INTEGRATED QUALITY ASSURANCE REVIEW

Family Centered Services of Alaska

November 2-4, 1999

Fairbanks, Alaska

 

SITE REVIEW TEAM:

Boy Collier, Community Member

Cliff Pananen, Community Member

Helen Stark, Community Member

Dave Newell, Peer Reviewer

Robyn Henry, Facilitator

Pam Miller, Lead DMHDD QA Staff member

Nancy Mathis, DMHDD QA Staff

Connie Greco, DMHDD QA Staff

 

INTRODUCTION

A review of Mental Health services provided by Family Centered Services of Alaska (FCSA) was conducted from November second to November fourth, 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 (DMHDD) of the State of Alaska Quality Assurance staff conducted the Clinical Record Review and provided that section of this report.

 

Description of Program services

FCSA provides services to families in the Fairbanks region whose children experience severe emotional difficulties. Through a variety of agency programs FCSA offers an array of individualized wrap around services. These agency programs include: the Youth Education Support Services (YESS) Program which offers educational services such as short and long term day treatment, summer school and individualized consultation; the Alaska Youth Initiative (AYI) Program which provides wrap around services to the most severely disturbed children who are at risk of out of state placement; the PathFinders Program which provides intensive services in the community to SED youth who are at risk but not eligible for the AYI program; the Crisis Prevention Services (CPS) Program which provides comprehensive support to families focused on preventing a crisis from occurring.

 

Other services provided by FCSA include peer support through a full time parent advocate, full time psychiatric services, psychological services, therapeutic foster care, therapeutic respite care, staff/family training and consultation to rural communities. FCSA’s collaborative projects include the WILD about Denali program offered in conjunction with the Denali Foundation and the US Park service, the Safe Schools / Healthy Students Project, a federal demonstration project offered in collaboration with the Delta Greely School District and various collaborative vocational projects offered in cooperation with a variety of community agencies.  

 

A 9-member board of directors, who meets monthly, governs FCSA. The staff of FSCA also takes suggested direction from a parent advisory committee made up of current and former clients of the program. The agency provides services to and average of 100 families at any given time, having served 232 families over the course of FY 99. The agency employs 92 full/part time staff.

 

According to the agency’s independent audit, total expenses for services in FY 99 were

$ 3,507,000.

  

Description of the process

To conduct this review, an interview team consisting of a facilitator, three community representatives and a peer reviewer met for three days in Fairbanks, Alaska. The team conducted 26 interviews, of which 10 were with individuals who receive services from FCSA, 7 with related service professionals, 3 with board members and 6 with FCSA staff. Interviews were held in person at FCSA's offices and by telephone. The interviews lasted from 15 minutes to an hour.

 

During this same period of time 3 members of the DMHDD Quality Assurance Unit did a review of randomly selected client records.

 

The interview team members also did a limited review of four agency selected personnel files, the agency policies and procedures manuals and other administrative documents. After gathering the information, all the team members met to review the data and draft the report, which was presented to the staff on the final day of the visit.

 

The review team's findings are reported below. The report includes a review of the previous findings, an administrative review, areas of programmatic strength, specific services or procedures that are recommended for improvement and tables of consumer satisfaction with quality of life and services.

 

Open Forum

 An open forum was held at the Fairbanks Public Library at 7:00pm on November second^. FCSA advertised the event for at least three days in the local newspaper,  posted the event on the local community web site and sent out flyers to all current service recipients. Four people attended the forum, three were parents of children who have received services from FCSA and one was an interested community member. The feedback provided to the team at the forum is incorporated in the body of the report.

 

FINDINGS

 

Progress Since Previous Review

As this is the first review of FCSA using the new program standards, there is no previous action plan for these integrated standards. A plan for improvement required for the chart reviews will be addressed separately in the DMHDD QA report.

 

Model Practices

Model practices are practices or programs within the agency that the team feels should be recognized as exceptional practices that are worthy of replication in other agencies.

 

Crisis Prevention Services – This program was praised by many of the families interviewed. One parent stated "CPS is their (FCSA) greatest asset…. they have been life savers”. It was obvious to the team that the program’s focus on prevention and immediate response to families in need has been very effective in producing positive outcomes to families in impending crisis. The program offers support to anyone in need and offers a range of services from “check-in” type monitoring to licensed emergency foster care.

