Action Plan
MH/DD/ILP Program Standards Site Review
Site Review Team
Recommendation
|
Actions Planned
by Agency
|
Implementation
Date(s) |
|
1. Assure that all consumer files contain
Individual Service Plans. (Prior review) |
All files that were reviewed did contain ISP’s
except one consumer who had been recently drawn for waiver as an emergency
draw. FCS had started services because
of the urgency, but because the consumer was in the guardianship process, his
team had not been formalized. Plan of
care as well as ISP were in the process but not yet ready to be in the file. |
All FCS ISP’s have been submitted and
acknowledged by our program specialist.
Only ISP’s not written are for new draws and they are under in progress
along with Plans of Care. |
|
2.
Assure that all Individual Service Plans
contain measurable goals and objectives.
(Prior review) |
Plans do have measurable goals as set by the
interdisciplinary team, consumer and family. FCS is currently designing tracking
sheets for every consumer for easy identification by management,
consumer/family/audit teams of progress on the identified goals of both FCS
and consumer. |
Being done when Plan of Care and ISP meeting are
held and submitted to Program Specialist. |
|
3. Assure that there is a feedback system
regarding respite, verification of respite provision and the family’s
approval of that respite. (Prior
review) |
This was confusing to FCS. A feedback form has always been given to
individuals receiving respite. Most
are not returned. When we receive a
call for respite, we always ask for provider preference. If there is none, we send an available
employee. If the family calls and
tells us that they were not satisfactory, they are not sent again. FCS feels that the only way to assure
feedback would be to require a form for each prior occurrence before
accessing additional respite, as there is not time to individually call every
family/consumer. |
Already being done, FCS will track return of
responses as much as possible. |
Site Review Team
Recommendation
|
Actions Planned
by Agency
|
Implementation
Date(s) |
|
4. The Board is to evaluate the Director in
formal, written form annually.
(Standard #9) |
The Board of FCS feels that there are many levels
of review of a director and that any director is evaluated on a day-to-day
and month-to-month basis. The FCS
director has been with the agency for many years and for most of those did
receive written evaluations. To meet
this standard, the Board has recently written an evaluation and will continue
to do so. |
March, 2001 |
|
5.
Formalize the utilization of consumer and family input
in determining policy and program delivery.
(Standard #12) |
Board of
Directors meeting are open and every consumer/family receives a survey on their
plan anniversary date. The Board would
be more than pleased to have input to utilize and have discussed ways to
encourage people to return surveys and give input at their meeting.
|
September
2001. Planning to hold a
formal town meeting like affair in the fall and advertise it as we did the
site review meeting and see what happens. |
|
6.
Systematically involve consumers and families, staff
and community in annual agency planning and program evaluation. (Standard #13) |
Staff DD
Services meeting are and have been held weekly for input and planning. A form will be designed and suggestions
logged. Board of Directors meeting are
open and every consumer/family receives a survey on their plan anniversary
date. The Board would be more than
pleased to have input to utilize and have discussed ways to encourage people
to return surveys and give input at their meeting.
|
Staff involvement is
already in progress. See above for
families and community. Our review
sheets showed good interagency cooperation and planning and we will attempt
to expand on this. |
Site Review Team
Recommendation
|
Actions Planned
by Agency
|
Implementation
Date(s) |
7. Formalize a process to
develop annual goals and objectives in response to consumer, community and
self-evaluation activities. (Standard
#14)
|
Board of
Directors sets agency goals yearly and always has. These goals are developed by feedback
received. If additional feedback is
received from the more formalized process, the Board will incorporate it.
|
November
2001. A self-evaluation
will be conducted yearly following the EIP evaluation tool on the years there
is no site review. |
|
8. Facilitate the reception of critical
feedback to management from consumers and their families and from staff. |
Both the Executive Director and Board are very available. Critical feedback has always been welcome, but not given. FCS will strive to design a system, which facilitates and encourages this feedback. An employee suggestion box was installed right after the survey and to date, we have received one suggestion. “That we put the phones on answer mode when we are having staff meeting as the ringing is distracting.” |
Suggestion box
installed December
2000. On-Going work will be done for feedback
from other parties. |
|
9. Provide additional structured and on-going
staff training in positive behavioral supports, developmental disabilities,
body mechanics, etc. |
A Human
Resource Coordinator was hired in February 2001 one of their duties will be
to formalize and log our staff training.
Body Mechanics training has been conducted twice and will be on-going
by our contractual physical therapist and other training is planned including
Dr. Mathias in April. FCS advertised
for a behavioral interventionist and received no response to the add. FCS would also like to mention that it
would be beneficial if the state offered training opportunities that FCS
staff could take advantage of. FCS
feels that the lapse in offering care coordinator training was unacceptable.
FCS currently sends staff to training as it becomes available in the
community and around the state.
|
December,
2000 and on-going. |
Site Review Team
Recommendation
|
Actions Planned
by Agency
|
Implementation
Date(s) |
|
10. Consistently utilize agency procedures for
consumer input in hiring and evaluation of support staff. (Standard #22) |
FCS feels that
we do include consumers and families in the hiring process. We will
acknowledge that there are times when we have to fill vacancies on an
emergency basis and there may not be time.
We also must state that often, we may have only a pool of one to take
certain positions. As identified
throughout the state, the hiring pool is very small.
|
Hiring of the Human
Resource Coordinator – February
2000 – is expected to give us
a more available pool of employees and allow time to always include consumer
input. |
|
11. Assure that performance appraisals are
applied consistently to all employees and that they include feedback and
recognition. (Standard #28) |
Human Resource
Coordinators will now do evaluations.
