MH/DD Program Site Review
north
slope borough community counseling center/DD
April 5-8, 1999
Barrow, Alaska
Site Review Team:
Elouise
Ivanoff, Barrow
Martha
Mae Nukapigak, Barrow
Israel
Nelson, McGrath
Teri
Firor, Fairbanks
Connie
Greco, Quality Assurance Specialist
Kathleen
Karella, Co-facilitator
Bess
Clark, Facilitator
A review of the mental health (MH) services offered by the North Slope Borough Community Counseling Center (NSBCCC) and Developmental Disabilities Services (DD) in Barrow, Alaska was conducted from April 5-8, 1999. This is the first review conducted at NSBCCC & DD using the Mental Health, Developmental Disability and Early Intervention Integrated Program Standards and Quality of Life Indicators. NSBCCC offers MH services that include Emergency Services (ES), Community Support (CSP) and General Mental Health (GMH) Services, including 24 hour emergency access, crisis intervention, screening and referral, outreach, case management, limited vocational, family support, assurance of medical-nursing, treatment of seriously emotionally disturbed (SED) youth, rural outreach, and individualized services. Residential services are offered within the SED youth and CSP programs. NSB offers DD services that include respite and care coordination. North Slope Borough Department of Health and Social Services (NSBDHSS) is the Borough governing agent that offers this array of services. Not subject to this review are day care assistance, domestic violence and sexual assault counseling, detoxification and outpatient substance abuse services.
To conduct this review a team consisting of a facilitator, a co-facilitator, two community representatives, (a parent of a child receiving services and an adult who receives services from NSBCCC), two peer providers: one from DD and one from MH and two staff from DMHDD Quality Assurance Unit. The team met for four days in Barrow. The team reviewed individual family records, reviewed program and agency materials, and interviewed 34 people who were family members, program staff, Board members, community members, and related service providers. Of those interviewed, 18 were randomly selected individuals and families who receive services from NSBCCC & NSB Developmental Disabilities Services.
Interviews were conducted in consumer homes, in the community, at the NSBCCC offices, or by telephone. The interviews lasted from thirty minutes to ninety minutes. After gathering the information, the team members met to draft this report, which was presented to the staff on the final day of the visit. This report is based on the State of Alaska Department of Health and Social Services combined Mental Health (MH), Developmental Disabilities (DD) and Early Intervention (EI) program standards.
Monitoring and reporting the quality of life and the quality of services for individuals and families makes an important contribution to the State of Alaska’s understanding of the effectiveness of program services and supports. The review team’s findings are reported below. The report includes a review of public comment, other suggestions, comments and conclusion.
During the previous review of NSB’s DD respite program, the
review team made several recommendations.
Since then, the agency has taken the following actions:
·
Regarding the recommendation that the program
follow through to form an advisory group made up of parents, consumers, and
professionals, the NSB Health Board is made up of people who represent each
community/village they service. Continue to find ways to include family
members of DD and Mental Health Consumers on the Board of Directors. (1.3.1
&1.3.2).
·
Regarding the recommendation to increase public
awareness and develop materials using People First language, no action has been taken. (1.6.1.).
·
Regarding the recommendation to involve families in
the hiring process of a new coordinator, no
action has been taken.
·
Regarding the recommendation to remove barriers to
screening and obtaining criminal background checks of prospective providers, there are inconsistent reports about
implementation of this recommendation (2.1.3).
·
Regarding the recommendations to conduct a formal
needs assessment and develop a plan to meet the identified needs: the agency
has completed a needs assessment of Barrow and the outlying villages; there are
inconsistent reports about implementation of this recommendation. (6.1.1 &
6.1.2)
·
Regarding the recommendation to develop a consumer
satisfaction feedback system: there is a system in place for mental health
consumers; there is no system in place
for DD consumers (6.2.1 & 6.1.2).
·
Regarding the recommendation to revise the safety
checklist, no action has been taken.(6.5.1)
·
Regarding the recommendation to develop a “user
friendly” checklist of individualized respite procedures and provider
competencies in collaboration with program staff, families and providers, no action has been taken (6.5.2).
