INTEGRATED QUALITY ASSURANCE REVIEW

ALASKA YOUTH AND PARENT FOUNDATION

February 1, 2000 - February 3, 2000

Anchorage, Alaska

SITE REVIEW TEAM:

Gail Igo, Community Member

Bernadine Janzen, Community Member

Suzanne Price, Facilitator

Pam Miller, DMHDD Quality Assurance Staff Member

INTRODUCTION

The Site Review Team reviewed DMHDD-funded Mental Health Services provided by Alaska Youth and Parent Foundation (AYPF) from February 1 through 3 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. DMHDD Quality Assurance staff participated in the review process by reviewing the mental health files.

Alaska Youth and Parent Foundation provides limited Mental Health services. The agency was founded in the 1970’s as an organization dedicated to advocacy for youth. Their primary mission has been to serve at risk teens by providing shelter, referral and advocacy. AYPF has short- term residential programs; electronic monitoring services; street outreach for teens; partnering for outreach health care; AYI programming (long term); and Mental Health services for emotionally disturbed (ED) and severely emotionally disturbed (SED) youth and children. Mental Health and AYI programming are a very small part of their services. Major funding sources include DFYS, the Department of Juvenile Justice, municipal funding, United Way and Federal grants. Mental Health provides therapeutic services for 1-5 children at any given time while the total number of shelter beds is 26 at three different sites. Approximately 50 full and part time staff, emphasizes responsibility, personal choice and reconnecting young people with their families. In FY 2000 the agency’s budget is approximately $1.5 million. The agency is governed by a 9-15 member Board of Directors. There are currently 6 seats occupied and recruiting is underway to fill the empty seats.

DESCRIPTION OF REVIEW

Three team members conducted this review in 3 days. The review team’s Peer Reviewer was absent due to illness. Three interviewers conducted fifteen interviews with 3 related service providers, 1 Guardian Ad Litem, 5 staff members, 3 consumers & 1 consumer foster parent, 1 Board member, and 1 consulting Mental Health Professional. The interviews lasted from 30 to 60 minutes and were conducted at the AYPF offices or in the offices of the collateral agencies involved.

The initial teleconferences for the purpose of planning this review were held on January 6 & 7, and included DMHDD regional staff, Pam Miller & John Bajowski, review facilitator Suzanne Price and AYPF Executive Director Sheila Gaddis. At that time (and in a subsequent letter), the team requested that interviews be scheduled with 5 consumers, consumer family members, guardians, direct service staff, board member(s), advocates, and community agencies. These agencies were to include the school district psychologist, DFYS, NAMI, Disability Law Center, Dept. of Corrections, consulting Mental Health Professionals and other providers such as South Central Counseling. When the team assembled on the first day of the review, the agency had scheduled 3 collateral agency interviews and 1 Mental Health Professional interview. The team requested additional interviews to include: consumers, consumer families and staff and one consumer and one foster parent were scheduled as well as 5 staff. At John Bajowski’s request the following day, 2 additional consumers were scheduled for day two. Two young consumers were interviewed together at their request. Although the staff was helpful and very cordial, they did not prepare a schedule for the review as requested by the facilitator. Therefore, a less than comprehensive review became more difficult and less encompassing.

OPEN FORUM

The agency was asked to schedule this event for the first night of the review or during lunch of day one or two. The team was informed that the Open Forum would be held day one from 5:30-7:00PM. No one attended. The facilitator was given a copy of the newspaper ad the agency ran to advertise the Open Forum. It was actually scheduled for day two of the review from 6:30-8:00PM. The facilitator returned to the site but again no one attended. No notice of this meeting was apparent in the building. The facilitator and one Community Member checked the doors and bulletin boards for signs or notices and found none. Weather related problems might well have been a factor as weather forced the closing of the schools for two days during the review.

FINDINGS

Progress Since Previous Review:

No previous Mental Health Review has been conducted.

Choice and Self Determination

The team identified the following strengths under Choice and Self-Determination for people receiving Mental Health services from APYF:

+ Consumers feel comfortable identifying their choices and goals.

+ Consumers feel that they can participate in problem solving with staff.

The team identified the following weaknesses in this area:

- Children are often placed in care and do not always live with families. (System-wide issue)

- Children are unaware of treatment plans or do not feel like part of the process.

