CQIR ANNUAL REPORT 2013 NORTHERN REGION ANALYSIS

Report Snapshot
Northern Region served 5,486 clients and families in FY13. 73% of Northern Outcome Goals were met. The Northern Region Compliance & Quality rating on Peer Record Reviews was 88%. 5 out of 6 program categories scored an A in overall client satisfaction

REPORT PREPARED BY KIMBERLY D. CLARK CQIR SYSTEMS ANALYST PLEASE DIRECT INQUIRIES TO: KCLARK@ONEHOPEUNITED.ORG
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Table of Contents
LETTER FROM THE EDITORS ................................................................................................................2 CQIR TEAM & HIGHLIGHTS ....................................................................................................................3 NORTHERN LEADERSHIP ......................................................................................................................5 EXECUTIVE SUMMARY ..........................................................................................................................6 CLIENTS SERVED ...................................................................................................................................9 OUTCOME MANAGMENT .....................................................................................................................10 PEER RECORD REVIEWS ....................................................................................................................12 CLIENT SATISFACTION ........................................................................................................................15 INCIDENT REPORTS .............................................................................................................................16 OFFICE SYSTEMS REVIEWS ...............................................................................................................17 SUPERVISORY SYSTEMS REVIEWS ...................................................................................................18 PRIORITY REVIEWS .............................................................................................................................19 EMPLOYEE RECOGNITION ..................................................................................................................21 QUALITY IMPROVEMENT TEAMS ........................................................................................................22 APPENDIX..............................................................................................................................................23
Appendix A: Child Development Highlights ............................................................................................................ 23 Appendix B: Counseling Highlights ........................................................................................................................ 24 Appendix C: Family Preservation Highlights .......................................................................................................... 31 Appendix D: Placement Highlights......................................................................................................................... 33 Appendix E: Prevention Highlights......................................................................................................................... 40 Appendix F: Youth Services Highlights .................................................................................................................. 42

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Letter from the Editors

October 19, 2013 To Our Readers: This is our 13th year of providing the Continuous Quality Improvement and Research (CQIR) annual report on the agencys outcomes and other quality improvement activities and results. The CQIR team takes great pride in preparing and presenting this report to you, our valued stakeholders. In Fiscal Year 2013, the CQIR team has adopted a Risk Management orientation in the processes and functions we facilitate. This shift was made at the request of staff so that we could ensure that we are spotting and addressing small problems before they become larger problems. Therefore, this type of orientation is meant to be proactive rather than reactive in order to alleviate risks and ideally prevent them before they occur. With this orientation, the CQIR team has begun using a new Risk Management report during Quality Improvement Teams (QITs). This type of approach requires participation at all levels; therefore, during this process, all staff (from direct service staff to program and agency leadership) are looking at current CQIR data to identify areas for improvement and develop action plans to meet and/or exceed best practice. Staff members have reported that this approach is better for them as they are able to see the data from their programs more regularly and develop solutions to areas of concern. In the human services field, organizations are constantly being asked to, do more with less while at the same time being asked to perform at higher levels than ever before. In these economic times many programs are being scaled back or eliminated for not reaching outcomes and targets set by funders. Now more than ever, One Hope United needs to look at each program, even those that consistently perform at high levels, and use creativity, research, and innovation to become even better. Each and every program can improve upon something. If One Hope United becomes stagnant, we will fall behind. Ultimately, at the end of the day, this constant attention to data and program improvement is for the clients we serve. By asking ourselves, what can we do even better we are investing our time and energy into making sure that our clients become healthy and productive adults when they leave One Hope United. In the next year, the CQIR team will spend time developing methods to learn what happens to our clients after leaving services in order to see what sticks from our service and genuinely changes lives. This work will help us ensure that One Hope United is here for our future clients. We hope that you find this report informative and that you will let us know what you think and how we could make the report better in the future. Thank you for your support.
Kimberly D. Clark CQIR Systems Analyst Fotena A. Zirps, PhD Executive Vice President

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Continuous Quality Improvement & Research Team

To support direct service providers and ensure best practice quality of service throughout the agency, the Continuous Quality Improvement and Research (CQIR) team at One Hope United guides the organization in 14 core tasks (PQI Standards) that are aligned with internal OHU principles and external accreditation standards. Dr. Fotena Zirps Executive Vice President Tina McLeod Assistant to the EVP Florida Region Hudelson Region Northern Region Research Team Ruann Barrack Senior Vice President Ryan Counihan CQIR Technician Jeffrey Honaker CQIR Director Katurah Roby CQIR Coordinator Ron Culbertson CQIR Coordinator Linda Weiss CQIR Medicaid Coordinator Stan Grimes CQIR Coordinator Elizabeth Hopkins CQIR Medicaid Coordinator Jackie Schedin CQIR Coordinator Special thanks to Katrina Brewsaugh of the CQIR team who left in FY13. Information presented in the Northern Region annual report is organized by these CQIR Core Tasks: Outcome Management Peer Record Reviews Client Satisfaction Incident Reports Office Reviews Supervisory Reviews Priority Reviews Employee Recognition Quality Improvement Teams Sarah Tunning Director of Research Kimberly Clark Systems Analyst

The CQIR Team achieved the following accomplishments in FY13. Accomplishments have been categorized in line with the OHU promises of Innovation, Collaboration, Leadership, Results, and Hope. Innovation The CQIR team has been utilizing Survey Monkey technology to enter Incident Reports, Office Reviews, and Supervisory Reviews which has made the data entry process more efficient. A pilot for utilizing Survey Monkey for Peer Record Reviews is planned for FY14 using Tablet technology. The CQIR team has taken a Risk Management focus which included a pilot and a full implementation of the OHU Risk Management Report in Local, Service, and Regional Quality Improvement Teams. Under the direction of Fotena Zirps, PhD. and Sarah Tunning; Ruann Barack, Jeffrey Honaker and Kimberly Clark are members of Team Data which is looking at the current and future data needs of the organization in alignment with the agencys strategic plan. In addition, there are
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many members from Operations (including the Team Excellence Outcomes committee) and IT that are collaborating on this project. Peer Record Review Training has been developed and placed on the Essential Learning Website.

Collaboration Stan Grimes, Jackie Schedin, and Elizabeth Hopkins have all participated as volunteers with the Council on Accreditation to re-accredit 3 organizations. In collaboration with the Department of Children and Family Services, all OHU CQIR staff have access to SACWIS which will assist with electronic review of case files. The CQIR team participated in a WorkSmart training facilitated by Larry Kujovich from Executive Partners. Jackie Schedin was a presenter at a CANS training in collaboration with the Casey Foundation. Linda Weiss and Elizabeth Hopkins continued to collaborate to ensure consistency across Regions with the Medicaid Rule Changes. This included monthly meetings with program leaders to ensure all involved participated in the process of change. Jackie Schedin and Ron Culbertson collaborated with operations in the Northern and Hudelson Regions in revising the Intact Operating Procedures for the Agency Operating Manual based upon Rule changes. The group also collaborated in the revision of the Intact Quality Review Tool. Linda Weiss worked with operations in the revision of the SASS Model for service delivery to achieve a team approach to provide more efficient and effective service delivery. Ron Culbertson provided technical assistance with Missouri Leadership to assist the Missouri office in maintaining their Licensing as a Child Placement Agency. Leadership Linda Weiss from Hudelson and Elizabeth Hopkins from Northern have led the process of implementing the new Medicaid Rule to ensure all Medicaid programs are in compliance. They have also consolidated forms to one Mental Health Assessment and two Individualized Treatment Plans so that there is more consistency amongst the Northern and Hudelson regions. Stan Grimes, Jeffrey Honaker, and Kimberly Clark are participants in the 2013 Leadership Academy facilitated by CEO Bill Gillis and Executive Vice President Fotena Zirps PhD. Ruann Barack was awarded the Promise Award for Leadership. Jackie Schedin was awarded a STAR Award for exemplary service during the 4th quarter of FY13. Results The CQIR team in Florida has launched a weekly data reporting process that takes a proactive stance in addressing programmatic concerns. The Medicaid Team in Hudelson achieved a 97% rating and Northern achieved a 94% rating (a 19 point increase) on their Post Payment Reviews for FY13 services. The CQIR team participated in a CQI Capacity Assessment administered by the Department of Children and Family Services and received a 19 out of 20 rating. The assessment focused on Foster Care Programs in Illinois. Members of the CQIR team completed a Program Evaluation of the Circle of Hope program in Springfield, MO. Members of the CQIR Team completed a 100% file review of the Tampa program. Hope Katurah Roby joined the CQIR team in Tampa, FL. Sarah Tunning has taken on the Director

of

Research

role

for

the

Federation.

