INTEGRATED QUALITY ASSURANCE REVIEW

Alaska Children’s Services

January 19, 2000-January 21, 2000

Anchorage, Alaska

 

SITE REVIEW TEAM:

 Kathy Ivy, Community Member

Rhea Ridley, Community Member

Dee Foster, Peer Reviewer

Robyn Henry, Facilitator

Connie Greco, DMHDD QA Staff member

 

 

INTRODUCTION

 

A review of Mental Health services provided by Alaska Children’s Services (ACS) was conducted from January 19 to January 21, 2000, using the Integrated Quality Assurance Review process.

 

The contents of the report is the summation of the impressions of the 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.  DMHDD Quality Assurance staff conducted the Clinical Record Review and provided that section of this report.

 

 

Description of Program services

Alaska Children’s Services operates as a non-profit corporation serving children and their families throughout Alaska. Mental health services provided by ACS include residential treatment, intensive residential diagnostic treatment (RDT) services, therapeutic foster care, home based case management and support services, and wraparound services.  Approximately thirty percent of the youth served by ACS are Alaska Native and another twenty percent represent other minorities.

 

A 23-member board of directors, who meets eight times a year, governs the overall corporation.  The agency employs approximately 180 full and part time people.

 

Description of the process

To conduct this review, an interview team consisting of a facilitator, two community representatives and a peer reviewer, conducted 29 interviews over three days in Anchorage, Alaska.  Fifteen interviews were conducted with clients who receive services from ACS including parents, foster parents, and guardians of children who have received treatment.  Nine interviews were conducted with related service professionals, one interview was with a board member, and four were with ACS staff.  Interviews lasted from 15 minutes to an hour and were held in person, at ACS's offices, in the community or by telephone.

 

The interview team members also reviewed 6 personnel files, the agency staff-training plan & schedule, the agency policies and procedures 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 agency staff on the final day of the visit.

 

During this same period of time a member of the DMHDD Quality Assurance Unit did a review of randomly selected client records.

 

 

Open Forum

 A public forum was held at the NAMI Alaska Meeting Room at 144 W. 15^th Ave. at 7:00pm on January nineteenth.  ACS advertised the event by placing an ad in the Anchorage Daily News and by posting flyers throughout the agency buildings.  Unfortunately, the address was misprinted in the newspaper ad.  No one attended the forum.

 

FINDINGS

 

Progress Since Previous Review

As this is the first review of ACS using the integrated quality assurance review process, there is no previous action plan based on these integrated standards.  A plan for improvement required for the chart reviews will be addressed separately in the DMHDD QA report.

 

Areas of Excellence

 The provision of Residential Diagnostic Treatment (RDT) Services: ACS is the only known program in the area that provides RDT services.  The program is funded through a separate state grant and is well documented.  Program staff provided the site review team with an overview of the program including detailed statistics on the program’s effectiveness for the 17 children who have been in the program.  Given the fact that early intervention is known to have a tremendous impact on later-life treatment effectiveness, the site review team was impressed with the agency’s willingness to provide this very needed service.

 

Choice/Self-determination

The team identified the following strengths under Choice and Self Determination for those receiving services from ACS

+    Most people interviewed said they felt they were very involved in the treatment planning process.

+    Several people interviewed said they felt they were given choices and options whenever possible.  One parent stated, “They gave us an option on everything they did for us.”

+    Most people interviewed had a high regard for the staff and their work with the families.  Staff were identified as being very caring and helpful, “a delight to work with.”

+    Many people interviewed said that the agency provided excellent case management and follow through services.

+    One parent complimented the agency in their thorough research and support to her when providing her with referrals when she moved out of state.

 

The team identified the following weaknesses in the area of Choice and Self Determination for those receiving services from ACS

-    Several foster parents indicated that they would have liked to have more history and information on the children they care for so that they can make informed choices regarding treatment.

-    Several people said that services were good when the child was in the treatment program, but that once the child was out of the program (dropped out, was discharged or was removed) services were dropped and that there was little or no after-care.  One person suspected that lack of Medicaid payments was related to the decline in services.  Another person stated “You don’t get options if you don’t fit into the (treatment) mold”.

