Meeting Minutes

CDS Family & Behavioral Health Services, Inc.

Meeting: CINS/FINS

Date: July 8, 2016

Time: 9:30 a.m.

Location: Bivens

Date of Next Meeting: August 19, 2016

Attendance: Jim, Sam, Cindy Cassandra, Zeke, Tracey, Rhonda, Jessica

Absent: Pam

I.	Business Operations:

A.	Monthly Budget (Revenue and Expenses)

1.	Sub-topic: Youth Care Worker Budget

Discussion: The end of the year YCW budget expenditures were reviewed as well as the first report of the new year.

Outcome, Actions, Timeframe: Sam will get with Fiscal to update the allocation per shelter to address new hourly rates and more realistic expectations.

2. Sub-topic: Contact with Fiscal

Discussion:

Outcome, Actions, Timeframe:	To avoid confusion, please ask staff not to contact Fiscal unless they have tried to resolve the issue through a manager

B.	Marketing and Business Development

1. Sub-topic: FL Network Special Funding

Discussion Has everyone turned in all of your receipts?

Outcome, Actions, Timeframe:	Central still owe receipts. Please get them in to Fiscal

2. Sub-topic: Federal Monitoring Visit July 12th -14th

Discussion: Reviewed the Federal Monitoring site visit schedule as well as check lists to be used by the monitors during the review. Discussed ways to help staff prepare around specific cases.

Outcome, Actions, Timeframe:

C.	Regulatory Issues

1.	Sub-topic: CINS/FINS QI Standards 2016/17

Discussion: Specific changes were addressed.

Outcome, Actions, Timeframe: These were e-mailed to all the managers July 7, 2016

D.	Human Resource Issues (Staffing and Training)

1. Sub-topic: Training Plans for the John at the Network

Discussion: Peggy and Cindy have staff working on a response to John

Outcome, Actions, Timeframe:	Please copy Sam

2. Sub-topic: Med Cart Training for Nurses and Super Users

Discussion: Cassandra described this recent training.

Outcome, Actions, Timeframe: Tracey will reach out to Tiffany at the Network to see how we can get set up in each shelter to view and manage the key reports as well as ask Tiffany which reports the Network will be focusing on.

3. Sub-topic: Emergency/Disaster Call Down List

Discussion: Sam asked for corrections to this list.

Outcome, Actions, Timeframe:	Sam will distribute and get on the Intranet.

4. Sub-topic: Rate adjustments

Discussion:	Sam mentioned the staff that we have not processed personnel actions

Outcome, Actions, Timeframe:	Please get them in. The effective date should be July 3rd.

E.	Annual Budget Planning and Process

1.	Sub-topic:

Discussion:	No discussion

Outcome, Actions, Timeframe:

II.	Health and Safety: Program/Regional Coordinators

A.	External Inspections

1. Sub-topic: Florida Network QI Reviews (Pending further updates)

Discussion: Focused on several areas that we could improve based on the QI reviews: The Training Tracking system is not being fully utilized based on some parts not being user friendly and other parts not being fully understood. (Some issues printing reports; not being able to get in if someone else is in; can it be set up so each program has its own access? Naming the training in a consistent manner and perhaps listing alphabetically; is drop box the best way to access and share? Travel safety policy was also discussed related to single transports.

Outcome, Actions, Timeframe:	Sam will review this further with several key users.

Sam will also get with Laura to discuss the Gmail process to access FL Network training.

2. Sub-topic: QI Review Exceptions/ Quality Improvement Plan

Discussion: Sam provided another copy of the Performance Improvement Plan forFY16/17 based upon exceptions identified in the 15/16 reviews. He also noted that Forefront is now requiring written follow up plans on Indicators with Exceptions and below.

Outcome, Actions, Timeframe: It is critical that when issues are identified to be addressed in staff meetings that this is done on the time frames indicated as we will have to produce documentation that this has occurred. Please look at the document provided as it is relevant to your program and ensure that you have complied. One easy way to do some of this is to do a cut and paste from CINS/FINS and EMT minutes.

B.	Self-Inspections (Reports, analysis, and recommendations)

1.	Sub-topic: Safety and Maintenance Inspection Semi-Annual Residential Review

Discussion:

Outcome, Actions, Timeframe: This inspection is due this month for all three shifts. This is a CARF requirement. Make sure to keep this in your Notebooks. This form is in the Risk Management Forms section on the Intranet

C.	Incident Reports (Reports, analysis of trends, recommendations)

1.	Sub-topic: Complaints and Grievances

Discussion:

Outcome, Actions, Timeframe:

III.	Quality Improvement

A.	File Audits and Case Record Review (reports and recommendations)

1. Sub-topic: Behavior Management System/Trauma Sensitive Approach- Managers (Pending)

Discussion:

Outcome, Actions, Timeframe:

B.	Outcome Management (status, reports, recommendations)

1. Sub-topic:

Discussion:

Outcome, Actions, Timeframe:

C.	Accreditation and Regulatory Requirements

1. Sub-topic:

Discussion:

Outcome, Actions, Timeframe:

D.	Policy and Procedure Updates and/or Review

1. Sub-topic: Policy/Form issues generated from the Nurses Meeting-Managers/Nurses

Discussion:

Outcome, Actions, Timeframe: Pending

2. Sub-topic: P-1120 Medication Provision, Storage, Access, Inventory, and Disposal

Discussion:

Outcome, Actions, Timeframe: A meeting for Managers/Nurses and Super Users if available will occur on August 5, 2016 at 9:30 at Bivens to discuss the medication policy and implementation issues. Sam asked that if people had ideas/issues related to the draft policy that was previously sent out to get them to Sam, so we can better prepare for the meeting.

