November 17-19, 1999
Valdez, Alaska
SITE REVIEW TEAM:
Keilah Wall, Community Member
Louise Parish, Community Member
Gina Kaiser, Peer Reviewer, Anchorage
Sherry Modrow, Facilitator
Nancy Mathis, DMHDD Lead Quality Assurance Staff Member
A review of the DMHDD-funded Developmental Disabilities Supported Services provided by Horizons Unlimited was conducted from November 17 - 19, 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 peer reviewer and facilitator provided an informal review of consumer files during the site review. DMHDD Quality Assurance staff participated in the review process by telephone.
The site review team met for three days at Horizons in Valdez. The team consisted of two community members, a peer reviewer, and a facilitator. Team members conducted 30 interviews, as follows:
· 10 consumers
· 4 guardians
· 3 board members
· 11 employees— 9 direct service staff, the program director and the agency’s executive director
· 2 related agencies: Connecting Ties and Valdez Native Tribe
Of the Medicaid-funded consumers randomly chosen for interviews, all seven plus the alternate had direct consumer interviews and several guardian interviews. Of the three non-Medicaid consumers, two consumers were interviewed and the third consumer's guardian participated in an interview. Interviews lasted between 20 minutes and one hour and were conducted by telephone or in person at people’s homes or at the agency.
Horizons Unlimited is a nonprofit organization providing support for 21 individuals in Valdez who experience developmental disabilities. Horizons has a seven-member board that includes parents and guardians of several Horizons consumers. The board sets policy and supervises the executive director. The organization employs 40 full and part-time staff members.
Horizons receives DMHDD funds to provide core services and respite support for individuals who experience developmental disabilities. All individuals who receive residential supports through Horizons have Medicaid waivers. The program provides in-depth, wrap-around services aimed at supporting individuals in their own homes or in one of the agency's two group homes.
Staff at Horizons operates within a framework of dedication and caring to help people have meaningful choices and dignified lives. Care providers treat consumers with great respect. Staff ensures that confidentiality and the privacy of individuals are not broached. Integrity of care results from a high level of professionalism among staff, particularly in light of limited budgets.
Horizons Unlimited needs development of both internal supports (stronger financial reporting abilities, greater administrative depth) and support from the state (partnering for technical assistance and finances) to continue providing quality services within the scope of their mission. People at all levels of the organization--board, line staff, administrators and mid-level managers--express concerns about the lack of an adequate network of support for funding, program improvements, mastering the intricacies of Medicaid waivers and staff development. The site review team noted a pervasive feeling of stress in interviews with staff and board members related to cash flow and debt in the agency.
Horizons’ policies include guidelines for guardian involvement. In the past, some guardians have interpreted the guidelines to be overly restrictive. The team saw no indication of current concerns with the policy or the way it is being implemented
Horizons Unlimited planned and advertised an Open Forum on November 17 in the Royal Center. The room in which the Open Forum occurred was in the same building as the Horizons office but separate from the agency's suite. Notices were provided for the agency’s consumers and posted on the television. No one attended.
Progress Since
Previous Review:
1. Assure that parents and guardians are consistently notified of unusual incidents.
The agency has
implemented an incident report process that includes documentation of guardian
notification. This item appears to have been met.
2.The offices of Horizons are not accessible.
The agency continues
to occupy a suite of second-floor offices in a building that does not have an
elevator or lift. Continued attention to the need for accessible offices is
required.
3. Include documentation of consumer and guardian participation in hiring and evaluating staff.
This has not been met.
4. All staff must demonstrate knowledge and understanding of all client abuse, neglect and mistreatment laws.
Staff orientation
includes an overview of the regulations and the agency's expectations regarding
abuse and neglect. On-going, informal staff training is provided.
5. Assure that all employees receive timely evaluations.
This item continues to
need appropriate resolution.
6. Until a new van is purchased, the people living on Cottonwood have reduced opportunities to go where they want to go.
Residents of the group
home on Cottonwood have a van.
7.The IHP should address the activities that are designed to include consumers in integrated settings. The cover sheet could also identify important relationships.
Interviews provide
adequate evidence of consumer involvement in normal community settings, but it
is not easy to substantiate those activities in the consumer files. Within the
context of a general upgrade of consumer files, this item should receive additional
attention.
8. Strategies used to achieve goals and consideration of unpaid supports aren’t always evident.
While data collection provides ample evidence of natural supports, the consumer files do not. Consumer case notes could provide ongoing documentation of this information.