“ I see my treatment plan when my counselor asks me to sign it.

Dignity, Respect and Rights

The team identified the following strengths under Dignity, Respect and Rights for people receiving Mental Health services from AYPF:

+Children and Foster Parents feel respected and valued by the staff.

“ The agency has an open door policy and is always willing to listen “

+ Children do seem to understand their rights.

The team identified the following weaknesses in this area:

- Consumers seem unaware of a document called the Consumer Bill of Rights.

Health, Safety and Security

The team identified the following strengths under Health, Safety and Security for people receiving Mental Health services from APYF:

+ Consumers feel safe in their homes.

+ Consumers have adequate resources and their basic needs met.

The team identified the following weaknesses in this area:

- Direct staff training is weak for the complex issues surrounding treatment of SED youth

- Placements and timing of placements do not evidence concern for the child.

“DFYS only cared about how fast they could get this kid out of the hospital.”

Relationships

The team identified the following strengths under Relationships for people receiving Mental Health services from APYF:

+ Consumers have meaningful relationships.

“ I get to talk to my mom everyday.”

“Kristen is really nice and listens to me.”

The team identified the following weaknesses in this area:

- Natural support building for consumers is needed.

Community Participation

The team identified the following strengths under Community Participation for people receiving Mental Health services from APYF:

+ Consumers participate in community activities and events.

+ Consumers attend school daily.

The team identified the following weaknesses in this area:

- Consumers believe that staff is sometimes too tired to take them anywhere.

- Transportation to activities or events is not always available.

Staff Interviews

Five staff members, one Board Member, and one consulting Mental Health Professional on contract with the agency were interviewed. Without exception the staff were excited and articulate about their roles within the agency. They are a team and relate their confidence in the agency and its mission with pride. They feel encouraged, supported and valued. “I owe a lot to this agency”. “ I feel that I’m able to learn from my mistakes”

Three direct service staff and two administrators were interviewed. Each were familiar with the Board of Directors, had been to a Board meeting, and expressed an understanding of the changes and goals planned for the agency. They have input into program enhancement and are treated with the same dignity and respect that they are expected to exhibit with consumers.

Staff felt that they could effect change and when problems surface they report open communication. “ If I have a problem with a program, I go to the program coordinator and we work it out.” Problem solving and program planning are accomplished through regular staff meetings; supervision and a unique format called “Lunch with a Purpose”.

The staff seem to understand budget issues and appear to work together to find ways to fund new projects. They report feeling supported in their efforts to try an innovative approach. “ I’m not afraid to fail here. I’m encouraged to try new things”.

The interviewee’s discussed the changes within the agency in a positive and constructive manner. However, they also reported feeling that training had not kept pace with the changes, especially in the area of Mental Health services. Many of the staff are young and energetic and express an interest in furthering their education and training. The Executive Director fosters this motivating belief in education.

The staff reports that they like working at AYPF, feel they are given creative latitude and opportunities for growth. “We’re like a family serving families.” “ The staff are committed, helpful and idealistic.”

Some difficulty was noted in the agency’s challenge to transition from their traditional role as an advocate for teens to treatment planning for SED children; from strictly short term transitional housing to longer term care for the AYI consumers; and from problematic teens to SED children. The agency is working to keep pace with some of the dramatic changes and growth.

Collateral Agency Interviews

The team interviews included three representatives of area agencies: DFYS, Juvenile Justice and the public school system. The summary of the responses to the uniform questions is attached at the end of the report.

It is noteworthy that each representative interviewed remarked that AYPF staff members are committed to their mission and respectful of consumers and other agency staff. “ They really care about kids.”

“ The monitor Program is wonderful and Denise is excellent in following-up.” These interviews, without exception, spoke to the improvements in agency staffing, programming and communication in the last 6 months.

Provider concerns included:

1. High turnover in staff.

2. Better screening needed when hiring direct service staff.

3. More specialized training in mental health (SED & ED).

Administrative/Personnel Standards

The Administrative Checklist is included at the end of this report. It includes 34 items, 19 of which are completely met. Seven standards are partially met.

