INTEGRATED QUALITY ASSURANCE REVIEW
Assets, Inc.
April
3, 2000 – April 7, 2000
Anchorage,
Alaska
A review of
Developmental Disabilities (DD) and Mental Health (MH) services provided
by Assets, Inc. was conducted from April 3, 2000 to April 7, 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. Division of
Mental Health and Developmental Disabilities (DMHDD) Quality Assurance staff
conducted the Clinical Record Review and provided that section of this report.
Assets prominently displays its mission statement
in all of its publications and throughout the agency building. This statement and the core values that it
represents have been integrated into job descriptions, employee orientation and
employee evaluations. These statements
and the beliefs they represent permeate the agency.
Assets has evolved from an employment and training
center into employment services, contract services and supported living
services for children and adults. The
target population includes those receiving developmental disabilities and
mental health services and in need of long term supports. The agency has aided individuals with the
transition from long term institutional placements into the community. Assets also serves consumers needing to
develop safe and healthy sexual behaviors.
Approximately 250 individuals are served each year
by some 160 employees. Supported living
services are currently received by 17 children and 74 adults; employment
services are currently being provided to 155 adults.
The agency is governed by an eleven member executive
board. Of the nine currently occupied
seats, one is held by a consumer and three by family members of consumers.
During the five-day period from April 3 – April 7,
a team of ten interviewed 84 consumers, family members/guardians, staff of
related agencies and Assets staff. The
team consisted of two peer reviewers, five community members, a representative
of DMHDD and two facilitators.
The QA staff had requested 15 consumer interviews,
all of which were to be taken from their randomly generated list. Of the 32
consumers interviewed, all were taken from this list. The team conducted 34 staff interviews, 16 interviews with the
staff of related agencies and 2 interviews with board members.
Interviews were held at Assets, at the homes or
work sites of consumers, at the offices of other agency staff and by
telephone. The interviews were from 5
minutes to 60 minutes in length.
A clinical file review was conducted by DMHDD QA
staff during this same period. The
results of that review were presented in a separate exit interview and are
provided in a separate report.
The agency advertised an Open Forum for Monday,
April 3, 2000, at 7:00 P.M. at the Z.J. Loussac Public Library. Five hundred copies of the announcement were
mailed and the event was published in the newspaper on Friday, March 31st
and Monday, April 3rd.
Three individuals participated, two in person and
one by telephone. The comments received have been integrated into the body of
the report.
This is the first review of Assets’ Mental Health
services using the Integrated Quality Assurance Review. Consequently there is no prior MH review on
which to comment.
The last review of Assets’ Developmental
Disabilities services was conducted in October, 1997, and listed 10 areas
requiring response.
1.
Perform
a fiscal audit as soon as possible. Assets has a current audit.
2.
Develop
a multifaceted budget review process. Assets has a multifaceted budget review
process.
3.
Prepare
a financial statement for the Board at the next opportunity. Assets has provided the Board with monthly
financial statements. The Finance
Director meets with the Board regularly.
The Board has a Finance Committee that reviews the budget in more
detail.
4.
Develop
a method of documenting consumer participation in hiring and evaluating staff. While it is clear that consumers do
participate in the hiring and evaluation of staff, no documentation of that
participation was found in the 10 personnel files reviewed by the team.
5.
Assure
that employee evaluations are brought up to date. A review of 10 personnel files found some
evaluations missing. However, the
evaluations were promptly provided, having been in the possession of the staff
member or the director.
6.
Assure
that assisted living homes provide age appropriate supports. These supports are in place.
7.
Continue
to explore ways to increase opportunities for people to develop relationships
with other community members. While an ongoing issue, increased opportunities
have been provided.
8.
Continue
to explore ways to increase opportunities for community activities. These opportunities are parts of most
individuals’ service plans.
9.
Could
you explore ways to develop back up supports when public transportation fails? Alternate transportation has been developed.
10. Explore ways to decrease employer dependence
on Assets staff for problem solving. While there is inconsistent dependence by
employers on Assets staff, efforts have been made to comply with this
expectation. The team notes, however,
that the program description of employment services states that consumers will
be supported “indefinitely” in their employment.
