INTEGRATED QUALITY ASSURANCE REVIEW

Bethel Community Services

September 28-30, 1999

Bethel, Alaska

 

Site Review Team:       

Joe Nicholas, Community Member

Kathy Polty, Community Member

Dottie Vasquez, Community Member

Melissa Stone, MH Peer Reviewer

Wini Crosby, DD Peer Reviewer

Pam Miller, DMHDD QA Staff Member

Carl Evertsbusch, Facilitator

 

INTRODUCTION

 

A review of the Mental Health and Developmental Disabilities services provided by Bethel Community Services (BCS) was FCMFwas conducted from Tuesday, September 28, 1999, through Thursday, September 30, 1999, 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.  The Division of Mental Health and Developmental Disabilities of the State of Alaska (DMHDD) Quality Assurance staff conducted the Clinical Record Review and provided that section of this report.

 

The Mental Health (MH) services provided by Bethel Community Services (BCS) include psychosocial development and client support, which includes residential care (Chamai House, Bautista House) and programs at the Learning Resource Center.  Developmental Disabilities (DD) services include assisted living (Malone Home), core services, individualized assistance, case management, respite, vocational/subsistence support, in-home support, day habilitation.  Funding is from state grants, Medicaid reimbursements and generated revenues from Bethel Community Foundation.  In FY 2000 the agency’s budget is $422,400 for MH services and $1,778,948 for DD services.

 

BCS also offers Infant Learning Program (ILP) services, day care assistance and a child care center, but they are not included in this review.

 

A seven member executive board governs the agency.  Of the occupied seats, 5 represent Bethel and two represent outlying villages. BCS has responsibilities to serve not only the Bethel community but also an area that contains 56 rural communities of the Kuskokwim Delta.  They currently serve consumers in 30 of those communities.  The board feels that representation from outlying areas is vital if the board is to comply with the requirement to have a governing body that represents the areas served.

 

 

 

 

DESCRIPTION OF REVIEW

 

This review was conducted over the course of three days and included interviews of 15 minutes to one-hour duration conducted by telephone or in person at the main office of BCS, the LRC or the Malone Home.  DMHDD requested 15 consumer interviews and provided BCS with 21 randomly selected case numbers or names for this purpose.  Of the 21 individuals selected, 16 consumers were available and willing to be interviewed as of Tuesday, September 28. As some consumers were not able to be interviewed at the scheduled time, the result was that 15 of those consumers interviewed were from the random list.

 

A teleconference with Tonja Rambow and Bob Hammaker yielded these requests for interviews: local school district personnel, a representative from law enforcement or the court system, a representative from the local hospital, a person from the infant learning program, a representative of Yukon-Kuskokwim Mental Health Services (YKMHS), a representative from AVCP, a representative from NAMI-Alaska and a representative from the local substance abuse program.  In addition, an interview with a Board representative was requested. Appointments with all the above, with the exception of substance abuse and YKMHS, were set by BCS.  The team was unable to contact the hospital representative at the appointed times and in subsequent attempts.  All other contacts were made and all items listed for particular review were completed.

 

In regards to grant compliance, the team was asked by DMHDD to: determine the number of consumers receiving mental health services and diagnostic information regarding those individuals receiving services; review the recent decision to transfer Mental Health services to Yukon-Kuskokwim Mental Health Services; identify staff training needs; determine if there are current Individual Service Plans; determine the quality of record keeping; determine how personal funds are managed; review the list of restrictions in the Malone Home; determine the time frame for the planned closing of Malone Home; review the high turnover of staff; describe the services provided at the Learning Resource Center; clarify DD services provided under Day Habilitation; determine the extent of the rural outreach efforts.

 

The result of the team’s efforts was 9 interviews with staff (6 direct service staff, 3 managers) and several informal conversations with the newly hired Executive Director; 6 interviews with the staff of other related agencies; 15 consumer interviews (7 residential consumers and 7 parents of consumers) and 1 with the board president. Those 30 contacts in addition to the 10 contacts at the Open Forum described below provided the team with the data from which to produce this report.

