INTEGRATED QUALITY ASSURANCE REVIEW
April
18-20, 2000
LeRoy
White, Community Member
Ken
Roberts, Mental Health Peer Reviewer
Terri
Firor, Developmental Disabilities Peer Reviewer
Robyn
Henry, Mental Health Facilitator
John
Havrilek, Developmental Disabilities Facilitator
Connie
Greco, DMHDD QA Staff Member
Dan
Weigman, DMHDD QA Staff Member
A review of Mental Health (MH) Counseling Services
and Developmental Disabilities (DD) Services provided by the Maniilaq
Association was conducted April 18 - 20, 2000, using the Integrated Quality
Assurance Review process.
The contents of
the report is the summation of the impressions of the 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 Maniilaq
Association is a non-profit Alaska Native association (PL 93638) serving the
state’s Northwest Arctic Region. The region size is equivalent to the State of
Indiana and includes eleven Native villages and the city of Kotzebue. The
Association also serves the village of Point Hope in the North Slope Borough.
The Association provides direct and preventative medical and health services to
the entire region.
The MH services
provided by Maniilaq Association through their Counseling Services include
psychotherapy; counseling for adults and adolescents; play therapy for
children; marital and family therapy; 24 hour a day on-call crisis intervention
services; grief counseling; hospital assessments; court screenings. Itinerant
counselors provide support to each village with monthly visits.
The DD services
provided by the Maniilaq Association include residential treatment in the
program’s Lake Street House in Kotzebue, emergency placement services and in-home
support in Kotzebue and the villages.
A 12-member
Board of Directors, which includes one community member from each village,
governs the overall Association. Individual Tribal Governments appoint
representatives to be members of the Board.
Description of the process
To conduct this review, an interview team
consisting of two facilitators, one community representative, and two peer
reviewers conducted 29 interviews over three days in Kotzebue, Alaska. Consumer
interviews included people who receive services from both the MH and the DD
programs. Four of the six MH consumers scheduled were interviewed. Eight consumers from the DD program were
interviewed. Seven interviews were conducted with related service professionals
and ten interviews were with program staff. Although two interviews were
scheduled with Association Board members, neither person appeared. Interviews
lasted from 15 minutes to an hour and were held in person, at Maniilaq
Association’s offices, in the community and by telephone.
The interview team members also reviewed seven
personnel files, the Association’s staff orientation plan and the Association’s
and programs’ Policy and Procedure Manuals. After gathering the information,
all the team members met to review the data and draft the report that was
presented to the administrative staff on the final day of the visit.
During this same period of time, two members of the
DMHDD Quality Assurance Unit did a review of randomly selected clinical
records. A report of these findings was provided under separate cover.
Open Forum
An open forum was held in Kotzebue at the
elementary school at 7:00 P.M. on April eighteenth. The Maniilaq Association
advertised the event by posting flyers throughout the community and by
announcing it on the local radio station. No one attended.
Progress Since Previous Review
This is the
first review of the MH program using these program standards. Therefore there is no previous action plan
for comparison.
The DD program
was reviewed in January, 1998. That
site review team made several recommendations, most of which have yet to be
addressed. Two recommendations (one regarding staff training and one addressing
the incorporation and use of vouchers) have been implemented. The following
recommendations still need to be addressed:
1. The team suggests the DD Program either
re-institute an Advisory Board with consumer representation or have
representation on the present Maniilaq Board of Directors to meet state DD
standards and provide advocacy for the DD Program. (1.3.2)
2. Develop plans with input from consumers and
other key people in areas of program development and habilitation. (1.4.1, 1.5.1, 1.5.2)
3. The team recommends the program come up with
a locally and culturally appropriate way
to get systematic consumer satisfaction feedback from consumers and family
members. (1.5.3)
4. Develop plans and work with consumers and
their families, schools, DVR, and the community on employment and subsistence
options for those on your case load who have made this choice. (5.1.1)
5. A combined culturally sensitive and
informal/formal assessment should be implemented, i.e., the coordinator could
phone to talk with parents/guardians and fill out assessments based on that
input. (6.1.1) (6.1.2) (6.2.1)
6. The team did not see any formal advertising,
other than the state DD brochure and informal word of mouth is the primary
procedure. We suggest the newspaper, T. V. scanner, newsletter, etc. be used.
(6.4.1)
7.
Develop Futures plans with consumers and family members and related
agencies to meet present and upcoming needs.