 

Parent Advisory Committee- On several occasions, people interviewed indicated the effectiveness of the Parents Advisory Committee. The committee clearly has a direct line of communication and feedback to the administrative staff. The pervasive sentiment was that feedback was well received and that suggestions were implemented almost immediately. One parent commented that, in many ways, the committee has more influence on daily program operations than the board. The team is impressed with this proactive move, taken by the agency, to formally incorporate parent feedback in program improvement.

 

Youth Counselor Services – It was clear to the team that one of the critical elements of this agency’s success is the provision of youth counselor services to families. This practice of having youth counselors provide support to families in their home and in the community is a lifeline for many families interviewed. A parent stated the youth counselor “helped me through hell”. Services clearly focus on providing support to the family where and when it is needed.

 

Choice/Self-determination

The team identified the following strengths under Choice and Self Determination for those receiving services from FCSA:

+  Overall, most people interviewed indicated that FCSA is a very family centered organization and that staff worked hard to provide services that catered to individual family needs.

+  One family member stated that the agency had “younger people to help with my grandchildren” another parent stated their counselor “was the best thing that ever happened to the family”.

+  The agency strives to make the family the center of the service planning process. One person indicated that they were impressed with the fact that a child could have the opportunity to call their own team meeting if they wanted one.

+  FCSA staff actively listen to the people they serve and respond to the needs that are expressed.

 

The team identified the following weaknesses under Choice and Self Determination for those receiving services from FCSA:

-         Several families commented on the lack of choice regarding counselors and that at times the counselor assigned was not a good match for the family.

-         Also mentioned was the continual turnover of counselors.

-         One family mentioned the limited time frame of services and that service options did not meet

      the needs of their schedule.

 

Dignity, Respect and Rights

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

+     Generally, parents interviewed felt very respected and valued by most of the staff at the 

       agency. One parent stated that “they made me feel like I was a good parent”.

+     Several people interviewed, including related service agency staff, said that they feel that the

       program is a safe place to express their feelings about services. They felt that their concerns

       were listened to.

+     The agency’s overall philosophy focuses on care and unconditional support to families.

+     Both consumers and staff interviewed stated that the FCSA office environment contributes to a

       relaxed and welcoming atmosphere.

 

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

-         One parent said they felt their confidentiality was broken when another service provider knew

Information although a release was not provided.

-     One client felt that the counselor accused them unjustly of dealing and using drugs.

-     A couple of parents indicated that they do not remember hearing about their service rights.

 

Health, Safety and Security

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

+    Several families clearly stated that the services provided to them from the program contributed

      to a more safe and secure home environment. The support appeared to serve as a stabilizing

      factor to an otherwise turbulent ( and sometimes violent) home environment.

+    Overall, families interviewed indicated that their basic needs and health care issues are

      adequately addressed.

 

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

-         Several families expressed their frustration in not having a secure community based treatment

      facility for adolescents in need of intensive support. Many are now sent to Fairbanks Youth

      Facility or are sent out of Fairbanks.

-     One parent indicated that they were upset when their child did not get his medications while in

       the Fairbanks Correctional Center even after the intervention of Dr. Ackley, FCSA’s staff

       psychiatrist. (Note: This situation is not within the control of this agency)

 

Relationships

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

+   Most of the families interviewed felt strongly that FCSA services enhanced their family’s

     relationships. One parent stated “I finally feel like I have my kids back”.

+  One parent indicated that the youth counselor helped their child build supportive relationships.

+  Several parents indicated that services enhanced relationships among siblings.

 

The team identified the following weaknesses under Relationships for those receiving services from FCSA:

-  Several parents indicated that Youth Counselors varied in their ability to handle relationship and

    behavioral issues.

 

Community Participation

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

+    Youth counselor services contribute to getting youth out into the community more and

       to increasing their self-esteem.

+    Community vocational projects offer opportunities for youth to work and interact in community

      settings. Several people specifically cited the woodworking and bike repair projects as valuable

      activities.

+   The WILD about Denali program was praised as creative, life enhancing and fun experience for

      the youth. Such opportunities can offer first time experiences for youth that can build self-

      esteem.

