INTEGRATED QUALITY ASSURANCE REVIEW

Alternatives Community Mental Health Center

February 22-25, 2000

Anchorage, Alaska

 

SITE REVIEW TEAM

Angela Camos, Community Member

Corey Knox, Community Member

Chris Haskell, Peer Reviewer

Bill Doherty, Peer Reviewer

Robyn Henry, Facilitator

Connie Greco, DMHDD QA Staff member

Pam Miller, DMHDD QA Staff Member

 

 

INTRODUCTION

A review of Mental Health (MH) services provided by Alternatives Community Mental Health Center was conducted from February 22^nd to February 25^th, 2000, using the Integrated Quality Assurance Review process.

 

This 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

Alternatives is a non-profit community mental health center providing outpatient services to adults, children and their families who live primarily in the Anchorage bowl area. The MH services provided by Alternatives include individual, family and group therapy; psychiatric evaluations; medication management; crisis intervention; case management. Through their DayStream program the agency provides an intense combination of activity and group therapy to improve the life skills of children experiencing behavioral and emotional difficulties.  As part of the agency’s Transitions Program, Alternatives provides case management, youth and family counselor support, and home based therapy. The agency also administers a therapeutic foster care program. Alternatives serves an average of 180 consumers each month.

 

A seven-member board of directors meets monthly and governs the overall corporation. The agency employs approximately 100 full and part time people.

 

 Description of the process

To conduct this review, an interview team consisting of a facilitator, two community representatives and two peer reviewers conducted 42 interviews over four days in Anchorage, Alaska. Client interviews, which included parents of children and adults who receive services, were determined from a list of 80 randomly selected clients. Of the people successfully contacted from that list, 23 were scheduled for interviews and 12 actually spoke with team members. Seventeen interviews were conducted with related service professionals; three interviews were with board members; ten were with Alternatives staff. Interviews lasted from 15 minutes to an hour and were held in person, at Alternatives’ offices or by telephone.

 

The interview team members also reviewed five randomly selected personnel files, the agency staff-training plan, the agency policies and procedures manual, the agency annual report 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, two members of the Division of Mental Health and Developmental Disabilities (DMHDD) Quality Assurance (QA) Unit did a review of randomly selected client records.

 

Open Forum

 A public forum was held at the Loussac Public Library in Anchorage at 7:00 PM on February twenty- second. Alternatives advertised the event by sending flyers out to the agency’s mailing list and by posting flyers throughout the agency buildings. There was no attendance at the forum.

 

FINDINGS

 

Progress Since Previous Review

As this is the first review of Alternatives using the new program standards, there is no previous action plan. A plan of correction required for the charts will be addressed separately in the DMHDD QA report.

 

Area of Excellence: Therapeutic Foster Care Program

Both clients and related agencies praised the effectiveness of the Therapeutic Foster Care Program, identifying positive outcomes as a result of the program services. It is apparent that the program provides more support, education and supervision than similar programs in the area. The agency has a well-documented program for training and supporting foster parents in the program. It was very apparent to the team that this program fills an essential need in the community.

 

Choice/Self-determination

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

 

₊               Almost everyone interviewed reported that they were involved in their treatment plan and that the plan reflected their needs and desires.

₊               Many people said they appreciated the staff’s flexibility in scheduling and providing support.

 

The team identified the following weaknesses under Choice and Self determination for those people receiving services from Alternatives

-          Several people felt their choices were limited by the expectation that they receive all their services at Alternatives and that they discontinue their services from other agencies. In at least one case, they cited the rationale for that as a Medicaid billing issue. (Note: The agency reports that the requirement that clients use Alternatives for clinical services applies only to Medicaid rehab clients and that is for the purposes of clinical oversight.)

-          Two people indicated they did not have a choice about receiving services because their children were in state custody.

-          Two family members claimed their recommendations and feedback were not incorporated in the treatment plan. One person stated that their desire to get their child into group therapy was not acted upon, not even by putting the child on the waiting list. The family felt that not receiving the services they desired contributed to the child’s subsequent hospitalization.