(Note: The items listed above are referenced
to the previous DD program standards.)
Administrative
and Personnel Standards
Narrative
NSB
Community Counseling Center (NSBCCC) and NSB Developmental Disability services
are programs within NSB Department of Health and Social Services. NSB serves
both MH and DD populations. It was reported by agency administrators that NSBCCC
and DD/Respite is currently undergoing reorganization; the re-organization is
based on an effort to consolidate resources, reduce duplication of services,
and respond to consumer demands or unmet need. Previously, Arctic
Women-in-Crisis, Community Counseling Center, Children & Youth Services,
Substance Abuse Treatment Services, Day Care Respite/ILP, and the Village
Counseling Service were separate units under the North Slope DHSS
Behavioral/Preventative Health Services. The plan is to consolidate these services
under one unit, the NSBCCC. Counseling Services will serve the populations
previously served by Women in Crisis, Children Youth Services, and Substance
Abuse Treatment. Developmental
Disabilities services will be housed under the Day Care unit, which also
includes Day Care and ILP. The plan is
for the Village Counseling Services to serve both MH and DD populations in the
seven village communities.
The
Deputy Director of Behavioral/Preventative Health Services position's
responsibilities have been expanded to include the oversight of the
reorganization and the integration of programs.
The
NSBDHSS has a governing board that is representative of all seven villages and
the community of Barrow. The board
meets quarterly. This governing body
has oversight of all Behavioral/Preventative Health programs including approval
of program budgets and selection of top administrators. Board meetings are open
to the public and are available by teleconference. Meetings are advertised on TV and radio. Historically the board
has responded directly to public comments by interceding personally with NSBCCC
staff.
Frequent
staff turnover and lengthy periods of unfilled positions have created problems
in service delivery. Vacant positions
have "crippled" some programs and added additional stress to
remaining staff. An example of a
critical position to be filled is the DD Specialist. There is optimism among staff and other service agencies that the
planned changes and reorganization will relieve stress experienced by staff
seeking to meet consumer needs.
However, staff members are unsure of what their roles will be and how
they will be trained to fulfill their increased responsibilities to unfamiliar
consumer populations and to learn technical skills required to work with the
different funding sources. The outcome
from this reorganization cannot be evaluated at this time. Business processes,
personnel hiring, consumer treatment and habilitation planning, and on-going
service documentation need to be developed and staff need to be trained. This will equip them with the knowledge and
support necessary to provide efficient and effective services to consumers.
NSBCCC
enjoys good working relationships with other related service agencies and
professionals and is highly regarded by members of the community. One service provider stated, "We
couldn't ask for better help. NSBCCC is always responsive when we need to make
a referral or have a crisis in the school." Another provider stated of the staff," They are committed to
the people in the community."
Quality of Life
This
portion of the narrative refers to the Quality of Life Values and Outcomes
Indicators, as they relate to the specific services offered by NSBCCC &
NSBDD. The items listed below are those
that the review team identified as strengths and concerns. If the team concluded that any of the
concerns warranted improvement, they are listed in the Areas Requiring Response
Section of the report.
Choice
and Self Determination
The
team identified the following under Choice/Self-determination for all people
receiving services from NSBCCC & NSBDD:
·
Families/people
have flexibility in scheduling times.
·
Families/people
have committed existing respite providers.
·
One consumer
was court ordered to treatment and decided to remain in treatment.
Additional
indicators for families receiving Respite that were identified:
·
One respite
provider put aside her own thoughts and focused on what the client wanted.
·
Parents report
that they have very good respite providers when they had them.
·
Natural
support systems continue to function.
·
Although
unable to recruit respite care providers, those they have are supported very
well due to a high level of commitment in Barrow.
NSBCCC
& NSBDD staff:
The
following are examples of statements consumers/families gave to the review
team:
"Everyone
goes out of their way they see me at lunch, on weekends to see me and my kids
when
they need it”- mom
"They help me come back to Barrow from
Fairbanks." MH Consumer
"My counselor tells me I'm in control."
