Reports/Open Communication

1. Mission Linking Faith and Service Vision A bridge to a brighter future through lifelong learning Core Values • Learning as a focus across all Glade Run’s programs as evidenced by: • Discerning the strengths and cultures of families • Emotional and behavioral management to facilitate academic achievement • Innovative learning opportunities for staff, children and families • Program excellence and positive impacts as evidenced by: • Partnerships with families to understand their needs and achieve success at home and in the community • Data that indicates successful outcomes for individuals and families • Improved academic performance • High satisfaction ratings • A welcoming culture • Working with individuals and families in the most appropriate setting available • Work environments that thrive on the seven commitments of sanctuary • Our Christian foundation Reports/Open Communication The Director of Quality and Compliance is a direct link to the Quality Council (EMT) – report progress, findings, etc. The role of the QI Department will be to support the Champions and Quality Improvement Teams. Champions will complete a quarterly report/update on the progress of the QI measure to QI Director and Quality Council. Quality Initiatives Champion (s) will be assigned to each quality initiative. Quality Improvement Teams will be created for each quality initiative – consisting of staff with the expertise, skills and knowledge needed. The Quality and Compliance Director is a support to all Quality Improvement Teams for support and guidance of quality initiatives.

2. QUALITY COUNCIL (EMT) EMG consists of EMT, EPT, and EST. The implementation and leadership of the Continuous Quality Improvement initiatives is the responsibility of the EMG. EMT: Oversees program excellence and strategic growth EPT: Implements the strategic goals established by the EMT while ensuring program excellence and compliance EST: Provides support for the EMT and EPT to achieve program excellence and strategic growth Program Excellence Through Lifelong Learning Quality Initiatives Impact Statement; The end result of the Quality Initiative Evidence Based Practices: Program excellence is achieved with the training and utilization of evidence based practices Family Partnership: Families feel empowered in the decision making process and express a sense of connectedness to supportive networks Life Long Learning: Staff, families/individuals and other professionals gain knowledge and competence through training and skill attainment Academic Excellence: The learning environment at St. Stephen’s Lutheran Academy reflects academic excellence and an Accountable, Safe and Kind environment Individualization/ Generalization: families/individuals learn and practice skills that will transfer to their unique home and community settings Goals and Action Steps to Achieve Outcome/Impact Quality Initiative Measurement Tools Quarterly Summary/Follow-up

3. Lifelong LearningChampion Nickole Pribozie Staff, families/individuals and other professionals gain knowledge and competence through training and skill attainment Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools. • Develop career tracks for all job classifications • 2. Assess, prioritize and evaluate training needs for staff, individuals families and other professionals • 3. Educate and train employees and supervisors regarding career tracks. • 4. Design web-based trainings • 5. Develop professional skill evaluation checklists • Establishment of learning goals for employees 1. Training records will identify the completion of career track trainings. 2. Quarterly training effectiveness survey’s 2. New hire surveys initial and at first quarter 4. Google analytics will be used to evaluate utilization of web-based trainings. 5. Clinical case review evaluations/checklists 5. Skill evaluation checklists 5. Exit interviews/ Review and revise to include skill development Retention rates Parent survey PAS audits reviews

5. Quarterly summary/follow up Life Long Learning • 105 Training Assessment needs have been completed. This is a six Question survey to identify training needs by position. This data is currently being evaluated to help assist in the continued development of Career Tracks. • 70 Training Evaluation surveys have been completed. The surveys are administered after new hire training and then again at the quarterly basis. The survey is an eight question survey that evaluates the employees skill confidence to job duties and an evaluation of the effectiveness of the trainer to deliver the material in a way that the employee is able to relate the training to skill development and job preparedness. • Average score of 4.27 on the Question I feel the training provided me new knowledge or insight. • Average score of 4.67 on the question “I feel confident that I have the knowledge and skills to be able to use what I learned in my work” • Average score of 4.59 on the question “Overall, this training will help me do my job well.” • Five new trainings created by Glade Run have been added to Essential Learning (Residential 3800 regulations, Child Psychomarmacology, Sanctuary module 3 and 4, welcoming environment and HIPAA security.)