While the team was not prepared to identify a model
practice during this review, we did express the opinion that Assets’ use of the
psycho-rehabilitation model, successfully blending MH and DD services, is
unique and bears further exploration in subsequent reviews.
1.
Assets has effectively instituted the
psycho-rehabilitation model of services and successfully and appropriately
blended MH and DD services within this model.
One staff member describes this as “a
fantastic hybrid.”
2.
Assets’ proactive protocols for health and safety
needs of consumers are exemplary.
3.
Assets’ effective and thorough risk management
allows for the provision of supports and services to consumers who present
complex and high risk needs, consumers who other agencies might consider
liability risks.
4.
Assets’ initiative and creativity in identifying
businesses to employ consumers and the ability to satisfy these employers’
needs are a particular strength of this agency.
5.
Assets’ persevering optimism in accepting and
working with consumers with complex support needs, including those
transitioning from institutional settings and those requiring skills for the
healthy management of sexuality, exhibits flexibility and a “can do” attitude.
“We’ll try to do anything and if it doesn’t
work, we’ll get together and brainstorm.” – staff
member
6.
Assets’ value system pervades all aspects of the
agency’s work, is an integral part of employee orientation, training and
evaluation, is posted throughout the agency and routinely recurs in
conversation among agency staff.
7.
Assets’ ability to create and maintain what one
staff member referred to as a “linked
system”, teaming staff from a wide variety of agencies, exhibits a mature,
non-territorial attitude toward services and makes for excellent relationships
with those agencies. The dignity of the
other service providers is maintained and the focus on the consumer enhanced by
this team concept.
Quality
of Life Indicators for Consumers
The team identified the following strengths under
Choice and Self-Determination for those receiving DD and MH services:
+
Consumer choice and self-determination are core values at Assets and
pervade services.
“(At Assets we) meet people where they are
at.” – staff member
“It is all about (the consumers). It is all individualized. They need to be involved in every step.”
– staff
member
+
Consumer choice is honored even if staff do not agree with the
consumer’s goals.
“People didn’t want me to live in my own
apartment, but (Assets) let me do it.” -- consumer
+ Some consumers have
long-standing jobs, allowing for increased choices of tasks or hours.
+ In the
children’s program, choice is honored as is the consumer’s “right to fail.”
+ Consumer independence is honored even if that independence involves some risk. Assets’
ability to manage risk allows for this choice.
“I try to let them make their path.” –
staff member
“(We) deal with liability through good
consensus building.” – staff member
“(We) take chances. No hurdle is too high.” – staff member
+ Assets perseveres with job choices until finding the right match.
“(We say) ‘Tell us what you want to do.’”
– staff member
“The clients’ choice of work is the most
important thing.” – staff member
“(We) let people taste real life.”
-- staff member
The team identified the following weaknesses under
Choice and Self-Determination for those receiving DD and MH services:
-
Some consumers desire even more risks in their
striving for independence.
-
Some consumers felt that job options were too
limited and that their own unique interests were not represented in the job
options presented to them.
-
While improved, staff turnover was cited by several
consumers as detrimental. The result of frequent changes was described by one
caregiver as “devastating.” The
agency has formed a retention committee to address this issue.
-
Some consumers stated that the choice not to work
was not honored. In one example, the
choice of subsistence work rather than paid employment was not honored. Both are value issues and the second is a
cultural issue as well.
The team identified the following strengths under Dignity, Respect and Rights for those receiving DD and MH services:
+
Dignity, respect and rights are core values at Assets and are
demonstrated throughout the
agency.
“(Assets providers) really care about the
people they are serving. They are part
of their lives.”
+
Consumers are aware of whom to approach regarding what they need and are
generally
successful in resolving any issue.
+ The high
degree of autonomy achieved by some consumers is a living example of dignity
and
respect.
“(We) want to see clients succeed!”
– staff member
“I learned to take care of myself (and) I
graduated the program!” --consumer
+ Assets
responds well to consumer needs, requests and opinions.
“You don’t have a meeting (at Assets) without the individual.”
