REFUGE HOUSE, INC.

PURPOSE:

To operationalize FC-CQI-01 by specifying how Refuge House runs its CQI/PQI cycle — outcome measurement, the client and stakeholder satisfaction program, incident/trend (PQI) review, internal audits and corrective action, and reporting. This procedure leans on activities already established elsewhere and cross-references them rather than duplicating their detail.

RESPONSIBILITY:

• CQI Coordinator (T3C Infrastructure Function #6)
• Director of Quality Development / HRQAD
• Program Directors / Treatment Directors
• Case Specialists
• Executive Director (oversight; Board reporting)

PROCEDURE:

1. Logic Models, Outcome Measurement & Data Collection

Refuge House uses its existing per-package Logic Models and CQI Models (Basic, MBH, IDD/Autism, STASS, SU, TFFC — cookbook/previewforms; data/placement-datasheets.json; master CQI Plan / Logic-Model Integration). This procedure runs the cycle against those models; it does not recreate them. Each Logic Model's CQI Process block (Data Collection · Program Review · Implementation Adjustments) governs the activities below per TAC §749.665.

2. Client & Stakeholder Satisfaction Program

This is the agency's formal client-satisfaction program. It consolidates the satisfaction tools already in use and adds a defined cadence.

3. Incident & Trend Review (PQI)

4. Internal Audits & Corrective Action / QIP

4a. 2INgage Monitoring & Risk Review

SSCC-2INGAGE — addition start (provider-specific; remove this block if the 2INgage contract ends)

For the 2INgage network, Refuge House participates in 2INgage quarterly desk reviews and an annual on-site joint monitoring (minimum 10% file review), provides any missing documentation within 72 hours, implements a Quality Improvement Plan within 30 days of identified deficiencies, and may submit a written response to disagreements within 5 business days. Risk management is reviewed monthly during 2INgage network data calls, with results reported to agency leadership. (2INgage Provider Manual Rev. 1.2026 §12, pp.48–49; §11, p.47)

SSCC-2INGAGE — addition end

SSCC-EMPOWER — addition start (provider-specific; remove this block if the EMPOWER contract ends)

For the EMPOWER network, Refuge House participates in EMPOWER quarterly desk reviews and annual on-site monitoring (minimum 10% file review; 100% if fewer than five children), provides missing documentation within 72 hours of the exit interview, implements a Quality Improvement Plan within 30 days, and may submit a written response to disagreements within 5 business days (EMPOWER's final response within 10 business days); risk management is reviewed monthly during network data calls (EMPOWER Provider Manual Rev. 1.2026 §12, pp.51–55).

SSCC-EMPOWER — addition end

SSCC-OCOK — addition start (provider-specific; remove this block if the OCOK contract ends)

For the OCOK network, Refuge House participates in OCOK's annual Monitoring Review (announced/unannounced, on-site or desk; at least 24-hour notice, up to 30-day advance notice; a 10% client-file and 10% CPA-personnel sample, 100% if fewer than five), receives the final report within 30 business days of the exit interview, completes any PQI/QIP within 30 days, and may submit a written disagreement within 5 business days (OCOK responds within 10); improvement follows OCOK's DMAIC cycle. Refuge House also participates in OCOK's annual stakeholder/client satisfaction survey (OCOK Network Management Operations Manual Rev. 7-1-2025 §4.03, pp.47–50; §4.04, pp.61–62; §4.09, p.79).

SSCC-OCOK — addition end

SSCC-4KIDS — addition start (provider-specific; remove this block if the 4Kids4Families contract ends)

For the 4Kids4Families network, Refuge House participates in DFPS Community-Based Care evaluation activities and reports quality/performance data at the child level on the SSCC's quarterly cadence (4Kids4Families Subcontractor Agreement Art. XVIII §3, Exhibit D).