(7.1.1)
8. The team recommends that planning occur in
close collaboration with family and other community members with careful
attention to individual family and cultural values as guidelines for
planning. (7.1.4)
9. The team recommends that agency services be
driven by the plans. (7.1.5, 7.1.4,
7.1.2)
10. The team suggests that an independent review
committee comprised of community members (e.g., the NWABSD Special Education
Director, Maniilaq Health Center Social Worker) be created to review behavior
plans when needed. (8.2.3) (8.2.4)
.
The team
identified the following strengths under Choice and Self-Determination for
those receiving services from Maniilaq:
+ One person
reported that services helped them overcome a lot of anger and that since they
have
come to therapy their outlook has changed and they are much happier. (MH)
+ Most
people reported that the goals that are worked on are ones they have chosen. (MH)
+ Several
people reported that their therapist helps them solve their problems. (MH)
+ One
person indicated that they often recommend counseling services to others that
need help.
(MH)
The team identified the following weaknesses under
Choice and Self-Determination for those receiving services from Maniilaq:
- One
person reported that they “know what to
choose, but no one is there (to help).” (DD)
- One
person reported that they had no choice in having their child placed
out-of-home
and out-of-state. They were not part of
that decision. (DD)
- One
guardian reported that the plan for the person for whom they were responsible
was
changed without their notice or their participation and that they have
not been able to get
a copy
of the new plan. (DD)
- Many
consumers interviewed were not aware of the service options available. (DD)
- The
team is very concerned about the overall lack of DD services to people who are
not in the
residential program. (DD)
Dignity, Respect and Rights
The team
identified the following strengths under Dignity, Respect and Rights for those
receiving services from Maniilaq:
+ Most
people interviewed said they felt respected by the staff and the clinicians.
(MH and DD)
+ Several
people indicated that staff were flexible about services. (MH)
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving services from Maniilaq:
-
A couple of people interviewed stated that, while
they felt respected and valued, they did not
feel
they had access to information regarding their illness and treatment. (MH)
- One
person indicated that they had not signed a release of information form for
the interview or at any other time in
the past. (MH)
- One
person interviewed indicated that they had requested services but no one had
ever called
back.
(DD)
The team
identified the following strength under Health, Safety and Security for those
receiving services from Maniilaq:
+ Most people interviewed indicated that,
overall, they felt safe and secure in their current
situation and that there were no problems
in this area. (MH and DD)
The team identified the following weaknesses under
Health, Safety and Security for those receiving services from Maniilaq:
-
One person interviewed, who is a relative of a
person receiving services, indicated that they
have
serious health problems and they have been given no support for accessing out
of town
treatment (i.e. transportation to Anchorage) (medical services issue)
(DD)
-
One person who is homeless indicated that they had
been given no support with housing and were told they had to work on getting
housing on their own. (DD)
-
One person reported that other family members were
stealing from them when they visited and
no
one would help them with this issue. (DD)
-
Two person reported that a consumer was held
down/restrained on the floor for an hour and
they
felt this was an inappropriate action. (DD)
-
Two village members interviewed indicated that the
only service they have received from the
program is help with rides from the airport to the hospital. (DD)
-
The mental health program appears to provide
support with either once a month village home
visits or once a week office visits in
Kotzebue, except in the case of an emergency. This limited
service provision is of concern when supporting people with serious and
persistent mental
illness who may need more regular community based support.
Relationships
The team
identified the following strengths under Relationships for those receiving
services from Maniilaq:
+ Most
people reported being happy with the relationships they have with others. (MH
and DD)
+
Several people reported that they were satisfied with the level of
support they receive with
building and maintaining relationships. (MH and DD)
+ Two
consumers in the residential program reported (and records substantiated)
frequent
contact with family members. (DD)
The team identified the following weakness under
Relationships for those receiving services from Maniilaq:
-
Several people reported that staff had limited
knowledge of their natural support system. (MH and DD)
The team identified
the following strengths under Community Participation for those receiving
services from Maniilaq:
+ Most
people interviewed were happy with their level of community participation (MH
and DD)
+ Most MH
people interviewed have regular full time jobs that are satisfying
+ One DD
client interviewed reported they had a job they liked in the community.
+ Staff
members take Lake St. House residents into the community on a regular basis
including
facilitating participation in subsistence and other outdoor activities.
The team identified the following weakness under
Community Participation for those receiving services from Maniilaq:
-
The team is
concerned about the level of community participation for people who are
eligible
and funded for services but are
not receiving services (MH and DD)
Staff Interviews
The team
interviewed 10 staff from the MH and DD programs. It should be noted that only
one staff member interviewed had been with the agency longer than a year. The
staff member who had been with the agency the longest said that they felt the
agency had been improving and that things were more organized.