This will allow them to be timely and identify problem areas as well
as areas of expertise that demand recognition.
|
February,
2000 |
|
12. Write a staff development plan annually
for each professional and paraprofessional staff person. (Standard #29 and prior review) |
This will be
developed with the employee at the time of their evaluation. FCS has employed most professionals working
with individuals with developmental disabilities for many years.
|
Written
at the time of employee’s evaluation. |
|
13.
Develop agency-wide training plans and implement a system for
assessing, providing and tracking the training of staff. (Standard #30) |
This was primarily covered in response to Site Team recommendation #9. The Agency training program will be formalized and will include written curriculum. The new Human Resources Coordinator has visited both ARCA and Hope to review their training for DD staff. However, this training is not agency-wide as the recommendation states as training requirements are completely different for staff offering services to the other populations we serve. |
Started
January 2001 – Completely implemented by May 2001 |
Site Review Team
Recommendation
|
Actions Planned
by Agency
|
Implementation
Date(s) |
|
14.
Assure that the performance appraisal system adheres to reasonably
established timelines. (Standard #31) |
Evaluations
are done currently, but not always on time.
FCS’s goal is to hire additional staff and hopefully overcome the
problem. The Human Resources Coordinator was a step in this direction.
|
February,
2001, on-going |
|
15.
Establish goals and objectives for the period of employee
appraisal. (Standard #32 and prior
review) |
Goals will be
established at the time of evaluation.
|
At
each employees evaluation. |
|
16.
Assure that consumers/guardians can exercise choice in the assignment
of support staff and that consumers as well as guardians have a choice of
roommate. |
See Action
Planned #10. FCS does make every attempt for
choice. If you look in the life areas,
it states that we moved employees at consumers request. FCS was confused over part of this
recommendation, as guardians do have the final say and we can suggest, but
not overrule their decision as far as the choice of living situation for
their ward.
|
On-Going |
|
17.
Develop a plan to improve staff morale. |
Staff is now receiving a monthly staff
newsletter. FCS has recently increased
the starting wage. FCS realizes that
support staff has a hard job and although benefits and wages have been
increased challenges still face us. |
February
2001 and On-Going. |
Site Review Team
Recommendation
|
Actions Planned
by Agency
|
Implementation
Date(s) |
|
18. Clarify with all staff the expectations for
relationships between staff and consumers. |
FCS has a number of consumers that have very
structured plans that must be followed for the consumer’s health and
safety. An interdisplinary team writes
these plans. Staff are orientated to
these plans, but often do not agree with them and let friendships develop to
a point that they impact the consumers health and safety. The Site Review Team interviewed a couple
of these consumers during their visit.
The only other restriction on the depth of the relationship is that
employees don’t give out their home numbers and don’t accept gifts from
consumers. The phone number
restriction was put in place after the agency paid to change numbers for
employees when use of their home numbers was abused after they gave them to
consumers. |
Orientation
and policy procedures have always been in place and explained. |
|
19.
Collaborate with staff on developing and communicating consumer staff
ratios in a variety of circumstances. |
Ratios are set
when plans are written before employees are hired. If staffing problems are identified, FCS
amends the plan if possible. Staff
ratios are outlined and approved by DMH/DD in the consumers Plan of
Care. Most consumers have a one to one
staff ratio. The area of concern can be related to one of our residential
homes. The consumers in this home
experience severe disabilities including health and behavioral issues. The home is staffed at a 3/2 ratio, except
when residents are at their vocational site.
Some staff feel that 3/2 is needed at all times in case consumers need
to be brought home early from their day program. The ratio has been discussed regularly at
house staff meetings.
|
Input
being solicited regularly |
Site Review Team
Recommendation
|
Actions Planned
by Agency
|
Implementation
Date(s) |
|
20.
Continue developing the systems and infrastructure to accommodate
recent growth. |
Infrastructure
development has been identified by every provider agency as being
problematic. FCS continues to expand
systems and personnel, as funding is available to keep ahead of the growth
including management personnel, clerical support, equipment and space.
|
On-Going |
|
21.
Provide additional information to families regarding FCS activities. |
FCS holds a
holiday celebration and invites every consumer from every department in the
agency. Over 300 people attended this
year. FCS currently sends an activity
calendar of our recreation program to families/consumers who have expressed a
desire to participate in this program.
We will expand our mailing to include all families/consumers known to
the agency. We have recently hired a
new program assistant who will make every effort to publish our newsletter on
a regular basis.
|
Expansion
of information started March 2001 |
|
22. Document the reasons and conditions when
consumers are unable to spend their money as they choose. |
FCS will be
sure to include any monetary restriction in the consumer files.
|
November,
2000 |
|
23.
Continue efforts to improve timeliness and provide adequate notice of
meetings. |
This
recommendation is being addressed as if it is referring to ISP and waiver
meetings. FCS is currently up to date
on all renewals and ISP’s of on-going consumers. Staff is currently writing plans and ISP’s
of consumer drawn during the last two months.
All meetings are scheduled at the time and choice of the
consumer/family so we can’t address the adequate notice unless it was a
meeting called in responses to problems that may have developed in an
existing plan.
|
Completed |
Action Plan
MH/DD Program Standards
FCS would like to include the following comments. Most of the Site Review Teams Recommendations were areas fo weakness that had already been identified by FCS. FCS was in the process of a reorganization of the DD Community Supports Department at the time of the review. The following steps have already been taken:
I want to take this opportunity to thank Northern Community Resources and the team members for conducting our review.