-    At least two people indicated that services are not flexible enough especially when a crisis occurs.  Response time for immediate needs is inconsistent and expectations are high that the parent stick to the treatment requirements (attend all meetings etc.) - One person indicated that when differences of opinion occurred relevant to the treatment plan the professional's opinion usually prevailed.

-    One parent commented that there appears to be no services that meet his child’s needs.  His child has a dual diagnosis of FAS/SED and is now placed out of state. (system need)

-    Several families and professionals identified the need for more residential treatment services including foster care and respite homes and small group homes. (system need)

 

Dignity, Respect and Rights

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

+     People indicated that they felt respected by staff.

+    One person stated that the staff’s honesty about the severity of their child’s problems helped prepare her for his care.

+    One person indicated that she appreciated the fact that staff respected her authority as a parent during the team meeting

+    The program philosophy emphasizes the least restrictive environment with a focus on decreasing the use of restrictive treatment methods.

+    Several people who no longer receive services from the agency expressed a desire to have their children re-enter the programs with ACS.

 

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

-    Several people indicated that they were not clear about their rights, especially when multiple people were involved in the child’s life (i.e. foster parents/biological parents/guardians).

-    One foster parent said they didn’t feel they had any rights.  They felt they were in a contract they could not get out of.

-    One person said that they received only a delayed notification of a change in the child’s treatment plan.  Another person said they felt that the agency was hesitant to release information about their child.

 

Health, Safety, Security

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

+    Overall, people felt that the agency’s follow through with health and dental referrals was good.  One guardian said they were very pleased with the agency’s addressing the child’s medical and dental needs.

+    One person indicated that staff helped them create a safer home environment by suggesting ways to increase structure and discipline.

+    One person said they felt the staff provided good follow through with a child who was placed out of state, ensuring they were getting good treatment.

 

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

-    Provision of respite care varied.  Some people said the agency paid for care while others said they had to pay for respite themselves.  Several people said there was a need for increased respite care.

-    In several cases, safety issues were identified relevant to different family members – parent, child and sibling.  One foster parent said they felt they were forced to keep a child they thought was a danger to others in the home.  Another person indicated that they thought that staff did not take threats from the child seriously enough.

 

Relationships

The team identified the following strengths under Relationships for those receiving services from ACS

+    Activity therapy promotes positive relationships.

+    One guardian indicated that ACS “bent over backwards to connect the child to their support network” by making sure he got to visit with his siblings who were also in state custody.

+    One person stated that staff made a special effort for a child who did not have family by taking the child out on an activity when other residents were visiting with their family members.

+    The agency is willing to work with hard-to-treat children; one parent commented that the Jesse Lee home saved her child from being institutionalized.

 

The team identified the following weaknesses under Relationships for those receiving services from ACS

-    Many people said that their children did not have friends.

-    One person felt that a child’s visitation with family was often contingent on behavior.

-    One person said that friendships were discouraged in the residential treatment setting because children in that setting “use” one another.

-    One staff noted that activity therapy was contingent on parent/care giver being compliant with the treatment plan.

-    One parent suggested that in addition to offering foster parenting

classes, that the agency also offer parenting classes for biological

parents

 

Community Participation

The team identified the following strengths under Community Participation for those receiving services from ACS

+    Overall, people interviewed felt that they were seen by staff as having something valuable to contribute to the community

+    The community program appears to focus on community participation with a focus in linking families to other service providers and community activities.  Several parents indicated that their children were active in the community and staff supported this.

+    The agency appears to view services from the perspective of linking clients to a network of community providers rather then attempting to provide all services themselves.

 

The team identified the following weaknesses under Community Participation for those receiving services from ACS

-    Residential Services, especially RDT, appear to be highly structured and self contained with limited integration into the community.

-    Self-contained classrooms offer no opportunity for mainstreaming with other students and may impede academic progress (as substantiated by one employee interviewed)

-    Several foster parents cited problems within their neighborhood about having a SED child (NIMBY). (community issue)

 

Staff Interviews

The team interviewed 4 ACS staff, three selected by the agency.  The general overall feeling from staff was very positive.  Staff felt that they were very supported by the agency.  One person indicated that there was an open door policy from top to bottom.  Staff said they felt valued by the agency and supported through training and solicitation of their input in most aspects of the program.  One person also cited the two-way staff evaluation process as being very positive.  Overall staff seemed upbeat and dedicated to their jobs.  One staff member commented, “ You won’t get rich doing this job but it is rewarding”.

