Board of Directors Meeting

Transcription

1 Board of Directors Meeting December 8, 2011 Initiative Updates, Site Visit Schedule and Summaries Item VII.D. CORRECTIVE/DEVELOPMENT ACTION PLANS STATUS REPORT & RELATED ISSUES Beginning Date Status Girl Scouts of West Central Florida Gender Specific 8/26/11 Complete. REPORTS ON NEW INITIATIVES None CONTRACTS NOT EXECUTED None TIME LIMITED CONTRACTS None 1

2 SITE VISIT SCHEDULE (Board Members are invited to participate in site visits. For information, please contact Lisa Sahulka, ). December 2011 Alpha House Residential Program December 1, 2011 Pinellas County Head Start Early Head Start Match December 6, 2011 January 2012 Family Resources, Inc. SafePlace 2B January 5-6, 2012 The Children s Home Kinship Services Network of Pinellas January 23-26, 2012 City of St. Petersburg TASCO Center Based Teen Program January 23 February 3, 2012 Community Pride Homeless Program January 31, 2012 February 2012 Operation PAR Alpha February 13-24, 2012 COSA February 13-24, 2012 Pinellas Assoc. for Retarded Children Discovery Learning Center and Homebound February 29 March 2, 2012 Respite & Family Support Services February 29 March 2,

3 AGENCY SITE VISIT SUMMARIES Site visits are conducted annually, and are a means to evaluate performance, monitor program delivery and recommend improvements as necessary. Serious program deficiencies result in a Corrective Action Plan being issued, with a deadline of up to 10 months for resolution and implementation. These actions are included in the quarterly Compliance Report. An agency s failure to respond to the Corrective Action Plan and continued under-performance, may lead to a recommendation for further action, such as probation or termination of the contract. Citizen Alliance for Progress A.S.S.E.T. Compliance Letter Pinellas Association for Retarded Children - A.S.S.E.T. Compliance Letter Pinellas County Health Department School Based Health Services 3

4 Juvenile Welfare Board November The Children s Services Council of Pinellas County th Street North Suite 100 Clearwater FL David Archie Executive Director Citizens Alliance for Progress 401 MLK Jr Drive Tarpon Springs FL Board Members Elise Minkoff Board Chair Dear The JWB Children s Service Council of Pinellas County is pleased to announce Citizens Alliance for Progress has achieved ASET Certification for the following program Neighborhood Family Center Maria Edmonds Vice Chair Gubematorial Appointee The Certification outcome indicates that there is evidence of James Sewell Ph D Secretary Brian J Aungst Jr fulfillment of the ASSET standards and it is apparent that present conditions represent an established pattern of operation that is likely to be maintained or improved in the foreseeable future The Honorable Bob Dillinger Your ASET Certification is effective November Public Defender Citizens Alliance for Progress Neighborhood Family Center must The Honorable Raymond Gross consistently meet ASET eligibility requirements achieve Sixth Judicial Court contracted service levels meet performance objectives maintain The Honorable Bernie McCabe stakeholder health and safety and meet the general conditions of the State Attorney JWB contract including fiscal integrity to remain certified Raymond H Neri Angela H Rouson Sinc y The Honorable Karen Seel Pinellas County Commissioner John Stewart Ph D Gay L er Pinellas County Schools Interim Superintendent Execu Director i OPP D Gay Lancaster Cc Delphinia Davis JWB Senior Contract Manager Executive Director Karen Woods JWB Senior Contract Manager Marcie Biddleman Director Program Development Support Phone Fax Website JWBPinellas org Data Site AboutPineltasKids org fl hityou

