Petersburg
Mental Health Services, Inc.
May
3 – May 5, 2000
Joyce
Bergmann, Community Member
Ron
Adler, Peer Reviewer
Barbara
Price, Facilitator
A review of the Mental Health (MH) services provided by Petersburg Mental Health Services, Inc. (PMHS) was conducted from May third through May fifth, 2000, using the Integrated Quality Assurance Review process.
This report is the summation of the impressions of a community team after interviewing consumers, staff members, community members and staff of other agencies. It also includes a limited administrative review. It does not represent or reflect a comprehensive review of this agency. The Division of Mental Health and Developmental Disabilities’ (DMHDD) Quality Assurance staff will conduct the Clinical Record Review at another time and will provide their report separately.
Description of
Services
PMHS provides services to a population of 3500 year-round residents and another 1000 summer residents/transients in the City of Petersburg, Mitkof Island and the City of Kupreanof. The majority of the population resides within a six-mile radius of downtown Petersburg. At any given time, the caseload is approximately 100, with some 225 individuals being served in a year’s time.
The services provided are outpatient counseling for individuals, couples, families and groups; psychosocial rehabilitation and client support services for adults; activity therapy, family support services and school- and home-based therapy for youth; advocacy; consultation; prevention/education; a batterers’ program; Critical Incident Stress Debriefing for hospital and Forest Service staff; crisis intervention; case management; outreach; psychiatric care. PMHS is also a service provider for five area Employee Assistance Programs.
The services are provided by a full time director/clinician, a part time clinician, three part time case managers and a contract psychiatrist who provides services for one or two day periods, six times per year. PMHS also employs a full time office manager.
The agency is governed by a seven member executive board, all of whom are either consumers or family members of consumers. Funding that currently totals $310,000/year is received from a State of Alaska Community Mental Health grant, the City of Petersburg, donations and client fees.
Description of
Process
The interview team of three: a community member, a peer reviewer and a facilitator, conducted 24 interviews. Those interviews included 9 consumers, parents or guardians, 9 staff of other agencies, 4 PMHS staff, 1 member of the City Council and 1 PMHS board member. Initially, 10 consumer interviews had been scheduled, all taken from the random list provided by DMHDD QA staff. Two of those consumers were unable to keep their appointments. One additional consumer volunteered for an interview and five other consumers made informal contact with the team. Interviews were of 10 minutes’ to 60 minutes’ duration.
Open Forum
An Open Forum was scheduled for the evening of May third in order to provide an opportunity for interested community members to offer their views of PMHS’ services. The agency advertised the forum by radio announcements, TV scanner and posters. Four people attended. The views expressed at the Forum are integrated into the narrative of this report.
FINDINGS
Progress Since
Previous Review
As this is the first interview of PMHS using the Integrated Quality Assurance Review process, there are no prior findings for comparison.
Areas of Excellence
1. Petersburg Mental Health Services is characterized by superior standards of client care including, in the words of one consumer, “absolute confidentiality.” Several informants noted the high degree of professionalism that is the hallmark of all interactions between PMHS staff and consumers, community members and other professionals.
2. Petersburg Mental Health Services collaborates with other service providers to an unusually high degree, enhancing the positive impact of the community’s helping agencies.
3. Petersburg Mental Health Services maintains an outstanding resource library that includes books, handouts, pamphlets, audio tapes and video tapes, all available to consumers and to the community.
4. Petersburg Mental Health Services is completely integrated into the community, is generously supported by local government and private citizens and claimed as the community’s own. One consumer noted “I was referred (to PMHS) by friends and I refer my friends; this place has a real good reputation.”
5. The Director of Petersburg Mental Health Services provides exemplary leadership and has emerged as the undoubted spokesperson for Mental Health in the area; her philosophy, actions and intentions demonstrate a clear, complete dedication to this community.
Life Domains
Choice and Self Determination
The team identified the following strengths under Choice and Self-Determination for those receiving services from PMHS:
+ Despite being a relatively small program, PMHS provides a choice of therapist including a choice of a male or a female therapist.
+ Consumers can change therapists as needed without negative consequences. One consumer said: “(They) were very accommodating” when a change in counselor was requested and “(they) asked no questions.”
