Butler County Mental Health Board

Butler County Mental Health Board

Agency Name:

Prepared by:

Period Beginning: Period Ending:

I. CONSUMER CENSUS

1ST Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Year to Date
Total # of unduplicated consumers served during quarter / Total # of unduplicated consumers served during quarter / Total # of unduplicated consumers served during quarter / Total # of unduplicated consumers served during quarter / Total # of unduplicated consumers served year to date
qq / aa / 224444 / 444

A. Please provide a brief narrative regarding identified unduplicated Butler County consumer census at your organization.

Response:

II. QUALITY IMPROVEMENT PLAN

/ Yes / No
1. Has the agency developed an approved written Quality Improvement Plan?
2. Has the Quality Improvement Plan been updated and approved annually?
3. What is your accrediting organization? (i.e. Joint Commission, CARF, COA)
4. When is your accreditation due to expire?
5. Are any of these plans, accreditations in jeopardy or are you currently on probation status?

III. WAITING LIST MANAGEMENT

(From initial contact to first available diagnostic assessment session. Averaged over a quarter of the year from the organization’s biweekly waiting time data)

Entry Point for initial contact (explain): ______

1ST Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Year to Date / Year to Date
Average Waiting Period / Average Waiting Period / Average Waiting Period / Average Waiting Period / Average Waiting Period

A. Please provide a brief narrative regarding identified waiting list trends / patterns and corrective actions, as appropriate, at your organization.

Response:

IV. INVOLUNTARY TERMINATIONS

1ST Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Year to Date
# of involuntary terminations / # of involuntary terminations / # of involuntary terminations / # of involuntary terminations / # of involuntary terminations
444444444444777 / 33333444

A. Please provide a brief narrative regarding identified involuntary terminations trends / patterns and corrective actions, as appropriate, at your organization.

Response:

V. REPORTABLE INCIDENTS / MAJOR UNUSUAL INCIDENTS

1ST Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Year to Date
# of Major Unusual Incidents / # of Major Unusual Incidents / # of Major Unusual Incidents / # of Major Unusual Incidents / # of Major Unusual Incidents
333333 / 333 / 444

A. Do any of the Reportable incidents / MUI’s have a potential for civil or legal action resulting in financial loss to the organization?

B. Please provide a brief narrative regarding trends / patterns and corrective actions regarding incidents identified as Reportable Incidents / MUI’s, as appropriate, at your organization.

Response:

VI. CONSUMER / FAMILY MEMBER GRIEVANCES

(“Grievance” means a written complaint initiated either verbally or in writing by a client or by any other person or agency on behalf of a client regarding denial or abuse of any client’s rights (ODMH Rule 5122:2-1-02)). BCMHB considers grievances as meeting a higher threshold of formality as compared to complaints including such activities as formal written or verbal report & written documentation to a designated individual (i.e., Client Rights Officer (agency or BCMHB staff), Grievance Officer (agency or BCMHB staff), formal consideration by agency and/or BCMHB staff, and the adherence to agency/BCMHB grievance policy).

1ST Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Year to Date
# of consumer / family member grievances / # of consumer / family member grievances / # of consumer / family member grievances / # of consumer / family member grievances / # of consumer / family member grievances

A. Please provide a brief narrative regarding the nature of each grievance, trends / patterns and any corrective actions undertaken regarding consumer and/or family member grievances, as appropriate, at your organization.

Response:

VII.  PEER REVIEW / CLINICAL RECORDS REVIEW

(At least a 5% random sample of average total Butler County consumer annual census or last fiscal year’s actual unduplicated census)

1ST Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Year to Date
# of consumer records reviewed / # of consumer records reviewed / # of consumer records reviewed / # of consumer records reviewed / # of consumer records reviewed
5

A. Please provide a brief narrative regarding identified strengths and weaknesses in the clinical records review sample, any trends / patterns and corrective actions, as appropriate, at your organization.

Response:

VIII. SATISFACTION

“In an overall, general sense, how satisfied are you with the services you have received?”

(Key: 4 = very satisfied, 3 = mostly satisfied, 2 = indifferent or mildly dissatisfied, 1 = quite dissatisfied)

1ST Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / Year to Date / Year to Date
# of surveys in sample / % of sample very satisfied or mostly satisfied / # of surveys in sample / % of sample very satisfied or mostly satisfied / # of surveys in sample / % of sample very satisfied or mostly satisfied / # of surveys in sample / % of sample very satisfied or mostly satisfied / # of surveys in sample / % of sample very satisfied or mostly satisfied

A. Please provide a brief narrative regarding identified consumer / family member satisfaction trends / patterns and corrective actions, as appropriate, at your organization.

Response:

IX. DIRECT SERVICE UNIT PRODUCTIVITY

*(Optional Excel spreadsheet should be provided as an additional attachment while leaving the table below blank.)

Service / 1st Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / YTD
Budget / Actual / % / Budget / Actual / % / Budget / Actual / % / Budget / Actual / % / Budget / Actual / %
Pharmacological Management
MH Assessment
Psych Diagnostic Int.
Ind. Counseling (15 min)
Group Counseling (15 min)
Crisis Intervention
Partial Hospitalization
CPST – Ind. (15 min.)
CPST Group (15 min.)
Hotline Services
Self Help/Peer Services
Adult Education
Consultation
Consumer Operated Services
Employment
Information and Referral
MH Education
Occupational Therapy
Other MH Services
Social/Recreational Svcs
Community Residence
Residential Care
Respite Care
Forensic Evaluation
Inpatient Psych. Services
PASARR
Other (comment below)
Total:

A. Please provide a brief narrative regarding identified direct service unit productivity results for the quarter, any trends / patterns and corrective actions, as appropriate, at your organization.

Response/Comments:

X. FISCAL REPORT

*(See BCMHB Quality Improvement Quarterly Provider Report Compliance Guidelines)

Service / 1st Quarter / 2nd Quarter / 3rd Quarter / 4th Quarter / YTD
Budget / Actual / % / Budget / Actual / % / Budget / Actual / % / Budget / Actual / % / Budget / Actual / %
Pharmacological Management
MH Assessment
Psych Diagnostic Int.
Ind. Counseling (15 min)
Group Counseling (15 min)
Crisis Intervention
Partial Hospitalization
CPST – Ind. (15 min.)
CPST Group (15 min.)
Hotline Services
Self Help/Peer Services
Adult Education
Consultation
Consumer Operated Services
Employment
Information and Referral
MH Education
Occupational Therapy
Other MH Services
Social/Recreational Svc.
Community Residence
Residential Care
Respite Care
Forensic Evaluation
Inpatient Psych. Services
PASARR
Other (comment below)
Total:

A. Please provide a brief narrative regarding identified Fiscal Report results for the quarter, any trends / patterns and corrective actions, as appropriate, at your organization.

Response/Comments:

XI. Is there any known potential for a significant reduction or termination in current funding within your organization? (i.e. grant expiration, potential serious financial loss exposures, etc.) If yes, please provide details including corrective actions taken, effectiveness of corrective actions and pending solutions.

Response:

XII. Please forward the completed QI Quarterly report to the BCMHB Associate Executive Director of Evaluation and Quality Assurance at on or before the 30th day of the month following the end of each fiscal year quarter (i.e., Oct. 30, Jan. 30, April 30, & July 30). The BCMHB staff is using provider report submission requirements as a system measure beginning in FY09. Providers should insure timely submission of the QI Quarterly Provider Report.

Any question in regards to the QI Quarterly Provider Report, please contact Scott Rasmus, Associate Executive Director of Evaluation & Quality Assurances @ email: or phone: 513-860-8388.

Thank you.

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