Accreditation Report. Quality Improvement Plan & Benchmarking Data. Prepared for St. Joseph s Villa of Sudbury

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2 Report Quality Improvement Plan & Benchmarking Data Prepared for St. Joseph s Villa of Sudbury

3 Decision Three-Year Expiration: November 2015 Organization St. Joseph s Villa of Sudbury () 1250 South Bay Road Sudbury, ON P3E 6L9 Canada Organizational Leadership Natalie Ferguson, CQI Advisor Survey Dates November 1-2, 2012 Survey Team George M. Grant, CEAP, RSW, Administrative Surveyor Lisa S. Skopal, B.S., M.A., CASP, Program Surveyor Programs/Services Surveyed Person-Centred Long-Term Care Community Governance Standards Applied 1 St. Joseph's Villa of Sudbury Report

4 Survey Summary Areas of Strength St. Joseph s Villa of Sudbury () has strengths in many areas. The governance structure at maintains a strong focus on the mission and values of the organization and how decision making is guided by ethical considerations. The continual focus on the mission of the organization, supported by clear values, results in high quality and caring services to persons served. Leadership and staff members embrace these values, which directly impacts the level of care provided to persons served. Quality improvement activities at are extensive and include participation from all areas and staff in the facility. Leadership and staff are continually engaged in improving services, resulting in a high level of effective service for persons served, their families, and other stakeholders. Strategic planning activities include input from every area within. Staff and leadership are extensively involved in this process, resulting in a thorough awareness, understanding, and consideration of strategic service options that will directly affect the future work within facilities in Sudbury. As a result of these planning activities, the organization is well positioned to consider how best to provide ongoing services for its persons served within the evolving health care funding and service structure in the province of Ontario. The senior management team is a cohesive group that is responsive to the needs of persons served, family members, and staff. Opportunities for improvement are continually sought, and the organization is committed to moving the program forward. There is consistent evidence of an opendoor policy and support to the front-line team. has compassionate, friendly, and dedicated staff members who obviously care very much for the persons served. A significant number of staff members have been with the organization for many years, demonstrating their dedication and commitment to what they do. This is clearly evident in their interactions with persons served, family members, and volunteers. has developed an internal software program to support all aspects of the preventive maintenance program and to coordinate required building services. has also developed a system to help the food service manager track and monitor the temperatures of the refrigerator and freezers. This program provides time savings in auditing and monitoring staff requirements and accountability. It also will provide cost savings by moving towards a paperless system. It is understood that the organization is well underway in developing a similar program for the laundry department. s Guardian Angel program is aimed at respecting each individual s right to die with dignity and peace, while maintaining his or her quality of life; managing pain; and supporting the person served, family, friends, and staff through the physical, psychological, spiritual, and emotional stress of this final transition of life. Of particular note is the Caring for My Spirit brochure the person served fills out to honour his or her wishes when he or she can no longer communicate, which includes his or her conversations and memories and favourite books, poetry, music, and spiritual and religious practices, to assist family and friends by ensuring that they know what the person likes prior to his or her death. St. Joseph's Villa of Sudbury Report 2