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Northern Leadership
The Northern Region is led by an Executive Director, 2 Associate Executive Directors, and 4 Senior Vice Presidents. Additionally, there are 5 Directors of Programs who assist in the leadership of specific program categories/programs. The Northern Region offers services in 6 program categories: Child Development, Counseling, Family Preservation, Placement, Prevention, and Youth Services. Mark McHugh Executive Director David Fox Associate Executive Director Beth Lakier Associate Executive Director Senior Vice Presidents Directors of Programs Josie Disterhoft Laura Franz Joyce Heneberry Timothy Snowden

Christina Czech Rosanne DeGregorio Jill Novacek Karen Powell John Zupancic

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Executive Summary
This year OHU programs in the Northern Region served 5,486 clients and families a 2.16% decrease from last year. The Compliance & Quality of service and record documentation overall was 88%. The efforts of Northern programs resulted in 73% of all outcome goals being met.

OUTCOME MANAGEMENT

PEER RECORD REVIEWS

Across all programs, 73% of Outcome goals were Out of 896 files reviewed in FY13, the Northern met in FY13. Region Compliance & Quality rating on service documention was at 88%. CLIENT SATISFACTION INCIDENT REPORTS

Northern Region Overall satisfaction score has In the Northern Region, the number of incidents remained above 4.50 (A) for the past three years. decreased about 12% across most incident types. Incidents involving Client/Caregiver Property (-93%), Education incidents (-50%), and Client Deaths (-30%) had the largest decreases from FY12 to FY13. OFFICE REVIEWS SUPERVISORY REVIEWS PRIORITY REVIEWS

In the Northern Region, 94% of Office Reviews and There were 16 priority reviews conducted in FY13: 5 Level III, 3 Level II and 8 Case Consultations. 79% of Supervisory reviews were compliant. EMPLOYEE RECOGNITION QUALITY IMPROVEMENT TEAMS

There were 13 STAR awards and 4 GALAXY There was an average QIT attendance rate of 96% awards distributed this year. in the Northern Region.

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In reviewing each area assessed in this report, the following actions are recommended in FY14 based on outcomes and peer record reviews in FY13. Programs Reviewed Child Development Risk Management Topics for FY14 QITs: Recommended Areas to Develop Action Plans
Supervisory Reviews did not achieve the 90% target specifically in areas of individual supervision/team meetings and on-time performance reviews. Counseling programs did not achieve the following outcomes: 1. Client treatment goals will be met at discharge did not reach the target in DCFS Counseling, Foster Care Counseling-Cook, Foster Care/Comprehensive Counseling Downstate, and Intact Counseling. 2. Clients discharged will show an overall improvement between initial and closing CANS ratings did not reach the target in Foster Care CounselingCook, Foster Care/Comprehensive Counseling Downstate, and Intact Counseling. 3. Clients who reside in foster care or other out of home placement will remain in that placement or achieve permanency did not reach the target in Foster Care/Comprehensive Counseling-Downstate. 4. Clients who reside in the home of a parent at the time of referral will remain in the home did not reach the target in Intact Counseling. 5. Clients will demonstrate improved well-being did not reach the target in Community Counseling-Gurnee, Sexual Abuse Counseling Programs did not achieve the following outcomes: 1. Clients who reside in the home of a parent will remain in the home at the time of discharge did not achieve the target in Adolescents with Sexual Behavior Problems-Gurnee/Kenosha and in St. Charles. 2. Clients will have a reduced level of sexual re-offense was not achieved by Adolescents with Sexual Behavior Problems-Gurnee/Kenosha. 3. Clients will have achieved at least 90% of their treatment plan goals at planned discharge did not reach the target in Adolescents with Sexual Behavior Problems-Gurnee/Kenosha. 4. Clients discharged will show an overall improvement between initial and Closing CANS did not reach the target in Adolescents with Sexual Behavior Problems-Gurnee/Kenosha. In Peer Record Review the following areas of service documentation did not achieve the agencys target: 1. Intake was not achieved in Foster Care Counseling-Cook, DCFS Counseling, Intact Counseling OHU, Foster Care Counseling-Downstate, Children with Sexual Behavior Problems-St. Charles, and CARE Day Treatment. 2. Assessment was not achieved in DCFS Counseling, Intact CounselingOHU, Comprehensive Counseling-Downstate, Anger Management, Sexual Abuse Treatment Program-Adults, Adolescents with Sexual Behavior Problems-St. Charles, Adolescents with Sexual Behavior ProblemsGurnee, CARE Day Treatment. 3. Treatment Planning was not achieved in DCFS Counseling, Intact Counseling, Intact Counseling-OHU, Comprehensive CounselingDownstate, Anger Management, Sexual Abuse Treatment Program-Adults, Adolescents with Sexual Behavior Problems-St. Charles & Gurnee, Children with Sexual Behavior Problems-St. Charles, and CARE Day Treatment. 4. Service Delivery was not achieved in Intact Counseling-OHU, Anger Management, and CARE Day Treatment. 5. Closing was not achieved in Intact Counseling and Anger Management. In Peer Record Review the following areas of service documentation did not achieve the agencys target: 1. Intake was not achieved in Intact Family-Cook Team A. 2. Assessment was not achieved in Intact Family-Waukegan and Intact Page 7 of 43

Counseling

Family Preservation

Placement

Prevention

Youth Services

Family-Cook Team A. 3. Treatment Planning was not achieved in Intact Family-Waukegan and Intact Family Cook Team A. 4. Service Delivery was not achieved in Intact Family Waukegan. Foster Care-Cook did not achieve 2 outcomes. Children will achieve permanency within 24 months of the child coming and children who are reunified with their families will be reunited within12 months of the child coming into care did not achieve their targets. Foster Care-Downstate did not achieve 2 outcomes. Children will not be abused and/or neglected by a substitute caregiver while in foster care and children will remain reunified for a period of 6 months without re-entry into foster care did not achieve their targets. Specialized Foster Care did not achieve 3 outcomes. Children will achieve permanency during the fiscal year, children discharged will show improvement between initial and closing CANS and children will not require a higher level of care did not reach their designated targets. Rebound did not achieve 4 outcomes. Youth will be discharged into the community in a planned manner, treatment clients will have received their GED at the time of discharge, youth will be employed while enrolled in the program, and youth will improve their life skills did not achieve their targets. In Peer Record Review the following areas of service documentation did not achieve the agencys target: 1. Intake was not achieved in Foster Care-Cook, Foster Care-Downstate, Specialized Foster Care, and CARE Residential. 2. Assessment was not achieved in Licensing-Cook, Foster Care-Cook, Foster Care Downstate, Specialized Foster Care, and CARE Residential. 3. Treatment Planning was not achieved in Foster Care-Cook, Foster Care Downstate, and CARE Residential. 4. Service Delivery was not achieved in Foster Care-Cook, Foster CareDownstate, Specialized Foster Care, and CARE Residential. 5. Closing was not achieved in Foster Care-Cook, Foster Care-Downstate, and Rebound. In Peer Record Review the following areas of service documentation did not achieve the agencys target: 1. Intake was not achieved in Wings-CPS. 2. Assessment was not achieved in Wings and Wings-CPS. 3. Treatment Planning was not achieved in Healthy Families and Wings-CPS. 4. Closing was not achieved in Wings. MST Probation, MST Kane, and MST Re-Entry did not achieve 3 outcomes. Youth will be maintained in a home like setting, youth will be deflected form further involvement in the juvenile justice system and youth will remain in school, alternative education, vocational training or employed did not achieve their targets. In Peer Record Review the following areas of service documentation did not achieve the agencys target: 1. Intake was not achieved in MST Re-Entry and MST Probation. 2. Assessment was not achieved in CCBYS, MST Re-Entry, and MST Probation. 3. Treatment Planning was not achieved in CCBYS and MST Re-Entry, 4. Service Delivery was not achieved in CCBYS. 5. Closing was not achieved in MST Probation.