5 Juvenile Welfare Board 1 November dill lit Mrs Karen Higgens Executive Director EY PARC The Children s Services Council 3190 Tyrone Blvd of Pinellas County St Petersburg FL RAC N 1 z 2r th Street North Dear Mrs Higgens Suite 100 Clearwater FL I would to take this opportunity to follow up on the ASET Compliance and Quality Review Report from the July 2011 review of Pinellas Association for Retarded Citizens PARC In August you received a letter describing the Juvenile Welfare Board JWB decision to withhold a final determination of the programs overall compliance and ASET Board Members recertification Martha Lenderman Board Chair Elise Minkoff Vice Chair Maria Edmonds Secretary The Honorable Bob Dillinger Public Defender Over the past three months PARC has demonstrated great quality enhancements JWB feels the program has made efforts to meet and in many cases exceed each requirement As a result of PARC s commitment to rectify the areas of concern JWB finds PARC s Discovery Learning Center and Homebound Family Focus Program to be in full compliance and therefore will receive ASET recertification I would like to extend my sincere appreciation for the cooperation The Honorable Raymond O Gross extended by your staff during the past several months Judge of the 6th Circuit Court Julie Janssen Ed D Pinellas County Schools Superintendent The Honorable Bernie McCabe Sinc riely State Attorney yam Gz John Milford D Gi ncaster Execu e Director The Honorable Karen Seel Pinellas County Commissioner James D Sewell Ph D Cc Jennifer Rayl Senior Contract Manager Lisa Sahulka Director of Performance Management Joseph Smith D Gay Lancaster Executive Director Phone Fax Website JWBPinellas org Data Site AboutPinellasKids org J pp

6 JWB CHILDREN S SERVICES COUNCIL OF PINELLAS COUNTY COMPLIANCE cqual ITY REVIEW REPORT AGENCY NAME Pinellas County Health Department PROGRAM NAME School Based Health Services REVIEW DATES September 19 and REVIEW TEAM MEMBERS Jennifer Rayl Qian Fan and Karen Woods REPORT SUBMITTED BY Jennifer Rayl LCSW DATE OF REPORT October Agency Description The Pinellas County Health Department PCHD is a government entity established as the seventh county Health Department in the State of Florida in 1936 PCHD employs over 600 employees within its seven locations throughout the county and provides a plethora of health services to the community The Director of the PCHD is Claude M Dharamraj MD MP1lFAP who was appointed in 2006 The PCHD has established a value statement which reflects I CREATE Integrity Commitment to Service Respect Excellence Accountability Teamwork and Empowerment The mission statement is to promote protect and improve the health of all people in Pinellas County The School Based Health Services program is one of the services in which the PCHD s carries out this mission The agency has an annual budget of approximately 50 million dollars of which Juvenile Welfare Board JWB directly contracted for during FY School Based Health Services is funded by JWB for which represents 50 of the total program budget of School Based Health Service s mission is to assess protect and promote the health of adolescents helping to ensure they are healthy in the classroom and ready to learn The program intends to improve the health and well being of adolescents by providing preventative health screening guidance on adolescent development and health risk behaviors early intervention and prevention services School Based Health Services are provided by a multi disciplinary team of health and mental health professionals The School Based Health Services supports JWB s Strategic Plan goal of ensuring school success as healthy children attend more consistently in the classroom and are better prepared to learn Summary of Site Visit Findings Related to Program This report provides an overview of the services being providing to Pinellas County School students Service delivery was evidenced by facility tours thorough file review interviews and review of data and performance measures The Pinellas County Health Department remains ASET certified through 2012 As a component of the current review previous requirements were assessed for progress The Compliance and Quality Review Report completed for the contract year was previously provided to the Pinellas County Health Department and included the following feedback The program must sub contract with a local mental health provider for case consultation for the licensed clinical services provided by the two licensed clinical staff The licensed clinical staff must complete the JWB Case Management Series JWB program management staff and Pinellas County School staff will meet and discuss the utilization of resources and staffing patterns at the JWB clinics

