Survey Report 67390 - ICLinc

1 Three-Year Accreditation CARF Survey Report for Institute for Community Living, Inc. Three-Year Accreditation Organization Institute for Community Living, Inc. (ICL) 40 Rector Street, Eighth Floor New York, NY 10006 Organizational Leadership Howard M. Goldberg, , Associate Executive Vice President, Chief Quality and Compliance Officer, Privacy Officer Survey Dates July 17-19, 2013 Survey Team Veronica A. Madrigal, , Administrative Surveyor Janys Esparza, Program Surveyor Steve Reffner, , LSW, PCC-S, Program Surveyor Programs/Services Surveyed Community Housing: Integrated: AOD/MH (Adults) Community Housing: Mental Health (Adults) Community Housing: Mental Health (Children and Adolescents) Outpatient Treatment: Family Services (Adults) Outpatient Treatment: Family Services (Children and Adolescents) Governance Standards Applied Previous Survey June 7-9, 2010 Three-Year Accreditation Survey Outcome Three-Year Accreditation Expiration: May 2016 Page 2 Survey SUMMARY Institute for Community Living, Inc.

2 (ICL), has strengths in many areas. ICL has a clear and unwavering commitment to doing the right things for the persons served and enjoys a reputation as an organization that is truly committed to operational excellence. The organization has established high expectations regarding the administrative and clinical systems. It is apparent that significant groundwork and resources were put into the ongoing implementation, review, and revision of policies and procedures. They were comprehensive and well written. The leadership team is experienced, dedicated, committed to the needs of the persons served, and supportive of growth and works well as a cohesive, mission-focused team. The longevity of many staff members is particularly impressive. They bring stability, history, and continuity to service delivery. The staff is competent, caring, and genuinely dedicated to the success and long-term viability of the organization and the accomplishment of its mission.

3 The board of directors offers leadership and dedication to the organization. It meets its fiduciary responsibilities, meets its obligations to be representative of community needs, and is highly supportive of the organization. The leadership is committed to the implementation of best practices and evidence-based research practices to position the organization for growth and/or changes in the behavioral health marketplace. The organization appears to be financially stable and has benefited from strong leadership and sound financial management and decision making. The chief executive officer is well respected in the health management field and is recognized for his expertise and vision. He has a long and distinguished legacy of leadership, and, although early in his current tenure, brings longstanding knowledge and rapport with care management and other third party payers that will result in further stability to the organization.

4 ICL engages in a thorough process in developing the organizational strategic plan. Many stakeholders are involved, and input is obtained from a variety of sources and methodologies. The environmental scan is comprehensive. The strengths, weaknesses, opportunities, and threats (SWOT) analysis shows that much thought is invested in the process. The resulting plan is a useful and relevant tool to guide the organization s future growth and/or changes in the behavioral health marketplace. The process of performance improvement is of high priority. There is ample evidence that data are used effectively in refining services, programs, and overall operations. The organization has an interactive state-of-the-art training facility and can be linked to other providers within the community mental health system. The training system allows accessing mandatory clinical training in areas required for state licensure and competency-based trainings for personnel.

5 Page 3 The organization demonstrates the use of multiple languages that afford accessibility to persons who are non-English speaking. This is evidenced by the organization having staff that provides services in primary languages of the persons served including English, Spanish, Creole, and Russian. Throughout the organization s apartments, it is evident that countless accommodations have been made to ensure that the decor of each individual s room and the special collection displays honor the individual s taste while maintaining a safe and healthy environment. It is evident that the clients hold the staff in high regard. Key workers have been assigned to each person served in community housing. They are responsible for coordinating the team in the development, implementation, and monitoring of the individual plan. In addition, the staff members of the community homes develop community activities on a regular basis.

6 The staff is acknowledged for a commitment to providing positive behavior supports for the persons served who demonstrate challenging behaviors in their supportive living environments. The staff is passionate about providing quality care that truly makes a difference in the lives of the persons served. The organization and staff members are committed to delivering services in an atmosphere characterized by a high level of regard for removing stigma and affording dignity and respect to the persons served. The staff members at all levels of the organization demonstrate true compassion and are proud of the programs delivered and the progress of the persons served. In the following area ICL demonstrates exemplary conformance to the standards. The organization has developed comprehensive training protocols in trauma-informed care/management. This process enables clinicians to practice an empirically based intervention to effectively address trauma.

7 The organization also engages in trauma sensitivity training that enables leadership and direct treatment staff to enhance a supportive environment in the treatment of the persons served who have witnessed or experienced trauma. ICL should seek improvement in the areas identified by the recommendations in the Report . Consultation given does not indicate nonconformance to standards but is offered as a suggestion for further quality improvement. On balance, ICL is highly regarded in the community for providing needed and quality services. ICL has competent leadership and is dedicated to the development, implementation, and evaluation of the services provided. The persons served and referral sources Report a high level of satisfaction with the effectiveness of the services. The management staff members continually explore new ways to improve the quality of services and the financial stability of the organization.

8 ICL demonstrates substantial conformance to the CARF standards. The organization is aware of the areas for improvement that include educating personnel on the written ethical code of conduct, consistently reviewing and updating job descriptions, developing performance objectives for personnel, and assessing their attainment in the coming year. As the organization moves toward a paperless process, coupled with new leadership, there is no doubt that ICL is dedicated to the ongoing development, implementation, and evaluation of the services provided. Page 4 Institute for Community Living, Inc., has earned a Three-Year Accreditation. The leadership and staff members are congratulated on this accomplishment. They are encouraged to continue to use the CARF standards to continuously improve the quality of the programs and the services provided. SECTION 1. ASPIRE TO EXCELLENCE A. Leadership Principle Statement CARF-accredited organizations identify leadership that embraces the values of accountability and responsibility to the individual organization s stated mission.

9 The leadership demonstrates corporate social responsibility. Key Areas Addressed Leadership structure Leadership guidance Commitment to diversity Corporate responsibility Corporate compliance Recommendations It is recommended that the organization review its cultural plan annually and update it as needed. (4)(f) (2)(a) through (1) It is recommended that the written ethical codes of conduct include the witnessing of documents and time frames that are adequate for prompt consideration and result in timely decisions. Further, it is recommended that the organization consistently educate personnel on ethical codes of conduct. Page 5 B. Governance Principle Statement The governing board should provide effective and ethical governance leadership on behalf of its owners /stakeholders interest to ensure that the organization focuses on its purpose and outcomes for persons served, resulting in the organization s long-term success and stability.

10 The board is responsible for ensuring that the organization is managed effectively, efficiently, and ethically by the organization s executive leadership through defined governance accountability mechanisms. These mechanisms include, but are not limited to, an adopted governance framework defined by written governance policies and demonstrated practices; active and timely review of organizational performance and that of the executive leadership; and the demarcation of duties between the board and executive leadership to ensure that organizational strategies, plans, decisions, and actions are delegated to the resource that would best advance the interests and performance of the organization over the long term and manage the organization s inherent risks. The board has additional responsibilities under the domain of public trust, and as such, it understands its corporate responsibility to the organization s employees, providers, suppliers, and the communities it serves.