Northern Community Resources

P. O. Box 7034

Ketchikan, Alaska 99901

 

 

 

INTEGRATED QUALITY ASSURANCE REVIEW
Copper River Community Mental Health Center
April 30, 2001May 2, 2001
Copper Center, Alaska

 

Site Review Team

Sue Moore, Community Member

Frank Addrisi, Peer Reviewer
Barbara Price, Facilitator

                                

                                

INTRODUCTION

 

A review of the Mental Health (MH) services provided by Copper River Community Mental Health Center (CRCMHC) was conducted from April 30, 2001 to May 2, 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

 

CRCMHC provides MH and other human services through its parent agency, Copper River Native Association (CRNA).  MH services are open to all residents of the service area, a service area of approximately 14,000 square miles that includes eleven communities.  The population has increased by about 12% in the last two years, now numbering some 5,500 year round residents.  In addition, CRCMHC is available to serve the seasonal, transient and tourist population in excess of 70,000 per year and increasing with the recent construction of a major hotel and a National Park Information Center.

 

CRCMHC’s MH services are integrated within a Behavioral Health Services department that also includes substance abuse out patient and residential treatment, a Safe Families program, support for families at risk for FAS/FAE and services for those affected.  The State MH grant of $200,000 represents only 15% of the Behavioral Health Services budget.

 

The integration of services represented by the creation of a Behavioral Health model results in integrated, non-categorical services complicated only by funding and data collection systems which remain categorical. It should be noted that the funding for Behavioral Health is largely federal funding through Indian Health Services and SAMSHA.  The requirements of those funding sources and of those related to Native associations complicate the agency’s ability to respond to the regulations that are unique to the State’s Division of Mental Health and Developmental Disabilities (DMHDD).

 

Mental health services are provided by a full time clinician (funded by SAMSHA), an administrator/clinician, a case manager and contract staff.  The contract psychiatrist provides monthly services for a period of two to three days at each visit and has been providing these services for five years in the Copper River region. 

 

Additionally, a neuropsychologist is under contract for the FAS/FAE program, as is a physician with a specialty in treating developmental disabilities. The latter two contract staff are funded through the FAS/FAE project. Clearly, there is some carry-over of these latter services to MH services, although they are not funded through the DMHDD grant.

 

As a Native association, CRNA has a single governing board.  However, since the last site review, the program has been successful in establishing an active advisory board with eight core members and additional members who represent related service agencies.  The eight core members are consumers, family members of consumers or elders.

 

The MH services provided are emergency services, out patient treatment (individual, group, family, couples), community support program for adults experiencing chronic mental illnesses, consultation and training. Dually diagnosed consumers can receive treatment within the same agency.  While Behavioral Health Services provides care to some 300 individuals during a typical year, there are fourteen MH consumers among this number who receive priority services as defined by DMHDD: ten adults and four minors.

 

Description of Process

 

The team of three met for three days in Copper Center, Alaska and conducted 22 interviews including interviews with 8 adult consumers of services, 2 minors who are consumers of services, 4 staff members, 1 Advisory Board member and 8 professionals who work for related agencies.  Interviews were conducted at the CRCMHC offices, in the community, in person and by phone and were from 10 to 60 minutes in duration.

 

Of the consumers interviewed, 7 were consumers chosen by the random selection process.  Two randomly selected consumers originally scheduled for interviews were not available.

 

The facilitator’s local phone number was advertised so that those not chosen for an interview and not able or willing to attend the Open Forum could provide the team with their perception of CRCMHC’s services.  An additional 3 consumers volunteered information to the team regarding their experiences with CRCMHC’s services.

 

The related agency staff members included professionals from the school, local housing authority, district court, juvenile probation, DFYS, Alaska State Troopers, the local pharmacy and a local physician. All agencies identified by the DMHDD regional coordinator were interviewed with the exception of DVR.  CRCMHC has not collaborated with DVR to date.

 

The facilitator also reviewed CRCMHC’s publications, two personnel files, the employee handbook, CRNA financial policies and CRNA personnel policies.

