Norfolk Area Program Newsletter - July 2007

2008 Quality Assurance Review Summary

Each year NorthStar Services conducts an internal Quality Assurance Review to evaluate services at a number of levels, specifically the areas of administration and compliance with regulation, safety and sanitation, personnel, IPP related services, medications and due process, health services and financial records, along with a review of the Strengths and Concerns Action Plans from the 2007 review. Reviews were completed by Donna Nickel, Director of Health Services, Kirby Hall, Fiscal Analyst, Diane Wagner, Director of Program Development and Cheryl Montgomery, Program Specialist. The local Management Teams were asked to develop plans to retain and grow in areas identified as strengths and to improve or correct those areas identified as concerns. A review of those plans will be included in the 2009 Quality Assurance Review. It should be additionally noted that the state of Nebraska Health and Human Services, Division of Developmental Disabilities has continued the recertification process for individual area programs. All 9 area programs received certification in 2007 or 2008. The 2 year cycle is beginning again in 2009, so approximately half of the area programs will be reviewed in 2009, including Columbus, (they received a 1 year certification in 2008).

Below is a summary of regional strengths and concerns that were taken from the Quality Assurance Reviews completed in 2008. Each strength and concern may or may not apply to an individual area program. Please contact the Area Director if you have specific questions about an area program.

Strengths: These areas were identified during the QA reviews as areas where the expectations were consistently met or exceeded during the review period.

1) Person Centered Planning tools are being used and updated on the agreed upon cycle.
2) Corrections for issues identified with nurses monitoring reports were initiated immediately upon discovery.
3) Personnel and Unit files continue to be well organized and complete
4) Program methodologies are improving in content.
5) Income and Expense sheets are completed and verified per procedure.
6) Area and Regional Committee Memberships and Minutes are well organized and complete.
7) Health Services review checklists (medications, treatments, storage, documentation) completed by the RNs meet regulation and NorthStar Services policy/procedures.
8) Bank statements were reconciled and all balance records matched
9) Receipts are maintained per procedure and available for review.
10) Fire and Severe Weather Drills were conducted correctly.
11) H&L reviews were complete in that almost without exception Med 21's were completed for psychoactive medications.

Areas of Concern: These areas were identified during the QA reviews as areas where the expectations were inconsistently met, and improvement is necessary.

1) Need to continue strengthen Community Education and Information activities.
2) Advance Directives and Voter registration forms are not consistently found.
3) Criterion 1 (accuracy criterion) was missing on numerous long term goals and short term objectives.
4) The Property, Temperature and Safety Checklists were not always completed on the new forms
5) Tracking the required reviews for medications prescribed for mental health or behavioral reasons on an annual basis is inconsistent.
6) The two year review by the H&L Rights committee for some Programs and Intervention Plans were also missing.
7) Med 18 information was often subjective. Forms were incorrectly completed.
8) Financial entries are not consistently initialed per procedure.
9) Data is not providing needed information, it is not always being recorded as indicated in the methodology, or the methodology does not request enough specific information.
10) Goals and objectives are not written in behavioral terms more often than in previous years.
11) Checking account balances are not consistently kept under $500, and there is no documentation of the team approving balances over that amount in IPPs.
12) Multiple concerns are repeated year to year.
13) Some area programs did not complete and submit a QA response plan.