The identified leadership of the organization shall be accountable for leadership structure; leadership guidance; commitment to diversity; corporate responsibility; and corporate compliance
A. The organization shall identify the internal leadership and external governance providing organizational oversight. External governance shall provide leadership guidance to ensure corporate responsibility and compliance.
B. The organization shall implement the Cultural Competency Plan. The plan shall be reviewed annually and updated as relevant to the organization’s needs. The Cultural Competency Plan shall address take into consideration culture, age, gender, sexual orientation, spiritual beliefs, socioeconomic status, and language.
Action Plan 1:
i. Governance shall not provide direct services to individuals served by the organization.
ii. Members of the external governance committee shall meet on a quarterly basis to discuss overall health of the organization, quarterly goals and objectives, and financial status of the organization. Relevant information shall be shared with upper management staff and stakeholders as needed.
iii. The organization’s President shall conduct a monthly management meeting to share relevant organizational updates.
iv. Cultural Competency plan shall be created by the organization’s Compliance Team. A Cultural Competency policy and procedure shall be included in the organization’s operations manual. An annual training shall be completed by all staff members of the organization.
v. The Cultural Competency shall be reviewed on a quarterly basis by the Compliance Officer and revised and updated as needed.
SMGC STRTP shall concentrate on the persons served and other stakeholders. Input from all persons served and other stakeholders shall be used by the organization to create effective services to meet the needs of persons receiving treatment.
A. Collection of information through various surveys of services.
B. Evaluation of service delivery and effectiveness of services based on survey results.
C. Implementation of an action plan by internal leadership to improve service delivery.
Action Plan 2:
i. SMGC shall utilize the software Survey Monkey and/or Google survey to create and implement surveys for individuals served, including current and former residents, county representatives, etc.
ii. Individuals served shall be provided with a confidential, voluntary survey during their treatment stay to provide feedback on services, staff, and suggestions for improvement in various areas of the program.
iii. A community forum shall be created for stakeholders.
iv. SMGC shall utilize the data from survey and forum to create goals and objectives to include in the strategic plan. These goals and objectives shall be geared towards improvement of service delivery and efficiency. The data received will also provide SMGC guidance on implementation on new practices, systems, and trainings.
SMGC shall strive to be financially responsible and adhere to generally accepted accounting principles (GAAP) to fulfill the organization’s financial management.
A. Fiscal management shall support the organization’s annual performance objectives.
B. Fiscal management shall address daily operational cost and extended plan for long-term financial stability.
C. The organization’s financial management team shall prepare a budget that coincides with the organization’s annual goals and objectives.
D. Annual review of financials results in comparison to budgeted performance.
E. Annual review of fiscal policies and procedures.
F. The organization shall contract with a third-party provider to complete annual review and audit.
Action Plan 3:
i. The Executive Director (ED) shall be responsible in creating the annual budget for the organization. The budget shall be based on the overall operational needs and input from other members of the external governance.
ii. The annual budget shall be reviewed and approved by the ED and Board President.
iii. Annual review of the financials by ED and Board financial committee.
iv. Annual review of fiscal policies and procedures by BOD Financial team and needed revisions completed by Executive Director & Compliance Team.
SMGC shall provide coordinated procedures to control threatening environments to individuals served and property.
A. The organization shall identify risk factors in the environment.
B. The organization shall develop a risk management plan to minimize or eliminate risk to individuals served and property.
C. The organization shall ensure adequate insurance coverage.
D. The organization shall review the risk management plan annually and make changes relevant to the organization’s needs.
Action Plan 4:
i. Risk Management factors: identification of assets that require protection; determination of risk factors; measures to reduce risk via SWOT Matrix and SWOT analysis (strengths, weaknesses, opportunities, and threats)
ii. The Compliance team shall use the risk management factors to create the organization’s Risk Management Plan.
iii. The Risk Management Plan shall be reviewed by the Executive Director, and Board of Directors.
iv. The Risk Management Plan shall be reviewed and revised as needed on an annual basis.
SMGC shall maintain a healthy and safe environment to minimize risk of harm to individuals served and the organization’s personnel.
A. The organization shall train all personnel and persons served on the organization’s emergency procedures.
B. The organization shall designate a Health and Safety Committee to create emergency protocols, inspections, and training in safety procedures.
