INTEGRATED QUALITY ASSURANCE REVIEW

The ARC of Anchorage

January 10, 2000 to January 14, 2000

Anchorage, Alaska

SITE REVIEW TEAM:

Rich West, Community Member

Bertha Shimoe, Community Member

Ann Hutchings Community Member

David Maltman, Community Member

John Cannon, Wasilla, Peer Reviewer

Jeff Duncan, Anchorage, Peer Reviewer

Suzanne Price, Facilitator

Sherry Modrow, Facilitator

Connie Greco, DMHDD Quality Assurance Staff Member

INTRODUCTION

A review of the DMHDD-funded Mental Health (MH) and Developmental Disabilities (DD) Services provided by ARC of Anchorage was conducted from January tenth through fourteenth, 2000, 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. The peer reviewer and facilitator provided an informal review of consumer files during the site review. DMHDD Quality Assurance staff performed a mental health file review.

Description of Program Services

The ARC of Anchorage is a nonprofit organization providing support for individuals in Anchorage who experience disabilities. The following list of programs indicates the number of consumers or families served by each program in the past year. Individuals may be served by more than one program.

· Arctic Resource Center: 200

· CE/QL: 19

· Children’s Mental Health AYI/REY: 26

· Community Living Services: 90

· Community Support Network: 53

· Deaf and Hard of Hearing Center: 52

· Family Services; 193

· Family Support Project 375 families

· Student Living Center: 13

· Substance Abuse: 10

· Supported Employment: 29

· Supported Parenting: 5

The ARC of Anchorage has an 11-member board that includes a consumer and several people who are family members of consumers. The board sets policy and supervises the executive director. The organization employs approximately 100 full-time and 215 part-time staff members. The total agency budget is $11.5 million.

Description of the Process

The site review team met for the five day review in Anchorage. The team consisted of four community members, a peer reviewer for mental health programs, a peer reviewer for developmental disabilities programs and two facilitators. Team members conducted 59 interviews, as follows:

· DD: 15 consumers and/or family members

· MH: 10 consumers (6 children and 4 adults)

· 2 board members

· 29 employees:18 direct service staff, 11 program managers and executive staff

· 13 staff of related agencies which were, for MH: DFYS, Southcentral Counseling Crisis Response, Anchorage Center for Families, Alternatives, Whaley School, DVR and for DD: University Affiliated Programs, Anchorage Neighborhood Housing, Assets, Catholic Social Services, DVR, ACE/ACT (School District), Hope

The mental health consumers are all Medicaid-funded. Ten were randomly chosen for interviews. Of the DD consumers randomly chosen, seventeen were scheduled for interviews, however two did not arrive and the team was unable to contact them for telephone interviews. As a result, fifteen DD consumer interviews were completed.

Open Forum

The ARC of Anchorage planned and advertised an Open Forum for the evening of January eleventh. Notices were published in the ARC’s consumer newsletter, posted at ARC of Anchorage and distributed to other agencies. Six members of the site review team and seven parents of consumers attended. Topics included the availability and cost of recreation; lack of communication between staff/board and membership; growth and change of focus in programs and policies; difficulties obtaining and keeping direct care staff.

FINDINGS

Progress Since Previous Review (1996):

1. The team recommends that the substance abuse treatment facility and other facilities should be assessed for accessibility.

Action Taken: The facilities were assessed and modifications undertaken.

2. The team recommends that the agency make a stronger effort to include people with disabilities on the board and other policy bodies.

Action Taken: Several secondary consumers and a consumer who experiences a developmental disability sit on the board.

3. The team recommends that the agency board and staff leadership place a priority on adopting a program quality/consumer satisfaction survey, implementing it, analyzing the results, and fine tuning it.

Action Taken: This item is still under development.

4. The team recommends that the agency address the issue of continuity of service provision when turnover occurs.

Action Taken: This issue is unresolved; the agency is actively working to reduce turnover and to recruit appropriate staff.

5. The team recommends that residents of group homes have greater input into the selection of live-in staff.

Action Taken: This item has not been addressed and has been identified in the current site review as still needing to be developed.

