Methodology: Each quarter Rehabilitation Services Director will audit the charts of the patients involved in the Vocational Rehabilitation Program to review treatment plans and progress notes to ensure they are being completed in a timely manner and updated on a regular basis. The numerator will be the number of patient charts with the required documentation and the denominator will be the total number of patients in the Vocational Rehabilitation Program. Goal: To achieve and maintain an overall goal of 100% for 4 consecutive Quarters Type of Measure: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Each patient 100% 100% 100% 100% 100% working in the Target Voc. Rehab. 60% Program has 50% 91% 97% 76% Actual the required 6/12 29/32 29/30 25/33 documentation Data Analysis: Charts were audited the Rehab. Services Services tool. There –Vocational was only 1 chart in which a weekly note was not done on time. Action Plan: Continue with the monthly audits to assist with attaining the goal of 100% so that the Vocational documentation can reach the goal of 4 consecutive quarters of 100%. Safety & Security Responsible Party: Philip Tricarico, Safety Officer I. Measure Name: Grounds Safety & Security Incidents Measure Description: Safety/Security incidents occurring on the grounds at Riverview, Grounds being defined as the building footprint of the facility; being the “outside secured yards, parking lots, pathways surrounding the footprint, unsecured exterior doors, and lawns.” Incidents being defined as of thefts, vandalism, injuries, “Acts
Methodology: Each quarter Rehabilitation Services Director will audit the charts of the patients involved in the Vocational Rehabilitation Program to review treatment plans and progress notes to ensure they are being completed in a timely manner and updated on a regular basis. The numerator will be the number of patient charts with the required documentation and the denominator will be the total number of patients in the Vocational Rehabilitation Program. Goal: To achieve and maintain an overall goal of 100% for 4 consecutive Quarters Type of Measure: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Each patient working in the Voc. Rehab. Program has the required documentation 60% 100% 100% 100% 100% 100% Actual 50% 6/12 91% 29/32 97% 29/30 76% 25/33 Data Analysis: Charts were audited the Rehab. Services –Vocational Services tool. There was only 1 chart in which a weekly note was not done on time. Action Plan: Continue with the monthly audits to assist with attaining the goal of 100% so that the Vocational documentation can reach the goal of 4 consecutive quarters of 100%. Safety & Security Responsible Party: Philip Tricarico, Safety Officer I. Measure Name: Grounds Safety & Security Incidents Measure Description: Safety/Security incidents occurring on the grounds at Riverview, Grounds being defined as “outside the building footprint of the facility; being the secured yards, parking lots, pathways surrounding the footprint, unsecured exterior doors, and lawns.” Incidents being defined as “Acts of thefts, vandalism, injuries,