Northern Community Resources
P. O. Box 7034
Ketchikan, Alaska 99901
(907) 225-6355
FAX 225-6354
September 13 – September
15, 2000
Site
Review Team
Ann
Wolf, Community Member
Randy
Meyer, Peer Reviewer
Barbara
Price, Facilitator
A review of the Mental Health (MH) services
provided by Kuskokwim Native Association Community Counseling Center (KNACCC)
was conducted from September 13, 2000 to September 15, 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.
KNACCC serves a population of just fewer than 2,000 residing in ten villages within a 16,200 square mile service area. Most inhabitants belong to the Yupik language group. The area has a high percentage of youth that are educated in three different school districts.
Approximately one half of the agency’s funding is
from a Division of Mental Health and Developmental Disabilities grant. Additional funding is received from the
Division of Alcoholism and Drug Abuse, Project ACT (suicide prevention, drug
and alcohol prevention grant) and from the Bureau of Indian Affairs.
Of the approximately 175 people served directly
each year, some 85% are dually diagnosed.
Approximately 1500 outreach/primary prevention contacts are also made
each year, with the school population being the primary target of these
efforts. The staff estimates that of
the 175 consumers, about 20 are adults with chronic mental illnesses. Nearly four times that many consumers are
severely emotionally disturbed children.
Given the cost and difficulties of travel, some
services are provided by telephone.
The agency is developing a Memorandum of Agreement
with Yukon Kuskokwim Health Corporation and Kuskokwim Native Association to
coordinate services including case finding.
The agency also collaborates with 4Rivers Counseling Services based in
McGrath.
Currently the staff consists of the Director who
provides program administration, supervision and direct services; a chemical
dependency counselor serving children and adults; a prevention coordinator/MIS
coordinator/secretary/quality assurance and outreach staff member; assistant
administrator/benefits coordinator.
There is a village counselor employed in one village, one open village
position, and two additional village counselor positions are being created.
Psychiatric coverage is provided by an
Anchorage-based psychiatrist with admitting privileges at YKHC who travels to
the area six times per year and a Bethel-based pediatric psychiatrist who
provides services quarterly and consults by telephone between visits.
The program is governed by the 6 member Executive
Committee of the Kuskokwim Native Association.
There is no mental health advisory board.
Description
of Process
The review team of one community member, a peer reviewer and a facilitator conducted a three-day review in Aniak, Upper Kalskag and Lower Kalskag. Interviews were conducted at the health clinics in Upper and in Lower Kalskag, in consumers’ homes, at the KNACCC office in Aniak and by telephone.
Twenty-one interviews lasting from fifteen to 60 minutes were conducted with 8 consumers (6 adults and 2 children all taken from the random selection list provided to the agency), 7 staff of related agencies (DFYS, two schools, law enforcement, YKHC, 4Rivers Counseling, clinic), all 4 staff members (including substance abuse treatment staff) and 2 KNA administrators. No board member was available for an interview.
Open
Forum
An open forum was held the first evening of the
review at 7 PM at the Community Hall.
KNACCC advertised this opportunity with posters in seven locations in
Aniak. No one attended the forum.
Staff and team members were advised to invite
consumers or their family members to call the team at the agency or at their
lodgings if they were unable to or uncomfortable with attending the public
event. No calls were received. Local
residents volunteered their views of the counseling services informally to team
members and their opinions are included in this report.
Progress
Since Last Review
The last review of KNACCC was held in February 1999. At that time, the site review team identified the following Areas Requiring Response:
1. Institute the option for clients to have regular
consistent appointments with a counselor when needed and wanted and institute
appointment reminder system.
Action taken: The agency has an appointment system
and is open regular hours including evenings.
No appointment reminder system is in place. Only one comment was received about missed appointments by
current staff. Standard partially met.
2. Increase the psychiatric coverage.
Action taken: Psychiatric coverage exceeds the
State requirement. Standard met.
3. Fill the vacant counselor position as soon as
possible to help address the increased service needs identified by those
interviewed.
Action taken: This position had been filled until
6/00. The position has been redefined
to allow for the hiring of two additional village counselors. Recruiting is
underway. Standard partially met.
4. Track referrals made to the counseling center
and document follow-up services.
Action taken: This system has been
established. Standard met.