+ The waiting list has all but been eliminated.
+ Most consumers were clear that they participated in setting and revising treatment goals. One consumer stated “I lead the conversation and direct the treatment.” Another indicated “They always answer my questions.” And another: “I set goals based on my issues.”
+ Flexible scheduling allows for the provision of services 7 days each week.
+ Services are provided at school, in the home and in other locations in the community in addition to the office.
+ Services are locally based and highly accessible. One consumer reported that, “Prior to (PMHS) I couldn’t get any kind of help.” Another said that their needs were met by the therapist changing their own personal schedule in order to adjust to the consumer’s schedule.
+ The services of a child and adolescent psychiatrist are available through PMHS.
+ Some consumers can seek additional subsidies for the cost of care through Denali Kid Care.
The team identified the following weaknesses under Choice and Self-Determination for those receiving services from PMHS:
- Some consumers, ineligible for subsidized care, find PMHS’ cost prohibitive.
- Those wishing to see a male therapist are limited to weekend appointments.
- Family members of children who receive medication management services only, are unaware of any treatment plan for those services and do not recall being consulted or giving approval of those services.
- In one case, the parent of a child receiving only medication management services was dissatisfied at the time of case closure.
Dignity, Respect
and Rights
The team identified the following strengths under Dignity, Respect and Rights for those receiving services from PMHS:
+ Confidentiality is a core value at PMHS and consumers are confident that confidentiality is guarded appropriately.
+ Every consumer
interviewed reported being treated with respect. A consumer commented: “They
greet you!” And another said of the
therapist: “…whenever we were in session
together I felt that I was (the) only
client.”
+ All those consumers interviewed reported being advised of their rights and the review of client files substantiated that.
+ Telephone contact with PMHS is discreet and appropriate.
+ PMHS staff are
described as “positive” and “non-judgmental.” Another consumer stated “They helped me recognize my negative
behavior.” And “I experienced total acceptance.” And “(At
PMHS) I can be completely honest.”
+ The atmosphere of professionalism is, in itself, an indication of respect.
+ PMHS staff are described as compassionate.
+ Professional boundaries are maintained even in informal, social contact between staff and consumers.
+ PMHS staff thoroughly explain mandated reporting laws to consumers.
+ All phone calls to PMHS are promptly returned.
+ PMHS staff are punctual.
+ One consumer responded: “What did I gain from services here? Strength. I gained strength.”
The team did not identify any weaknesses under Dignity, Respect and Rights for those receiving services from PMHS.
Health, Safety and
Security
The team identified the following strengths under Health, Safety and Security for those receiving services from PMHS:
+ PMHS’ services include outreach to those who may not initiate contact despite need.
+ PMHS staff follow up when there is a lack of contact or a break in a pattern of contact with a consumer.
+ PMHS fully complies with mandatory reporting laws.
+ PMHS staff receive regular physical examinations by policy.
+ Denali Kid Care can be used to finance health care for some youth.
+ PMHS’ intake process includes a review of physical health issues.
+ Safety is increased by the close cooperation of PMHS with the Petersburg Police Department.
+ Security is increased by the availability of PMHS clinicians 24 hrs/day, 7 days/week.
+ Health and safety are increased by PMHS’ immediate crisis response and appropriate level of services. One consumer asserted: “They’re ready for your emergency!”
+ Health and safety are increased by PMHS’ energetic provision of education and prevention services to the community as well as to consumers.
+ Health and safety are increased by PMHS’ close collaboration with the schools, especially in the area of suicide prevention and the early identification of at-risk youth.
+ Health and safety are increased by providing service to batterers.
+ Health and safety are increased by prompt referrals to and from the community substance abuse treatment program.
+ The home-like atmosphere of the PMHS offices increases the sense of safety and security for those receiving services. Comments included: “This place is very comfortable.” “(PMHS) is basically welcoming.” “(At PMHS) I feel safe.” “I like the atmosphere. It’s very pleasant and friendly.”