6. Quarterly summary/follow up Life Long Learning • Six career tracks have been developed • Direct care – includes TSS, MHW’s, Teaching Assistants, Adventures staff • Therapist – MHP, BSC, Mobile therapists • Clinical Supervision • Leadership • Support Staff • Case Management • New Trainings developed • Progress note training utilizing DAP format. (56 have attended) • BHRS Redesign • Sanctuary Modules • Alolescent and Autism • CAASP principles • Suicide Prevention • Orientation and Training Surveys

7. Training Survey’s

8. New Hire Campus Orientation Survey

9. Community New Hire Orientation survey

10. Families/Individuals feel empowered in the decision making process and express a sense of connectedness to supportive networks Family PartnershipChampion Leslie Walter Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools Grow the Glade Run Family network data base Increase decision making and participation of families in agency events/activities family partnership support will increase visibility and continue communicating their role in glade run culture Family advisory counsel continues to grow and become involved in decision making and planning. Review the number and percentage of active participants in the Glade Run Family Network Database Review family participation/voice in treatment plans, progress notes and ISPT and treatment plan signature pages Training records Review advisory counsel minutes. 3, 6, 9 month aftercare calls Family satisfaction surveys Database communication form.

12. Quarterly summary/follow upFamily Partnership Quarterly summary/follow upFamily Partnership/First Quarter • To Date there are 147 families entered into the data base.. • 97% would like to receive updates on family/community events • 76% would like to become more involved and share their voice and experience with us. • 78% would like information on how to connect with other families • 53% would like to be connected to spiritual and/or other supports within the community • 93% would like to receive the Glade Run newsletter, The Bridge. • Parent satisfaction surveys are in final stages. The survey is complete just working out the process for administration, frequency and person responsible.

13. Family Partnership/2nd Quarter Update • Advisory Counsel meeting quarterly and have added 5 new members. • Continue to bring sanctuary to meetings and to our families • Working on how to bring the families together. Several families did help on the family survey • Working with Training Department to develop and deliver the training. • Finalized Family Satisfaction Survey’s. Sent out approximately 2000, and have received back more than 10%, good representation among all program areas. • Working with families to find out what trainings they would like to have. Identified behavior management and parenting skills as first focus based on survey feedback. • Changed the way we do medication sheets for therapeutic leaves based on feedback from a family member through the survey. • Utilization of e-blast to share stores, events, themes, resources etc. • Still working on how to show family engagement with the agency. There has been a recent culture change to include families in events such as Marthen’s and Reiber’s cottage families events, positive parenting in Beaver Falls and the Jeremiah Village community information sharing meetings.

14. Quarterly summary/follow upFamily Partnership

17. Family Satisfaction Survey - Sanctuary

21. Academic AchievementChampion Amy Williams Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools Attendance Records School wide grade reports Positive Behavior Support Assessment; Incident Report review; ASK points Aims-WEB reports CBITS evaluation tools Walk through observation/evaluation cards Goal Attainment Scale Leadership groups Teacher and teacher Aid staff retention Staff, student, parent, school district surveys 85% attendance Rate Grades will improve school wide Major incidents will decrease (Acts of violence, self injurious behavior, awol, restraint, police involvement, psychiatric hospitalization) Students will demonstrate increased proficiency in reading comprehension and math Implement the CBITS Classroom Engagement The learning environment at St. Stephens’ Lutheran Academy reflects academic excellence and an Accountable, Safe and Kind environment

22. Education

23. Quarterly summary/follow up • Education observation/evaluation cards

25. Individualization/GeneralizationChampion Beth Hines Families/individuals learn and practice skills that will transfer to their unique home and community settings. Quality Initiative Mesurement Tools Goals and Action steps to Achieve Outcome/Impact Strength Needs and Cultural Discovery Treatment Plan Reviews Goal Attainment Scale Parent/client surveys 3, 6 and 9 month after care surveys Treatment plan reviews Progress Notes review 100% of Treatment plans will identify family strengths and prioritized needs 100% of Treatment plans will develop goals and interventions to include natural and informal supports Progress note format training Progress notes reflect evidence of skill transfer through teaching, modeling, evaluation and/or monitoring