5 Areas for Improvement should seek improvement in the following areas. When bills for services provided, it should conduct a quarterly review of a representative sampling of these billings to ensure that the dates of service coincide with billed episodes of care, ensure that the bills accurately reflect the services that were provided, and identify necessary corrective action. Although provides an account reconciliation for persons served whose funds are handled by the organization, is urged to increase the frequency of these reconciliations to monthly. Although the organization has a risk management policy, it should implement a risk management plan that identifies and analyzes loss exposures, as well as identifies how to rectify those exposures. The plan should also include the implementation, monitoring, and reporting results of actions taken to reduce risks. This plan should be reviewed at least annually and updated as needed. The organization should also include a risk reduction indicator in its performance improvement activities. The organization is urged to develop and implement written emergency procedures for evacuation route signage that is accessible and understandable to persons served, personnel, and other stakeholders. Although conducts announced tests of emergency procedures, it should ensure that unannounced tests of all emergency procedures are conducted annually on each shift and include complete actual or simulated physical evacuation drills. These tests should then be analyzed for performance improvement, result in improvement of or affirm satisfactory current practice, and be evidenced in writing. Although has developed a critical incident analysis report, it should ensure that the report is reviewed annually and that the analysis addresses the necessary education and training of personnel. The organization should develop written procedures for voluntary and involuntary internal transitions. These procedures should address any counseling available regarding transitions as well as an appeal process related to involuntary transitions. The organization should then make these procedures available to persons served for clarification. Although the organization appears to have sanitary procedures for food preparation, it is urged to ensure that all food stored in refrigerators and freezers is covered and dated. In addition, food items should be stored in a manner that is safe and should therefore be stored away from any potentially hazardous items. When transportation is provided for persons served, there should be evidence of a regular review of the driving records of all drivers. Personnel performance reviews should be consistently conducted at least annually and be based on job functions. Performance reviews should also assess performance related to the measurable objectives established in the last evaluation period and establish measurable performance objectives for the next review. The organization is urged to include its refund policy in the Residency Agreement so that persons served are aware of the procedure. 3 St. Joseph's Villa of Sudbury Report

6 In addition to the established training, personnel responsible for medication management at should receive competency-based training on the implications of abrupt discontinuation as well as indications and contraindications of the medications they are dispensing. Decision St. Joseph s Villa of Sudbury has earned a Three-Year. On balance, the organization has many strengths, as demonstrated by its conformance to the applicable standards, while simultaneously recognizing the areas for improvement. provides high quality and caring services to persons served. The governance structure has maintained a strong focus on the organization s mission and values, and leadership and staff members embrace these values and carry them out. The organization is urged to address the areas for improvement in this accreditation report and to continue to use the CARF standards to further enhance the provision of its services. St. Joseph's Villa of Sudbury Report 4

7 Consultation Section 1. ASPIRE to Excellence B. Governance could consider a more extensive annual review of its current executive leadership succession planning than is currently conducted. L. Accessibility Current documentation of reasonable accommodation requests is contained in different locations, making it difficult for leadership to obtain a single source for all requests. may consider a more efficient method for gathering information. Section 2. Care Process for the Persons Served A. Program/Service Structure may want to consider including the program s theft and loss policy in the Resident Handbook to better communicate it to persons served. could consider including the Pet Policy in the Resident Handbook to ensure that persons served understand their responsibilities regarding visiting pets. B. Congregate Residential Programs may wish to include in the Resident Handbook information regarding the responsibility of persons served for contracted outside services. may wish to include information about the visitor policy in the Resident Handbook. Consultation does not indicate non-conformance to standards, but is offered as a suggestion for further quality improvement. 5 St. Joseph's Villa of Sudbury Report

8 Standards Conformance This section of the Report displays the specific reasons for any partial or non-conformance to standards identified as a result of the survey. The standards listed in this section are addressed in the organization s Quality Improvement Plan, which can be accessed at customerconnect.carf.org. Below are the possible reasons for partial or non-conformance to standards, along with an explanation of why each reason is cited. To receive the information contained in this section in an alternate format, please contact editing@carf.org. Reason for partial or non-conformance All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below the median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate Is cited: When a standard element requires more than one item, at least one item (but not all) is not in full conformance. When a standard element requires that an individual possess a specific credential or level of credential, the specific credential is not possessed, or the credential possessed is below the specified level. When the issue addressed by the standard element has not been considered and, consequently, the information necessary to address conformance has not been collected and/or evaluated in connection with the issue addressed. When a standard element requires documentation or that documentation contain specific information, the documentation either does not exist or does not contain the specific information. When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity. When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50 th percentile. When a standard element requires use of a specific form or that the form contain specific information, the form is not used or does not contain the specific information. When a standard element requires that an activity occur with a specific frequency or some unspecified regularity, the performance of the activity does not occur, occurs less frequently than required, or occurs less frequently than appropriate if regularity unspecified. When a standard element requires that information be shared with certain persons, the information is either not shared or not shared in a manner that allows for comprehension by the recipient. When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner. When a standard element requires compliance with a legal requirement or a process for achieving legal compliance, sufficient evidence of compliance or the compliance process is not demonstrated. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance does not occur with sufficient regularity to be deemed standard operating procedure. When a standard element requires a policy/plan/procedure/practice, it is not in existence. When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance has not been in place for sufficient time to establish a track record. When a standard element requires that certain training occur, it either does not occur or does not occur with sufficient regularity to be deemed standard operating procedure. When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply. St. Joseph's Villa of Sudbury Report 6