C. The organization shall have a procedure to properly report, review, and address critical incidents.
D. The organization shall implement proper procedures and policies for infection control.
Action Plan 5:
i. SMGC shall create a Health and Safety Committee with the following members: Executive Director; Clinical Director; Program Director; and Compliance Officers.
ii. The Health and Safety Committee shall meet on a quarterly basis.
iii. The Health and Safety Officer shall coordinate emergency evacuation drills at all the organization’s facilities, which may include, but not limited to active shooter, earthquake, and fire.
iv. The Administrators shall create and implement the use of the organization’s Incident Report form for all residents and/or staff who are involved in incidents.
v. The Compliance Officer shall implement the organization’s Health and Safety policy and procedure.
vi. The organization shall implement the organization’s policy for Infection
Control. The Infection Control policy shall include: all persons served shall submit to a TB test within 30 days of admission; all staff members shall submit to a TB test at time of hire.
vii. SMGC will adhere to all Center for Disease Control (CDC) related to the novel virus, COVID19. SMGC will ensure that all staff and residents are safe via the usage of PPE, temperature, and contact tracing via screenings at the main office and facilities.
SMGC shall involve the personnel in its continuous efforts in improving service delivery to individuals served.
A. The organization shall ensure adequate qualified staff to effectively deliver services to individuals served.
B. The organization’s management team shall conduct annual performance
reviews of each staff member to evaluate competencies and establish
measurable performance objectives for the following operating year.
Action Plan 6:
i. The organization shall conduct staff performance evaluations and establish measurable performance objectives.
ii. Each staff person shall be responsible in completing their annual self-evaluation. Each manager or director will then complete a performance evaluation and set goals for each staff person.
iii. Performance evaluations and reviews shall be conducted on an annual basis.
iv. Maintain annual review of job descriptions to ensure they reflect essential job functions of each position and are aligned with the current organizational structure. Annually, all years.
v. Pay competitive compensation to all staff (wages and benefit package combined) based on norms of our local communities. Use Salary Surveys, local employment office data, surveys, etc., national and local benchmarks to measure this objective.
vi. Maintain a positive work culture and high employee morale
o Mentoring program
o Ongoing management training
o Staff recognition
o Employee Assistance Program (EAP)
vii. Monitor staff retention and reduce annual turnover by 10 % per year over the course of 3 years for a total of 30%. Annual, all years.
SMGC shall create a plan for the use of technology to support efficient service delivery.
A. The organization shall implement the technology and system plan.
Action Plan 7
i. Review current technology and assess its efficiency in the organization’s data reporting needs.
ii. Assess current technology to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA).
iii. Maintain a reliable information technology storing and recovery system via electronic health records (EHR).
iv. IT personnel shall be responsible in creating and implementation of policy and procedures related to information technology.
SMGC shall implement policies that protect the rights of the persons served while receiving services
A. The organization’s plan to protect the rights of the persons served shall include: communication of rights, policies that promote rights, grievance procedure, and review process of complaints.
Action Plan 8
i. The organization shall implement policies and procedures to protect the rights of the persons served. These policies and procedures shall maintain compliance with HIPAA and title 22.
ii. All service providers within the organization shall complete Confidentiality training on an annual basis.
iii. All persons receiving treatment services shall be provided copies of program documentation pertaining to their rights, confidentiality, and grievance procedure.
iv. All grievances and complaints shall be reviewed by the Compliance team: The Board of Directors, Executive Director, Compliance Officer, and the respective department director or manager.
SMGC strives to continually improve service delivery to meet the needs of persons served. The organization’s Compliance Officer shall be responsible for data collection and analysis. The data shall be used to evaluate the efficiency of service delivery to persons served.
A. The organization shall measure service delivery performance for all its programs.
B. The following components shall be assessed: effectiveness of services; efficiency of services; service access; and feedback from persons served and stakeholders.
Action Plan 9
i. The organization shall utilize the Survey Monkey and/or Google survey software to collect feedback data from persons served.
ii. Individuals served shall be asked to provide evaluations of the following areas: services received, staff interaction, quality of care received, and areas requiring improvement.
iii. The data gathered from these surveys shall be used to create measurable objectives for the organization with the goal of improving service delivery and efficiency, as well identification and implementation of necessary trainings for employees.
SMGC strives to ensure that all individuals serve have ease in accessibility and barriers are identified and corrected promptly. The organization’s goals are to:
A. Identify barriers
B. Remove barriers for persons served, staff, and other stakeholders
C. Develop and implement a plan of action to correct or remove identified barriers
D. Prepare annual status report regarding accessibility.
Action Plan 10:
i. The organization shall have a Compliance Team (CT) consisting of the: Executive Director; Program Director; and Compliance Officer.
ii. The CT shall identify barriers to accessibility and create an action plan to correct barriers.
iii. An annual status report shall be completed by the organization’s Compliance Officer.