Policy Manual

 
  13.MEP.1  

Quality Assurance Procedure      

Type: Procedure                 Category: QA/QI                 Level: Community Care 

Parties: Community Care employees and/or contractees.

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Supporting References: COA G2.6.02

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  5-1-2000  Management Team    N/A
Related Document Code Related Document Name Type

Procedure:  .

It shall be the policy of Community Care to utilize an agency-wide approach to quality assurance by measuring, assessing, and improving performance and service delivery.

 

CLIENT RECORD REVIEWS -

 

The Client Record Review Process will assess:

        Any variations of planned care from that which is delivered.

        Completeness and accuracy of records.

        Compliance with licensing regulations.

        Compliance with accepted standards of care.

        Compliance with agency policies.

        Customer participation in and satisfaction with the process of care.

 

PROCEDURE:

 

1.                  On a monthly basis, a minimum of 3 client records will be reviewed by each area office utilizing the quality review checklist.

2.                  Completed checklists will be signed by the person/s reviewing the record submitted. The completed original record review checklist will be given to the provider assigned to the client record that was reviewed. Copies of the record review checklist will also be submitted to the Team Clinical Supervisor (TCS) /Program Supervisor/Manager.

3.                  Should any deficiencies exist, the team responsible for that record will have 10 working days or 2 weeks to correct the deficiency/ies. Once deficiencies have been corrected the original record review will be filed by the team in the area office.

4.                  TCS/Program Supervisor/Manager will compile data submitted from each area office for evaluation of data received quarterly.

5.                  Evaluation of Data will focus on:

        Whether outcome indicators were met.

        Possible improvements for existing services.

        The effectiveness and efficiency with which resources were utilized.

        What opportunities for improvement were discovered.

        What changes or needs for new services were identified by customer feedback.

        In what way are current services not meeting expectations.

6.                  A Team Peer Review Process will be conducted quarterly that ensure:

        The effectiveness of interdisciplinary team functioning.

        The efficacy and appropriateness of all treatment.

        The appropriate and efficient utilization of services and resources.

        The safety and welfare of clients served.

        The satisfaction of our customers.

 

7.                  TCS/Program Supervisor/Manager will send out quarterly, a service satisfaction questionnaire to the guardian of each client record reviewed.

8.�������� Quarterly documentation of results will be submitted by the TCS/Program Supervisor/Manager to the area team and management team for feedback and review.

 

FOSTER PARENT RECORD REVIEWS -

 

The Foster Parent Record Review Process will assess:

        Completeness and accuracy of records.

        Compliance with state and federal licensing regulations.

        Compliance with agency policies.

 

PROCEDURE:

 

1.      The Foster Care Developer of Maine/designee will be responsible for the review and completeness of these records bi-annually. All foster parent records will minimally include:

        Current license

        Current contract

        Placement agreement/s

        Current training records

2.      Should any deficiencies exist, the TCS/team responsible for that record will have 10 working days or 2 weeks to notify foster parents of the deficiencies. All deficiencies will be corrected within 30 days of notice. Once deficiencies have been corrected the original record review will be filed by the team in the area office.

3.      TCS/designee will compile data submitted from each foster care developer for evaluation of data received bi-annually. This data will then be reviewed by the area team/foster parents and management team for feedback.

 

PERSONNEL RECORD REVIEWS -

 

The Personnel Record Review Process will assess:

        Completeness and accuracy of records.

        Compliance with state and federal licensing regulations.

        Compliance with agency policies.

 

PROCEDURE:

 

1.                  All employee personnel records will be reviewed by their assigned supervisor at the end of the 6 month probationary period and every year after on their anniversary date for completeness and accuracy utilizing the Personnel Folder Review Checklist and Training Policy checklist.

2.                  A copy of the completed personnel folder record review will be submitted to the TCS/Program Supervisor/Manager and Human Resources with a plan of correction.

3.                  Human Resources will compile data quarterly and will share that data with the supervisory structure and management teams for feedback.

 

PHYSICAL BUILDING SAFETY -

 

The Physical Safety of the Building Review Process will assess:

        Compliance with state and federal licensing regulations.

        Compliance with agency policies.

 

PROCEDURE:

 

1.      The Physical safety of each building occupied will be monitored monthly for compliance utilizing the Safety Checklist.

2.      Copies of the completed building safety checklist will be sent to the TCS/Program Supervisor/Manager and Safety Coordinator with plan of correction.

3.      The Safety Coordinator will compile data semi-annually and will share that data with area teams and management team for feedback.