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Clients Served
In fiscal year 2013, One Hope United served 5,486 clients and families in the Northern Region a decrease of 2.2% from FY12.

# of Clients Served by Fiscal Year

Child Development Counseling Family Preservation Placement Prevention Youth Services TOTAL FY13 2,180 1,049 355 701 965 236 5,486 FY12 2,137 1,136 466 830 800 238 5,607 FY11 2,045 938 256 923 7001 207 5,069

The main influences contributing to the decrease in clients served occurred in Family Preservation and Placement. In Family Preservation, the closing of the Differential Response program contributed to the decrease. In Placement, there was a decrease in the number of referrals which attributes to the decrease in the number of clients served. Prevention programs saw an increase in the number of clients served due to an increase in the number of clients served in Parenting Groups.

Clients Served: Northern

18%

4% 40%

13% 6% 19%

Child Development

Counseling

Family Preservation

Placement

Prevention

Youth Services

The Child Development programs continue to be the largest source of clients for the Northern Region, accounting for 40% of their client population. The next largest program categories are Counseling, accounting for 19% of Northerns client population and Placement, accounting for 13% of the client population.
In FY11 the Prevention clients served number was originally reported at 1,135. Due to turnover and lack of documentation this number could not be confirmed. Therefore, the number was changed to 700 which was confirmed in documentation. Page 9 of 43
1

Outcome Management
An outcome or accomplishment can be defined as the result of efforts or outputs (interventions by an individual or team) within an agency that have value to the goals of the agency. Outcome CQIR monitors contract and agency goals are important to establish because they outcome goals established by federal provide purpose for the work with children and and state standards and OHU values. families and should tie either directly or indirectly to the mission of the agency. Additionally, outcome goals create a culture of accountability and also provide an evaluation of Child Welfare Measures (referring to a clients safety, permanency and well-being). CQIR monitors contract and agency outcome goals established by federal and state standards and OHU values.
Percentage of Out come Goal Achievement: Northern Regi on FY13 FY12 FY11 OVERALL TOTAL 73% 83% 83% Safety 90% 80% 100% Permanency 55% 68% 74% Well-Being 76% 90% 80%

This year, the Northern Region achieved 73% of its outcome goals. The Northern Region holds itself to a number of outcome goals depending on the program category. Below is the outcome goal achievement by Child Welfare Measures by program category for FY13. For further outcome achievement information please see Appendices A-F.
Percentage of Out come Goal Achievement: Program Categor y % Family % Achieved Counseling Achieved Preservation 100% 100% Safety Safety (1/1) (3/3) 100% 83% Permanency Permanency (4/4) (5/6) 100% 56% Well-Being Well-Being (5/5) (5/9) 72% TOTAL TOTAL (13/18) / % % Prevention Youth Services Achieved Achieved 67% 100% Safety Safety (2/3) (1/1) 40% 100% Well-Being Permanency (4/10) (22/22) 50% 100% TOTAL Well-Being (4/8) (23/23) 48% TOTAL (10/21)

Child Development Safety Well-Being TOTAL

% Achieved 100% (1/1) 100% (1/1) 100% (1/1) 100% (3/3) % Achieved 100% (1/1) 33% (1/3) 33% (2/6) 40% (4/10)

Placement Safety Permanency Well-Being TOTAL

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ADDITIONAL PERMANENCY ACHIEVEMENT OUTCOMES FOR FOSTER CARE

Foster Care programs in Illinois measure permanency achievement each Fiscal Year. Below are the permanency outcomes for both Specialized Foster Care and Traditional & Relative Foster Care for the Northern Region. Specialized Foster Care Permanency Outcomes Region Northern Starting Caseload 16 Total Permanencies (measured by points) 2 FY13 Permanency Rate 13% FY13 Goal 20%

Specialized Foster Care Actual Children Region Northern Adoption 1 Return Home 0 Guardianship 0 Other 0 Total 1

Illinois Traditional & Relative Foster Care Permanency Outcomes Total FY13 Starting Permanencies Region Permanency Caseload (measured by Rate points) Northern Cook 32% 158 50 Northern Downstate 35% 209 73.5 Illinois Traditional & Relative Foster Care Actual Children Return Region Adoption Guardianship Home Northern Cook 8 14 16 Northern-Downstate 22 19 8

FY13 Goal 29% 33%

Other 0 1

Total 38 50

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Peer Record Reviews

A Peer Record Review is the process by which CQIR internally examines records in depth for timely completion of required activities (a Compliance Review) and for quality of services (a Quality Review). COA standards require OHU to randomly select a sample of records to review for all programs. COA standards require OHU to CQIR Coordinators conduct file reviews for randomly select a sample of records to each program every quarter and the results are communicated via a report for each review review for all programs. date, as well as Risk Management reports that show individual program results and results by program category. For the annual report, peer reviews are looked at for the fiscal year beginning July 1st, 2012 through June 30th, 2013. The program categories reviewed for the Northern Region in this report are: Child Development, Counseling, Family Preservation, Placement, Prevention, and Youth Services. # of Northern Region File Reviews by Quarter Program Category Q1 Q2 Q3 Q4 Child Development 95 97 91 89 Counseling 47 47 50 49 Family Preservation 12 11 11 12 Placement 51 51 45 46 Prevention 12 13 13 12 Youth Services 9 10 12 11 TOTAL 226 229 222 219 In FY13, 896 files were reviewed across all six program categories. There are 11 tools utilized in the Northern Region that assess Compliance & Quality. There are some tools that are used that assess only compliance and then other tools that assess quality (Ex. Foster Care utilizes a Standard Compliance Tool and then a Foster Care Quality Tool). There are other programs that use one tool that assess both compliance and quality (Ex. Child Development). Results were combined across all tools to produce the following graph which looks at how the Region performed as a whole. The goal for each phase of client services is 90%, represented by the black dashed line on the chart below. The purple solid line represents how each phase of client services scored cross-regionally.

TOTAL 372 193 46 193 50 42 896

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Compliance & Quality - Across All Northern Programs

100% 80% 60% 40% 20% 0% Intake Actual Target Cross-Region 94% 90% 90% Assessment 86% 90% 85% Treatment Plan 84% 90% 84% Service Delivery 85% 90% 84%

Closing 91% 90% 83%

Overall 88% 90% 86%

In FY13, the Northern Region met the 90% Compliance & Quality target in Intake and Closing. The Region is performing at or above the Cross-Regional rates in all areas measured and achieved an 88% Compliance & Quality overall rating this was an increase of 5% from FY12. Compliance & Quality performance for the Northern region was also analyzed by program category to produce the following graph. Overall Compliance & Quality - Across All Program Categories
100% 80% 60% 40% 20% 0%

Child Development 96% 90%

Counseling 89% 90%

Family Preservation 89% 90%

Placement 80% 90%

Prevention 93% 90%

Youth Services 90% 90%

Program Category Target

Child Development Centers, Prevention programs, and Youth Services are all meeting or exceeding the agencys 90% target for Compliance & Quality across all areas measured. Counseling and Family Preservation programs are within 1% of the target. Placement programs are within 10% of the target. Each program category is analyzed more closely in Appendices A-F to identify additional trends and areas of growth.
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During fiscal year 2013 there were 73 case managers, therapists, supervisors, and directors who assisted in reviewing 896 files as a part of the CQI peer record review process. These champions of quality serve as an integral part of the continual process of assessing the quality of our files, providing feedback on how to improve, and ensuring that plans of correction are being completed on time. Peer Record Reviewers Katie Jackson George Husick Denny Clouse Shantina Griffin Lisa Wiemhoff Deborah Holmes-Thomas Andrea Gray-Strutzenberg Lorena Duran Freya Gorenstein Jim Ogle Brian McGannon Carleen Otto Shirley Hawkins Cindy Peterson Cortney Rhadigan Dennis Delgado Kristin Patten Beth Tuthill Denise Herron Joi LaMon Jennifer Forbes June Galinski Diana Guzman Karen Felix Carolina Rodriguez Samella Taylor Julius Benjamin Devin Dittrich Andrew Hamlyn Karen Powell Latrina Presley Terry Kean Megan Sullivan Jane Lough Cecilia Rivas Beth Ericksen Lakiethia Butler Dana Torres TOTAL: 73