"Willing to change things if they need to." -
Mother of respite child
"They don't over help. The counseling Center is not intrusive." - Consumer
"All I see is Dr. McCathy
every month and I don't want any other help.
Choice? - "Oh, absolutely." - Consumer
Concerns:
MH
·
Some instances
of inconsistency where consumers report both positive and negative experiences
in the area of choice. These
inconsistencies are seemingly dependent on which worker they receive.
·
Some consumers
reported not being involved in treatment planning process.
·
Some consumers
had no knowledge of treatment plans.
DD:
·
"No one home for the last nine
months."- consumer
·
Limited choice
exists because of limited services that exist.
·
Adults with DD
have limited options for employment/subsistence and community living.
·
MH and DD
consumers report that staff does not elicit their personal preferences.
Dignity,
Respect and Rights
The
team identified the following strengths and concerns under Dignity, Respect and
Rights for all people receiving services from NSBCCC & NSBDD:
Families/people:
·
Are aware of
right to confidentiality
NSBCCC
& NSBDD staff:
·
Another
provider stated of the staff, "They
are committed to the people in the community." A consumer gratefully reported "they gave me the tools to get to where I am
today."
·
Staff are friendly, kind, and caring
·
One service
provider stated "We couldn't ask for
better help. NSBCCC is always responsive when we need to make a referral or
have a crisis in school."
"Services
are really good. It's one of the reasons why I don't leave
(Barrow)."-consumer
"Yes,
the staff treat me with respect and dignity."-consumer
Concerns:
·
A consumer
reported attempting to get services three different times over a five-year
period from l994 to l999. The consumer
went through the assessment process three different times and was told, because
she was not suicidal, she could not receive further services. This same
consumer requested services for her 21-year-old son who was reportedly paranoid
and hiding from guests who came to their home. She was told because of his age
he would need to ask for services himself. Mother asked for services because of
her belief that her son was unable to ask for himself.
·
Another
consumer reports that she requested services for herself and her son. Services
were denied until a psychiatrist referred the son to NSBCCC for services.
NSBCCC staff report that these are not isolated incidences. Hope was expressed
by consumers and staff that the reorganization would address these problems.
·
People receiving services have little awareness of
rights other than confidentiality.
"I wouldn't know what to do
if I had a complaint." - consumer
·
Several consumers reported experiencing a lack of
respect and sensitivity from selected providers. Example: a staff person
referred to a DD consumer as a “monkey”.
·
Community service providers express concerned about
referring to NSBCCC because of negative feedback they have received from shared
consumers.
The team identified the following strengths and
concerns under Health, Safety and Security for all people receiving services
from NSBCCC & NSBDD:
Families/people:
·
"I don't think they gave me any choices, but
they kept me safe."- consumer with suicide history
NSBCCC
staff:
·
When staff are
aware of unsafe situations, they attempt to respond.
For families receiving Respite:
·
When respite
care providers are there, families felt safe leaving children with them, even
in the home of the respite care provider.
·
In villages
and Barrow, respite care providers are often the educators and health care
workers.
·
Families feel
their child is safe and secure with the respite providers
Concerns:
·
Residential facility is too easily accessed by
outsiders, and there is too little enforcement of security policy at the facility.
·
Some staff are not consistent about maintaining
security of access.
·
DD Care coordinator needs to review cases to
identify health, safety and security issues in this high-risk area of a
vulnerable population.
The team identified the following strengths and
concerns under Relationships for all people receiving services from NSBCCC
& NSBDD:
Families/people:
·
Community
includes and accepts children and adults with developmental disabilities in all
activities.
·
Day program at
mental health center fosters peer relationships
·
Consumers
utilize "natural supports" in the community
NSBCCC
& DD staff:
·
Agency fosters
the development of community relationships by paying admission to buses, gym,
Nalukataq and Kivgiq.
·
A client felt
comfortable enough that he/she declined the opportunity to focus upon
relationships in counseling programs. A consumer stated, "My therapist has suggested I develop
relationships. Right now I want to
focus on me and my recovery."
