1. The goal of 60% of intakes will be scheduled within 2 weeks after receiving referral was met. There results collected from the 98 clients added in 2013 showed that 66% of intakes were completed within 2 weeks after receiving the referral. The results indicated that the average number of days between referral and intake were 15 days.
a. The agency will provide the Clinical Director with the referral and the intake will then be scheduled.
b. The agency will inform the clinicians in training to provide referrals to the Clinical Director within 1 week of receiving the referral.
2. The goal of 90% of clients report that their needs are being met was met. The results collected from 84 clients and stakeholders indicated that 100% stated that their needs are being met.
a. The agency will continue to train therapists and rehab specialists on the importance of meeting the client's needs and determining the clients' needs.
3. The goal of removing barriers found and identifying any new barriers was met. The results collected from 66 clients and stakeholders indicated that 10% had no barriers. The results were also collected from 6 staff and 12 contractors. The results from staff indicated that staff members had no identified barriers. The results from contractors indicated that 1 contractor had a barrier: he/she reported that he/she had experienced communication barriers due to the client not answering the phone or the client no communication effectively with him/her.
a. The agency will inform staff, management, and contractors of barrier and ways to remove barriers.
4. The goal of 95% of clients' report that they were informed of services offered and grievance policies at intake was met. The results collected from 138 clients and stakeholders indicated that 100% reported that they were informed of services offered at intake and 100% reported that they were informed of grievance policies at intake.
a. The agency will continue to provide training for staff and contractors about proper intake procedures and informing client of services offered and grievance policies.
5. The goal of 95% of assessment interpretive summaries being written in detail was not met. The results collected from 98 clients admitted in 2013 showed that 93% of the assessments had detailed interpretive summaries.
a. The agency will continue to train staff and therapists who conduct intakes on how to write detailed
interpretive summaries.
6. The goal of 95% of treatment plans will be completed within 30 days from intake was met. The results collected from 98 clients admitted in 2013 showed that 95% of the treatment plans were completed within 30 days from the intake. The results indicated that the average number of days between intake and treatment plan were 6 days.
a. The agency will continue to train staff and therapists to complete treatment plans within 30 days of finishing the intake.
7. The goal of 95% of treatment plans interpretive summaries will be written in detail was met. The results collected from 301 clients in 2013 showed that 98% of the treatment plans had detailed interpretive summaries.
a. The agency will continue to train staff and therapist on how to write detailed interpretive summaries.
8. The goal of 90% of treatment plan updates will be completed within 180 days of previous treatment plan approval date was met. The results collected from 175 treatment plan updates completed in 2013 showed that 93% of the treatment plan updates were completed within 180 days of the previous treatment plan. The average number of days late was 15, which usually occurred due to client's Medicaid insurance being out.
a. The agency will continue to train staff and therapists to complete the treatment plan updates within 180 days of the previous treatment plan.
b. The agency prints a report at least 2 months before the updates need to be completed and the executive team is given copies.
9. The goal that 90% of clients will be satisfied with services provided was met. The results collected from 337 clients and stakeholders surveyed indicated that 100% were satisfied.
a. The agency will continue to provide training regarding appropriateness of service intervention and service effectiveness to meet clients' goals.
10. The goal that 90% of clients will have a decrease in number of symptoms was met. The results collected from 84 clients and stakeholders surveyed indicated that 100% perceived a decrease in number of symptoms.
a. The agency will continue to provide training regarding appropriateness of service and intervention.
b. The agency will continue to provide training regarding appropriateness of service effectiveness to meet clients' goals.
11. The goal that 90% of clients will have improvement in employment status or school functioning was met. The results collected from 25 clients and stakeholders surveyed indicated that 100% had improvement in school functioning.
a. The agency will continue to provide training regarding the importance of meeting clients' and families' goals with appropriate service effectiveness.
12. The goal that 85% of clients will have a decrease in number of disciplinary actions was met. The results collected from 82 clients and stakeholders surveyed indicated that 100% had a decrease in number of disciplinary actions.
a. The agency will continue to provide training regarding appropriateness of service and intervention.
b. The agency will continue to provide training regarding appropriateness of service effectiveness to meet clients' goals.
13. The goal that 90% of clients will have a decrease in use of substances was met. The results collected from 17 clients and stakeholders surveyed indicated that 100% had a decrease in use of substances.
a. The agency will continue to provide training regarding the importance of meeting clients' and families' goals with appropriate service effectiveness.
14. The goal of 40% of contractors will attend training events held by the agency was not met and 90% of employees will attend training events held by the agency was met. The results collected from the training throughout the year indicated that 31% of contractors attended the training events. The results collected also indicated that 91% of employees attended the training events.
a. The agency will continue to notify employees and contractors by phone and e-mail of upcoming trainings.
b. The agency will continue to e-mail employees and contractors that are unable to attend trainings the material and test forms along with the meeting minutes.
c. The agency will continue to provide incentives to contractors that attend monthly meetings.