9 Standard Number Standard Text Reasons for Partial or Non-conformance 1.F.7.a. If the organization bills for services provided, a review of a representative sampling of records of the persons served is conducted: At least quarterly. All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 1.F.7.b.(1) If the organization bills for services provided, a review of a representative sampling of records of the persons served is conducted: To: Document that dates of services provided coincide with billed episodes of care. 1.F.7.b.(2) If the organization bills for services provided, a review of a representative sampling of records of the persons served is conducted: To: Determine that the bills accurately reflect the services that were provided. 1.F.7.b.(3) If the organization bills for services provided, a review of a representative sampling of records of the persons served is conducted: To: Identify necessary corrective action. 1.F.9.f. If the organization takes responsibility for the funds of persons served, it implements written procedures that define: How monthly account reconciliation is provided to the persons served. 1.G.1.a.(1) 1.G.1.a.(2) 1.G.1.a.(3) The organization implements a risk management plan that: Includes: Identification of loss exposures. The organization implements a risk management plan that: Includes: Analysis of loss exposures. The organization implements a risk management plan that: Includes: Identification of how to rectify identified exposures. 1.G.1.a.(4) The organization implements a risk management plan that: Includes: Implementation of actions to reduce risk. 1.G.1.a.(5) The organization implements a risk management plan that: Includes: Monitoring of actions to reduce risk. 1.G.1.a.(6) The organization implements a risk management plan that: Includes: Reporting results of actions taken to reduce risks. 1.G.1.a.(7) The organization implements a risk management plan that: Includes: Inclusion of risk reduction in performance improvement activities. 1.G.1.b.(1) The organization implements a risk management plan that: Is: Reviewed at least annually for relevance. 7 St. Joseph's Villa of Sudbury Report

10 Standard Number Standard Text Reasons for Partial or Non-conformance 1.G.1.b.(2) The organization implements a risk management plan that: Is: Updated as needed. All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 1.H.5.c.(10)(a) There are written emergency procedures: That address evacuation, as follows: Evacuation route signage that is: Accessible. 1.H.5.c.(10)(b)(i) There are written emergency procedures: That address evacuation, as follows: Evacuation route signage that is: Understandable to: Persons served. 1.H.5.c.(10)(b)(ii) There are written emergency procedures: That address evacuation, as follows: Evacuation route signage that is: Understandable to: Personnel. 1.H.5.c.(10)(b)(iii) There are written emergency procedures: That address evacuation, as follows: Evacuation route signage that is: Understandable to: Other stakeholders, including visitors. 1.H.6.a.(1) Unannounced tests of all emergency procedures: Are conducted at least annually: On each shift. 1.H.6.b. 1.H.6.c. 1.H.6.d. Unannounced tests of all emergency procedures: Include complete actual or simulated physical evacuation drills. Unannounced tests of all emergency procedures: Are analyzed for performance improvement. Unannounced tests of all emergency procedures: Result in improvement of or affirm satisfactory current practice. 1.H.6.e. 1.H.9.a. 1.H.9.b.(5) Unannounced tests of all emergency procedures: Are evidenced in writing. A written analysis of all critical incidents is provided to or conducted by the leadership: At least annually. A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Necessary education and training of personnel. 1.H.11.b. When transportation is provided for persons served there is evidence of: Regular review of driving records of all drivers. 1.I.6.d.(1)(a) Performance management includes: Performance evaluations for all personnel directly employed by the organization that are: Based on: Job functions. St. Joseph's Villa of Sudbury Report 8