.
The team identified the following strengths under Choice and Self-Determination for people receiving DD services from Horizons:
+ Consumers clearly indicate preferences and choices, and Horizons works hard to meet people's desires.
+ Choice is the basis of all services at Horizons.
"You see it, you feel it, you experience it." Team member
A staff member expressed that a consumer has begun to realize the freedom and choice inherent in his life outside of Harborview. After two years of supported living in the community, the person clearly expresses his dislike of the former Harborview building.
+ Staff members use questions, visual cues and humor in communicating with consumers.
The team did not identify weaknesses in this area.
+ Since the closure of Harborview, people have increased dignity, choices and opportunities for personal growth through the services they receive at Horizons.
+ Caregivers focus on abilities of the people receiving services.
Several guardians expressed high levels of satisfaction with day to day lifestyles of their wards: "Thank you!"
+ Happiness of consumers is considered of greatest importance. Horizons staff recognizes that some things can't be conquered; goals tend to be valued for their basis in reality.
+ Horizons has built a holistic system of care by incorporating the strengths and recognizing weaknesses of the community, the board, the administration, managers and line staff and the consumers.
+ Staff who have provided services to consumers for many years express deep commitment to the well-being of the individuals receiving services, and they feel they know consumers well.
The team did not identify weaknesses in this area.
The team identified the following strengths under Health, Safety and Security for people receiving DD services from Horizons:
+ Level of care and medication management for medically fragile individuals appear to have substantially improved with implementation of contract nursing.
+ Overall attention to health and safety of consumers is good.
The team identified the following weaknesses in this area:
- Nursing services appear to be inconsistently available for people with less critical ongoing needs, and may not be adequate.
- Preventive medical and dental care appears limited, and training in normal oral hygiene seems to be inadequate to prevent eventual dental crises.
- Staffing patterns do not appear to allow adequate and systematic cross-training, relief or back-up coverage.
- Some consumers need additional food and household allowances to adequately stock supplies for Y2K preparedness (i.e. grocery staples, extra bedding, personal supplies such as adult Depends, water).
- Restricted budgets could impact consumers' and staffs' health and well-being and reduce access to special dietary or nutritional needs.
"Sometimes we take second choice when buying groceries." Staff member
The team identified the following strengths under Relationships for people receiving DD services from Horizons:
+ Consumers and care providers have positive and genuine relationships.
"I receive more from ___ than I give." Staff member
+ Horizons assists consumers to have and maintain the broadest possible network of relationships.
+ Staff facilitates consumer relationships with people of all abilities.
+ Many consumers have long-term relationships with a wide variety of people in the community of Valdez.
The team did not identify weaknesses in this area.
The team identified the following strengths under Community Participation for people receiving DD services from Horizons:
+ Horizons seems to continually invite community participation, and the community reciprocates. There is a commitment to increasing consumers' circles of friends. Several people expressed enthusiasm for swimming, noting that the pool will be heated to a warmer than normal temperature once a week this winter to accommodate people who need warmer water.
+ Community attitudes toward consumers appear to be highly positive.
The team identified the following weaknesses in this area:
- Staffing levels may limit community participation for medically fragile individuals and for people living in group situations with those individuals.
"Funding is scarce for activities in the winter." Staff member
"We don't have enough people to get everybody else to an event if a consumer needs to stay at home." Staff member
- A number of community buildings do not have access for wheelchairs or for people with mobility challenges, including the Horizons office. Winter mobility is a particular challenge because of heavy snowfall, icy conditions and build-up of snow banks.
Staff files include documentation of training received and needs for training identified as part of the evaluation process. These tend to reflect certifications and targeted trainings. New employee orientation to Horizons includes review of agency policies and procedures and an overview of regulatory and safety information.
Increased systematic planning and implementation of more formal staff development opportunities would assist the development of greater professional depth within the organization. Horizons has a close working relationship with Prince William Sound Community College, and many employees express goals of completing certificates or degrees through the school.
Group staff activities appear limited; development of consistent care patterns and team approaches would enhance overall staff effectiveness and provide avenues for greater cross training and on-call relief staff.