7 Establish a mechanism for adding the Social Work Component objectives into the overall data collection system Designate additional staff resources for data entry support Develop written policies and procedures regarding the social work component Update the program methodology with approved changes School Based Health Services program has undergone substantial restructuring over the past contract cycle In the program was providing services at Northeast High School Meadowlawn Middle School John M Sexton Elementary School Lealman Intermediate School and Clearwater Intermediate School The program now provides services only at Northeast High School and Gibbs High School This reorganization occurred after careful review of service utilization and included input from JWB Pinellas County Health Department and Pinellas County Schools in the decision making process In addition to the service delivery reorganization the Pinellas County Health Department now subcontracts the mental health service component of this program to Suncoast Center Inc The current subcontract includes provision for both the direct mental health service providers as well as a clinical supervision component The current review establishes the following recommendations and requirements Recommendations Develop written procedures outlining a standard practice for consents to include expiration details Ongoing collaboration should continue to occur between partnering agencies to ensure quality services and the continuation of enhancing current services Supervision of licensed clinical staff be documented by Suncoast and monitored by PCHD as a component of overseeing the current subcontract This supervision should include a file review of documentation to ensure all case action is being captured Requirements The program staff will cease use of correction fluid in participant files Licensed clinical staff will work with the JWB Research Department to arrange for technical assistance related to Goal Attainment Scale GAS enhancement and GAS training for new employees Ensure clinical services are occurring and include summer break planning after care services continuity of care efforts collateral contacts and outside referrals as appropriate Ensure documentation is present in participant files to support all licensed clinical services which are provided to participants Develop and implement a quality assurance procedure to randomly review files using the SAMIS Case and Participant Detail Report Program management shall work with the JWB Contract Manager to increase Contracted Service Levels and reduce the average cost per participant to 636 The full Compliance and Quality Review Report continues on Page 3 2

8 Compliance and Quality Review Process Description A team of performance management staff from JWB conduct annual reviews of funded agencies and programs The process is consultative in nature and includes both measurements of quality and success and recommendations for development of innovations and efficiencies The process includes several core activities but is also tailored for the uniqueness of the agency and programs it provides Core processes include review of program methodology with a focus on target population service components outcomes and service levels review of contractual requirements and a fiscal review Activities include an entrance interview which includes an overview by the program s director a review for contract compliance a review of participant records and the data collection system staff interviews a review of organizational documents a facility tour observation of services as appropriate and an exit interview A followup to the site visit includes the writing ofthis report the development of a corrective action plan in collaboration with agency representatives if necessary and a copy of this report to the JWB Program Description Service provisions under the current School Based Health Services program are delivered by a multi disciplinary team of health mental health professionals and paraprofessionals which include a pediatrician nutritionist advanced registered nurse practitioners health support technicians registered nurses a licensed practical nurse licensed mental health therapists and clerical support School Based Health Service staff deliver healthcare on site and provide the infrastructure necessary for treating a range of health care concerns as well as chronic diseases provide for acute illnesses work towards alleviating comorbidities among atrisk high school students delivers culturally competent primary preventative and emergency health care and improves the overall health status in a substantially uninsured and medically underserved population through shared school based and community resources The School Based Health Services program underwent restructuring over the past contract cycle In the program reduced the service delivery schools from Northeast High School Meadowlawn Middle School John M Sexton Elementary School Lealman Intermediate School and Clearwater Intermediate School The program now provides services only at Northeast High School and Gibbs High School This reorganization occurred after careful review of service utilization and included input from JWB PCHD and Pinellas County School in the decision making process In addition to the service delivery reorganization the PCHD now subcontracts for mental health services with Suncost The current subcontract includes provision for both the direct mental health service providers as well as a clinical supervision component Contract General Special Conditions General conditions of the contract have been met Special conditions of the contract include those listed below The program has met all of the special conditions of the contract The School Based Health Services program has the following special conditions in their current contract Audit and management letter is waived Board members and meetings dates are waived Government entities who received JWB funding are waived from personnel and fiscal reviews Insurance is waived Program Staff will collaborate as appropriate with any other JWB funded program that may be providing services at the same school site 3

