Georgia Quality Management System - Department of Behavioral ...

GQMS Year 3 Annual ReportJuly 2010 – June 2011Table 5. QEPR Provider InformationJuly 2010 – June 2011Number Sample Number TotalReceiving for III & of NumberProvider NameRegion Services ISP QA Services on StaffNormal Life of Georgia 4 252 67 7 250Owls Retreat 3 17 15 1 10Pathways CSB 6 130 51 12 125Pineland CSB 5 301 60 13 302Serenity Behavioral Health System 2 288 62 13 207Sharlene Moore Personal Care Home Inc 4 4 3 1 6Southern Resources Consultants Inc 3 5 6 2 9Village Nursing 1 12 11 4 31Wesley Glen Ministries 2 50 26 1 62Yax Incorporated 2 4 4 1 7QEPR Administrative ReviewEach provider receives one Administrative Review, which includes two review instruments:Administrative Qualifications and Training (A Q&T) and Administrative Policy and Procedures (A P&P).The A Q&T includes a review of a sample of personnel/employee records to determine if staff has thenecessary qualifications, specific to services rendered, and if the training was received within requiredtimeframes. The A P&P includes a review of organizational records to determine if policies are in placeand if procedures are delineated that are in compliance with state regulations. Due to the degree ofrevisions in the Standards for All Providers this year, those modifications were implemented in theAdministrative tools and procedures, and consequently it is not appropriate to make comparisons toYears 1 or 2.The Administrative Policy and Procedure review instrument measures 10 different Expectations. EachExpectation is comprised of a different number of elements/questions, ranging from one to 30, with atotal of 124 questions scored for each provider. Administrative P&P Expectations are listed in Table 6,showing the average percent present for the 40 providers reviewed this year. The average A P&Pcompliance score for these providers was 77.6 percent, ranging from a low of 65.1 percent (Personalfunds are managed by the individual and are protected) to a high of 86.3 percent (Quality improvementprocesses and management of risk are a priority).________________________________________________________________________________________________August 31, 2011 73