11 Standard Number Standard Text Reasons for Partial or Non-conformance 1.I.6.d.(4)(a) Performance management includes: Performance evaluations for all personnel directly employed by the organization that are: Used to: Assess performance related to objectives established in the last evaluation period. All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 1.I.6.d.(4)(b) Performance management includes: Performance evaluations for all personnel directly employed by the organization that are: Used to: Establish measurable performance objectives for the next year. 1.I.6.d.(5) Performance management includes: Performance evaluations for all personnel directly employed by the organization that are: Performed annually. 2.A.1.c. 2.A.11.e.(7) Each program/service: Reviews the scope of services at least annually and updates it as necessary. Based on the scope of services, there is a written agreement: That contains information regarding: Refund policies. 2.A.12.a.(1)(a) 2.A.12.a.(1)(b) The program implements written procedures: Regarding transitions within the continuum which address: Internal transitions that are: Voluntary. The program implements written procedures: Regarding transitions within the continuum which address: Internal transitions that are: Involuntary. 2.A.12.a.(3) 2.A.12.a.(4) 2.A.12.b. The program implements written procedures: Regarding transitions within the continuum which address: Receiving counseling regarding transitions. The program implements written procedures: Regarding transitions within the continuum which address: Appealing involuntary transitions. The program implements written procedures: That are available at all times to persons served for clarification. 2.A.31.d.(1) 2.A.31.d.(2) When the program provides dining services, it: Prepares food in a manner that is: Sanitary. When the program provides dining services, it: Prepares food in a manner that is: Safe. 9 St. Joseph's Villa of Sudbury Report

12 Standard Number Standard Text Reasons for Partial or Non-conformance 2.A.39.b.(8) Personnel responsible for medication management/assistance receive competencybased training on medication: That includes: Implications of abrupt discontinuation. All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 2.A.39.b.(10) Personnel responsible for medication management/assistance receive competencybased training on medication: That includes: Indications and contraindications. St. Joseph's Villa of Sudbury Report 10

13 Benchmarking This section of the Report benchmarks your organization s conformance to standards. By comparing strengths and areas for improvement with various comparator groups, benchmarking encourages your organization to improve effectiveness, efficiency, satisfaction, and access. This information should also stimulate discussions among stakeholders focused on better meeting the needs and preferences of the persons served. In addition, benchmarking: Encourages a culture of continuous evaluation and improvement. Accelerates understanding of and agreement on areas for improvement. Helps prioritize improvement opportunities. Shifts internal thinking towards a focus on outcomes. Provides a reference to increase performance expectations. Motivates your team to work collaboratively to surpass benchmarks. This report provides benchmarks (mean % of conformance) for each section of the ASPIRE to Excellence quality framework. * When available, benchmark comparison groups include: All surveyed organizations. All surveyed organizations in the same primary CARF customer service unit. Surveyed organizations with the same ownership type. Surveyed organizations in the same geographic region. Surveyed organizations with similar number of persons served annually. Surveyed organizations with similar staff size. In addition, standards conformance for each organization undergoing resurvey is benchmarked against its previous survey in all standards areas. Benchmark Comparison Groups Primary area of accreditation: Aging Services (AS) Ownership type: Private, Not for Profit Geographic region: Canada - ON Staff size (FTEs): Persons served annually: To receive the information contained in this section in an alternate format, please contact editing@carf.org. * Excluding Governance and Strategic Integrated Planning. 11 St. Joseph's Villa of Sudbury Report

