Policy: 123b
(SCDDSN Directive 100-28-DD)

Quality Management Plan


BACKGROUND

The organizational context within this policy promotes the intent of the agency's Vision, Mission and Values Statement.

VISION:

  • All participants are able to live to their fullest potential as active and independent members of their communities, regardless of ability or need.

MISSION:

  • We provide access to high-quality services and proactively advocate for the rights of those with disabilities and special needs in conjunction with their families.

VALUES:

  • We will respect and elevate the dignity of all people.
  • We will ensure the health, safety and welfare of every person we work with.
  • We will prioritize the availability and accessibility of our services.
  • We will maintain excellence through integrity at each level of our organization.
  • We will promote equality and equity for our individuals in all aspects of their lives.

The basic requirements for internal monitoring include Risk Management and Quality Assurance activities, as outlined in the SCDDSN Administrative Agency Standards. These components include:

  • Person-Centered and Community Inclusivity;
  • Responsive, efficient and accountable to participants and families;
  • Practical, positive and appropriate approaches;
  • Strength-based and results-oriented activities;
  • Inclusive opportunities to be productive and maximize individual potential and independence;
  • Based upon "Best Practices."

These strategies are designed to:

  • Offer the highest quality services that promote choice and control in people's lives;
  • Promote and protect the health, safety and rights of people receiving services;
  • Implement promising practices; and
  • Ensure compliance with standards, policies and/or other requirements.

These strategies incorporate functional priorities that focus attention on person-centered outcomes:

  • Participant access to services;
  • Participant-centered service planning and delivery;
  • Provider capacity and capabilities;
  • Participant Rights and Responsibilities;
  • Participant Outcomes and Satisfaction, and
  • Overall system performance.


RISK MANAGEMENT ACTIVITIES

MDCBDSN utilizes a variety of measurable risk management activities that strive to prevent negative occurrences in the lives of those supported. These activities include:

  1. Traditional activities that include common operating strategies that address buildings, vehicles, equipment, OSHA compliance, pre-employment screening requirements, pre-service training requirements, insurance coverage, financial auditing, and legal considerations.
  2. Participant-oriented activities are aimed to assure the health and safety of those who depend upon MDCBDSN daily and those who receive twenty-four (24)-hour supports and services. Activities in this area include tracking and reviewing to any responses to allegations of abuse, neglect and exploitation, critical incidents, complaints, appeals, grievances and death/mortality tracking.
  3. Participant determined activities include strategies and opportunities for participants to have more control of their lives and the decisions that are made regarding services and supports that they receive. Participants are given the opportunity to weigh the risks of their decisions with the choices that they make. Some examples include the following: choice of food/diet; exercise; compliance with medical advice; level of supervision; sexual preferences; compliance with hygiene recommendations; acceptance of behavioral health services, etc. At the root of all of these issues, is the balance between the participants' right to determine the direction and quality of their lives and the duty to protect participants from foreseeable negative consequences. Activities or strategies used may include Circle of Supports, Conflict-Free Case Management, Human Rights Committee, Self-Advocacy Group Meetings etc.
  4. Internal and External Audit Activities are an important aspect of our Risk Management Process. MDCBDSN welcomes review by SCDDSN Internal Audit Division to review the adequacy and effectiveness of governance and risk management, including internal controls, to support the achievement of MDCBDSN organizational objectives, and to promote continuous quality improvement. External audit activities provide additional assurance to satisfy expectations that protect the stakeholders and satisfy requests by management and the MDCBDSN Board of Directors regarding resource allocation and frugality.


QUALITY ASSURANCE / QUALITY IMPROVEMENT ACTIVITIES

  1. Licensing Activities: Activities and reviews that assist in providing a foundation of health and safety upon which other quality of life initiatives may be built. Such examples include Fire Marshall Inspections and inspections by a contracted provider to ensure that facilities meet defined standards and that deficiencies are corrected.
  2. Contract Compliance Activities: Quality Assurance Reviews are completed twelve-(12) to eighteen-(18) months cycle by a contracted Quality Improvement Organization to measure and evaluate the health and safety of the participants receiving services.
  3. Post-Payment Claims Review: A random sampling of Medicaid claims for services rendered annually to determine if those claims are supported by adequate documentation which verifies the authorized services were delivered appropriately. This contractual agreement with SCDDSN will be reviewed no less than every three-(3) years.
  4. Observation of Residential and Day Services: The Residential and Day Observation/Participant Survey stands alone as a distinct measure of continuous quality improvement. The surveys may be completed in conjunction with other quality assurance/improvement activities or may be conducted as a separate activity internally or by external contracted sources.
  5. Participant/Family Satisfaction Measures: Although MDCBDSN strives to satisfy all participants and families, it is still a distinct possibility that a participant may receive needed supports and services and still feel dissatisfied with service provision. Participant and family surveys will be conducted annually. These results will be shared with the Board of Directors for review and consideration of how to address areas of concern for improvement. Additionally, MDCBDSN participates in completing the National Core Indicator (NCI) surveys each year with the assistance of Case Managers and those that provide direct services. This data is collated to be used to compare data from the state and compare it with states providing similar services.
  6. Quality Enhancement Activities: MDCBDSN embraces multiple approaches to collect data to enhance the quality performance of the organization. These approaches include the following but is not an all-inclusive list.


