Northern Community Resources

P. O. Box 7034

Ketchikan, Alaska 99901

(907) 225-6355

FAX 225-6354

 

INTEGRATED QUALITY ASSURANCE REVIEW
 
Wrangell Community Services
March 19-21, 2001
Wrangell, Alaska

 

Site Review Team

Mike Curran, Community Member

Vickie Buness-Taylor, Community Member
Tom Rooney Jr., Community Member
Doug Veit, Peer Reviewer – Mental Health
Sarah Munn, Peer Reviewer – Developmental Disabilities
John Havrilek, Facilitator

 Robyn Henry, Facilitator

 

 

INTRODUCTION

 

A review of the mental health (MH) and developmental disabilities (DD) services provided by Wrangell Community Services (WCS) was conducted from March 19th to 21st, 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

Wrangell Community Services is a non-profit, community-based program incorporated in 1989. The agency provides MH and DD services to children, their families and adults who live in Wrangell and in some of the surrounding areas. The current population of Wrangell is between 1,900 and 2,000.  A six-member board of directors governs WCS. The agency employs 5 full-time and 27 part-time people.

 

The WCS MH program provides services to approximately 30 people including outpatient individual, family and group therapy, emergency services, psychiatric services, psychosocial rehabilitation and case management services. Services to children and youth include family support, counseling, peer helpers in the schools and wrap-around services.  

 

Through the agency’s Community Support Program the agency provides outreach, case management, employment/education and recreation services to adults diagnosed with a major mental illness and severe emotional disturbances.

 

The agency provides services to eleven individuals who experience developmental disabilities.  Services provided under the DD program include: case management, respite care, shared care and in-home support service.

 

Description of Process

 

An interview team consisting of two facilitators, three community members and two peer reviewers conducted this review and completed 45 interviews over a three-day visit in Wrangell, Alaska.

 

Nine interviews were with adults who receive mental health services. Three interviews were with parents of children who receive mental health services. Three interviews were with parents of children who receive DD services and five interviews were with adults who receive DD services. Ten interviews were conducted with related service professionals and 14 interviews were with program staff. One of the interviews was with a person who serves on the WCS governing board. The interviews lasted between 15 minutes and an hour and were held in person at WCS offices or by telephone.

 

The interview team members also reviewed five personnel files, the agency employee handbook, the program’s Policy and Procedure Manual and other administrative documents. After gathering the information, all the team members met to review the data and draft the report, which was presented to the administrative staff on the final day of the visit.

 

Open Forum

 

A public forum was held at the Wrangell Middle School at 7:00 P.M. on March 19th. WCS advertised the event by announcing it on the radio and posting flyers around town. There were four people in attendance at this meeting. In addition eight people requested and received individual meetings with team members. The opinions voiced during these contacts are included in the narrative.

 

FINDINGS

 

Progress Since Last Review

 

The following recommendations were identified during the January 1999 site review as areas that needed attention from the organization. Progress in these areas is noted:

 

1.  Board meetings need to be accessible to the community and should be advertised at least

     one week in advance.

     Progress: The agency now advertises the board meeting on the radio one week prior to the

     meeting.  Standard met.

 

2.  Consistently include service providers in the individual’s/family’s goal planning process and

     document the inclusion of all team members present, including signatures.

     Progress: As a practice the agency now includes related service providers in the service

     planning process, as appropriate, including representatives from DFYS, the school district and

     the addictions program.  Standard met.

 

3.  Include staff and community members in the development of an agency mission or value

     statement. (Standard #1)

     Progress: The agency has recently revised its mission statement and included staff and

     community members in the revision process.  Standard met.

 

4.  Involve staff in developing a system to revise job descriptions as new programs are

     developed and implemented. (Standard #20)

     Progress: The agency is currently in a process of revising all personnel job descriptions and

     has included staff member feedback in this process.  Standard met.

 

5.  Develop a uniform policy regarding information sharing between WCS and the hospital

     medical staff following crisis assessment.