 

 

OPEN FORUM

 

BCS scheduled an open forum, as requested, on the first night of the review.  It was held at the U.S. Fish and Wildlife Offices. The agency advertised with flyers at their facilities, by mail, by cable television scanner and advertised the forum in the Tundra Drums.

 

The forum lasted from 7:00 PM to 8:30 PM.  Of the nine audience people who attended, three are employed by the local school district, two are parents, one is a former employee, one is a legal advocate and two are consumers. 

 

 One parent read from a prepared statement detailing the frustrations his family has experienced with what was characterized as an unresponsive statewide system of service delivery. (The statement is attached.)

 

The local legal advocate expressed that he has enjoyed a “good rapport” with BCS, while not always getting what his clients want.

 

A school staff member stated that BCS could do a better job of informing communities in the Kuskokwim Delta as to the service options available both locally and statewide.  She shared the opinion that BCS as an organization is doing the best that it can, but feels there is much room for improvement.  One primary area she identified was recruiting and training respite staff.  This person has strong feelings that the people in the Delta area are underidentified and underserved.

 

A former employee was critical of the lack of success of an outside agency’s efforts to transform BCS supports and services.  She attributed much of this failure to BCS’ “internal and external politics” that undermined the other agency’s efforts.  She also strongly feels that there is disportionate BCS funding expended in the outlying villages.

 

Other comments are included in the body of the report.

 

FINDINGS

 

PROGRESS SINCE PREVIOUS REVIEW

During the previous review of BCS DD services, the review team made several recommendations.  BCS staff was unable to produce an Action Plan or any indication that the following recommendations were formally addressed.  However, the team noted that some of the following areas of concern have seen some progress:

·        Update the mission statement to be in line with employee manuals, services and the concept of normalization (1.1.1).

·        Staff in all areas needed job-related training and planned training options, there is still need for improvement (1.1.2).

·        BCS Board has all grant/program proposals and budgets presented to them, (1.3.3).

·        Individual plans need to be current and include family input,  (1.4.1).

·        An appeals process needs to be written and presented to families, (1.4.2).

·        Any short and long term planning needs to be based on verified family needs (1.5.1, 1.5.2).

·        Brochures and other educational material need to be placed throughout town and villages, (1.6.1)

·        Operation training manuals, policies on research etc. need to be made and or updated, (1.6.2, and 1.6.3).

·        Job descriptions need to be updated (2.1.1).

·        Upgrade staff orientation and training both at the time of hire and on-going training options.  This requires ongoing improvement (2.3.1, 2.3.5).

·        Signs should not depict the Homes.  The Malone Home continues to have a sign in place  (3.1.1).

·        Homes should serve fewer consumers. This is an area that BCS has begun initial planning targeting three people for transitioning into the community of choice (3.1.2, 3.2.1, 3.5.3, 3.5.4).

·        Actively seek employment opportunities with consumers (5.1.1, 5.1.2, and 5.2.1).

·        Gather input from families, surveys, or assessments (6.1.1).

·        Create and distribute advertisements or brochures about the program in the community (6.4.1).

·        Inform families of programs like TEFRA, Medicaid Waivers, community based Medicaid Waiver, etc, there is evidence that many families still do not possess this information  (6.4.1).

·        Create current plans for consumers in the villages. This continues to be a serious gap in service delivery and should be remedied as soon as possible (7.1.1, 7.1.2).

*Note: The items listed above are referenced to the previous DD program standards.

 

CHOICE AND SELF-DETERMINATION

 

The team identified the following strengths under Choice and Self-Determination for people receiving and DD services from BCS:

+  Consumers can get where they need to get to when they want to.

+  Five staff have been trained in person centered planning. (DD)

+  Families are provided vouchers for respite that provides them with a choice of providers. (DD)

+  Some consumers reported they liked their jobs.