The team identified the following weakness under Health, Safety and Security for those receiving services from PMHS:
- Reports indicate that in some situations the hospital may take action in Title 47 cases without informing PMHS. While the frequency of this seems to have decreased, the possibility of PMHS not being included in these actions negatively impacts on the continuity of care and appropriate after-care planning. (This is not the responsibility of PMHS.)
Relationships
The team identified the following strengths under Relationships for those receiving services from PMHS:
+ Services are
available to family members of all ages, to families as a whole and to
couples. A consumer described PMHS as “family oriented… (and)“in tune with what the needs are of the kids.”
+ Families report being strengthened by PMHS’ interventions. One consumer reported “Our family could not have survived this trauma without (PMHS).”
+ PMHS provides parenting, communication and relationship education materials and presentations.
+ PMHS provides information on mental illness: “They helped me to understand this was (an illness), not just behavior.” – family member
+ Home-based services are provided with respect for parental roles and values.
+ Family members reported rapid and positive change as a result of PMHS’ services: “(The therapist) is why (my child) was able to do this, to succeed.” And “I’ve been real happy about the results of (therapy); (my child) has shown a lot of improvement.”
The team identified the following weakness under Relationships for those receiving services from PMHS:
- There is a need for case management services for non-SED and non-CMI consumers.
Community
Participation
The team identified the following strengths under Community Participation for those receiving services from PMHS:
+ The community is tolerant, generous and supportive of local people who have special needs.
“This community is pretty accepting; people just step in and help.” – family member of consumer
+ The Human Service Advisory Council, an informal interagency group, coordinates services with an eye to inclusion.
+ The Youth Center is utilized for case management services.
+ To date, pool and gym passes have been made available at no cost to consumers.
The team identified the following weakness under Community Participation for those receiving services from PMHS:
- The community exhibits unease regarding people with special needs who are not locals.
File Review
While the DMHDD QA staff will provide a formal audit of the clinical files later this month, the facilitator was permitted access to the files of two of the consumers interviewed, a release of information for that purpose having been signed.
Those files both contained signed client rights and consent to treatment forms along with current treatment plans signed by the consumer. One case had been open long enough for a treatment plan review to have been completed, documented and signed by the consumer. The files are orderly, the treatment plan format clear, consistent and thorough.
Staff Interviews
The staff of PMHS are proud to work for an organization that is respected and effective. Staff feel appreciated and report appreciation for their work being expressed regularly. All report satisfaction with the training and the supervision provided. The orientation/training for case managers is an outstanding piece of work and a significant support to these vital employees.
The PMHS personnel policies are professional, clear and have been reviewed by the Department of Labor for compliance with Alaska law.
PMHS staff seem satisfied with their salaries and benefits. The program has clear and consistent standards and staff know they are held to them. Case managers receive regular verbal evaluations and careful review of their records. The Office Manager has received regular written evaluations that meet the State standards.
PMHS is managed by a strong leader who supervises all staff directly, one who works long hours and responds around-the-clock as needed. Few duties appear to be delegated. As the Director models total devotion to the agency, the question arises, in the words of one team member, “Is there room to be average?” (The agency points out, correctly, that not all employees were interviewed and, if they had been, this impression might well have been different.)
A repeated theme among consumers, community members, staff and other professionals was the need for additional staff. Suggestions included increasing the number of case managers, designating a lead case manager and adding an additional clinician. The Director has already considered these options and generally supports them, noting, however, the difficulty of finding employees who identify strongly with this community and who, at the same time, have the needed skills or the willingness to receive training.
Collateral Agency
Interviews
The other professionals interviewed were unanimous in their praise for PMHS. Descriptions of the agency staff were: “always available,” “totally professional and supportive” and willing and able to provide “immediate service.” In fact, “(The Director) bends over backward to help.”
The court system and law enforcement report that thanks to the participation of PMHS, involuntary commitments can be handled smoothly, in a coordinated manner and without burdening any one entity. The Director’s presence at weekly school meetings to review behavioral concerns is valued. PMHS’ collaboration with the school, hospital, police department, substance abuse services, court system and other helping agencies (through the Human Services Advisory Council) allows for the “maximizing of resources.”