1. The inclusion of consumers or consumer family members on the board. The board is currently recruiting new members to fill empty seats. ( Standard #6)

2. Board meetings are open to the public. While staff knows about board meetings, no advertising for the public, or notices of meeting times is evident. (Standard #8)

3. Facility accessibility. The main office building is accessible but two of three residential sites are not ADA retrofitted.(Standard #11)

4. Agency solicits input and carefully utilizes data in agency policy and program delivery. While the agency solicits input from consumers and families there is no formalized procedure for utilizing this information.(Standard #12)

5. The agency systematically involves consumers, staff and community in annual agency planning and evaluation of programs. The agency solicits this input and appears to value and use such information but no formal policy or procedural mechanism exists to record or utilize input in a systematic way. ( Standard #13)

6. The agency uses consumer input to develop annual goals and objectives. There is no evidence of this occurring. (Standard #14)

7. Adequate staff training, experience, education and supervision. While basic training and orientation to the agency is adequate, specialized training for Mental Health services is not evident. Supervision is provided by the agency and staff are encouraged to seek additional education (Standard #19)

8. Review and revision of job descriptions. This in fact takes place during the annual staff evaluation but no policy or procedure is evident to explain the process. (Standard #20)

9. Consumer involvement in hiring and evaluating direct service providers. There is some evidence of consumer choice, but none addressing policy or procedures are evident. (Standard # 22)*

10. The agency provides a timely, comprehensive employee orientation. The agency has an excellent orientation package; they appear to value cultural diversity as part of their philosophy, but they offer no formal training in cultural diversity or sensitivity. (Standard #25)

11. Policy and Procedures to facilitate community volunteerism. Although the agency does a commendable job of recruiting volunteers and interns, they have no policies or procedures formalized.(Standard#26)

12. Annual staff development plan. This process is not delineated clearly in the annual evaluation documents.(Standard #29)

13. Agency identifies resources to meet training needs. While the staff are encouraged to attend training and identify resources, no formal system is evident to locate special needs.(Standard #30)

14. Performance appraisal system adheres to timelines. The employee policy manual states that evaluations will be held twice a year, while employees report evaluations once a year. New human resource guidelines and personnel management seems to be correcting small inequities. The agency has recently hired an experienced and knowledgeable manager who is currently reviewing the procedures.(Standard #31)

15. Performance evaluation appraisal system establishes goals and objectives. No evidence of formal procedure found but new manager is reviewing procedures. (Standard #32)

Further, the team suggests that the agency needs to develop policies concerning evaluation and research, as well as a formal quality assurance policy and procedures. Also, the agency has not conspicuously posted the Client Bill of Rights.

* DMHDD recognizes that the standard of including consumer and family opinion in the hiring of staff may not be applicable to all agencies/programs serving mental health populations. If you feel this standard does not apply to your agency or a specific program, please explain on the submitted Plan of Action.

Program Management

It should be noted that compliance with these standards for community mental health centers in Alaska has been approximately 60%. AYPF is a limited Mental Health provider and this is their first mental health review. Their level of compliance is excellent given these precursors.

AYPF has recently hired staff that has expertise in human resources, clinical practice and supervision. Collateral agencies, staff and consultants have reported improvements in a variety of areas.

It should also be noted that AYPF receives funding from DFYS and often is compelled to adhere to DFYS mandates and/or instructions, even when they disagree. Follow-up or documentation for exit information can be difficult or impossible because DFYS cannot or will not give out forwarding addresses, or information concerning outcomes.

The following system-wide concerns face the community and affects the care provided by AYPF:

1. Children are often placed in care by the state and do not always live with families.

2. Placements and timing of placements, seem to often lack concern for the child, but instead are

based on expediency.

3. Difficulty hiring and retaining qualified staff in a growth economy.

4. The State has no continuum of care plan for high-risk kids past the 30 days in the shelter.

5. There are no adequate respite services for Foster Parents.

6. There is a reported lack of information passed to Foster Parents.

7. Past the 30 days in the shelter, a child can be “bounced” back and forth from the shelter

to foster care.

File Review

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 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. A total of seven Medicaid charts were reviewed. There were no non-Medicaid charts to be reviewed.

