

Choking: 4

Police with no report taken: 25

Theft < $50: 0

Unexpected or risky absence: 3

Other: 29

o Q4: Achieved

o Q4 summary: The Human Rights Committee and Quality Enhancement








Injury: 10


Choking: 2


Theft < $50: 0


Other: 5

o Q4 action plan: The Human Rights Committee and Quality Enhancement

Department will continue to review incidents for trends.


o Q3: Achieved

o Q3 summary: The Human Rights Committee, Abuse and Neglect Workgroup, and

Quality Enhancement Department reviewed incidents for trends.



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Injury: 14


Choking: 0


Theft < $50: 0


Other: 19

o Q3 action plan: The Human Rights Committee, Abuse and Neglect Workgroup,

and Quality Enhancement Department will continue to review incidents for

trends.


o Q2: Achieved









Injury: 14


Choking: 1


Theft < $50: 0


Other: 2

o Q2 action plan: The Human Rights Committee, Abuse and Neglect Workgroup,

and Quality Enhancement Department will continue to review incidents for

trends.


o Q1: Achieved

o Summary: The Human Rights Committee, Abuse and Neglect Workgroup, and



Abuse allegations:11





Injury: 15


18

Choking: 1


Theft < $50: 0


Other: 3

o Q1 action plan: To continue to review incidents for trends.

o Q1 actions taken: The Human Rights Committee, Abuse and Neglect Workgroup,

and Quality Enhancement Department reviewed incidents for trends in quarter

one, and in prior quarters.

11) Category of Measure: Review all Reportable Incidents

Goal: To review Reportable Incidents for trends.

Status:

o Annual: Achieved

o Annual summary: The Human Rights Committee and Quality Enhancement


o Reportable Incident Types: 293

Death: 15


o Individual/Staff: 36

o Individual/Individual: 12

o Individual/Community Member: 8

Neglect allegations: 19


o Individual/Community Member: 1

Hospital admission: 115

o Non-Psychiatric: 100

o Psychiatric:15

Injury: 7

Medication error: 5

Choking: 0

Police with report taken: 23

Fire department: 3

Theft > $50: 4


Unauthorized/inappropriate use of restraints: 1

Other outbreak of communicable diseases: 34

Other Suicide Attempt: 3

Other Suicide Threat: 3

Other- Three of a kind: 4

o Q4: Achieved

o Q4 summary: The Human Rights Committee and Quality Enhancement



Death: 5

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o Individual/staff: 15

o Individual/individual: 0

o Individual/community member: 2






o Psychiatric: 1

Injury: 2

Medication error: 0

Choking: 0


Fire Department: 0

Theft > $50: 1



Other outbreak of communicable diseases: 0

Other suicide attempt: 0

Other suicide threat: 1

Other three of a kind: 0



o Q3: Achieved



o Reportable Incident Types:78

Death: 1










o Psychiatric: 2

Injury: 4

Medication error: 1

Choking: 0

Other- Outbreak of communicable diseases: 5


Fire Department: 3

Theft > $50: 0

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o Q2: Achieved




Death: 6



o Individual/individual: 9 allegations involving 5 individuals

o Individual/community Member: 2





o Non-psychiatric: 21

o Psychiatric: 5

Injury: 0

Medication error: 3

Choking: 0


Fire department: 0

Theft > $50: 1



Other communicable disease: 5






o Q1: Achieved

o Summary: The Human Rights Committee, Abuse and Neglect Workgroup, and



Death: 3





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o Non-psychiatric: 33

o Psychiatric: 7

Injury: 1

Medication error: 1

Choking: 0


Fire department: 0

Theft > $50: 2



Other communicable disease: 24






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 Annual: Achieved

o Annual summary: There were 57 incidents in quarter three. All were assessed

for preventability. 2 were deemed preventable and response plans were

developed.

Elopement: 13

Preventable: 2

Not Preventable: 11

Emergency hospitalization medical: 1

Preventable: 0

Not Preventable: 1

Emergency hospitalization psychiatric: 7

Preventable: 0

Not Preventable: 7

Emergency medical treatment: 9

Preventable: 0

Not Preventable: 9

Illness: 0

Preventable: 0

22

Not Preventable: 0

Injury to other youth: 1

Preventable: 1

Not Preventable: 0

Injury to youth subject to incident: 3

Preventable: 0

Not Preventable: 3

Medical event: 4

Preventable: 0

Not Preventable: 4

School expulsion: 0

Preventable: 0

Not Preventable: 0

Theft: 0

Preventable: 0

Not Preventable: 0

Property damage: 2

Preventable: 0

Not Preventable: 2

Substance use: 0

Preventable: 0

Not Preventable: 0

Other: Auto accident: 2

Preventable: 0

Not Preventable: 2

Other: School suspension:

Preventable:

Not Preventable:

Other: Assault on foster parent: 0

Preventable: 0

Not Preventable: 0

Other: Assault on other adult:

Preventable:

Not Preventable:

Other: Fire Setting: 1

Preventable: 0

Not Preventable: 1

Other: Suspected Abuse: 1

Preventable: 0

Not Preventable: 1

Other: Assault on other staff: 1

Preventable: 0

Not Preventable: 1

Other: Emergency psychiatric evaluation: 2

Preventable: 0

Not Preventable: 2

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o Q4:

o Q4 summary: There were 18 incidents in quarter four. All were assessed for

preventability. One was deemed preventable and a response plan was

developed.

Elopement: 4

Preventable: 0

Not Preventable: 4


Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 1


Preventable: 0

Not Preventable: 1

Illness: 0

Preventable: 0

Not Preventable: 0


Preventable: 1

Not Preventable: 0


Preventable: 0

Not Preventable: 2

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: 1

Preventable: 0

Not Preventable: 1


Preventable: 0

Not Preventable: 0

Other: School suspension: 0

Preventable: 0

Not Preventable: 0


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Preventable: 0

Not Preventable: 0

Other: Assault on other adult: 0

Preventable: 0

Not Preventable: 0

Other: Fire Setting: 1

Preventable: 0

Not Preventable: 1

Other: Suspected Abuse: 1

Preventable: 0

Not Preventable: 1

Other: Assault on other staff: 1

Preventable: 0

Not Preventable: 1

Other: Emergency psychiatric evaluation: 2

Preventable: 0

Not Preventable: 2

o Q4 action plan: A certain degree of incidents can be expected and DHR reporting

requirements result in a report for even normal and expected childhood injuries.


o Q3: Achieved

o Q3: Summary:

o Reportable Incidents: There were 15 incidents in quarter three. All were

assessed for preventability. One was deemed preventable and a response plan

was developed.