15. The goal of 100% of employees unable to attend will receive information on training events and staff meetings were met. The results collected from the trainings throughout the year indicated that 100% of employees received information on training events and staff meetings. The results also indicated that 100% of contractors received information on training events and staff meetings.
a. The agency will continue to e-mail the end of the month meeting minutes and training information to the employees and contractors who were unable to attend the meetings.
b. The agency will continue to put the end of the month meeting minutes and training information in the boxes of the employees and contractors who were unable to attend the meetings.
16. The goal that 100% of employees and contractors will be trained in CPR and First Aid within 30 days of employment and contract was not met. There were no new employees hired in 2013 that provide therapeutic services to clients. The results collected from the 10 new contractors that started in 2013 indicated that 90% were trained in CPR and First Aid within 30 days of signing of contracts.
a. The agency will continue to inform all new employees and contractors the importance of being trained in CPR and First Aid within the first 30 days of hire or contract.
17. The goal that no more than two critical incidents was met and zero physical injuries was not met. The results collected showed that there were 2 critical incidents. One incident included the CEO hitting a car with the company van but no physical injuries were reported. The other incident included a client falling at a bowling alley and hurt his shoulder and EMSA was called and the client was taken to OU Children's Hospital and he was released to go home with no broken bones or pulled muscles or torn ligaments found.
a. The agency will continue to provide trainings regarding reporting abuse and reporting crictal incident reports within 24 hours of the incident to the agency and other appropriate reporting sites.
b. The agency will continue to provide training on ways to reduce the possibility of critical incidents.
18. The goal that 90% of employees and contractors will be satisfied with their employment was met. The results collected from 7 employees indicated that 98% were satisfied. The results collected from 12 contractors indicated that 95% were satisfied. The results from staff indicated that 1 survey reported that her salary or pay was not competitive with similar jobs she might find elsewhere; 1 reported that the pace of the work does not enable him/her to do a good job; 1 reported that the amount of work is unreasonable. The results from contractors indicated that 1 reported that he/she does not receive useful and constructive feedback from his/her manager; 1 reported that he/she is not given adequate feedback about his/her performance; 1 reported does not receive feedback that helps him/her improve his/her performance; 1 reported that teamwork is not encouraged and practiced in this organization; 1 reported that there is not a strong feeling of teamwork/cooperation in this organization; 2 reported that there compensation is not competitive with similar jobs that they may find elsewhere, 1 reported that he/she does not think his/her manager encourages and supports his/her development; 1 reported that communication is not encouraged in this organization; 1 reported that his/her manager does not do a good job of sharing information; 1 reported that he/she does not feel comfortable sharing his/her opinions at work; 1 reported that people with different ideas are not valued in this organization.
a. The agency will continue to compare salaries for positions to similar positions within the state based on education level and knowledge on a state website to determine pay range.
b. The management will reassess workloads and responsibilities to help make them more reasonable. The CEO will address possible restructuring with the Executive team as an avenue to possibly hire additional staff to lessen the work load.
c. Management conducts yearly performance reviews and quarterly reviews with each staff member. Management conducts 90 day reviews with new hired employees and new contractors. Management conducts yearly performance reviews for each contractor and will begin semiannual reviews for contractors.
d. The agency sends e-mails to invite staff and contractors to end of the month meetings and when individuals are unable to attend an e-mail is sent out with the meeting minutes and training information. The meeting minutes and trainings are kept in the office that everyone has access to view.
19. The goal that 100% accuracy of comparison between projected budget and actual budget was met. The results indicated:
Total Program Income 105.1%
Total Income 105.1%
Gross Profit 105.1%
Total Contract Services 120.4%
Total Facilities and Equipment 104.0%
Total Operations 104.5%
Total Other Types of Expenses 70.9%
Total Payroll Expenses 84.8%
Total Travel and Meetings 168.7%
Total Expense 102.2%
Net Ordinary Income 67.9%
Total Other Expense 96.5%
Net Other Income 96.4%
Net Income 74.9%
a. The agency will continue to write a projected budget each year and analyze problem areas in the budget to improve current actual budget and write a better projected budget for the following year.
20. No more than 40% of employee turnover was met and no more than 35% of contractor turnover was met. The results indicated that there was 25% employee turnover and 32% contractor turnover.
a. The agency will continue to be more thorough in the interviewing process.
b. The agency will continue to provide a more thorough training process to ensure that new employees and contractors understand the agency's expectations.
c. The agency will continue to give incentives to encourage employees and contractors to stay with the agency.