Integrated Quality Assurance Review

Tanana Chiefs Conference, Inc.

August 30-September 3, 1999

Fairbanks, Alaska

 

Site Review Team:

Sam Bush, Community Member                         Jeri Lanier, Community Member

Christine Butler, Community Member                  Jane Franks, Peer Reviewer

Linda Hurley, Peer Reviewer                             Vicki Thayer, Peer Reviewer

Connie Greco, Lead DMHDD QA Staff                Pam Miller, DMHDD QA Staff

Jane Atuk, ILP Technical Assistance Staff           John Havrilek, Facilitator

Sherry Modrow, Co-Facilitator

 

Introduction

The Site Review Team conducted a review of state-funded Infant Learning, Developmental Disabilities and Counseling Center services at Tanana Chiefs Conference from August 30 to September 3, 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 includes a limited administrative review.  The report does not represent or reflect a comprehensive review of this agency.  The community team has collaborated on this report and the findings represent their consensus.  DMHDD Quality Assurance staff conducted the Clinical Record Review and provided that section of this report.

Description of Tanana Chiefs Conference, Inc.

Tanana Chiefs Conference, Inc. (TCC) is a nonprofit tribal organization representing 42 tribal governments in Interior Alaska. TCC incorporated as a nonprofit organization in 1972. It serves and represents approximately 14,000 Alaska Natives residing in an area of 235,000 square miles, covering 39% of the state. The corporation provides services through state grants and federal contracts and grants to Alaska Natives and non-native residents of small communities along the Yukon, Tanana, Koyukuk and Kuskokwim Rivers and their tributaries.

TCC’s organizational history reflects the importance of balancing traditional Native values with the modern demands facing indigenous peoples. The organization provides specially tailored programs to its constituents in health, employment, education, economic development and general family services.

Tanana Chiefs Conference’s member tribal organizations elect a 43-person Board of Directors and a nine-member Executive Board. The full Board elects the president, who serves as the CEO of the corporation. TCC administers over 40 programs through seven regional offices. The corporate administration is located in Fairbanks.

 

In 1998, TCC was recognized as one of the 60 largest employers in the state of Alaska, with more than 600 full-time and part-time staff distributed between the regional office in Fairbanks, seven subregional district offices, and more than 30 communities.

TCC manages approximately $65 million annually. The organization completes an annual independent audit.

Services Reviewed

Infant Learning Program: 3 FTE staff, 43 children receiving services in 20 villages

Infant Learning Specialists work as a team with families, other providers and contract specialists to provide family-centered services, which respect the cultural differences and community values of rural Alaska. The Fairbanks-based staff members travel regularly, attempting to visit each family approximately every 5 weeks to evaluate, plan services, and provide or facilitate special instruction, advocacy and specialized therapy.  

Developmental Disabilities Program: 1 FTE staff, 42 individuals in 21 villages active on respite caseload, 10 individuals on waitlist

This program offers assistance for families of children with developmental disabilities primarily by providing vouchers for respite care.  The program’s sole staff member provides limited case management, advocacy and referral and helps families to develop individual plans of service based on a child’s needs and family preferences.  From the Fairbanks office, the Family and Community Services Specialist uses telephone and fax to stay in contact with individuals and tribal coordinators in the villages.  The program provides vouchers to families, who hire their respite providers.  The relationship between consumers and respite providers is a contractual agreement in which TCC has no involvement beyond voucher payments.  The program does not supervise or provide funding for training respite provider.  Although there is a travel budget, the staff person has no back-up coverage for office functions, so is only rarely able to visit the villages where most of the consumer families live.

Counseling Center: 6 FTE staff, 40 clients in case management, coverage in all TCC villages and Fairbanks

The TCC Counseling Center, located in the Fairbanks Memorial Hospital building, provides mental health services and support to Alaska Natives and American Indians. Residents of Interior villages fly to Fairbanks at TCC’s expense for regular appointments for psychiatric evaluation and medication management, case management, referral and information, intake and crisis intervention services. The Counseling Center offers crisis intervention and information and refers clients to outpatient services by contracting with Fairbanks-area mental health professionals.  The Paul Williams House also provides services for crisis respite.  The Institutional Discharge Program and Community Support Program provide case management services to the chronically mentally ill from the villages and Fairbanks.

