Risk management and quality assurance are two sides to the same coin. Risk management activities strive to eliminate the potential negatives from a consumer’s life, while quality assurance activities strive to accentuate the positives. DDSN conducts many on-going risk management activities that assist in assuring that risks encountered in everyday life are kept as low as possible, as balanced against a consumer’s rights and desires for choice and autonomy.
DDSN recognizes that providers are the vital link in the continuing flow of information regarding Critical Incidents and Abuse, Neglect and Exploitation reporting. As part of our ongoing assessment and review process, we want to make the reporting process as complete, accurate, and efficient as possible. With that in mind, we offer some “REMINDERS” to assist in several important areas.
SOME IMPORTANT REMINDERS:
- Serious consumer injuries of unknown or unexplainable origin must be reported to the appropriate state investigative agency according to the procedures outlined in 534-02-DD. A serious injury of known cause (e.g., auto accident or fall) must be reported as a critical incident unless abuse is alleged in which case the report must be made to the appropriate state agency.
- Failure to provide proper supervision may be a form of neglect if the employee fails to intervene in a situation or provide proper supervision when they clearly have a duty to do so.
- Providers are required to have a safety plan in place whenever there is an allegation of abuse, neglect or exploitation. Please remember: 534-02-DD states the alleged perpetrator must be placed on administrative leave without pay pending the outcome of the investigation.
- If you have reported an incident to SLED and SLED did not investigate or vet to Local Law Enforcement (e.g., they vetted to the Ombudsman’s Office), and your own internal review indicates no violation of policy, you may return staff to active employment. You DO NOT need to submit a Request for Reinstatement of the employee(s). If your internal review indicates a violation of policy, follow your respective Agency and Personnel policies regarding issues of policy/procedure violations and disciplinary action. Once completed, you may return the employee to active employment.
- Only SLED, Local Law Enforcement or the Attorney General’s Office can make a determination of “founded” or “unfounded” on ANE Reports and Incidents. The Exception would be if a case was initially referred only to DSS, as in cases of Day Program reporting, then DSS CAN determine whether the allegation is founded or unfounded. The Ombudsman’s Office CANNOT make a determination of founded or unfounded criminal level abuse, neglect or exploitation. They may make a determination of non-criminal abuse, but this will not be counted as abuse according to the Omnibus Adult Protection Act.
- Submission of Addendum forms for Critical and ANE reports should reflect additional information subsequent to the Final Reports, verification of dates employees were reinstated and any change in disposition of administration/management review due to results of SLED or Local Law Enforcement investigations.
- If SLED accepts a report “For Information Only”, the ANE reporting process must be followed and Initial and Final ANE reports must be submitted to DDSN. Once SLED assigns an Intake Number, DDSN must follow this case to conclusion through required ANE reporting. If SLED vets a case of alleged ANE to the Ombudsman’s Office, you must still complete the required ANE reports and send to us, including the management review.
- Consistent with Directives 100-09-DD and 534-02-DD, reports must be submitted on the Incident Management System.
For additional training information related to the DDSN Directives on Critical Incident and Abuse/ Neglect/ Exploitation reporting, the following slides are available:
For technical assistance with the Incident Management System, please contact the DDSN Helpdesk at 803-898-9767.
Abuse, Neglect and Critical Incident Reporting - Frequently Asked Questions
- If SLED elects not to investigate a case (ICF/ID, non-ICF/ID and/ or day programs) and accepts the report “For information only”, does the provider have to conduct a review?Yes. SLED assigns an intake number for “Information only” cases and the information is entered into their database. As a result, we must have administrative closure to the case, and ANE reporting process must be followed. We need to know what prompted the call to SLED and what actions, if any, may have resulted. SLED will send DDSN a Case Status Report.
- If an allegation occurs at home or in the community, do we report to DDSN? If the person is served in an ICF/ID and is on a home visit, you must report to SLED and to DDSN. If the person is served in a non-ICF/ID setting, a licensed DDSN residence, or in a day program, the report must be made to DSS and documented in your agency files.
- When is a case considered “Closed?” If SLED investigates for criminal intent, the case is “Closed” when SLED sends their Case Status Report to DDSN. Cases vetted to the Ombudsman and DSS are “Closed” when the respective agencies render a finding. Employees are permitted to go back to work prior to case closure under certain circumstances as outlined in 534-02-DD.
- If an allegation is made in the community and staff is involved but not on duty, should staff be placed on leave? The staff must be placed on administrative leave without pay to protect the consumer from harm. The appropriate review must be completed.