6. The team recommends that the residents at Lionheart be involved in a discussion or series of discussions about the décor in the common household areas.

Action Taken: Appears to have been completed.

7. The team recommends that the program continue to find creative ways to expand people’s residential options.

Action Taken: This has been an on-going effort, with significant progress, including new housing and a new effort to develop ownership options is in development.

Choice and Self Determination

The team identified the following strengths under Choice and Self-Determination for people receiving DD and MH services from ARC:

+ People have meaningful choices about services. People recognize that they can receive services from the agency that best meets their needs.

+Advisory boards enhance people’s access to decision-making and direction of services.

The team identified the following weaknesses under Choice and Self-Determination for people receiving DD and MH services from ARC:

- Some families expressed needs for more information about how the system of supports works and how Medicaid waivers work.

- In developmental disabilities programs, case loads get shifted to different caseworkers as programs change through growth; families have little choice about caseworker reassignment.

Dignity, Respect and Rights

The team identified the following strengths under Dignity, Respect and Rights for people receiving DD and MH services from ARC:

+ Consumers perceive that they are treated with dignity and respect.

+ Many ARC employees have relationships with family or friends who experience disabilities.

+ The Arctic Resource Center is seeking methods to employ people with developmental disabilities

in its recreation programs.

+The ARC of Anchorage utilizes a system of random consumer satisfaction checks.

The team identified the following weaknesses under Dignity, Respect and Rights for people receiving MH and DD services from ARC:

- There appears to be inadequate attention to ensuring that people know how to address concerns or grievances.

- The primary focus of the agency seems to be to serve the DD population; insufficient attention is given to serving the deaf population and people with mental illness.

Health, Safety and Security

The team identified the following strengths under Health, Safety and Security for people receiving DD and MH services from ARC:

+ People in residential settings appear to have good supports for health and safety.

+ ARC sets high standards for care.

+ People expressed feeling safe in ARC residences.

+ Staff are well-trained in health and safety issues.

The team identified the following weakness under Health, Security and Safety for people receiving MH and DD services from ARC:

- Individuals who experience developmental disabilities and who demonstrate violent and aggressive behaviors pose a high risk.

Relationships

The team identified the following strengths under Relationships for people receiving DD and MH services from ARC:

+ The ARC of Anchorage fosters good relationships among people who receive services, families, friends and staff.

+ People at ARC talk about liking their jobs and they enjoy their work with consumers.

+ Individuals and families trust the people who provide care at the ARC.

The team identified the following weakness under Relationships for people receiving DD and MH services from ARC:

- The rapid growth of the agency has caused changes in personnel, creating a situation in which people sometimes don’t know whom to call or where to turn.

Community Participation

The team identified the following strengths under Community Participation for people receiving DD and MH services from ARC:

+ People who use services at ARC are active in community recreation and education.

Individualized supported employment is being developed for some consumers.

+ Art shows offer the community a new way to appreciate the skills and talents of people with

disabilities.

+ Recreational choices bring people into contact with the community at restaurants, sports

facilities, concerts, etc.

+ ARC staff encourage high levels of independence and mobility in the community. A staff member

reported using a consumer as a resource regarding People Mover routes and schedules.

The team identified the following weakness under Community Participation for people receiving DD and MH services from ARC:

- Consumers need to have community alternatives for safe, relaxed activities with peers. Some

people talked about missing the old recreation center where teens and adults could drop in and

hang out with friends.

Staff Interviews

The ARC of Anchorage has a strong reputation in the community and among its employees. Staff are committed to the people they serve and to their needs, as well as to the agency. They like their jobs. Consumer satisfaction is high. Staff display respect in their interactions with consumers.

Staff are loyal to ARC and dedicated to its mission. The number one focus is providing quality service. Everyone knows the mission statement; it is posted everywhere; they believe it.

“I believe in what this place is doing.” Staff member

Staff talk about and truly appear to enjoy working with the consumers.

“I love my job and I love the ARC.” Multiple staff members

The direct service staff respect and work well with their immediate supervisors but feel pressure from the rapid growth and changes within the agency.