 

 

 

Description of Review:

The Integrated Quality Assurance Site Review Team met for five days in Fairbanks. The team consisted of three community representatives, three peer providers, two facilitators, two DMHDD staff and an ILP staff person. The team reviewed individual ILP and DD consumer files and program and agency materials, and interviewed 24 consumers of TCC services and 14 staff members.   The review also included interviews with 12 individuals from the following related service agencies: Public Health Nursing, Fairbanks Correctional Center, Adult Learning Programs of Alaska, TCC Head Start, University of Alaska Rural Programs, Division of Family and Youth Services, Public Defender Agency, Fairbanks Resource Agency, ACCESS Alaska and Yukon Flats School District. Interviews lasted between 30 minutes and an hour.

Monitoring and reporting the quality of life and the quality of services for individuals and families make significant contributions 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 TCC’s responses to the previous action plan; related service agency comments; an administrative review; consumer responses to the Quality of Life Standards. The report also includes recommended improvements and tables of consumer satisfaction and file reviews.

Open Forum: TCC staff advertised an Open Forum by distributing a flier in Fairbanks and in each village. The flier was posted in several locations in the TCC building in Fairbanks and was provided to other community agencies. The flier included prominent notice of a toll-free telephone number for people outside the Fairbanks area to call to provide their comments. A meeting room was provided in the Fairbanks North Star Borough’s Noel Wien Library. No one attended or called.

 

 

Mental Health Program Findings

Progress Since Previous Review: As this was the first site review under the Integrated Quality Assurance system, there was no previous review available for comparison or response.

It must be noted here that the site review team felt their review of TCC’s mental health services was inadequate. The core of the measure of outcomes in the lives of consumers is based on consumer interviews.  Generally, in an agency with this level of state funding, 15 consumers would be included, thus providing a significant sample and one from which conclusions may be drawn.  Unfortunately, TCC’s MH program could only offer five consumers in a residential facility to be interviewed and those chosen were not able to be completely available, emotionally and cognitively, for an interaction of this sort.  Therefore the team cannot claim that the findings below present either an adequate or an accurate picture of TCC’s MH services.

Given the above facts, the team recommends that another review be scheduled that would include a sufficient number of consumer interviews to present a balanced picture of the satisfaction of TCC consumers with their services and their lives. 

 

 

 

CHOICE AND SELF DETERMINATION

Based on the small number of consumer interviews conducted, the team was unable to identify the strengths under Choice and Self-Determination for people receiving MH services from TCC.

                                               

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

-         There is a long wait-list for seeing a psychiatrist.

-         There is a perceived lack of therapeutic services: “We need a therapist that does therapy.”--consumer

 

DIGNITY, RESPECT AND RIGHTS

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

+ Consumers and other agencies recognize the respect with which consumers are treated:

 “I would rather work with TCC than other providers.  They give us prompt, up-to-date info. and they care about their clients.”—related service agency

Consumers reported they feel extremely respected.

+ Case managers reflect their respect and concern for the consumers by their hard work.  They are a recognized strength of the program: “Case managers are working their tails off; they’re awesome.”--consumer

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

-         Three of the five consumers interviewed had not signed the release of information provided.

-         Some related agencies would like more collaborative efforts and communication with TCC.

 

HEALTH, SAFETY AND SECURITY

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

+ TCC psychiatric staff does an excellent job of medication management.

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

-         Budget cuts are perceived as negatively affecting staffing and service levels.

 

RELATIONSHIPS

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

+ One of the Counseling Center staff’s strong points is their longevity.  Stable staff can build professional relationships with consumers.