Elopement: 6

Preventable: 1

Not Preventable: 5


Preventable: 0

Not Preventable: 1


Preventable: 0

Not Preventable: 3


Preventable: 0

Not Preventable: 1

Illness: 0

Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 0


Preventable: 0

25

Not Preventable: 0

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: 1

Preventable: 0

Not Preventable: 1

Substance use: 0

Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 1

Other: School suspension: 1

Preventable: 0

Not Preventable: 1


Preventable: 0

Not Preventable: 2

Other: Assault on other adult: 1

Preventable: 0

Not Preventable: 1

Q3 action plan: Overall, we had 15 incidents in Q3. The increaser in

elopement was mostly comprised of the same two youth. We instituted

additional support as a result.

Q3 actions taken: To address elopement, we instituted and recommended

higher levels of care and supervision and collaborated with foster parents

and external providers to ensure that the youth are getting the services

needed.

o Q2: Achieved

o Q2 summary:

o Reportable Incidents: There were 15 incidents in quarter two and each was

deemed not preventable. The increase in medical treatment and psychiatric

hospitalizations is mostly comprised of several youth. Foster Care will

continue to be mindful of, and focus on, how to best prepare youth and

families to respond during incidents.

Elopement: 2

Preventable: 1

Not Preventable: 1


Preventable: 0

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Not Preventable: 0


Preventable: 0

Not Preventable: 3


Preventable: 0

Not Preventable: 5

Illness: 0

Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 0

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: 1

Preventable: 0

Not Preventable: 1

Substance use: 0

Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 1

Other: School refusal: 1

Preventable: 0

Not Preventable: 1


Preventable: 0

Not Preventable: 2

o Q2 action plan: In order to support youth with higher acuity needs, Foster Care

may see an increase in overall incidents. Foster Care will continue to be mindful

of, and focus on, how to best prepare youth and families to respond during

incidents.

o Q2 actions taken:

Foster Care has a responsive on call process, which in some incidents

results in an in-person staff response, especially for hospitalizations.

27

Foster Care increased its support to the children and families and has

collaborated with its foster parents, and external providers, to ensure that

the youth are getting needed services.

o Q1: Achieved

o Q1 summary: There were 9 incidents in quarter one and each was deemed not

preventable. However, Foster Care continues to examine each incident closely to

ensure the safety of its youth, foster parents, and staff.

o Reportable Incidents: 9

Elopement: 1

Preventable: 0

Not Preventable: 1


Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 2

Illness: 0

Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 0


Preventable: 0

Not Preventable: 1

Medical event: 1

Preventable: 0

Not Preventable: 1

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



28

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

Goal: 100% compliance with completing Annual Assessments.

Status:


o Annual summary: 29 out of 30, or 97% of the Annual Assessments were

completed on time.

o Q4: Achieved

o Q4 summary: 14 out of 14, or 100% of the Annual Assessments were completed

on time.



o Q3: Achieved

o Q3 summary: 5 out of 5, or 100% of the Annual Assessments were completed on

time.



o Q2: Achieved


time.


o Q2 actions taken:

Foster parents were reminded a month prior to the due date that the

assessments were coming due.

When possible, the assessments were scheduled two weeks prior to the

due date.

o Q1: Not achieved


time.

o Q1 action plan:

For all annual assessments, foster parents are reminded a month prior to

the due date that the assessments are coming due.

Attempts are made to schedule the assessment two weeks prior to the due

date.

The late assessment in quarter one, was due to a parent having a medical

emergency that resulted in the meeting to complete the assessment

needing to be cancelled.

o Q1 actions taken:

Per policy and keeping with regulation, the parent was suspended from

taking new placements until the assessment was complete.

29

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

Goal: 100% compliance with completion of CANS Assessments Ansell Casey

Assessments.

Status:


o Annual summary: 113 out of 115, or 98% of the CANS and Ansell Casey

Assessments were completed on time.

o Q4: Not achieved

o Q4 summary: 25 out of 26, or 96% of the CANS and Ansell Casey Assessments

were completed on time.

o Q4 action plan: All staff currently maintain a tracking system to ensure the due

dates are met.

o Q4 actions taken: The supervisor began sending monthly reminders and reiterate

due dates in supervision.

o Assessments are scheduled with some time to spare, incase rescheduling is

needed.

o Q3: Achieved




o Q3 actions taken:

o Q2: Not achieved



o Q2 action plan:

For all annual assessments, parents are notified a month in advance that

assessments will be due.

Attempts are made to schedule the meeting at least 2 weeks prior to the

due date, to allow for cancellations, emergencies, and other happenings.


o Q1:Achievd





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:

30


o Annual summary: 21 out of the 24 youth, or 88% remained with their initial foster

family for the entirety of their stay in Foster Care.

o Q4: Not achieved

o Q4 summary: 0 out of the 1 youth, or 0% remained with their initial foster family

for the entirety of their stay in Foster Care.

o Q4 action plan: Throughout the youth’s stay in foster care, all efforts were made

to be proactive and observant such that issues did not result in a crisis or

placement disruption.


o Q3: Achieved

o Q3 summary: 6 out of the 6 youth, or 100% remained with their initial foster

family for the entirety of their stay in Foster Care.



o Q2: Not achieved

o Q2 summary: 8 out of 9 children, or 89% remained with their initial foster family


o Q2 action plan: The youth who did not remain in her original placement achieved

permanence through adoption in Q2. Since her original placement disruption

occurred in 2003, an action plan would most likely not have prevented the

disruption.


o Q1: Not achieved

o Q1 summary: 7 out of 8 children, or 88% remained with their initial foster family


o Q1 action plan:

None needed. The child who did not remain with original foster family,

was moved to a foster home within The Arc Baltimore, where his brother

was lives; this was a move towards permanence and stability.


