Support Coordination Record Review

The Quality Enhancement Provider Review (QEPR) is conducted by Qlarant as part of the Georgia Collaborative ASO, under contract with the Georgia

Department of Behavioral Health and Developmental Disabilities. The Overall Score is based on indicators measuring the quality of your organizations systems and practices, and adherence with the Provider Manual for Community Developmental Disability Providers and policies specific to Support Coordination. Results are gathered from individuals records and employee records maintained by your organization.

Review Components Percent Met Score Weight¹ Weighted Score

Safety 100% 0.23 23%

Whole Health 100% 0.17 17%

Person Centered Practices 80% 0.17 14%

Community Life N/A N/A

Rights 73% 0.14 10%

Choice 100% 0.11 11%

Staff Qualifications & Training 100% 0.11 11%

Service Guidelines 100% 0.07 7%

Overall Score

Support

Coordination

Record

Review

¹ Explanation: The Support Coordinator Record Review (SCRR) is organized around six Focused Outcome Areas (FOA), as shown in the table. The Percent Met is the number of indicators scored present over the total number scored. The Weight of Score is the proportion of the total score attributed to each review area. To calculate the Weighted Score, multiply the Weight of Score times the Percent Met (unweighted score). The sum of the Weighted Scores is equal to the Overall Provider Score. Note: Weighted scores may not total to the o e all eighted s o e sho e ause of ou di g.

Quality Enhancement Provider Review (QEPR)

Final Assessment Report

Creative Consulting Services

Lead Assessor: Allyson Banks Region: 1,2,3 Review Method: Remote Quality Review - 100% EMR Review Date(s): 5/10/2021 - 5/17/2021 Review Period: 5/10/2020 - 5/9/2021

QEPR Highlights

The QEPR Highlights section includes your organization s overall strengths based on systems and practices documented in the records reviewed. This section also includes any Quality of Care Concerns (QCC), the immediate action items identified based upon findings from the records reviewed.

Strengths

Support Coordinator Record Review

• Documentation demonstrated Support Coordinators evaluated support and service delivery to assess if there were any unmet safety needs. • Documentation demonstrated how Support Coordinators continuously advocated for individuals to maintain own safety.

• Documentation demonstrated Support Coordinators consistently evaluated if there were any emerging health risks.

• Documentation demonstrated how Support Coordinators routinely promoted individuals' preferences for managing health. • Documentation demonstrated how Support Coordinators advocated for individuals to have a voice in healthcare decision-making. • Documentation demonstrated how Support Coordinators evaluated services to ensure they had the intended effect and approaches.

• If Support Coordinators identified service providers were not providing services according to individuals' preferences or needs, documentation demonstrated discussions with the provider in delivering supports and services according to individuals' preferences or needs.

• Documentation demonstrated how Support Coordinators consistently respected and acted upon individuals' choices. • “uppo t otes i luded spe ifi details o iti al i ide ts, a d su se ue t follo -up, th ough to esolutio .

• Requests for Clinical Reviews (RCR) were submitted when additional services or technical assistance was needed. • The Supports Intensity Scale (SIS) domains were descriptive of individuals' preferences and supervision required.

Administrative Review

• Areas of risk to individuals served and to the organization were identified and monitored based on services, supports, treatment or care offered.

Staff Qualification & Training

• Annual staff training exceeded the required 16 hours.

Quality of Care Concerns

Review Tool

Total N Identified

No Quality of Care Concerns identified

Immediate Action Items

QEPR Results by Review Component

The QEPR Results section includes findings from each tool of the review: Support Coordination Record Reviews (SCRR), Administrative Review, Staff

Qualifications and Training (Q&T), Service Guidelines, and Individual Service Plan Quality Assurance (ISPQA). Results for all tools show, as applicable, key findings as identified through the records reviewed, recommendations for improvements to documentation, additional consultation and suggestions for quality

improvement to systems and practices, and findings for quality indicators. Results for the SCRR are presented by Focused Outcome Area (FOA), Staff Q&T

results are presented by staff title, Service Guidelines results are presented by service, and ISPQA results are presented by the individual service plan sections.

Support Coordination Record Review Results by Focused Outcome Area

When all responses to a Focused Outcome Area question are "Not Applicable," no percentage is displayed.

The following figure displays SCRR results by FOA.

Key Findings

• All records included documentation (as needed) of how support coordinators addressed, coached, explained, or discussed with individuals or service providers any identified safety risks.

• All of the eight applicable records contained documentation of how:

◦ A Request for Clinical Review (RCR) was submitted when additional services or technical assistance was needed in response to increases in behavioral support needs

◦ Support coordinators addressed, coached, explained, or discussed with the individual or service providers, as needed, any identified safety risks Whole Health:

• All records contained documentation of how support coordinators:

◦ Evaluated service delivery to determine if there were any unmet health needs ◦ Promoted individuals' preferences for managing their health

◦ Advocated for individuals to have a voice in healthcare decision-making Rights:

• Six of 24 records did not contain documentation that reflected how support coordinators supported individuals to understand how to exercise rights and responsibilities that come with certain rights.

