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Performance & Quality
Improvement Dashboard
June 2025 – November 2025 · Director: Samantha Lapomardo
At a Glance
Six-month summary across all program areas · June – November 2025Census & Capacity
Monthly placement counts by program type| Month | Emerg. Shelter | QRTP | Total | Hotline Calls | Survey Respondents |
|---|---|---|---|---|---|
| June 2025 | 12 | 7 | 19 | 1 | 6 |
| July 2025 | 14 | 10 | 24 | 0 | 9 |
| August 2025 | 17 | 9 | 26 | 3 | 12 |
| September 2025 | 14 | 9 | 23 | 2 | 10 |
| October 2025 | 21 | 12 | 33 | 1 | 17 |
| November 2025 | 16 | 7 | 26 | 2 | 12 |
Client Satisfaction
Goal: 90% across all categories by year-end · Based on discharge assessments & monthly surveysRisk Management & Incidents
Monthly incident and AWOL tracking| Month | Incidents | AWOLs | Severity | Notable Events |
|---|---|---|---|---|
| June | 8 | 4 | High | 4 AWOLs (same client), 2 drug paraphernalia, 2 overdose emergencies |
| July | 2 | 0 | Low | Property destruction, 1 ER transport / acute care (did not return) |
| August | 8 | 0 | High | 2 property destruction, ER suicidal ideation, 2 acute homicidal, police transport |
| September | 8 | 0 | High | Property destruction, 2 acute suicidal, inappropriate sexual comments (2 hotline calls), 1 acute homicidal |
| October | 7 | 7 | High | 2 medical ER, 2 acute suicidal, physical harm to YA, physical altercation, 4 repeat AWOL clients |
| November | 4 | 1 | Medium | 1 medical ER, physical altercation (JDC), suspected sexual assault, 2 AWOLs (self-returned) |
Monthly Deep Dive
Select a month for detailed outcomes, improvement plans, and highlightsClient Outcomes
- 1 client attended FCA camp for 3 nights
- 1 client had two Saturdays with a mentor
- 1 client placed with fictive kin
Improvement Plans
- New YA training modules: trauma-informed care, de-escalation
- Shared shift communication log implementation begun
- Weekly supervisor observations of group activities
Staff Recognition
YA staff recognized for exceptional commitment, active initiative in supervision duties, and contributions to program development.
Future Plans
- Reintroduce structured weekly house meetings
- Launch YA recruitment campaign with referral bonuses
- Pilot flexible educational structure in the fall
- Weekly cross-department huddles (clinical, education, residential)
Client Outcomes
- 4 clients participated in an adoption event with caseworkers
- 1 client continues bi-weekly mentor meetings with positive engagement
- 1 client attended an overnight church camp — enriching experience
Improvement Plans
- Additional trauma-informed care, de-escalation training modules
- Shared shift communication log in progress
- Weekly supervisory observations for real-time coaching
Staff Recognition
One newer staff member recognized for outstanding active supervision and leadership during shift coverage.
Future Plans
- Hired part-time teacher for enhanced educational support
- Actively working to purchase life skills curriculum
- Welcomed experienced kitchen manager to improve food service
Client Outcomes
- 1 QRTP boy allowed weekend pass with a friend and church outing
- Several QRTP residents signed up for school sports; attending games & practices
- 1 ES girl competing in a sport, receiving praise from her coach
Improvement Plans
- Full-day YA Training end of September (de-escalation, Conscious Discipline, teamwork)
- Group communication tools for real-time team updates
- Weekly supervisory program observations
Staff Recognition
Promoted a Youth Advocate to new Youth Advocate Manager role. Acknowledged multiple staff members for going above and beyond.
Future Plans
- Monthly support visits for mission alignment
- Ongoing staff development after September training
- New recreational programming (wellness, creativity, leadership)
- Implement quarterly recognition program
Client Outcomes
- 1 QRTP boy allowed weekend passes; individual exploring long-term placement
- 1 client discharged to PRTF (appropriate level of care)
- 2 QRTP clients participating in school band and sports
Improvement Plans
- Evaluating barriers to therapeutic services access
- Clinical team meets weekly to improve services and treatment plan adherence
Staff Recognition
New QRTP therapist recognized for seeing each QRTP resident weekly and providing group therapy on a consistent basis — a first for the program.
Future Plans
- Push for life skills groups: cooking, bill pay, job applications
Client Outcomes
- 1 QRTP client moved to higher level of care (appropriate)
- All treatment plan services delivered with part-time therapist
- 2 boys participated in adoption event
- 2 QRTP residents gained mentors — went fishing as reward
- Clients continue in after-school band and sports
Improvement Plans
- YAs attended semi-annual Summit: de-escalation, healthy boundaries, trauma-informed care
- New staff completed all required training and background checks
Staff Recognition
All Summit attendees and new staff recognized for completing mandatory training and certifications.
Future Plans
- Improve staff morale through recognition and engagement
- Increase retention via consistent training and professional development
- Host additional YA Seminars; continue staff feedback surveys
Client Outcomes
Numbers lower than October — typical for the holiday season. Unexpected annual audit resulted in one finding (initial PCP appointment date not documented); intake form updated to address this going forward.
Improvement Plans
- One-on-one staff support visits reinstated
- Bi-weekly meetings resumed
- FAQ document and staff survey distributed; complaints addressed via email
Staff Recognition
Shelter Manager Amber Carter recognized for stepping up during Residential Director's absence.
Future Plans
- Replace 2 departed YAs (funding cuts & termination)
- 3 new hires pending clearance
- Actively filling 3–11, overnight, and weekend positions by year-end