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:

o Annual: Partially achieved

o Annual Summary:

Foster Families: 95.6% reported satisfaction. Response rate of 50% (18/36

responses)

Birth Families: 62.5% reported satisfaction. Response rate of 22% (4/18)

DSS Workers: 95.2 % reported satisfaction. Response rate of 20% (7/35)

Placement Unit Workers: 87% reported satisfaction. Response rate of 22%

(4/18)

31

o Q4: N/A

o Q4 summary: This is an annual goal and results were posted with quarter three’s

results.

o Q4 action plan: N/A

o Q4 actions taken: N/A

o Q3: Not Achieved

o Q3 Summary:

Foster Families: 95.6% reported satisfaction. Response rate of 50% (18/36

responses)

Birth Families: 62.5% reported satisfaction. Response rate of 22% (4/18)

DSS Workers: 95.2 % reported satisfaction. Response rate of 20% (7/35)

Placement Unit Workers: 87% reported satisfaction. Response rate of 22%

(4/18)

o Q3 action plan: No action plan needed for Foster Families and DSS workers. For

Birth Families, the FC program will analyze and ensure that survey questions get

at the root of the information we want to measure and determine the appropriate

recipients for those surveys.

o Q3 actions taken: No action needed for Foster Families and DSS workers. The

staff person responsible for placements has been designed to, regularly, speak to

DSS Placement workers at the time of placement to identify any unmet needs and

check in about the working relationship. Social workers, when working with Birth

Families will provide additional information/education about roles and

responsibilities of DSS, the court system and The Arc Baltimore Survey questions

for Birth Families will be tweaked to ensure families provide information about

their satisfaction with the Arc Baltimore rather than another entity Biological

Families who lack legal permission/autonomy to engage with their children

independent of court oversight may get another survey version, or be removed

from the survey pool, as they are inherently dissatisfied.

o Q2: This is an annual goal and results will be posted with quarter three’s results.



o Q1: This is an annual goal and results will be posted with quarter three’s results.



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 350 individuals.

Status:


32

o Annual summary: 344 people have attended the educational series to date.

o Q4: Not achieved

o Q4 summary: 344 people have attended the educational series to date.

o Q4 action plan: Targets were almost met this year and successful strategies used

to increase the number of new attendees.


o Q3: Annual goal

o Q3 summary: 139 people have attended the educational series to date


o Q3 actions taken: None taken. We expect Q4 to have the highest number of

attendees based on prior year data.

o Q2: Annual goal




o Q1: Annual goal




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

Status:

o Annual: Achieved

o Annual summary: 141 of the 344, or 41% of the attendees were new attendees.

o Q4: Achieved

o Q4 summary: 83 of the 205, or 41% of the attendees were new attendees.



o Q3: Annual goal




o Q2: Annual goal




o Q1: Annual goal




33

Goal 3: 80% satisfaction with the topics presented.

Status:

o Annual: Achieved

o Annual summary: 88% of the attendees YTD report satisfaction with the topics

presented.

o Q4: Annual aggregate goal

o Q4 summary: 94% of the attendees YTD report satisfaction with the topics

presented.



o Q3: Annual aggregate goal

o Q3 summary: 87% of the attendees YTD report satisfaction with the topics

presented.



o Q2: Annual goal

o Q2 summary: 83% of the attendees reported satisfaction with the topics presented.



o Q1: Annual goal

o Q1 summary: 87% of the attendees reported satisfaction with the topics presented.



Outreach/Intake

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

Goal: 95% satisfaction with the intake process.

Status:

o Annual: Achieved

o Annual summary: 14 of the 14 survey respondents, or 100% reported satisfaction

with the intake process.

o Q4: Achieved

o Q4 summary: 1 of the 1 survey respondents, or 100% reported satisfaction with

the intake process.



o Q3: Achieved


the intake process.

34



o Q2: Achieved




o Q1: Achieved


the intake process.



Employment and Day Services

1) Category of Measure: Number of individual competitive jobs (full time or part time

on a community business’ payroll)

Goal: To increase the total number of individual competitive jobs from 92 to 132.

Status:


o Annual summary: At the end of quarter four, 122, or 92% of the target goal of 132

had competitive jobs.

o Q4: Not achieved

o Q4 summary: The total number of competitive employer paid individual

placements in quarter three was 122, or 92% of the target goal of 132 competitive

jobs.

o Q4 action plan:

Increase job development activities throughout FY18

Build job competency through job shadowing, internships, and Career

Catalyst.

Explore the possibility of expanding our Career Catalyst program

Institute a new highbred position of job developer/community integrator

housed out of the Day Program. The hope being to provide a majority of

our day programs with this staffing. The new job developer/community

integrator will concentrate on individuals served at their assigned center

and will seek to individually assess each person’s need while helping them

obtain employment or meaningful community activities.

o Q4 actions taken:

Attended 66 Networking events throughout the year (with 14 of these

events occurring in the 4th quarter).

Added a 4th Job Developer to department in the last quarter.

Started our first mobile Career Catalyst in quarter 4 (2 individuals were

hired after this intensive training and 1 more is in the interview process).

4th Workforce Development Specialist (Job Developer) hired – should be

starting in April. Position is being posted again this month with the hope

35

of hiring 1 more. WDS’s will be developing relationships with individuals

on crews and at centers to foster interest in competitive employment

Continued attendance at networking events. Hosted a general meeting of

the Baltimore City Chamber of Commerce that featured Diversity

employment.

Developed relationship with Marshall’s in Towson to host first Part 1 of

new career catalyst model beginning in mid-April

Project SEARCH programs continue to focus on job development for

current interns with a goal of having a 50% placement rate before

graduation.

The process of downsizing the large ACE and UniFirst enclaves continues

with some individuals being referred to Business Services for individual

placements. Some will hopefully find employment with a new partnership

that is being developed with UP To Date Laundry where we plan to

implement our new supported employment model Approximately 10

people initi8ally will be hired directly by Up To Date in individual

placements throughout the business on 2 shifts and in different locations,

and we will provide a coach on site for support of those individuals.