Others report “a wonderful working relationship” and agencies can be assured that “help is a phone call away.” Furthermore, despite the Director’s youthful and delicate appearance, she is described as “…mature. She’s tough. She’s no pushover!”
Administrative/Personnel
Narrative
Of the 34 Administrative and Personnel Standards established by DMHDD, PMHS fully complies with 24 and partially complies with nine, by meeting standards indirectly or in a manner not fully documented. Needing further refinement are:
1. Standard #11 “All facilities and programs operated by the agency provide equal access to all individuals.” PMHS does provide services at an alternate site for those unable to use the stairs to the second floor office. No signage in Braille is evident nor are accommodations for the hearing impaired. There is no indication that anyone has been excluded from services based on these limitations. However, because the agency itself is not fully accessible it might seek an ADA review of their site with the resulting recommendations to determine if compliance can be accomplished without unreasonable expenditures.
2. Standard #12 “The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery.” PMHS does solicit this information as evidenced in the 100 replies to this winter’s survey. However, how the results of this and other surveys are used to guide policies and service delivery is not clearly stated as a policy. The creation and implementation of such a policy would meet the standard.
3. Standard #13 “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.” This feedback is solicited as noted above. However, a formal policy for annual planning and evaluation activities that involve consumers, staff and community does not exist. The creation and implementation of such a policy would meet the standard.
4. Standard #14 “The agency develops annual goals and objectives in response to consumer, community and self-evaluation activities.” While the Board does identify goals and priorities, there is no policy that governs that action nor one that describes how consumers, community opinion and self-evaluation are to inform that process. The creation and implementation of such a policy would meet the standard.
5. Standard #22 “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 … have been approved by the family or consumer.” The first part of this standard is met informally but no written policy exists. The second part of the standard is met. Formalizing and documenting how consumer opinion guides hiring and evaluation would suffice to meet this standard.
6. Standard #24 “The hiring process includes background and criminal checks (when appropriate) for direct care providers, personal and professional references and follow-up on required references.” The policy to meet this standard exists. However, only one complete personnel file was available and that was not of a direct service provider. Informal files of case managers indicated that a release had been obtained for the check but the results had been communicated informally but had not been documented. Standardize the documentation of reference and background/criminal checks to meet this standard.
7. Standard #25 “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…, cultural diversity issues and potential work related hazards associated with serving individuals with severe disabilities.” A fine training and orientation guide has been created for case managers. This guide includes policies and procedures, program philosophy and confidentiality. Training in mandated reporting is reviewed verbally but should be stated in the orientation/training guide itself. Cultural diversity issues should be addressed in the broadest sense: minorities by language, ethnicity, values, etc. While this training may also be provided verbally, it too should be included in the guide and broadened to include those differences presented by summer residents, transients and tourists. Work related hazards including communicable diseases, the use of de-escalation skills, etc. should also be specified in the guide to complete the compliance with this standard.
8. Standard #29 “A staff development plan is written annually for each professional and paraprofessional staff person.” The one complete personnel file did comply with this standard. The case managers are reviewed informally and their development plans are also informal and not documented. The Director reports never having received a performance evaluation, a responsibility of the Board. A policy exists that meets the standard, it must simply be applied uniformly.
9. Standard #31 “The performance appraisal system adheres to reasonably established timelines.” Case managers report regular appraisals and the one personnel file also evidences this. The standard is only partially met because the evaluation of the Director has never been completed. The Board’s annual evaluation of the Director and plan for the next evaluation period would provide compliance with this standard.
10. Standard #32 “The performance appraisal system establishes goals and objectives for the period of the appraisal.” Again, this standard is met in the one personnel file available. This needs to be documented for the case managers and, in the case of the Director, be completed by the Board in order to be in full compliance.
Program Management
There is no question that PMHS is a responsibly managed, professional agency. The Director has been successful in obtaining funding from a variety of sources and in expanding services as needed with a careful eye on funding that expansion. The responsible fiscal policies are a strength of this agency.
The team is impressed with the creation of a fine, locally based agency by a Director who describes herself as "just out of school” at the time she assumed this position. She is multi-task oriented so, despite her inexperience, she has moved quickly and efficiently to establish a program that is excellent in many respects.