 

The team identified the following weaknesses under Community Participation for those receiving services from FCSA:

-         Several parents thought there were not enough options for work in the vocational projects

      offered.

-    Several people interviewed expressed concern that wrap-around services have the potential to

      create service dependency and that this may create community isolation.

-         One client indicated that the lack of transportation services prevented her from using services

       to which she was referred.

 

Other Strengths

+    The team commends the agency’s attempt to provide educational services through the YESS

       program to youth who have been unable to achieve in other school settings. One parent

       indicated that the YESS program was the only place his son did well academically.

+     FCSA board, staff and consumers appear to work very collaboratively on service and program

       improvement.

 

Other Areas of Concern

-         While the team supports the idea of the YESS program and the agency’s efforts to provide

      services to this population, several people interviewed indicated that they had concerns about

      the program. Concerns included the level of clinical expertise in the program, the fact that the

      program may contribute to isolating kids, the lack of outcomes and accountability, the lack of

     structure and monitoring and the lack of vocational emphasis.

-         Several parents indicated their concern over the lack of transitional services. (Note: This is a

      system issue and is outside the control of this agency.)

 

 

Consumer Satisfaction Chart

MH	Choice   N=10			Dig&Res. N=10			Hth,Saf,Sec N=10			Relatns. N=10			Com.Par. N=10
Outcome	Yes	No		Yes	No		Yes	No		Yes	No		Yes	No
Person/Parent/guardian	8	2		7	3		9	1		8	2		8	2
Staff Performance
Person/Parent/guardian	9	1		8	2		8	2		8	2		8	2

 

 

Staff Interviews

 

The team interviewed six FCSA staff selected by the agency. The general overall feeling from staff interviewed was that they really liked working for the agency. They felt that they were valued by the agency and they liked the program service philosophy and work environment. Draw-backs included low pay for line staff, lack of consistent hours, inconsistent communication between main office and offsite programs, increased documentation requirements (including Medicaid, ARORA and other state and federal requirements) and lack of consistency and longevity in Youth Counselor assignments to families.

 

One staff member mentioned the need for more cultural sensitivity training especially in Native Alaskan traditions and practices. Several staff members mentioned the agency’s rapid growth as both good and bad. They were generally positive about the increased capacity to serve more clients but also felt the “growing pains” as the agency tries to keep up with its increasing size. One staff member mentioned that the agency used to be “bottom heavy” and now it is more “top heavy” and that the line staff feels more isolated. Several people interviewed echoed this fear of staff isolation. One staff member mentioned that there are so many chains of command its hard to know how to communicate with the top. Another staff member indicted that she felt that she needed more back up from the agency when setting limits with families. She said she often felt like the “bad guy” when she had to say “no” to families who were asking for services beyond her job description.

 

Collateral Agency Interviews

 

Seven people from collateral agencies were interviewed including representatives from The Fairbanks Resource Agency, the Court System, the Fairbanks and Delta/Greely school districts, corrections, Fairbanks Counseling and Adoption and the Fairbanks Community Mental Health Center. The general consensus is that collateral agencies interviewed have a very positive relationship with FCSA. All people interviewed indicated that they felt that FCSA did a good job following up on cases referred to them and that collaborative efforts in general were very positive and productive.

 

The concerns identified included: that the AYI referral form was far too long and that the wait for the program (sometimes up to 4 months) prevents the agency from referring clients; that the level of clinical knowledge varied among staff members and that there was, therefore, a lack of consistency.

 

 

Administrative/Personnel Narrative

 

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 31 of which are completely met by FCSA. It should be noted that this score is an exceptional level of administrative compliance. Those standards not fully met include:

1.       Standard #22 states: “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.” The procedure for hiring and evaluating staff was identified as a staff function with limited direct input from consumers/families.

2.       Standard #29 states: “A staff development plan is written annually for each professional and paraprofessional staff person.”  While each job description included annual minimum professional development hours, there were no records of individualized staff development plans.

 

3.       Standard #32 states: “The performance appraisal system establishes goals and objectives for the period of appraisal”  While some evaluations reviewed included comments and informal suggestions, no specific goals and objectives where noted.