+ The staff model healthy relationships: TCC fosters teamwork among case managers: “We have great teamwork.”—direct service staff

Based on the small number of consumer interviews conducted, the team was unable to identify the weaknesses under Relationships for people receiving MH services from TCC.

                                   

COMMUNITY PARTICIPATION

Based on the small number of consumer interviews conducted, the team was unable to identify the strengths and/or weaknesses under Community Participation for people receiving MH services from TCC.                                                         

Consumer Satisfaction Chart *

MH

  Choice   N=5

 

  Dig&Res. N=5

  Hth,Saf,Sec N=5

  Relatns. N=5

  Com.Par. N=5

Outcome

Yes

No

 

Yes

No

 

Yes

No

 

Yes

No

 

Yes

No

 

Person/Parent/guardian

3

2

 

4

1

 

5

 

 

4

1

 

5

 

 

Staff Performance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person/Parent/guardian

5

 

 

3

   2

 

5

 

 

4

1

 

5

 

 

* Five consumers in a residential facility were interviewed from this program. Not all were unable to respond to necessary questions. The team does not feel that this chart adequately reflects the life situations of TCC MH consumers as a group.

 

Staff Interviews

The staff appeared to be extremely supportive of consumers and their ability to work together as a team, but was concerned about budget cuts.

Collateral Agency Interviews

Agencies were very supportive of TCC services, but would like more collaborative efforts in the  Community Support Program, in the Institutional Discharge Program and in crisis intervention.

 

Administrative and Personnel Narrative

TCC overall has strong administrative policies and procedures. In an organization of this size, input of consumers in small programs may not be reflected in the agency’s overall processes. Consequently, the Counseling Center does not meet Administrative and Personnel Standards numbers 6, 12, 14,and 22.  (See Areas Requiring Response)

Program Management

Budget cuts appear to have negatively affected staffing and service levels.

QA Clinical Chart Review

 

 INTRODUCTION - The clinical chart review was conducted for the purpose of determining the agency’s training needs in order to provide documentation that reflects good clinical practice.  Another reason for the review was to conduct a mini-event audit 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.  The number of charts to be reviewed was determined by a Range Table based on the total number of cases supplied by DMA.  There were fifteen (15) Medicaid charts reviewed, ten (10) adult charts and five (5) child charts. There were no non-Medicaid charts reviewed.

 

 STRENGTHS- One of the most noteworthy strengths of this agency is their desire for information.  The clinical director has expressed a desire to have training in areas of Medicaid billing and documentation requirements.  In the area of documentation, the charts reflect assessments that are well written, and do a great job in supporting the given diagnoses. Overall, progress notes were well documented.

 

WEAKNESSES- If psychiatric assessments are used as comprehensive assessments, please make sure they include all the components required by regulations and standards.  It appears that the agency puts more time into the assessment process than is being reflected in the billings.  There appears to be few rehab services indicated for children, and some of the charts reflected only substance abuse issues.  A review of the billing allowances and contents required for assessment (comprehensive and psychiatric) and medication management might be helpful.  Some charts do not contain treatment plans and others contain goals that were not recommended in the assessment material.  In some treatment plans, problems were identified (mostly clinical) that were not recommended for treatment.  If the agency only offers psychiatric and case management, they should document outside referral for other treatment modalities.  Please include the specific goal being addressed during service episodes and the client progress toward the goal. The practice of clearly stating active interventions can be more consistent.  In some charts, there were discrepancies in the progress notes between the amount of time reflected for the session and the amount that was billed to and paid by Medicaid.   This resulted in less revenue being paid than was indicated in the progress note.  If there is not a system in place to track billing follow-up, it is recommended that one be implemented. Some charts did not contain treatment review documents.

