NRVCS

FY 2016 Report Card

NEW RIVER VALLEY
COMMUNITY SERVICES

Financial and Productivity

NRVCS will strive to meet DBHDS productivity targets as outlined in the performance contract.
Core Service Targets by Disability

July Aug Sept Oct Nov Dec Jan Feb March April May June
100 Mental Health Services 250 Acute Psychiatric or SA
Inpatient Services
310 Outpatient Services A A A A A A A A
320 Case Management
Services
D C B A B B B A A
350 Intensive Community
Treatment
A A A A A A A A A
410 Day Treatment/Partial
Hospitalization
F F B A C D C A A
420 Ambulatory Crisis
Stabilization
B A A A C C F F B
425 Rehabilitation A A A A A A A A
510 Residential Crisis
Stabilization
F B B A C F B A B
521 Intensive Residential
Services
A A A A A A A A A
551 Supervised Residential
Services
A A B B A B B B
581 Supportive Residential
Services
A A A A A A A A A
FY 16 Report Card 1
 July Aug Sept Oct Nov Dec Jan Feb March April May June
200 Development Services 320 Case Management
Services
A B A B B c c B A
420 Ambulatory Crisis
Stabilization
425 Rehabilitation
B
A
A
A
B B
A
A
C
A
C
B
D F
F |A
510 Residential Crisis
Stabilization
A A A A A A C B A
521 Intensive Residential
Services
A A A A A A A A A
551 Supervised Residential A A A A
Services
A A A A A
581 Supportive Residential
Services
A A A A A A A A A

300 Substance Abuse Services 310 Outpatient Services A A A A A A A A A

313 Intensive Outpatient
Services
A A A A A A A
320 Case Management
Services
F F P F B $ C A
501 Highly Intensive
Residential
A A A A A A A A A
521 Intensive Residential
Services
A A A A A A A C B

400 Emergency & Ancillary

Services
100 Emergency Services A A A A A B A A
318 Motivational Treatment
Services
A A A A A A A A A
720 Assessment and
Evaluation
A B F B B B B A
Grading Scale: 75% or Higher=A; 65%-74%= B; 60%-64%= C; 55%-59% target= D; 54% or below = F

Comments:

FY 16 Report Card 2
 NRVCS will strive to achieve an Unqualified Opinion resulting from the annual Independent Audit
Review and Report.

Audit Results
Annual
Unqualified Opinion on Annual Independent Audit A
Grading Scale: Unqualified Opinion= A; Qualified Opinion = F
Comments:

NRVCS will strive to meet the annual budgeted fee revenue target identified in the original budget.
Financial Targets
Annual
Meeting Budgeted Fee Revenue
Grading Scale: A = 98.5% of target & above; B = 97.5 - 98%; C = 96.5 - 97%; D = 95 - 96%; F = 94% & below

Comments:

FY 16 Report Card 3
NRVCS
NEW RIVER VALLEY
COMMUNITY SERVICES

Customer Service

NRVCS will monitor consumer satisfaction through an annual customer satisfaction survey and
develop improvement plans based on the results.

Overall Consumer Satisfaction

Survey Question Annual
"1 like the services that 1 receive here" A
Grading Scale: 90%-100%= A; 80%- 89%= B; 70%-79%=C; 60%-69%= D; 59% and below =F

Comments: According to the NRVCS FY 2016 Consumer Satisfaction survey 65%- Strongly Agree and 29%- Agree that they like the
services they receive. QA plans will be developed regarding the following areas noted for improvement:

Communication- with individuals, within agency departments, with guardians and parents

More Service time- Being seen more than once monthly, more time during services, more convenient group times and app availability

Staff- staff being more genuine, flexible, more sensitive to needs, high staff turnover leading to change in assigned staff, new staff
needing a mentor

Transportation- parking, a facility in Radford or more central, offer services at outlying clinics, more flexible transportation options

FY 16 Report Card 4
NRVCS will monitor stakeholder satisfaction through the annual stakeholder satisfaction survey
and develop improvement plans based on the results.

Overall Stakeholder Satisfaction

Survey Question Annual
"1 would recommend NRVCS services to my colleagues"
Grading Scale: 90%-100%= A; 80%- 89%= B; 70%-79%=C; 60%-69%= D; 59% and below =F

Comments:
NRVCS will engage individuals age 18 and older in conversations about employment at their
annual review.