- If a local law enforcement case is not founded, is the staff person allowed to return to work? DDSN must have written verification of case status from the LLE or SLED. The reinstatement request may be submitted with a valid justification only after a Management Review has been completed by the provider agency. If the reinstatement request is approved by DDSN, an Addendum to your report must be submitted within 24 hours.
- If abuse is alleged in a CRCF, is this reported in the same manner as an allegation in an ICF/ID is reported? No. The process for reporting an allegation in a DDSN operated CRCF is the same as a CTH or SLP.
- Which review process should be completed for an allegation in an ICF/ID? An Administrative Review of Alleged Abuse, Neglect, or Exploitation--ICF/ID Facilities should be completed.
- How are dates calculated for submission of Initial Critical/ANE and Final Critical/ANE Reports? The counting STARTS on the day the incident occurred or day of “discovery”/date incident was first reported. All Initial Reports must be submitted via IMS to DDSN Quality Assurance within 24 hours of the occurrence/discovery excluding week-ends and holidays. DDSN observes all State and Federal Holidays. However, Facility or Board observed holidays may also be included in calculating Final report due dates. Any observed holiday by your Facility or Board during the respective reporting period must be noted on reports to avoid incorrect calculations.
All Final Critical and Final ANE Reports must be submitted via IMS to DDSN Quality Assurance within 10 business days of incident date or date the incident was first reported/ discovered. However, Final Critical and ANE reports for incidents occurring in an ICF/ID must be submitted via fax within 5 days, excluding week-ends and holidays.
If the information or investigation is not concluded by the Final Report due date, submit the Final Report by the due date and then submit an Addendum when the investigation is complete or as new information becomes available.
SCDDSN Quality Management
Contract Compliance Activities
DDSN also conducts Contract Compliance Review (CCR) activities that provide a more in-depth look at the overall functioning of the provider agency. As part of this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to assure that services are being implemented as planned, that the consumer/family still want and need them, and that they comply with contract and/or funding requirements and best practices.
Contract Compliance Review (CCR) Process
SC DDSN contracts with a Quality Improvement Organization, Alliant ASO, to conduct annual assessments of service providers by making on-site visits in its Contract Compliance Review (CCR) process. During this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to make sure that services are being implemented as planned and based on the consumer’s need, that the consumer/family still wants and needs them, and that they comply with contract and/or funding requirements and best practices. In addition, the service provider’s administrative capabilities are reviewed annually to ensure compliance with DDSN standards, contracts, policies, and procedures.
Contract Compliance Review (CCR) Instruments
As another cornerstone in the foundation of Quality Management, DDSN maintains a program of performing contract compliance reviews. DDSN conducts these annual assessments of service providers by making on-sight visits under its Contract Compliance Review (CCR) process. As part of this process, records are reviewed, consumers, staff, and family members interviewed, and observations made to assure that services are being implemented as planned, that the consumer/ family still wants and needs them, and that they comply with contractual and/ or funding requirements and best practices. In addition to health and safety, the CCR process assesses the provider's basic administrative strengths and weaknesses, and where necessary, may refer a provider agency to receive special technical assistance or to undergo a more extended financial and managerial audit. These activities are very important to assure a foundation of quality service delivery. In conducting Contract Compliance reviews, DDSN utilizes the following forms and documents.
Review Instruments: In conducting Contract Compliance reviews, DDSN utilizes the following forms and documents.
FY17-18 CCR Indicators (All Services)
FY17-18 CCR Indicators for Direct Service Providers
FY17-18 CCR Indicators for Intake, Case Management and Early Intervention
FY17-18 CCR Indicators for EIBI Providers
FY17-18 CCR Key Indicator Crosswalk
FY17-18 Residential Observation Tool
FY17-18 Day Services Observation Tool
QM Changes for FY17-18
Q & A for the FY18 Quality Assurance Process
FY18 QIO Provider Orientation Slides
Residential Observation Tool
FY2016-17 Compliance Review Key Indicator Crosswalk - Revised (063016)
FY2016-17 Compliance Review Key Indicators - Revised (063016)
Licensing and Certification
State law requires licensing of certain programs and residential facilities. This licensing relates to the health and safety aspects of facilities and services. The law authorizes the establishment of standards for the qualifications of staff, staff ratios, fire safety, medication management, facility size and construction, storage of hazardous liquids and health maintenance. All Residential and Facility-Based Day programs must be licensed. Licensing activities occur on a regular basis and may involve staff from DDSN, DHEC, and/or the State Fire Marshall’s Office. DDSN has contracted with Alliant ASO to conduct licensing inspections. The Application to Operate will continue to be submitted to DDSN, but Alliant ASO will complete the inspection. Upon approval, DDSN will issue the license to the provider to operate the facility.