9 The PCHD has updated and submitted their Continuity of Operations Plan for review in May 2011 Additionally the agency continues to function from the Strategic Plan due to a pending re organization at the state level which could highly impact the direction of the Strategic Plan The agency will update the plan when the scope of the pending reorganization is established Program Outcomes Outcomes include two measurable components performance measures referred to as measurable objectives in the current contract and contracted service levels CSL There are currently three identified performance measurements in place for School Based Health Services two of which reflect similar services The first of these performance measures relates to primary youth participants receiving requested clinic or school health services to promote student health The goal is identified in the current contract as 90 The program achieved 100 of this measure for contract year The program is currently achieving 100 of this measure for the contract year The second performance measure relates to primary youth achieving significant improvement in identified goal areas as defined in the counseling plan It should be noted this performance measure was in place related to direct PCHD staff providing the counseling service The program achieved 91 of this measure for contract year with an identified goal of 80 The program achieved 88 of this measure for the current contract year and this was prior to the development of the subcontract with Suncoast Center for these services Given this measure was intended only to capture direct PCHD staff providing the service this performance measure is set to be expired at the close of this fiscal year A third performance measure was developed to measure the Suncoast Center sub contractual performance The measurement was initiated during this contract year and relates to primary youth participants achieving significant improvement in identified treatment plan goals as developed with their therapist The goal identified in the current contract is 80 It should be noted Suncoast began working within the School Based Health Services in March of 2011 and therefore their evaluation period was abbreviated Due to this abbreviated evaluation period only five participants were measured two of which met their treatment plan goals The measurable component of the program related to contracted service levels CSLs is identified in the contract cycle as a goal of 1000 primary youth participants At the time of this report the program has achieved of the goal having served a total of 1018 primary participants The School Based Health Service location of Gibbs and Northeast High School were also assessed independently related to each schools contribution toward the current CSL performance At the time of this review Gibbs High School accounts for approximately 30 of the current service levels During the current contract cycle the School Based Health Service participants have remained with the program an average of 172 days Comparatively participants were remaining in the program an average of 255 days for the contract year This variation may be linked with the change in delivery sites and the timing of this reorganization Related to contract year the program served 1327 primary participants achieving of the contracted service level Staffing School Based Health Services is overseen by the PCHD s Public Health Services Manager currently held by Susan Finlaw Dusseault The program also has an Assistant Community Health Nursing Director This 4

10 position provides direct oversight of the clinic s Advanced Registered Nurse Practitioners ARNP ARNPs at each school location provide oversight for their clinic staff During the contract year Pinellas County Health Department subcontracted with Suncoast for two Licensed Mental Health Counselor positions The two mental health providers receive direct clinical supervision as an element of the subcontract This clinical supervision includes weekly 1 supervision in addition to monthly group supervision Given the nature and variety of medical staff these personnel are required to have current medical certifications as required by law Operational licenses are obtained and maintained by the Pinellas County School Board and the PCHD Currently the program utilizes volunteers within the two clinic locations to varying degrees The program collaborates with local schools to provide learning opportunities for medical students It varies greatly the degree to which an individual volunteers At this time the program has individuals who volunteer regularly and others who serve Less than ten hours a month In lieu of a personnel file review the statutory requirements related to background screenings were reviewed with management staff PCHD staff report all those volunteering over ten hours a month are processed through the Health Department with appropriate background screening Oversight and monitoring of volunteers is provided by the clinic ARNP s No volunteers were interviewed however several were onsite during the review process and were observed to be in direct contact with the clinic s ARNP During the course of this review four clinic staff were interviewed two of which are employees of the sub contractual provider Suncoast Center Inc The clinic staff interviewed expressed enjoyment for their current line of work With recent changes it appears the two clinic locations and related staff are adjusting to the re structuring of clinics and addition of the subcontractual services This year has represented great change requiring increased flexibility and communication among various levels of program staff Of note the two Suncoast staff interviewed conveyed similar adjustments over the course of the past six months It was reported Suncoast and PCHD staff met at the start of the new school year in an effort to enhance several factors related to the creation of the subcontracted providers and the manner in which these two entities collaborate communicate and monitor appropriate functions This process is encouraged to be ongoing as noted below There is opportunity to enhance the mental health service component of this program Participant File Review During the course of the two day review approximately twenty five files were reviewed which included files from both sites These files were comprised of both opened and closed cases The current procedure is to close participant episodes at the conclusion of the school year unless services will be provided during the summer months The School Based Health Service provides a packet of documentation to the participants for parent signature at the start of each school year This packet of information includes the program s consent form While these forms were often in participant files there were instances where the new consent had not been returned to the clinic Of note current consent forms do not have a stated expiration date It was discussed with management the recommendation for the program to develop a standard procedure for the expiration of these consents and staff procedures in the event the child presents to the clinic prior to having an updated consent on file The files were reviewed and compared to SAMIS data using the Case and Participant Detail Report In the majority of cases there was evidence of data integrity however there were occasional instances of inconsistent information The program is therefore recommended to develop and implement a quality assurance procedure related to random file selection and review of files compared to SAMIS data utilizing the SAMIS Case and Participant Detail Report 5