“I wish the ARC would stop growing.” Staff member

“ARC has the potential to balance excellence in program delivery with excellence as a

business entity.” Staff member

People feel their mid-management jobs allow them creativity and autonomy, but several noted the lack of access to or involvement in budget and agency-wide planning.

“They trust me to do the right thing.” Staff member

Staff express feelings of being hurt and disappointed by changes that happen without adequate notice or explanation. Some mentioned the need for input into proposed changes; they would like to be involved and informed earlier.

“It appears that management does not understand the chain effect of decisions regarding

change down through all aspects of the ARC system.” Staff member

“There’s a greater gap now between upper and middle management than ever before.”

Staff member

“It appears that we have approached growth in a reactive way instead of proactively.” Staff

member

Some staff feel disconnected from the full agency decision-making process, or feel invisible.

“Separation between us and them is getting wider, because changes are not put forth in a

positive manner.” Staff member

Plans are currently underway to address and improve some areas of employee concerns. Examples include internal needs assessment surveys, inclusion of middle management in management meetings and implementation of new training plans.

Collateral Agency Interviews

Thirteen collateral agency staff were interviewed by the team, six from MH agencies and seven from DD agencies. Unfortunately, interviews were not scheduled with NAMI, juvenile justice, substance abuse providers, Native medical providers or tribal leaders. However, all of the collateral agency staff interviewed described ARC as client-centered.

Comments from related agency personnel included:

“I think ARC provides the best wraparound services in town.”

“They truly have the best interests of the kids (at heart).”

“The best bunch of people I’ve ever worked with.”

One concern regarding the recognition of the diversity of the population served was

“I would like to see people at the front desk be able to sign.”

Another concern voiced was that internal strife at ARC seems to be creating some problems and some confusion, such as getting different answers from different people in the agency.

Administrative/Personnel Standards

The Administrative and Personnel Checklist is included at the end of this report. It includes 34 items, 25 of which were completely met by ARC. Those standards not met or not fully met are:

1. Record keeping seems very good, however there are no policy statements concerning business practices, budget controls or state requirements. Standard partially met. (Standard #4)

2. Board meetings are technically open to the public, but they are not advertised or posted and it is reportedly not common knowledge when or where they are held. Standard partially met. (Standard #8)

3. There is no evidence of a written conflict of interest policy. Standard not met. (Standard #10)

4. Although efforts are in development, comprehensive collection and incorporation of consumer and family input does not appear to take place currently. Standard partially met. (Standard #12)

5. There is no evidence that the agency has a system of involving consumers, staff and community in agency planning. Standard not met. (Standard #13)

6. Annual agency goals and objectives were not apparent. Standard not met. (Standard #14)

7. Consumers are not systematically involved in the hiring or evaluation of direct service providers, other than respite. Standard partially met. (Standard #22)

8. Cultural diversity training is scheduled but has not been received to date. Standard partially met. (Standard #25)

9. The agency does not maintain written policies for disciplinary action. Standard not met.

(Standard #33)

Program Management

The unmet needs of consumers in the community drive ARC’s decisions to add new service components and the ARC’s good physical facilities and good financial condition allow the agency to respond to these unmet needs. Some of the recent changes have been positive and have contributed to the improvement of agency-wide systems, i.e. modernization and expansion of the main facility, development of a human resources department and reduction in case management loads.

The speed of growth and change appears to be outpacing the agency’s capacity for integration and the development of understanding and acceptance of new policies and procedures. Furthermore, the agency does not appear to be operating within a strategic plan that encompasses the current rate of growth and changes in program focus that may impact direct service. Agency management is cognizant of these issues and the Board of Directors will hold a Strategic Planning Retreat later in January.

Middle management supervisors are commended for responding quickly and appropriately to direct service staff’s requests for assistance and direction. On the other hand, ineffective and/or inconsistent communication was reported between executive management and staff which raises concerns about trust, loyalty and the isolation of groups or individuals.

As the programs provided by the ARC of Anchorage have diversified, the agency seems to the team to operate as if its primary mission were to serve people who experience developmental disabilities. Additional training in sensitivity to the diversified population would seem to be imperative, particularly as concerns the deaf population and people with mental illness. At the same time, Anchorage is experiencing great diversification in the cultural makeup of the community. Needed training in cultural diversity has not been provided, although it is planned for FY01.