MDCBDSN QA Efforts

CQI Efforts QA Efforts Quality Improvement Efforts Risk Management Efforts
Use of Cameras in common areas of day and residential facilities Medication Error Tracking Completion of Annual Action Plan Completion of Sans Cyber Security Training Yearly
Participation with NCI Surveys for the State Medication documentation error Unannounced Quarterly Home Visits I-Train for online yearly recertification training
Engagement with Enterprise Fleet Management to assure that vehicles are current, safe and affordable GER report tracking Behavior Support Training Use of Therap Training Module to track employee training
National Safety Council for First Aid, CPR and Defensive Driving ANE/CI Tracking Regular Human Rights Committee Meetings Review consumer Cash on Hand balances monthly
Internal Preparation of Financial Reporting by CPA Worker's Compensation Tracking Monthly Reconciliation of consumer bank accounts. Regular Fire Drills, Emergency Drills and Active Shooter Drills at Day Centers
Use of GPS-Tracking Devices on residential and day service vehicles Reviewing Overtime Report and Rationale Encourage consumer participation in self advocacy activities Regular Fire Drills and Disaster Drills at the residences
Annual Training for CRCF Administrator Alliant Reviews Use of Camera System for day and residential services Review of Camera Footage to monitor for any safety issues
Serve Safe Certifications Annual Financial Audit by Outside CPA Firm Exit Interviews to track employee trends Review monthly data from GPS Tracking devices
Membership with the SC Human Services Provider Association Board of Directors received Monthly Financial Reports Monitoring employee vacancy rate to the time it takes to fill positions Tracking Supplies and Inventory to ensure health and safety of consumers
Active Participation with Pee Dee Providers Meeting to include various program counterpart meetings Swallowing Disorder Consultations and Follow Up Monthly Safety Committee Meetings Use of a Beam Security System to prevent theft at Marion day program; hope to purchase for Dillon location as well
Daily Checklists for Agency Vehicles Preparation of Annual Budget with Interdepartmental Input Regular safety inspection completed by Safety Committee Changing door codes immediately after an employee is separated from the agency
Use of Online Financial Software Monthly Discussion of Consumer Movement Issues at Executive Staff Meetings

MDCBDSN Benchmarks

Program Benchmark
Early Intervention All IFSP/FSP will be completed on time 100% of the time per BabyNet and DDSN standards
Maintaining a 90% or better on Annual Contractual Compliance Reviews
95% of the families will participate in the Transition process to part B services
 
Case Management Support Plans will be completed by the CM within 365 days of the previous plan, 100 % of the time
Level of Care's will be completed within 365 days of the previous LOC, 100% of the time
Maintaining 90% or better on annual Contract Compliance Reviews
 
Human Resources Agency turnover rate of 20% or less
New Hire timelines are 30 days or less
Worker's Compensation Modifier is .90 or less
 
Finance A 1.5% profit margin is realized in all departments
To end the fiscal year with a surplus
To have 2 or less exceptions on annual independent audit
 
Residential 35% or less annual staff turnover rate
0.06% or less annual med error rate
0.12% or less annual medication documentation error rate
Score 90% or better on annual Contractual Compliance Review
 
Employment/Day Services Score 90% or higher on annual Licensing Reviews for both day centers
Maintain 90% or better on annual Contractual Compliance Reviews
80 % of consumers will attend the day program at least 4 days per week
 

Continuous Quality Improvement is an ongoing and evolving process. MDCBDSN recognizes and deploys a variety of measures to assess, review and take appropriate action steps to improve the overall performance of agency programs. MDCBDSN strives to stay informed regarding new and emerging trends, programs and processes to enhance continuous quality improvement of the agency.

Purpose

The purpose of this policy is to establish the conceptual framework for the Marion-Dillon County Board of Disabilities and Special Needs (MDCBDSN) Quality Management (QM) oversight of services delivered to participants eligible for MDCBDSN services and ensuring compliance with standards, polices and/or other requirements.

Effective Date:
March 23, 2023