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Quality Assurance

DMRS Q.A. Report Card
Four Star Agency 2014

Court Monitor Review Score
Quality Tier Provider

As part of the overall internal quality assurance system, WTFS conducts quality inspections of target areas on a quarterly basis.  Comprehensive program evaluations are conducted at minimal, two times per year, or more frequently if indicated. The Targeted Elements Review is conducted on unannounced visits for all individuals served by WTFS, and focus on life safety areas, as well as areas where concerns or problems have been identified in prior reviews.  Such areas include, but are not limited to, ISP Implementation, Individual Risk Assessment, Environmental Safety, Risk Management, Personal Funds Management, Medication Administration, Service Recipient Records, and Staff Training.


The Comprehensive Quality Oversight Review is conducted on either announced or unannounced visits for a sample (approximately 20%) of people served and focuses on all areas as indicated by the DMRS Quality Assurance Individual, Organizational, and Clinical Checklists as well as Dr. Ray’s Community Status Review.  The Comprehensive Review occurs prior to the annual DMRS Quality Assurance Review and prior to Dr. Ray’s annual Community Review.  Additional reviews are conducted as needed.

A Report Card is generated for all Targeted Elements Review based on a percentage scale:  80-100% = Compliance – no further action;   70-79% = Partial Compliance – will be referred to the Clinical Committee for development of a Risk Improvement Plan; below 69% = Non-compliance – A Comprehensive Review for that individual will be conducted and an emergency Clinical Committee meeting will be called and held within one week.  Any time there is a Life Safety issue identified it will immediately trigger an incident report and will be acted on within 24 hours.


Comprehensive Reviews generate a separate report in the same format as the DMRS QA Review.  Results from the Comprehensive Review will be presented to the Clinical Committee.

Results from all internal Quality Assurance Reviews are shared with WTFS Administrative staff and WTFS Board of Directors Risk Management Committee.



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