Throughout the community, turnover and shortage of direct care staff result in gaps in service delivery. At the ARC, some effects appear to be:

- increases in family stress;

- feelings of helplessness when families do not have caregivers;

- perceived expectation by ARC that families need to accept workers when they can be found;

- some families talked about their experiences with direct care staff, who in their judgement seemed inappropriate, made serious errors in judgement and failed to assure adequate safety;

- agency funding concerns and perceived criticism of families when consumers do not utilize

full waiver funding or services

Mental health services and treatment planning are coordinated with mental health professionals and medical specialists in the community. Contracted services appear to be adequate for the mental health consumers served under the mental health grants. Outcome based measurements, however, do not appear to be a vital part of programming. (MH)

File Review Performed by DMHDD Quality Assurance 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 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 cases. The number of charts to be reviewed was determined by a Range Table based on the total number of cases supplied by DMA. The Quality Assurance file review consisted of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews. The team reviewed a total of five (5) Medicaid charts.

STRENGTHS

An overview of ASSESSMENT MATERIAL indicates that each year the assessments are better developed. An excellent feature of the current TREATMENT PLAN is that it contains a section for" those invited but unable to attend the team meeting" and often states the reason for their not being in attendance. The treatment teams listed in the charts that were reviewed were well developed and provided good representation (signing and credentialing, consumer participation, and timeliness of treatment plans). Frequency and duration and person responsible are dependably found in treatment plans. 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. An overview of PROGRESS NOTES show that notes were found in charts for all billings, dates and units are being included, and signing and credentialing,

AREAS FOR IMPROVEMENT

The ARC should make sure that a comprehensive ASSESSMENT is conducted by a Master’s level clinician annually. The multi-axial diagnosis in this assessment should be based on information contained in the assessment. It is recommended that the format of the TREATMENT PLANS be reviewed. Treatment Plans are currently based on service modality and the goal is focused on the use of the service. This limits the number of services to address a problem or requires that problems/goals be repeated when another service is needed to address the problem. It is suggested that the treatment plans address specific problems and then list the goals to address those problems in measurable and observable terms. The service modalities should be listed that will be used to meet those goals, as there could be several services used to address each goal. An overview of PROGRESS NOTES indicates that they are highly automated. Please be careful that you do not lose the ability to read the chart and determine what has transpired during the course of treatment. The progress notes are where the action that is taking place is usually documented. This is particularly noticeable at the ARC because there are no clinic services documented in the charts to provide this type of information. In TREATMENT PLAN REVIEWS, the greatest area of concern was formatting of the treatment review form. The form should reflect that it is a Review document not the Treatment Plan (which is reviewed periodically and rewritten annually). Effective 10/15/1998, the Treatment Plan Review is a separate document.

.

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. There are training needs surrounding documentation and a need to review some of the processes to determine effective ways to eliminate paperwork that is not essential. It is recommended that the agency review the Mental Health File Review Checklist that is located in the Integrated Standards Manual. All of the components necessary to comply with the Standards for Mental Health are located in this checklist. Once it is ascertained that current forms contain this information, training is recommended to ensure that the staff is completing the forms correctly. The Division of Mental Health and Developmental Disabilities Quality Assurance staff is available for technical assistance upon request.

Areas Requiring Response

1. The ARC needs to develop policy statements concerning business practices, budget controls and state requirements. (Standard #4)

2. Board meetings need to be advertised and posted. (Standard #8)

3. A conflict of interest policy must be passed by the board and included in a board policy manual. (Standard #10)

4. The team recommends that the agency board and staff leadership place a priority on adopting a comprehensive program quality and consumer satisfaction survey, implementing it, analyzing the results, and incorporating the recommendations. (Prior review and Standard #12)

5. The agency needs a system of involving consumers, staff, membership and community in agency planning. (Standard #13)

6. The agency does not appear to be operating within a strategic plan that encompasses the

current rate of growth and changes in program focus that may impact direct service. Setting

annual goals and objectives should be a priority. (Standard #14)

7. Consumers should be systematically involved in hiring and evaluating direct service

providers. (Prior review and Standard #22)

8. Cultural diversity training should be developed in concert with agency-wide training plans.

(Standard #25)

9. The agency does not maintain written policies for disciplinary action. (Standard #33)

10. The agency needs to secure confidential records left in agency resident facilities. (AS

47.30.590)

11. The agency should continue to address the issue of continuity of services when turnover

occurs. (Prior review)

Additional Recommendations

1. The agency needs consistent and accessible means for consumers to know about

scholarships, fee waivers and sliding fee scales.