·
Staff support
client participation in peer groups.
·
Staff teaches
problem solving skills in an effort to enhance personal relationships
Concerns:
·
DD
specialist/coordinator position vacant for the last 12 months.
·
A parent of a
child with developmental disabilities reported,"…no one helps outside of the respite provider." Parent feels very isolated because people
are afraid of the child.
·
Small
community size fosters multiple crossover relationships.
Community
Participation
The
team identified the following strengths and concerns under Community Participation
for all people receiving services from NSBCCC &DD:
People/families:
·
Residential programs encourage positive community
involvement.
·
MH center is developing connections between
consumers and the university system for limited vocational services.
·
One person with developmental disabilities is
learning job skills at the day care.
NSBCCC &DD staff:
·
There is a
lack of MH & DD vocational services and training.
The following recommendations were identified by
the team as areas that need attention from the organization:
1. The
agency should develop a clinical practice policy based on the five (5) Quality
of Life Values (Choice, Dignity, Respect and Consumer Rights, Health, Safety
and Security, Relationships and Community Participation).
2.
Train all staff on the five (5) Quality of Life
Values as a foundation of service delivery (as defined in the Integrated
Standards adopted by the State of Alaska, October 15, 1998).
3.
Provide community education about the five (5)
Quality of Life Values that govern service delivery.
4. Implement service delivery in compliance
with the five (5) Quality of Life Values.
5. Review hiring practices in order to
expeditiously fill vacant positions.
6. Hire a full time DD Specialist
position.
7. Develop and implement individualized
employment/subsistence goals of consumers.
8. Remove barriers to accessing service. (REF.
To concerns under Dignity, Respect & Rights)
9. Create a documentation process that will
substantiate and support budget controls, conduct staff training on the process
developed so that good clinical practices are used and conform to State of
Alaska DMHDD requirements. (Admin Standard #4)
10.
Continue to
find ways to include family members of DD and Mental Consumers on the Health
Board of Directors. (Admin Standard #6)
11.
Include
consumers’ and family members’ input in the reorganization plan and future
policy setting. (Admin standard #12

)
12. Agency
needs to develop annual goals and objectives in response to consumer
feedback. (Admin. Std. #14).
13. The
agency needs to collect required DD data and submit it to the appropriate state
agency. (Admin. Std. #18)
14. DD
staff need to have technical training with regard to grant and waiver
management. (Admin Std. #22)
15. The
agency needs to assure that criminal background checks are completed on
prospective employees and place documentation in employee files. (Admin. Std.
#24)
16. The
agency has not yet fulfilled an annual written staff development plan for each
staff member. (Admin. Std. #29)
17. Develop
a training plan for the Day Care Coordinator and the new DD specialist that is
specific to the development and maintenance of DD services. ( Admin. Std. #30)
18.
Educate the
community about the duplicity of roles/relationships (i.e. small community
where family members play many roles can be both positive and negative). Offer outside referrals.
19.
Please see areas to improve from the previous site review.
The DMHDD Quality Assurance Unit will
present a separate report on the MH file review.
Designated members of the
team reviewed the files of those DD consumers who provided their consent, and
these are the results of those findings.
Documentation requirements of all plans:
·
There are no
written dates of referral, eligibility determinations, description of social
history or social networks in any file reviewed. Contact logs were written in two files. There were significant gaps in time in those contact logs.
·
Progress notes
to substantiate service delivery were not present in any file. It appears, from the review of files, that
no service has been provided to any consumers during the nine months to
one-year preceding the review. There
was one consumer that did not have a file.
Medicaid Plan Requirements:
·
From the
review of the consumer list and case files it appears that there are two
current Medicaid waivers. All required
documentation was in the files for each waiver except a cost worksheet and
progress notes to substantiate that Care Coordination. Other services were provided as outlined in
the Plan of Care and waiver cost sheet.
There is no indication that any Medicaid waiver services have been
billed since April, 1998. Through
interviews with consumers and providers it is clear that a significant level of
services has been provided in at least one of these two cases.