5. Increase services to youth addressing issues
such as teen pregnancy, child abuse, suicide prevention, grief counseling and child
counseling.
Action taken: The agency has youth as their major
focus in outreach and prevention efforts. Standard met.
6. Meet Standard #1: creation of a written mission
or philosophy that is consumer centered.
Action taken: The mission statement was created by
the staff in a team decision making process.
Standard met.
7. Meet Standard #2: educate all staff regarding
the mission or philosophy of the agency
Action taken: The staff participated in the
creation of the mission statement and own it.
Standard met.
8. Meet Standard #6: include consumers or family
members of consumers on the governing board
Action taken: One half of the 6-member executive
council are consumers or family members of consumers. Standard met.
9. Meet Standard #7: have the governing body
oversee the agency budget and program quality
Action taken: The KNA Executive Council serves as
the governing body. KNA oversees the
budget and reviews program quality through the Director’s quarterly
report. Standard met.
10. Meet Standard #12: include consumer and family
opinion in policy setting and program delivery
Action taken: A consumer survey is in place. The agency team meets to incorporate the
results of this survey into policies and programs. Standard met.
11. Meet Standard #13: include consumer and family
opinion in planning and evaluation of programs including present and past
consumer satisfaction
Action taken: A consumer survey is in place. The agency team meets to incorporate the
results into planning and evaluation.
Standard met.
12. Meet Standard #14: develop annual goals and
objectives based on consumer, community and self-evaluation activities
Action taken: A consumer survey is in place. As yet, the results have not been utilized
for set goals and objectives. Standard
partially met.
13. Meet Standard #16: have all agency publications
reflective of consumer centered values
Action taken: Agency publications are respectful
and consumer centered. Standard met.
14. Meet Standard #17: maximize resource
availability and service delivery
Action taken: The use of village counselors,
memoranda of agreement with other agencies, work in the schools, increased
village travel and increased psychiatric coverage combine to this end. Standard met.
15. Meet Standard #20: have a system for review and
revision of all job descriptions
Action taken: The policy is in place. Standard met.
16. Meet Standard #22: incorporate consumer choice
in hiring and evaluating direct service staff and have individualized services
approved by the family or consumer
Action taken: To date, consumers are not involved
in the hiring and evaluation of direct service staff. Individualized services are approved by consumers. Standard partially met.
17. Meet Standard #24: include in the hiring
process background and criminal checks and follow up on references
Action taken: The policy is in place. Criminal background checks had been
completed for staff. There was no
documentation of reference checks.
Standard partially met.
18. Meet Standard #26: facilitate the development
of non-paid relationships between consumers and other community members
Action taken: Consumers participate fully in the
life of the community; a recent sobriety event brought together many community
members; a new project will match elders with youth. Standard met.
19. Meet Standard #28: include an opportunity for
agency feedback to employees during the evaluation process and for employees to
provide a response to the agency
Action taken: The policy exists and the personnel
files reflect that this occurs.
Standard met.
20. Meet Standard #30: identify resources to meet
the training needs of staff
Action taken: An informal agreement to do this
exists. The policy has been proposed
but is not in place. Current personnel
files do not document the source of training funds. Staff report that they are to receive this support. Standard partially met.
21. Meet Standard #32: establish goals and
objectives for the period of employee evaluation
Action taken: Some files showed “comments” that
indicated goals and objectives.
Standard partially met.
22. Meet Standard #33: create a written personnel
policy for disciplinary action
Action taken: The policy is in place. Standard met.
Model
Practices
The team recommends for consideration as a model practice the inclusion of the benefits coordinator within the counseling center. This staff member aids with general assistance, public assistance, social security benefits, location of birth certificates, burial assistance, and acts as a fee agent. In effect, this staff member provides case management on a broad scale. This facilitates the normal flow of people in and out of the center, diminishing the stigma of going to the center for treatment services and incorporates practical helping into the therapeutic environment. This model could be used by other rural programs unable to fund a formal case management position.
Areas
of Excellence
1. Mental health and substance abuse treatment services are offered within an integrated system, maximizing services to the dually diagnosed.
2.
The center has a fine working relationship with
local law enforcement, school and health clinic, facilitating crisis response.
3.