 

The team identified the following weaknesses under Choice and Self-Determination for people receiving MH and DD services from BCS:

-     There are no current Individual Service Plans. (DD)

-         Although some meetings have occurred, there is no documentation supporting any planning meetings involving individuals. (DD)

-         People have limited choices in their daily lives.

-         Staff lack training and skills in supporting individual choice.

-         MH consumers have not been involved in planning the transition of services to Yukon-Kuskokwim Mental Health Services. (MH)

-         People have not been presented with living options.

-         Consumers’ lives appear to be managed, rather than supported at the Malone Home. (DD)

-         Some families revealed a lack of awareness of the extent of BCS services.

 

DIGNITY, RESPECT AND RIGHTS

 

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

+   Consumers reported staff respected them.

+   Staff who were interviewed demonstrated a high regard for people with disabilities.

+   Staff respects consumers’ privacy and protect confidentiality.

+   Participation at Fish Camp provides opportunities for consumers to maintain cultural ties and could lead to opportunities for the development of natural support networks.

 

The team identified the following weaknesses under Dignity, Respect and Rights for people receiving MH services from BCS:

-         Most consumers who were interviewed were neither aware of their rights nor of a grievance procedure.

-         A consumer who uses a wheelchair finds the ramp to Camai House too steep and the vans are too steep.

-         Homes are referred to by title of program rather than the address.

-         Some consumers reported wanting to make more financial decisions.

-         Privacy is difficult for people living in the Malone Home.

 

HEALTH, SAFETY AND SECURITY

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

+   Consumers who were interviewed reported they felt safe and secure where they lived.

+   Consumers consistently described fire safety procedures.

+   Consumers were comfortable that immediate medical and dental needs will be met.

 

The team identified the following weaknesses under Health, Safety and Security for people receiving services from BCS:

-         Some consumers revealed lack of awareness of individual health needs and where they could receive various medical services.

 

RELATIONSHIPS

 

The team identified the following strengths under Relationships for people receiving services from BCS:

+   Consumers shared with reviewers that they enjoyed several friendships.

+   Staff make efforts to maintain family ties with consumers.

 

The team identified the following weaknesses under Relationships for people receiving services from BCS:

-         Consumers have limited opportunities to make friends in the community.

-         There is concern expressed by staff regarding the lack of family ties that several consumers experience.

 

COMMUNITY PARTICIPATION

 

The team identified the following strengths under Community Participation for people receiving services from BCS:

+  Consumers are assisted with attending their churches of choice.

 

The team identified the following weaknesses under Community Participation for people receiving services from BCS:

-         Consumers participate in segregated activities.

-         Public perception is that people receiving supports from BCS spend most of their time together, both at home and in the community.

 

 

Consumer Satisfaction Chart

MH

Choice   N=5

Dig&Res. N=5

Hth,Saf,Sec N=5

Relatns. N=5

Com.Par. N=5

Outcome

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Person/Parent/guardian

2

2

1

5

5

5

4

1

Staff Performance

Person/Parent/guardian

4

1

5

5

5

5

 

DD	Choice   N=10			Dig&Res. N=10			Hth,Saf,Sec N=10			Relatns. N=10			Com.Par. N=10
Outcome	Yes	No	Unk	Yes	No	Unk	Yes	No	Unk	Yes	No	Unk	Yes	No	Unk
Person/Parent/guardian	5	3	2	9	1		9	1		7	3		5	5
Staff Performance
Person/Parent/guardian	5	4	1	9	1		10			7	3		7	3

 

 

Staff Interviews

 

Staff are dedicated and caring of the people they support.  “The best part of my job is the people I work with.” BCS experiences high staff turnover rates and continually seeks ways to recruit and retrain qualified staff.  “I don’t know why, but we can’t seem to find enough people who want to do this work.”  Several of the recently hired staff have brought new energy to their positions, but care must be taken that they do not become overextended and ‘burn out’. 

