March
7-9, 2000
Glenda
Gologergen-Vial, Community Member
Agnes
Rychnovsky, Alaska Mental Health Board Representative
Larry
Lutz, Mental Health Peer Reviewer
Amanda
Race, Developmental Disabilities Peer Reviewer
Robyn
Henry, Mental Health Facilitator
John
Havrilek, Developmental Disabilities Facilitator
Pam
Miller, DMHDD QA Staff Member
A review of Mental Health (MH) and Developmental
Disabilities (DD) services provided by Norton Sound Health Corporation (NSHC)
was conducted from March 7th to March 9th, 2000, using
the Integrated Quality Assurance Review process.
This 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. DMHDD Quality Assurance staff conducted the
Clinical Record Review and provided that section of this report.
Description
of Program services
NSHC is an
Alaska Native Health Corporation serving the state’s Bering Strait Region. The
region’s size is 44,000 square miles. The service area includes fifteen Native
villages and the city of Nome and encompasses three distinct Native Alaska
ethnic groups. The corporation provides direct and preventative medical and
other health services to the entire region.
Services
provided by NSHC through their Behavioral Health Services (BHS) Unit include a
combination of Mental Health Services, Developmental Disabilities Services and
Substance Abuse Services. The BHS outpatient services include the Day Treatment
Program, the New Horizons Program (AYI), and the Pathfinders Program, which is
a mental health youth program.
The agency’s Rainbow
Program provides developmental disabilities services and the village-based
program focuses on providing support to people in their home communities,
outside of Nome. The BHS mental health
program serves approximately 300 clients, 60% of whom live in the villages
outside of Nome. The Rainbow Program serves 42 clients with developmental
disabilities.
A 24-member board of
directors governs the overall corporation. The corporation employs
approximately 400 full and part time people. Sixty-two clinical staff are
employed in the Behavioral Services Unit.
Description
of the process
To conduct this review, an interview team
consisting of two facilitators, one community representative, one
representative from the Alaska Mental Health Board and two peer reviewers
conducted 55 interviews over three days in Nome, Alaska. Client interviews
included people who receive services from both the mental health program and
the developmental disabilities program.
Mental Health client interviews, which included children
and adults receiving services, were determined from a list of randomly selected
clients. Of the people successfully contacted from that list, 16 were scheduled
for interviews and seven actually spoke with team members.
All six clients scheduled from the developmental
disabilities program were interviewed. Fifteen interviews were conducted with
related service professionals, one interview was with a board member, and
twenty-seven interviews were with BHS staff. Interviews lasted from 15 minutes
to an hour and were held in person, at NSHC’s offices, in the community or by
telephone.
The interview team members also reviewed five
randomly selected personnel files, the agency’s staff training plan, the agency
policies and procedures manual 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 agency staff on the final day of
the visit.
During this same period of time a member of the
DMHDD Quality Assurance Unit did a review of randomly selected client records.
Open
Forum
A public forum was held in Nome at the elementary
school at 7:00 P.M. , March seventh.
NSHC advertised the event by posting flyers throughout the community. Four
people from the community attended the forum. The feedback provided at the
forum is incorporated into the body of this report.
Progress
Since Previous Review
This is the
first review of the Mental Health program using the new program standards.
Therefore, there is no previous action plan. The Rainbow program was reviewed
two years ago and the following is a report on the program’s progress since
that review.
A plan for improvement required for the chart reviews
will be addressed separately in the DMHDD QA report.
NHSC has made some progress since their previous
review. The items listed below describe remedies NHSC has taken and the ones
that still need to be addressed.
Previous Recommendation (DD):
Norton Sound Health Corporation (NSHC) Board and the Rainbow DD Advisory Board
meetings need to be announced and open to the public. NSHC Board meetings are open to the public, but it is unclear
how they are announced. Presently the DD Advisory Board is inactive.
Current
Action Needed: The recommendation is that the NSHC Board meetings
be regularly announced on the TV scanner and the Rainbow DD Advisory Board be
reactivated with regular, announced meetings that are open to the public.
Previous Recommendation (DD):
NSHC needs to develop a policy for addressing the use of individuals in
research. This has been accomplished
through an Ethics and IRB process.
Previous Recommendation (DD):
An expressed need for interagency communication i.e. school district MOA. This
has been accomplished through specific MOA’s for services.
Previous Recommendation (DD):
Need to work on gaining input from families and individuals. The DD Advisory Board had begun to address
this recommendation, but needs to be reactivated.
