Reports/Open Communication

2. 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.

3. Quality and Compliance The primary focus of this report is to provide the board with an overview of the Quality Management Plan. An action step of the agency 2013-2014 strategic plan was to improve the QI plan and Ongoing QI processes – align the quality improvement plan with strategic goals and identified outcome measures. The Executive Management Group has successfully aligned the quality initiatives with the goals and action steps. The quality initiatives and outcome measures closely align with the following goals and actions steps. AGENCY WIDE: Goal 1: All programs will demonstrate excellence through integrated approaches within and between program areas - Measurability/outcomes/impacts - Consistency - Coaching/training - Incorporate agency values Action Step 1: Identify, develop and implement evidenced based interventions across programs. - Identify the evidence based methodologies (CBIT; CBT; PCIT; PBIS; ABLES; Family Structural Therapy - Train program staff in the identified interventions (trauma informed care; sanctuary) - Supervise and coach the models (frequency,; content; live observations Action Step 2: Ongoing implementation and monitoring of the initiatives of generalization, individualization, and family partnership. The next chart represents the current quality initiatives:

4. 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

5. 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 • Assess, prioritize and evaluate training needs for staff, individuals families and other professionals • Educate and train employees and supervisors regarding career tracks. • Design web-based trainings • Develop professional skill evaluation checklists • Establishment of learning goals for employees Training records will identify the completion of career track trainings. Quarterly training effectiveness survey’s New hire surveys initial and at first quarter Google analytics will be used to evaluate utilization of web-based trainings. Clinical case review evaluations/checklists Skill evaluation checklists Exit interviews/ Review and revise to include skill development Retention rates Parent survey PAS audits reviews

7. Summary/follow up Life Long Learning TRAINING ASSESSMENTS • 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. CAREER TRACKS: • Six career tracks have been developed. These career tracks will be available to staff on a voluntary basis. They are designed to help enhance skills and competencies. The six staff categories are: • Direct care – includes TSS, MHW’s, Teaching Assistants, Adventures staff • Therapist – MHP, BSC, Mobile therapists • Clinical Supervision • Leadership • Support Staff • Case Management

8. NEW TRAININGS: • Residential 3800 regulations • Child Psychomarmacology • Sanctuary module 3 and 4 • Creating a welcoming environment • HIPAA security • Progress note training utilizing DAP format: This training is an agency wide format on progress note writing. • BHRS Redesign: A service delivery model that enhances family strengths, natural resources and transfer of skill. • Sanctuary Modules: Five sanctuary modules are available agency wide. • Adolescent and Autism • CAASP principles • Suicide Prevention • Generalization Part I and Part II: This training focuses on how individuals can effectively transfer skills to parents/caregivers and create positive behavior change. • ORIENTATION AND TRAINING SURVEYS : • 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.”

9. Training Survey’s

10. New Hire Campus Orientation Survey

11. Community New Hire Orientation survey

12. 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.

13. Summary/follow upFamily Partnership DATA BASE: • To Date there are 194 families active in the family partnership data base. • 97% would like to receive updates on family/community events • 79% would like to become more involved and share their voice and experience with us. • 79% would like information on how to connect with other families • 48% would like to be connected to spiritual and/or other supports within the community • 90% would like to receive the Glade Run newsletter, The Bridge. FAMILY SATISFACTION SURVEYS: • Parent satisfaction surveys have been streamlined across all program areas of the agency to one survey that focuses on four major categories: Family partnership, sanctuary, generalization and individualization. The survey will be sent out twice a year in January and July. The first survey’s went out in July of 2013. All current active clients in treatment or in the education setting received a survey. Surveys are sent out in a multitude of forums: email, mail or face to face. • Over 2000 surveys went out in July and over 200 have been returned. The following charts represent the results of the family partnership section of the survey. • In the survey, parents are able to identify what trainings they would like to have. The common theme is behavior management and parenting skills. The family partnership staff are working closely with the Training department to develop curriculum. • A process has been put in place to provide immediate follow up to any family that expresses concern regarding the quality of service delivery when reviewing the surveys. • As a result of feedback from a survey, the Residential Treatment Facility changed the way they do medication sheets for therapeutic leaves to improve the communication and instructions on medication use.

17. Summary/follow upFamily Partnership FAMILY ADVISORY BOARD: • Family advisory counsel continues to meet quarterly with 5 new family members having recently been added. The family representation is across the full continuum of services for Glade Run. FAMILY ENGAGEMENT: • Family partnership continues to develop strategies and opportunities to enhance family engagement within the agency. There has been a recent culture change to include families in events. • Reiber cottage had an open house to showcase their sensory room. They had 100% family participation. • Marthen’s cottage is also scheduling family events. • Beaver Falls office conducted a positive parenting group. • Many of our families were invited and attended the Jeremiah Village community information sharing meetings.