– staff member
+ The
front desk personnel are attentive to consumers and courteous and friendly to
all;
consumers
are greeted by name; the reception area is open, allowing for consumer contact
with
staff. One consumer described
the atmosphere as “relaxed, friendly”
and accessible.
+
Consumers, including youth, are included in the teams and have input
into the decisions that
affect
their lives.
+ Assets’ excellent relations with other agencies further increases the dignity and respect afforded
their clients in receiving services elsewhere.
+ The
agency’s consumer grievance policy was developed by a committee of consumers.
+ Alaskan
Native individuals living in the Triplex attend activities at the Quiana House
run by
South
Central Foundation and also purchase and eat traditional foods.
The team identified the following weakness under
Dignity, Respect and Rights for those receiving DD and MH services:
-
Subsistence activities and the cultural values they represent should be
afforded respect equal
to that
of paid employment.
The team identified the following strengths under
Health, Safety and Security for those receiving DD and MH services:
+
Consumer health, safety and security are core values of Assets and are
carefully attended to.
“If I’d stayed (elsewhere), I’d be
dead.”
+ Consumers
are aware of necessary, basic information for their welfare: their address,
whom to
contact, how to get where they need to go.
+ All
consumer files include maps to the consumers’ homes, jobs, doctors, etc.
+
Consumer security is enhanced by Assets’ attention to consumers even
when all is going well:
an
excellent preventive measure.
+ All
consumers indicated that their medical and dental needs were met.
+
Consumer housing was all in good condition, was located in reasonably
safe neighborhoods,
was
clean and well kept.
+ Assets
provides transportation to consumers as needed.
The team identified the following weaknesses under
Health, Safety and Security for those receiving DD and MH services:
-
As consumer income increases, so does rent,
resulting, in some cases, in less money for basic needs including food. (This is likely a system issue.)
-
In one case, the delay in receiving adaptive
equipment needed for employment was a hardship for the consumer. (This was the responsibility of another
agency.)
The team identified the following strengths under
Relationships for those receiving DD and
MH services:
+ The
enhancement of consumer relationships is a core value and consistently
practiced at
Assets.
+ Assets
does not inhibit mutual choices to live together.
+ Consumers with long-term job placements have opportunities for additional friendships.
+
Consumers in foster care, shared care and other residential placements
are encouraged to
maintain
relations with their families.
+
Consumers in valued relationships with problematic partners are still
supported in their choice
while
maintaining safety.
+ Stable
foster homes reflect good recruitment and good matching; the increased stability
allows
for
the development of enduring relationships between consumers and their foster
families.
The team identified the following weakness under
Relationships for those receiving DD and
MH services:
- Some
parents expressed alienation from the team.
“(Parent) caregivers aren’t always given
opportunities to contribute.”
“Parents are the last resource considered
by Assets.”
The team identified the following strengths under
Community Participation for those receiving DD and MH services:
+
Community participation is a core value at Assets and is a continued
focus of service plans.
+
Consumers have the choice of several job placements in the community.
+ Assets
is well aware of the need for even more community inclusion.
+ The
community of Anchorage is accepting of consumer participation.
The team identified the following weaknesses under
Community Participation for those receiving DD and MH services:
-
Consumer participation is still a difficult goal.
(This is a systems issue.)
“Community participation is the last thing
we work on.”
- The
community of Anchorage is more accepting than inclusive. (This is a systems issue.)
The attitude of Assets’ staff can be summed up in the
two-word description of one staff member: “We
serve.” The philosophy of Assets
is based on service and that philosophy is pervasive to an unusual degree and
enforced throughout the agency. Indeed,
one staff member stated that the philosophy of the agency is “drilled into you.” Another staff member commented: “(We) live the mission and put it into
practice.”
Assets staff, by and large, are pleased with their
employment and the way in which they are treated within the agency. The job environment was described to the
team as “a great place to work”, the “favorite job I’ve ever had”, “dynamic”, “progressive”, full of “opportunities to be creative”. This is a workplace always “willing to try new things” where staff
feel trusted and included in decision making.
Most staff have been with the agency two or three
years or less. Compared to the former
agency environment, one related agency staff member commented: “I have seen a metamorphosis.” Change at this agency could not be described
as once and done. In fact, “change is accepted, encouraged” because “change
is not something we’re afraid of.”