Confidentiality is absolutely maintained. Many consumers and other residents commented
on this and expressed their increased trust in the agency due to this careful
observation of client rights and dignity.
4. Despite
the difficulties of regional travel, the agency does provide outreach services
to the
adult,
chronically mentally ill population.
The team identified the following strengths under
Choice and Self Determination for those receiving MH services:
+ Increased
travel to the villages provides more services to more people.
+
Children’s services are available.
+ Six
consumers reported participating in the development of their treatment plans.
The team identified the following weaknesses under
Choice and Self-Determination for those receiving MH services:
-
There is no Yupik speaking counselor despite the
wide use of this language, especially among
elders.
-
Most villages do not have a village counselor at
this time, resulting in unequal and limited
services throughout the region.
- Two
consumers were not aware of their treatment plan.
The team identified the following strengths under Dignity, Respect and Rights for those receiving MH services:
+ By all
reports, confidentiality is scrupulously maintained by current staff.
+ All
medicated consumers were aware of their rights to refuse medication.
+ Consumers
expressed that they could communicate well with their psychiatrist.
+ Consumers felt respected by staff.
“They treat me nicely.”
– consumer
+
Self-respect and dignity are a result of receiving services.
“They helped me get my dignity and respect.”
– consumer
“Just being able to speak my mind (showed
dignity and respect).” -- consumer
“Mike understood what I was going
through.” –consumer
+ Consumers acknowledge positive outcomes.
“I was a mess before counseling…Now I have
a different outlook.” –consumer
+ Some consumers described services as culturally
appropriate.
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving MH services:
-
The lack of a Yupik speaking counselor or a
translator with basic training in confidentiality and
ethics limits the effectiveness of services.
- Some
consumers feel that services are not culturally sensitive.
-
Not all consumers are aware of the grievance process
nor are they all aware of the need for a
written release of information.
-
Under former management, confidentiality had
reportedly not been maintained. This
has
resulted in a lack of trust that the current staff needs to overcome.
The team identified the following strengths under Health, Safety and Security for those receiving MH services:
+ Consumers reported being safe in their homes.
+ Through the efforts of the benefits coordinator, consumers have access to
many resources.
+ The agency makes a strong effort to provide outreach, consultation,
counseling and prevention
services
to at risk youth.
+ Other area professionals report that this agency
is very responsive in a crisis, especially in
response
to a threat of suicide.
“They are always there in a crisis.”
The team identified the following weaknesses under
Health, Safety and Security for those receiving MH services:
- Limited
village services have resulted in concerns about medicated consumers.
- Pharmacy
services have been disrupted at times, leaving a consumer without medication
for a
two-week
period.
- One consumer reported difficulty in accessing
medical services through YKHC.
- One consumer has waited two years for a ramp
allowing wheelchair access to and from the
home.
The team identified the following strengths under Relationships for those receiving MH services:
+ Supportive
families and supportive neighbors model good relationship skills.
+ The agency’s project to aid the
interaction of elders and youth will aid in the strengthening of
intergenerational relationships.
+ Relationship skills may be part of
the treatment plan.
“(Following treatment) I am more conscious
of others and treat others better.” – consumer
+ After receiving services, a consumer realized the
need the children had for treatment and took
them for
help.
The team identified no weaknesses under Relationships for those receiving MH
services.
The team identified the following strengths under Community Participation for those receiving MH services:
+ Community
support and family support are high and aid consumers in participating in
community
activities.
+ A recent sobriety event sponsored by
the agency attracted a large group of community members
to a
positive, sober social event.
+ The agency sponsors sober dances for
teens.
+ The
agency participated in the Interior Rivers State Fair with an information
booth.
+ The
agency’s project to aid the interaction of elders and youth will aid both
groups to participate
in
community activities.
The team identified no weaknesses under Community Participation for those
receiving MH services.
Staff
Interviews
This staff has experienced a great many changes. The longest-term employee has worked with 9 different directors. The current Director has held his position for one year and in that period of time several changes have had to be made.
The team expressed concern that the demand on all
staff for flexibility and a variety of skills may push them to work beyond
their areas of expertise and beyond their area of comfort.
The agency is understaffed considering the number
of villages to be served. There is a
plan to increase the number of village counselors. But in the meantime, the staff are faced with high demands and
limited access to training.