A Job Coach Training Program is in the development process that will

reinforce an Employment First focus.

o Q3: Not achieved


placements in quarter three was118, or 89% of the target goal of 132 competitive

jobs.

o Q3 action plan:

Expand Business Services Department

Increase number of business relationships/partnerships and overall

presence in the business community (Across all depts.: SE, PS & CC)

Encourage individuals and their families to consider individual

employment in the community

Retrain and set new expectations for staff of work crews, etc. to encourage

individuals to consider individual employment in the community

Downsize ACE and Unifirst enclaves and move as many people into

individual placements as possible.

o Q3 actions taken:

4th Workforce Development Specialist (Job Developer) hired – should be

starting in April. Position is being posted again this month with the hope

of hiring 1 more. WDS’s will be developing relationships with individuals

on crews and at centers to foster interest in competitive employment

Continued attendance at networking events. Hosted a general meeting of

the Baltimore City Chamber of Commerce that featured Diversity

employment.

Developed relationship with Marshall’s in Towson to host first Part 1 of

new career catalyst model beginning in mid-April

Project SEARCH programs continue to focus on job development for

current interns with a goal of having a 50% placement rate before

graduation.

The process of downsizing the large ACE and UniFirst enclaves continues

with some individuals being referred to Business Services for individual

36

placements. Some will hopefully find employment with a new partnership

that is being developed with UP To Date Laundry where we plan to

implement our new supported employment model Approximately 10

people initi8ally will be hired directly by Up To Date in individual

placements throughout the business on 2 shifts and in different locations,

and we will provide a coach on site for support of those individuals.

A Job Coach Training Program is in the development process that will

reinforce an Employment First focus.

o Q2: Annual goal


placements in quarter two was 121, or 92% of the target goal of 132 competitive

jobs.

o Q2 action plan:

Expand Business Services Department


presence in the business community (Across all depts.: SE, PS & CC)

Implement Employment Discovery and Customization practices


employment in the community


individuals to consider individual employment in the community

o Q2 actions taken:

3rd Workforce Development Specialist (Job Developer) hired – started in

October. Position is being posted again this month with the hope of hiring

2 more. WDS’s will begin to develop relationships with individuals on

crews and at centers to foster interest in competitive employment

“Networking Group” met with Andrew Rose on 11/17 for networking

training and advice

Continue to have targeted staff attend networking events

Exploring other avenues to promote The Arc as workforce solution. For

example, hosting a general meeting of the Baltimore City Chamber of

Commerce.

In the process of freeing up select ESA’s from some current

responsibilities so they can focus on Employment Discovery &

Customization (under Nancy)

Project SEARCH programs are beginning now to focus on job

development for current interns; any LY graduates who are not employed

goal is for them to be placed by spring

o Q1: Annual goal


placements in quarter one was 113, or 86% of the target goal of 132 competitive

jobs.

o Q1 action plan:

Expand Business Services Department.


presence in the business community (Across all depts.: SE, PS & CC).

Implement Employment Discovery and Customization practices.

37


employment in the community.


individuals to consider individual employment in the community.

o Q1 actions taken:

Hired second Account Manager/Job Developer to start in October.

Planning to hire third Account Manager/Job Developer in next few

months.

Create “Networking Group” of staff across departments to clarify and

make uniform employment message to employers and train staff on

networking.

Continue to have targeted staff attend networking events.

Moved Employment Discovery & Customization under Business Services.

2) Category of Measure: Non-disability specific community based engagement

Goal: To increase the number of community partnerships with associations, classes,

leagues, organizations, and community groups by two each quarter.

Status:

o Annual: Achieved

o Annual summary: The number of community partnerships with associations,

classes, leagues, organizations, and community groups increased by two each

quarter (see quarter summations below).

o Q4: Achieved

o Q4 summary:

o Dundalk:10

o Miniature golf

o Added 3 more people to the senior center for a total of 5 individuals 2 x

week

o Hair Salon- in community

o Nail Salon- in community

o Clown Troop performed at 1 school Glenn Mar School

o Art Museum tour

o Movies- weekly

o Health Fair

o Aunt Anne’s White Marsh- working and making pretzels

o Using services in the community, snowballs, ice cream, Rita’s

o Loch Ridge: 3

o Local movie club at Cinemax

o Healthy Weights weekly classes at Towson University

o Minimally twice monthly visits to Baltimore City Department of

Recreation

o Seton: 8

o My Sisters Place volunteered 2x@month passing out food to the homeless

o Twice Monty walk Montebello Lake where individuals socialize with

other walkers

o Church spaghetti day lunch

o Visited Social Security for snowball day

38

o Visited several museums

o Visited Safety City at Druid Hill park

o Tour of Turkey Hill Ice Cream

o Strawberry Farm to pick organic foods

o Woodlawn: 5

o Meals on Wheels

o Peep Show (Howard Co. Fairgrounds)

o Universal Circus

o Woodlawn Library

o Glynn Taff Nursing Home

o Towson: 5

o Meals on Wheels volunteering

o Visits to Inner Harbor

o Shopping visits to Five Below

o Several small group visits to Golden Corral

o Shopping visits to

o Wal-Mart,

o Lowe’s,

o Home Depot

o Homeland: 7

o M Meals on Wheels

o Visited 3 local museums

o Participated in Healthy Weights weekly

o Attended local movies

o Visited local parks and had picnics



o Q3: Achieved

o Q3 summary:

o Dundalk:9

Community Center- voice, drama, dance—working on a play that will

be offered to the community,

Battle Monument students visited the center,

Senior center- Tuesday/ Thursday added one more senior to our group,

Delivering food- to people in the community,

Bags of Hope – delivered to office for use in the community

Meals on Wheels- 3 runs 5 days a week,

Bowling- weekly,

Book Club- on going at Beanies Ice Cream Store,

Clay works-6 individuals are in the community

o Loch Ridge: 2

Glen Meadows Nursing Homes,

Towson movie club 2x in quarter

o Seton: 5

Evans Temple Church the last Friday of each month passing out food

Columbia Mall Walkers,

Charity Christian Church pass out food,

39

My Sisters Place,

MOW

o Woodlawn: 2

Baltimore Clayworks

Woodlawn Library

o Towson: 2

Individuals delivered Meals on Wheels 12 days a month for this

quarter

Walters Art Gallery for in depth tour

o Homeland: 4

MOW,

Local movies,

Healthy weighs,

ACC group at Towson Wellness center



o Q2: Achieved

o Q2 summary:

Dundalk: 4

Delivered bags of Hope to a church and Keepers of the Green-

connection

Individuals went shopping in the community to purchase

Christmas gifts for others

Visited local train garden

Valley View for holiday shopping

Play at the Government Center, “Sky’s the limit”