 

SUMMARY- The file review should identify areas of documentation that need more attention in order to reflect good clinical practice.  These areas can be the focus of training for the agency.   In this review, the strengths of the documentation process are reflected in assessment and progress notes.  The psychiatric notes are very good. However, there appears to be a shortage of clinical services delivered by therapists other than a psychiatrist.  TCC may consider using other Mental Health Professional Clinicians to provide clinical services and utilize their psychiatrists for evaluations and monitoring of medications. The treatment plans and treatment plan reviews reflected the most need for documentation training. You are encouraged to arrange for training in areas of billing and documentation and to refer to the Integrated Standards (Oct. 98) and/or to the provider- approved standardized clinical record forms for the required components. The Mental Health File Review Checklist in the Integrated Standards discusses the components required and the timelines for assessments, treatment plans, progress notes, and treatment plan reviews.  The standardized forms are available in hard copy and on disk (instructions are included).  While the forms are optional, the components of the forms are mandatory, in order to meet all the requirements of the Medicaid Regulations and Integrated Standards.


 

 

 


Developmental Disabilities Program Findings

Progress Since Previous Review:

Previous Recommendation: “The team recommends that, in the absence of a designated representative, the program explore effective ways to inform the TCC Executive Board of the program’s accomplishments and needs as well as the issues and level of satisfaction of its consumers.”

         Action Taken: The consumer survey has been completed; results will be given to the administration and board. Staff plans to join a related program in forming an advisory board. Each year the program’s annual report is presented to the Executive Board.

Previous Recommendation: “The team recommends that a clear process of appeals be developed for the DD program and made available to all consumers of the program’s services.”

         Action Taken: The program has a grievance process in place; the grievance policy is provided to families in the respite packet.

 

Choice and Self Determination

The team identified the following strengths under Choice and Self Determination for people receiving DD services from TCC:

+ The DD program maintains a strong focus on consumer choice: “Amanda has been my best resource.”-- consumer

+ TCC provides families with a service that allows them to define respite according to their needs, interests and individual respite needs: “I don’t know what I would have done without TCC.  I was lost, frustrated; they gave me guidance.”--consumer

 

The team identified the following weaknesses under Choice and Self Determination for people receiving DD services from TCC:

-         Staff should be prepared to consistently provide information and assist families in making referrals to other resources.

-         There is a larger case load than one staff person can accommodate.

 

Dignity, Respect and Rights

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

+ The respite program is community based: “This respite provider really knows what we are going through.”--consumer

+ DD staff are very responsive to consumer needs.

 

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

-         Consumers said they would benefit from more visits in the villages from the DD staff person; respite providers also expressed a need for training and more on site visits from the staff.

 

Health, Safety and Security

The team did not have enough information to identify strengths under Health, Safety and Security for people receiving DD services from TCC.

 

The team identified the following weaknesses under Health, Safety and Security for people receiving DD services from TCC:

-         The program lacks a training component for respite providers

 

Relationships

The team identified the following strengths under Relationships for people receiving DD services from TCC:

+ Respite providers function as a natural extension of family life in the village.

 

The team identified the following weaknesses under Relationships for all people receiving DD services from TCC:

-         Staff turnover appears to have been a problem: “In my three and a half years receiving TCC services, there have been three different staff people.”--consumer

 

Community Participation

The team identified the following strengths under Community Participation for all people receiving DD services from TCC:

+ The respite program is community based.

 

The team did not identify weaknesses under Community Participation for people receiving DD services from TCC.

 

Consumer Satisfaction Chart

DD

  Choice   N=10

  Dig&Res. N=10

  Hth,Saf,Sec N=10

  Relatns. N=10

  Com.Par. N=10

Outcome

Yes

No

 

Yes

No

 

Yes

No

 

Yes

No

 

Yes

No

 

Person/Parent/guardian

5

5

 

9

1

 

8

2

 

8

2

 

8

2

 

Staff Performance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person/Parent/guardian

9

1

 

10

 

 

8

2

 

9

1

 

10

 

 

 

Staff Interviews

With a caseload of 42 and 10 on waitlist, the single DD specialist needs additional staff, and has requested a three-quarter position. Current staffing limits the ability of the specialist to travel since that would leave the office without coverage. Additional staff would allow for production of a respite booklet with training information about general disabilities to send respite providers and families.