Jennifer Woods Jennifer Riha Jennifer Hedrich Margaret Vergamini Terri Cummings Brian McConville Brandy Kukurba Bessie Whitehurst-Smith Bobbie Weiner Sue Olson Keith Wheeler Cindy Rotman Mary Mann Shirica Flowers Jennifer Keith Sarah Martin Noell Juola Kahdijah Hakeem Danielle Sines

Adrienne Patterson-Green Marlice Waddy Felicia Foster Liza Simon-Roper Joanna Zakhem Jill Bulakowski Tammy Ambre Brenda Gossett Amy Collins Brigette Davis Lois Aliotta Mindy Kwoh Brenda Gossett Ann OMalley Cindy Paladino Ron Smith

Thank you for your time, efforts, and commitment to quality service delivery.

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Client Satisfaction
CQIR conducts an annual Client Satisfaction Survey to monitor OHU clients impressions of the services provided. After all surveys have been received, regional and program reports are compiled to Client Satisfaction Surveys monitor provide stakeholders with a Consumer Report Card that compares their program to the clients impressions of the services OHU programs in their program category and to provides. regions as a whole. Please contact Sarah Tunning, Director of Research for One Hope United, for a report card on any program or region.

Overall OHU Client Satisfaction: Northern Region

5.00 4.80 4.60 4.40 4.20 4.00 3.80 3.60 Child Development Counseling Family Preservation Placement Prevention Youth Services

Child Development FY13 FY12 FY11

Counseling

Family Preservation

Placement

Prevention

Youth Services

4.81 (N=619) 4.70 (N=597) 4.74 (N=547)

4.67 (N=349) 4.54 (N=351) 4.63 (N=351)

4.79 (N=108) 4.63 (N=131) 4.78 (N=137)

4.28 (N=343) 4.34 (N=345) 4.29 (N=334)

4.93 (N=189) 4.83 (N=169) 4.89 (N=165)

4.53 (N=59) 4.68 (N=97) 4.79 (N=86)

Across Region and fiscal year, all programs except Placement scored in the fine tuning range. Four program categories saw an increase in Overall satisfaction with OHU. Placement has scored in the needs improvement range for the past three years, and in FY13 Overall satisfaction with OHU decreased from FY12. Overall satisfaction in Youth Services also decreased; however, this program is still in the fine tuning range 2013 2012 2011 4.67 4.60 4.64 (N=1,667) (N=1,690) (N=1,620) In the Northern Region, overall client satisfaction with OHU has remained above 4.50 (A) for the past three years. This year, there were 1,677 surveys returned for Northern Region, a 1.36% decrease from the 1,690 surveys collected in 2012.
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Incident Reports
An incident is any occurrence that may have the potential for increased risk for our clients and the liability of our agency. Reportable Incident reports track situations that may incidents also include situations that raise have the potential for increased risk for our risk to staff or agency property, such as a clients and the liability of our agency. theft or natural disaster. CQIR provides monthly reports on incident trends and correlations. Annually, this report rolls up data for the fiscal year and presents incident trends by region and circuit over three fiscal years.

Incident Types by Year: Northern Region Programs

800 600 400 200 0

FY13

FY12

FY11

In the Northern Region, there was an 11.8% decrease in the number of incident types in FY13 compared to FY12. There was only one incident type that increased and that was Behavioral Issues, which increased by 4.4% in FY13. All other incident categories saw a decrease. The most significant decreases were in Client Caregiver Property (-92.9%), Education (-50%), Deaths (-30%), Behavior Management (-27.5%), and Sexually Problematic Behaviors (-22%). It is important to note that the number of Behavior Management incidents (incidents involving a restraint) in the CARE Day Treatment (DTx) and Residential (RTx) programs decreased for the first time since FY10. In FY12, 34% of all incidents in the Northern Region involved a restraint. In FY13, out of the 1,475 incidents, 28% involved a restraint, a 6% decrease.

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Office Systems Reviews

The Office Systems Review is a process to determine if an office is meeting agency standards. This includes professional appearance, staff response to answering telephone calls, maintaining client confidentiality and safety and risk management. CQIR coordinators conduct OHU office systems reviews annually. Office Systems Compliance: Northern Region
100% 80% 60% 40% 20% 0% Child Develoment Centers Program Offices Region 93% 95% 94%

Seventeen Office Systems Reviews were conducted in the Northern Region (9 Child Development Centers and 8 Program Offices). As a Region, 94% of all office system reviews were compliant a 2% decrease from FY12. Both Child Development Centers and Program Offices are exceeding the agencys 90% target.

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Supervisory Systems Reviews

On an annual basis CQIR conducts an assessment of supervision provided by each direct service supervisor in the organization. The review uses a standardized form and involves a check of a number of supervision tasks. Although there are several items addressed, there is a concentration on the frequency of supervision and quality documentation of supervisory activities. Supervisory Systems Compliance: Northern Region
100% 80% 60% 40% 20% 0% Child Development Program Offices Region 73% 85% 79%

Fifty-seven Supervisory Systems Reviews were completed in the Northern Region (37 from Child Development Centers and 20 from Program Offices). As a Region, supervisors were 79% compliant with items measured a 2% increase from FY12. Both Program Offices (85%) and Child Development Centers (73%) are below the agencys 90% target. Items missed most on Supervisory Systems Reviews at Child Development Centers were: Supervision occurs monthly (Management Team Meetings and/or Individual). Annual performance reviews are completed within 30 days of review date. Items missed most on Supervisory Systems Reviews at Program Offices were: Individual supervision occurs. The supervisor completes annual staff performance reviews within the month they are due.

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Priority Reviews
A priority review is a process that examines the quality of services provided Priority review is a process that examines to a client or family and compliance with program policies and procedures. There the quality of services provided to a client or are three levels of priority reviews: The family. Level 1 Priority Review also called a case consultation is voluntary and can be conducted on any case upon the request of the supervisor. The Level 2 Priority Review are conducted in the event of a serious injury to a client or a crime. Level 3 Priority Reviews are held when there is a client death, suicide attempt, or felony. # Priority Reviews in FY13 Case Program Category Level 2 Level 3 Consultations Child Development 0 0 0 Counseling 1 0 2 Family Preservation 2 0 0 Placement 5 3 1 Prevention 0 0 1 Youth Services 0 0 2 5 TOTAL 8 3 (see footnote)

TOTAL 0 3 2 8 1 2 162
(unduplicated)

There were 16 priority reviews conducted in FY13 (down 10 from FY12). The decrease can be attributed to a decrease in the number of Case Consultations and Level 3 Reviews. Case Consultations are preventative in nature and are meant to be used as a method to share thoughts and ideas about a case that may be challenging. Northern conducted 3 less Case Consultations in FY13 compared to FY12. There were three Level 2 Priority Reviews conducted in FY13 (up 1 from FY12). One was due to the abduction of a child from Foster Care, one was due to inappropriate behavior between 2 clients, and one was at the request of program leadership. There were five Level 3 Priority Reviews conducted in FY13 (down 7 from FY12) (one review was for a client that was enrolled in 2 OHU programs). Four reviews were due to suicide attempts made by clients and one was due to a client death. Below are some highlights of lessons learned throughout the year:

When there is a significant safety issue or history of abduction with a natural parent, that case needs to be staffed immediately with the Director of Programs to devise a plan for visitation and services with the supervisor moving forward.

