Northern Community Resources

P. O. Box 7034

Ketchikan, Alaska 99901

(907) 225-6355

FAX 225-6354

 

INTEGRATED QUALITY ASSURANCE REVIEW

PILOT PROJECT

Frontier Community Services
January 23 – 25, 2001
Soldotna, Alaska

 

Site Review Team

Chris See, Self Advocate, Community Member

Marge Hays, Community Member

Corbi Aaronson, Community Member
Linda Leveque, Community Member
Matt Jones, Peer Reviewer, Anchorage
Sherry Modrow, Facilitator

 

 

INTRODUCTION

 

A review of the developmental disability (DD) services provided by Frontier Community Services was conducted from February 23 to 25, 2001 using the Integrated Quality Assurance Review process.

 

This report is the summation of the impressions of a community team after interviewing consumers, staff members, community members and staff of other agencies.  It also includes a limited administrative review.  It does not represent or reflect a comprehensive review of this agency.  The community team has collaborated on this report and the findings represent their consensus. 

 

Description of Services

 

Frontier Community Services (FCS) offers DD services in the Central Kenai Peninsula, primarily the communities of Kenai, Soldotna and Anchor Point, and has recently begun providing services in Valdez. DD services include vocational and living supports, care coordination, family support, foster care, respite, and core services.

 

FCS also provides services for early intervention, adults with physical disabilities and older Alaskans, and provides diagnostic services for people with alcohol-related disorders but those services are not part of this review.

 

 

 

 

 

 

Description of Process

 

At the direction of the Quality Assurance Committee, this site review pilots a slightly different review structure. Following the selection of individuals receiving services who would be interviewed, FCS and the facilitator developed interviews based on the circles of people involved in each consumer's life. The team worked to develop a rounded familiarity with each person receiving services that was selected for interviews and with the people involved in his or her life.

 

The team interviewed 9 individuals who receive services at Frontier, 11 support staff who are directly involved in the lives of one or more of these individuals, 4 people who are natural supports in these consumers’ lives, one employer and 13 related agencies. The team also interviewed three management staff, two board members and 9 people who attended the open forum.

 

Open Forum

 

FCS arranged an open forum and advertised it with a mailing to all consumers and with newspaper notices. Eight people attended and one was interviewed by telephone. The applicable comments of those people have been included in appropriate sections of the report.

 

 

 

FINDINGS

 

Progress Since Last Review

 

1.       Most Individual Service Plans (ISP’s) don’t contain measurable goals and objectives.

The agency has been addressing this; of the nine consumers reviewed, the team was not able to locate ISPs or goals in some of the files.  Standard not met.

2.       One of the ISP’s reviewed was two years old.

ISP’s were up to date, but two files did not have ISP’s.  Standard not met.

3.       Include specific goals and procedures when people desire changes in an individual’s challenging behavior.

FCS has addressed this with behavior plans, and should continue to formalize positive behavioral supports and develop staff training programs.  Standard met.

4.       Respite provision should have a feedback system that is common across the agency, that verifies respite provision and that assures that respite is provided in the manner that the family desires. See Administrative & Personnel section.

All consumers (or their families) receive a consumer satisfaction survey annually. Standard partially met.

5.       Assure that a staff development plan, including goals and objectives, is included in each employee’s annual evaluation (Administration & Personnel Standards #29 & 32).

Continued attention needed in the area of training and staff development.  Standard not met.

 

 

 

 

 

Areas of Excellence

 

The dedicated staff at FCS are passionate about their work.

 

Frontier Community Services has excellent interaction with other agencies. The staff use a collaborative approach to building support for people across the many organizations in the area.

 

FCS has been willing to take on new unmet needs in the region. This has brought growth-related stresses to the agency. The staff is actively working to establish systems and infrastructure that will provide for smoother operations, improvements in personnel management and efficient paperwork.

 

 

The Five Life Areas

 

Choice and Self Determination

The team identified the following strengths under Choice and Self Determination for those receiving DD services:

+ Nearly everyone talked about how happy they were that FCS is available.

+ There is a strong family presence and choices are respected by FCS

+ People that a consumer did not want to work with anymore have been reassigned upon the consumer's request.

 

The team identified the following weaknesses under Choice and Self Determination for those receiving DD services:

- Some people are concerned that individuals don't get to choose when and where to use their spending money; documentation does not always indicate a behavioral plan related to using money as a re-enforcer.

- Individuals in shared living situations do not always have choice of roommates, although their guardians do.

- Support staff are sometimes assigned to work with an individual without the consumer/guardian having a choice.

Dignity, Respect and Rights

The team identified the following strengths under Dignity, Respect and Rights for those receiving DD services:

+ Support staff and vocational staff appear to develop positive, caring relationships with the people they support.

"If I wanted to do something that FCS didn't agree with, they would respect that," a consumer said.

+ Families feel their rights are respected and valued in the development of ISP's.

+ FCS has improved in informing consumers about their rights, in the view of a family member.

+ Calls are returned in a timely manner.