 

Staff in the Malone shared that the weekly meetings provide them with opportunities to express their concerns and receive information about the programs and organization. Some staff also revealed a limited knowledge of what other programs were doing.  The review team also discovered that there is not a consistent philosophy across teams. 

 

Employees spoke of the hope for a new direction for BCS and their satisfaction with the recent additions to the management team. People gave positive comments on their coworkers, “We make a good team.”  Staff are dedicated, which is reflected in a willingness to work extensive hours to assure that things are completed.  “I often work over 50 hours a week, and I don’t resent that.”  Staff also recognize that there is a lot of work to do to get the agency to where they want.  In spite of many changes in personnel, staff feels supported by the administration.

 

Staff show respect for the people they support and want them to have good lives, “Working with the clients is the best part of my job.”

 

Staff expressed a desire to become more involved in what was going on in the agency.  “I don’t always know what’s going on.”  It is important that staff are included in any reorganization or strategic planning that occurs at BCS in the future.  Direct service staff at the Malone Home commented on the improvements in their work now that there are weekly meetings with their supervisor.  Direct service staff appreciate the opportunity to be involved in the hiring of new staff. 

 

Staff expressed a desire for more training, “I want to learn better ways to help the people I work with.”  Some staff members revealed that they didn’t receive enough of an orientation.  “I didn’t get any training when I started; I learned on the job.”  Some staff reported that they have not had an evaluation since working for BCS.  Partially, that can be attributed to their short tenure with the agency, but personnel files had no documentation of orientations.

 

There is a significant need for staff training to facilitate movement towards the new direction the agency is taking.  Person centered services, quality of life, positive behavior support, systematic teaching and documentation are a few of the areas where training is needed.  Staff orientation needs to be timely and thorough.  This, paired with the dedication, should help the organization achieve the goal of providing quality services in this region.

 

Direct service staff commented on their pay and benefits and expressed a desire that they could eventually earn a larger salary, “The pay here isn’t that good, but I understand that BCS can’t change that right now.”

 

As proof of an openness by which staff revealed their understanding of the quality of services offered, the initial presentation of the DD program revealed an extensive list of areas needing improvement: recruiting and retaining staff, timely performance evaluations and staff improvement plans, provision of regular staff supervision and support, person centered planning and program implementation, support of individual health needs, adequate staffing, knowledge of positive behavior support, effective program monitoring, documentation, relevant policy and procedures, creation and renewal of Medicaid waivers, individualized/core service/agreements revisions, family respite information, case management, interagency collaboration, acquiring necessary funding for adequate staffing/coordination/case management/outreach/services to unfunded individuals/true costs of Medicaid waiver services.

 

Basically, staff is anticipating changes that will be implemented by the new leadership and are looking forward to some stability and direction.  They are very interested in the welfare of the people they support and willing to help them have lives of quality.  With additional training and support, their efforts will be greatly enhanced, and, likely, successful.

 

Collateral Agency Interviews

 

The team’s interviews included 6 representatives of 6 agencies.  The summary of the responses to the uniform questions asked is attached at the end of this report.

 

Responses revealed a respect for the staff at BCS and talked about improvements in their relationships. “I love working with their staff.” “They are always good to work with.” “Things are much better with the new staff.” “They (BCS staff) care so much the clients.”

Other positive comments include the following:

Staff is guided by the best interest of the consumers.

 

Difficulties experienced by some providers include:

1.       A lack of knowledge of the services BCS provides. “If we had a list and description of services and who provides them and at what age students qualify for services, we would be able to refer more families.”

2.       A need for outreach, especially in the outlying area.

3.       A need to improve communication with some agencies.

 

Administrative and Personnel Standards

 

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 14 of which are completely met by BCS.  The additional 20 standards are either partly met or not met.  Those standards not fully met are included in the Areas Requiring Response.