The primary focus of the Licensing/ Certification review is to assure basic health, safety and welfare standards. Key indicators measure the following:
- The facility’s environment promotes the consumers’ health and safety.
- The physical plant of each facility, to include fire marshal inspections, HVAC, Water Quality, and Health and Sanitation.
- There must be evidence of Fire Safety training and evacuation, Disaster Preparedness, First Aid supplies and other emergency items.
- Facilities must provide documentation of continuous, coordinated health care, appropriate medical follow-up, and assistance with medications (as indicated in each consumers Plan).
- Facilities must demonstrate understanding and application of all DDSN policies regarding Abuse/ Neglect and Exploitation and Critical Incidents. Any instances of suspected abuse, neglect and/or exploitation as well as concerns relating to health and safety has resulted in appropriate action in accordance with Agency policy.
The facility review process must include an on-site review. During the course of the on-site review if substandard or noncompliant performance is found, the provider will be expected to take immediate corrective action.
As part of SCDDSN’s continuing efforts to improve the quality of services to people with lifelong disabilities, follow-up visits are completed with provider organizations. The purpose of the follow-up is to determine whether the plans of correction submitted to Alliant ASO have been implemented for all programs and locations.
In order to utilize staff and resources more effectively during this economic time, part of the follow-up process will be an opportunity for providers to submit evidence that the citations have been corrected. Documentation that verifies corrections have been made can be submitted to Alliant ASO prior to an onsite visit. This information should not be a repeat submission of the plan of correction. If the submitted documentation verifies correction, then an onsite review of that standard would not be necessary. The submission of documentation to verify correction of citations is voluntary, but a lack of documentation may necessitate an on-site review.
A report identifying the status of all citations will be issued after the completion of the follow-up survey.
For a copy of the Respite Standards that were established by DDSN, click here.
For a copy of the Residential Licensing Standards, click here.
For a copy of the Residential Habilitation/Certification Standards that were established by DDSN, click here.
Other Quality Indicators
DDSN collects, analyzes and reports information on how well service providers are performing on various other quality indicators which give an indication of the health and safety of each person, dignity and respect, personal choice, participation in the community and attainment of goals. Some of the ways this information is gathered include: comprehensive provider self-assessments, service coordinator oversight, peer reviews, consumer/ family monitoring, local human rights committee work, staff turnover, circle of support contacts, and the quality of facilitated plans.
The Quality Management Division of SCDDSN offers to service providers consultation, training and technical support focusing on personal outcome measures, training, organizational performance and continuous quality improvement
We are committed to supporting you and your agency as you strive for organizational excellence. Let us know your specific needs and we will gladly work with you at your site
Reinventing Quality Consensus Statements
- Person Centered
Each person shall have the authority to define and pursue his or her own vision. Person-centered supports start with listening to the person and honoring each person’s vision. The individual’s vision must be honored, respected, and supported. The goal must be to promote each person’s empowerment, dignity, and positive self-image.
- Consumer Controlled
Self-determination is a must. People and families are entitled to the freedom, authority, and support to control, direct, and manage their own services, supports and funding. Individuals and families have the right to select their own services and supports as well as decide how and by whom supports are provided.
- Community Inclusive
Personal relationships and community membership are valued. It is absolutely vital to promote the inclusion, presence, and participation in community life for all individuals, at all ages and across all dimensions of life. People must be supported in their social and spiritual life, friendships, and intimate relationships.
- Circle Of Support
All networks and systems of support must collaborate in support of the person’s vision. Families, neighbors, friends, co-workers, and classmates play important roles in the lives of people with developmental disabilities. These rich, vibrant networks of support connect people to their communities. Public systems must work hand-in-hand with these networks in supporting individuals.
- Full Participation
People and families must participate as valued and empowered partners in all decision-making. People and families must have meaningful leadership roles at all levels. It is crucial that government, providers, and community organizations welcome, listen to and collaborate with people and families in solving problems, making decisions, and pursuing excellence.
- Meaningful Work
Individuals must have supports to contribute to their communities and engage in meaningful work. People with developmental disabilities want to and can make valuable contributions to their communities. There must be supports that assist people to make a difference. Youth and adults must be supported to have real jobs, earn money, or run their own businesses.