-          Among the clients interviewed, the level of knowledge regarding treatment options agency practices and their diagnosis varied. Several people indicated that they felt that would like further education if it were offered. 

-          Several people stated that being put on a waiting list had been frustrating and suggested that the agency hire more Youth & Family Counselors. (Note: The agency indicated efforts to address this problem including ongoing recruitment of new counselors and the increase in the counselor pay scale to attract quality applicants.)

-          Many people interviewed identified staff turnover as contributing to service disruption and lack of continuity of care. While the team commends the agency on current efforts to limit staff turnover, we also see it as a treatment factor that should get continual attention. 

 

Dignity, Respect and Rights

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

₊               Generally people reported feeling very comfortable in the agency and with staff. One person said, “Of all the places I’ve been, Alternatives is the most understanding.” Another person indicated that the agency is one of the only places their daughter is not afraid to go and that has been true since the beginning.

₊               No one reported having any concerns about confidentiality.

₊               Most people reported that they felt valued and respected by staff and that their family and individual needs were explored.

₊               Almost all people reported that they felt that staff was very accessible and responsive to them.

₊               Several people indicated that they appreciated that the agency staff was discreet and respectful regarding personal issues.

₊               The agency’s initiative regarding community and in-house training events was cited as a plus. The team feels this is a very positive step towards educating staff, clients and community members and encourages the continuation and enhancement of this practice.

 

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

-          Several people reported that they did not remember being informed about their rights.

-          Two people did not remember signing any release of information forms for the sharing of information with other agencies.

-          Several people indicated that an unexpected and unexplained change in therapist signaled a lack of respect. One person indicated that they felt “betrayed”.

-          One person said they did not have access to their case information or chart.

-          One interviewer was struck by the reported long-term, devastating effects on a client that resulted from an agency action to change the person’s therapist. This action affected the individual as well as the whole family. While it should be noted that the event happened a year ago, it is a reminder of how important it is to be sensitive to the impact of such changes and the need to prevent, to the greatest extent possible, the effects of such changes on a person’s course of treatment.  

 

Health, Safety, Security

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

₊               Generally people reported that they felt safe and secure at the agency.

₊               Several people reported being impressed with the agency’s focus on safety in the home and in the community.

₊               Several people appreciated the fact that clinical staff kept them informed about their child’s emotional status after sessions as it related to potential safety issues. (e.g. suicidality, aggressiveness)

₊               One person appreciated the agency’s support in addressing physical health needs.

₊               Several people cited the addition of Dr. Nyman as a full time staff member as a tremendous asset to the program. His position is believed to enhance treatment credibility, continuity and quality of care as well as increase the opportunity for staff training.

 

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

-          One person felt unsafe when her son refused to continue with services due to a change of therapist. Given this prior experience with the agency, she feels insecure about coming back for services.

-          One parent indicated that they feel they have never gotten an adequate evaluation of their child’s condition and are anxious to get an accurate psychiatric diagnosis. They added that they have had problems getting cooperation from the doctor.

 

Relationships

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

₊               Several people cited the “Friday Family Picnics” as a very valuable activity to get to know staff and other families. One person indicated a desire to have such events year-round.

₊               The agency appears to have an overall focus on family support and relationship building.

₊               Many people acknowledge improved family relationships as a result of services.

 

The team identified the following weakness under Relationships for those receiving services from Alternatives

-          One person expressed frustration about their family situation, indicating that they had tried family therapy but it didn’t seem to help and then the sessions stopped. They cited “family diversity” as the possible problem. The interviewer got the sense that the person had given up on the situation since there was limited agency support.

 

Community Participation

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

₊               Several people stressed the value of activity therapy with a focus on community participation and the willingness of staff to go to community activities with the children.

₊               Several people identified the DayStreams Program as being very valuable. One person stated that the program “makes all the difference in the world”.

₊               Many clients were encouraged and supported to develop natural supports in the community.

 

The team identified the following weakness under Community Participation for those receiving services from Alternatives

-          A couple of people questioned the judgment of some Youth & Family Counselors in their selection of activities, for example running personal errands or “mall hopping”. One person suggested the need for better staff screening and training. (Note: The agency noted that they are very aware of this problem and have increased training and supervision of staff and have improved their staff screening process.) 