The Level 3 review that took place in Counseling and Prevention involved a client that was enrolled in Intact Family Counseling and the Wings CPS program. In the total column this review was only counted once. Page 19 of 43

Based on the dynamics of the case, the location of the visits needs to be assessed to identify safety concerns. Case aids need to be updated on the history and dynamics of each case in which they are supervising parent-child visits. Transportation requests need to be signed by the case manager as well as the supervisor to ensure the case aid has all the important case information needed for safety and security reasons. The history of the case needs to be shared with everyone involved in the case. Transitional programming for clients who have finished high school would provide increased structure and might help prevent boredom and some acting out behavior. Good communication on shared cases between programs is essential and aides in ongoing assessment and treatment planning. This was done effectively on this case. The importance of having the proper training and completion of an Eco-map to understand the family, strengths and resources. For non-traditional families that we work with, we need to look for non-traditional ways to engage them. The review was reminder to obtain consents within the agency for different programs that have the same client in order to communicate with each other. Continue to try to engage client even though they may be resistant.

Additional information can be found by contacting a member of the CQIR team.

Page 20 of 43

Employee Recognition
Two methods of awarding staff excellence are supported by CQIR. The first is the STAR Award for individual excellence, and the second is the GALAXY Award for team excellence. The awards recognize staff that have gone above and beyond normal work duties, exhibited exemplary performance and done their job under circumstances that are out of the ordinary. There were 13 Star awards and 4 Galaxy awards distributed in the Northern Region this year. In FY13 we were proud to recognize these Northern employees with a STAR Award. Quarter 1 Patty Diaz Eligibility Specialist (Aurora, IL) Andrew Rozanski Youth Care Worker (Lake Villa, IL) Delores Momen Case Manager (Kankakee, IL) Blanca Figueroa Payroll Manager (Lake Villa, IL) Ginny Kowalski Office Manager (Waukegan, IL/Busy Bee) Amy Hirsh Child Development Director (Wilmette, IL) Susan Spjuth Child Development Specialist (Des Plaines, IL) Quarter 2 Nicole Apolo Donor Database Administrator/Accountant I (Lake Villa, IL) Quarter 3 Yudelca Romano Counselor/Therapist (Gurnee, IL) Bonita Porter Therapist (Chicago, IL) Francine Williams Case Manager (Chicago, IL) Quarter 4 Jackie Schedin CQIR Coordinator (Chicago, IL) Devin Gazelle Supervisor (Joliet, IL)

The following teams were presented with a GALAXY Award this year. Quarter 1 CARE Day Treatment (Lake Villa, IL) Des Plaines Child Development Center (Des Plaines, IL) Quarter 3 Kenwood Support Staff (Chicago, IL) Quarter 4 Bridgeport II Child Development Center Classroom 2 (Chicago, IL)

Page 21 of 43

Quality Improvement Teams

Everyone in the agency participates in at least one Quality Improvement Team (QIT). This allows each employee the power to implement improvement within their own QIT. The QIT is focused on improving the quality of service at the local level using data, effective problem solving and action planning. Across the agency, there was an overall attendance rate of 96% in FY13. The attendance rate in the Northern Region was 96%. The following local, service center and regional Quality Improvement Teams were assembled three times this year in the Northern Region. QIT Names Service Center

Local Wonder Women The River Valley Responders KFC Kenwood Foster Care Whatever it Takes MST on The Prairie Super Crew Top Performing Butterflies OHU Advocates Social Workers for Justice The Guardian Angels Bridgeport II Edgewater Educators OHare CDC The Inspirations The Eclectics The Facilitators CLC Seeds of Change 24-7 Crew Team Extreme EBT The Rainbow Team Teach The 4 Runners Old School Rebounders Cheers Connect 6 Team Unity All Stars Educaneers The Show Must Go On Wilmette/Glenview CDC Eternal Optimists The Pilots The B.R.A.T.S.

Regional

Energizers To Infinity & Beyond Mission Movers CARE Leadership The Wanderers Prevention Supervisors

Community Transformers

Page 22 of 43

Appendix A Child Development Highlights

The Northern Region operates 11 Child Development Centers throughout the Chicagoland area. Across the 11 centers, 2,180 clients were served in FY13 which is a 2% increase from FY12. Outcomes Goals 1. Children served will not be subjects of abuse or neglect while physically present in the child development program. 2. Children in the center will meet or exceed widely held expectation for social and emotional development. 3. Children in the center will meet or exceed widely held expectations for physical development. 4. Children in the center will meet or exceed widely held expectations for cognitive development. 5. Children in the center will meet or exceed widely held expectations for language development. Target 90% % Achieved 100%

80%

94%

80%

94%

80%

93%

80%

90%

Peer Reviews Compliance & Quality: Child Development Centers

100% 80% 60% 40% 20% 0% Intake Child Development Target 97% 90% Assessment 97% 90% Service Delivery 95% 90%

Overall 96% 90%

Overall, Child Development Centers achieved a 96% Compliance & Quality rating on all areas measured across all centers. Intake, Assessment, and Service Delivery were within 3-5% of a 100% Compliance & Quality rating. When looking at each of the 11 centers individually, all centers across all phases of the case life-cycle were above the 90% target.
Page 23 of 43

Appendix B Counseling Highlights

The Northern Region operates Counseling programs throughout the Chicagoland area. Across all programs, 1,049 clients were served in FY13 which is a 7.7% decrease from FY12. Outcomes are reported below. For ease of analysis, results were condensed across specific types of Counseling Programs. 1. DCFS Counseling, ECHO, Foster Care (FC) Counseling Cook, Foster Care (FC) & Comprehensive (Comp) Counseling Downstate (program offices were combined), and Intact Counseling 2. Community Counseling 3. System of Care (SOC) 4. Sex Offender Counseling Programs 5. CARE Day Treatment DCFS Medicaid Counseling, ECHO, Foster Care Counseling, Comprehensive Counseling & Intact Counseling FC FC/Comp DCFS Goals Target ECHO Counseling Counseling Counseling Cook Downstate Clients served will not be subjects of indicated 90% 100% 100% 100% 98% reports of abuse or neglect during the service period. Clients who reside in the home of a parent at 90% 100% 100% N/A N/A the time of referral will remain in the home. Clients who reside in foster care or other out of home placement will 90% 100% 92% 87% N/A remain in that placement or achieve permanency. Clients discharged will show an overall 80% 86% 70% 78% improvement between N/A initial and closing CANS ratings. Client treatment goals having been 80% 76% 87.2% 65% 72% substantially met at discharge.

Intact Counseling

1.

91%

2.

80%

3.

N/A

4.

50%

5.

29%

Page 24 of 43

Community Counseling Goals Target 1. Clients will achieve at least 75% of the 70% treatment plan goals at discharge 2. Clients will demonstrate improved wellbeing as measured by a standardized 75% instrument, pre and post service (measured at discharge). SOC Goals 6. Clients will maintain their initial placement at the time of discharge. 7. Clients discharged will show an improvement between initial and closing CANS ratings.

Gurnee 100%

St. Charles 100%

50%

100%

Target 70% 80%

% Achieved 94% 94%

1.

2.

3.

4.

Sex Offender Counseling Programs ASBP Goals Target SATP Gurnee/Kenosha Client has reduced level of risk for sexual re-offense as measured by 75% 87% 71% the ERASOR and JSOAP (adolescents) and Static 99 and Vermont (adults). Clients who reside in the home of 90% 71% a parent will remain in the home N/A at time of discharge Client has achieved at least 90% of their treatment plan goals at 80% 96% 60% planned discharge or completion of treatment. Clients discharged will show an 80% 73% overall improvement between N/A initial and closing CANS ratings. CARE Day Treatment 3 Goals Youth will remain in the community while enrolled in the program. Youth will maintain their less restrictive placement for 6 months after being discharged from the CARE program. Youth shall experience an increase in one academic grade during the academic year, based on the results of the MAP testing. Parents shall indicate program satisfaction

ASBP St. Charles

90%

64%

100%

100%

Target 90% 80%

% Achieved 100% 100%

1. 2.

3.

80% 80%

100% 100%

4.
3

The final two outcomes are contract-based satisfaction outcomes. They are not included in the agencys overall outcome performance. Page 25 of 43

at the time of termination. 5. Referral Sources shall indicate program satisfaction at the time of termination.