Current
Action Needed: The
recommendation is that the DD Advisory Board be reactivated. The present
Wednesday staffing meetings to discuss families’ issues and the practice of
immediately addressing family/consumer/guardian concerns should be continued.
Both are commendable.
Previous
Recommendation (DD): Need
to make sure that your communication between the program staff and the
consumer/guardian is understood. This has
been addressed through Wednesday staffings.
Problems are addressed immediately with families and regular, frequent
communications are recorded in consumer files.
Previous Recommendation (DD):
The Norton Sound Rainbow DD services needs a way to evaluate itself. Families
are verbally asked for feedback following services.
Previous Recommendation (DD):
Consumers requested that they have a choice of direct service providers. Parents and teams sign off on the plans in
consumer files. Parents choose their own providers.
Previous Recommendation / Problem (DD): Staff
appears overworked and underpaid and over extended. Funding is still minimal but IHS and Harborview funding have helped
some in this area. Some staff still have to wear multiple hats and perform
extra duties.
Previous Recommendation (DD):
Recruit and train backup/alternative ILS staff for weekends and
emergencies. This program no longer exists.
Previous Recommendation (DD):
Information is being sought informally from consumers by talking to people
receiving services. Continue to find ways to gain consumer evaluation of services. The
agency sent out 3,000 surveys and 250 were returned. Family staffings, immediate response to consumer concerns and
frequent, regular communication as noted in consumer files may be the best way
to meet this recommendation.
Previous Recommendation (DD):
Formalize a checklist of special health and safety procedures that need to be
signed off by the family.
Current
Action Needed: This recommendation has not been addressed and needs
to be. Catholic Social Services has an excellent checklist and Rainbow Services
may want to get a copy so they can start to be compliant in this area.
Previous Recommendation:
Currently the agency talks to families, schools and other agencies informally.
There needs to be a more formal needs assessment.
Current
Action Needed: This recommendation has not been addressed. In
fact, during this review, some of the related agency interviewees reported that
they didn’t know Rainbow Services was still providing services in this area.
Previous Recommendation / Problem (DD):
Files currently exist and are well organized. It is difficult to identify the
level of service to be provided. Documentation of needs and services in the
files is inconsistent.
Current
Action Needed: A team approach has been developed. A problem list needs to be in the
habilitation plan. This is inconsistent. File notes
are anecdotal as if each client is only receiving case management services. Notes should focus more on action statements
related to the habilitation plans and/or the plans of service.
Previous Recommendation:
Be sure to include the consumer/family in the planning process. This
recommendation has been met.
Previous Recommendation:
Plans are being carried out but there is no documentation. Plans need to be
current and complete.
Current
Action Needed: Documentation of actions taken to meet plans still
needs to be done.
.
The team
identified the following strengths under Choice and Self-determination for
those receiving services from NSBS:
+ Several people reported that they liked
their counselor. (MH&DD)
+ One
family appreciated the fact that Rainbow Services is helping them look for
shared care or foster care in Fairbanks based on the family’s wishes to move.
(DD)
+ One
person’s life was improved, since “Rainbow
services is very helpful and helped us get our van.” (DD)
The team identified the following weaknesses under
Choice and Self-determination for those receiving services from NSBS:
- Three
adults indicated that they were not aware of having a treatment plan.
(MH&DD)
- None of
the children interviewed knew what was on their treatment plan. (MH)
- One
person said that they signed the treatment plan but that they were not part of
the development of the plan. (MH)
- One
person reported that the services of the last respite provider were not helpful
to them. (DD)
Dignity,
Respect and Rights
The team identified
the following strengths under Dignity, Respect and Rights for those receiving
services from NSBS:
+ Most people interviewed said their rights
were explained to them and that they understood them. (MH & DD)
+ Most people reported that they felt
respected by staff. (MH&DD)
+ One
interviewee stressed that “Rainbow
Services are beneficial for my daughter and I am happy with services.” (DD)
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving services from NSBS:
- Two children interviewed said they did not
know their rights. (MH)
- One child reported not feeling respected
by staff. (MH)
- One person reported a concern about
confidentiality but did not report any specific problems. (MH)
- One
parent said Rainbow Services had not been providing services to them for a
couple of years. Several months ago their funding for services was cut and they
are not receiving help now. They were very frustrated. The call to arrange the
interview was the first they had heard from NSHC since the fall of ‘99. (DD)
- One of
the team members overheard a BHS staff member talking in detail at a local café
about a client to non-staff members.
The team member felt this might not be an isolated incident.
