QUALITY IMPROVEMENT PLAN - DOC by 4780Gy

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									                                       QUALITY IMPROVEMENT PLAN
Company ID Number: 76689                                       Survey Number: 37603
Psychotherapeutic Services                                     Accreditation Decision: Three-Year Accreditation
942 Walker Road                                                Accreditation Expiration Date: 3/31/2010
Suite B
Dover, DE 19904                                                Survey Date(s): 3/1/2007 through 3/2/2007
US
Return to CARF by 7/5/2007
Completed by (Name): Deborah (Dusti) C. Jones                  Date Completed: July 2, 2007

Job Title: Chief Executive Officer



 Standard Number for                                                                         Completion Date
                           Action to be Taken
  Recommendation                                                                           (Actual or Estimated)
Section 1                  Business Practices
                           Criterion B. Accessibility
B.1.a to B.1.c.            The corporate strategic plan shall be revised to include              7/31/07
                           an enhanced accessibility goal to allow for a higher
                           quality of life for the persons served and address the
                           needs of personnel and/or other stakeholders. A new
                           accessibility goal for the Company that is being
                           considered is the researching and purchasing of
                           Company vans that are wheelchair accessible. This will
                           allow programs to provide greater support and
                           community coordination to persons served whom is
                           wheelchair bound. Research and feasibility study to be
                           conducted by the Company Risk Manager.
B.2. a (1) to              To enhance the quality of life of the person served and               8/30/07
B.2.a.(7)                  personnel Psychotherapeutic Services has adopted the
                           need to include in its strategic plan an accessibility goal
                           for the Company. By addressing one accessibility goal
                           throughout the Company, persons served and personnel
                           will experience consistent improved levels of support in
                           maintaining and achieving higher quality in area of
                           accessibility. An accessibility goal shall be added to the
                           Company’s Strategic Plan upon completion of the
                           research and feasibility study by the Risk Manager.
                           Criterion      C.    Information      Management        and
                           Performance Improvement
C.8.a. (1) to C.8.b.       The Information Management Coordinator expanded the                   6/28/07
                           information management and technology plan to include
                           in the Company’s IT Plan, the company’s anticipated
                           need(s) of software, hardware, any changes in security
                           or confidentiality, disaster recovery preparedness, and
                           virus protection. The need for assistive technology in
                           individual programs will be addressed by individual
                       programs and will be reflected in each program’s
                       accessibility evaluation. The IT Coordinator will also
                       utilize the data results from Company Employee
                       Satisfaction Surveys to support changes in information
                       management and performance improvement activities. A
                       written plan for Information Technology at Psychotherapeutic
                       Services has been completed for the next 3-5 years.
                       Criterion E. Health and Safety
E.2.a (1) to E. 2.b.   All Company programs will have an annual external                  7/31/07
(4)(a)                 inspection completed by a local community inspector
                       such as the City/County Fire Marshal. Programs will
                       maintain a copy of such in inspection within their
                       program. Any cited correction shall be handled
                       expeditiously. Only if there is a conflict in resolving any
                       required correction note by any local external inspector
                       for any location that is rented by the Company will the
                       Risk Manager and the Corporate Executive Team
                       become involved to resolve such conflicts. All program
                       locations owned by the Company will correct any cited
                       violations by such inspector. A copy of all facility
                       inspections completed by an external inspector, a copy
                       shall be sent to the Risk Management Department. An
                       external inspection to be completed at PCSA, KCCCP by
                       July 31, 2007.
E.3.a.(1) to           PCSA, KCCCP ACT Program will have a semi-annual                    7/31/07
E.3.b.(4)(a)           internal inspection completed by the Company Risk
                       Manager every June and December. This will ensure that
                       the program is receiving a review twice a year. The
                       program and the Risk Manager shall maintain a copy of
                       the review and any need corrections. The first inspection
                       to be completed by July 31, 2007.
E.6.a. (1) to E.6.b.   PCSA, KCCCP ACT Program shall complete a practice              7/31/07 & 8/31/07
                       emergency evacuation drill monthly. A schedule of the
                       type of drill (fire, bomb threat, natural disaster, utility
                       failures, medical emergencies or safety) that will be
                       conducted shall be developed and communicated to all
                       staff members identified in the program’s emergency
                       evacuation policy. The monthly drill schedule to be
                       posted by July 31, 2007. The first evacuation drill will be
                       completed and documented by August 31, 2007.
E.7.a. to E.7.c.(1)    PCSA, KCCCP ACT Program is scheduled to have a test                7/31/07
                       of their emergency and evacuation procedures by July
                       31, 2007. The Company Risk Manager will be
                       responsible for conducting the test and the written report.
                       The report to include and performance improvements
                       and results of performance improvements or the
                         acknowledgement of satisfactory performance. A copy of
                         the report to be maintained at the program and the Risk
                         Management Department.