It must be noted that all staff were complimented,
and complimented repeatedly, during the interviews the team conducted. Nancy was especially cited for her ability
to provide life-saving support by telephone in a crisis. Lisa was described as “wonderful…a Godsend to the program” and an effective communicator
with other agencies. The Director was described as active and visible in the
community, “a good man.” Twinks was described as “the one who knows!”
All informants stated that the agency has vastly improved under the current management. Monthly interagency team meetings allow for joint staffings and coordination of care. Three agencies especially appreciate KNACCC’s response to crises.
The staff of other agencies especially noted
improved follow-up on referrals, the positive responses of consumers,
increasing openness and improved communication, and collaboration to increase
training opportunities.
Concerns of other agencies were: the need to have a
greater presence in the villages, the need for improved discharge planning, a
number of appointment changes resulting in some inconsistency of services and too
often relying on the referred person to initiate contact.
Of the 34 Administrative and Personnel Standards for Mental Health centers, KNACCC fully meets 23 and partially meets the remaining 11 standards. It should be noted that this is an improvement over the 18 unmet standards cited in the prior review.
Standard #4 Budget controls, record keeping and
staff training support good business practices and conform to state
requirements.
The
budget is overseen by KNA, with the Director submitting purchase orders and
suggesting budget revisions. The
Director needs monthly statements of expenditures in order to be more fully
informed about the agency’s financial status at any given time and to aid in
decision making.
State and
Medicaid requirements suggest the need for additional training and
credentialing of staff.
Standard #11 All facilities and programs operated
by the agency provide equal access to all individuals.
The Aniak
office and the village clinics where consumers may be seen are wheelchair
accessible. Services are provided by
telephone and in homes to accommodate consumer needs. There is no telephone accommodation for the hearing
impaired. Signage is not in
Braille. There are no trained translator/counselors
offering services in Yupik.
Standard #14 The agency develops annual goals and
objectives in response to consumer, community and self-evaluation activities.
The
Director has developed long-range goals.
A consumer satisfaction survey is in place. Currently there is no direct, documented link between the goals
set and the information received.
Standard #19 Staff who are employed by, contract
with, or volunteer for the provider agency have appropriate training
(credentials where required), experience, and supervision to perform their job
functions and meet all necessary legal, ethical and regulatory requirements.
Some
staff have been assigned new duties that require specialized training. Some training is pending, but additional
training in providing children’s services, for example, is needed. The Director is certified in other states,
but does not have Alaska licensure or certification. The Director’s work needs to be supervised by a professional with
a superior credential.
Standard #22 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.
While
consumer satisfaction is surveyed, there is currently neither policy nor
procedure to incorporate this information into the hiring or staff evaluation
processes. Individualized services are
approved by the consumer, family or guardian.
Standard #24 The hiring process includes background
and criminal checks (when appropriate) for direct care providers, personal and
professional references and follow-up on required references.
There is
a policy for the completion of criminal checks and there is documentation of
their completion for all staff.
References are requested from applicants. There is no documentation that references have been checked.
Standard #25 The agency provides new staff with a
timely orientation/training according to a written plan that includes, as a
minimum, agency policies and procedures, program philosophy, confidentiality,
reporting requirements (abuse, neglect, mistreatment laws), cultural diversity
issues, and potential work related hazards associated with serving individuals
with severe disabilities.
A team
training syllabus and training/orientation checklist has been developed
recently. It does not appear in the
current staff personnel files. All of
the above items are included except reporting requirements.
Standard #29 A staff development plan is written
annually for each professional and paraprofessional staff person.
In the
four staff personnel files reviewed, two staff members had current evaluations
but neither had a complete plan for staff development. Of the two remaining files, one employee had
no documented job evaluation or development plan since 1990 and the other had,
after 15 months of employment, neither a job evaluation nor a development plan.
Standard #30 The agency identifies available
resources to meet the assessed training needs of staff.
A policy
has been written but awaits approval.
Three employees state that they have been notified of this assistance
but there is no documentation of that in the personnel files.
Standard #31 The performance appraisal system
adheres to reasonably established timelines.
The
policy is in place. The four personnel
files reviewed did not all reveal evaluations completed within these timelines.
Standard #32 The performance appraisal system
establishes goals and objectives for the period of appraisal.
The
evaluation form includes a comment section.