Loch Ridge: 2

Glen Meadows Nursing Homes

Site services-neighborhood business

Seton: 2

Evans Temple Church, the last Friday of each month passing out

food

Columbia Mall Walkers-weekly

Woodlawn: 4

Senior Expo at Timonium Fairgrounds

Cherry Hill Aquatic Center

Liberty Senior Center

Goucher College- 2 Separate shows

Towson: 4

Meals on Wheels

Developed friendship with local retailer

o Amish Market

o Golden Corral

o Towson Cinema

o Valley View Farms

Homeland: 4

Meals on Wheels

Local movies

40

Horse farm

Healthy Weights



o Q1: Achieved

o Q1 summary:

Dundalk: 3

Local hair salon

Nail salon

Walters Art

Loch Ridge: 2

Local movie club Cinemax

Baltimore city rec department water aerobics

Seton: 2

Participated in a twice weekly program to learn about horticulture

Partnership with equine farm

Woodlawn: 2

Liberty Senior Center

Meals on Wheels

Towson: 2

Meals on Wheels

CCBC Math class at Essex Community College

Homeland: 2

Developed friendship with local retailer

Meals on Wheels


o Q1 actions taken: Goal was discussed with center managers to ensure that they

understand the expectations of the goal.

3) Category of Measure: Opportunities for individuals who attend day centers to learn

about employment

Goal: To offer six employment related experiences every quarter.

Status:

o Annual: Achieved

o Annual summary: At least six employment related experiences were offered every

quarter (see quarter summations below).

o Q4: Achieved

o Q4 summary:

Dundalk: 6

CCBC at the college- hygiene and personal care- job readiness

weekly

Visiting Restaurants in the local area, Chick-Fil-A, Pizza Hut 2x’s,

Sweet Frogs, Mc Donald’s to discuss employment possibilities

41

Individual is Volunteering at Nursing Home down the street from

the center Future Care 2 x week

Simulated interviews with individuals—done weekly

Classes discussing proper dress for employment—done weekly

Discussions about safe lawn mowing with the lawn care crews

Loch Ridge: 8

Mock interviews

Discussions about employment in contract area

Filled out 4 applications; Dollar Tree, Big Lots, Savers and the

BCPL Library.

Also worked at TUNES Music and DVDs store for information

volunteer purpose.

Seton: 8

Gave 5 individuals job trial at Chase Brexton putting together

patient information packets for a month.

Began work preparedness classes – about 10 individuals attend

weekly classes—classes occurred 6 time so far

Submitted DORS application for individual to obtain

funding/training for cosmetology

Woodlawn: 6

AMF Woodlawn - inquired about job opportunities/ application

Woodlawn Library – inquired about job opportunities/ application

Group discussion about attendance and punctuality

Mock interviews weekly

Group discussion on what is needed for a job application 1x week

Towson: 2

Two individuals went filled out job applications at the work site

Three individuals filled out on-line job applications

Talked about best choices for each supported worker

Had group discussions regarding employment related skills needed

Met with 2 supported individuals regarding specific and individual

job interests

Two work groups had discussions concerning on the job behavior

Homeland: 2

Individuals went to apply for jobs at Walmart, Dollar General, and

Giant.

Discussed proper hygiene for job interviews.

Discussed completing resumes.

Discussed filling out job applications



o Q3: Achieved

o Q3 summary:

Dundalk: 7

Tenax- several (3) individuals tried out for jobs,

Tenax- one on going job for individual at Tenax,

Tenax- 3 contractual jobs,

42

Ladies group visited a store and talked about jobs in that store,

One individual asked about volunteering or working at the North

Point Library after visiting,

Ladies group went to restaurant and talked jobs the type of jobs in

the restaurant,

Talked to several individuals about the landscaping group as part

of lawn mowing.

Loch Ridge: 4

Mock interviews held,

3 actual interview occurred,

Regular discussions about employment with contract area,

2 individuals worked at community job for employment experience

Seton: 3

4 individuals were given a trial experience at Chase Brexton.

o 2 individuals were hired to work at Chase Brexton 4 hrs a

day/for 2 days a week.

6 individuals went down the see if the subway job would be a good

fit;

2 of those people are waiting to do some job sampling at the

subway.

Woodlawn: 4

Session on getting along with co-workers,

Discussion on utilizing MTA Mobility to gain independence,

Job opportunities frequently available and general duties

associated (janitorial, landscaping, clerical)

Importance of learning new skills to increase employment

possibilities

Towson: 2

Staff had supported workers speak with workers at the

following businesses in an effort to build a relationship and

discuss jobs:

o Home Depot

o Rita’s

o Gold Gym

o Goodyear Tire

Regular (usually weekly) discussions about employment with

supported individuals.

Homeland: 2

Individuals went out to apply for jobs at Family Dollar store,

Discussed:

o Proper hygiene for job interviews,

o How to complete a resume and an application,

o Proper attire,

o Proper attendance, and

o Looked for jobs openings on line.



43

o Q2: Achieved

o Q2 summary:

Dundalk: 7

Ladies group talked about:

o Daily hygiene

o Dream jobs

o Visiting new job sites

o Grocery shopping

o Three individuals had jobs in a community setting- two

were successful

Loch Ridge: 6

Mock interviews

Actual interview

Discussions about employment with contract area

Completed two online applications- Walmart & Rugged

Warehouse

Seton: 8

Job trails for 8 individuals for the Peat Log job. 4 were successful

in obtaining employment

Reviewed appropriate work behavior and appearance for work

Assisted individual in getting fingerprinted for a job at Chatsworth

School

Completed an application of another individual to work at the

Woodmoor school as a cafeteria aid

Woodlawn: 5

Answering incoming calls (receptionist desk)

Stocking supplies

Mock interview

Enhancing reading skills/word recognition

Enhancing writing skills

Towson: 8

Held Group Sessions

o Job as day care worker

o Cashier at a grocery store

o McDonalds

o Discuss job choices

o Strengths/abilities on a job

o Goals/interests in jobs

Homeland: 8

Completed applications for

o Dollar Store

o Giants

Discussed proper hygiene for job interviews

Discussed how to complete a resume



o Q1: Achieved

o Q1 summary:

