Northern Community Resources
P. O. Box 7034
Ketchikan, Alaska 99901
(907) 225-6355
FAX 225-6354
Kris
Johnston, Community Member
A review of the Mental Health (MH) and
Developmental Disabilities (DD) services provided by Sound Alternatives was
conducted from November sixth to November eighth, 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 community team has collaborated on this report and the findings represent their consensus.
Sound Alternatives, based in the Cordova Community Hospital, provides MH and substance abuse services, day care assistance, domestic violence intervention, EAP services for hospital employees and the U.S. Coast Guard, social services for the hospital’s geriatric program and DD respite services. The agency serves about 45 MH and DD consumers at any given time with a staff of four of whom three are direct service staff. Psychiatric services are contracted for through the Langdon Clinic. The psychiatrist makes six daylong visits each year and is available for consultation between visits.
The agency serves the population of Cordova which numbers 2500 in the winter and 5000 during the summer fishing season. Crisis services are available in Cordova to the residents of Chenega Bay and Tatitlek. The population of the area is 25% Native Alaskan and the remainder represent a wide variety of other ethnic and language groups.
The agency’s total annual budget of $400,000 comes largely from grants. In 1999 nearly 40% of the budget came from the MH grant, 20% from the substance abuse grant and 10% from the DD grant.
The agency is governed by the hospital board, acting as an executive board, and by an advisory board. Two members of the executive board also serve on the advisory board. The nine-member advisory board includes 6 primary consumers, one of whom is also a secondary consumer.
Description
of Process
The four-member review team included two community members, a peer reviewer and a facilitator. An additional peer reviewer was forced to withdraw from the team due to a family emergency. As director of an agency offering MH and DD services, the remaining peer reviewer was qualified to serve in this dual capacity.
Interviews were conducted in person at the hospital and in the community or by telephone and were from 10 minutes and 60 minutes in duration. The team interviewed 30 persons including 4 DD consumers and 12 MH consumers (11 adults and 5 children), 7 staff of related agencies, 3 agency staff, a hospital administrator and 3 board members. All scheduled consumer interviews were taken from the random selection; an additional 2 consumers volunteered to be interviewed.
The related agencies interviewed were the Cordova Police Department, the Ilanka Clinic, DFYS, Cordova Family Resource Center, Connecting Ties, Department of Vocational Rehabilitation and the Mt. Eccles School.
The facilitator reviewed the agency’s policies and procedures, the hospital’s personnel policies, four personnel files, agency publications and the 1999 and 2000 audit reports.
Open
Forum
An open forum was held at 7:00 P.M. the evening of Monday, November sixth, at Cordova High School. The agency advertised the opportunity to meet with the review team in the local newspaper. Two people attended the open forum and their comments are included in the narrative section of this report.
Progress
Since Last Review
The last review of Sound Alternatives was conducted in November 1998, and included only the DD services. At that time, the team identified 7 areas requiring response.
1.
No documentation exists identifying the training
that respite providers undergo. The
Policy and Procedure Manual outlines both the training provided by the agency
and the training to be provided by the family to respite providers. Standard met.
2.
No parents who receive respite are currently
on the Advisory Board. Currently, 6 of
the 9 advisory board members are primary consumers and one is also a secondary
consumer. Standard met.
3.
The program has not completed the action item from
the previous review to develop a process for gathering family input into
program decisions. Currently, the
program conducts a survey of the community, of consumers and of consumer
families seeking information on which to base the setting of annual goals and
objectives. Consumers are also asked to
evaluate the program upon completion or termination of services. Standard met.
4.
Sound Alternatives should undergo strategic
planning to map the future for DD services in the Cordova community and
determine the status of respite providers.
The agency continues to limit its DD services to respite and respite
providers are not employees. The agency
has submitted its first application for waiver services. Standard not met.
5.
A new job description needs to be written for the
respite coordinator. This position has
been eliminated and included in the duties of the case manager. A complete job description has been written. Standard met.
6.
There is no documentation that references are
checked for respite providers. There is
documentation of background and reference checks for respite providers. Standard met.
7.
Not all families are informed of the agency’s
grievance procedure. Once again, not
all consumers were aware of the agency’s grievance procedure. Standard not met.
Model practices are those that could serve as models for other agencies. This category is not included in all reviews.