Supporting Consumer Employment

Annual
Engaging individuals in employment discussions annually.
Grading Scale: 90%-100%= A; 80%- 89%= B; 70%-79%=C; 60%-69%= D; 59% and below =F

Comments:

NRVCS will assure individuals requesting or being referred to services at NRVCS will have access
to evaluation for requested services within 15 days of request.

Access to Services
Quarterly
Individuals receiving evaluation within 15 days of request for service D C C
Grading Scale: 90%-100%= A; 80%- 89%= B; 70%-79%=C; 60%-69%= D; 59% and below =F

Comments:
Qtr 1: 1219 evals scheduled/730 scheduled within 15 days; = 59.8% Avg. 15.7 days
Qtr 2: 1005 evals scheduled/ 739 scheduled within 15 days= 73% Avg. 12.78 days
Qtr 3: 1057 evals scheduled/756 scheduled within 15 days= 72% Avg. 12.3 days

FY 16 Report Card 5
NRVCS will resolve all client complaints made to the internal client advocate efficiently and with
satisfactory outcomes for the individual.

Complaints Resolved
Quarterly
Complaints resolved at the executive director level with satisfactory A A A
results
Grading Scale: 90%-100%= A; 80%- 89%= B; 70%-79%=C; 60%-69%= D; 59% and below =F
Comments: Qtr1: 3 Complaints, 3 Resolved at ED level with satisfactory results
Qtr 2: 2 Complaints, 2 Resolved at ED level with satisfactory results
Qtr 3: 9 Complaints; 9 Resolved at ED level with satisfactory results

NRVCS will strive to meet response time targets for crisis programs (ES and REACH).
Crisis Response Time

Quarterly
Responding to Crisis within designated timeframes -ES. A A A
Responding to Crisis within designated timeframes- REACH. A A A
Grading Scale: 90%-100%= A; 80%- 89%= B; 70%-79%=C; 60%-69%= D; 59% and below =F

Comment: QTR 1: REACH: 66 total crisis calls;23 face to face responses; 43 crisis calls handled thru phone consultation 00% of the face to face
responses were met within the 2 hour time frame- a erage response time 74 min; ES - 53 pre screenings-100% within the timeframe
QTR 2: REACH- 41 face to face crisis calls; 100% of the face to face responses were met within the 2 hours time frame average response time 69 min
ES- 89 prescreening- 88 were responded to within 2 hours= 98%
QTR 3: REACH- 53 fact to face crisis calls; 100% of the face to face responses were met within the 2 hours time frame average response time 52 min
ES- 55 Prescreening- 55 were responded to with 2 hours =100%

FY16 Report Card 6

NRVCS will strive to engage individuals after discharge from involuntary commitment to psychiatric
hospitals.
Hospital Discharge Follow up

Quarterly
Engaging consumers in seven day discharge appointments A A A
Grading Scale: 70% or above= A; 60-69% =B; 50-59% =C; 40-49%= D; Less than 40% = F

Comment: Qtr 1:148 individuals out of 172 engaged in 7DD appts. = 86%;

QTR 2: 167 individuals our of 202 engaged in 7DD appts = 82%;

QTR 3: 127 individuals our of 172 engaged in 7DD appts= 70.95%

FY 16 Report Card 7
 NRVCS
NEW RIVER VALLEY
COMMUNITY SERVICES
Compliance

NRVCS will monitor staff documentation efforts to maintain compliance with regulatory and quality
standards.
Documentation Compliance
Quarterly
Documentation Reviews A A A
Grading Scale: 90%-100%= A; 80%- 89%= B; 70%-79%=C; 60%-69%= D; 59% and below =F

Comments:
Qtr 1: 913/995 charts-91%
Qtr 2: 1087/986 charts-110%
Qtr 3: 1074/978 charts-110% of those 91% were routine reviews; 5% due to staff concerns; 3% due to client transitions

NRVCS will adhere to regulatory requirements as determined by the Code of Virginia, Department
of Behavioral Health and Developmental Services, Department of Medical Assistance Services
Department of Social Services and other Regulatory Bodies.
Compliance to Standards

Annual
Citations Received
Grading Scale: 0-1 =A; 2-3=B; 4-5=C; 6-7=D; More than 7= F

Comments:

FY 16 Report Card 8
NRVCS will maintain compliance to all physical environment standards set forth by ADA, Code of
Virginia, Department of Behavioral Health and Development Services and local standards.
Internal Facility Inspections

Annual
Internal Citations
Grading Scale: 0-1 =A; 2-3=B; 4-5=0; 6-7=D; More than 7= F

Comments:

FY 16 Report Card 9
 NRVCS
NEW RIVER VALLEY
COMMUNITY SERVICES
Staff Develo ment and Growth

NRVCS will strive to implement trauma informed culture by accessing and providing Trauma
Informed Care training for at least 70% of NRVCS staff in FY 16.