STRENGTHS

The overview of the comprehensive assessments proved to be the strongest area of documentation reviewed. They are well developed and provide good documentation of diagnosis, mental health problems and treatment recommendations. All assessments reviewed were current and present in the files. This agency has done an excellent job in meeting the Integrated Standards for assessments. The treatment plan has all of the necessary components of a strong treatment plan, including signatures of the consumer or their guardian. An overview of progress notes show that notes are consistently found in charts for billings. There is evidence that treatment reviews are occurring for those clients who receive services on a more long-term basis. These documents generally address progress towards goals and make recommendations to modify treatment or continue as is. The progression of improvement in this agency’s documentation is evident.

AREAS FOR IMPROVEMENT

The only suggestions for refining the comprehensive assessments are to be more specific in the identification of mental health problems and recommendations for treatment, and make clearer statements regarding the child's eligibility for the services they are receiving. The current treatment plan format needs to improve the designing of goals to be measurable/ specific/achievable and prescribing frequencies of services. Progress notes need to consistently identify the service modality being delivered and the specific goal being addressed as identified on client’s treatment plan (including group notes). Staff interventions need to be clearly documented. Clinically relevant information needs to be recorded. Other components that are required to be documented on the note are the amount of time spent delivering the service and a signature that includes credentials (or job title) and date. Please refer to the Integrated Standards for further information on progress notes. The number of notes reviewed indicated the possibility of under utilization of Medicaid billing in some instances. The agency appears to be using AYI Quarterlies and Case Reviews as their treatment plan reviews. While these documents partially met the Standards, they did not meet the standards fully. Please refer to the Integrated Standards for further information on the requirements for treatment review documents.

RECOMMENDATIONS:

The Division of Mental Health and Developmental Disabilities Quality Assurance staff is available for technical assistance upon request. DMHDD recommends an agency wide training for direct service staff that focuses on the documentation of progress notes.

Areas Requiring Response

1. Seek to include consumer, parent or guardian representation on your governing board. (Standard #6)

2. Advertise the opportunity for the public to attend board meetings. (Standard #8)

3. Investigate the possibility of increasing accessibility to all facilities. (Standard #11)

4. Formalize a procedure for incorporating consumer and family input into the development of policies and the delivery of programs. (Standard #12)

5. Formalize a procedure to record and utilize the input of consumers, family, staff and community members in the planning and evaluation of programs. (Standard #13)

6. Formalize a procedure to utilize consumer and family input into the development of annual goals and objectives. (Standard #14)

7. Seek additional specialized training for staff in mental health services. (Standard #19)

8. Formalize a policy for incorporating the review and revision of job descriptions. (Standard #20)

9. Formalize a policy for including consumer and family opinion in the hiring and evaluation of direct service providers. (Standard #22)*

10. Provide training in cultural sensitivity. (Standard #25)

11. Formalize procedures for facilitating community volunteerism. (Standard #26)

12. Include as part of the annual evaluation of staff a staff development plan. (Standard #29)

13. Seek to designate or locate resources to aid in the cost of staff training plans. (Standard #30)

14. Include timelines in the annual staff evaluation and development plan. (Standard 31)

15. Include goals and objectives for the next evaluation period in the staff evaluation process. (Standard #32)

* DMHDD recognizes that the standard of including consumer and family opinion in the hiring of staff may not be applicable to all agencies/programs serving mental health populations. If you feel this standard does not apply to your agency or a specific program, please explain on the submitted Plan of Action.

Other Recommendations

1. In the next review, it would be helpful to have the agency carefully review the pre-review teleconference and letter. They are encouraged to contact the State or their contractor should there be any questions. This would allow the review team the opportunity to more adequately process the information in the limited time of the visitation.

2. The agency should continue in its efforts to recruit, screen and adequately train new staff, with

additional attention to the needs of SED children and youth.

3. Consider the manner in which staff turnover might be reduced.

4. Establish policies regarding evaluation and research.

5. Establish policies regarding an internal quality assurance process.

6. Conspicuously post client rights.

Closing

The site review team wishes to thank everyone at the Alaska Youth and Parent Foundation who helped with the quality assurance site review.

This report will be finalized within 7 days and forwarded to DMHDD. AYPF should expect to receive the final report within 30 days of DMHDD’s receipt of the report. AYPF and DMHDD will collaborate on creating the action plan for making needed changes.