Choice:

• Twenty-two of 30 records (eight records were scored as non-applicable) contained supporting documentation reflecting SCs had follow-up conversations with providers when it was identified that preferences or needs were not being met regarding service delivery.

• All thirty records included documentation of how support coordinators respected and acted upon individuals' choices.

• Based on the four applicable records reviewed, dissatisfaction individuals expressed related to supports and services, including Support Coordination, was addressed to resolution.

Recommendations

Person Centered Practices

• Document how Support Coordinators review with individuals progress on their Individual Service Plan goal(s)/objectives.

Rights

• Document how Support Coordinators support individuals to understand how to exercise their rights and understand responsibilities of those rights.

Additional Consultation and Suggestions for Quality Improvement

• Though the "Human Rights Form" is reviewed and acknowledged by individuals at the annual Individual Service Plan (ISP) meeting, consider conducting pe iodi ights a d espo si ilities dis ussio s ith the . Use eal-life e pe ie es that i di iduals a elate to like dis ussio s a ou d taki g

edi atio s o the ight to o e's o o e a d fi a ial i fo atio . This ill help the suppo t oo di ato e a le to dete i e he i di iduals may want additional support or information on rights or gauge their awareness of rights and responsibilities. Lastly, document the details of these dis ussio s a d i di iduals' espo ses.

• The COVID- pa de i has ee a halle ge fo a i di iduals due to the li ited hoi es a aila le hile shelte i g-i -pla e. As life etu s to

normal, consider having discussions with individuals regarding their plans for living environments, meaningful day activities, and employment throughout the ea , ot just du i g the a ual I“P eeti g. These o e satio s ould o u as pa t of p e-I“P dis ussio s a d a ti ities. E su e that do u e tatio reflects these conversations in support notes or in the "Individual Quality Outcome Measures Review" (IQOMR).

Administrative Review Results

Indicator Results

There is a well-defined quality improvement plan for assessing and improving organizational quality. Yes Areas of risk to individuals served and to the organization are identified and monitored based on services, supports, treatment or care

offered. Yes

There is documented evidence of active oversight of the Contracted Provider/Professional capacity and compliance to provide quality

care. Yes

The organization has a policy, by job classification, that describes the competency-based training procedures for orientation and annual trainings; additional trainings for professional level staff; and additional training/recertification (if applicable) required for all other staff.

Total Percent Yes (not included in Overall Score) 100%

Additional Consultation and Suggestions for Quality Improvement

• Consider starting a "Support Coordinator Workgroup", facilitated by support coordinators, that meets quarterly to discuss documentation challenges and othe halle ges fa ed i thei positio a d ideas to e ediate these, a d p o ide this i fo atio to the ad i ist ati e tea fo o side atio .

Staff Qualifications and Training by Staff Title

The following table displays the staff record review results by staff title.

Staff Title Records

Reviewed

Indicators

Reviewed Percent Met

Certified/Licensed Professional (SE, LPN, RN, BA, PT, OT, SLP, etc.) 2 36 100%

Intensive Support Coordinator (ISC) 3 39 100%

Support Coordinator (SC) 3 52 100%

Key Findings

Both clinical supervisors' personnel records included the following documentation: • Signed job descriptions

• Motor vehicle record checks • Criminal records checks

• All required orientation training was present for the one new hire clinician and included documentation supporting additional training exceeding 34 hours • All required annual training was present for the one veteran clinician

All three intensive support coordination personnel records included: • Signed job descriptions

• Motor vehicle and criminal records checks • Performance evaluations

• A minimum of 16 hours of annual training

• Training on human rights, communication, and individuals' specific medication Support Coordination:

• For the two veteran support coordinators' personnel records, there was documentation of: ◦ Signed job descriptions

◦ Motor vehicle and criminal records checks ◦ Performance evaluations

◦ A minimum of 16 hours of annual training to include: ▪ Human Rights

▪ Communication

▪ Individuals' specific medication

• The one "new hire" support coordinator's personnel record included the following: ◦ A signed job description

◦ Motor vehicle records check ◦ Criminal records check

Additional Consultation and Suggestions for Quality Improvement

• Fo all li i ia s, e su e that a u e t li e se is ai tai ed i the pe so el e o d. Both e o ds had li e si g i fo atio p ese t, ho e e , the e e e pi ed. A e sea h of li e ses fou d that oth li e ses e e u e t, thus edit as gi e .

Service Guidelines

The following table displays the Service Guidelines results by service.