Health,
Safety and Security
The team
identified the following strengths under Health, Safety and Security for those
receiving services from NSBS:
+ Most people reported that they felt safe
in their home and community. (MH & DD)
+ All people reported that they felt their
medical needs were met. (MH)
+ One parent reported that they were
receiving staff support in moving the consumer out of the village when they
decided such a move would be safer. (DD)
The team identified the following weaknesses under
Health, Safety and Security for those receiving services from NSBS:
- One AYI
child reported not feeling safe in the home.
- One
person requested that the program provide more drug and alcohol services in the
village. (MH)
Relationships
The team
identified the following strengths under Relationships for those receiving
services from NSBS:
+ Most people reported that they have
regular contact with their natural support system including family members and
friends. (DD & MH) One person explained “I
have good relationships everywhere
and staff is supportive of my natural network”.
+ Most people reported that the staff knew
about their natural support system. (DD & MH)
The team identified the following weaknesses under
Relationships for those receiving services from NSBS:
- Two people reported that they did not have
regular family contact. One of those people indicated they did not want contact
with family members. (DD)
- One person reported not getting services
at all so there were no social support goals and staff did not know about their
support system. (DD)
- One
client expressed a great deal of concern about the safety and well being of
their child who is in DFYS custody. (MH) (Note: This is recognized by the team
as a separate agency issue)
- One client said the agency needs to be
more family oriented. (MH)
The team
identified the following strengths under Community Participation for those
receiving services from NSBS:
+ All adults reported that they felt part of
the community. (MH)
+ Several families reported that their
children are able to participate actively in the community. (DD)
+ Several
people reported that they were able to participate fully in the community.
(MH&DD)
+ One
person reported feeling very valuable to the community and the agency and is an
active part of the community. (MH)
The team identified the following weakness under
Community Participation for those receiving services from NSBS:
- One
parent reported that they do not want their child out in the community for fear
of them hurting someone. They reported that “The
community doesn’t understand (our child)”. (DD)
Staff
Interviews
The team interviewed 27 NSHC staff, most of them
selected by the agency. This is considered a large sample for this size site
review. The team’s overall impression of NSHC is one of a motivated staff
committed to giving quality care to its clientele. They feel positive about
their co-workers and especially their management. They’re enthusiastic about
serving the people of the region and like the integrated client-need driven
approach.
Most of the staff members interviewed, however, are
in their first year at the agency and the test of time is yet to come. Most
staff reported that they liked the direction of the agency and the changes that
have occurred. They feel the agency has
strong leadership with a good vision.
There were several specific agency strengths
identified in the interviews. Several village-based counselors said they were happy
with the improved services and increased support in the villages. One of the
staff doctors expressed appreciation for the thoroughness of the clinicians’
documentation, indicating that it made their job much easier. Another staff
member said they felt the organization is culturally oriented and that the
agency responds to the cultural needs of the employees. Several people
appreciated the training they have received.
Consumer interviews yielded positive comments such
as: “Martha is cool”(DD) and that Marv,
from many reports, is a very good counselor. One person expressed appreciation
for staff support saying, “I can go in at
8 A.M. and talk to Ali and get a lot of ideas from her”. (DD)
There were also areas of concerns reported by the staff
interviewed. One person indicated that they felt that communication with
support staff could be improved. A village-based counselor indicated that they
felt they should be more involved in agency staff meetings.
One person asked that we encourage the
administration to keep responding to stated staff needs. Another staff member
cautioned that the workload is such that they feared staff burnout.
One of the DD staff expressed some anxiety about an
incoming new director, indicating that the staff currently has a good team and
they don’t want that to change.
Several people said that they did not feel they
were adequately prepared and trained to work with the Native population.
Several long-term employees indicated that they had no orientation to the organization
when they started, although now orientation is given to new staff.
Two people interviewed, who had been with the
agency for many years, indicated that they never had an annual evaluation.
(Note: The agency reported that all personnel have received annual
evaluations.)
One respite provider reported that in the beginning
of providing services they received lots of training, but that now they receive
very little training and no supervision.
Collateral
Agency Interviews
Fifteen people from collateral agencies were
interviewed, including representatives from DFYS, DVR, the local police, the
Woman’s Shelter, the hospital, the Nome Youth Facility, the Nome Receiving Home
(youth emergency program), Kawerak Inc. (Native Association), the Nome School
District, a community health nurse, a guardian ad litem and a judge.
The overall responses from the agencies were mixed.