Given the stability and reputation of the agency, PMHS has entered a phase of development in which the Board must now clarify its role. The team recommends Board development that is, in contradiction to the policy manual, not provided by the Director. While that connection has been a necessary and healthy one during the early stages of the program, the Board needs to assume its role as the governing body, responsible and liable for the use of funds and the provision of services.
Board training in the management of non-profit agencies and in the multiple and appropriate roles of Boards (hiring and evaluation of the Director, support of the agency, fund raising, setting policy, providing checks and balances on the management of the agency, etc.) would strengthen the Board and relieve the Director of some concerns and duties.
Currently, consumers, community members, other professionals and Board seem to equate PMHS with the Director, describing it as “Susan’s agency.” That is appropriately complimentary, a true vote of confidence and, at the same time, a phase that the agency is outgrowing. As the roles of Director and Board are differentiated, the Board will also be better able to exert its authority over the Director in regard to her taking as good care of herself as she does of others. Facilitating the Director’s taking of regular leave time by asking what it will take to make that happen (hiring a temporary replacement? arranging for emergency coverage through the hospital? etc.) and then making that happen are some of the ways that the Board can assure the longevity of the Director and the continued quality and stability of the agency.
Areas Requiring
Response
1. Standard #11 Seek increased and equal accessibility to offices, possibly using an ADA review as a guide and document the steps you can take to meet these expectations.
2. Standard #12 Create and implement a policy for the gathering and using of consumer and family input as a guide to policy setting and program delivery.
3. Standard #13 Create and implement a policy for involving consumers, community and staff in annual planning and evaluation. Formalize the use of a survey of consumer satisfaction.
4. Standard #14 Create and implement a policy for setting annual goals and objectives based on consumer, community and self-evaluation activities.
5. Standard #22 Create and implement a policy for documenting consumer choice in the hiring and evaluation of direct service staff.
6. Standard #24 Document compliance with your policy regarding background/criminal checks and reference checks in individual personnel files.
7. Standard #25 Include in the written orientation/training guide those topics only covered in verbal form at present: mandated reporting requirements, cultural diversity, potential work hazards.
8. Standard #29 Document the annual staff development plan of each staff member.
9. Standard #31 The Board should comply with the agency’s policy of annual evaluation of the Director by the Board.
10. Standard #32 Document the goals and objectives for the next evaluation period for all employees; the Board should provide this for the Director.
11. Devise a plan for Board training and development activities to increase the Board’s autonomy and decrease the Director’s responsibilities.
12. Devise a plan for increasing the case manager positions or designating a lead case manager.
13. Devise a plan for filling an additional clinical position.
Other
Recommendations
1. Assure that the use of the seclusion and restraint room at the hospital results in an automatic referral to PMHS for emergency services. (This is not the responsibility of this agency.)
2. Consider the agency’s space needs, especially in the light of the need to expand. Be aware of space arrangements in relation to privacy.
3. Develop a staff training and development plan for clinical, case management and administrative support staff using external training resources to enhance the fine in-house training opportunities.
4. Include one or more open-ended questions in the client survey to elicit unmet or undermet needs.
5. Continue your efforts to seek additional funding through effective collaboration and less traditional sources.
6. Seek to become a site for the training of graduate interns.
7. Increase activity therapy and other children’s services as possible. This population was described to the team as underserved.
8. Create a specific policy for the regular review of job descriptions, beyond their inclusion in the annual review of the Policy and Procedure Manual.
9. Amplify the description of the public nature of Board meetings in the Board by-laws with reference to the Open Meetings statutes.
Closing
The team wishes to thank the staff of PMHS for their cooperation with this review. Although reviews are always stressful, the PMHS staff was both gracious and helpful.
This report will be reviewed and edited by Northern Community Resources (NCR), finalized and returned to you within approximately 30 days, along with a Plan of Action form. You are asked to complete the Plan of Action within 30 days and return it to NCR. After reviewing it, NCR will forward the completed plan of action to DMHDD.
Attached: Administrative and Personnel Checklist; Questions for Related Agencies (tallied); ReportCard (tallied).