Habilitation plans:
·
There are no
habilitation plans in any file. There
is no substantiating documentation (i.e. progress notes) to indicate that any
services have been provided to any consumer in the 9 months to one year
preceding this review.
·
After
reviewing the lack of planning and substantiating documents in the files, it
seemed prudent to review the consumer list and funding assigned to each
consumer. The list that is available is
not accurate. The consumer funding
sources are not clearly identified according to current funding possibilities
for Individualized Assistance Plan (IAP), Waiver and Respite Grant. This program is undergoing major changes in
method of operation and personnel responsibilities. It will require oversight and verified, accurate information
concerning the financial resources available to service consumers. Technical training concerning grant
management, Care Coordination, Waiver and IAP management will also be
helpful. When a new DD Coordinator is
hired, that individual will need to be trained on how to develop and support a
Habilitation Plan. Contact log and Progress
Note processes will also need to be developed.
Consumer
Satisfaction
Each
consumer interviewed by the team was asked whether or not they were satisfied
with the quality of their lives as they relate to each of the five Outcome
areas and with the quality of the supports and services they receive from
NSBCCC & NSBDD. The questions were
taken from the Consumer Satisfaction section of the five Outcome areas, and the
responses are presented according to type of service.
MH
|
Choice
N=12
|
Dig&Res. N=12
|
Hth,Saf,Sec N=12
|
Relatns. N=12
|
Com.Par. N=12
|
||||||||||
Outcome
|
Yes |
Part. |
No |
Yes |
Part. |
No |
Yes |
Part |
Part. |
Yes |
Part. |
No |
Yes |
Part. |
No |
Person/Parent/guardian
|
9 |
|
3 |
9 |
|
3 |
9 |
|
3 |
9 |
|
3 |
8 |
|
4 |
Staff
Performance
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Person/Parent/guardian
|
8 |
|
4 |
9 |
|
3 |
8 |
|
4 |
9 |
|
3 |
8 |
|
4 |
DD
|
Choice
N=5
|
Dig&Res. N=5
|
Hth,Saf,Sec N=5
|
Relatns. N=5
|
Com.Par. N=5
|
||||||||||
Outcome
|
Yes |
Part. |
No |
Yes |
Part. |
No |
Yes |
Part. |
No |
Yes |
Part. |
No |
Yes |
Part. |
No |
Person/Parent/guardian
|
4 |
|
1 |
5 |
|
0 |
5 |
0 |
0 |
5 |
0 |
0 |
3 |
|
2 |
Staff
Performance
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Person/Parent/guardian
|
2 |
|
3 |
4 |
|
1 |
2 |
1 |
2 |
2 |
1 |
2 |
4 |
|
1 |
Note: If an item is marked UNK (Unknown) or Not
Applicable (NA), will be entered in the No column.
Public
Comment
NSBCCC & NSBDD scheduled a public comment
meeting. The meeting was announced on
the local cable TV bulletin board and over the radio. Five people attended the meeting. Meetings were set up with those people who wanted to talk with us
individually.
The team thanks the
NSBCCC & DD staff for their wonderful hospitality during the site
review. It was a joy to experience your
community. The team thanks NSBCCC & DD staff for their willingness and
openness to be one of the first programs to participate in a joint review using
the new program standards, especially since the program is undergoing such
major restructuring.
You will receive a
finalized report within 30 days of this review, an overview of the agency's
compliance with the standards and a format for developing an action plan in
response to items identified in the review. NSBCCC & DD, in cooperation
with DMHDD will be responsible for developing a plan addressing the issues
noted in the Areas Requiring Responses.
There is no doubt that
NSBCCC & DD are committed to developing and providing supports in ways that
people prefer. The high regard staff
have for the people they support adds to the quality of service they deliver.
This review confirms that
NSBCCC & DD meets or exceeds most of the basic guidelines of the DMHDD and
DMHDD Integrated Standards. The team recognizes that all programs,
regardless of how good they are, can improve.
We trust the recommendations we have made will help you consider ways to
improve your services.
Once
again, thank you for making us feel at home and allowing us the opportunity to
review your supports and services.