Northern Community Resources

P. O. Box 7034

Ketchikan, Alaska  99901

(907) 225-6355

FAX  225-6354

 

INTEGRATED QUALITY ASSURANCE REVIEW
Kuskokwim Native Association Community Counseling Center

                                            September 13 – September 15, 2000

Aniak, Alaska

 

Site Review Team

Ann Wolf, Community Member

Randy Meyer, Peer Reviewer

Barbara Price, Facilitator

 

INTRODUCTION

 

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. 

 

Description of Services

 

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.

 

FINDINGS

 

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 Five Life Areas

 

 

Choice and Self Determination

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.

 

Dignity, Respect and Rights

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.

 

Health, Safety and Security

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. 

 

Relationships

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.

 

Community Participation

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!”

 

Interviews with Staff of Related Agencies

 

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.

 

 

Administrative and Personnel Narrative

 

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