3. Sub-topic: P-1119 Medical and Mental Health Alert Process

Discussion: “…Upon admission to shelter services, the youth and parent or guardian (if available) shall be interviewed about the youth’s current medications. This shall be part of the Medical and Mental Health Assessment screening process. This process will be conducted by a Registered Nurse if one is on premises. Otherwise, this interview will be conducted by on-duty staff and reviewed by the Registered Nurse within 5 business days.

Outcome, Actions, Timeframe: Sam will update the Intranet noting the highlighted change.

4. Sub-topic: F-PR- 1316 Participant Peer Review Form

Discussion: Sam discussed the updated Peer review form.

Outcome, Actions, Timeframe: Cassandra agreed to re-draft this form. If you have not turned in your 4th Quarter Peer Reviews to Data Systems, please do so.

5. Sub-topic: Participant Peer Review Supervisor Review Form Draft

Discussion:

Outcome, Actions, Timeframe: Cassandra will redraft combining the 2 forms

6. Sub-topic: Weekly Schedule Form Draft

Discussion:

Outcome, Actions, Timeframe: Sam will put this form on the Intranet for FAC

7. Sub-topic: Single/Third Party Transportation Exceptions Approval Form Draft

Discussion: This form was reviewed.

Outcome, Actions, Timeframe: Sam will put this form on the Intranet with modification noted. Cassandra will modify the Program Log Book as well and send it to Managers.

8. Sub-topic: Rule for opening non-residential cases at the beginning of the Fiscal Year

Discussion: Excerpt from Terry’s email of 6/16/16 see directly below.

Outcome, Actions, Timeframe:	Nonres cases opened between May 1 and June 30 of each fiscal year and are still open by July 31 will carry over and be counted as admissions in your July data. You will not have to close and reopen these cases – they will automatically carry over. Because our average length of stay is 12 weeks in nonres, the assumption is that you will still be actively working this case during the month of July in the new fiscal year.

For each subsequent month in the fiscal year, only new admissions into your program will count towards your annual deliverables.

For court ordered cases you will be able to administratively close (we are making a revision to NetMIS to make this an option) and reopen to count as a new admission at the beginning of each fiscal year if services continue to be court ordered. This will require that you update the Needs Assessment and the Service Plan and check all the correct boxes in NetMIS to make sure that it is counted as an admission.

9. Sub-topic: Video Surveillance Draft Policy

Discussion:

Outcome, Actions, Timeframe: Sam will put this form on the Intranet with modification noted.

10. Sub-topic: F-PR-1231 Parental/Legal Guardian Consent Regarding Medications

Discussion: Changes recommended by Cassandra were reviewed.

Outcome, Actions, Timeframe: Sam will put this form on the Intranet with modification noted.

E.	Participant Complaint and Grievance (specific and quarterly review of trends)

1.	Sub-topic:

Discussion:

Outcome, Actions, Timeframe:

F.	Planning Documents (reports, status of goals and objectives, reformulation)

1.	Sub-topic:	Strategic Plan

Discussion:

Outcome, Actions, Timeframe:

2.	Sub-topic:	Accessibility Plan

Discussion:

Outcome, Actions, Timeframe:

3.	Sub-topic:	Cultural Competence Plan

Discussion:	No discussion

Outcome, Actions, Timeframe:

4.	Sub-topic:	Input Plan

Discussion:

Outcome, Actions, Timeframe:

5.	Sub-topic:	Community Relations plan

Discussion:	No discussion

Outcome, Actions, Timeframe:

IV.	Risk Management

A.	Risk Management Plan (exposure to loss)

1. Sub-topic: Performance and Risk Management Reports

Discussion:

Outcome, Actions, Timeframe:

2. Sub-topic: Participant 25 Day or Longer-Managers (Pending)

Discussion: Share ideas and practices currently in place to address longer lengths of stay. Consider setting modest targets for each shelter during the 4th quarter.

Outcome, Actions, Timeframe:

B.	Employee Concerns or Complaints

1.	Sub-topic:

Discussion:	No discussion

Outcome, Actions, Timeframe:

C.	Potential regulatory audits and/or investigation of operations

1.	Sub-topic:

Discussion:

Outcome, Actions, Timeframe:

V.	Information Technology

A.	Technology Plan

1.	Sub-topic: Van Cameras (Pending)

Discussion:

Outcome, Actions, Timeframe:	Van cameras were not included in the Network Policy. We need to develop our own procedures.

VI.	Clinical/Program

A.	Medical and Medication Issues

1. Sub-topic: Doctors Prescriptions vs Court Orders

Discussion: The issue under discussion is what do we do if we get a prescription that we know is inconsistent with a Court Order.

Outcome, Actions, Timeframe:	This issue can be discussed further on the meeting scheduled on August 5th, but in short we do not want to violate a Court Order. One strategy is to call the Doctor and see if they would be willing to maintain the status of the medication on the Court order until it could be changed. Another is to tell the referral source that the youth must be removed if the issue cannot be cleared up.

Rhonda will also seek input from Melinda at the Partnership.

B.	Counseling and Programming Issues

1. Sub-topic:

Discussion:

Outcome, Actions, Timeframe:

VII.	Other Business:

1.	Sub-topic: 48 hours to respond to the CCC regarding follow up on CCC Reports

Discussion: Zeke requested clarification on what appears to be a change in the reporting protocols from the CCC.

Outcome, Actions, Timeframe:	Sam will contact the CCC and share what he learns.

Respectfully submitted by:

Sam Clark	July 15, 2016