 

The team identified the following weaknesses under Dignity, Respect and Rights for those receiving DD services:

- Several families spoke about late renewals, delays in writing plans and a sense of being rushed to make decisions once the staff is ready to act on the paperwork.

- A staff member made a related comment, saying: "Follow-through needs to improve."

- Some families expressed lack of knowledge about FCS activities and would like a consistent newsletter.

Health, Safety and Security

The team identified the following strengths under Health, Safety and Security for those receiving DD services:

+ The supports offered by FCS help families and individuals to feel safe in their homes.

+ The protocol for emergencies is well established and seems responsive.

 

The team identified the following weakness under Health, Safety and Security for those receiving DD services:

- A wide variety of people noted inadequate training, especially in supporting people with histories of challenging behavior and physical management of individuals in wheelchairs (lifting).

 

Relationships

The team identified the following strengths under Relationships for those receiving DD services:

+ Members of the FCS staff encourage individuals' contact with natural supports and families.

+ People have rich, varied relationships with a mix of paid and unpaid people.

+ Consumers develop positive, trusting relationships with staff. "She knows that what I'm telling her is in her best interest," a staff member said about a consumer.

+ Families expressed praise for support staff. " I don't know what I would do without the support staff. She's one of the family."

 

The team did not identify any weaknesses in the area of Relationships for those receiving DD services.

 

Community Participation

The team identified the following strengths under Community Participation for those receiving DD services:

+ Many individuals participate in Special Olympics.

+ People have a good time at the Activity Place. It provides opportunities for interaction among peers, skill building and fun.

+ FCS offers many outings, including trips to Homer and Anchorage.

+ Consumers enjoy shopping and other excursions.

+ Many people view FCS as providing a positive contribution in the Kenai/Soldotna community.

+ Consumers are employed in local businesses.

 

The team did not identify any weaknesses in the area of Community Participation for those receiving DD services.

 

Staff Interviews

 

+ Several staff members talked about developing high levels of trust with consumers and have built strong relationships. A number of direct service staff said they enjoy their jobs, and specifically working with consumers. "This is the best job I've ever had."

 

- FCS works with some very complex individuals. To increase success, both more general training and more comprehensive training in behavioral supports and developmental disabilities should become a structured and ongoing element. Staff from all parts of the agency indicated needs for training.

- A recurring theme was that direct service staff do not feel valued or appreciated and don't feel they can comfortably provide critical feedback to management.

- Several staff said community living situations are understaffed and under trained, which places consumers and staff at risk. Management and staff should develop a system for agreeing upon and clearly communicating consumer staff ratios in a variety of circumstances.

 

Interviews with Staff of Related Agencies

 

+ Staff communicate consumers’ needs well.

+ FCS staff and consumers are well received in the community.

+ Positive relationships exist between FCS and such agencies as Food Bank, DFYS, CPCS.

+ FCS staff always have best intentions with consumers.

+ FCS is very supportive of and good in working with consumers and families preparing to transition between school and adult life, especially the use of transition packets.

 

- FCS staff need more training in behavior management and general training in working with people with disabilities. One agency suggested FCS could consider bringing a behavioral specialist on staff.

 

Administrative and Personnel Narrative

 

Standard # 9. There is no formal evaluation of the agency director, although the board president maintains a close working relationship that includes informal evaluation.

Standard # 12, 13, 14. Other than the annual consumer satisfaction survey, which staff reported has very low response, consumer input is provided informally and does not appear to be actively solicited. FCS does not have a systematic annual process of involving consumers, staff and community in agency planning. Although reportedly this is informally accomplished, concerns voiced by staff and consumers/families indicate needs for concentrating on effective methods of feedback that feel comfortable and impact agency planning and program evaluation.

Standard # 19. Lack of adequate training for support staff was a recurrent theme of the review.

Standard # 22. FCS has procedures for hiring and evaluation of staff with consumer choice, but they appear to be implemented inconsistently.

Standard # 24. The agency meets this standard. The team recommends that FCS implement FBI background checks for all employees.

Standard # 28, 31, 32. Performance appraisals are not applied consistently to all employees and feedback and recognition seem lacking for some employees.

Standard # 29, 30. FCS should develop written professional development plans and agency wide training plans. Training occurs, both formally and informally; the agency should implement a system for assessing, providing and tracking the training.

 

 

 

 

Program Management

 

This agency is actively working to catch up with the growth and changes of recent years. People are presently being interviewed for a new management level human resources position. The team sees this as a very positive step that should allow objective treatment of issues between management and staff, as well as assisting the agency to provide better communication, conflict resolution, and employee relations.

 

Among the critical issues that need to be addressed are developing and monitoring regular written evaluations and staff development plans. Employees need to know what is expected of them and would like to receive credit when appropriate as well as knowing that disciplinary procedures will be uniformly applied.

 

FCS has grown rapidly but some systems still rely on procedures that worked well when everyone knew all the employees and consumers. In a larger agency, those informal processes can lead to inconsistency and discord. Several consumers and staff talked about not knowing how to get resolution of concerns without fear of retribution. "Don't rock the boat," was the operating principle expressed by more than one person.

