INTEGRATED QUALITY ASSURANCE REVIEW

SOUTHCENTRAL FOUNDATION COUNSELING SERVICES

December 14, 1999 to December 17, 1999

Anchorage, Alaska

 

SITE REVIEW TEAM:

Lola Reed, Community Member

Douglas Friday, Community Member

Pat Kouris, Community Member

Sheila Gaddis, Community Member

Fred Kopacz, Peer Reviewer

Robyn Henry, Facilitator

Connie Greco, Lead DMHDD QA Staff member

Nancy Mathis, DMHDD QA Staff

Pam Miller, DMHDD QA Staff

Dan Weigman, DMHDD QA Staff

 

INTRODUCTION

 

A review of Mental Health services provided by Southcentral Foundation (SCF) under the Behavioral Health Services Program and the Quyana Club House was conducted from December 14^th to December 17^th, 1999, 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 community team has collaborated on this report and the findings represent their consensus.  The Division of Mental Health and Developmental Disabilities (DMHDD) of the State of Alaska staff conducted the Clinical Record Review and provided that section of this report.

 

Description of Program Services

Southcentral Foundation (SCF) operates as the non-profit Health Corporation for Alaska Natives and American Indians in the Municipality of Anchorage and in the Matanuska-Susitna Valley. Mental Health (MH) services provided by SCF through the Behavioral Health Services Program include: intake/crisis management, off-site outreach, individual and group psychotherapy, psychiatric assessment, medication management, client support services, skill development, and psychological testing. The program also provides specialized crisis intervention and crisis follow-up services to victims of domestic violence, and specialized services to high-risk youth with severe emotional disturbances. Services provided through the Quyana Clubhouse include psychosocial rehabilitation, medication management, case management, employment skills, psychiatric services, group and individual counseling and supportive housing.

 

A 7-member board of directors, who meets every other month, governs the overall corporation. A six member board-appointed mental health advisory committee gives input to the governing board on Mental Health issues. The corporation employs over 600 people of whom 30 fill clinical positions in the Behavioral Health Services Program and 13 people run the Quyana clubhouse.

  

Description of the Process

To conduct this review, an interview team consisting of a facilitator, four community representatives and a peer reviewer conducted 31 interviews over four days in Anchorage, Alaska. Client interviews were taken from a list of 120 randomly selected clients. Of the clients successfully contacted from the list, 19 were scheduled for interviews and 13 actually spoke with team members. Ten interviews were conducted with related service professionals, one interview was with a corporation board member, one interview was with an advisory committee member and six were with SCF staff. Interviews lasted from 15 minutes to an hour and were held in person, at SCF's offices, in the community and by telephone. Most of the client interviews were conducted by telephone.

 

The interview team members also reviewed 7 personnel files, the agency staff training plan & schedule, 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, four members of the DMHDD Quality Assurance Unit did a review of randomly selected client records.

 

Open Forum

 A public forum was held at the SCF Administrative Building at 7:00pm on December fourteenth. SCF advertised the event by placing an ad in the Anchorage Daily News, running a public service announcement with KNBA radio and by distributing flyers through local organizations. All advertisements for the event included a request for prior notification of the intention to attend.  Four people attended the forum: three people who had previously received services from the organization and one who was an interested community member. The feedback provided to the team at the forum is incorporated in the body of the report.

 

 

FINDINGS

 

Progress Since Previous Review

As this is the first review of SCF using the new program standards, there is no previous action plan for these integrated standards. A plan for the improvement required by the chart review findings will be addressed separately in the DMHDD QA report.

 

Area of Excellence:

SCF is recognized for their excellence in providing Around-the-Clock Community Support. The team was impressed with the agency’s practice of providing 24 hour a day, 7 day a week non-crisis supports to clients living in the community. This service is offered through the Quyana Clubhouse program. This practice shows a commitment to client support that goes beyond common program practice.

 

 

 

 

Choice/Self-determination

The team identified the following strengths under Choice and Self-Determination for people receiving Mental Health services from SCF:

+    Most people interviewed felt they have choice in their life and choice about their services.

+    Most people said they were happy with their therapist and their treatment. One person 

      indicated that services she received from the Quyana house helped her turn around her life for

      the better.