26. Quarterly summary/follow upIndividualization/Generalizaion • 1, 3, 6, 9 month after care calls were centralized and created using survey monkey. • There have been 111 aftercare calls attempted for the RTF and 553 for the community programs • surveys were successfully completed for the community programs 30 Day Surveys: (84 Surveys Community) • 88% of clients were still living in the home they discharged to • 75% in school or vocational training • 95% had not experienced a significant crisis requiring hospitalization • 85% reported the program being helpful • 76% using skills they learned in the program. • 6 month Surveys (64 surveys Community) • 89% still living in the home they discharged to • 83% in school or vocational training • 89% had not experienced a significant crisis requiring hospitalization • 76% reported using skills they learned in the program • 79% reported program being helpful

27. RTF had a total of 51 total surveys answered • RTF (30 Day survey, 11 responses • 86% still in less restrictive placement • 62% made it to first aftercare appointment • 71% following aftercare plan • 35% felt they were doing better since discharge • 29% doing the same • 36% doing worse • RTF (60 Day survey, 12 responses) • 79% still in less restrictive placement • 80% following aftercare plan • 33% doing better • 33% doing the same • 33% doing worse • RTF (90 Day survey 17 • 76% in less restrictive placement • 71% following aftercare plan • 41% doing better • 17% doing the same • 41% doing worse • RTF (180 day Survey 12 completed • 92% in less Restrictive • 75% still following aftercare plan • 33% reported doing better than at discharge • 16% doing the same • 50% doing worse

31. Evidence Based PracticesChampion Beth Hines Program excellence is achieved with the training and utilization of evidence based practices Goals and Action steps to Achieve Outcome/Impact Measurement Tools Measurement tools associated with each modality if indicated/available: Child PTSD scale (CPSS); Pediatric Symptom Checklist (PSC) CAFAS reports Training records Review supervision records Research and obtain information on the following Evidence Based Practices (CBITS, DBT, CBT, TF-CBITS, PCIT, ABA, ART, SFT, PBIS) Academic curriculum, Identify and develop who will become trained trainers in the above mentioned modalities Train employees in the above mentioned modalities Develop clinical coaching supervision model to ensure fidelity of the modalities Quarterly summary/follow up

32. Evidence Based PracticesChampion Beth Hines Program excellence is achieved with the training and utilization of evidence based practices Goals and Action steps to Achieve Outcome/Impact Measurement Tools Research and obtain information on the following Evidenced Based Practices: • Cognitive Behavioral Therapy (CBT) • Dialectical Behavior Therapy (DBT) • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) • Cognitive Behavioral Intervention for Trauma in Schools (CBITS) • Parent-Child Interaction Therapy (PCIT) • Safe and Civil Schools Positive Behavioral Interventions and Supports Model (PBIS) Identify and develop who will become trained trainers in the above mentioned modalities Train employees in the above mentioned modalities Develop clinical coaching supervision model to ensure fidelity to the modalities Measurement tools associated with each modality if indicated/available: Suicide Attempt Self Injury Interview (SASII); Nonsuicidalself-injury (NSSI) Child Behavior checklists; child depression inventory; Weekly Behavior report; Parent Emotional Reaction Questionnaire ; Parenting Practices Questionaire(PPQ); Parent Support Questionnaire (PSQ) Child PTSD symptom Scale (CPSS); Pediatric Symptom Checklist (PSC); Dyadic Parent-Child Interaction Coding System (DPIS); Parenting Scale (PS); Eyberg Child Behavior Inventory (ECBI); Child Behavior Checklist; Home Situations Questionnaire—Modified (HSQM); Parenting Stress Index (PSI); Parent Locus of Control Scale (PLOC); Parent Sense of Competence Scale (PSOC); An Academic Index Kentucky Core Content Tests; California Standards Test in Mathematics; Positive Behavior Support (PBS) Assessment—Staff survey; Teacher Surveys Training Records Review Supervision records 3, 6, 9 month aftercare calls Treatment retention Quarterly Summary/Follow up

33. Quarterly summary/follow up