INTEGRATED QUALITY ASSURANCE REVIEW

Norton Sound Health Corporation

March 7-9, 2000

Nome, Alaska

 

SITE REVIEW TEAM

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

 

 

INTRODUCTION

 

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.

 

FINDINGS

 

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.

.

Choice/Self-determination

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)

 

Community Participation

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.

 

Areas Requiring Response

 

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)