Staff Trained in Trauma Informed Care

Annual
Trauma Informed Care Training
Grading Scale: 70% or above= A; 60-69% =B; 50-59% =C; 40-49%= D; Less than 40% = F

Comments:

NRVCS will strive to hire, train and retain quality staff in all departments.

Retaining Staff
Annual
NRVCS Staff Retention
Grading Scale: 70% and above = A; 65%-69% =B; 60%-64%= C; 55%-59%=D; 54% or less =F
Comment:

FY 16 Report Card 10
 July Utilization % Utilization % Utilization % Utilization %
Aug Sept Oct
250 Acute Psychiatric or SA Inpatient Services
310 Outpatient Services 3220 132.10% 3051 125.17% 3179 130.42% 3560 146.05%
320 Case Management Services 4239 57.64% 4642 63.12% 5103 69.39% 5868 79.80%
350 Intensive Community Treatment 3389 95.89% 3057 86.49% 3141 88.87% 3270 92.52%
100 Mental Health 410 Day Treatment/Partia! Hospitalization 5592 53.77% 5227 50.26% 7274 69.94% 8112 78.00%
420 Ambulatory Crisis Stabilization 252 9.09% 416 15.00% 394 14.21% 360 12.98%
Services 425 Rehabilitation 4556 100.13% 4458 97.98% 4634 101.85% 5211 114.53%
510 Residential Crisis Stabilization 96 39.45% 134 55.07% 132 54.25% 146 60.00%
521 Intensive Residential Services 74 81.10% 85 93.15% 81 88.77% 83 90.96%
551 Supervised Residential Services 1595 81.94% 1599 82.14% 1571 80.70% 1496 76.85%
581 Supportive Residential Services 745 101.88% 709 96.96% 752 102.84% 749 102.43%

320 Case Management Services 1107 75.69% 1052 71.93% 1108 75.76% 1094 74.80%
420 Ambulatory Crisis Stabilization 122 23.46% 182 35.00% 122 23.46% 113 21.73%
200 Development 425 Rehabilitation 4620 87.50% 3951 74.83% 4356 82.50% 4152 78.64%
510 Residential Crisis Stabilization 182 99.73% 163 89.32% 137 75.07% 162 88.77%
Services 521 Intensive Residential Services 790 89.57% 779 88.32% 736 83.45% 794 90.02%
551 Supervised Residential Services 1187 92.92% 1115 87.28% 1130 88.45% 1152 90.18%
581 Supportive Residential Services 1586 325.33% 1755 360.00% 1510 309.74% 1479 303.38%

310 Outpatient Services 748 167.38% 615 137.62% 576 128.90% 723 161.79%
300 Substance 313 Intensive Outpatient Services 291 716.31% 207 509.54% 209 514.46% 213 524.31%
320 Case Management Services 149 36.68% 131 32.25% 168 41.35% 193 47.51%
Abuse Services 501 Highly Intensive Residential 18 4.43% 20 4.92% 21 5.17% 9 2.22%
521 Intensive Residential Services 252 82.85% 236 77.59% 256 84.17% 253 83.18%

400 Emergency & 100 Emergency Services 1252 102.73% 1340 109.95% 1503 123.32% 1380 113.23%
318 Motivational Treatment Services 501 205.54% 520 213.33% 412 169.03% 452 185.44%
Ancillary Services 720 Assessment and Evaluation 672 75.19% 592 66.24% 527 58.97% 611 68.36%

With changes
change to 2 slot MH- 420 Ambulatory Crisis Stabilization 252 72.83% 416 120.23% 394 113.87% 360 104.05%
Change to 6 beds MH- 510 Residential Crisis Stabilization 96 52.60% 134 73.42% 132 72.33% 146 80.00%
change to 1 slot ID- 420 Ambulatory Crisis Stabilization 122 70.52% 182 105.20% 122 70.52% 113 65.32%
Change to 17 FTE 100 Emergency Services 1252 90.64% 1340 97.01% 1503 108.81% 1380 99.91%
 Utilization % Utilization % Utilization % Utilization % March Utilization %
No Dec Jan Feb April May June