SSCC-4KIDS — addition end

SSCC-BELONG — addition start (provider-specific; remove this block if the Belong contract ends)

For the Belong network, Refuge House cooperates with Belong Quality Assurance monitoring — an on-site visit within the first year, annual site visits, and quarterly case reviews of at least 10% of risk-flagged cases, with corrective action where errors persist — and participates in Belong satisfaction surveys of clients, employees, providers, and foster parents (Belong Stage I & II Provider Manual, pp.54–56).

SSCC-BELONG — addition end

5. Reporting

QUALITY ASSURANCE:

The CQI Coordinator verifies that each component above occurs on schedule and that the program is reviewed for effectiveness at least annually. Methodology follows a continuous PDSA cycle compatible with the SSCC's monitoring process (e.g., 2INgage "DO-RITE").

REGULATORY ALIGNMENT:

26 TAC §749.665 (Quality Assurance — the agency's CQI Process anchor); T3C System Blueprint (CQI Infrastructure Function #6; per-package Logic Models + CQI Models); 2INgage Provider Manual Rev. 1.2026 §12 (satisfaction surveys, QIP, DO-RITE) and §11 (reporting cadence); OCOK Network Management Operations Manual Rev. 7-1-2025 §4.04 (PQI/DMAIC), §4.09 (annual Stakeholder Satisfaction Survey), §4.05 (Quality Management); EMPOWER Provider Manual Rev. 1.2026 §12 (satisfaction/feedback), §11 (Monthly Case Status Report); cross-ref FC-SIR-01 (PQI engine), FC6-01 (placement-stability monitoring), and the per-package Logic/CQI Models (cookbook/previewforms; data/placement-datasheets.json).

SSCC alignment (FY-26): 2INgage Provider Manual Rev. 1.2026 — §12 (pp.48–49 monitoring); §11 (p.47 monthly risk call). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC coverage tracker (temporary-reference/fy26-sscc-joint-monitoring/sscc-alignment/).

SSCC alignment (FY-26) — EMPOWER: EMPOWER Provider Manual Rev. 1.2026 — §12 (pp.51–55 monitoring & monthly risk call). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

SSCC alignment (FY-26) — OCOK: OCOK Network Management Operations Manual Rev. 7-1-2025 — §4.03 (pp.47–50 monitoring); §4.04 (DMAIC); §4.09 (p.79 satisfaction). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

SSCC alignment (FY-26) — 4Kids: 4Kids4Families Joint Operations Manual (Dec 2025) / Subcontractor Agreement — Agreement Art. XVIII §3, Exhibit D (CBC evaluation; quarterly child-level data). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

SSCC alignment (FY-26) — Belong: Belong Stage I & II Provider Manual (Aug 2025) / Provider Services Agreement — pp.54–56 monitoring & satisfaction. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

SSCC alignment (FY-26) — SFCS: SFCS Placement Provider Manual (July 2020, publicly-sourced) — the SFCS requirements for this area (incidents/QI/IT) fall in the manual's truncated back-half; confirm against the current SFCS provider manual before relying on this. No additional provision applied yet. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

FORMS/ATTACHMENTS:

• Caregiver Satisfaction Survey
• Child/Youth & Young-Adult Satisfaction Survey (Youth Voice)
• Caregiver Feedback Form
• Stakeholder/Partner Feedback Survey
• Quality Improvement Plan (QIP) template
• Quarterly PQI / Quality Report template

This procedure operationalizes FC-CQI-01 Continuous Quality Improvement Policy and may be updated by the Executive Director to reflect regulatory or operational changes, provided alignment with the policy's intent is maintained.

IMPLEMENTATION GUIDANCE

Guidance for operationalizing the following enhancement(s), including build-out in Pulse. Recovered from the prior T3C Basic procedure draft (6/2025); align to the T3C Blueprint (April 2026).

IG · T3C service-delivery documentation & QA cadence

Implement a monthly child-progress summary due by the 5th of the following month, and a quarterly QA record review (TBRI® fidelity + compliance) that triggers a Program Director improvement plan within 10 days of the QA report. (Source: recovered T3C Basic procedure draft; align T3C Blueprint CQI, TAC §749.673.)