 

ISP’s do not consistently provide measurable goals, and in some cases there are no written goals.

Nobody can be held accountable for either the consumers' or the agency's progress if it isn't documented.

 

FCS has restructured to become more responsive to writing plans and renewals. Staff are addressing a backlog of overdue ISPs. Some families said when renewals are due, staff wait too long and create a situation that doesn't give families adequate notice to prepare for a meeting.

 

Medicaid waivers are part of a very complicated and confusing system. The State of Alaska can help by providing clear information about services to consumers and guidelines to agencies. FCS can help by encouraging clear communication between care coordinators and consumers/families about options and updates.

 

The frequency with which training emerged as a concern indicates the agency should place concerted efforts on strengthening the training provided to staff. FCS notes that it is difficult to locate appropriate training in developmental disabilities services. The team suggests the agency could take advantage of a variety of training opportunities through University Affiliated Programs, accredited or informal online courses, Community Schools, Stone Soup and many other possibilities.

 

Areas Requiring Response

 

1.       All consumer files should contain Individual Service Plans.  (Prior review)

2.       All Individual Service plans should contain measurable goals and objectives. (Prior review)

3.       Respite provision should have a feedback system that is common across the agency, verifies respite provision and assures that respite is provided in the manner that the family desires. (Prior review)

 

4.       There is no formal evaluation of the agency director, although the board president maintains a close working relationship that includes informal evaluation.  The Board is to formally evaluate the agency director (Standard # 9).

5.       Utilize the consumer and family input gathered in the consumer satisfaction survey and by other means to determine policy and program delivery.  (Standard #12)

6.       Systematically involve consumers, staff and community in annual agency planning and evaluation of programs, including feedback from the consumer satisfaction survey.  (Standard #13)

7.       Formalize a process by which to develop annual goals and objectives in response to consumer, community and self-evaluation activities.  (Standard #14)

8.        To comply with Standards 12, 13, and 14, facilitate the reception of critical feedback to management from consumers and staff.

9.       FCS staff need more general training and more comprehensive training in positive behavioral supports, developmental disabilities, body mechanics, such as for individuals in wheelchairs, structured and ongoing training programs (Standard # 19).

10.   Consistently utilize agency procedures for hiring and evaluation of support staff (Standard # 22).

11.   Assure that performance appraisals are applied consistently to all employees and that they include feedback and recognition.  (Standard #28)

12.   Write a staff development plan annually for each professional and paraprofessional staff person.  (Standard #29 and prior review)

13.   Develop agency-wide training plans and implement a system for assessing, providing and tracking the training of staff.  (Standard #30)

14.   Assure that the performance appraisal system adheres to reasonably established timelines.  (Standard #31)

15.   Establish goals and objectives for the period of employee appraisal.  (Standard #32 and prior review)

16.   Assure that consumers/guardians can exercise choice in the assignment of support staff and that consumers as well as guardians have a choice of roommate.

17.   Seek to improve employee morale.  Employees need to know what is expected of them and should receive credit when appropriate as well as knowing that disciplinary procedures will be uniformly applied. A recurring theme was that direct service staff do not feel valued or appreciated

18.   The organization should clarify with all staff the expectations for relationships between staff members and consumers.

19.   Management and staff should develop a system for agreeing upon and clearly communicating consumer staff ratios in a variety of circumstances.

20.   FCS needs to continue developing the systems and infrastructure that will accommodate its recent growth.

21.   Seek to familiarize families with FCS activities.

22.   When individuals don't get to choose when and where to use their spending money, documentation should indicate the reasoning or conditions associated with such limits.

23.   Continue efforts to improve timeliness and provide adequate notice of meetings.

 

 

 

 

Other Recommendations

 

1. Several consumers' families expressed great confusion and frustration about the DD service system. They find it difficult to know where to look for information and are overwhelmed by jargon, especially regarding Medicaid. The State of Alaska should publish clarifying information, both paper- and Web-based.

 

2. Some people requested more information and support with guardianship issues; this is an area in which the State could assist agencies and individuals.

 

3. The team recommends that FCS implement FBI background checks for all employees.

 

4. Not all board members have clear understanding about the role of the board, the amount of oversight they provide or their responsibilities as individual members of the board of directors. The site review team commends the agency for the board training planned in the spring, and recommends that it include training about roles and responsibilities.

 

 

Closing Note

 

The site review team appreciated the participation of everyone involved in the site review, and the hospitality and helpfulness of FCS staff.

 

The final draft of this report will be sent to Northern Community Resources for final review. You will receive the final report within approximately thirty days, including a Plan of Action form, listing the Areas Requiring Response. You will then have an additional thirty days to complete the Plan of Action. The directions on how to proceed from there will be included in a cover letter you will receive with the final report and Plan of Action form.

                                                          

Once NCR has reviewed the completed Plan of Action, it will be sent to the DMHDD Quality Assurance Section.  The QA Section will then contact you to develop collaboratively a plan for change.

 

Attachments: Administrative and Personnel Checklist, Interview Form for Staff of Related Agencies (tallied), Score Sheet (averaged)