Several staff members express satisfaction with the
availability and quality of their supervision.
Comments regarding supervisors included: “… always made time for me”; “…
is the strongest positive thing that happened
to this agency”; “… is awesome”; “… is
the best supervisor I’ve ever had; … loves it when I come back with my own
ideas”; “I really feel valued by…”; “… leads by example.” On the other hand, some direct care
workers, especially those working part time, expressed concern over the lack of
formal supervision.
Staff expressed esteem for the Director. Diana was described to us as “a good communicator and consensus builder”, “…a builder of people (who)
teaches us to communicate”, “incredibly supportive”, “really constructive” and
“generous with resources.”
The staff evaluation process is valued for the care taken, the peer response included and the opportunity it presents to set goals cooperatively. Staff are clearly valued for their skills and experience, rather than their credentials. There is a lack of consistency in staff’s reporting of how raises are awarded.
Staff generosity is exhibited in the leave bank that
allows staff to donate their leave time to a colleague with special needs. Staff display an inclusionary philosophy in
that “we rarely have parties where
consumers are not invited.”
Assets offers numerous in-house training
opportunities and supports training elsewhere as well. In fact, staff receive “as much training as we can (provide); as much information as we can
give them.” Staff reactions to
the training vary, with some staff very appreciative of the options and others
stating unhappiness with training: “I
don’t get much out of the training.”
The value of Mandt training was specifically called into question in
that it isn’t always appropriate to the individual.
Likewise, reactions to compensation are
varied. For some staff, “it’s not a money thing” but others feel
very well paid and pleased with the improving benefit package. More discontent is expressed by the PSAs who
would wish for an increase in pay and benefits and more opportunities for
advancement. Assets is consistently defined as a “flat system” without “hierarchical
arrangements.”
All staff praised the open communication that
characterized the agency: “I could walk
into the Director’s office any time.” In fact, “the open door policy is like a garage door; it’s so big, everything will fit.” Another staff member commented: “I feel my ideas are valued.” In this
atmosphere, staff consistently express feeling trusted, valued and rewarded in
ways other than salary: by positive treatment, gift certificates, employee
awards.
While issues regarding advancement, concerns regarding
the quantity of paper work and the inevitable noise associated with cubicles
exist, the level of job satisfaction appears to the team to be especially high.
As the attached chart shows, the satisfaction of
other agencies with Assets is also high.
One provider commented “Assets is
always right there with us!” and “always
willing to respond to requested
changes.” The team approach maximizes cooperation among agencies: “Communication is great!” says one; “(Assets is) probably the best agency I’ve ever dealt with” says
another. It is appreciated that “(Assets) is good at attending to system lapses.” API staff reserved special compliments for
the great job accomplished at the triplex with those leaving the institutional
setting.
While some mention that “they don’t refuse anyone” due to “their can-do attitude”, others are frustrated by the wait for
services, but acknowledge that “once they
are in, the services are great.”
The delay in foster care placement is a system-wide problem.
Collateral agency interviews included suggestions
for improvement: increasing social and recreational activities for consumers;
making Assets’ communication with other agencies more consistent; having a
medical professional on staff.
Of the thirty-four items included on the
Administrative and Personnel Standards Checklist, Assets fully complies with
thirty-one. Partial compliance is noted
with the remaining three. They are:
1.
Standard #22 “The organization has and utilizes a
procedure to incorporate consumer choice into the hiring and evaluation of
direct service providers…” This is
clearly accomplished and staff described ways in which this occurs,
particularly in residential services.
However, the team was unable to locate a policy documenting the
procedure by which this is accomplished and it was not clear if this is done
throughout the agency. The Procedure
Manual is currently under revision.
Incorporating a description of this procedure would meet the standard.
2.
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.” The agency
has a well-documented orientation procedure and employee handbook. The team did not find in either a discussion
of confidentiality (although many personnel files included a signed
confidentiality agreement), reporting requirements or cultural diversity
issues. The agency is encouraged to
include these items.
3.
Standard #29
“A staff development plan is written annually for each professional and
paraprofessional staff person.” While
it appears that these plans had been developed, they were not uniformly
occurring in personnel files.