44

Dundalk: 7

Discussed employment with individuals

Moved several individuals to PS

One individual tried 2 possible jobs

Filled out applications online

Added job at school

Loch Ridge: 7

Mock interviews

Resume building

Actual interview

Discussions about employment with PWS

Seton: 6

Went to school to fill out application to become cafeteria aid

Several individuals filled out applications

Discussed job expectations with individuals

Woodlawn: 6

Good work skills

How to find a job

Computer job search

Personal information on job application

Hygiene and proper attire on interview

Towson: 6

Assisted with application and transportation to Camden Yards

Individual was assisted with resume for job as office clerk

Individuals were assisted with filling out application for Walmart

Individual was assisted with application to apply for job at AMC

theater for ticket holder job

Towson CEC had a job session on august 13, 2016 on attitude and

appearance at the work place

Towson CEC had a work session on getting along with co-workers

Homeland: 8

Discussed employment with individuals

Filled out applications online

Went to local retailers inquiring about jobs



4) Category of Measure: Number of individuals in community based group integrated

jobs

Goal: To provide group integrated jobs to 30% of individuals attending day centers.

Status:

o Annual: Achieved

o Annual summary: On average, group integrated jobs were provided to 34% of

individuals attending day centers.

o Q4: Not achieved

45

o Q4 summary: 127 out of 449, or 28% of individuals attending day programs

participated in community based paid employment.

o Q4 action plan: The decline in quarter four is likely due to the fact that several

people working 5 hours or less were taken off The Arc Baltimore’s payroll on

April 1, 2017; they were working outside of the center performing such tasks as

policing and even contract work but may have been on bloated contracts.


o Q3: Achieved





o Q2: Achieved





o Q1: Achieved





5) Category of Measure: Percentage of individuals with employment related goals in

their Individual Plans.

Goal: To increase the percentage of individuals with employment related goals in

Individual Plan from baseline to 3% to 25%.

Status:

o Annual: Achieved

o Annual summary: The percentage of individuals with employment related goals

in their Individual Plans increased from the baseline of 3% to an annual average

of 47%.

o Q4: Annual goal

o Q4 summary: 160 out of 259, or 62% of individuals have employment related

goals in their Individual Plans.



o Q3: Annual goal

o Q3 summary: 120 out of 248, or 48% of individuals have employment related


o Q3 action plan: None taken


46

o Q2: Annual goal

o Q2 summary: 113 out of 260 or 43% of individuals have employment related




o Q1: Annual goal

o Q1 summary: 396 out of 1,145 or 35% of individuals have employment related




Training

1) Category of Measure: Employees receive specialized Autism training.

Goal: 20 employees will participate and graduate from the Autism Certification

Program.

Status:


o Annual summary: 11 participants in total are expected to have completed the

Autism Certification training.

o Q4: Annual goal

o Q4 summary: A class of seven participants began the program in March of 2017.

All are progressing through the program, and should complete the program on

August 1, 2017.



o Q3: Annual goal

o Q3 summary: Applications were accepted for the Spring/Summer 2017 session

and 10 applicants applied and were accepted into the program. The first class was

held on March 28, 2017.



o Q2: Annual goal

o Q2 summary: 4 of the 9 trainees enrolled in the Fall Autism Certification Program

completed the session.



o Q1: Annual goal



47

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 35 days or less.

Status:

o Annual: Achieved

o Annual summary: There were 322 applicants hired and 235, or 73% started

orientation within 35 days of submitting their application.

o Q4: Achieved

o Q4 summary: There were 128 applicants hired in quarter four and 100, or 78%

started orientation within 35 days of submitting their application.


o Q4 actions taken:

Once a position is posted managers start interviewing.

The time between interview date and the pre-employment date should be

three or four days. Managers schedule applicants for pre-employment

immediately after they make an offer. Pre-employment is offered twice a

week.

Managers make sure they communicate clearly with applicants what they

need to bring to pre-employment. This helps eliminate confusion, errors,

and reduce the time between pre-employment and orientation

Human Resources continues to schedule interviews for Community Living

managers to help reduce the time between phone screens and interviews.

Human Resources continues to sends out reminder text messages to

applicants before pre-employment to ensure they bring all the required

documents.

Human Resources held a Career Open House on March 17th, 2017 to

increase applicant’s traffic.

o Q3: Achieved

o Q3 summary: There were 69 applicants hired in quarter three and 55, or 80%


o Q3 action plan:

Once a position is posted managers need to be ready to start interviewing.


three or four days. Managers need to schedule applicants for pre-

employment immediately after they make an offer. Pre-employment is

offered twice a week.

Managers need to make sure they communicate clearly with applicants

what they need to bring to pre-employment. This helps eliminate

confusion, errors, and reduce the time between pre-employment and

orientation

o Q3 actions taken:



48

Human Resources continues to sends out reminder text messages to

applicants before pre-employment to ensure they bring all the required

documents.

Human Resources held a Career Open House on March 17th, 2017 to

increase applicant’s traffic.

o Q2: Achieved

o Q2 summary: There were 59 applicants hired in quarter one and 47, or 80%


o Q2 action plan:

None needed

o Q2 actions taken:



three or four days. Managers need to schedule applicants for pre-

employment immediately after they make an offer. Pre-employment is

offered twice a week.




orientation

o Q1: Not achieved

o Q1 summary: There were 66 applicants hired in quarter one and 33, or 50%


o Q1 action plan:


Managers need to block off more times on their calendar to help reduce

the time between the phone screen and the interview date. The time

between phone screens and interviews should be three or four days.


three or four days, and pre-employment is offered twice a week. Managers

need to schedule applicants for pre-employment immediately after they

make an offer.




orientation

o Q1 actions taken:

Automated the recruitment and onboarding process that helped streamline

the hiring process. The onboarding implementation was complete in July

of 2016.



Human Resources sends out reminder text messages to applicants before

pre-employment to ensure they bring all the required documents.

Recruitment Coordinator was hired in May of 2015 to increase phone

screens, and reduce the time between when an applicant submits his/her

application, and receives a call from Human Resources.

Human Resources attended several job fairs.

49

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 duplicated PO medications.

Status:

o Annual: Achieved

o Annual summary: At the beginning of the Quality Enhancement Plan year, there

were 77 individuals prescribed 10 or more medications. Combined the individuals

were prescribed 1,090 medications. The review process resulted in a reduction

from 77 to 73 individuals prescribed 10 or more medications, or a 5% reduction,

and a reduction from 1,090 to 827 prescribed medications, or a 24% reduction.

o Q4: Achieved

o Q4 summary: 69 individuals prescribed 10 or more medications were identified.