     Progress: The agency currently has a MOA with the hospital and provides assessment and

     planning services when requested.  Standard met.

 

6.  Individualize training for paraprofessionals before placing to work with MH /DD

     consumers.

     Progress: Many staff reported that they felt that they had adequate training but others reported

     that they felt they would benefit from further training including in areas such as CPR, safety, and

     blood borne pathogens.  Standard partially met.

 

 

The Five Quality of Life Areas – Mental Health

 

 

Choice and Self Determination

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

+        Overall, people are very positive about the agency regarding the choices they have and state that the agency accommodates them in choosing providers and scheduling appointments. Several people noted the agency’s flexibility in providing services.

+        Most people report that they are included in the service planning process and that the goals on their plan reflect their needs and preferences. One person reports that “agency staff makes suggestions and I’m happy with that.”

 

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

-          Several people report that there is not enough planning for services and that plans sometimes fall apart or there is no follow through.

-          Many people express frustration with the psychiatrist’s schedule, indicating that he is not here enough and that appointments are not long enough.

-          Several people feel that the agency is accommodating, but services are often fragmented.

-          One person feels they don’t have enough information to make choices and is confused about how to make choices.

-          Several people said they feel that consumers are not getting enough vocational support and

      that programs focus just on maintenance rather than rehabilitation.

 

Dignity, Respect and Rights

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

+        Many people report that they feel their rights are respected and that their confidentiality is kept.

+        Many people really appreciate the work done by staff. One said, “Alice does a great job, responds quickly and always treats me with dignity. I like Alice.” Another said, “Sondra is careful with my feelings.” A third exclaimed “Very much so about all the statements about dignity, rights and respect. I’ve been here for years and I’ve always been treated with respect.”

+    One person expresses appreciation for the fact that billing is lenient.

 

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

-     Several people say they don’t trust or want WCS services because they feel that certain staff

    members breach confidentiality. One person reports strong suspicion of a staff member

    following an alleged breach of confidentiality when information from WCS was passed

    around town.

-     One person reports that they “felt victimized” by the agency because their spouse’s therapy

    took precedence over their own and it took many months for them to receive services.

-     One person reports that a related service provider came to their door to provide services as a

    result of a WCS referral.  This arrangement was made without their consent or prior 

    knowledge.

-     Several people feel “looked down on” and “talked down to” by WCS staff.

-     Several people feel WCS puts dollars before services.

-     There is concern that a lack of information and education are provided  regarding peoples’  

      rights.

-     Several people expressed a concern that the agency does not provide full disclosure of either

    program information or funds allocation.

-     One person suggests the need for window coverings in the waiting room to protect client

    confidentiality.

 

Health, Safety and Security

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

+        Most people report that overall they feel safe and that their health needs are being adequately met.

+        One person reports “I’ve been given lots of help with SSI paperwork; it made me feel very secure.”

 

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

-          Several people report the need for anger management courses including classes for those who are not court ordered.

-          One person reports that there is “too much shuffling across agencies. I don’t feel protected.”

-          One person indicates the need for a shelter for victims of domestic violence here in Wrangell. (community need)

-          One person reports “I’ve tried to get services and didn’t get them. Someone has dropped the ball at WCS.”

-          One person expresses concern for the safety of young children in school and indicates that there is a need for counselors in the elementary and middle school. They add “The principals and teachers can’t do it all.” (community need)

 

Relationships

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

+        Several people express their appreciation for the support they have received in their relationships. One person reported “I was helped a lot with parenting skills and I would like more help in relating to people.” Another reports “I was helped a lot in learning socialization and relationship skills.” A third reports “ They give me a lot of opportunity (for growth), the only hold-up is me.”

+        One person reports that therapy has been very helpful to them in understanding their relationship with their spouse.

 

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

-          Several family members report that their children need socialization skills training and don’t know why it isn’t provided.

 

Community Participation

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

+        Several people report that they are satisfied with this area of their life and that they do not want these issues addressed.