There were many positive comments, supportive of Behavioral Services’ various
programs and staff. This was true even
to the point of people saying that, while they did not like the closing of the
Northern Lights Treatment Center, they would have closed it if they were in
Randy’s job.
Their major concern is the void the closing of this
program leaves in the community. Most liked the concept of village-based
services. The negative comments seemed to center on the difficulty and
frustration in the referral process to mental health and Rainbow. There also
seems to be a feeling that Rainbow isn’t offering services any longer and/or
has been without direction/leadership over the last couple of years. Some
aggressive public relations work and collaboration, along with getting the new
Rainbow director out and about in a high profile manner, can answer many of the
collateral agency concerns.
Several people interviewed indicated that they had
trouble collaborating with the AYI program staff. One person described it as
running into a wall. That same person expressed concern about the safety of the
children in the program. Hospital staff expressed great concern regarding the
initiation of Designated Evaluation and Treatment services and how high risk
psychiatric patients, introduced with this service, would be integrated into
the general hospital population.
Administrative
and Personnel Narrative
The
Administrative and Personnel Standards Checklist is included at the end of this
report. It includes 34 items, 24 of
which are completely met by NSHC. Those standards not fully met include:
1.
Budget controls, record keeping and staff training
support good business practices and conform to state requirements. (Standard
#4)
The mental health program
appears to meet this requirement but Rainbow Services does not. Record keeping,
especially quarterly reports, have not been turned in and one staff member interviewed
said they have not had training in 6 years. (DD)
2.
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)
The agency has made an
attempt in this area with a survey, but at present this is an area of
non-compliance.
3.
All agency publications, advertisements, brochures
and articles reflect the philosophy of a consumer-driven system, support the
service principles, and foster a positive and respectful portrayal of people
who experience disabilities. (Standard #16)
This is an area the
agency is working on and has some material in draft form, but at this time the
agency is not in compliance.
4.
The agency actively participates with other
agencies in its community to maximize resource availability and service
delivery. (Standard #17)
Interviews with 15
related agencies are all over the board.
Some agencies report a very positive working relationship, while others
report a great deal of difficulty referring clients. Some people commented that they have given up trying to make
referrals to mental health. We also received comments from a couple of local
agencies stating they didn’t know Rainbow Services was still offering services
in this area.
5.
The agency collects required data and submits it to
the appropriate state agency. (Standard #18)
Quarterly reports from
Rainbow Services have not been turned in for this fiscal year. (DD)
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)
Rainbow Services has been
following this procedure for the most part and clients have the opportunity to
choose their own respite providers. The agency currently has no way to get
consumer input in the hiring and evaluation of regular staff.
7.
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)
Some DD consumers
interviewed reported that they were not notified of change of services and one
DD file had documents for funding and services that had not been signed or
processed since October, 1999. (DD)
8.
The agency evaluation system provides performance
appraisal and feedback to the employee and an opportunity for employee feedback
to the agency. (Standard #28)
Two DD employees reported
they had not been evaluated, one during their 4 years of employment and the
other during their 9 years of employment. (DD)
9.
A staff development plan is written annually for
each professional and paraprofessional staff person. (Standard #29)
This does not appear to
be the case for some DD employees. (see above). (DD)
10. The
agency identifies available resources to meet the assessed training needs of
staff. (Standard #30) One DD employee
reported that they hadn’t received any training in 6 years, would like training
and needs training in seizures and behavior control in order to work with the
consumers. (DD)
CLINCIAL
RECORDS REVIEW (conducted by DMHDD QA staff)
There were a total of 16
charts reviewed. These included 6 child / 4 adult Medicaid charts, and 3 child /3
adult non-Medicaid charts. Files were reviewed with two agency representatives
and the peer reviewer. A more detailed report on the file review will be made
available to the director.
It needs to be clearly
stated that NSHC has made excellent progress since the time of the last chart
review in 1998. Not only is the required documentation present in most files,
it is comprehensive, current and timely. The staff at NSHC has evidenced a
proactive stance and attitude towards their desire to educate themselves in
good clinical documentation as a reflection of their good practice. Since the
time of the last review, NSHC has requested and received 2 training sessions
(from DMHDD, DMA and ADA) and numerous episodes of technical assistance. There
is a third training session scheduled for 3-10-00, which will focus on
educating the AYI/Pathfinders staff.
Assessments,
both intakes and psychiatrics, did a fine job of identifying mental health
problems and recommending appropriate treatment. Please note that there was a
discrepancy in non-Medicaid charts that was not noted in Medicaid charts.