 

Staff Interviews

The team interviewed 10 Alternatives staff, 9 selected by the agency. The general overall feeling from staff was positive. Several people indicated that recent changes made to the agency have been very positive. One person indicated that “morale is on the upswing” adding that they “really see things as turning around for the best.”

 

Staff indicated that they felt comfortable talking to supervisors and that there is an “open door” policy. Many also indicated that they feel their input is valued. Several staff reported that they are encouraged and supported in getting further education and training. Generally, staff expressed a family/consumer centered service orientation with a focus on client collaboration and inclusion. One board member described the current staff as being cohesive and professional. 

 

Collateral Agency Interviews

Seventeen people from collateral agencies were interviewed including representatives from the Anchorage School District, API, Providence Hospital, Alaska Children’s Services, Southcentral Counseling Center, Corrections, DFYS, P.A.R.E.N.T.S., Inc. and Anchorage Center for Families. Overall, the feedback was very positive. Two people indicated that the agency accepts clients that other agencies won’t take. Several people cited transition problems with high staff turnover and a lack of supervision and training, but many also praised the agency for recent positive changes. 

 

Several people noted staff’s willingness to “go the extra mile” and their commitment to building collaborative relationships. A couple of people expressed appreciation for the agency’s willingness to be flexible and to add services when needed. Another person was impressed with having an identified person to go to with problems and how that fact adds to accountability. A couple of people praised the agency’s leadership role in initiating the foster parent recognition dinner. Staff specifically identified as being exceptional to work with were Dave N., Elena, and Rachel.

 

Two people indicated they limited their use of the agency because of the waiting list. Only one person identified problems with the agency in collaboration and cooperation. The team wants to commend the agency’s increased efforts to collaborate and partner with other agencies as the positive change in this direction was cited in many interviews.

 

Administrative/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 Alternatives. 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) Of the agency’s seven-member board of directors, one is a consumer representative. The board expressed plans to expand to as many as 11 members.

 

2.       The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery. (Standard #12) The agency recently administered a consumer/family survey to get feedback regarding services. Out of the 120 surveys sent out, 24 people responded. The results of the survey were provided to the team. The agency indicated plans to look into developing a consumer advisory committee in order to meet this standard.

 

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) As mentioned above, the agency is currently searching for a way to accomplish the surveying of consumer opinion and utilizing that information in planning and evaluation.

 

4.       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 agency does not currently have a system for incorporating consumer choice into the hiring and evaluation of direct service staff. However, the Human Resource Director described a process that is being developed that will solicit consumer feedback regarding staff performance and that information will then be considered in both the permanent hiring of new staff as well as in annual staff evaluations. 

 

5.       A staff development plan is written annually for each professional and paraprofessional staff person. (Standard #29)  The agency states that this is being developed.

 

6.       The agency identifies available resources to meet the assessed training needs of staff. (Standard #30)  The agency states that this is being developed.

 

7.       The performance appraisal system establishes goals and objectives for the period of appraisal. (Standard #32)  Of the five personnel files reviewed, only one staff evaluation identified goals and objectives for the appraisal period. The Human Resource Director described a new appraisal format being developed that will include the establishment of goals and objectives.

 

 

CLINICAL 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 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 clients served during the period being reviewed. 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 twenty (20) Medicaid charts and ten (10) non-Medicaid charts.

 

 

 

STRENGTHS

There is a Quality Assurance person on staff that is reviewing and implementing new procedures routinely.  An overview of ASSESSMENT MATERIAL indicates that some newer assessments contain all of the elements needed to meet the requirements of the Integrated Standards.  What appears to be the most current TREATMENT PLAN contains all of the elements needed to meet  the requirements of the Integrated Standards. An overview of TREATMENT PLAN REVIEWS indicates that reviews also contain the elements required to meet the Integrated Standards.  An overview of PROGRESS NOTES show that notes are found in charts for most billings, and that signing and credentialing is consistently found to be in order.  There is also a component of the FSS and AT notes that is useful for determining outcome measures.