 

Open Forum

 

An Open Forum was held the first night of the review in order to provide an opportunity to community members and others who had not been selected for individual interviews.  The Open Forum was held at 7:00 P.M. at The New Caribou Café.  Refreshments were served.  The agency advertised the forum with posters.   No one attended the event.

 

 

FINDINGS

 

Progress Since Last Review

 

The last Integrated Quality Assurance Review of CRCMHC was conducted in June, 1999 and resulted in 17 areas requiring response.  Currently the consumer-centered review team does not review consumer files, therefore those areas requiring response that are related to files are reviewed solely in the case file review to be conducted by the DMHDD Quality Assurance staff.  In this report they are marked N/A.

 

  1. “Neither the governing board of CRNA nor the CRCMHC advisory board meet the standards for State funded mental health centers.  Document the balance of power and/or responsibilities of each board in regard to the MH program, empowering the advisory board to the extent possible; continue with recruitment efforts in order to fill board seats and strive for at least regular quarterly meetings.  (Standards #5, #6, #7, #8, #9)” The Advisory Board is meeting monthly, is providing consumer and community opinion to the agency and is dominated by members with direct knowledge of services.  Advisory Board meetings are open to the public and well attended.  Standard met.

 

  1. “Accessibility to the program and its services is somewhat limited.  Document attempts to provide equal access to all and seek low cost alternatives as possible.  (Standard #11)”  A ramp has been added to provide wheelchair access to the MH offices at considerable expense; there is an accessible rest room in the MH area.  Standard met.

 

  1. “Consumer involvement in program planning, evaluation and development is vital in light of the revised standards.  There is evidence that this is accomplished informally.  Create policy and document its implementation in regards to systematically surveying consumer opinion and incorporate that perspective into the program,  (Standards #12, #13, #14, #22)” A lively Advisory Board provides the agency with consumers’ points of view on programs, the quality of programs and on the need to develop additional programs.  The agency is currently researching appropriate survey instruments that will meet both state and federal requirements.  The proposed measurement tool will provide outcome data. A survey is not currently systematically applied.  Consumers evaluate the non-credentialed or paraprofessional staff but not credentialed staff.  Standard partially met.

 

  1. “Coordination of services with the area’s schools is not evident at this time.  Document these attempts to add the schools to the list of effective collaborations in light of the acknowledged need for services to the school-aged population.  (Standard #17)”  The work of the Safe Families coordinator enhances the work of the MH staff in this regard.  The school reports great satisfaction with the Safe Families’ communication with them.  The school requests additional guidance from MH staff as to how to respond to their students, who are receiving services, assuming a release of information can be provided.  Standard met.

 

  1. “Timely program information is not provided through systematic use of one or more management information systems.  Seek technical assistance with MIS reporting and document these attempts.  (Standard #18)”  The DMHDD Regional Coordinator reports that CRCMHC is in compliance with quarterly reporting requirements.  CRCMHC is also exploring integrated data collection for their entire Behavioral Health Services department.  Standard met.

 

  1. “There is no documentation of a policy regarding efforts to increase community participation of consumers.  Document the agency’s efforts in this regard.  (Standard #26)”  The agency provides a monthly trip to consumers during which they choose the places to visit for needed shopping, banking and other services.  The agency sponsors several community events in which consumers participate.  The Advisory Board is a lively forum for consumer participation.  Standard met.

 

  1. “Documentation of consumer involvement in the development of treatment plans and in the revision of treatment plans is uneven.  Standardize documentation of consumers’ involvement in treatment planning and the revision of those plans.  (Standard #27)”  N/A

 

  1. “No current Policy and Procedure Manual specific to the mental health program is available as it is under revision.  Complete revision of the Manual, making it specific to mental health services while relating it to CRNA policies as needed.”  The creation of a Behavioral Health Services model has been completed and a manual specific to those varied services is in the planning stages in collaboration with the University of Alaska, Anchorage.  CRNA policies are utilized for financial management and personnel policies.  Standard not met.