Staff would like funding to link respite providers to basic CPR and First Aid training that are periodically available.

TCC provides staff with an atmosphere of creative freedom, trust and support.

Collateral Agency Interviews

Agencies were very supportive of TCC services and Amanda. They request more training for respite providers and more travel to the villages from the Fairbanks office.

 

Administrative/Personnel Narrative

TCC overall has strong administrative policies and procedures. In an organization of this size, input of consumers in small programs may not be reflected in the agency’s overall processes, although Amanda has surveyed all consumers, with a very high return of surveys. This is being used to direct program-level decision-making.  The program does not, however, meet Administrative and Personnel Standards #6 (See Areas Requiring Response)

 

Program Management

In the past, frequent staff turnover has been a difficulty.  The caseload is extraordinarily large for the single staff person.

File Review

The DD files reviewed were well organized and fairly thorough. However, several files needed to have case notes inserted or updated.

 

Early Intervention/Infant Learning Program Findings

 It must be noted that the team performed its duties admirably under complex conditions.  In order to do justice to the ILP portion of the review, part of the team traveled to Delta, some 75 miles distant, to complete interviews.

Progress Since Previous Review:

Previous Recommendation: “Develop written orientation manual for families.”

         Action Taken: The new orientation sheet and parents rights have been in use since the beginning of 1999.

Previous Recommendation: “Assure that all team members contribute information to evaluation reports.”

         Action Taken: All suggestions are incorporated into the evaluation report.

Previous Recommendation: “Include criteria, procedures and timelines with each outcome statement.”

         Action Taken: Training was received from State ILP. This is an area for continued improvement.

Previous Recommendation: “Include statement of specific services needed in the IFSP.”

         Action Taken: All services are listed, whether available or not.

Previous Recommendation: “Expand MOAs with local service providers.”

         Action Taken: There are current MOAs with school districts and Head Starts; this needs to be a continuing effort with expansion to additional local service providers.

Previous Recommendation: ”Emphasize family needs in the transition planning process.”

         Action Taken: ILP staff is actively advocating in this area.

Previous Recommendation: “Individualized timelines in written transition plans.”

         Action Taken: Transition plans are more detailed and families are involved.

Previous Recommendation: “Review and revise program policies to conform to ILP standards.”

         Action Taken: Policy Manual has been updated to meet standards.

Previous Recommendation: “Make salaries competitive with school districts.”

         Action Taken: This continues to need additional action.

Previous Recommendation: “Improve program planning and collaboration.”

         Action Taken: Program staff collaborate in more activities with other agencies.

Previous Recommendation: “Give families input in the planning process. Utilize information from family in developing programs and priorities.”

         Action Taken: Parent survey results incorporated into program planning.

Previous Recommendation: “Assure family participation in hiring process.”

         Action Taken: This is ongoing.

Previous Recommendation: “Include more involvement of local supports to increase family visits.”

         Action Taken: MOAs are in place with local Head Starts and program is working closely with Head Start programs.

 

Choice and Self Determination

The team identified the following strengths under Choice and Self Determination for people receiving ILP services from TCC:

+ Most related service providers reported strong collaborative efforts: “Michelle is really good.  If there’s any questions, I can ask her.”    “They are our eyes and ears.”

+ Parents are given options and choice of family service coordinator when possible.

The team identified the following weaknesses under Choice and Self Determination for people receiving ILP services from TCC:

-         Some families were not aware they could get respite services.

-         Some Public Health Nurses expressed the need for stronger communication about the types of services available in ILP. 

-         Some Public Health Nurses reported that residents and service providers did not understand the Infant Learning services and program.

 

Dignity, Respect and Rights

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

+ Parents report high satisfaction with services received: “We were pleased with all the services we’ve had so far.”

+ Parents feel the staff does a good job: “They were right on the ball.”    “ILP staff have always been great to work with.”