Combined the individuals were prescribed 979 medications. The review process

did not result in a reduction of total individuals on 10 or more medications (at the

end of the quarter there were 73 individuals), but there was a reduction from 979

to 827 prescribed medications, or a 16% reduction.



o Q3: Achieved


Combined the individuals were prescribed 1,058 medications. The review process

resulted in a reduction from 74 to 69 individuals prescribed 10 or more

medications, or a 7% reduction, and a reduction from 1,058 to 979 prescribed

medications, or an 8% reduction.



o Q2: Achieved


Combined the individuals were prescribed 1,070 medications. The review

processes resulted in a reduction from 75 to 74 individuals prescribed 10 or more

medications, or a 1% reduction, and a reduction from 1,070 to 1,058 prescribed

medications, or a 1% reduction.



o Q1: Achieved


Combined the individuals were prescribed 1,090 medications. The review

processes resulted in a reduction from 77 to 75 individuals prescribed 10 or more

medications, or a 3% reduction, and a reduction from 1,090 to 1,070 prescribed

medications, or a 6% reduction.

50



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

Goal: 100% of nursing reviews are completed on time.

Status:


o Annual summary: 1,585 out of 2,000 or 79% of nursing reviews were completed

on time.

o Q4:

o Q4 summary: Out of 488 nursing reviews completed this quarter between CL, FL

and Day Services, 397 were completed on time. 31 nursing reviews were

identified as late and 60 are pending. At the end of the quarter, 81% of nursing

reviews were completed on time.

o Q4 action plan:

The Nursing Department director will encourage nurses to be more

diligent about completing the nursing reviews

o Q4 actions taken:

The Nursing Department director encouraged nurses to be more diligent

about completing the nursing reviews

Nurses continue to enter comments in LP to indicate the reason for nursing

reviews could not be completed. A list of individuals’ not receiving

nursing assessments at the day program has been sent to LP for updating.

The director of nursing will check LP monthly to ensure that nursing

events are entered and are current.

o Q3: Not achieved

o Q3 summary: Out of 461 nursing reviews completed this quarter between CL, FL

and Day Services, 359 were completed on time. 24 nursing reviews were

identified as late and 78 are pending. At the end of the quarter, 78% of nursing

reviews were completed on time.

o Q3 action plan:



o Q3 actions taken:

Nurses continue to enter comments in LP to indicate the reason for nursing

reviews could not be completed. A list of individuals’ not receiving

nursing assessments at the day program has been sent to LP for updating.

The director of nursing will check LP monthly to ensure that nursing

events are entered and are current.

o Q2: Not achieved

o Q2 summary: 319 out of 481, or 66% of nursing reviews were completed on time.

o Q2 action plan:



o Q2 actions taken:

51

Nurses continue to enter comments in LP to indicate the reason the

nursing review could not be completed.

A list of individuals’ not requiring nursing assessments at the day program

has been sent to LP for update.

Newly hired nurses have signed up for LP training scheduled for January

24th, 2017.

o Q1: 510 out of 570, or 89% of nursing reviews were completed on time.

o Q1 action plan:


diligent about completing the nursing reviews.

o Q1 actions taken:

Nurses enter comments into Life print when an individual’s nursing

review cannot be completed due hospital admission, rehabilitation

admission, decline in health (for day services), etc.

Community Living

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

Goal: 80% of appointments are completed on time.

Status:


o Annual summary: 80% of medical appointments were not completed on time (see

quarter summation below).

o Q4: Not achieved

o Q4 summary: 608 appointments were completed, of which 519 or 67% were

completed on time

o Q4 action plan:

Assistant executive director of Community Living will review medical

events with the directors during their supervision meetings.

Use the information gained from the coordinator job duty survey to better

emphasize what job areas should be prioritized.

o Q4 actions taken:

Coordinator job duty survey was completed by coordinators to better

determine how coordinators are spending their time.

Medical events are review during supervision meetings completed with

coordinators.

o Q3: Not Achieved

o Q3 summary:

Community Living

739 appointments were completed, of which 395 or 58% were

completed on time

o Q3 action plan:

52

Assistant executive director of Community Living will incorporate

medical event review into the supervision meetings completed with

coordinators, by directors.



o Q3 actions taken:

None

o Q2: Achieved

o Q2 summary:

Community Living East


completed on time

Community Living West


completed on time

o Q2 action plan: None needed, but Community Living will continue to work on

completing all medical events on time.

o Q2 actions taken: None needed, but Community Living will continue to work on


o Q1: Achieved

o Q1 summary:

o Community Living East:


completed on time

o Community Living West:


completed on time

o Q1 action plan: None needed, but Community Living will continue to work on


o Q1 actions taken: None needed, but Community Living will continue to work on


o Late Reasons:

Q4 CL: 14 late at fault out of 89:

Did not know about appointment: 3

Forgot appointment: 3

Individual refused: 2

Lack of staff: 5

Lack of transportation: 0

Staff/transportation got lost: 0

When called, no appointment available: 1

Q3 CL: 17 late at fault out of 98:

Did not know about appointment: 2

Forgot appointment: 4

Individual refused: 2

Lack of staff: 5

53

Lack of transportation: 2

Staff/transportation got lost: 0

When called, no appointment available: 2

Q2:

CL East: 11 late at fault out of 40:

o Did not know about appointment: 2

o Forgot appointment: 1

o Individual refused: 3

o Lack of staff: 4

o Lack of transportation: 0

o Staff/transportation got lost: 1

o When called, no appointment available: 0

CL West: 7 late at fault out of 45:




o Lack of staff: 1




Q1:

CL East: 1 late at fault out of 32:




o Lack of staff: 0




CL West: 15 late at fault out of 56:




o Lack of staff: 0




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

Goal: To decrease the number of overdue medical appointments.