1. The organization is engaged in a process of strengthening fiscal operations; there are continuing difficulties with tax liabilities and penalties, payments owed to vendors, and debt load on the agency. Standard #4
2. Horizons' board includes significant membership of secondary consumers of DD services (parents, guardians), but there is not a direct consumer on the board. Standard #6
3. The agency does not have a policy or procedure related to conflicts of interest. Standard #10
4. Horizons' occupies second floor offices in a building that has no elevator or stair lift. Standard
#11
5. The agency informally incorporates consumer and family input but does not systematically solicit or integrate such information into planning or program delivery. Standard #12
6. About 50% of guardians return the annual survey sent to them regarding satisfaction; there is no systematic evaluation of programs or participation in agency planning provided for the community, guardians or consumers. Standard #13
7. Horizons does not have a system for developing annual goals and objectives in response to consumer, community or self-evaluations. Standard #14
8. There is no evidence of documented consumer involvement in hiring and evaluating direct service providers. Standard #22
9. Staff development plans are not always completed annually; existing plans seem to reflect the agency-wide concern with finances by identifying minimum requirements at little or no cost. Standard #29
10. The performance appraisal system is well-implemented but not always timely. Standard #31
The site review team came away with an impression of an agency operating much as it did when its budget was a fraction of its current size. The attention to saving money and not increasing the cost of administration is evident, but the team recommends that the agency refocus its efforts on identifying and securing waiver funding that reflects the true costs of providing services. This activity, while intensive and requiring resources, could provide Horizons with its best opportunity to overcome existing financial difficulties.
At the same time, the team recommends that the board and executive staff engage in short-term and long-range strategic planning for the organization. Strategic planning should incorporate such activities as:
· training in forward projection and review of annual budgets
· setting and evaluating goals for the agency
· implementing consumer, community and staff involvement in planning and evaluation
· developing fundraising strategies
· defining board and staff roles
The team further recommends the board recruit members with business, finance and accounting expertise to help lead the organization's future development.
A fully integrated accounting system could provide board, staff and state partners with more reliable financial information and individualized tracking of funds.
The prior site review action plan was not signed and returned to the agency by the DMHDD administrator. Board and staff members expressed confusion and concern about the lack of a signed plan of action. The agency reported that it had implemented the action plan without the final signature. This review incorporated the information provided in that action plan.
File Review
All language in consumer files is very respectful.
A general recommendation would be to devise or adopt a system that provides improved access to current information, with an archiving system for older documents. Within a revised filing system, files would be less voluminous, less congested, and indexed for ease of access to specific information. Case notes would be included, and would cover specific strategies and activities taken in carrying out goals set in the consumers' plans. Timely updates of information, guardian consent and monthly or quarterly reports would be included. Concise, accurate financial summaries would document expenses for each consumer, including budgets and actual expenses for lodging and food.
1. It is not easy to substantiate activities related to goals or strategies in the consumer files. Written notes include daily activities but do not provide reasons or relate activities to goals. A coded statistical system may be adequate for reporting purposes, but would not tell a new employee, a guardian or a staff supervisor anything about what an individual likes, prefers, or does not accommodate on a day to day basis. The current system does not help agency personnel convey written information about the day to day care of or expectations for a person A general system upgrade of files is recommended. (See Progress Since Previous Review, #7 and #8)
2. Administrative/Personnel Standard #4. There are continuing difficulties with tax liabilities and penalties, payments owed to vendors and debt load on the agency; financial statements may not give adequate, accurate information for developing a comprehensive picture of the agency’s financial position. DMHDD and Horizons could examine the 1999 audit when it arrives, along with current financial statements, to get a clearer idea of fund balances, debts, receivables and cash flow. Upgrade of the agency's accounting systems, in direct collaboration with DMHDD, may be recommended.
3. Administrative/Personnel Standard #6. Horizons' board includes significant membership of secondary consumers of DD services (parents, guardians), but there is not a direct consumer on the board. The board should determine how to approach this standard.
4. Administrative/Personnel Standard #10. The agency does not have a policy or procedure related to conflicts of interest.
5. Administrative/Personnel Standard #11. Horizons occupies second floor offices in a building that has no elevator or stair lift. Accessibility is a difficult issue in the community of Valdez; the board and staff of the agency have an opportunity to provide leadership in the town as part of finding a way to come into compliance with this standard.
6. Administrative/Personnel Standard #12. The agency informally incorporates consumer and family input but does not systematically solicit or integrate such information into planning or program delivery.
7. Administrative/Personnel Standard #13. About 50% of guardians return the annual survey sent to them regarding satisfaction; there is no systematic evaluation of programs or participation in agency planning provided for the community, guardians or consumers. In a community with extensive integration of consumers, the agency could benefit from, and provide education to community members by including the public in evaluation and planning for Horizons services.