In this case, the team recommends for consideration
as a model practice the high level of communication among Sound Alternatives
staff regarding mutual cases and with other human service agencies to maximize
the continuity of care.
1. Two thirds of the members of the advisory board are consumers and are highly involved board members. The board’s stability and commitment is vital to the continuity of services.
2.
The agency environment is especially warm,
welcoming and home-like.
3.
Consumers express a high level of satisfaction with
services.
4.
The flexibility of Sound Alternatives staff is
exceptional: services are offered where needed including in the home; any staff
member is poised to respond as needed including in a crisis; staff adapt to the
needs to consumers. (MH)
The team identified the following strengths under
Choice and Self Determination for those receiving MH services:
+ Services are provided locally including
psychiatric care.
+ Psychiatric care is available on site at least 6
times per year.
+ Treatment plans reflect realistic consumer goals.
“I feel in control of realistic goals.”
-- consumer
+ Staff are flexible as to where, when, how and by whom services are provided.
“(The staff) have been wonderful. They even come to my home.”
-- consumer
+ There is
a choice of a male or a female therapist.
+ Services
are provided to individuals, couples, families and groups.
+ Care is
affordable.
The team identified the following weaknesses under
Choice and Self Determination for those receiving MH services:
- Staff
turnover has a negative impact on consumers and in some cases has resulted in
consumers withdrawing from services.
- The
agency has limited resources and is understaffed.
- There are
limited specialty services such as a child psychiatrist or child psychologist.
- Consumers
would like the choice of more frequent psychiatric visits.
- There is
a waiting list for services for school age children.
- There is
a lack of services for teens.
- There is
difficulty providing family therapy to school referred children. (This is not the responsibility solely of
the agency.)
The team identified the following strengths under Dignity, Respect and Rights for those receiving MH services:
+ Consumers
report improved courtesy and respect from this new staff.
“They always have time for me.” –
consumer
“(My therapist) is an angel, extremely
patient.” – consumer
“I am treated with the utmost courtesy and
respect.” -- consumer
“The latest crew is the best one yet.”
-- consumer
+ The
agency is warm, welcoming and homelike.
“(Staff are) very accommodating,
compassionate and welcoming.” – consumer
“The coffee is always on and there are
snacks too!” -- consumer
+ The staff is highly responsive to consumer needs.
“(They are) never too busy to help.” --
consumer
+ Crisis services are provided seamlessly and generously.
“They are there for me (in a crisis).” -- consumer
+ Consumers report an improved response to grievances.
+ Services
are locally based allowing consumers to remain in their community.
+ Staff
keep appointments.
+ Staff are
flexible in meeting the needs of consumers.
The team identified the following weaknesses under
Dignity, Respect and Rights for those receiving MH services:
- Not all
consumers are aware of the grievance policy.
- Consumers
complain of billing difficulties. (This is the responsibility of the hospital.)
- Past
experience with breaches of confidentiality, while beyond the responsibility of
current staff, discourages some consumers from being fully trusting.
The team identified the following strengths under Health, Safety and Security for those receiving MH services:
+ Consumer needs
are assessed with a holistic approach, taking into consideration their entire
life experience.
+ Staff respond promptly in a crisis.
“(Sound Alternatives) is my lifeline.”
-- consumer
+ There is good communication between
the agency’s contract psychiatrist and local physicians.
+ Locally
based services are easily accessible.
+ Consumers
report positive outcomes from services including increased income.
+ The
agency’s location in the local hospital provides easy access to a variety of
services.
+ Consumers
have safety plans as needed.
+ All
consumer state that their health needs are met.
The team identified no weaknesses under Health,
Safety and Security for those receiving MH services.
The team identified the following strengths under Relationships for those receiving MH services:
+ Staff
provide skill building in the area of appropriate boundaries.
+ Staff provide skill building for
parenting.
+ Behavioral plans are in place.
+ The
family can receive support as a whole.
“(Sound Alternatives’ services) helped me be
strong as an individual and us be stronger as a family.” -- consumer
+ Consumers
develop strong relationships with providers.
The team identified the following weakness under Relationships for those
receiving MH services:
-
Staff turnover equates to broken relationships,
especially when insufficient notice is given.
-
Consumers state the need for support groups.