 

Collateral Agency Interviews

Nine people from collateral agencies were interviewed including representatives from the Anchorage School District, the Human Relations Clinic, Good Samaritan, ASSIST, DFYS, a private psychologist and a private psychiatrist.  Most of the feedback about the program was very positive.  One person commented ‘”I think it’s a great program.”  Another said “they make my job very easy.”  The agency’s focus on wraparound services was cited as a real strength by at least two people.  One person identified the collaborative relationship between them and the agency as a real strength, stating “of all the agencies I work with I have the best rapport with ACS.”  Another provider stated that he enjoys working with ACS more then any other service provider.  Several other people cited the professionalism of the staff as a real asset along with the fact that many of the staff have long histories with the agency.  Several people indicated that the agency has good follow through on referrals.  One person commented on the agency's willingness to address issues with parents when they arise.

 

Agency deficits identified by several people interviewed were in the area of communication.  They stated that it is often difficult to reach staff by phone and to get a timely response.  Two people identified the treatment team communication with the school staff as being inconsistent.  One person indicated that it would be helpful to have more advance work done with school personnel before the student leaves treatment and enters school.

 

Administrative/Personnel Narrative:

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 29 of which are completely met by ACS.  Those standards not fully met include:

 

1.      The agency’s governing body includes significant membership by consumers (DD, MH) or consumer family members (ILP), and embraces their meaningful participation. (Standard #6)  The ACS board member interviewed and at least one staff member indicated that there were no consumer-family members on the board.  Administrative staff indicated that as many as four board members have received services from this or other agencies.  Considering the fact that the board is large (23 members) and that overt representation of consumers is questionable, compliance with this standard is questionable.

 

2.      The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery.  (Standard #12)  Input from consumers of services is not directly solicited when making policy and program decisions

 

3.      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 with the planning and delivery of services. (Standard #13) )  Agency staff survey service users at treatment discharge and also annually survey foster parents.  Input regarding satisfaction with services from the perspective of all service users is not solicited on a regular basis or with regard to program evaluation.

 

4.       The agency develops annual goals and objectives in response to consumer, community and self-evaluation activities. (Standard #14)  This information is not sought from all service users, nor is there a scheduled collection of this data.

 

5.      The organization has and utilizes a procedure to incorporate consumer choice into the hiring and evaluation of direct service providers, and to ensure that special individualized services (e.g. foster care, shared care, respite care providers) have been approved by the family or consumer. ( Standard #22).  The staff hiring and evaluation process does not involve consumers.

 

 

CLINCIAL RECORDS REVIEW

(Conducted by DMHDD QA staff)

 

INTRODUCTION

The clinical chart review was conducted for the purpose of determining what information the agency needs to be able to generate documentation that reflects good clinical practice.  Another reason for the review was to conduct a mini-event audit for the Division of Medical Assistance (DMA) to determine that the services delivered are reflective of the services billed to Medicaid.  The charts reviewed were determined by a random sample taken from data supplied by DMA for Medicaid charts and the data received form the agency for non-Medicaid charts.  The team reviewed a total of ten (10) Medicaid charts and five (5) Non-Medicaid charts.  The number of Medicaid charts reviewed was determined by a Range Table based on the total number of cases billed in a period of one year prior to the review, as supplied by DMA.  Due to the small number identified, all of the non-Medicaid charts were reviewed.  The Quality Assurance file review consisted of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews.

 

STRENGTHS

Alaska Children’s Services was strong in all areas.  An overview of ASSESSMENT MATERIAL indicates that recommendations have been followed from the prior review and the assessments are very comprehensive  TREATMENT PLANS contain evidence that the treatment teams were well developed and provide good representation (signing and credentialing, consumer participation, and timeliness of treatment plans).  An overview of PROGRESS NOTES show that notes were good at documenting interventions and client’s response to the interventions.  An overview of TREATMENT PLAN REVIEWS indicates that reviews are consistently present in the file and that consumers and the entire team are participating in the process.  The treatment plan reviews meet or exceed requirements of the Integrated Standards.