+    Most people said that they felt involved in the development of their treatment plan and that the

      goals on the plan were the focus of their treatment sessions. One client stated “ I’m involved

      in everything… we both decide on my goals together.” (BHS)

 

The team identified the following weaknesses under Choice and Self-Determination for people receiving MH services from SCF:

-    Several people commented on the stress of transition and on their sense of loss in losing their 

      former therapist. One person commented that they were on their third therapist and that they

      had no choice of whom they see. The agency indicated that the transition of staff would have

      contributed to this situation. (BHS)

-    One woman said that she has never seen her treatment plan and would like to know what it

     says and learn about her progress. (QH)

 

Dignity, Respect and Rights

The team identified the following strengths under Dignity, Respect and Rights for people receiving MH services from SCF:

+    Most people interviewed felt they were treated with respect by agency staff.

+    Most people interviewed indicated that they understood their rights regarding treatment and

      confidentiality.

+    One staff member expressed his feelings about respect and dignity for clients by saying that he

      would never place a person in a housing situation that he would not live in himself.

 

The team identified the following weaknesses under Dignity, Respect and Rights for people receiving MH services from SCF:

-         One person reported they felt their rights were violated when neither the agency nor the governing board addressed their grievance as prescribed by the written agency policy.

-     One person said they did not know about their right to see their treatment plan/record.

-     Several people commented on the need for more Native counselors who understand the Native

      culture. In response to this finding, the agency discussed their concerted, ongoing effort to

      recruit Native Alaska counselors and the barriers to the success of that effort.

 

Health, Safety, Security

The team identified the following strengths under Health, Safety and Security for people receiving MH services from SCF:

+    The agency’s provision of overnight support services available to clients in the community

      helps to provide people with a safety net.

+    All people interviewed said they felt their basic needs were met and that they felt safe. One

      person stated, “I feel safe in my apartment; in the village I felt unsafe.”

+    The agency’s practice of having a once a week housing meeting to look at safety issues helps

      members learn community safety skills. (QCH)

+    The encouragement of consumer mentorship between clubhouse members regarding safety

       issues.  (QCH)

+    The agency’s practice of assessing everyone’s safety risk and specifically looking at the

       possibility of domestic violence.

+    One person indicated that the Domestic Violence Program helped her to feel safer in her living

      situation.

+    The practice of matching Quyana House members with primary care physicians.

 

The team identified the following weakness under Health, Safety and Security for people receiving MH services for people receiving services from SCF:

-    One person described a volatile living situation related to his relationship with his roommate.

 

Relationships

The team identified the following strengths under Relationships for people receiving MH services from SCF:

+     Most of the people interviewed live in a home of their own with their family members and report

       having strong relationships that they are either very satisfied with or they feel positive about

       the work they are doing on building those relationships.

+    Agency supported social skills development focuses on everyday life situations. One

      reported, “I talk every week about things in my life…social skills are directly related to

      what’s happening in my life and keeping a healthy outlook”.

+    Many people expressed their gratitude for the relationships they have developed through the

      programs. One person explained, “Appointments here at the Foundation are part of my

     (community) network”

+    Quyana Clubhouse activities focus on developing outside relationships.

+    Several people reported that staff members go out of their way to encourage family support.

      One person reported that her daughter’s therapist encouraged her to get support for herself. A

      staff member talked about the practice of supporting clients to get phone cards to keep in

     contact with out-of-town family members.

 

The team identified the following weakness under Relationships for people receiving MH services from SCF:

-         Several people talked about the negative effects of losing their therapist during the transition

      and their sense of abandonment and loss. At least two people said that as a result of the loss

      they would not come back to the agency again for help.

 

Community Participation

The team identified the following strengths under Community Participation for people receiving MH services from SCF:

+    The program has an overall, philosophical focus on community participation and making

      community connections. A related service provider praised the practice of staff going out with

      clients to the village to help with their transition back to the home environment. (QCH)

+    Parents/guardians interviewed reported that their children are involved and supported at

      school.

+    All of those who were asked reported that they feel they provide a valuable contribution to the

      community and that they feel valued by staff.