Many people
interviewed indicated that they worked a lot of over-time hours. Several people
indicated they have gotten good training while one person felt they did not get
enough training. Several people specifically identified the lack of
orientation/training in addressing cultural issues. This was problematic for making the adjustment to working in the
village. One person reported that the orientation session was “hostile” and
that the speaker indicated to the new hires that, if they could, they would
replace them with a Native person.
Two people
interviewed indicated that they did not want to answer many of the questions
because they had not been with the agency long and did not want to get anyone
angry with them, explaining “I like my
job and I want to keep it”. One person expressed mistrust for the
organization indicating there is “…no
stability from the top;…the organization can be toxic”. Staff morale seemed
very low.
Seven people
from collateral agencies were interviewed including representatives from DFYS,
the local police, Family Services, the Kotzebue Children’s home, the school
district, the substance abuse program and a local judge. The overall responses
from the agencies were mixed. Most people interviewed indicated that the
programs were very good at following up with referrals.
One person
interviewed expressed great concern for system issues such as the lack of
leadership in working with people who “fall
through the cracks”. They also indicated that they felt there needed to be
more collaboration among agencies especially when looking at cultural issues
with youth in the villages. They stated
that once a month visits to the village were not enough. Also cited was the
lack of any services addressing FAS/FAE.
Specific issues
identified relevant to current services included the lack of good DD services
outside of the Lake Street House and the lack of “village helpers” for both DD
and MH. Several agencies reported that communication regarding mutual clients
was not always good, but two people said that it had gotten better in the last
six months. Several people identified
the need for more preventative/outreach services. One community service agency
identified the need for more MH training in their own program to help them
better deal with MH clients.
Administrative/Personnel Narrative
The
Administrative and Personnel Checklist is included at the end of this
report. It includes 34 items, 21 of
which are completely met by Maniilaq Association. Those standards not fully met
include:
1.
The agency’s governing body includes significant
membership by consumers (DD, MH) or consumer family members (ILP), and embraces
their meaningful participation.
(Standard #6)
While the Association’s Board of Directors includes
members from each village being served, the Board does not include MH and DD
consumer membership.
2.
The agency actively solicits and carefully utilizes
consumer and family input in agency policy setting and program delivery.
(Standard #12)
The agency does not formally solicit MH and DD
consumer and family input in setting policy or program delivery.
3.
The agency systematically involves 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.
(Standard #13)
While the association apparently does have a
process for visiting villages annually for the purpose of getting feedback
regarding health services, there is no systematic means for specifically
involving MH and DD consumers in that process.
4.
The agency develops annual goals and objectives in
response to consumer, community and self-evaluation activities. (Standard #14)
Again, there is no systematic means for involving
MH and DD consumers in the agency goal setting process.
5.
The agency actively participates with other
agencies in its community to maximize resource availability and service
delivery. (Standard #17)
Related agency staff interviewed reported that they
would like stronger and more frequent collaboration in this area.
6.
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. (Standard #22)
Families using respite services hire their own
providers, but other consumers do not have input into the hiring and evaluation
of staff.
7.
The agency provides new staff with a timely
orientation/training according to a written plan, that includes, as a minimum,
agency policies and procedures, program philosophy, confidentiality, reporting
requirements (abuse, neglect, mistreatment laws), cultural diversity issues,
and potential work related hazards associated with serving individuals with
severe disabilities. (Standard #25)
The agency provides new staff with orientation to
the Association, but staff interviews indicated a strong need for cultural
orientation, especially to village life, as a major component of orientation.
8.
The program obtains and documents informed consent
from consumers (or ILP family members) before services are initiated and when
services are changed or modified. (Standard #27)
A guardian, a staff member and a consumer reported
instances where informed consent had not been requested or given.
9.
The agency evaluation system provides performance
appraisal and feedback to the employee and an opportunity for employee feedback
to the agency. (Standard #28)
10. A
staff development plan is written annually for each professional and
paraprofessional staff person. (Standard #29)
11. The
agency identifies available resources to meet the assessed training needs of
staff.
(Standard #30)
12. The
performance appraisal system adheres to reasonably established timelines. (Standard
#31)
13. The
performance appraisal system establishes goals and objectives for the period of
appraisal.
(Standard #32)
While the Association has a comprehensive system
for evaluating staff annually which meets the Standards, Standards 28-32 are
not being met as evidenced by a review of the only two eligible employee files.
Neither had an evaluation in the file.
Program Management
There appears to
be a large gap between the MH/DD program staff and the Association leadership.
The MH/DD programs seem to lack ability/authority to work autonomously and
effectively in the midst of the large bureaucracy of the Association.