E.11.d. (4)              Psychotherapeutic Services has added to its Occurrence        7/31/07
                         Report Form for reporting or critical incidents, the
                         category of “communicable disease”. All program
                         managers will be sent the revised corporate form and
                         instructions for the addition of reporting of communicable
                         disease category by July 31.2007.
E.11.d. (5)              See above correction.                                         7/31/07


E.23.b.                  PCSA, KCCCP ACT Program has placed fire                       6/30/07
                         extinguishers in all vehicles. The extinguisher is securely
                         mounted within the trunk of the vehicle.
                         Criterion F. Human Resources
F.5.a                    Job descriptions will be reviewed by June 30th each year.     6/30/07
                         Documentation will be placed in the job description
                         binder.
F.9.b                    Hiring Supervisors will complete Verification of              6/30/07
                         Credentialing Form. The form lists methods of primary
                         verification and the method utilized will be checked off.
                         The person verifying the credentials will sign the form.
                         Audits will be performed by the Human Resources
                         Department within 30 days of hire to ensure that primary
                         verification has been performed.
                         Criterion G. Leadership
G.8.a                    Company Policies will be reviewed and approved by             12/31/07
                         Executive     Committee/Board      of    Directors when
                         presented. Executive Minutes will reflect the specific
                         name of any policy approved or not approved. Annually
                         the Executive Committee/Board of Directors will review
                         and approval all Company policies. Documentation will
                         be placed in the Company Policy & Procedure Manual.
                         Criterion I. Financial Planning and Management
                         The Company’s Chief Financial Officer is considering the
                         CARF consultation for this criterion. To date no decision
                         has been made regarding this consultation.
Section 2                General Program Standards