 

The team identified the following weaknesses under Community Participation for people receiving MH services from SCF:

-         While most people interviewed indicated that they had the option to do whatever they want,

very few people reported that they do outside activities in the community.

-         While the Quyana House program focuses a great many of its activities on pre-vocational skill

      development, there appears to be a need for services that focus on individualized, community

      based employment. Most people interviewed were unemployed. In response to this finding, the

     agency reported that it has also identified this need and plans to hire a full-time mental health

     clinician just to focus on employment issues.

 

Staff Interviews

 

The team interviewed six SCF staff selected by the agency. The overall feeling from staff was that they really liked working for the agency. Most people felt that they were valued by the agency and that they got a lot of support both personally and professionally through clinical supervision. One staff member expressed a fear of the agency growing too large and having clients and staff lose their focus. Quyana House staff said that they felt that the longevity of some staff was a plus. Clinical staff reported that they had reasonable size caseloads and that they did not have to work much overtime. 

 

When asked about the program, professional level clinical staff felt they had a clear understanding of the agency’s direction and mission, while administrative and the lower level direct-care staff were not clear on these issues. The staff members interviewed, expressed a high respect for clients. The overall staff focus is on identifying and addressing clients needs. The advisory board member interviewed was very enthusiastic about the program and was forward-thinking with a focus on prevention. 

 

One concern from the team regarding staff is the lack of clinical/professional staff who are Alaska Native. This is also a concern that the agency has expressed and is trying to address.

 

Collateral Agency Interviews:

 

Ten people from collateral agencies were interviewed including representatives from the Bristol Bay Health Corporation, Probation and Parole, ASSETS, the SCF Primary Care Center (under a separate department), Cook Inlet Pre-Trial, the Department of Corrections, AWAIC, Juvenile Probation, the IDP Plus Program and the Office of Public Advocacy.

 

Overall the feedback the team got about the program was very positive from almost all of those interviewed.  One person stated she was “Enormously pleased with the organization…They have taken risks (working with clients) that other agencies wouldn’t take”. Another interviewee stated that they get “100% from Quyana house (staff) and it’s always been that way”.  A village provider stated that SCF had proven him wrong about his fear that a big city provider could not meet the needs of a village client. 

 

Several people interviewed praised the Quyana House staff for their commitment to and support of clients who are offenders. Another interviewee stated that they were impressed with the way the agency staff encourages clients to participate in a variety of programs. Most people interviewed stated that the agency provides good communication to them about mutual clients. One person explained “ when something happens to a client I hear about it”.

 

Regarding agency deficits, a couple of people stated that paperwork could be slow, particularly when closing client cases. Another interviewee stated that the transition was rough and that they couldn’t get information when they needed it. Concerning clinical services, one person commented that it was difficult at times to get someone to make a decision regarding a joint project. Another person said there is a need for a quicker response from a doctor when a client is decompensating.  

 

Administrative/Personnel Narrative

 

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 23 of which are completely met by SCF. Those standards not fully met include:

 

1.       The agency’s governing body includes significant membership by consumers (DD, MH) or consumer family members (ILP), and embraces their meaningful participation. (Admin. Standard #6). The governing board of the organization has no members who are self-identified as mental health consumers but is made up of people who receive other services from the corporation. The mental health advisory board has only one mental health consumer on the six-member committee. The agency reported actively recruiting additional consumer members to the advisory board.

 

2.       The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery. (Admin. Standard #12).  While consumers may have indirect influence on policy setting and service delivery through surveys and suggestions, there is no direct solicitation of consumer input regarding policy and service delivery decisions.

 

3.       The agency systematically involves consumers, staff and community in annual agency planning and evaluation of programs, including feedback from its current and past users about their satisfaction with the planning and delivery of services. (Admin. Standard #13). Again, while consumer surveys can influence planning, there is no formal system for having consumers directly involved in planning.  

 

4.       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. (Admin. Standard #22) The staff hiring and evaluation process within each program has minimal, if any, incorporation of consumer choice. The clubhouse manager said that he was considering having a consumer on the staff interview team. The review team encourages this practice.