+        One person says they are encouraged by a staff member to get together with another person and they go out and do things together.

+        One person reports that they like to go to craft bazaars and school functions.

 

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

-          Several people express a concern for the lack of employment services and meaningful activities for people.

-          One person would like help with casual group relationships and socialization.

-          Team members notice a lack of WCS brochures and agency visibility in the community.

 

 

The Five Quality of Life Areas – Developmental Disabilities Program

 
Choice and Self Determination

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

+        WCS appears to involve consumers in choosing their own service providers and participating in the plan development. One person reports “Alice does her best to give us the services we want”. Another said, “The agency sends a provider based on what I need.”

 

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

-          One person reports a situation where they were told they would be receiving some equipment and it never happened, explaining, "sometimes the staff drops the ball.”

-          One parent reports that they are not able to get answers from staff to questions regarding Medicaid insurance.

-          Several people feel that consumers are not getting enough vocational support and that programs focus just on maintenance rather than rehabilitation.

 

Dignity, Respect and Rights

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

+        Overall, people feel they are supported and treated with respect. One person explained, “I feel very comfortable with my care coordinator.” Another said, “I feel if I ever have a problem I can go to my care coordinator and we work it out”

+        Several people express appreciation for staff support: “Alice makes every effort to help out and she is always on top of things”.  “I feel I could use their services anytime I need it” and “Marci helps out in every way”

+        Most people report that they are aware of their rights.

 

The team identified the following weaknesses in the area of Dignity, Respect and Rights for those receiving DD services.

-     Several people say they don’t trust or want WCS services because they feel that certain staff

      members breach confidentiality.

-     Several people feel “looked down on” and “talked down to” by WCS staff.

-     Several people feel WCS puts dollars before services.

-     Several people express a concern that the agency does not provide full disclosure of either

    program information or of funding allocation.

-     A concern is expressed that a lack of information and education is provided regarding

      peoples’ rights.

-    One person notes that there is no accessible parking for people with mobility problems

   because staff takes all the close parking spaces.

 

Health, Safety and Security

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

+        Several people express their confidence in the agency. One parent says the providers are well trained. Another says, “They are very careful of my child’s care and are very responsible”. A third exclaimed, “I will never move because of the great services I receive.”

+        One person expresses appreciation for support in meeting their basic needs. “WCS is helping me get my (vehicle) fixed so I can get around and they help me get food stamps.”

 

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

-          One family member expresses concern for the overall physical health and daily care of their loved one in the group home and that they have trouble accessing medical information about the client.

-          Team members notice that the group home appears to be overcrowded. (community need)

-          One person says it is difficult to get qualified staff to work with clients with complex medical needs.

 

Relationships

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

+        Most people report that WCS is very helpful in the area of building relationships.

+        A parent is very thankful for WCS’ arranging sign language classes to help them communicate with their child.

+        Several people report that they receive support on family relationships. One person reports that staff “helps me keep close to my family.” Another indicates that the agency helps the family use a sibling for respite services.

 

The team did not identify any weaknesses under Relationships for those receiving DD services.

 

Community Participation

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

+        Many people report that WCS staff is very supportive in getting consumers out in the community. One person explained “My respite provider goes out with me to eat a couple of times a week.” 

+        Providers take consumers swimming, to ball games, open gym and the teen center.

 

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

-          The team notices, and others comment on, the need for vocational skill building and placement activities for clients.

 

Staff Interviews

 

Fourteen staff were interviewed. All of the staff interviewed expressed a consumer-centered approach to their work with clients. Each person expressed a commitment to the organization and to providing the best possible services to their clients. Overall, the staff spoke highly about their work and were generally very satisfied with the organization.

 

Staff identified strengths of the work environment including open and supportive communication among staff, support with getting training and a positive evaluation process. Areas of need identified by staff include the need for training in family support, basic safety, CPR and blood-borne pathogens and the agency mission, the need for health insurance and retirement benefits and a chance to meet all other staff members.