IDD Service(s) Provided Records Reviewed

Indicators

Reviewed Percent Met

Intensive Support Coordination 3 6 100%

Support Coordination 27 69 100%

Overall Score 100%

Key Findings

Intensive Support Coordination (ISC)

• All th ee I“C e o ds i luded do u e tatio that efle ted:

◦ Individuals' unmet needs resulted in a "Coaching and Referral" or an RCR

◦ Support notes that included the date, time, and location (as necessary) of the activity ◦ Visits/contacts were in compliance with the required frequency based on DBHDD policy Support Coordination (SC)

• All 27 SC records included documentation of:

◦ Support notes that included the date, time, and location (as necessary) of the activity ◦ Visits/contacts being in compliance with the required frequency based on DBHDD policy

Quality Indicators Results by Service

• Intensive Support Coordination: Intensive Support Coordinator evaluates the quality and outcome of services provided, such that services are delivered in a manner based upon the individual s preferences. Protects the health and safety of the individual and promotes improved quality of life.

• Support Coordination: Support Coordinator evaluates the quality and outcome of services provided, such that services are delivered in a manner based upon the individual s preferences, protect the health and safety of the and promote improved quality of life.

Quality Indicator Key Findings

• All I“C e o ds e e s o ed "Meets". The I“C dis ussed the eeds health a d safet a d goals of i di iduals du i g fa e-to-fa e isits ith i di iduals, p o ide s, a d fa ilies. If ha ges e e eeded, the I“C ade a e essa efe als o follo ed up ith espo si le pa ties to e su e ha ges e e i ple e ted a d eeds e e et. As eeded, effo ts to i p o e the ualit of life fo i di iduals e e ade.

Support Coordination (SC)

• All “C e o ds e e s o ed "Meets". The “C dis ussed the eeds health a d safet a d goals of i di iduals du i g fa e-to-fa e isits ith i di iduals, p o ide s, a d fa ilies. If ha ges e e eeded, the “C ade e essa efe als o follo ed up ith espo si le pa ties to e su e ha ges e e i ple e ted a d eeds e e et. As eeded, effo ts to i p o e the ualit of life fo i di iduals e e ade.

Quality Indicator Additional Consultation and Suggestions for Quality Improvement

• Continuously evaluate the quality of ISC services being provided and have discussions with individuals, family members, providers, and other natural suppo ts. Do u e t these o e satio s i suppo t otes o the IQOMR. De elop a p o ess that ill suppo t “Cs i o ti uousl lea i g hat is important to and for individuals, and advocating to ensure preferences, goals, dreams, and health and safety needs are met.

Support Coordination (SC)

ISPQA Results (N=30)

(not included in the overall score)

Individual Service Plan (ISP) review section summarizes the results based on the ISP Quality Assurance Report. Note: N represents the total number of ISPs reviewed.

ISPQA Section Indicators Reviewed Percent Met

Informed Choice 30 97% Current Needs 180 51% Goals 186 95% Overall Score 75%

Key Findings

• Twenty-nine records of 30 included individuals' signatures and ISP signature pages were uploaded into IDD Connects. Current Needs

• Home Living Domain:

◦ Eighteen of 30 records did not contain documentation that reflected any new changes in support needs since the last annual ISP. ◦ Three of 30 records did not include individuals' preferences.

• Community Living Domain:

◦ Sixteen of 30 records did not include documentation to specify if there were any new changes in support needs since the last annual ISP. ◦ Three of 30 records did not include individuals' preferences related to what is important to the individual in relation to the community. • Lifelong Learning Domain:

◦ Sixteen of 30 records did not include documentation to specify if there were any new changes in support needs since the last annual ISP. ◦ Two of 30 records did not include documentation of who (paid service or natural support) supported individuals with lifelong learning activities. • Employment Supervision Activities Domain:

◦ One out of 12 applicable records did not contain documentation to reflect the following: ▪ Supervision needs related to employment

▪ Who (paid service, natural support, or employer) supported the individual with employment activities • Health and Safety Activities Domain:

Thank you again for the time and effort the organization s team put into making this a successful and productive Quality Enhancement Provider Review. We would appreciate any feedback you may have on the review process. To access an online survey, please go to https://www.surveymonkey.com/s/PGJFNHJ . If you have any questions regarding these results, please contact The Georgia Collaborative ASO at 1-866-755-3506.

• Social Activities Domain:

◦ Eighteen of 30 records did not have documentation to specify if there were any new changes in support needs related to social activities, since the last annual ISP.

◦ Two of 30 records did not include supervision needs. • Exceptional Medical and Behavioral Supports Domain:

◦ Two of 30 records contained documentation indicating that exceptional behavioral support needs were identified but, there was no current Positive Behavior Support Plan or safety plan uploaded, and no documentation of how the needs would be addressed.

Goals:

• All 30 ISPs included the following: ◦ Person-centered goals

◦ I di idual st e gths that efle ted a ilities, skills, o tale ts ◦ Action plans that included:

▪ Individuals' preferences from the person-centered goal section

▪ Strategies, interventions, or steps to define how individuals will accomplish the objective(s) ▪ How often the provider would track/implement the objective(s)

▪ Measures that specifically related to the desired objective(s)

Additional Consultation and Suggestions for Quality Improvement