# REFUGE HOUSE, INC. | Procedure Information | Details | | :---- | :---- | | **PROCEDURE NAME** | Continuous Quality Improvement (CQI/PQI) Procedure | | **PROCEDURE NUMBER** | FC-CQI-01.1 | | **RELATED POLICY** | FC-CQI-01 Continuous Quality Improvement Policy | | **APPROVED BY** | Executive Director | | **EFFECTIVE DATE** | 6/16/26 | | **REVISION DATE** | 6/16/26 | | **LAST UPDATED** | 5/15/2026 | | **LAST APPROVED** | 5/22/2026 | | APPLICABLE T3C PACKAGES: | APPLICABLE T3C ADD-ON SERVICES: | | :---- | :---- | | ☒ T3C Basic Foster Family Home | ☒ Transition Support Services for Youth & Young Adults | | ☒ Substance Use Support Services | ☒ Kinship Caregiver Support Services | | ☒ Short-Term Assessment | ☒ Pregnant & Parenting Youth or Young Adult | | ☒ Mental & Behavioral Health | | | ☒ Sexual Aggression/Sex Offender | | | ☒ Complex Medical Needs or Medically Fragile | | | ☒ Human Trafficking Victim/Survivor | | | ☒ Intellectual or Developmental Disability (IDD)/Autism Spectrum Disorder | | | ☒ T3C Treatment Foster Family Care | | ## 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. | Who | How | When | Where | Reference | | :---- | :---- | :---- | :---- | :---- | | CQI Coordinator | **Data Collection:** monthly child-level outcomes, quarterly foster-home analysis, CANS 3.0 utilization, and documentation-quality reviews against each package's Logic Model outcome measures (safety, permanency, well-being); track placement stability and disruption patterns | Monthly / quarterly | Radius / quality dashboard | TAC §749.665; per-package Logic Models; FC6-01 | | CQI Coordinator / Program Director | **Program Review:** 30–60-day Service Plan reviews, continued-stay criteria, TBRI® fidelity monitoring, and the **quarterly Logic Model review** | Per cadence; Logic Model review quarterly | Radius / dashboards | TAC §749.665; T3C Blueprint | | CQI Coordinator | **Implementation Adjustments:** service-delivery refinement, training enhancements, resource reallocation, and **annual Logic Model updates** | As indicated; Logic Models annually | Quality dashboard / Logic Models | 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. | Who | How | When | Where | Reference | | :---- | :---- | :---- | :---- | :---- | | CQI Coordinator | Administer a **caregiver (foster/kinship/adoptive) satisfaction survey** measuring support, training, communication, and overall satisfaction (consolidates the R&R retention "family satisfaction" analysis and the Kinship caregiver satisfaction survey) | At least annually + at placement closure | Survey tool; results in Radius | **2INgage Provider Manual Rev.1.2026 §12, p.51** | | CQI Coordinator / Case Specialist | Administer a **child/youth & young-adult satisfaction survey** ensuring youth voice (consolidates the Aftercare/Transition youth satisfaction surveys); collect **caregiver feedback forms** | At least annually + at discharge/aftercare completion | Survey tool; results in Radius | **2INgage Provider Manual Rev.1.2026 §12, p.51**; Aftercare / Youth Transition | | CQI Coordinator | Gather **stakeholder feedback** (DFPS, SSCC, community partners, CPS workers, client team members) and **staff feedback**; maintain an accessible, anonymous **concern/feedback channel**; participate in and support the SSCC's own stakeholder satisfaction survey | Annually + ongoing | Survey / concern channel | **2INgage Provider Manual Rev.1.2026 §12, pp.51–52** (anonymous feedback; Consumer Affairs); **OCOK Operations Manual Rev.7-1-2025 §4.09** (annual Stakeholder Satisfaction Survey); **EMPOWER Provider Manual Rev.1.2026 §12** (satisfaction/feedback) | | CQI Coordinator | Compile satisfaction results, identify themes, and feed findings into the quarterly PQI review and improvement plans; ensure youth voice informs decisions | Quarterly | PQI meeting record | FC-CQI-01; 2INgage §12 | ### 3. Incident & Trend Review (PQI) | Who | How | When | Where | Reference | | :---- | :---- | :---- | :---- | :---- | | Director of Quality Development | Review serious/non-serious incident reports for patterns and trends; compile a quarterly report for the PQI meeting; develop action plans and present to the Executive Director | Monthly review → quarterly PQI | PQI meeting record | **Cross-ref FC-SIR-01 §"Quality Assurance (PQI)"** (do not duplicate) | ### 4. Internal Audits & Corrective Action / QIP | Who | How | When | Where | Reference | | :---- | :---- | :---- | :---- | :---- | | CQI Coordinator | Conduct internal quality audits (documentation, compliance, TBRI fidelity); prepare for external audits/credentialing | Per audit calendar; before monitoring reviews | Audit reports in Radius | TAC §749.665; T3C Blueprint | | CQI Coordinator / Program Director | When deficiencies are identified, develop and implement a **corrective action plan / Quality Improvement Plan (QIP)**, including any QIP requested or approved by an SSCC; evaluate effectiveness of the change | Within timeframe set by the finding or SSCC | QIP document | **2INgage Provider Manual Rev.1.2026 §12, pp.49–51** (QIP process) | ### 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 | Who | How | When | Where | Reference | | :---- | :---- | :---- | :---- | :---- | | CQI Coordinator | Prepare quarterly quality reports (outcomes by Service Package, satisfaction results, PQI trends, audit/QIP status) for leadership and the Board; report to regulatory/contract bodies as required; maintain audit-ready documentation | At least quarterly | Leadership / Board / SSCC / DFPS | T3C Blueprint; 2INgage §11–§12 | ## 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.)*