 

With the new leadership and the eagerness displayed for improving services, the next year will be critical to BCS’s efforts to enhance their influence over supporting families and people with disabilities.

 

Program Management

 

Of primary concern is the lack of a strategic plan, or of measurable goals and objectives that would help guide the organization’s efforts to improve services.  A recent Board decision to transition Mental Health services to Yukon-Kuskokwim Mental Health Services has resulted in the initial step of transferring clinical supervision to that agency on October first.  A Memorandum of Agreement (MOA) detailing the complete transition has been drafted, but a final decision has not been made.  Staff involvement has been limited in the initial planning process.   The Board and new administrator are revisiting this decision and are considering an alternate approach to making a final determination. If plans continue to negotiate a contract with YKHC to provide clinical supervision, treatment team leadership and assessment, care needs to be taken that staffing is adequate to meet those needs.  Care must also be taken to assure that both organizations have a shared treatment philosophy if they are to collaborate in providing MH services The review team urges the Board and management to quickly develop a clear direction for BCS and include staff in the process.  This should go a long way to easing the discord experienced by staff while facing an uncertain future. 

 

The review team also recommends that goals and objectives be developed that will show improvements that have already occurred, those that have been initiated and those that will be implemented in the future.  Positive comments were received from staff regarding the new Executive Director.  The feeling is that BCS will begin to move forward. 

 

Recruitment, retention and training of staff are a recognized problem, and the team suggests that the organization also consider conducting market survey of staff salaries to make BCS competitive for the recruitment of new staff.

 

The review team wishes to acknowledge the efforts of the organization to balance a budget that was at one time seriously deficit.  The review team recommends that the Directors receive Board training to assist them in their goal to improve services in the Delta.

 

The review team found what they perceive as a lack of centralized effort across program teams.  There doesn’t appear to be a shared philosophy of care and support which is manifested in a mixing of institutional and community living models.  Training issues that have been identified by the staff and the site review team need to be addressed in order to infuse and support a cohesive and effective agency service delivery philosophy that is consistent with the DMHDD Service Principles and Quality Assurance Standards. The team suggests that BCS evaluate their organizational structure to develop a management system that would include defined teams with emphasis placed on individualized service delivery.

 

A lack of technical assistance may be partially responsible for the existence of barriers to successful organizational change and growth, especially in the areas of enhancement of the quality of life, community participation, waiver planning, Medicaid billing, medical record management, individual service planning, challenging behaviors, etc.  The team recommends that BCS receive technical assistance from DMHDD to assist their efforts to provide a high quality of services in this region.

 

 

 

 

QA CLINICAL CHART REVIEW

 

INTRODUCTION

The clinical chart review was conducted for the purpose of determining what information the agency needs to be able to generate documentation that reflects good clinical practice.  Another reason for the review was to conduct a mini-event audit for the Division of Medical Assistance (DMA). This audit determines 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 and by the provider for non-Medicaid cases.  The number of charts to be reviewed was determined by a range table based on the total number of cases. 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  (5) Medicaid charts (there were no non-Medicaid recipients).

 

Strengths

 

 BCS has made excellent progress following through with the recommendations made from the previous site review conducted by DMHDD's QA staff. Every file reviewed contained a current intake assessment and several current psychiatric evaluations and updates. Assessments now include components that were found to be lacking in the previous review. The quality of all documentation appears to have improved dramatically. Treatment plans address goals and objectives in measurable and observable terms in a more consistent practice. The team, supervising clinician and consumer are signing the majority of them. Treatment reviews are also present in files. Excellent job in addressing progress towards each goal on the treatment plan on review documents.  Most all notes billed for were present in the charts.

 

Areas For Improvement

 

Assessments need refining to contain clear written summaries of mental health problems and treatment recommendations, clear statements regarding eligibility for services, and clear documentation of supporting evidence for the diagnosis given. The designing of treatment goals to be more specific and individualized is an ongoing process. Please include service modalities on treatment plans. Progress notes need to identify the specific goal being addressed and document clinically relevant information. Be careful not to get caught in a "canned" treatment process (where all plans and notes look the same with different dates and client names). Treatment reviews are required to occur every 6 months if a consumer is receiving rehab services. If they are receiving IRS, reviews need to occur quarterly.