 

5.       The agency evaluation system provides performance appraisal and feedback to the employee and an opportunity for employee feedback to the agency. (Admin. Standard #28)  A staff development plan is written annually for each professional and paraprofessional staff person. (Admin. Standard #29) The performance appraisal system adheres to reasonably established timelines (Admin. Standard #31) The performance appraisal system establishes goals and objectives for the period of appraisal. (Admin. Standard #32)  While the agency has an extensive system for employee evaluation and feedback coordinated through their HRD department, of the seven employee personnel files reviewed (six with a hire date of twelve or more months ago), only one file included a current evaluation.

 

 

Program Management

 

Overall, SCF seems to be a well managed program run by caring and energetic people. The atmosphere of the agency is positive. The recent transition of the agency that resulted in a mass exodus of staff seems to have greatly affected a significant number of the clients with whom we spoke. There seems to be a sense of loss for many people.  While the change may have been inevitable and needed, it is important that the agency be aware of the unintended results of the change. The agency reported to the team the efforts they had made to lessen the effects of the transition on client care including efforts to make personal contact with each client to offer additional support.

 

CLINCIAL RECORDS REVIEW (conducted by DMHDD QA staff)

 

INTRODUCTION

The clinical chart review was conducted for the purpose of determining what information the agency needs to be able to generate documentation that reflects good clinical practice.  Another reason for the review was to conduct a mini-event for the Division of Medical Assistance (DMA) to determine that the services delivered are reflective of the services billed to Medicaid.  The charts reviewed were determined by a random sample taken from data supplied by DMA for Medicaid cases and by the provider for Non-Medicaid cases.  The number of charts to be reviewed was determined by a Range Table based on the total number of cases. The Quality Assurance file review consisted of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews.  The team reviewed a total of  (36) charts, Twenty (20) Medicaid charts and  (16) Non-Medicaid charts.

 

STRENGTHS

Southcentral Foundation has an Internal Quality Assurance person who is currently reviewing the documentation and working with the Division of Mental Health and Developmental Disabilities Quality Assurance Section to ensure that the agency is in compliance in this area.

 

AREAS FOR IMPROVEMENT

The documentation process currently in place has could benefit from consistency, as there were various types of assessments, treatment plans, progress notes and treatment plan reviews being generated.  A comparison of the assessment document with the Mental Health Standards requirements would also be helpful.  The files were not easily assessable and there were occasions where the client numbers were duplicated.

 

 

 

 

 

 

SUMMARY

This agency is making efforts to improve their charting process and appear to be on the right track by having a Quality Assurance person on staff.  The agency demonstrated a willingness to be in compliance and a desire to provide good services using sound clinical practices.

 

 

 

Areas Requiring Response:

 

1.       The agency should increase mental health consumer membership on both its mental health advisory committee and, if possible, on it’s overall governing board.

 

2.       The agency should develop a system for formally incorporating consumer input in decisions regarding policy setting and program delivery.

 

3.       The agency should develop a system for involving consumers, all staff and community members in the annual planning and evaluation of programs.

 

4.       The program should develop a system for incorporating consumer choice in the hiring and evaluation of staff.

 

5.       Supervisory staff need to provide timely and at least annual feedback to staff through the agency personnel performance evaluation system.

 

 

Other Recommendations:

 

·        Continue to work with the SCF Primary Care Center to clarify the agency’s identity separate from their services.

 

·        It is apparent that SCF has an extensive cultural training program. Continue to work on developing this cultural focus in treatment and planning, especially while training new staff.

 

·        Continue to work on increasing the hiring of clinical staff who are Alaska Native.

 

·        Ensure that all clients, to the greatest extent possible, participate in the treatment planning process and have knowledge of their treatment plan.

 

·        Continue to develop support services for clients who want to work in the community or attend school.

 

 

Closing

The team wishes to thank the staff of SCF for their cooperation and assistance in the completion of this review. A process such as this can be very disruptive to the office environment and your hospitality was much appreciated by all of the team members.

.

The final draft of this report will be prepared within 21 days and sent to DMHDD.  After an additional 30 days DMHDD will contact SCF to develop collaboratively a plan for change.

 

Attach: Administrative and Personnel Checklist; Questions for Related Agencies (tallied), Report Card (tallied)