80%

100%

Peer Record Reviews are reported below. For ease of analysis, results were condensed across specific types of Counseling Programs. 1. Cook County Counseling Reviews 2. Downstate Counseling including: Foster Care, Comprehensive, Community, & Anger Management Counseling Reviews (results were combined across offices) 3. Sexual Offender Counseling Program Reviews 4. CARE Day Treatment Reviews Compliance & Quality: Counseling - Cook
100% 80% 60% 40% 20% 0% Intake FC Counseling Cook ECHO DCFS Counseling SOC Intact Counseling Intact Counseling-OHU Target All Programs 85% 98% 82% 96% 95% 88% 90% 93% Assessment 90% 91% 81% 99% 100% 74% 90% 92% Treatment Plan 91% 92% 39% 100% 89% 79% 90% 90% Service Delivery 95% 94% 93% 100% 91% 88% 90% 95% Closing Overall 91% 95% 77% 99% 89% 84% 90% 93%

97% 100% 96% 33% 100% 90% 93%

Overall, Counseling Programs in Cook County achieved a 93% Compliance & Quality rating. DCFS Counseling (77%), Intact Counseling (89%), and Intact Counseling-OHU (84%) are the only programs that did not achieve the 90% target. ECHO and SOC exceeded the target in all areas measured. Foster Care Counseling met or exceeded the target in Assessment, Treatment Planning and Service Delivery, and was within 5% of the target in Intake.

Page 26 of 43

Compliance & Quality: Counseling - Downstate

100% 80% 60% 40% 20% 0% Intake Foster Care Counseling Comprehensive Counseling Community Counseling Anger Management Target All Programs 88% 93% 100% 92% 90% 91% Assessment 95% 89% 100% 33% 90% 94% Treatment Plan 97% 71% 100% 22% 90% 91% Service Delivery 98% 98% 100% 23% 90% 95% Closing 100% 100% 30% 90% 65% Overall 96% 88% 100% 36% 90% 93%

Overall, Downstate Counseling Programs achieved a 93% Compliance & Quality rating. Comprehensive Counseling (88%) and Anger Management (36%) are the only programs that did not achieve the 90% target. Community Counseling achieved a 100% Compliance & Quality rating. Foster Care Counseling exceeded the target in all areas measured with the exception of Intake, which was within 2% of the target.

Compliance & Quality: Counseling - Sex Offender Programs

100% 80% 60% 40% 20% 0% Intake SATP - Adults ASBP St. Charles CSBP - St. Charles ASBP - Kenosha ASBP - Gurnee CSBP - Gurnee Target All Programs 99% 97% 87% 100% 100% 100% 90% 98% Assessment 83% 89% 100% 100% 86% 100% 90% 88%

Treatment Plan 88% 81% 62% 100% 63% 100% 90% 84%

Service Delivery 95% 98% 93% 100% 96% 100% 90% 96%

Closing 100%

Overall 93% 92% 83% 100% 89% 100% 90% 93%

100% 100% 90% 100%

Overall, Sex Offender Counseling Programs achieved a 93% Compliance & Quality rating. Children with Sexual Behavior Problems St. Charles (83%) and Adolescents with Sexual Behavior Problems Gurnee (89%) are the only programs that did not achieve the 90% target. Adolescents with Sexual Behavior Programs Kenosha and Children with Sexual Behavior Problems Gurnee achieved a 100% Compliance & Quality rating.
Page 27 of 43

Compliance & Quality: Counseling - CARE Day Treatment

100% 80% 60% 40% 20% 0% Intake CARE DTx Target 69% 90% Assessment 49% 90% Treatment Plan 50% 90% Service Delivery 28% 90%

Closing 100% 90%

Overall 49% 90%

Overall, CARE Day Treatment scored an overall Compliance & Quality Rating of 49%. Closing is the only category that met the agencys 90% target with a 100% rating. To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. Foster Care Counseling-Cook Intake (85%) Are Releases of Information completed, signed and current? (4/8) DCFS Counseling Intake (82%) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (2/6) Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (2/6) Assessment (81%) Was the updated assessment report completed within the required timeframe of the program contract? (2/2) Treatment Plan (39%) Is the current copy of the service plan/treatment plan/case plan in the file (Per Program Contract/Plan)? (3/5) Intact Counseling Treatment Plan (89%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (3/4)
Page 28 of 43

Closing (33%) Is the Closing Summary in the record? (1/1) If follow-up services were recommended were appropriate referrals and linkages made? (1/1) Intact Counseling-OHU Assessment (74%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (3/5) Treatment Plan (79%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (3/4) Service Delivery (88%) Does the record confirm sufficient contacts according to program requirements with the client/family to accomplish the goals? (2/5) Foster Care Counseling-Downstate Intake (88%) Are Releases of Information completed, signed and current? (5/20) Comprehensive Counseling Assessment (89%) Is a copy of the Initial Assessment Report in the record? (1/9) Was sufficient information recorded to understand the presenting problem? (1/9) Treatment Plan (71%) Is the current service/treatment/case plan signed and dated by the client and parent/guardian? (4/9) Is there evidence in the record that the family participated in the development of the service/treatment plan? (4/9) Anger Management Assessment (33%) Is a copy of the Initial Assessment Report in the record? (2/3) Treatment Plan (22%) Is the current copy of the service plan/treatment plan/case plan in the file (Per Program Contract/Plan)? (2/3) Service Delivery (23%) Is there required documentation of current client progress (or lack there of) towards their service goals in the case record? (2/3) Closing (30%) Is the Closing Summary in the record? (1/2) SATP-Adults Assessment (83%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (9/17) Treatment Plan (88%)

Page 29 of 43

Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (8/17)

ASBP-St. Charles Assessment (89%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (2/6) Treatment Plan (81%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (2/6) CSBP-St. Charles Intake (87%) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (1/3) Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (1/3) Treatment Plan (81%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (2/3) ASBP-Gurnee Assessment (86%) Is a copy of the Initial Assessment Report in the record? (1/4) Treatment Plan (63%) Is the current copy of the service plan/treatment plan/case plan in the file (Per Program Contract/Plan)? (1/4) CARE Day Treatment Intake (69%) Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (16/24) Assessment (33%) Is a copy of the Initial Assessment Report in the record? (9/28) Treatment Plan (22%) Is the current copy of the service plan/treatment plan/case plan in the file (Per Program Contract/Plan)? (12/28) Service Delivery (23%) Is there required documentation of current client progress (or lack there of) towards their service goals in the case record? (20/28)

Page 30 of 43

Appendix C Family Preservation Highlights

The Northern Region operates two Family Preservation programs: one located in Waukegan, IL and the other one located in Cook County, IL, which is divided into 2 teams. Across the programs, 355 clients were served in FY13 which is a 23.8% decrease from FY12 which is attributed to the closing of the Differential Response program. Outcomes Family Preservation Goals Target 1. Families will not have a confirmed abuse or 85% neglect report during the service period 2. Families remain together during service 90% period. 3. Families discharged from the Family Preservation program will show an overall 80% improvement between initial and closing CANS. Cook 97% 97% Waukegan 93% 97%

91%

N/A

Peer Reviews Compliance & Quality: Family Preservation

100% 80% 60% 40% 20% 0% Intake Intact Family-Waukegan Intact Family-Cook A Intact Family-Cook B Target All Programs 91% 89% 92% 90% 90% Assessment 73% 82% 94% 90% 85% Treatment Plan 55% 79% 93% 90% 80% Service Delivery 75% 98% 99% 90% 95%

Closing

Overall 72% 88% 95% 90% 89%

100% 100% 90% 100%

Across all programs and all areas measured, the Family Preservation programs achieved an 89% Compliance & Quality Rating, which is just below the 90% target. Across all programs, Intake, Service Delivery and Closing exceeded the 90% target. When looking at individual programs, Intact FamilyCook B exceeded the 90% target in all areas measured and received a 95% Compliance & Quality rating overall. Cook A achieved the target in Service Delivery and Closing and was within 2% of the agencys target. Waukegan achieved the target in Intake.