The team identified the following strengths under Community Participation for those receiving MH services:
+ Staff
accompany consumers into the community when appropriate.
+ Staff provide life skills training.
The team identified the following weakness under Community Participation for
those receiving MH services:
- There is
a need for outreach to the teen population to avoid isolation of this age
group.
The team identified the following strengths under
Choice and Self Determination for those receiving DD services:
+ Families
choose their respite providers from among community residents.
+ Families assist in training their
respite providers.
+ Families choose the location for
respite care.
The team identified the following weaknesses under Choice and
self-determination for those receiving DD services:
- Staff
turnover has a negative effect on consumers, especially children.
- There are
limited specialty services such as speech therapy and occupational therapy.
- There are
limited resources for DD consumers.
- Some
consumers feel overwhelmed by paperwork.
“I need paperwork clarity!” – family member
of consumer
- Some
consumers find a disconnect between school services and DD services. (This is not solely the responsibility of
this agency.)
The team identified the following strengths under
Dignity, Respect and Rights for those receiving DD services:
+ Consumers
note an improvement in the courtesy and respect with which they are treated.
+ At the agency, the atmosphere is
warm, welcoming and homey.
+ Consumers state that the staff is
very responsive to their needs.
+ Crisis
services are provided seamlessly and generously.
+ There is
an improved response to grievances.
+ Services
are available locally allowing for children to remain with their families.
+ Staff are
on time for appointments.
+ Staff are
flexible in the way they meet consumer needs.
The team identified the following weakness under Dignity, Respect and Rights
for those receiving DD services:
- Not all
consumer families are aware of the grievance policy.
The team identified the following strengths under
Health, Safety and Security for those receiving DD services:
+ Services
are locally based.
+ Staff are willing to do research
regarding diagnoses and interventions.
+ The agency is located in the local
hospital, providing easy access to a variety of services.
The team identified the following weakness under Health, Safety and Security
for those receiving DD services:
- Home
modifications are not available. (This
is not a primary responsibility of this agency.)
The team identified the following strengths under
Relationships for those receiving DD services:
+ Staff aid
in skill building for parents.
“This service is a lifesaver.” – parent
of consumer
+ Behavioral plans are in place.
+ Parents are informed regarding
reasonable expectations for their child.
+ Consumers
develop strong relationships with staff including respite providers.
The team identified the following weakness under Relationships for those receiving
DD services:
- There are
insufficient services for the entire family of DD consumers.
The team identified the following strengths under
Community Participation for those receiving DD services:
+ Staff
accompany consumers into the community as appropriate.
+ Staff provide life skills training.
The team identified the following weaknesses under Community Participation for
those receiving DD services:
- Key
buildings in Cordova are not accessible including the school, pool, gym and
library. (This is not primarily the
responsibility of the agency.)
Staff
Interviews
The staff of Sound Alternatives work as a well-coordinated team despite being recent hires. Regular staffings and open communication provide continuity of care for consumers and a relaxed, egalitarian atmosphere for staff. Staff are quick to acknowledge the positive outcomes they have seen in consumers’ lives and get satisfaction from witnessing these changes.
Staff want to provide more services including
expanded DD services and the use of Personal Care Attendants. Staff note the need for more space and more
training to meet the need for expansion.
The staff of related agencies are unanimous in their praise of Sound Alternatives as shown in the Interview Form for Related Agencies attached to this report. Particular strengths noted in these interviews were the availability of services in the elementary school, the active interagency consortium which meets regularly and the high degree of collaboration.
The only concern noted in these interviews is the
waiting list for services in the school despite the severity of the need.
There are thirty-four Administrative and Personnel Standards that agencies providing MH and DD services are to meet. Of these, Sound Alternatives fully meets 29 and partially meets the remaining 5 standards. This represents a significant improvement since the last review.
1. Standard #4 Budget controls, record keeping and staff training support good business practices and conform to state requirements. Both the 1999 and the 2000 audits of the hospital note the need for changes in financial practices. This standard is partially met and the responsibility for this lies with the hospital.
2. Standard #10 The agency maintains policies and procedures for preventing and correcting conflicts of interest. The hospital’s personnel policy prohibits nepotism. The board reports a history of board members abstaining from votes when a conflict of interest occurs. However, neither the advisory board’s bylaws nor the agency’s policies and procedures fully address conflict of interest.
