Fairbanks Resource Agency 1999 Integrated Quality Assurance Review Report

INTEGRATED QUALITY ASSURANCE REVIEW

Fairbanks Resource Agency

October 12 to October 15, 1999

Fairbanks, Alaska

SITE REVIEW TEAM:

Jane Trainor, Community Member

Kathie Elmore, Community Member

Cindy Zimmerman, Community Member

Jay C. Bush, Peer Reviewer, Anchorage

Sherry Modrow, Facilitator

Dan Weigman, DMHDD QA Staff Member

INTRODUCTION

The Site Review Team reviewed DMHDD-funded Developmental Disabilities Supported Services provided by Fairbanks Resource Agency (FRA) from October 12 to 15, 1999, using the Integrated Quality Assurance Review process.

This report summarizes 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.

FRA is a nonprofit organization providing support for people who experience developmental disabilities. The organization’s mission is to assure the full inclusion of people with disabilities in the community. The mission appears in offices and in publications, and concerted efforts are undertaken to base all services on the stated mission.

FRA’s 15-member board of directors is composed of community volunteers. The board sets policy, monitors and guides fiscal activity, and supervises the executive director. Some members of the board have served in that capacity for over a decade. Approximately one-third of board members have close relatives who experience disabilities and use FRA services.

DMHDD-funded programs at FRA form a life span support system that includes employment services, community living services, family support services, respite care, care coordination and STAR, the family support project. The organization employs about 169 full- and part-time staff members. FRA currently receives approximately $1.6 million in funding from DMHDD and $1.45 million as Medicaid waivers. The Fairbanks North Star Borough forms the service area.

The site review team met for four days at FRA’s office in Fairbanks. The team consisted of 3 community members, a peer reviewer, a member of the DMHDD Quality Assurance staff, and a facilitator. Team members conducted 54 interviews. These included 21 consumers and 8 family members or guardians. Interviews were completed with 3 board members, 10 direct service employees, the agency’s executive director and assistant executive director. The team also interviewed 3 community employers of consumers and 8 individuals who work at the following related agencies:

Alaska Division of Vocational Rehabilitation

Crossroads

Adult Learning Programs of Alaska

Alaska Division of Family and Youth Services

Public Health Nursing

FNSB School District HIRE program

FNSBSD special education teacher

Fairbanks Community Mental Health Center

Interviews lasted between 20 minutes and one hour and were conducted by telephone or in person at people’s homes or at FRA.

Open Forum

FRA planned and advertised an Open Forum on October 12 at the Noel Wien Library. Postcards were mailed to the agency’s consumers. Businesses and related service agencies received fliers describing the event. Two persons attended, a consumer and the parent of a consumer. Comments made at the Open Forum centered on the STAR and respite programs, and have been incorporated into the body of this report.

FINDINGS

Progress Since Previous Review:

1. Develop a process that results in consumer membership on the Board (e.g., mentor ship, partnering with People First, reasonable accommodation, etc.).

The agency has responded by developing a plan to fill a vacancy on the board with a current consumer who experiences developmental disabilities and who receives services from FRA. Completion of this process is dependent on identifying a willing candidate.

2. Include a statement or policy for addressing the use of individuals in research.

This has been accomplished.

3. Include consumers in the hiring and evaluating of staff.

This has been implemented successfully.

4. Observations suggest that inadequate staffing ratios occur in some areas.

The agency is aware of this concern and has taken reasonable steps to assure that staff ratios remain within appropriate and safe levels.

5. Continue to seek ways for making all homes accessible.

All individuals requiring accessibility accommodations are living in accessible homes.

6. Increase opportunities for people to participate in typical community activities.

Direct contact staff review current community opportunities on a weekly basis with individuals in order to offer choice. This has been met.

7. Advocate to assure people’s right to use public transportation.

FRA has been and continues to be instrumental in the community and in the state to provide people access to and to assure increased availability of public transportation.

8. Assure that all people are assisted in finding work in regular community settings.

Considerable improvement has been made in this area. FRA continues to explore and secure employment opportunities in the community. FRA has been successfully placing those individuals who request either paid or volunteer community employment opportunities.

9. Explore multiple methods for accurately assessing the quality of service delivery.

The agency has implemented a survey of people on the respite care list who are not using services to determine reasons for non-utilization as well as to assess attitudes about the program. The agency has also completed surveys of residential, employment, family and respite care participants. Consumer satisfaction is assessed informally, in conversations with people, as well as through meetings and surveys.

Model Practice

Recognizing the rights and desires of individuals who experience developmental disabilities to become parents, FRA has, since 1996, developed a multi-sensory supported parenting program that combines in-home supports with hands-on instruction conducted in a group setting. FRA is to be commended in taking the moral high road and finding ways to support individuals through this complex and controversial issue.