11 Due to the transition of the mental health component being subcontracted to Suncoast there were variations in files and forms beginning March 2011 and forward The current mental health component providers are entering participant data into Avatar Suncoast electronic record system Given this system program staff are then printing and placing a hard copy into the participant file Documentation was observed to have been entered timely Several participants were engaged in services very late in the school year and therefore were not provided adequate time to reach goals prior to closure at the conclusion of the school year It was discussed with management during the review that there was a lack of documentation which would support continuity of care and all services which were provided While the subcontracted staff came into the clinics in the spring of 2011 there was a lack of documentation to support appropriate summer planning follow up to treatment planning timeframes aftercare planning collateral contacts and outside referrals It is required that all case action occurring for participants be captured to ensure appropriate follow up In the future mental health providers should also seek to assess the appropriateness of initiating services near the conclusion of the school year as well as ensure sufficient care is provided to each participant Goal Attainment Scale GAS forms were reviewed during the site visit as an element of the file review process Within the twenty five reviewed files eight contained treatment planning and related GAS goal development The files contained all appropriate documentation and met JWB GAS data collection requirements However some technical problems were found concerning the scaling of the goals eg overlapping double dimension within one scale and blanks In addition the Mental Health Counselor at Gibbs High School was newly hired and has not received training on GAS Therefore it is recommended that the relevant program staff contact JWB Research and Evaluation for GAS training and technical assistance to enhance the development and scaling of goals Other findings of the file review included some evidence of correction fluid program staff will be required to cease the use of correction fluid in participant files The use of correction fluid is outside of best practice as the nature of the alteration to the document cannot be fully assessed When errors occur staff shall draw one line through the error and initial This type of practice allows a clear understanding to the type of edit that is made With these factors noted the files were able to be reviewed with ease The majority of the files contained appropriate releases which did include JWB The PCHD is currently in process of converting to an electronic record system during the next fiscal year The two clinic locations have served 1040 participants for FY 1011 At this level of service the average cost per participant is approximately 788 In FY 0910 School Based Health Services served 1327 clients with an average cost per participant of 536 It should be noted the reorganization of clinic services enables the agency to provide full scale clinic services at each location Program Management shall work with JWB to increase contracted service levels especially at the new Gibbs clinic location and thereby reducing the average cost per participant Program Management School Based Health Services maintains appropriate forms and releases of information within files as appropriate Currently the program does utilize subcontractors for mental health services and the supervision of the mental health providers The PCHD has a quality improvement plan for the agency The Health Department also has an agency strategic plan which is on file from as previously discussed The Pinellas County Health Department currently maintains ASET certification through 2012 The agency and program structure supports this program s mission The agency also recently updated their Continuity of Operations Plan COOP which addresses the agency s plans to execute essential functions in the event of an emergency 6

12 Interviews The two day review process included interviews of six participants The interviews included students from each of the location sites Participants were interviewed in a private space and each conveyed a program atmosphere which is respectful comfortable efficient and confidential in nature The participants described utilizing a wide range of services for various health concerns such as chronic illness sexually transmitted diseases sports physicals mental health services daily care needs and more common illnesses such as the occasional headache Participants did note recent enhancements to the clinics to ensure accountability of the participant s utilizing the clinic appropriately and not as a hang out location to avoid class Students must now have passes from their teachers in order to seek services Length of student participation varied from two months to just over three years One student explained a benefit of the clinic as her ability to access services for illness her parents would not be able to afford due to the high cost of insurance copayments Of these six interviews each stated without hesitation they had no recommendation for improvements to the current program In addition to these six interviews program observation occurred at each service delivery site The clinic s pace is dependent on the flow of participants and can vary from hour to hour Specifically observed were the ARNP s at each site Each of these staff were observed to engage with the students in an appropriate and respectful manner During the review staff were observed to know participants by name and communicated with them in a respectful manner yet hold youth accountable for their behaviors The observation portion of this review demonstrated the benefit of mental health services being available directly on site The flow of needs is apparent and a warm hand off to mental health services occurs whenever possible The Northeast High School clinic staff were observed to reach out to the participants who allowed for a genuine exchange of risk behavior information and healthy living strategies Such an exchange enhances the potential for creating positive change in the lives of these young adults to improve their overall health All staff interviewed andor observed conveyed determination to treat participants so they may return promptly to class ready to learn Significant Accomplishments The school based health centers serve as a training resource for pediatric residents medical and nursing students and nurse practitioner students This valuable resource offers these students an optimum opportunity to gain experience and firsthand knowledge in the field of adolescent health The Pinellas County Health Department in partnership with the Pinellas County School Board replicated the School Based 1lealth Center to provide health care to additional low income uninsured and medically underserved students at Gibbs High School The Pinellas County Health Department in partnership with the Pinellas County School Board have been awarded funding from Health Resources and Services Administration HRSA to construct and equip a stand alone school based health center at Gibbs High School Clinic Fiscal Review and Personnel File Review As noted School Based 1Iealth Services is a program of the Pinellas County Health Department and is therefore exempt from a fiscal and personnel review School Based Health Services is currently an expense reimbursement contract Due to a delay in hiring of staff under the Suncoast subcontract the program is anticipating a lapse of J WB contracted funds for the 1011 contract year 7