 

Interviews with Staff of Related Agencies

 

Ten people from related agencies were interviewed. Agencies represented in the interviews included: DFYS, the local police, three people from the school district, the local hospital, the group home / respite program, Head Start, the court system, the Department of Corrections, and a physician. Overall the agencies spoke very highly about the program.

 

Identified program strengths included positive communication and case follow up, collaboration in working with families and the agency’s professionalism. One person expressed great confidence in the program, indicating the community’s mental health is in capable hands.

 

Three other people were very impressed with the director and expressed how much they enjoyed collaborating with him and WCS. Their collaborative efforts have resulted in a $675,000 grant with the schools over the next three years that will benefit every school-aged child in Wrangell.

 

Administrative and Personnel Narrative

 

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 27 of which are completely met by WCS. Those standards not fully met are:

 

1.       The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery. (Standard #12) The agency has a DD advisory board. In the past the agency has used a survey to get MH & DD consumer and family input, but is not currently doing this on a regular basis.

 

2.       The agency systematically involves consumers, staff and the community in annual agency planning and evaluation of programs, including feedback from its current and past users, and about their satisfaction with the planning and delivery of services.  (Standard #13) Aside from past surveys and the DD advisory board, there is currently no systematic means for involvement in annual planning and evaluation.

 

3.       The agency develops annual goals and objectives in response to consumer, community and self-evaluation activities. (Standard #14) Aside from past surveys and the DD advisory board, there is currently no systematic means for involvement in developing agency goals and objectives.

 

4.       The agency evaluation system provides performance appraisal and feedback to the employee and an opportunity for employee feedback to the agency. (Standard #28) The current evaluation format does not provide for employee written feedback to the agency.

 

5.       A staff development plan is written annually for each professional and paraprofessional staff person. (Standard #29) The current staff evaluation system does not include annual staff development plans.

 

6.       The performance appraisal system adheres to reasonably established  timelines (Standard #31). Of the five employee files reviewed, three had current evaluations on file.

 

7.       The performance appraisal system establishes goals and objectives for the period of appraisal. (Standard #32). The current evaluation system does not include a process for establishing goals and objectives.

 

Program Management

 

Judging from the number of people who either attended the public forum or requested private interviews, the review team feels there are a number of community members who currently feel disenfranchised from WCS. Several people feel that management staff are unapproachable and either stay behind closed doors or value degrees and licenses over the provision of good services.

It was further noted that, in talking with many of these people, they could very likely benefit from services and yet are not currently comfortable with the agency.

 

It appears to the team that WCS has limited staff to meet the obligations of the multiple services offered. WCS has been very innovative, but the agency may not currently be able to sustain the broad array of services it has so dedicatedly created. A return to basics and to those services WCS does well seems appropriate at this time.

 

Areas Requiring Response

 

  1. The agency needs to devise a process to actively solicit and carefully utilize consumer and family input in agency policy setting and program delivery. (Standard #12)
  2. The agency needs to systematically involve consumers, staff and community in annual agency planning and evaluation of programs, including feedback from its current and past users about their satisfaction with the planning and delivery of services. (Standard #13)
  3. The agency needs to develop annual goals and objectives in response to consumer, community and self-evaluation activities. (Standard #14)
  4. The agency evaluation system needs to provide an opportunity for employee feedback to the agency. (Standard #28)
  5. A staff development plan needs to be written annually for each professional and paraprofessional staff person. (Standard #29)
  6. The performance appraisal system needs to provide evaluations to all staff annually (Standard #31).
  7. The performance appraisal system needs to establish goals and objectives for the period of appraisal. (Standard #32).
  8. Provide additional training to staff on CPR, safety, blood borne pathogens and family support.  (Prior review)

 

 

Closing

The team wishes to thank the staff of WCS for their cooperation and assistance in the completion of this review. A process such as this can be very disruptive to the office environment and your hospitality was much appreciated by all of the team members.

 

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 30 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 sheets (averaged)