 

  1. “Services are reported by consumers as being received, yet are not documented in their file.  Systematize documentation of all services received by each consumer.”  N/A

 

  1. “Treatment plans are, in some cases, unchanged since 1995 although services continue to be offered.  Update all treatment plans in open files; systematize updating of all treatment plans as cases are reopened; systematize review and revision of treatment plans every 90 days.”  N/A

 

  1. “Acknowledgement of the consumer’s receipt of a copy of clients’ rights is not documented in all files.  Systematize use of this form and include the signed form in all open or new files.”  N/A

 

  1. “Treatment plans do not list specific goals and objectives, do not indicate measurable outcomes, and do not include all services being provided.  Seek technical assistance with the development of treatment plans.”  N/A

 

  1. “All but one consumer file reviewed lacked an assessment summary and none had assessments regularly updated.  Seek technical assistance on the preparation of and regular review of assessment summaries.”  N/A

 

  1. “CRCMHC staff and CRNA act as payee for certain consumers.  Develop and/or document a policy for the safe handling of consumer funds.  Consider using a neutral party rather than MH staff as payee.”  No alternative payee has been found.  Currently CRCMHC is a payee for five consumers who take varying amounts of personal responsibility for their funds.  Budgeting is part of the case management function.  Careful records are kept.  The consumer’s bank account can only be accessed by the signature of the client and of the case manager or administrator/clinician.  No consumer interviewed objects to this system of financial management.  Standard met.

 

  1. “The relationship of CRNA Human Services and CRCMHC, while beneficial to most consumers and to staff, is not clearly delineated.  It is unclear which services are available to all and which to a defined Native population.  With the Director holding positions in both areas, it is especially important to document the guidelines for and limitations on this relationship.”  Access to these services is carefully documented and this information is provided to consumers.  No consumer expresses concern about this.  Standard met.

 

  1. “Incomplete documentation inhibits billing, as does frequent changes in billing responsibilities.  Systematize billing in order to increase program income.” No concern is expressed about billing by the consumers.  Standard met.

 

  1. “The vast majority of clinical services are provided by one individual.  Seek a program design that allows for more equal division of clinical services.”  Program design has been enhanced and services are provided by a team.  Standard met.

 

 

                                                            Best Practices

 

The agency submitted two programs for consideration as “Best Practices” within the definition provided by the Quality Assurance Steering Committee.  The requirements for this designation are an inclusionary philosophy; placement that is non-categorical and age appropriate; intervention that is community-referenced with goals and objectives that are based on an assessment; systematic and data-based instruction and management; involvement of the family and of consumers in planning, implementation and evaluation and provision of families with access to needed information and training; that it can be replicated; that it has meaningful outcomes; that it is cost effective and that it involves community collaboration.  For the full text of these requirements, see the “Best Practices Checklist” attached to this report.

 

1.  The Copper River Native Association (CRNA) has developed an Integrated Behavioral Health Services Plan since their last site review.  This plan was developed in conjunction with the Institute for Circumpolar Health Studies and the Center for Alcohol and Addiction Studies at the University of Alaska Anchorage.  The purpose of this plan is to identify the behavioral health needs of those who may potentially utilize the services of CRNA, inventory current services, identify the gaps between needs and services, guide the integration of services and identify facility needs related to those services.

     In the opinion of the team, this plan for integrated services should be viewed as a best practice, although the plan has not been in place sufficient time to ascertain two requirements: outcomes and cost effectiveness.  Documentation will be provided to the Quality Assurance Steering Committee for their review.

 

2.CRNA has also submitted a proposal for a Comprehensive Service Plan for Families at Risk for Fetal Alcohol Syndrome in the Copper River Basin.  This plan was developed in conjunction with the Center for Alcohol and Addiction Studies at the University of Alaska Anchorage.  The purpose of this plan is to build on the existing Multi-Disciplinary Developmental Disabilities Team and provide training to families, community members and service professionals; provide ongoing screening and diagnostic services for at-risk families; provide prevention and intervention; provide direct care services; conduct ongoing research and evaluation.

     In the opinion of the team, this plan for intensive services should be viewed as a best practice, although the plan has not been in place sufficient time to ascertain two requirements; outcomes and cost effectiveness.  Of particular import is the provision of treatment services stressed in the plan.  This is not a plan that contents itself with identification and labeling.  Documentation will be provided to the Quality Assurance Steering Committee for their review.