Status:

o Annual: Achieved

54

o Annual summary: There were 340 overdue medical appointments at the end of

this quarter, which is a 24% decrease from last year’s quarter four. There were

423 overdue medical appointments in quarter four of last year.

o Q4: Achieved

o Q4 summary: There were 340 overdue medical appointments this quarter, which

is a 34% decrease from last quarter. There were 512 overdue medical

appointments last quarter.



o Q3: Annual goal

o Q3 summary:

There were 512 overdue medical appointments this quarter, which is a

35% increase from last quarter. There were 379 overdue medical


o Q3 action plan:

Assistant executive director of Community Living will meet with the

directors of Community Living to review all overdue medical events and

create an action plan for completing those appointment.

o Q3 actions taken:

Assistant executive director of Community Living will incorporate

medical event review into the supervision meetings completed with

coordinators, by directors.



o Q3 actions taken:

None

o Q2: Annual goal

o Q2 summary:



21% decrease from last quarter. There were 170 overdue medical




22% increase from last quarter. There were 209 overdue medical


o Q2 action plan:

Assistant executive director of Community Living will meet with the

director of Community Living West to review all overdue medical events

and create an action plan for completing those appointment.


o Q1: Annual goal

o Q1 summary:


55

There were 170 overdue medical appointments this quarter, which is

an 11% decrease from last quarter. There were 191 overdue medical




2% decrease from last quarter. There were 214 overdue medical




3) Category of Measure: To increase the number of director support professionals who

attend individual planning meetings

Goal: Direct support professionals attend 70% of individual planning meetings.

Status:

o Annual: Achieved

o Annual summary: On average, direct support professionals attended 70% of

individual planning meetings that occurred this year.

o Q4: Not achieved

o Q4 summary: Direct support professionals attended 65% of individual planning

meetings.

o Q4 action plan:

Continue to invite direct support professionals to Individual Planning

meetings.

o Q4 actions taken:

Community Living continues to encourage attendance and promote value

of DSP’s input/attending. CL is working to ensure DSP’s who cannot

attend provide input prior to the meeting.

Many Individual Planning meetings are held during day hours when

Community Living direct support professionals are not available.

Community Living coordinators will be reminded to always extend an

invitation to direct support professionals to the Individual Planning

meetings.

Community Living will also work to schedule meetings at non-traditional

hours.

o Q3: Not Achieved


meetings.

o Q3 action plan :

Many Individual Planning meetings are held during day hours when

Community Living direct support professionals are not available.

Community Living coordinators will be reminded to always extend an

invitation to direct support professionals to the Individual Planning

meetings.

Community Living will also work to schedule meetings at non-traditional

hours.

o Q3 actions taken:

56

CL encourages attendance and promotes value of DSP’s input/attending.

CL is working to ensure DSP’s who cannot attend provide input prior to

the meeting.

o Q2: Achieved


meetings.

o Q2 action plan:

Although the goal was met, some direct support professionals were not

available for when the individual plan meetings were scheduled.

o Q2 actions taken:

CL will continue to encourage attendance and promote value of DSP’s

input/attending. CL is working to ensure DSP’s who cannot attend provide

input prior to the meeting.

o Q1: Achieved


meetings.



4.) Category of Measure: Direct support professionals meet with their supervisor

individually and in groups

Goal one: 95% of house meetings occur on a monthly basis.

Status:


o Annual summary: On average, monthly house meetings occurred 76% of the time.

o Q4: Not achieved

o Q4 summary: 91% of house meeting occurred on a monthly basis.

o Q4 action plan:

Continue to emphasize the importance of house meeting during

supervision meetings.

o Q4 actions taken:

Coordinator positions were filled.

Coordinators will be reminded that house meetings must occur on a

monthly basis.

Coordinators will be offered more parameters regarding how house

meetings can be done e.g., pulling houses together for a large meeting,

utilizing technology like Skype for employees who are unable to attend

the meeting physically, but could call in etc.

o Q3: Not achieved


o Q3 action plan:

Coordinators will be reminded that house meetings must occur on a

monthly basis.

57

Coordinators will be offered more parameters regarding how house

meetings can be done e.g., pulling houses together for a large meeting,

utilizing technology like Skype for employees who are unable to attend

the meeting physically, but could call in etc.

o Q3 actions taken:


o Q2: Not achieved


o Q2 action plan:

Ensure that coordinators know the expectation that they hold monthly

house meetings.

o Q2 actions taken:


o Q1: Not achieved

o Q1 summary: 62% of house meetings occurred on a monthly basis.

o Action Plan: Community Living management will clarify expectations with the

coordinators regarding the house meetings needing to be held on a monthly basis.

Community Living is restructuring in October of 2016, which should help ensure

that the meetings occur.

o Actions Taken: Community Living is working to fill open coordinator positions.

Goal two: 90% of supervision meetings occur between managers and the direct support

professionals they supervise (in Q3 supervision changed to quarterly).

Status

o Annual: Not measurable

o Annual summary: The supervision requirements changed from monthly to

quarterly in quarter three. See quarterly summation below.

o Q4: Achieved

o Q4 summary: 96% of supervision meetings occurred between managers and the

direct support professionals they support.


o Q4 actions taken:

Assistant executive director of Community Living changed the

requirement from monthly to quarterly.

Ensured that coordinators know the expectation that they meeting with

their staff at least once per quarter.

Coordinators are aware of the supervision requirements and adjustments

were made to better enable the coordinators to meet with their employees.

Coordinators will be reminded of the expectations and held accountable to

meeting the expectations.

o Q3: Not Achieved

o Q3 summary: 50% of supervision meetings occurred on a quarterly basis.

o Q3 action plan:

Coordinators are aware of the supervision requirements and adjustments

were made to better enable the coordinators to meet with their employees.

58

Coordinators will be reminded of the expectations and held accountable to

meeting the expectations.

o Q3 actions taken:



Ensured that coordinators know the expectation that they meeting with

their staff at least once per quarter.

o Q2: Not Achieved

o Q2 summary: 43% of supervision meetings occurred on a monthly basis.

o Q2 action plan:

Ensure that coordinators know the expectation that they meeting with their

staff at least once per quarter.

o Q2 actions taken:



o Q1: Not achieved

o Q1 summary: 65% of supervision meetings occurred on a monthly basis.

o Q1 action plan: Community Living management will clarify expectations with the

coordinators regarding the supervision meetings needing to be held on a monthly

basis. Community Living is restructuring in October of 2016, which should help

ensure that the meetings occur.

o Q1 actions taken: Community Living is working to fill open coordinator

positions.

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