3. 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 (abuse, neglect, mistreatment law), cultural diversity issues, and potential work related hazards associated with serving individuals with severe disabilities. The agency’s orientation meets all of these requirements with the exception of addressing cultural diversity issues.
4. Standard #27 The program obtains and documents informed consent from consumers (or ILP family members) before services are initiated and when services are changed or modified. In the past, informed consent was documented at the initiation of services but not when changes were made to the plan. The new Director is addressing the latter at this time.
5. Standard #32 The performance appraisal system establishes goals and objectives for the period of appraisal. The evaluation addresses training issues but no other goals and objectives are documented.
Program
Management
Sound Alternatives has been plagued, as have most MH and
DD programs in Alaska, with high staff turnover. Despite that fact, the agency is stable, no service disruption
has occurred and the staff is busy and focused. This professional team has “hit
the ground running” and is commended for their energy and organization. In addition, the new Director is
complimented on his casual and supportive manner. Clearly, communication is open and the staff is mutually
supportive. Staff describe this
atmosphere as “cool” and “laid back.” A related agency comments that the Sound Alternatives’ staff have “a good, strong working relationship.”
The advisory board is exceptional in having
consumers in two thirds of its seats.
Interest in the advisory board remains strong: a recent vacancy was
responded to with three letters of interest.
The board is described as enthusiastic, professional, stable, active,
vocal and placing an emphasis on advocacy.
The board is active in the interviewing of all job applicants and making
recommendations for hire.
Staff retention should be a goal in order to
increase consumer confidence and continuity of care. In the opinion of the team, staff salaries are quite low. An increase in compensation might improve
staff retention.
There are additional resources available to the
staff of Sound Alternatives including consultation with other agencies who have
increased revenue through appropriate Medicaid billing such as South Peninsula
Community Mental Health Center and with regional training resources such as
Connecting Ties.
Given the transient nature of Cordova’s population,
the agency’s services are not universally known. The agency might consider periodically disseminating more
information about its services.
At this time, with a new administration in the hospital and a new staff in Sound Alternatives, the time is ripe for the development of a strategic plan for the expansion of services. The advisory board could be key in the development of such a plan.
Areas
Requiring Response
1. Seek to educate all consumers regarding their rights, especially the use of the grievance policy. (Prior review)
2.
Develop a strategic plan for the expansion of DD
services. (Prior review)
3.
Request that the hospital develop financial
policies in accord with the suggestions of auditors. (Standard #4)
4.
Develop a policy regarding conflicts of interest
for both staff and for the advisory board.
(Standard #10)
5.
Include cultural diversity issues in the new staff
orientation and training. (Standard
#25)
6.
Document the informed consent of consumers at the
initiation of service and revision of service plans. (Standard #27)
7.
Expand the goals and objectives for the evaluation
period of each staff member to include more than training issues. (Standard #32)
Other
Recommendations
1. That the agency, the hospital and other service agencies collaborate on training events for professionals and community members on such topics as suicide, psychopharmacology, etc.
2.
Consider training peer counselors in the high
school as a means of outreach to teens.
3.
Consider collaborating with the hospital on a
strategic plan for the expansion of services.
4.
Consider expanding services through meeting
Medicaid requirements and so increasing revenue.
5.
Develop a plan to increase space for the agency’s
use.
6.
Survey other agencies to compare salary scales and
consider increasing salaries within that context.
7.
Provide training in-house on how to maximize
revenue.
8.
Consider periodically disseminating information
regarding the services you offer.
9.
Family members of consumers would benefit from instructions
for completing paperwork. (DD)
10. Advocate
for accessibility in public buildings. (DD)
Closing Note:
The final draft of this report will be sent to
Northern Community Resources for final review. You will receive the final
report within approximately thirty days, including a Plan of Action form,
listing the Areas Requiring Response. You will then have an additional 30 days
to complete the Plan of Action. The directions on how to proceed from there
will be included in a cover letter you will receive with the final report and
Plan of Action form.
Once NCR has reviewed the completed Plan of Action,
it will be sent to the DMHDD Quality Assurance Section. The QA Section will then contact you to
develop collaboratively a plan for change.
Attachments: Administrative and Personnel
Checklist, Interview Form for Staff of Related Agencies (tallied), Score Sheet
(averaged)
NCR 10/00