The MH and DD
programs seem to be in a continual state of flux. Staff turnover was identified
on many occasions as a major challenge for both programs. Only two staff in the
MH program had been there more than one year and all of the staff in the DD
Program had been there less than a year including both program managers. It does appear that the recent changes to
the programs have been positive.
Areas Requiring Response
1. The team suggests the DD Program either
re-institute an Advisory Board with consumer representation or have
representation on the present Maniilaq Board of Directors to meet state DD
standards and provide advocacy for the DD Program. (1.3.2) (Prior review and Standard #6; should include a MH
advisory board as well)
2. Develop plans with input from consumers and
other key people in areas of program development and habilitation. (1.4.1, 1.5.1, 1.5.2) (Prior review)
3. The team recommends the program come up with
a locally and culturally appropriate way to get systematic consumer
satisfaction feedback from consumers and family members. (1.5.3 (Prior review)
4. Develop plans and work with consumers and
their families, schools, DVR, and the community on employment and subsistence
options for those on your case load who have made this choice. (5.1.1) (Prior review)
5. A combined culturally sensitive and
informal/formal assessment should be implemented, i.e., the coordinator could
phone to talk with parents/guardians and fill out assessments based on that
input. (6.1.1) (6.1.2) (6.2.1) (Prior review)
6. The team did not see any formal advertising,
other than the state DD brochure and informal word of mouth is the primary
procedure. We suggest the newspaper, T. V. scanner, newsletter, etc. be used.
(6.4.1) (Prior review)
7.
Develop Futures plans with consumers and family members and related
agencies to meet present and upcoming needs.
(7.1.1) (Prior review)
8. The team recommends that planning occur in
close collaboration with family and other community members with careful
attention to individual family and cultural values as guidelines for
planning. (7.1.4) (Prior review)
9. The team recommends that agency services be
driven by the plans. (7.1.5, 7.1.4,
7.1.2) (Prior review)
10. The team suggests that an independent review
committee, comprised of community members (e.g., the NWABSD Special Education
Director, Maniilaq Health Center Social Worker) be created to review behavior
plans when needed. (8.2.3) (8.2.4) (Prior review)
11. The
agency needs to develop a process to formally solicit consumer and family input
in setting policy and program delivery. (Standard #12)
12. The
agency needs to develop a process for formally involving consumers in both DD
and MH program planning and evaluation, including feedback from consumers about
their satisfaction with services.
(Standard #13)
13. The
agency needs to develop annual goals and objectives in response to consumer,
community and self-evaluation activities.
(Standard #14)
14. The
agency need to work on stronger collaborative efforts with other agencies,
especially with the idea of designating a lead person or advocate to follow
through on mutual clients where several agencies are involved. This would help keep clients from falling
through the cracks. (Standard #17)
15. The
agency needs to develop a process to involve consumers in the hiring and
evaluation of program staff. (Standard
#22)
16. Consistently
require and obtain consumer/parent/guardian consent and input before starting
or changing services. (Standard #22)
17. Provide
a timely orientation/training to new staff according to a written plan that
includes at least the minimal content as per the Standard. (Standard #25)
18. Systematically
obtain and document informed consent from consumers before initiating or
modifying services. (Standard #27)
19. Systematically
provide performance appraisals and feed back to employees and an opportunity
for employee feedback to the agency.
(Standard #28)
20. The
evaluation system needs to be completed and documented on an annual basis. (Standard #29)
21. The
agency needs to systematically identify available resources to meet the
assessed training needs of staff.
(Standard #30)
22. The
performance appraisal system should be systematic and adhere to reasonably
established timelines. (Standard #31)
23. The
performance appraisal system should systematically establish goals and
objectives for the period of appraisal.
(Standard #32)
24. The
organization needs to develop a comprehensive cultural orientation process for
new staff that would include a focus on how to work with people in the village
setting.
Other Recommendations
1.
Work with the
Division of Mental Health and Developmental Disabilities to increase the use of
Mental Health Medicaid funds as a resource to increase your program/staff
capacity including the use of paraprofessionals to provide support.
2.
The
organization could work with current village residents to identify people who
live in the village who could provide support to others. Consider increasing
the use of the UAF Rural Human Services training program for these
paraprofessionals.
Closing
The team wishes to thank the staff of Maniilaq
Association for their cooperation and assistance in the completion of this
review. 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 30 days and sent to you along with a
Plan of Action. You will then have 30
days in which to complete the Plan of Action and return it to Northern
Community Resources. NCR will review
your response and forward it to DMHDD.
Attached: Administrative and Personnel Checklist;
Questions for Related Agencies (tallied), Report Card (tallied)