                         B. Screening and Access to Services
B.9.f., B.9.m. (6)(a),   PCSA, KCCCP ACT Program has revised the Initial                3/2/07
& B.9.m. (6)(b)          Assessment Form to include preferences, and history of
                         abuse and neglect. The form revised on March 2, 2007
B.10.b. (1) to B. 10.    PCSA, KCCCP ACT Program treatment plan form has                  3/2/07
b. (3)                   been revised to include an interpretive summary of
                         assessment data. The form was revised on March 2,
                         2007.
                         C. Individual Plan
C2a                      All PCSA, KCCCP ACT Program staff members were                   3/2/07
                         informed of the required completion and use of
                         interpretive assessment summary information on March
                         2, 2007. All future treatment plans will be reflective of the
                         use of interpretive assessment summary information.
                         D. Transition/Recovery Support Services
D. 9.d. (3) to D. 9.d.   PCSA, KCCCP Discharge Summary Report Form was                    3/13/07
(6)                      revised on March 13, 2007. To include the persons
                         served strengths, needs, abilities, and preferences. All
                         ACT staff members required to complete discharge
                         summary reports was given a copy of the new form. All
                         future discharge reports after March 13, 2007, includes
                         this information.
                         E. Pharmacotherapy
E.2.c                    PCSA policy 4.06 Biohazardous & Medications has been            6/20/2007
                         revised to include a statement on the safe disposal of
                         medication.
E.5.b                    PCSA policy 4.00 Medication Management has been                 6/20/2007
                         revised to include a statement on the availability of a
                         physician for consultation 24 hours a day, 7 days a week.
E.5.c                    PCSA policy 4.04 Medication Prescription has been               6/20/2007
                         revised to include a statement on the identification and
                         the documentation of medication reactions that is
                         experienced by the person served.
E.5.d (1-3)              PCSA policy 4. 04 Medication Prescription has been              6/20/2007
                         revised include the effectiveness, the side effectives, and
                         any allergies or adverse reactions
E.5.e                    PCSA policy 4. 04 Medication Prescription has been              6/20/2007
                         revised to include a statement that requires an evaluation
                         of co-existing medical conditions of persons served.
E.5.f                    PCSA policy 4. 04 Medication Prescription has been              6/20/2007
                         revised to include a statement on the identification of
                         alcohol and other drug use.
E.5.g                    PCSA policy 4. 02 Medication Administration Record has          6/20/2007
                         been revised to include a statement requiring the
                         documentation of informed consent for each medication
                         prescribed.
E.5.h                    PCSA policy 4. 02 Medication Administration Record has          6/20/2007
                         been revised to include a specific statement on
                         documenting and reporting of medication errors.
E.5.i             PCSA policy 4.00 Medication Management has been             6/20/2007
                  revised to include a statement that addresses the use of
                  over-the-counter medications. All members have a
                  signed Informed Consent for Psychotropic and Other
                  Medication Form in their chart that contains the
                  statement that the member has been educated on the
                  use of over-the-counter medications.
E.5.j             PCSA policy 4.00 Medication Management has been             6/20/2007
                  revised to include a statement on the use of medications
                  by women of child bearing age. All members have a
                  signed Informed Consent for Psychotropic and Other
                  Medication Form in their chart that contains the
                  statement that the member has been educated on the
                  use of medications by women of child bearing age.
E.5.k             PCSA policy 4.00 Medication Management has been             6/20/2007
                  revised to include a statement on the use of medications
                  during pregnancy. All members have a signed Informed
                  Consent for Psychotropic and Other Medication Form in
                  their chart that contains the statement that the member
                  has been educated on the use of medications during
                  pregnancy.
E.5.l             PCSA policy 4.06 Biohazardous & Medications has been        6/20/2007
                  revised to include a statement on the education of the
                  person served on the management of biohazards
                  associated with the use of medications.
E.5.m (1) & (2)   PCSA policy 4.00 Medication Management has been             6/20/2007
                  revised to include a statement on the requirement of
                  having posted close to a program telephone the number
                  of the poison control center for accessing by persons
                  served and personnel. The poison control number has
                  been posted on the wall next the member phone located
                  in member lobby.
E.5.n.            PCSA policy ### on Quality Improvement has been             6/20/2007
                  revised to include a specific statement on the monitoring
                  of medication errors by the Risk Management
                  Department via Program Occurrence/Incident reports.
                  Quality monitoring also occurs via personnel peer review
                  of person served charts during quarterly reviews/case
                  conferences. All person served case review forms will
                  contain documentation regarding the present of absence
                  of medication errors.
E.5.o             PCSA policy 4. 04 Medication Prescription has been          6/20/2007