 

AREAS FOR IMPROVEMENT

It is recommended that Alternatives make sure that a comprehensive ASSESSMENT is conducted by a Master’s level clinician annually.  The assessment should include all material reviewed in order to determine the diagnosis, the problems list, and the recommendations for services.  It is recommended that the most current TREATMENT PLAN be used consistently throughout the agency, as some of the older treatment plans are based on service modality.  This limits the number of services that can be used to address a problem or requires that problems/goals be repeated each time another service is needed to address the problem.  It is suggested that the treatment plan 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. The problem list may be repeated in the treatment plan, however it should be developed in the comprehensive assessment.  An overview of PROGRESS NOTES indicates that the format varies considerably depending on the service delivered. It is noted that some notes are designed to measure outcome and to provide a narrative that discusses interventions used and client response to the interventions.  Please be careful that both areas are utilized fully and correctly.  The progress notes are where the action that is taking place is documented.  For TREATMENT PLAN REVIEWS, the greatest area of concern was consistent use of a treatment review document that meets requirements, and getting the review completed when due.

 

 

 

 

SUMMARY:

Alternatives continues to improve their ability to ensure that sound clinical practices are being carefully and fully documented.  The Quality Assurance staff is working to make sure that the documentation is strong and to evaluation suggestions and recommendations; this is a definite asset to the agency. Training needs surrounding documentation and processes to determine effective ways to eliminate non-essential paperwork are being addressed. The agency’s Quality Assurance staff and the Division of Mental Health and Developmental Disabilities Quality Assurance staff are collaborating on ways to provide necessary training and technical assistance.   The reorganization of the Medical Records section should provide for better access and tracking of charts and provide for easier review of charts by clinicians.

 

 

 

 

 

 

 

 

 

 

 

 

Program Management

Overall, Alternatives seems to be a well-managed program run by caring and energetic people. The overall atmosphere of the agency is very positive. It is apparent that agency leaders, in particular the executive director and the clinical director, have worked very hard to make positive changes to the agency.

 

There is a focus on forward thinking. As one staff put it there is a “youthful vigor in this agency …(with a) we-can-do-it attitude”. 

 

Areas Requiring Response

1.       The agency needs to increase its consumer representation on the governing

      board especially given the plan to expand the board. (Standard #6)

2.       The agency needs to develop a more systematic method to actively solicit and utilize consumer and family input in policy setting and program delivery. (Standard #12)  This input should be incorporated in the development of annual goals and objectives. It is suggested that the agency expand the use of their survey and follow through with their plan to develop a consumer advisory committee.

3.       The agency needs to develop a more systematic method to involve consumers, staff and community in planning and evaluation of programs.  (Standard #13)

4.       The agency needs to implement their planned system to incorporate consumer choice and feedback in the hiring and evaluation of direct service providers.  (Standard #22)

5.       The agency needs to revise its staff evaluation system to allow for an annual staff development plan for each staff member.  (Standards #29)

6.       The agency needs to revise its staff evaluation system to identify available resources to meet the assessed training needs of staff.  (Standard #30)

7.       The agency needs to revise its staff evaluation system to include goals and objectives for the period of appraisal.  (Standard #32)

 

Other Recommendations

1.       Continue an ongoing assessment of the effectiveness of client orientation and

      education regarding agency policy and practices, all available treatment

      options and each person’s diagnosis. Focus particularly on clarifying the

      clients’ understanding when presenting information relevant to these issues.

2.       Clarify the agency’s policy regarding a client’s use of a similar agency’s services (e.g. Can a client see a therapist outside the agency and still see the doctor here?) 

3.       Follow through with your plans to increase the membership to your board allowing for increased consumer and community participation.

 

Closing

The team wishes to thank the staff of Alternatives 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.

 

We would like to particularly thank you for the extra measures you took for us such as the availability of all your meeting space. Another example of your “extra mile” efforts!

.

The final draft of this report will be prepared within 21 days and sent to DMHDD.  DMHDD will then contact Alternatives within 30 days to develop collaboratively a plan for change.

 

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