 

AREAS FOR IMPROVEMENT

Alaska Children’s Services should make sure that a comprehensive ASSESSMENT is conducted by a Master’s level clinician annually.  The multi-axial diagnosis should be based on information contained in the assessment and that the diagnosis codes be included along with the written diagnosis.  There are a couple of optional suggestions that are being offered for your consideration.  Although the information is located in other areas of the assessment, it is suggested that an area for Summary of Problems and Recommendations for Services be included in the Comprehensive Assessment.  Your agency might benefit from eliminating the current SED Screening and including a paragraph in the assessment that speaks to eligibility.  Another consideration is the separation of the functional assessment component from the clinical assessment.  This is not an issue at this time, however it is anticipated that a Functional Assessment will be required to deliver children’s services in the future.  A functional assessment may be conducted by a paraprofessional, at less expense than the cost for a professional clinician to do a comprehensive assessment.  There are no recommendations for TREATMENT PLANS.  Overall, PROGRESS NOTES are good, however the filing system could benefit from a review.  Some notes were not in the correct order or were missing from the files.  There should be a review of the requirements for Crisis Intervention.  All Crisis Intervention services must be delivered by a Master's level clinician at a minimum.  There has been discussion in the past about bush communities and it was determined that a qualified clinician could deliver services by telephone if there was a paraprofessional assisting and following direction from clinician.  This was an exception for bush communities and does not apply to urban areas.  Another suggestion would be to specify which goal is being addressed at the beginning of the note.  Some programs already do this and it appears to help to keep the note focused.  The requirement is that the goal being worked on will be addressed in the note.  There are no recommendations for TREATMENT PLAN REVIEWS.

 

SUMMARY:

The supervisory staff who assisted in a review of the files is very vested in making sure that the documentation is strong and the staff is willing to evaluation suggestions and recommendations and this is a definite assess to the agency.  The charts indicate that the staff work diligently to provide good service to their consumers.  This agency has done extensive work on their documentation process.  It is understood that there may be reasons other than compliance with the Integrated Standards for the amount of charting being done, however it is noted that the chart documentation exceeds the requirements of the Standards.  The graph below depicts the findings of the clinical records review portion of the site-review.  The overall Statistical Summary score is 98.5%.  This score reflects Alaska Children’s Service’s excellent attention to documentation and recognition of the importance of documentation to the treatment process.

 

 

 

Program Management:

Overall, ACS seems to be a well managed program run by caring and energetic people.  The overall atmosphere of the agency is positive.  The organization’s personnel system is well organized, providing regular and timely feedback to staff regarding their job performance.  The organization’s policy and procedure system is thorough and appears to be updated on a regular basis.

 

Areas Requiring Response:

1.       The agency needs to increase its consumer representation on the governing board.  (Standard #6)

2.       The agency needs to develop a system to actively solicit and utilize consumer and family input in policy setting and program delivery.  (Standard #12)

3.      The agency needs to involve consumers, staff and community in program planning and evaluation.  (Standard #13)

4.       The input from consumers and families should be incorporated in the development of annual goals and objectives.  (Standard #14)

5.      The agency needs to develop a system to incorporate consumer choice and feedback in the hiring and evaluation of direct service providers.  (Standard #22)

 

Other Recommendations

 

1.        Continue to collaborate with school district staff on maintaining the highest academic standard appropriate for students in the residential programs ensuring that students receive equal access to standard academic opportunities.

2.        Refine and/or develop a process for educating parents, foster parents, and guardians about their rights relevant to their relationship with the child in services.  This process may have to be done on a case by case basis.

3.        Attempt to provide more information to foster parents so they can make informed choices.

 

Closing

The team wishes to thank the staff of ACS 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 prepared within 14 days and sent to DMHDD.  DMHDD will then contact ACS within 30 days to develop collaboratively a plan for change.

 

Attach: Administrative and Personnel Checklist; Questions for Related Agencies (tallied), Report Card (tallied)