 

In the opinion of the team these two programs are innovative to the extent that they view people as whole beings and provide for fluid interaction among substance abuse, domestic violence, mental health and social services.  These programs utilize a prevention model: primary, secondary and tertiary and a continuum of services from prevention to rehabilitation.  Further, these programs are a fine example of the bio-socio-cultural-psychological model in which respect for culture is preeminent.  The team applauds this holistic approach to services and feels that other agencies would profit from examining the work of CRCMHC and duplicating it.

 

                                                    Areas of Excellence

 

1.While not funded by DMHDD, CRCMHC provides fine, comprehensive case management services to MH consumers.  This is not the norm in rural Alaskan MH programs.  Cheryl Smith, case manager, represents the best of providers, one who generously presents a broad array of personalized support, information and guidance delivered in a respectful and compassionate manner.

 

2.Ed Krause, Director of Behavioral Health Services and clinician, “lives the values he believes in” and has developed a program based on his philosophy of respect for the individual in their cultural context.  Ed is neither confused nor deterred by shifting enthusiasms, shifting funding or shifting theories.  He perseveres.  And his staff and those they serve are the richer for it.

 

3.The enthusiasm, involvement and pragmatic approach of the Advisory Board is exemplary.  The Advisory Board serves to “train the agency” in the cultural and personal needs of consumers.  The core members of the Advisory Board are all consumers, family members of consumers or elders, all uniquely capable of guiding the development of Behavioral Health Services.  The Board enjoys direct contact with the Director and freely provides him with direction.  The Advisory Board provides constant, current evaluation of the agency’s programs.  The Advisory Board is involved in future planning, is committed to self-education, to review of current treatment literature and to increasing community involvement.  A long-time consumer and Board member states that the Board is “very organized, very steady.”

 

4.The team is impressed by the high degree of consumer satisfaction expressed by every consumer interviewed, whether volunteers or randomly selected consumers, despite their age, the type of service received, diagnosis or other variables.  Certainly, the variety of services and modalities provided enhances consumers’ experience with the program. The ingenuity, creativity and reality-based approach of clinician Adele Valenti should also be noted in this regard.

 

 

The Five Life Areas

 

Choice and Self Determination

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

+  Youthful consumers are provided both individual and group sessions.

+  Consumers are clear about their role in choosing treatment goals.

+  When consumer and provider disagree about a goal, the disagreement is acknowledged and worked through.

+  Consumers are clear that they have the right to be medicated or not, to choose the type of medication and to be fully informed about its effects.

+  Consumers choose the activities provided during the monthly trip: where to stop, where to eat, what to do, making these outings “fun trips.” -- consumer

+  Consumers can usually choose their counselor.

+  Consumers have the choice of a male or a female clinician.

+  Art therapy and play therapy are provided.

+  Consumers have been able to reduce their medication as the result of their therapy.

 

The team identified no weaknesses under Choice and Self-Determination for those receiving MH services.

 

Dignity, Respect and Rights

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

+  Consumers are well informed about medication and can exercise their right to be medicated or not or to change medications.

+  Consumers of all ages consistently describe their experience with providers as “comfortable.”  

+ “People here are real nice.” -- consumer

+  Consumers note that they have access to providers without waiting and often have access even if they do not have an appointment scheduled.

+  They treat me like a human being, not like a number.” – consumer

+ Consumers are aided in scheduling their time and reminded of key appointments with other providers, allowing for a continuity of care.

+  Consumers uniformly report knowledge of their rights and that their rights are respected.

 

The team identified no weaknesses in the area of Dignity, Respect and Rights for those receiving MH services.

 

Health, Safety and Security

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

+  Consumers are aided in keeping medical appointments with reminders and with transportation as needed.

+  Consumers have been aided in qualifying for disability payments and for Medicaid.

+  Consumers have been aided with energy assistance.

+  Consumers receive good education regarding their medication.

+  The contract psychiatrist provides services monthly.

+  A consumer has been aided through a mini-grant for dental care.

+  Coordination with the local housing authority results in safe, secure buildings where repairs are completed in a timely manner.

+  A local physician, the local pharmacist and the contract psychiatrist coordinate services routinely.

+  Consumers have been able to decrease the use of medication as they increase their skills through therapy.