In some cases this section suggested goals for the employee, but not in
all cases.
Program
Management
All informants noted the vast improvement in services during the last one to two years. Many new policies have been put into place in the last few months and as they are put into practice, even greater gains will have been made. All staff note the value of a team approach to certain aspects of the program but are aware that not all decisions are made in this manner, nor can they be.
The program, not unlike other rural Alaskan
centers, has experienced high staff turnover.
This complicates the management picture and burdens KNA and the
communities. Consultation with other
programs may be helpful in developing strategies to support and retain
qualified staff.
While the Director is licensed or certified in
other states, he does not have Alaskan licensure or certification. Completion of these tasks might demonstrate
a further commitment to the agency. In
addition, it would aid in meeting the Medicaid requirements for MH direct
service providers (an Alaska licensed or Alaska certified Master’s level Mental
Health Professional).
The Director’s request for timely indications of
budget status, while additional work for KNA’s staff, could aid in the more
efficient use of funds.
Currently, the Director provides crisis response 24
hrs/day and 7 days/week unless out of the area, at which time a staff member
assumes those duties. This is stressful
and contributes to provider exhaustion (“burn-out”). An alternate means of coverage or at least aid in triage might
reduce this stress.
The current personnel policies include a reference
to compensatory time. This may be
judged as illegal. Flextime may be a
more appropriate concept and may prevent the accumulation of a large number of
“overtime” hours with the resulting stress and exhaustion.
While not included in the standards, the agency
meets additional MH grant regulations: there is a sliding fee scale and no one
is turned away due to an inability to pay; there is an internal quality
assurance process.
Areas
Requiring Response
1.
That a means be found to communicate with Yupik
speakers in their language. (Standard #11 and the concerns of the communities
regarding cultural sensitivity)
2.
That advocacy of consumer needs (such as the ramp
needed for a wheelchair-bound individual) be vigorous.
3.
That the Medicaid requirements be met as to staff
training and credentialing. (Standard #4, Standard #19 and as a response to
increasing demands on staff)
4.
That accommodations for the hearing and sight
impaired be made as possible. (Standard
#11)
5.
That annual goals and objectives be created based
on consumer and community reaction and team discussions. (Standard #14 and prior review)
6.
That a means be found to incorporate consumer
opinion into the hiring and evaluation of direct service staff. (Standard #22 and prior review)
7.
That reference checks of applicants be made and
documented. (Standard #24 and prior
review)
8.
That the staff orientation/training plan be
implemented and documented and that it include training on reporting
requirements. (Standard #25)
9.
That staff evaluations are completed annually. This includes an annual evaluation of the
Director by the governing board.
(Standard #29)
10. That
resources be identified to aid staff with training. (Standard #30 and prior review)
It is understood that a policy is pending.
11. That
timelines for improvement or accomplishment of goals be included in the staff
evaluations. (Standard #31)
12. That
all staff evaluations document goals and objectives for the coming evaluation
period. (Standard #32 and prior review)
13. Institute
an appointment reminder system. (prior
review)
14. Fill
vacant positions as soon as possible.
(prior review)
Other
Recommendations
1. The services of a trained play therapist would be a valuable addition to the program.
2.
Village outreach could be increased by use of the
radio, mailings, a newsletter or other means that are cost effective.
3.
Staff stress needs to be taken into consideration
and remediated.
4.
Crisis response could be routed through law
enforcement or the clinic or on-call could be shared in some manner to reduce
provider exhaustion.
5.
Post a complete list of consumer rights. (This is a grant regulation.)
6.
Consider the communities’ need for a grief
workshop.
The final draft of this report will be sent to
Northern Community Resources for final review. You will receive the final report within approximately thirty
days, including a Plan of Action form, listing the Areas Requiring
Response. You will then have an
additional 30 days to complete the Plan of Action. The directions on how to proceed from there will be included in a
cover letter you will receive with the final report and Plan of Action form.
Once NCR has reviewed your completed Plan of
Action, it will be sent to the DMHDD Quality Assurance Section. The QA Section will then contact you to
develop collaboratively a plan for change.
Attachments: Administrative and Personnel
Checklist, Interview Form for Staff of Related Agencies (tallied), Consumer
Satisfaction Score Sheet
NCR 8/00