 

 

 

CLINCIAL RECORDS REVIEW

There was real strength noted in the course of review of this agency.  All members of the file review team commented on the severity of the issues being treated and the documented progress of the consumers toward reaching their goals.  Assessments were the strongest area followed by treatment plans.  Progress notes and treatment plan reviews are not as strong, as depicted by the below graph.  Any suggestion for improvement in these areas is documented in the clinical report that reflects the findings of this review team. A review of two of the day treatment charts indicates the need for the agency to review all documents in these charts to ensure that they meet all requirements of the Mental Health Standards. Family Centered Services could benefit from documentation training provided by DMHDD, QA staff.  It is further recommended that a desktop review of Day Treatment charts be conducted once the agency has had an opportunity to review these charts and implement necessary changes.

 

 

 

 

 

 

 

 

Program Management:

Overall, FCSA seems to be a very well managed program run by very caring and creative people. The overall atmosphere of the agency is one of optimism with a focus on providing high quality, client centered services. Lines of communication among staff appear to be respectful, considerate and very open. Overall the team was very impressed with the professionalism and thoughtfulness with which the agency is managed.

 

While the agency should be commended for weathering through their recent financial crisis, the team has significant concerns about the agency’s limited cash reserves and their ability to prevent a future financial crisis. Your efforts to diversify your funding sources are appreciated and further encouraged.

 

 

Areas Requiring Response

 

1.        The agency needs to devise a system for incorporating consumer choice into the hiring and evaluation of direct service providers. (Standard #22)

2.        The agency needs to further develop its staff evaluation process to include specific staff development plans and annual goals and objectives for each staff person as they are evaluated and support in meeting these goals. (Standard #29)

3.       The agency should re-evaluate the YESS program, through a process which would include  surveying consumers, staff and collateral agencies, to identify areas of service improvement needs. (Standard #32)

4.       Given the concern expressed regarding confidentiality, review with all the staff the limits set by law on the exchange of information.  Although this may be a review, it would answer this concern.

5.       Given the concern expressed regarding service rights, check that service rights are reviewed with all family, supply them to each family in written form, provide staff with copies and post copies if this are not already done.

6.       Devise a plan to decrease turnover among counselors.

7.       Given the staff concerns, consider the ways in which changes in the agency have negatively impacted staff in the areas of communication, isolation and working conditions for counselors.

8.       Attempt to shorten the waiting list for AYI or document the rationale for the wait.

9.       Provide cultural sensitivity training to all staff working with Native families including, if possible, Native family systems.

 

 

Other Recommendations

 

1.       In your continual growth, especially in acquiring grants, it is advised that you caution staff regarding burn out, particularly in upper management, as you take on further obligations.  It is advised that adequate resources be available to meet the increased need.

2.       It is suggested that you continue to pay close attention to line staff turnover as it was identified as a concern by many of those interviewed and can be very disruptive to service delivery.

3.       It is suggested that the Board and staff acquire a 90  day operating cash reserve

4.       Given the concern expressed regarding choice of counselors, make every effort to aid the adjustment of family to counselor and vice versa.

5.       Given the concern expressed regarding vocational project choices, attempt to increase or individualize these options if feasible.

6.       Given the concern expressed regarding service dependency and isolation from the community, devise a plan to remediate those outcomes.

7.       While not the responsibility of this agency, attempt to collaborate with other agencies regarding the transportation needs of those you serve.

8.       While not the responsibility of this agency, attempt to collaborate with other agencies regarding transitional services.

9.       While not the responsibility of this agency, attempt to collaborate with other agencies and funding sources regarding the need for a secure community based adolescent treatment facility offering intensive services.

10.   While not the responsibility of this agency, attempt to collaborate with Corrections regarding medication administration.

 

Closing:

The team wishes to thank the staff of FCSA for their cooperation and assistance in the completion of this review. Many of the FCSA staff went out of their way to accommodate the team’s need both on site and in preparation for our visit.  A process such as this can be very disruptive to the office environment and your hospitality was much appreciated by all of the team members.

.

The final draft of this report will be prepared within 7 days and sent to DMHDD.  DMHDD will then contact FCSA within 30 days to develop collaboratively a plan for change.

 

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