2. Some families expressed needs for more information about how the system of supports works

and how Medicaid waivers work. Seek to provide this information.

3. Case loads get shifted to different caseworkers as programs change through growth; families

have little choice about caseworker reassignment. Consider consumer choice when changes

are inevitable; plan for transitions when reassignment is necessary.

4. The speed of growth and change appears to be outpacing the agency’s capacity to adequately

incorporate changes in a healthy manner for staff and consumers. Staff members need a

process to allow integration and the development of understanding, and acceptance of new policies and procedures. Seek to improve the management of change.

5. The ARC’s ability to respond to community needs is one of the agency’s strengths. The team recommends that such responses would benefit from a strategic plan dealing with internal issues related to growth. The team formulated these questions: Is there a comprehensive view of community needs? At some point, is the quality of service at risk of being impaired by the constant demands of unplanned change?

6. Rapid growth seems to be inherent in the current program delivery system and external environment. We encourage and support the agency in recognizing this and recommend the agency develop mechanisms to help decrease the potential for negative impact of such rapid growth and change. Growth already has caused continual changes in personnel, creating a situation in which people sometimes don’t know whom to call or where to turn.

7. The agency should develop a comprehensive policy and procedures manual covering fiscal, board, clinical practice, as well as personnel and conflict resolution.

8. Outcome based measurements do not appear to be a vital part of programming, as required in

the guidelines: Mental Health Standards and Practices. Consider the development of outcome

based measurements. (MH)

9. Individuals who experience developmental disabilities and who demonstrate violent and aggressive behaviors pose a high risk; the ARC of Anchorage and the community of Anchorage need to develop a planned response for this population in conjunction with other service provider agencies.

10. Lack of effective communication between executive management and staff raises internal concerns about trust, loyalty and isolation of groups or individuals. Seek to improve internal communication.

11. As part of a strategic focus for management, maintaining positive relationships throughout the

agency takes on increased importance during times of rapid growth and change. People feel

their mid-management jobs allow them creativity and autonomy, but several noted the lack of

access to or involvement in budget planning. Consider how to inform and, if appropriate,

involve mid-management staff in budget and other planning.

11. The ARC needs to post the client bill of rights and implement procedures that ensure all

consumers know how to address concerns and utilize the agency grievance procedure.

13. Some people talked about missing the old recreation center, where people could drop in and

hang out. There are limited community alternatives for safe, relaxed activities with their peers.

Consider how to expand these opportunities.

14. Several families talked about the expense of using the Arctic Resource Center, and said they

were unaware of State or other kinds of assistance available for individual payment. Consider

how to best keep families informed regarding the availability of financial assistance.

15. Service provider agencies, including the ARC of Anchorage, report difficulties with the

development of natural supports in the Anchorage area, supports that might partially replace the

need for paid supports to help individuals participate in the community. We recommend

continued work in utilizing natural supports; staff training at all agencies should incorporate

creative methods to help consumers make friends and utilize natural supports.

Special Note:

Agencies report a need for advance notice of state quadrant draws and the effect those draws will have on services. The team recommends the State of Alaska examine this and develop a more strategic and planned method for releasing new funding when it is available.

Closing

The site review team wishes to thank everyone at the ARC of Anchorage who helped with the quality assurance site review. The food was great, and the cooperation of management, consumers and staff in making themselves available made this a productive review.

This report will be finalized within seven days and forwarded to DMHDD. ARC should expect to receive the final report after an additional 30 days. ARC and DMHDD will collaborate on responding to the action plan.