General Program Characteristics

+ The atmosphere throughout the agency encourages a high level of respect for people who utilize the services and for the people who provide the services. Everyone seems part of the FRA family.

+ Typically, people expect and receive assistance in a caring, committed, and knowledgeable way from FRA.

One parent commented on her experience when FRA helped her to negotiate the morass of paperwork and locate services for her child after her physician had referred her to the Internet to search for supports.

Choice and Self Determination

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

+ Staff support choices while offering appropriate safeguards.

+ People can choose to participate in cultural heritage activities and go to fish camp.

+ The Family Support Project (STAR) provides fast, flexible results and is very responsive to the needs of families.

+ People can find their respite providers independently and FRA will hire them.

+ People choose the level of involvement service providers have in their lives and in their activities.

“Every person is an individual. We can open doors and provide possibilities for people—we can’t make anybody go through a door, and we aren’t magicians.” (Staff member)

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

- In regard to respite, several people reported a lack of flexibility on the part of the agency, and an inability of FRA to accommodate the choices they want.

A consumer stated the agency will not allow the respite care to be provided at the respite worker’s home.

Dignity, Respect and Rights

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

+ The team observed tremendous respect being shown for the wants and needs of people.

+ Interior decoration of FRA-supported residences reflects particular attention to individualization. Individuals also are well dressed, maintain good hygiene and demonstrate clothing selections based on pride of choice.

One consumer invited team members to view her room and a new outfit.

+ Staff respect privacy and independence.

“They step in when needed and step out when asked.” (Family member)

+ Individuals state they know who to go to for problem resolution.

The team did not identify weaknesses under Dignity, Rights and Respect for people receiving DD services from FRA.

Health, Safety and Security

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

+ Staff feel empowered by FRA to advocate for consumers’ needs in interacting with health care providers.

+ People at FRA consistently state that they feel cared for and supported by the agency.

+ Individuals state that they know FRA will assure their health care and help them with scheduling appointments and accessing transportation.

The team did not identify weaknesses under Health, Safety and Security for people receiving DD services from FRA.

Relationships

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

+ FRA is like a big family for staff and consumers.

“I feel supported and loved. Even people I didn’t know called me by name.” Staff member

+ Several people who have chosen FRA supports commented on their friendships in the community.

+ FRA supports frequent communication between individuals and their families who live outside the Fairbanks area.

The team did not identify weaknesses under Relationships for people receiving DD services from FRA.

Community Participation

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

+ Residential staff provide many opportunities for people to engage in community activities.

+ Individuals indicate that FRA shows them how to access community activities and that because of this they are individually able to access activities of their own choosing.

+ People have opportunities to join the FRA softball team and cross-country ski group.

The team did not identify weaknesses under Community Participation for people receiving DD services from FRA.

Consumer Satisfaction Chart

Note: This chart applies to consumer satisfaction with quality of life and supports that FRA services can impact. Funding affects conditions that prompt some responses.

DD N=29

Choice

Dignity & Respect

Hth,Saf,Security

Relationships

Com.Particip.

Outcome

Yes

Partial

Yes

Partial

Person/Parent/

guardian

Performance

Person/Parent/guardian

Two consumers expressed lack of satisfaction with structural inflexibility in the Respite program.

One person indicated that she is dissatisfied with the location of the Respite Care apartment, but another said she tries to use it but finds it constantly busy for weekends.

Agency-wide statistics compiled by FRA indicate that 82% of consumers are satisfied with the services they use, 9% are partially satisfied, and 4% are not satisfied.

Staff Interviews

Staff members describe an atmosphere that supports employees: “It’s fun to work here.” There is good access to supervisors and an open door policy throughout the agency. As a director said, “Vicki is always available to me.”

As the agency has grown, new staff have brought refreshing new thoughts about providing greater levels of individualized services. Individualization of care appears to have been adopted as a goal agency-wide. The consumer-driven nature of the STAR program was cited by some people as having provided a model for other agency services.

Turnover, attributed both to Alaska’s mobile population and to the relatively low wages paid to beginning direct service workers, is an issue the service coordinators and program directors are addressing with a combination of efforts in recruitment and retention. New training initiatives, including the addition of a Staff Development Coordinator, are being implemented to provide greater depth of staff development as part of investing in the people they hire. As the agency works in independent programs with increasing numbers of people who have complex issues, staff report they need targeted behavioral training.

Several staff expressed concerns about lack of planning at the state and community levels for supporting people with developmental disabilities when they become parents.

Collateral Agency Interviews

The team interviewed eight individuals at related agencies. Most people reported positive interactions with FRA staff and characterized FRA as having dedicated employees. “FRA won’t let consumers fail,” one person said.