Standardizing their inclusion would meet this standard.
Assets is philosophically homogeneous and this fact
is vigorously maintained. The
philosophy is entirely client centered.
The staff worked together on the development of the mission statement,
core values and standards based on this philosophical approach.
Of particular interest is the degree to which the
governing board involves itself in this honoring of consumers. While the board is clear about the “desire to stay out of the day-to-day
operations”, the board’s annual two day retreat for the purposes of
planning includes having board members visit consumers in their homes and at
their job sites in order to be in touch with their needs and the agency’s
purpose. The board is also attempting
to “broaden attendance” at board
meetings and numbers among its members a consumer of services and three family
members of consumers.
The esteem in which the Director is held is
mentioned above. Her relationship with
the board is described as “excellent.” Of particular note is the financial
stability of the agency under her leadership and the inclusion of a highly
professional finance director. Indeed,
financially Assets is “in an enviable
position” and not entirely dependent on grant funds or Medicaid
reimbursements.
The management of Assets is characterized by
courage: accepting high risk and complex cases, managing liability “by consensus” and by intelligent risk
management. The use of many supportive
protocols mitigates the risk of this course of action. The agency’s
non-territorial, team approach to cases allows for a “linked system” that utilizes community-based expertise.
One note of concern: caregivers who are parents or
other family members expressed some isolation from the team, describing
themselves as “not always involved in
staffing decisions” regarding their family member and not fully educated
about or supported through the agency’s philosophy. Some family members were not aware of the array of services or of
the staff directly involved with their family member’s services. Perhaps additional efforts could be made to
draw these individuals into the philosophical and practical aspects of Assets’
excellent teams.
Another suggestion that arose from staff was to increase public awareness of the agency and its mission. The board clearly has adopted this goal and is currently recruiting two board members with this in mind.
The agency in general and the Clinical Consultant
in particular are acknowledged for the excellence of their MH treatment plans
and other documentation. The team
understands that Assets received a record-high 99.5% on the QA review of these
records. On the other hand, the team
felt that the DD treatment plans included some goals that were not measurable.
Areas Requiring Response
1. Document the ways in which you incorporate consumer choice into the hiring and evaluation of direct service providers. (Standard #22 and prior review)
2.
Document the ways in which new staff are trained
regarding confidentiality, reporting requirements and cultural diversity
issues. If any of these items are not
included in orientation or training, seek to include them. (Standard #25)
3.
Consistently include in each personnel file the current staff
development plan. (Standard #29)
4.
Examine DD service plans and state objectives in
measurable terms.
5.
Some families and individuals are not fully
informed regarding the availability of services and how to access them. Take steps to increase awareness of services
and of how they can be accessed.
6.
Seek to decrease employers’ dependence on Assets
staff. Examine the conflict of doing so
while offering employment services “indefinitely.” (Prior review)
1. Family member-caregivers should be offered education, training, support and information equal to or similar to that provided paid caregivers.
2. In keeping with the agency’s mission statement, offer consumers and family members additional opportunities to increase their knowledge about self-advocacy.
3. Consider including consumers as members of the training team.
4. Consider the impact of value conflicts with family members in regards to your core values and of how to work with families not supportive of independence as a goal.
5. Increase your exploration of individual interests in regard to work placements.
6. Your practices are impressive but the written descriptions of them do not do them justice. Attempt to have your new Procedure Manual reflective of your many innovations and your support of the spirit of the Standards.
7. Examine the smoking policy in consumer housing with an eye to balancing health concerns with autonomy.
8. Consider the means by which the traditional medical community could benefit from involvement in consumer based services.
9. Explore the use of Social Security Work Incentives to enhance the consumers’ ability to work additional hours without penalty to existing benefits.
Closing
The team wishes to thank the staff of Assets (particularly Anita whose skills at scheduling are superb!) as well as all of those who participated in this review. You were all most gracious about sharing your space and your thoughts with us.
This report will be completed within two weeks and
sent to you along with a plan of action for your response.
Attached: Administrative and Personnel Checklist;
Questions for Related Agencies (tallied), Report Card (tallied)