Page 31 of 43

To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. Intact Family - Waukegan Assessment (73%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (3/8) Was the Home Safety Checklists for Intact and Permanency Workers updated every six months during the life of the case? (2/2) Were the Home Safety Checklists updated every 90 days during the life of the case? (2/2) Treatment Plan (55%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (4/8) Was the familys comprehensive service plan completed within 30 days of case opening? (2/2) Service Delivery (75%) Is there evidence of quarterly case supervision in which the case is reviewed at least quarterly and includes an evaluation of the clients progress toward achieving his/her service goals? (3/8) Intact Family Cook A Intake (89%) Is there documentation in the record of written correspondence with the funding/referral source indicating the actual date of case opening and/or case closing? (4/19) Did the transitional visit occur within two business days of receiving the intact case referral? (4/12) Assessment (82%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (7/19) Was a CERAP completed within 5 working days of case opening? (3/6) Was a SACWIS Risk Assessment completed every 90 days? (2/3) Is there evidence that the initial CANS was completed? (2/6) Was the Home Safety Checklist for Intact and Permanency Workers completed within 30 days of case opening?(2/6) Treatment Plan (79%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (7/19) Did the initial Child and Family Team meeting occur within 45 days of the transitional visit? (4/6) Was the familys comprehensive service plan completed within 30 days of case opening? (5/6)

Page 32 of 43

Appendix D Placement Highlights

The Northern Region operates a number of different Placement programs including CARE Residential Treatment, Rebound, Foster Care services in Cook County, Downstate Foster Care services, and Specialized Foster Care. Across the programs, 701 clients were served in FY13 which is a 15.5% decrease from FY12 which is primarily attributed to a decrease in the number of referrals in Foster Care. Outcomes are reported below by program and/or by program contract. Foster Care Goals 1. Children will not be abused and/or neglected (an indicated report) by a substitute caregiver while in foster care. 2. Children will achieve permanency within 24 months of the child coming into care (all other permanencies outside of reunification). 3. Children will experience two or fewer placement settings within a 12 month period. 4. Children who are reunified with their families will be reunified within 12 months of the child coming into care. 5. Children will remain unified for a period of 6 months without re-entry into foster care. 6. Clients discharged from the foster care program will show an overall improvement between the initial and the closing CANS ratings. Target 99.6% Cook 99.7% Downstate 99.4%

32% 95% 46% 91%

10% 98% 14% 100%

35% 99% 61% 85%

80%

100%

99%

1.

2. 3. 4. 5.

6.

Specialized Foster Care Goals Target Children will not be abused and/or neglected 99.6% (an indicated report) by a substitute caregiver while in foster care. Children will achieve permanency during the 20% fiscal year. Children will experience two or fewer 85% placement settings within a 12 month period. Children will remain unified for a period of 6 91% months without re-entry into foster care. Clients discharged from the foster care program will show an overall improvement 80% between the initial and the closing CANS ratings. Children will not require a higher level of 85% care (i.e. psychiatric hospitalization or residential care).

% Achieved 100% 5% 100% N/A

50%

76%

Page 33 of 43

Rebound 1. 2. 3. 4. 5. 6. 7. Goals Youth will be discharged into the community in a planned manner. Diagnostic clients will be participating in the GED assessment and courses. Treatment clients will have completed and received their GED at time of discharge. Youth will participate in initial job searching skill development. Youth will be employed while enrolled in the Rebound program. Youth will reconnect with family members as visiting resources. Youth will improve their life skills as measured by the Ansell-Casey Life Skills Assessment. CARE Residential Goals 1. Youth served will not be subjects of indicated reports of abuse or neglect while physically present in the residential treatment program. 2. Youth served will achieve and sustain a positive or neutral discharge placement for a period of 90 days following discharge 3. The treatment opportunity rates will be achieved. Target 95% % Achieved 100% Target 25% 70% 50% 90% 50% 80% 80% % Achieved 8% 100% 17% 100% 13% 100% 30%

22.49% 95.32%

23.53% 96.24%

Peer Record Reviews are reported below by program and/or by program contract. Compliance & Quality: Placement - Cook
100% 80% 60% 40% 20% 0% Intake Licensing FC - Cook Target All Programs 94% 71% 90% 89% Assessment 81% 64% 90% 72% Treatment Plan 74% 90% 74% Service Delivery 90% 71% 90% 73%

Closing

Overall 91% 71% 90% 77% Page 34 of 43

78% 90% 78%

Across all programs and all areas measured, the Foster Care programs in Cook County achieved a 77% Compliance & Quality Rating, which is below the agencys 90% target. All phases of the case life cycle were below the 90% target. When looking at individual programs, Licensing met or exceeded the 90% target in Intake and Service Delivery and received a 91% Compliance & Quality rating overall. Foster Care Cook achieved an overall Compliance & Quality rating of 71% and did not achieve the target in any areas measured. . Compliance & Quality: Placement - Downstate
100% 80% 60% 40% 20% 0% Intake Licensing - Downstate FC-Downstate Target All Programs 93% 77% 90% 91% Assessment 99% 73% 90% 88% Treatment Plan 82% 90% 82% Service Delivery 93% 75% 90% 77%

Closing

Overall 94% 76% 90% 84%

67% 90% 67%

Across all programs and all areas measured, the Downstate Foster Care programs achieved an 84% Compliance & Quality Rating, which is below the agencys 90% target. Intake was the only area, across all programs to meet/exceed the agencys target. When looking at individual programs, Licensing Downstate achieved an overall Compliance & Quality rating of 94% and exceeded the target in all areas measured. Foster Care Downstate achieved an overall Compliance & Quality rating of 76% and did not achieve the target in any areas measures.

Page 35 of 43

Compliance & Quality: Placement - Specialized Foster Care

100% 80% 60% 40% 20% 0% Intake Specialized FC Target 79% 90% Assessment 73% 90% Treatment Plan 90% 90% Service Delivery 84% 90%

Closing

Overall 83% 90%

90%

Overall, Specialized Foster Care achieved an 83% Compliance & Quality Rating. Treatment Planning is the only area that met the agencys 90% target. Compliance & Quality: Placement - CARE Residential
100% 80% 60% 40% 20% 0% Intake CARE Target 74% 90% Assessment 72% 90%

Treatment Plan 70% 90%

Service Delivery 70% 90%

Closing 100% 90%

Overall 70% 90%

Overall, CARE Residential achieved 70% Compliance & Quality Rating. Closing is the only area that exceeded the agencys target.

Page 36 of 43

Compliance & Quality: Placement - Rebound

100% 80% 60% 40% 20% 0% Intake Rebound Target 97% 90% Assessment 99% 90%

Treatment Plan 93% 90%

Service Delivery 97% 90%

Closing 89% 90%

Overall 97% 90%

Overall, Rebound achieved a 97% Compliance & Quality Rating. Closing is the only area that did not achieve the 90% target; however it was within 1% of the goal. All other areas measured exceeded the target. To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. Licensing - Cook Assessment (81%) Initial Home Study: Physical environment of the home, both inside and outside. (7/22) Initial Home Study: Knowledge and skill of foster parents such as, understanding of child development, attitude toward natural parents, educational level, communication skills, etc. (7/22) Foster Care - Cook Intake (71%) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (20/32) Assessment (64%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (11/26) Substance Abuse Screen (For all cases). (14/29) Child/Caregiver Matching Tool. (5/7) Treatment Plan (74%) Is the current service/treatment/case plan signed and dated by the client and parent/guardian? (23/31) Service Delivery (71%)
Page 37 of 43