 

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

-  Some consumers do not seem to be aware of the extent of case management services and so do not bring to the providers the full range of their needs.

 

Relationships

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

+  A consumer is routinely assisted in visiting a family member in another community.

+  Relationships and social skills may be the focus of treatment, as appropriate.

+  Youthful consumers are provided with social skills training as part of their group therapy experience.

+  The monthly trips for consumers allow for the practice of social skills.

+  Consumers are aided in developing and practicing assertiveness.

 

The team identified no weaknesses in the area of Relationships for those receiving MH services.

 

Community Participation

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

+ The monthly trip for consumers allows for greater participation in the community.

+  Consumers are offered volunteer opportunities.

+  Copper River Native Association sponsors many community activities in which consumers can easily participate.

+  Youthful consumers are able to attend the local public school.

+  The Director/clinician models community participation through his own extensive community involvement.

 

The team identified the following weakness in the area of Community Participation for those receiving MH services:

-  Some consumers, particularly those in outlying areas, remain isolated and need increased assistance to participate in activities.

 

                                                            Staff Interviews

 

+  Staff descriptions of the workplace at CRCMHC sound like a description of the Peaceable Kingdom.  Staff are happy and comfortable in their work setting.  Staff describe the “peaceful environment” and “nurturing environment” in which they work and their full assurance that “(The director,) Ed cares.”

 

+  Staff are clearly willing to go the extra mile for their coworkers and for consumers while maintaining proper, professional boundaries.

 

+  The addition of the case management position has improved services and provided for continuity of care.

 

+  The Director’s devotion to a consumer-centered philosophy pervades the agency and motivates the staff.

 

+  One employee describes the staff evaluation process as the best she has experienced in her many years of employment and Ed as the best director for whom she has worked.

 

                                                Interviews with Related Agencies

 

+  The District Court reports reduced recidivism among those juveniles referred to CRCMHC.

 

+  A local professional with twelve years experience in the area describes the current services at CRCMHC as “the best they’ve ever been.”

 

+  Another local professional reports markedly decreased hospitalizations in the area thanks to
CRCMHC, noting that many formerly hospitalized residents “essentially can be treated on an out-patient basis (now).”

 

+  A local professional states that CRCMHC “responds quickly” to suicidal ideation, suicidal gestures and suicidal actions.

 

+  “(CRCMHC) serves a very real purpose in our community (and I am) very appreciative of its being here in the community."

 

+  Another local professional notes CRCMHC’s “progressive ideas” and “innovative projects.”

+  While not funded by DMHDD, the team wants to note the numerous positive comments received regarding the work of Gaye Wellman, coordinator of the Safe Families project, and her ability to interact successfully with all related agencies to the benefit of consumers.

 

-Some regional agency staff state that CRCMHC provides services chosen by the consumer rather than adhering to the dictates of the related agency.  They feel that they, not the clinicians, should be in control of the case.  These comments account for some of the negative responses shown on the tally of related agency responses attached to this report.

 

                                         Administrative and Personnel Narrative

 

Community mental health centers must meet thirty-four administrative and personnel standards.  CRCMHC fully meets twenty-eight of those standards and partially meets the other six.

 

1. Standard #10 “The agency maintains policies and procedures for preventing and correcting conflicts of interest.”  There is a staff policy to prevent conflicts of interest and a CRNA policy to prevent nepotism.  Currently there is not a documented policy to prevent conflicts of interest for members of the Advisory Board although the Board feels it deals effectively with this.

 

2.  Standard #13  “The agency systematically involves consumers, staff and community in annual agency planning and evaluation of programs, including feedback from its current and past users about their satisfaction wit the planning and delivery of services.”  While the Advisory Board effectively represents consumer interests and facilitates community involvement, there is currently no systematic means of gathering this information.

 

3.  Standard #17  “The agency actively participates with other agencies in its community to maximize resource availability and service delivery.”  While most agencies are quite pleased with their interaction with CRCMHC, some agencies either need to be educated regarding the value of consumer choice and the consumer right to release or withhold confidential information or need to be invited to clarify their needs.  Otherwise, the agency’s commitment to consumer advocacy may be misinterpreted.