13 Recommendations Develop written procedures outlining a standard practice for consents to include expiration details Ongoing collaboration should continue to occur between partnering agencies to ensure quality services and the continuation of enhancing current services Supervision of licensed clinical staff be documented by Suncoast and monitored by PCHD as a component of overseeing the current subcontract This supervision should include a file review of documentation to ensure all case action is being captured Requirements The program staff will cease the use of correction fluid in participant files Licensed clinical staff to work with the JWB Research Department to arrange for Technical Assistance related to GAS goal enhancement and GAS training for new employees Ensure clinical services are occurring and include summer break planning after care services continuity of care efforts collateral contacts and outside referrals as appropriate Ensure documentation is present in participant files to support all licensed clinical services which are provided to participants Develop and implement a quality assurance procedure to randomly review files using the SAMIS Case and Participant Detail Report Program management shall work with the JWB Contract Manager to increase Contracted Service Levels and reduce the average cost per participant to 636 8

14 JWB CHILDREN S SERVICES COUNCIL OF PINELLAS COUNTY COMPLIANCE QUALITY REVIEW SUMMARY Agency PCHD Program School Based Health Services Fully Partially Needs Comment Standard Meets Meets Improvement Contract General Conditions Special X Conditions 5 indicators Program Methodology 12 indicators X Ensure clinical services are occurring and include summer break planning after care services continuity of care efforts collateral contacts and outside referrals as appropriate Ensure documentation is present in participant files to support all licensed clinical services which are provided to participants The program staff will cease of the use of correction fluid in participant files Contract Service Levels Measurable X Licensed clinical staff to Objectives Other Deliverables 7 indicators Program Staff andor Volunteer Management 12 indicators X work with the IWB Research Department to arrange for Technical Assistance related to CAS goal enhancement and CAS training for new employees Data Collection Reporting 11 indicators X Develop and implement a quality assurance procedure to randomly review files using the SAMIS Case and Participant Detail Report Program Management 11 indicators X Develop written procedures outlining a standard practice for consents to include 9 expiration details Ongoing collaboration should continue to occur between partnering

15 agencies to ensure quality services and the continuation of enhancing current services Administrative Standards 6 indicators X Supervision of licensed clinical staff be documented by Suncoast and monitored by PCHD as a component of overseeing the current subcontract This supervision should include a file review of documentation to ensure all case action is being captured Program to work to increase CSL s and decrease cost per participant Fully Meets Program met every indicator Partially Meets Program received a partial rating in one or more of the indicators Needs Improvement Program received a needs improvement in one or more of the indicators Overall Rating Program is in full compliance X Program is in partial compliance level 1 and is able to complete correction without further assistance or requires prescriptive training and technical assistance Program is experiencing compliance infractions of a more severe nature level 2 Provider must demonstrate compliance within six months Prescriptive training technical assistance and more frequent monitoring will be conducted Program is required to implement a corrective action plan level 3 CjJ l LC Je firer ayl L Lisa S a Director of Performance Management Senior C tract Manager a 10