 

For more detailed information, please refer to the Clinical Findings Report dated 9-29-99.

 

 

 

 

 

 

The team discovered a general lack of organization of BCS’s program record keeping system. 

No review was conducted of the DD individual service plans, because none are current.  The review team strongly recommends that individual planning begin immediately as a means to bring the agency into compliance with state regulations.

 

 

AREAS REQUIRING RESPONSE

 

1.       The Board needs to create a strategic plan.

2.       Assure that the transition plan of MH services to YK includes protections against disruptions in treatment services for individuals. (MH)

3.       Efforts should be made to include consumers in operation of LRC. (MH)

4.       Develop individual service plans. (DD)

5.       Make effort to eliminate segregated activities.

6.       Increase training for staff in areas of respite, person-centered planning, community connections and relationship building and advocacy and self-determination.

7.       Work with individuals to determine where they want to live and develop plans and strategies to help them accomplish this.

8.       Provide more opportunities for people to become a part of their community and develop relationships. (DD)

9.       Assure that all individuals have access to homes and transportation (one person reported the ramp to his home was too steep and he had no accessible transportation).

10.   Assure that families and consumers are provided information regarding available service options and community resources.

11.   Continue to work to reestablish family ties to consumers. (DD)

12.   Create a clear, written mission or philosophy that focuses on the services it provides and how it empowers consumers and their families. (Admin. Standard #1)

13.   Provide agency-wide education and orientation about mission, philosophy and values to promote understanding and commitment to consumer-centered services in daily operations. (Admin. Standard #2)

14.   Assure that all facilities and programs operated by the agency provide equal access to all individuals. (Admin Standard #11)

15.   Actively gather and utilize consumer and family input in agency policy setting and program delivery. (Admin Standard #12)

16.   Include 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. (Admin Standard #13)

17.   The agency should develop annual goals and objectives in response to consumer, community and self-evaluation activities. (Admin Standard #14)

18.   Assure that all agency publications and materials include People First language. (Admin Standard #16)

19.   Improve collaboration with other community agencies to maximize resource availability and service delivery. (Admin Standard #17)

20.   Collect required data and submit it to DMHDD. (Admin Standard #18)

21.   Provide appropriate training and supervision to enable staff to perform their job functions and meet all necessary legal, ethical, and regulatory requirements. (Admin Standard #19)

22.   Develop a system to systematically review all job descriptions. (Admin standard #20)

23.   Include consumers in the hiring and evaluation of direct care staff. (Admin Standard #22)

24.   Assure that all direct staff receive criminal background checks. (Admin Standard #24)

25.   Provide 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. (Admin Standard #25)

26.   Update policies and implement procedures to address the development of non-paid relationships between consumers and other community members. (Admin Standard #26)

27.   Provide staff with timely evaluations and work improvement plans. (Admin Standard #29, #31)

28.   Identify available resources to meet the assessed training needs of staff. (Admin Standard #30)

29.   Improve the quality of performance goals and objectives for the period of appraisal. (Admin Standard #32)

 

OTHER RECOMMENDATIONS

1.       Communicate/clarify to consumers and families the transition plan of MH services to YKMHS

2.       Provide training to Board of Directors.

 

 

CLOSING COMMENTS

The team thanks the staff of BCS for their kind hospitality and candor.  It is rare that an organization is as forthcoming of information that reveals significant areas of concern in their internal operations. The review team wishes BCS the best in meeting their challenges and is encouraged by the attitudes expressed by a dedicated staff.

 

The final draft of this report will be prepared within 7-14 days and sent to DMHDD.  DMHDD will then contact BCS to develop collaboratively a plan for change.