Some difficulties were reported, and these include:

delays in referrals or reports

lack of transition periods when direct service staff change

perceived needs for staff training about complicated behaviors and out-of-control adolescents

Related service agencies agree that collaborating requires lots of effort, especially when there are overlapping boundaries of service. One teacher indicated she would like more contact with a child's case worker to provide greater consistency for the child. People indicated a gradual and sustained improvement in intensity of effort related to involving more people on teams for consumers and carry-through in residential and vocational services.

Several individuals said that collaboration has improved in the last two years. “FRA heard my concerns and responded to them.”

Administrative/Personnel Standards

FRA has a well-developed set of policies and implements them with consistency. The agency implemented a procedure to involve consumers in the hiring process. FRA meets the standards set by the division, as noted on the attached checklist, with the exception of one partial in the requirement of direct membership of consumers on the board of directors. The board and executive director have developed a plan to include a consumer on the board, and with a recent vacancy are planning to begin recruitment activities. FRA seeks to avoid tokenism and is proceeding carefully with this process. The agency expects to invite a consumer to join the board by early 2000.

Program Management

Staff at FRA report feeling supported and valued.

Individuals, families and other service agencies commented that staff turnover among mid-management and direct staff has resulted in some reduction of continuity of services and relationships between FRA, consumers and other community agencies.

Program director turnover may have positive effects on services and supports in the long run, and the agency is aware that the turnover in direct care staff is an ongoing issue. Successful resolution of this issue will require management to develop creative responses.

State efforts to increase funding, particularly to increase wages at entry levels, would be a critical step in the alleviation of this industry-wide problem.

There are some areas of disagreement between FRA and the DMHDD Regional Program Specialist, but FRA staff feel Rebecca Hilgendorf has gone to bat for them.

File Review

Head sheets are in use in most consumer files. The team recommends that FRA implement head sheets in all consumer files, and add the following types of information:

The types of funding the person receives

Date of an individual’s admission to FRA

What other services the person is utilizing, and through what agency or agencies

The agency might consider some training for coordinators on quality assurance and timeliness for personal service plans.

Areas Requiring Response

1. Respite receives positive response from an overwhelming percentage of people who use the service. Perceptions of program inflexibility cause frustration among some consumers, and both the limited scope of respite and the limitations of funding mean the program does not work for everyone. Make efforts to reduce situations in which a family may have unrealistic expectations of the program.

2. Administrative and Personnel Standard #6 requires membership of direct consumers on the board. The agency has taken steps to accomplish this. Continue to make every effort to include direct consumers on the board.

Other Recommendations

1. Interviews with consumers, staff and related agency personnel indicate some inconsistencies in administration of the STAR program. FRA staff could work with the Regional Specialist to develop guidelines for DD eligibility, intensity and length of assistance, and standardization of a face sheet to be included in client files.

2. FRA should continue to seek additional funding sources agency-wide to support services. Receipt of such funds may allow the agency to develop innovative ways to be more responsive to families' requests, such as for a flexible respite program.

3.Collaborative service delivery requires lots of effort, both across programs within an agency and across agencies, especially when there are overlapping boundaries of service. FRA should continue to seek additional funding to support the extra costs of coordinating services, and should encourage staff to continue striving for excellent communication to provide the best services possible.

Editor’s Note: References included in the narrative suggest the following:

4. Staff request targeted behavioral training. Make an effort to provide this training.

5. Work to minimize delays in referrals and reports when collaborating with another agency.

6. Seek transition planning when direct service staff change.

7. Standardize the use of and information on head sheets in all consumer files.

8. Consider training coordinators on quality assurance.

9. Train coordinators on the timely preparation of personal service plans.

State base grant funding continues to be compartmentalized, reducing the agency’s ability to provide flexible services across categories of care. State policies need to be revised to develop funding that supports integrated services.

Medicaid waivers have created a huge burden administratively at FRA and other agencies, along with the dramatic operational change from annual grant funding to costing and billing for services each month. Medicaid billings result in carrying an extreme level of receivables for a period of several weeks to several months, severely impacting cash flow. Board and staff report increasing concerns about FRA’s viability as a result of interrupted cash flow and related interest expenses. The Division’s savings as Medicaid waivers have been implemented are not returning to FRA or other providers. FRA needs assistance to pay for the additional costs of coordinating care across agencies and administering and billing waivers.

Several people mentioned the need for more age-appropriate social and recreational activities for adolescents. The need for inclusive or specialized child care, and associated training was also spoken.

Closing

The site review team wishes to thank FRA staff, board members and consumers for their assistance in the review. It has been a pleasure to spend time in your friendly, inclusive office and to visit people in their homes.

The final draft will be prepared within 7-14 days and sent to DMHDD for further refinement. FRA and DMHDD will collaborate on a plan to make needed changes.