18. 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

19. Education

20. POSITIVE BEHAVIOR INTERVENTIONS IN SCHOOLS • Critical Elements of PBIS implementation include • PBIS Team • Faculty Commitment • Effective Procedures for Dealing with Discipline • Data Entry and Analysis Plan Established • Expectations and Rules Developed • Reward/Recognition Program Established • Lesson Plans for Teaching Expectations and Rules • Implementation Plan • Classroom Systems • Evaluation • On October 24th, 2013, education staff were sent an anonymous survey for the National PBIS team to evaluate the staff perceptions of implementation of PBIS at St. Stephen’s. 70 school staff completed the survey. The areas evaluated for implementation include System: school wide; (18 items) System: non classroom (9 items); System: classroom (11 items); and system: individual (8 items). This survey is repeated yearly and provides the certification team a tool to determine the schools readiness for certification process.

21. Summary/Follow up Academic Excellence • STUDENT/TEACHER ENGAGEMENT: • Walkthroughs have become increasingly popular as a tool for improvement. They are brief, informal and focused. In essence, they are a quick snapshot that gathers data and documents trends over time. St. Stephen’s views walkthrough observations for a shared leadership perspective where staff expertise is valued. We believe that staff involvement is instrumental in using walkthroughs as a tool for promoting reflection in the art of teaching and the improvement of instruction and learning. Below you will find a snapshot of the walkthroughs from the end of the last school year.

22. POSITIVE BEHAVIOR SUPPORT • St. Stephen’s utilizes a positive behavior point card in which students receive points in the areas of Accountable, Safe and Kind. These points are utilized in the overall positive behavior support system, which is tied into the PBIS Reward/Recognition Program. The following chart provides a quick overview of the percentage of points earned. The chart represents elementary, middle school and high school classes.

23. Individualization/GeneralizationChampion Beth Hines Families/individuals learn and practice skills that will transfer to their unique home and community settings. Quality Initiative Measurement Tools Goals and Action steps to Achieve Outcome/Impact 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 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

24. Summary/follow upIndividualization/Generalization GOAL ATTAINMENT SCALES (GAS) • is a means of measuring outcome data that is directly related to clients’ goals set out on a 5 point scale of -2 to +2. • All programs implemented GAS in October of 2012, however it was discovered that there was inconsistency in scoring of the scales and unclear parameters to establish the timeframes of collecting the scores. Staff will be retrained and user guides are being developed. • Moving forward scores will be utilized in a more consistent manner making the data more reliable. PARENT/CHILD SURVEYS: • As mentioned under the Family Partnership Quality Initiative a standardized family satisfaction survey has been developed and is sent out at the same time for all program areas. The following reflects the overall parent satisfaction in regards to generalization.

29. Summary/follow upIndividualization/Generalization • AFTERCARE CALLS • The Community programs and the RTF both do follow up aftercare calls. The questions and frequency of the calls are somewhat different. The RTF does 30, 60, and 90 day follow up calls and the community programs do 30 day and 6 month aftercare follow up surveys. • In previous years there were not a lot of calls being completed for the community programs. During this past year the aftercare call surveys have been centralized and are electronically entered into Survey Monkey. This has significantly improved the number of calls being completed as well as the ability for immediate analysis of the data being collected. • Please find below in the next few pages the results of survey’s completed during this fiscal year. The RTF completed 103 surveys out of 214 attempted calls. The community programs attempted 665 calls and successfully completed 177 surveys.

35. TREATMENT PLAN REVIEWS • In the treatment planning process parents should be involved from the beginning and the treatment plan goals and interventions are to individualized and demonstrate transfer of skill back in the homes and community’s. The treatment plan should also reflect goals and interventions that include natural and informal supports. The following are results of treatment plan audits conducted for this fiscal year.

41. 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); Nonsuicidal self-injury (NSSI) Child Behavior checklists; child depression inventory; Weekly Behavior report; Parent Emotional Reaction Questionnaire ; Parenting Practices Questionnaire (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

42. Summary/follow upEvidenced Based Practices The following Evidenced Based Practices are currently being utilized with the Glade Run Continuum. Aggression Replacement Therapy (ART) * ART is a cognitive behavioral intervention program to help children and adolescents improve social skill competence and moral reasoning, better manage anger, and reduce aggressive behavior. Dialectical Behavioral Therapy(DBT) *DBT is a cognitive-behavioral treatment approach with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. Cognitive Behavioral Intervention for Trauma in Schools (CBITS) *CBITS program is a school-based group and individual intervention designed to reduce symptoms of posttraumatic stress disorder (PTSD), depression, and behavioral problems; improve peer and parent support; and enhance coping skills among students exposed to traumatic life events, such as community and school violence, physical abuse, domestic violence, accidents, and natural disasters. Parent-Child Interaction Therapy (PCIT) *Parent-Child Interaction Therapy (PCIT) is a treatment program for young children with conduct disorders that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) *TF-CBT is a psychosocial treatment model designed to treat posttraumatic stress and related emotional and behavioral problems in children and adolescents. Initially developed to address the psychological trauma associated with child sexual abuse, the model has been adapted for use with children who have a wide array of traumatic experiences, including domestic violence, traumatic loss, and the often multiple psychological traumas experienced by children prior to foster care placement.