 

4.  Standard #22  “The organization has and utilizes a procedure to incorporate consumer choices into the hiring and evaluation of direct services providers, and to ensure that special individualized services have been approved by the family or consumer.”  Non-credentialed or paraprofessional staff are hired and evaluated with community and consumer input.  Currently, credentialed staff are not formally subject to this scrutiny although the Advisory Board is outspoken in presenting the consumer perspective on this and other topics.

 

5.  Standard #24  “The hiring process includes background and criminal checks (when appropriate) for direct care providers, personal and professional references and follow-up on references.”  The facilitator reviewed two personnel files.  Comments from references are documented in both files.  Background and criminal checks are limited to a review of the driving record.  Currently CRNA has an attorney researching and drafting a policy regarding these checks to comply with ICWA requirements.  The issue has been complicated by the cutback in Troopers who no longer will do the fingerprinting or background checks locally. 

 

6.  Standard #25  “The agency provides new staff with a timely orientation/training according to a written plan, that includes, as a minimum, agency policies and procedures, program philosophy, confidentiality, reporting requirements, cultural diversity issues and potential work related hazards.”  The agency does have a written orientation that includes policies and procedures, program philosophy and confidentiality.  Cultural knowledge is a requirement for hire.  There is not a specific review of mandatory reporting (which may differ for Native associations) nor is there a review of work related hazards.

                                                        Program Management

 

+  The Advisory Board provides active advocacy for consumers.

 

+  The Director enjoys the full support of the Advisory Board.

 

+  The Director’s style is consumer-centered philosophy in action.  His strong values and irrepressible enthusiasm create a positive, can-do work environment.  “Ed doesn’t take ‘no’ for an answer.  He finds a way.”

 

+  “Ed has a mission, not a job.”

 

+  The Behavioral Health Services program is an integrated, holistic approach to human services.

 

+  CRCMHC has successfully diversified their funding sources in order to support their integrated service approach.

 

+  CRCMHC takes a realistic and effective approach to the human service needs of rural residents.  This is based on an understanding of the cultural and life style values of those served.

 

+  CRCMHC is no longer plagued by high staff turnover despite the prevalence of this problem in DMHDD programs throughout the state.

 

The team notes the frustration of human service staff with the lack of understanding by regulatory agencies of the realities of rural needs.  Their description of this lack is compelling.  In the opinion of the team, CRCMHC has been successful despite the limitations of these regulatory agencies and presents a model for how rural services can be integrated and can result in high consumer satisfaction.

 

                                                   Areas Requiring Response

 

The team notes no faults in this program outside of the administrative requirements listed below.

 

1.  Develop a policy for the Advisory Board to prevent conflicts of interest.  Standard #10

 

2.  Systematize the survey of consumer, staff and community opinion in planning and evaluation.  Standard #13  (Prior and current reviews)

 

3.  Engage representatives of child service agencies in discussion and coordinate with them to avoid consumers experiencing the negative consequences of interagency conflict.  Standard #17

 

4.  Provide a means of utilizing consumer opinion in the hiring and evaluation of credentialed staff, possibly as a part of the proposed consumer survey.  Standard #22  (Prior and current reviews)

 

5.  Develop and institute a policy for the completion of background and criminal checks for direct care providers.  Standard #24

 

6.  Include in the employee orientation materials an explanation of reporting requirements as they relate to staff, a statement of the mandatory cultural knowledge policy and information on work related hazards.  Standard #25

 

7.  Develop a Policy and Procedure Manual specific to Behavioral Health Services to augment the more general CRNA policies. (Prior review)

 

Other Recommendations

 

The team feels that staffing, while it has increased in the last two years, is still not adequate to the intensity of services provided and recommends the addition of a clinician should funding allow.

 

 

 

 

Closing Note

 

The team wishes to thank Cheryl Smith for her work in scheduling interviews and gathering the documents necessary for the site review.  Her work reduced our work and we thank her for that.  Thanks also to all the staff of CRNA who cheerfully tolerated our comings and goings for three days and juggled room assignments to allow for our work to be completed.

 

The final draft of this report will be sent to Northern Community Resources for 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), Report Card (averaged), Best Practices Checklist

 

NCR 8/00