3210 131.69% 3064 125.70% 2820 115.69% 3359 137.81% 3922 160.90%
5104 69.41% 4910 66.77% 4976 67.67% 5696 77.46% 5890 80.10%
2895 81.94% 3263 92.32% 3101 87.74% 3158 89.35% 3573 101.09%
6560 63.08% 5781 55.59% 6392 61.46% 7827 75.26% 9078 87.29%
224 8.08% 216 7.79% 180 6.49% 155 5.59% 237 8.55%
4295 94.40% 4762 104.66% 3518 77.32% 4512 99.16% 5638 123.91%
112 46.03% 73 30.00% 126 51.78% 147 60.41% 129 53.01%
80 87.67% 84 92.05% 88 96.44% 80 87.67% 77 84.38%
1369 70.33% 1462 75.10% 1413 72.59% 1365 70.12% 1391 71.46%
606 82.87% 761 104.07% 659 90.12% 669 91.49% 841 115.01%

1004 68.65% 926 63.32% 929 63.52% 1028 70.29% 1206 82.46%
206 39.62 144 27.69% 120 23.08% 31 5.96% 88 16.92%
3378 63.98% 3278 62.08% 2968 56.21% 2856 54.09% 3961 75.02%
149 81.64% 152 83.29% 116 63.56% 129 70.68% 138 75.62%
724 82.09% 718 81.41% 724 82.09% 684 77.55% 703 79.71%
1065 83.37% 1118 87.51% 1108 86.73% 992 77.65% 1118 87.51%
1373 281.64% 1357 278.36% 1358 278.56% 1331 273.03% 1472 301.95%

618 138.29% 775 173.43% 688 153.96% 686 153.51% 925 206.99%
205 504.62% 295 726.15% 276 679.38% 267 657.23% 375 923.08%
123 30.28% 206 50.71% 192 47.26% 245 60.31% 447 110.03%
17 4.18% 10 2.46% 14 3.45% 10 2.46% 17 4.18%
244 80.22% 282 92.71% 257 84.50% 185 60.82% 206 67.73%

1277 104.78% 1040 85.33% 1029 84.43% 1201 98.54% 1343 110.19%
341 139.90% 383 157.13% 427 175.18% 402 164.92% 485 198.97%
654 73.17% 618 69.15% 637 71.27% 947 105.96% 911 101.93%

224 64.74% 216 62.43% 180 52.02% 155 44.80% 237 68.50%
112 61.37% 73 40.00% 126 69.04% 147 80.55% 129 70.68%
206 119.08% 144 83.24% 120 69.36% 31 17.92% 88 50.87%
1277 92.45% 1040 75.29% 1029 74.50% 1201 86.95% 1343 97.23%
 Annual YTD Grade

250 Acute Psychiatric or SA Inpatient Services

310 Outpatient Services 3265 133.95% A
320 Case Management Services 5158.667 70.15% B
350 Intensive Community Treatment 3205.333 90.69% A
100 Mental Health 410 Day Treatment/Partial Hospitalization 6871.444 66.07% B
420 Ambulatory Crisis Stabilization 270.4444 78.16% A
Services 425 Rehabilitation 4620.444 101.55% A
510 Residential Crisis Stabilization 121.6667 66.67% B
521 Intensive Residential Services 81.33333 89.13% A
551 Supervised Residential Services 1473.444 75.69% A
581 Supportive Residential Services 721.2222 98.63% A

320 Case Management Services 1050.444 71.83% B

420 Ambulatory Crisis Stabilization 125.3333 72.45% A
200 Development 425 Rehabilitation 3724.444 70.54% B
510 Residential Crisis Stabilization 147.5556 80.85% A
Services 521 Intensive Residential Services 739.1111 83.80% A
551 Supervised esidential Services 1109.444 86.84% A
581 Sup ort e Residential Ser ices 1469 301.33% A

310 Outpatient Services 706 157.99% A

300 Substance 313 Intensive Outpatient Services 259.7778 639.45% A
320 Case Management Services 206 50.71% F j
Abuse Services 501 Highly Intensi e Residential 15.11111 3.72% A
521 Intensive Residential Services 241.2222 79.31% A

400 Emergency & 100 Emergency Services 1262.778 91.42% A

318 Motivational Treatment Services 435.8889 178.83% A
Ancillary Services 720 Assessment and Evaluation 685.4444 76.69% A