43. Positive Behavioral Interventions and Supports (PBIS) **One of the foremost advances in school-wide discipline is the emphasis on school-wide systems of support that include proactive strategies for defining, teaching, and supporting appropriate student behaviors to create positive school environments. Instead of using a piecemeal approach of individual behavioral management plans, a continuum of positive behavior support for all students within a school is implemented in areas including the classroom and non-classroom settings (such as hallways, buses, and restrooms) Executive Program Team is currently evaluating the above Evidenced Based Practices to identify what programs we want to use them for. The group has identified currently employees who are trained in these modalities. Once these decisions are made than identification of measurement tools will be developed.

45. The importance of a Compliance program is to ensure that our agency meets the highest possible standards for all relevant federal, state and local regulations, laws and guidelines. The compliance plan helps establish a culture within the organization that promotes prevention, detection, and resolution of any activities that do not conform to federal and state laws as well as our agency’s own business and ethical policies. A compliance program provides a framework for disseminating information and establishes mechanisms for investigation potential noncompliance. An effective compliance program sends an important message to employees. Having an Agency wide Compliance Program in place encourages an environment of quality and continuous improvement. As an agency we are continuing our efforts toward a solid compliance program. Value Behavioral Health provided Glade Run with an audit tool for Provider Compliance Program Checklist. This is just anther example of the attention that is continuing to be placed upon Agency’s to operationalize their compliance policies and procedures. The following will provide a brief overview of the compliance activities conducted during the past fiscal year. HIPAA: The HIPAA privacy and HIPAA security meetings have been combined. This committee is chaired by the Director of Information Management and the Director of Quality and Compliance. The committee reviewed 6 reported HIPAA privacy violations. Two reported violations were not determined to be violations. However, there were 4 violations during the past year that resulted in retraining and progressive discipline for employees. The agency also provided Identify Theft Protection to three families as a result of the HIPAA violation. The HIPAA security officer with the assistance of the training director developed a new HIPAA security training to address potential risks and vulnerabilities related to the advances in the use of electronic devices and technology and the agency use of the Electronic Medical record. The HIPAA privacy officer will developing an updated course on HIPAA privacy. Fraud Waste and Abuse: Glade Run conducted a self audit of an allegation of potential fraud. After a thorough review of this allegation, it was determined that Glade Run did not believe that the allegation rose to the level of Medicaid Fraud, however Glade Run elected to self report to the Managed Care Organization’s Fraud, Waste and Abuse department. Glade Run did however, identified several performance improvement areas and other personnel issues that led to the termination of employment for one employee and a voluntary resignation of the other.

46. Glade Run was asked to participate in an Fraud, Waste and Abuse investigation with CCBHO regarding the questioning of the staffing credentials of an employee delivering BHRS services. After several months of investigation the MCO did rule that the employee did not meet the qualifications of the position and requested a payback of revenues generated during services rendered by this employee. Glade Run did not limit the scope of the investigation to just this one employee we conducted a full self audit of all employees providing master level services and made employment decisions accordingly. We also improved on several areas of the on-boarding process. Streamlining external audits/complaints/grievances: Significant efforts have been made to ensure that the Director of Quality and Compliance is notified of any external audits, grievances and complaints. This is a major culture shift as program personnel have relied on their own internal structure to coordinate these activities in the past. We believe that this will provide uniformity and greater systemic approaches to problem solving and opportunities for continued compliance with regulations and enhance quality service delivery. Internal Audits: The Quality and Compliance team with the collaboration of program personnel have developed program specific audit tools that incorporate both qualitative and quantitative reviews of medical records. The teams have developed an admission, quarterly and discharge audit. During fiscal year 2012-2013 were 382 recorded medical record/chart audits. The first quarter of this fiscal year has already seen an increase as 408 audits have been recorded. Results of these audits are forwarded to program managers to use a supervision tool with employees but also for them to evaluate their processes and their compliance with standards. This continues to be an evolving system to ensure full effectiveness. The Joint Commission Accreditation: There continues to be a steady volume of audit activities related to the Joint Commission standards. Historically the results of Joint Commission surveys became the foundation of our quality improvement activities and focused very heavily on the RTF program.

47. As you can see, from the extensive work reported in this report, significant movement has been made to develop audit activities that go across all of Glade Run’s Continuum of services. With that being said, there is still a significant amount of audit activity associated with compliance with The Joint Commission Standards. Over 1000 audits have been conducted in several difference areas ranging from infection control to Utilization Reviews in response to previous Joint Commission findings. Communication: There is a clear culture shift occurring regarding the importance of compliance. The agency has always strived and provided quality of service delivery, however with the increased emphasis at a national level for increased enforcement of Fraud, Waste and Abuse initiatives, the seriousness of compliance has reached the awareness of providers. We have seen an increase in external audit activity and an increase in requests for paybacks. There is on-going meetings and consultation between Executive Program Team and the Quality and Compliance Department. Next Steps: The focus for 2013-2014 will remain on imbedding a culture of compliance and quality service delivery. We need to develop a concrete compliance plan, educate staff and ensure implementation of that plan occurs.