14 All surveyed organizations A: Assess the Environment Leadership CARF Three-Year CARF One-Year 90.8% 98.5% Nonaccreditation 75.9% S: Set Strategy Strategic Planning CARF Three-Year CARF One-Year Nonaccreditation 48.4% 80.8% 98.3% St. Joseph's Villa of Sudbury Report 12

15 All surveyed organizations continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders CARF Three-Year CARF One-Year Nonaccreditation 49.6% 82.6% 99.6% Legal Requirements CARF Three-Year CARF One-Year Nonaccreditation 99.4% 92.5% 83.1% 13 St. Joseph's Villa of Sudbury Report

16 All surveyed organizations continued Financial Planning and Management CARF Three-Year CARF One-Year Nonaccreditation 72.2% 91.8% 91.0% 99.1% Risk Management CARF Three-Year CARF One-Year 65.6% 79.4% 97.3% Nonaccreditation 60.7% St. Joseph's Villa of Sudbury Report 14

17 All surveyed organizations continued Health and Safety CARF Three-Year CARF One-Year 85.2% 91.9% 96.5% Nonaccreditation 70.6% Human Resources CARF Three-Year CARF One-Year Nonaccreditation 96.2% 97.5% 89.9% 79.3% 15 St. Joseph's Villa of Sudbury Report

18 All surveyed organizations continued Technology CARF Three-Year CARF One-Year 80.8% 98.7% Nonaccreditation 53.7% Rights of Persons Served CARF Three-Year CARF One-Year Nonaccreditation 98.4% 93.3% 86.4% St. Joseph's Villa of Sudbury Report 16

19 All surveyed organizations continued Accessibility CARF Three-Year CARF One-Year 68.8% 95.4% Nonaccreditation 41.7% R: Review Results Performance Measurement and Management CARF Three-Year CARF One-Year Nonaccreditation 32.3% 63.1% 96.7% 17 St. Joseph's Villa of Sudbury Report

20 All surveyed organizations continued E: Effect Change Performance Improvement CARF Three-Year CARF One-Year Nonaccreditation 15.3% 42.4% 93.5% St. Joseph's Villa of Sudbury Report 18

21 Other benchmarks A: Assess the Environment Leadership Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 98.3% 98.0% 98.3% 98.8% 100 to 499 Persons Served 98.1% S: Set Strategy Strategic Planning Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 96.7% 98.0% 96.8% 99.2% 97.4% 19 St. Joseph's Villa of Sudbury Report

22 Other benchmarks continued P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 98.6% 99.4% 98.2% 99.8% 99.0% Legal Requirements Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 98.1% 98.9% 99.0% 99.4% 99.1% St. Joseph's Villa of Sudbury Report 20

23 Other benchmarks continued Financial Planning and Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 91.8% 98.4% 99.0% 98.5% 99.3% 98.9% Risk Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 65.6% 96.2% 95.8% 95.8% 97.9% 96.2% 21 St. Joseph's Villa of Sudbury Report

24 Other benchmarks continued Health and Safety Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 91.9% 97.3% 96.0% 96.2% 96.9% 95.8% Human Resources Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 96.2% 96.0% 97.2% 95.7% 97.9% 97.2% St. Joseph's Villa of Sudbury Report 22

25 Other benchmarks continued Technology Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 97.0% 97.7% 97.1% 98.9% 97.8% Rights of Persons Served Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 97.8% 97.9% 96.7% 98.3% 98.1% 23 St. Joseph's Villa of Sudbury Report

26 Other benchmarks continued Accessibility Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 92.5% 93.9% 92.8% 95.9% 94.3% R: Review Results Performance Measurement and Management Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 98.0% 95.9% 97.1% 97.8% 96.2% St. Joseph's Villa of Sudbury Report 24

27 Other benchmarks continued E: Effect Change Performance Improvement Aging Services Private, Not for Profit Ontario 100 to 499 FTEs 100 to 499 Persons Served 96.7% 92.6% 93.5% 95.6% 92.6% 25 St. Joseph's Villa of Sudbury Report

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