- Family Involved
Families are supported and valued. Families support people with developmental disabilities of all ages. Support networks must partner with families and offer critical services that not only address the needs of the family member with a disability but also support and strengthen the family itself. The unique needs and preferences of each family shall be acknowledged, respected, and accommodated.
- Support Availability
All people and families must have access to supports when and, as they need them. Every individual must have easy and timely access to vital services and supports in order to achieve his or her personal vision and enjoy quality of life. There will be energetic outreach to all our nation’s diverse communities so that they can access supports on their own terms.
- Personal Security
The personal security and well being of people must be ensured. People must be secure in their own lives. They must not be exposed to neglect, abuse, or exploitation. They must have high quality health care. Ensuring the personal security and well being must not sacrifice the right of individuals to live everyday lives of their choosing in the community, exercise choice and pursue their dreams and aspirations.
- Continuous Quality Improvement
There must be a resolute, continuous commitment to achieve excellence in all dimensions of supporting individuals and families. High quality services enable people to realize their vision. Excellence in person-centered supports demands a strong, sustained commitment to securing and maintaining a high quality workforce, ongoing training and education, and continuous quality improvement. Individuals and families are essential partners in promoting excellence.
(Excerpted & adapted from “Person-Centered Supports- They’re for Everyone!” National Association of State Directors of Developmental Disabilities Services, Inc., December 2000)
Consultation & Technical Assistance
Consultation and/or technical assistance focusing on organizational performance and continuous quality improvement is available to your agency.
The Division of Quality Management is committed to support ing you and your agency as you strive for organizational excellence. Let us know your specific needs and we will gladly work with you at your site.
Contact Quality Improvement at 803.898.9691
Outcome-Based Performance Measures
Historically, measures of quality were often far removed from the actual impact in the lives of the consumers of the services. Agencies would focus on “process measures” rather than “outcome measures”, since they were often easier both to measure and to control. If the administrative and programmatic processes, protocol, procedures and paperwork were in place, then the quality of service was assumed.
Over time measures of quality shifted from “processes” to “outcomes,” but still the focus was often on what the agency could measure and control best, and this was not the consumer. Under this model, quality was assumed by measures of service objectives written, or units of service delivered.
It has only been recently in the evolution of the nation’s long term care system that quality measures have started to become personalized and individualized relative to specific consumers.
DDSN strives to use personal outcome measures to determine how well the service and support providers are helping an individual consumer achieve personal goals. Activity in this area is based on the work of The Council on Quality and Leadership.
Personal outcome measures are often founded on goals that the individual has set for themselves in conjunction with their family and their “circle of support”. They are thought about and discussed, hopefully weighed against alternative goals and decided upon. To this degree they are objective and “matters of the head”.
On the other hand, measures of consumer satisfaction have a larger affective component; satisfaction is a “matter of the heart”. It is very possible for a consumer to have met all of his personal outcome measures, but still feel dissatisfied with his life or the services and supports that he is receiving. Thus, measures of consumer satisfaction must go hand in hand with personal outcome measures in order for an agency to be truly consumer- focused and driven.
Consumer satisfaction surveys are conducted periodically with consumers, families and other stakeholders. DDSN and service providers use this information to improve services and make them more responsive to consumers’ needs and wishes.
Personal Outcome Measures 2005SM
The 21 Personal Outcome Measures focus on the outcomes of the person receiving services. By placing the person at the center the definition of quality is responsiveness to the person rather than how well the organization performs. The Personal Outcome MeasuresSM are a powerful tool for evaluating quality of life and the degree to which organizations individualize supports to facilitate outcomes.
– People are connected to natural support networks.
– People have intimate relationships.
– People are safe.
– People have the best possible health.
– People exercise rights.
– People are treated fairly.
– People are free from abuse and neglect.
– People experience continuity and security.
– People decide when to share personal information.
– People choose where and with whom they live.
– People choose work.
– People use their environments.
– People live in integrated environments.
– People interact with other members of the community.
– People perform different social roles.
– People choose services.
– People choose personal goals.
– People realize goals.
– People participate in the life of the community.
– People have friends.
– People are respected.