                  revised to include the requirement of documenting any
                  special dietary needs and restrictions associated with
                  medication use for the person served.
E.5.p         PCSA policy 4.00 Medication Management has been              6/20/2007
              revised to include a statement on the notification of the
              prescribing professional regarding medication reactions
              or problems, including errors.
E.5.q         PCSA policy 4. 04 Medication Prescription has been           6/20/2007
              revised to include a statement requiring the person
              served to receive all necessary laboratory studies, tests,
              or other medical procedures.
E.5.r         PCSA policy 4.02 Medication Administration Record has        6/20/2007
              been revised to include a statement that requires the
              documentation of the continuation of medications
              prescribed by a source other than the organization in the
              medical chart of the person served.
E.5.s         PCSA policy 4.02 Medication Administration Record has        6/20/2007
              been revised to include a statement on the requirement
              of documenting the coordination with the primary care
              physician providing care needs for the person serve.
E. 6.a. (2)   PCSA policy 4.02 Medication Administration Record has        7/30/2007
              been revised to ensure that the medical staff of the
              program documents how they are applying the most
              recent treatment guidelines to ensure the safety of the
              person served while applying any pharmacotherapy
              practice. Documentation of such practices shall be noted
              with the program quality assurance manual.
E.6.b         PCSA policy 4.02 Medication Administration Record has        7/30/2007
              been revised to include the requirement of the program
              having a medication utilization review that will be
              completed by the Chief Medical Officer on a quarterly
              basis. Documentation of such reviews and any
              corrections shall be kept in the program quality
              assurance manual.
E.7.a         PCSA policy 4.04 Medication Prescription has been            6/20/2007
              revised to include a statement on the non-purchasing of
              medication samples and medications for persons served
              that the program is not the representative payee. The
              policy has been expanded to require program staff to
              document all efforts to coordinate any community
              resources to assist the person serve in purchasing
              needed medications.
E.7.b.        PCSA policy 4.02 Medication Administration Record has        6/20/2007
              been revised to include a statement on staff being
              required to document the need of transportation and or
              delivery of medications to the person serve.
E.7.f.        PCSA policy 4.06 Biohazardous & Medications has been         6/20/2007
              revised to include how the program will handle the safe
              disposal of medications.
E.7.g.       PCSA policy 4.02 Medication Administration Record has            6/20/2007
             been revised to include a statement regarding the
             medical staff’s responsibility in completing an inventory
             of all sample medications. The inventory shall be
             completed quarterly.
E.7.i. (3)   PCSA policy 4.00 Medication Management has been                  6/20/2007
             revised to include a statement requiring the medical staff
             of the program to document the use and benefits of as
             needed (prn) medications.
E.8.a. (1)   PCSA policy 4.00 Medication Management & the                     6/20/2007
             Psychiatric Visit Report Form have been revised to
             require the documenting of the person serve needs and
             preferences,
E.8.a (2)    PCSA policy 4.00 Medication Management & the                     6/20/2007
             Psychiatric Visit Report Form has been revised to require
             the documenting of the efficacy of medications by
             medical staff.
E.8.b        PCSA policy 4.00 Medication Management & the                     6/20/2007
             Psychiatric Visit Report Form has been revised to require
             the documenting of the presence of side effects, unusual
             effects, and contraindications.
E.8.c        PCSA policy 4.00 Medication Management & the                     6/20/2007
             Psychiatric Visit Report Form has been revised to require
             the documenting of the assessment of abnormal
             involuntary movements at the initiation of treatment and
             every three months thereafter for persons served
             receiving antipsychotic pharmacotherapy.
E.8.d        PCSA policy 4.00 Medication Management & the                     6/20/2007
             Psychiatric Visit Report Form has been revised to include
             a statement on the use of multiple simultaneous
             medications.
E.8.e        PCSA policy 4.00 Medication Management & the                     6/20/2007
             Psychiatric Visit Report Form has been revised to
             include a statement on the program psychiatrist being
             required to document medication interactions. The
             documenting of such interaction shall be recorded on the
             program’s psychiatric visit report form and on the
             psychiatrist’s progress note.




                     (Please make additional copies of this form as needed)
Ms. Charlene Slimp
4891 East Grant Road
Tucson, Arizona 85712


                                                July 3, 2007


Dear Ms. Slimp:


Enclosed is the Quality Improvement Plan (QIP) for Psychotherapeutic Services. We appreciate
another opportunity to improve and elevate the quality our Company and Program.

Should additional information or further explanation be needed for this QIP Plan you may contact
Grace Bagwell, DEO for Northeast Region (410) 778-9114 and/or Sharon Stephenson, Delaware
Director for PCSA, KCCCP ACT Service at (302) 678-3366.

                                                               Sincerely,


                                                               Deborah C. Jones
                                                               CEO, Psychotherapeutic Services

								
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