8. Administrative/Personnel Standard #14. Horizons does not have a system for developing annual goals and objectives in response to consumer, community or self-evaluations. A board strategic planning activity could initiate development of response to this standard.
9. Administrative/Personnel Standard #22. There is no evidence of documented consumer involvement in hiring and evaluating direct service providers. This was noted in prior reviews. (See Progress Since Previous Review, #3)
10. Administrative/Personnel Standard #29. Staff development plans are not always completed annually; existing plans seem to reflect the agency-wide concern with finances by identifying minimum requirements at little or no cost. Plans could identify group training activities as well as goals identified for individual staff members to assist their professional development and provide the agency with opportunities for advancement of existing staff.
11. Administrative/Personnel Standard #31. The performance appraisal system is well-implemented but not always timely. Identification of strategies for implementing consistent performance appraisals could be included in broader agency planning.
12. Although financial concerns appear to be the engine running many aspects of decision-making, Horizons Unlimited needs to take a comprehensive approach to strengthening the agency. Two-way action between Horizons and DMHDD may provide the platform the agency needs to accomplish a turn-around. Essential elements of creating a healthy agency will include improving financial accountability, developing accurate waivers that bear the full cost of providing services, and using accurate data to plan for the future.
13. Staffing patterns do not appear to allow adequate and systematic cross-training, relief or back-up coverage. Staffing levels may limit community participation for medically fragile individuals and for people living in group situations with those individuals. Accurate forecasting of adequate staff needs will provide the agency with the tools to request funding that reflects true needs.
14. Nursing services appear to be inconsistently available for people with less critical ongoing needs, and may not be adequate. Waivers should be examined to determine if adequate nursing is included.
15. Restricted budgets could impact consumers' and staffs' health and wellbeing and reduce access to special dietary or nutritional needs. Some consumers need additional food and household allowances to adequately stock supplies for Y2K preparedness (i.e. grocery staples, extra bedding, personal supplies such as adult Depends, water).
16. Preventive medical and dental care appear limited, and training in normal oral hygiene seems to be inadequate to prevent eventual dental crises.
17. Increased systematic planning and implementation of more formal staff development opportunities and large group training activities could assist the agency with development of greater professional depth and flexibility.
18. Because Horizons and Connecting Ties share responsibilities for services to some of the same individuals, notification of IHP meetings and other kinds of case meetings should occur with adequate advance time to allow and encourage broad participation.
Other Recommendations
Based on information provided by Horizons board members, administration and staff alike, there is a general conclusion of the existence of a gap between the performance and delivery of services and the funding resources available. The team understands that consumers while in Harborview cost the State of Alaska's health care system $300,000 or more annually per recipient for medically necessary services. When based upon a head count of 21 consumers and a projected annual budget of $1.25 million, an average annual cost of care per person receiving services at Horizons currently computes at $59,523. The site review team perceives the true average cost of care to be considerably higher.
The team believes there is a need for Horizons to document the full costs of care and to request increases in waiver funding to accommodate the cost of care and delivery of services based on the individual in his or her environment. The State and Horizons could work together to build waiver budgets based on true costs of providing services. The team suggests that, if possible, all plans of care and budgets be revisited and amended to cover all direct costs not previously included but documentable and related to the delivery of services.
Consideration of true costs should include the following:
· need for additional supplies within each consumer's residence
· staff relief
· staff training and development
· real costs of care assessments
· consumers' choices
· schedule flexibility of staff for individualized treatment plans
· the immediate requirement for additional staff for crisis intervention
· possible quality assurance staff role
· cross training for existing staff
· other operating expenditures
In addition to the fiscal gap, there have been communication barriers between Horizons and the State of Alaska. To ensure that all needs of the individuals, the agency and the State can be met, collaboration between Horizons and DMHDD is vital.
Financial management should aim for fiscal stability in the future. An increase in funding and resources, built on true costs, should result in flexible, stable programs without financial inconsistencies. A functional assessment of the agency's financial management and accounting system may be one of the strategies to be employed in the process.
The site review team thanks everyone at Horizons Unlimited who helped with the integrated quality assurance site review. The staff provided invaluable assistance with scheduling and then rescheduling due to weather delays. Everyone graciously accommodated the changes, allowing the site review to proceed smoothly.
This report will be finalized within 7-14 days and forwarded to DMHDD. Horizons should expect to receive the final report within 45 days. Horizons and DMHDD will collaborate on creating the action plan for making needed changes.