©Copyright 2005, The Council on Quality and Leadership (CQL)
Basic Assurances SM
Developed by The Council on Quality and Leadership
Factor One: Rights and Protection and Promotion
A. The organization implements policies and procedures that promote people’s rights.
B. The organization supports people to exercise their rights and responsibilities.
C. Staff recognize and honor people’s rights.
D. The organization upholds due process requirements.
E. Decision–making supports are provided to people as needed.
Factor Two: Dignity and Respect
A. People are treated as people first.
B. The organization respects people’s concerns and responds accordingly.
C. People have privacy.
D. Supports and services enhance dignity and respect.
E. People have meaningful work and activity choices.
Factor Three: Natural Support Networks
A. Policies and practices facilitate continuity of natural support systems.
B. The organization recognizes emerging support networks.
C. Communication occurs among people, their support staff and their families.
D. The organization facilitates each person’s desire for natural supports.
Factor Four: Protection From Abuse, Neglect, Mistreatment and Exploitation
A. The organization implements policies and procedures that define, prohibit and prevent abuse, neglect, mistreatment and exploitation.
B. People are free from abuse, neglect, mistreatment and exploitation.
C. The organization implements systems for reviewing and analyzing trends, potential risks and sentinel events including allegations of abuse, neglect, mistreatment and exploitation, and injuries of unknown origin and deaths.
D. Support staff know how to prevent, detect and report allegations of abuse, neglect, mistreatment and exploitation.
E. The organization ensures objective, prompt and thorough investigations of each allegation of abuse, neglect, mistreatment and exploitation, and of each injury, particularly injuries of unknown origin.
F. The organization ensures thorough, appropriate and prompt responses to substantiated cases of abuse, neglect, mistreatment and exploitation, and to other associated issues identified in the investigation.
Factor Five: Best Possible Health
A. People have supports to manage their own health care.
B. People access quality health care.
C. Data and documentation support evaluation of health care objectives and promote continuity of services and supports.
D. Acute health needs are addressed in timely manner.
E. People receive medications and treatments safely and effectively.
F. Staff immediately recognize and respond to medical emergencies.
Factor Six: Safe Environments
A. The organization provides individualized safety supports.
B. The physical environment promotes people’s health, safety and independence.
C. The organization has individualized emergency plans.
D. Routine inspections ensure that environments are sanitary and hazard free.
Factor Seven: Staff Resources and Supports
A. The organization implements a system for staff recruitment and retention.
B. The organization implements an ongoing staff development program.
C. The support needs of individuals shape the hiring, training, and assignment of all staff.
D. The organization implements systems that promote continuity and consistency of direct support professionals.
E. The organization treats its employees with dignity, respect and fairness.
Factor Eight: Positive Services and Supports
A. People’s individual plans lead to person-centered and person-directed services and supports.
B. The organization provides continuous and consistent services and supports for each person.
C. The organization provides positive behavior supports to people.
D. The organization treats people with psychoactive medications for mental health needs consistent with national standards of care.
E. People are free from unnecessary, intrusive interventions.
Factor Nine: Continuity and Personal Security
A. The organization’s mission, vision and values promote attainment of personal outcomes.
B. The organization implements sound fiscal practices.
C. Business, administrative and support functions promote personal outcomes.
D. The cumulative record of personal information promotes continuity of services.
Factor Ten: Basic Assurances System
A. The organization monitors Basic Assurances.
B. A comprehensive plan describes the methods and procedures for monitoring Basic Assurances.
The Quality Measures 2005
Organizational values drive organizational behaviors
Collective values shape organizational culture
Organizational culture assures which options are available to people
•Determine link between values and practice
•Identify values for a future vision
•Establish immediate and long term action strategies to put values into action
Bridging Organizations and Social Capital
•Organizations as bridges between people and their communities
•Importance of social capital for all members of the organization
– People receiving supports
– Families and volunteers
Self Determination and Choice
•People direct decisions that impact their lives.
•People develop self-determination capacity.
•People contribute to their communities
•People live in communities.
•People achieve personal goals and outcomes in communities.
•People have responsibilities in the community.
•Communities promoted social capital for all people.
•The organization and civic networks enhanced Community Lifesm for all people
•The organization defines and exercises its responsibility in building social capital.
•The organization enables people to participate in community development activities.
•The organization involves community partners in the affairs of the organization.
•The organization’s members assume leadership positions in community activities.
•The organization recruits community representatives for leadership positions.
•All people demonstrate leadership and responsibility.
•Organizational participants contribute to the goals and priorities of the organization.
•Organizational participants develop relevant skills and knowledge.
•Organizational participants contribute to networks of trust and reciprocity.
•The organization promotes communication between and among staff, families and people supported.
•The organization communicates its mission, priorities and management plan.
•The organization has procedures for soliciting input from people served, supporters and t