Assessments identified many severe mental health problems, particularly in SED
children. The treatment plans did
not reflect the intensity of the services needed and often prescribed limited
clinical services. However, treatment plans were related to the assessments and
most contained the required elements. Further refinement of documenting
specific and measurable goals is an area that needs ongoing attention. Treatment plan reviews were present in
almost every file. They did not appear in 2 of the 3 adult non-Medicaid files.
Treatment reviews contained most all required components. The writing of progress notes is the area that needs
the most improvement. Both clinic and rehab notes need to clearly and
consistently document the goal being addressed per service episode, and the
active intervention conducted by staff during that service episode. Please
remember to sign, date and credential each service episode. Reviewing progress
notes indicated the need for clarification of rehab services and appropriate
interventions. These are issues that will be addressed at the training session
scheduled for 3-10-00.
Program
Management
Several of the staff interviewed remarked that Jane
Franks was a great manager, very supportive and encouraging of staff. Staff
also commented on Dr. Moss’s excellent leadership and forward thinking,
especially his direction in village-based services. Staff is also very
impressed with Randy’s and Jane’s support and encouragement of staff increasing
their skills and moving up within the agency.
Related agency, consumer, and staff interviews
indicated concern with Rainbow Services’ past administration having poor or no
leadership. This has left major gaps
that still exist throughout their program, to the point that some agencies and
consumers were unaware that Rainbow was even offering services.
1.
NSHC Board meetings should regularly be announced
on the TV scanner and the Rainbow DD Advisory Board should be reactivated with
regular and announced meetings that are open to the public. (Prior review) (DD)
2.
The recommendation is that the DD Advisory Board be
reactivated. The present Wednesday staffing meetings to discuss families’
issues should be continued, as should the practice of immediately addressing
family/consumer/guardian concerns. Both
are commendable. (Prior review) (DD)
3.
Formalize a checklist of special health and safety
procedures that need to be signed off by the family. Catholic Social Services has an excellent checklist and Rainbow
Services may want to get a copy so they can start to be compliant in this area.
(Prior review) (DD)
4.
Develop a more formal needs assessment. Some of the interviews with related agencies
reported that they didn’t know Rainbow Services was still providing services in
this area. (Prior review) (DD)
5.
A team approach has been developed and a use of a
problem list is in the habilitation plan. However, this is inconsistent. File notes are
anecdotal, as if each client were only receiving case management services. Notes should focus more on action statements
related to the habilitation plans and/or plans of service. (Prior review) (DD)
6.
Documentation of actions to meet plans still needs
to be done. (Prior review) (DD)
7.
Rainbow Services needs to complete and send in
their first and second quarter financial reports. (Standard #4) (DD)
8.
The agency needs to involve consumers, staff and
community in program planning and evaluation. (Standard #13)
9.
Create and distribute information regarding your
services. (Standard #16)
10. Increase
collaboration and networking with other agencies to maximize resources and
service delivery. (Standard #17)
11. Rainbow
Services needs to complete their first and second quarter narrative reports.
(Standard #18) (DD)
12. Develop
a process to incorporate consumer choice in the hiring and evaluation of staff.
(Standard #22)
13. Consistently
inform consumers about new services they are going to receive and services they
are losing. Involve them in the
process. (Standard #27)
14. Consistently
involve all employees in the evaluation system, specifically the Rainbow
Services employees. (Standard #28)
15. Develop
annual staff development plans for all employees. (Standard #29)
16. Identify
the available resources for identified staff training needs. (Standard #30)
17. The
agency needs to readdress the issue regarding breach of confidentiality in
public and private places.
Other
Recommendations
1.
It is recommended
that, in your continuing efforts to plan for providing Designated Evaluation
& Treatment services through the hospital, you include a comprehensive
strategic plan. This would include policies and procedures for integrating
high-risk patients into the regular hospital facility.
2.
The new
director for Rainbow Services should be very active in networking and
collaborating with related agencies as well as making contacts with consumers.
3.
Village based
counselors would like to be more connected to the agencies and be a part of
staff meetings through weekly teleconferences.
Closing
The team wishes to thank the staff of NSHC for
their cooperation and assistance in the completion of this review. This process
can be 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 sent to
Northern Community Resources for approval.
The final report will be sent to you within approximately thirty days
with a cover letter outlining the process for submitting your plan of
action.
.
Attach: Administrative and Personnel Checklist;
Questions for Related Agencies (tallied), Report Card (tallied)