Fingerprints for all children age 6 months or older. (27/29) Did the initial Family Meeting occur within 48 hours of case assignment (with Supervisor present)? (21/29) Consent for Ordinary/Routine Medical and Dental Care. (17/29) Child Identification Form. (15/29) Closing (78%) Was the evaluation of the service plan completed? (1/1) Foster Care - Downstate Intake (77%) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (18/48) Is the Family Face Sheet/Case Cover Sheet in the record? (16/49) Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (16/42) Assessment (73%) Is a copy of the Initial Assessment Report in the record? (10/49) Was the Initial Assessment Report completed within the required timeframe of the program contract? (12/40) Substance Abuse Screen. (14/35) Child/Caregiver Matching Tool. (4/9) Treatment Plan (82%) Is the current service/treatment/case plan signed and dated by the client and parent/guardian? (22/41) Service Delivery (75%) For the past 6 months: Are there monthly supervision notes in the case record? (20/36) Did the initial Family Meeting occur within 48 hours of case assignment (with Supervisor present)? (22/36) Fingerprints for all children age 6 months or older. (25/31) A photograph of the child annually (the photograph needs to be labeled on the back with the childs name, birth date, DCFS ID # and the date on which the photo was taken) (23/35) Closing (67%) Does the record contain documentation of an aftercare plan completed with and signed by the client or a reason why an aftercare plan was not needed? (1/2) Specialized Foster Care Intake (79%) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (2/3) Assessment (73%) Is a copy of the Initial Assessment Report in the record? (1/4) Substance Abuse Screen. (3/4) Service Delivery (84%) Did Child and Family Team meetings occur quarterly? (3/3) CARE-Residential Intake (74%)
Page 38 of 43

A letter to the funding source documenting the date of case acceptance and case closure. (5/8) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (7/20) Assessment (72%) Is there a Children's Global Assessment Scale (CGAS) completed with assessment and quarterly reports? (5/8) Does the current Mental Health Assessment include: General physical health. (5/8) Treatment Plan (70%) Is the current service/treatment/case plan signed and dated by the client and parent/guardian? (10/20) Does the record contain the most current 497? (4/8) Has a current written visiting plan (in the 497) been developed for all siblings in substitute care? (5/6) Service Delivery (70%) Did the record contain a minimum of one service provided and documented every day during the past 30 day sample period? (8/8) Case note documentation reflects the level of client contact per program requirements? (8/12) If sibling visitation is not occurring per the 497, has a plan been developed to attempt to achieve compliance with visitation? (6/6) Rebound Closing (89%) Does the record contain documentation of an aftercare plan completed with and signed by the client or a reason why an aftercare plan was not needed? (1/2)

Page 39 of 43

Appendix E Prevention Highlights

The Northern Region operates four Prevention programs. Across the 4 programs, 965 clients were served in FY13 which is a 20.6% increase from FY12 which is attributed to an increase in the number of clients enrolled in the Parent Group. Outcomes for the Prevention Programs have been condensed to show the number of outcomes achieved by outcome category (i.e. Safety and Well-Being). For a full listing of Prevention outcomes please contact Kimberly Clark. % of Safety Outcomes Achieved 100% (1/1) 100% (1/1) N/A 100% (1/1) 100% (1/1) % of Well-Being Outcomes Achieved 100% (10/10) 100% (10/10) 100% (10/10) 100% (10/10) 100% (12/12)

Healthy Families Wings Parent Group Wings CPS Success by 6 Peer Reviews

Compliance & Quality: Prevention

100% 80% 60% 40% 20% 0% Intake Healthy Families Wings Wings-CPS Success by 6 Target All Programs 93% 89% 96% 98% 90% 93% Assessment 94% 86% 74% 100% 90% 88% Treatment Plan 89% 97% 82% 100% 90% 91% Service Delivery 100% 97% 93% 99% 90% 98% Closing Overall 93% 93% 88% 99% 90% 93%

60% 100% 100% 90% 93%

Across all programs and all areas measured, Prevention programs achieved a 93% Compliance & Quality rating, which exceeds the 90% target. Across all programs, Assessment (88%) is the only area that was below the target. The Success by 6 program achieved an overall Compliance & Quality rating of 99%, with three areas (Assessment, Treatment Planning, and Closing) achieving a 100% rating. Healthy Families and Wings both achieved a 93% overall Compliance & Quality rating. Healthy Families exceeded the target in Intake, Assessment, and Service Delivery and Wings exceeded the target in Treatment Planning and Service Delivery. The Wings-CPS program achieved an overall
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Compliance & Quality rating of 88%, within 2% of the target. Intake, Service Delivery, and Closing all exceeded the target. To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. Healthy Families Treatment Plan (87%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (3/11) Wings Intake (89%) Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (3/9) Assessment (86%) Was the updated assessment report completed within the required timeframe of the program contract? (3/5) Closing (60%) Is the Closing Summary in the record? (1/1) Wings-CPS Assessment (74%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (4/15) Was the child screened within 45 days of starting the program? (2/4) Is the Curriculum Checklist complete and up to date within the last 30 days? (2/5) Treatment Plan (82%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (3/15) Is the current copy of the service plan/treatment plan/case plan in the file (Per Program Contract/Plan)? (2/15) Does the IFSP address developmental goals of children, objectives and expected outcome(s) for the specific service(s) provided to the client and/or family? (2/5)

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Appendix F Youth Services Highlights

The Northern Region operates four Youth Services programs. Across the 4 programs, 236 clients were served in FY13 which is a 0.8% decrease from FY12. Outcomes Youth Services Goals 1. Youth served will not be subjects of indicated reports of abuse or neglect during the service period. 2. Youth will be maintained in a home like setting. 3. Youth will be deflected from further involvement in the juvenile justice system 4. Youth will remain in school, alternative education, vocational training or employed Peer Reviews Compliance & Quality: Youth Services
100% 80% 60% 40% 20% 0% Intake CCBYS MST Re-Entry MST Probation MST 16th Circuit Target All Programs 92% 80% 86% 97% 90% 91% Assessment 89% 50% 69% 90% 90% 82%

Target

CCBYS

Target

MST Probation

MST Kane

Target

MST Re-Entry

90%

100%

90%

98%

100%

90%

100%

90%

96%

70%

46%

65%

50%

35%

90%

95%

70%

67%

27%

50%

35%

90%

96%

70%

33%

54%

55%

35%

Treatment Plan 71% 77% 98% 98% 90% 87%

Service Delivery 89% 95% 93% 99% 90% 94%

Closing 100% 100% 53% 100% 90% 92%

Overall 86% 82% 86% 97% 90% 90%

Across all programs and all areas measured, Youth Services programs achieved a 90% Compliance & Quality rating, which meets the agencys target. Across all programs, Assessment (82%) and Treatment Planning (87%) are the only areas that were below the target. The MST 16th Circuit program achieved an overall Compliance & Quality rating of 97%, with all areas meeting or exceeding the target. CCBYS and MST Probation both achieved an 86% overall Compliance & Quality rating. CCBYS exceeded the target in Intake and Closing and MST Probation exceeded the target in
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Treatment Planning and Service Delivery. The MST Re-Entry program achieved an overall Compliance & Quality rating of 82%. Service Delivery and Closing exceeded the target. To improve in FY14, programs should focus on the areas missed most on reviews throughout the year. Below is a full item analysis for each review conducted in FY13 by program (only those programs that did not achieve 90% in an area were analyzed). The percentage indicates the percent of files in compliance. The number in parentheses at the end of each statement indicates the number missed out of the total for each review, excluding those items marked N/A. CCBYS Assessment (89%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (6/17) Treatment Plan (71%) Was the current service plan/treatment plan/case plan written, signed and dated by the Case Manager/therapist and supervisor within the required timeframe of the program contract? (9/15) Service Delivery (89%) Is there evidence of quarterly case supervision in which the case is reviewed at least quarterly and includes an evaluation of the clients progress toward achieving his/her service goals? (3/15) Case note documentation reflects the level of client contact per program requirements? (3/17) MST Re-Entry Intake (80%) Are the Clients Rights and Responsibilities in the record & signed by all relevant parties? (2/4) Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (2/4) Assessment (50%) Was the Initial Assessment Report completed within the required timeframe of the program contract? (3/4) Is a copy of the Initial Assessment Report in the record? (2/4) Treatment Plan (77%) Is the current copy of the service plan/treatment plan/case plan in the file (Per Program Contract/Plan)? (1/4) MST Probation Intake (86%) Are the Release of Information Forms current (within 1 year) for correspondence with ALL entities outside of the agency? (4/8) Assessment (69%) Is a copy of the Initial Assessment Report in the record? (3/8) Was the Initial Assessment Report completed within the required timeframe of the program contract? (6/9) Closing (53%) If follow-up services were necessary, did the Closing Summary contain a formalized After Care Plan (when appropriate), signed by the client, parent/guardian, caseworker and supervisor? (2/2)

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