+ Staff are aware of the agency mission and are respectful of family and community cultural norms.

 

The team did not identify weaknesses under Dignity, Respect and Rights for people receiving ILP services from TCC.

 

Health, Safety and Security

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

+ ILP staff have developed a process for ChildFind utilizing the “Ages and Stages” questionnaire that could be a model for rural communities in Alaska.

 

The team did not identify weaknesses under Health, Safety and Security for people receiving ILP services from TCC.

 

 

Relationships

The team noted the following strengths under relationships for people receiving ILP services from TCC:

+ The team found that the ILP staff assisted families in making connections with support networking.

+  The staff fosters relationships between siblings and infants.

 

The team did not note specific weaknesses under Relationships for people receiving ILP services from TCC.

 

Community Participation

The team noted the following strengths under community participation for people receiving ILP services from TCC:

+ The ILP staff supports families to become active members of the community in culturally relevant activities through use of assistive technology and other methods.

+  The ILP staff assist children to participate in their natural environment and activities in their home and community.

 

The team did not note specific weaknesses under Community Participation for people receiving ILP services from TCC.

Staff Interviews

ILP goals are several years old and family involvement has been limited for changing the program goals. Staff asked if funds could be made available to bring program participants to Fairbanks annually to perform a group discussion about ILP goals and program changes.

Staff report that reliable evaluation and survey information are difficult to obtain.

Staff would like to facilitate participation of families in the process of hiring direct service providers. (Administrative and Personnel Standard #22) Suggestions include: A supervisor could ask parents for some questions they would like to have asked during an interview for a new staff member. A supervisor could take a finalist for a position to one or more villages on several home visits as the final step in the hiring process, thereby giving families real involvement in the decision.

Staff would like to see staffing levels adequate to provide on-going programming in the villages. The belief was expressed that visits in intervals of five weeks or longer seriously underserve the intent of ILP and the needs of children and families. The current system sets up family expectations that ILP will have an appreciable impact on a child’s development, but the level of program activity and funding are not sufficient to make those expectations realistic.

More than one staff person expressed anger about a job classification that occurred two years ago: “I am not a Tech II; ever since that happened, I have been really angry.” “The agency doesn’t acknowledge the professionalism of staff. I don’t know why.” The Program Director acknowledged agency-wide concerns about job classifications, and said it is being worked on.  An individual grievance procedure does exist.

Collateral Agency Interviews

Related agencies expressed that they like the services from ILP, but they feel there is a need for more frequent visits and a need to explain ILP services at community-wide meetings.

There was concern that three staff people are not enough to serve an area this large.

 

Administrative/Personnel Narrative

TCC overall has strong administrative policies and procedures. However, there is no mechanism for membership of ILP consumers on the Board.

Program policies and procedures have been recently updated and are beginning to be implemented.

It was reported that staff do not feel a good level of administrative support within the agency.  Examples cited included the job classification and lack of support to implement the new Childfind process.

Present ILP staffing is insufficient to serve the caseload adequately or meet goals laid out in the IFSPs.  The two vacant ILP positions need to be filled as soon as possible by qualified staff.

Distances and the demands of travel impact the Fairbanks-based program staff negatively.  A suggestion was made that the program should look at hiring and supporting paraprofessional staff to work out of each subregional center with appropriate support from professional staff.

The program does not fully meet Administrative and Personnel Standards #6, #20, #39, #41 (See Areas Requiring Response).

 

Program Management

The classification of these staff positions as Tech II has been a source of real concern. While TCC has procedures for individuals to file appeals to their job classifications, the ILP staff feel their concern needs to be handled for the entire group rather than individually.

 

File Review

Review of ILP files indicates gaps in documentation, but conversations with consumers and related service agencies shows general satisfaction with services and rapid follow-up on referrals. On-going level of services is not documented well.

One file example: Part C eligible child

         Only one entry in contact log, blank direct service reports; only evidence of contacts is:                                         Eval                   5/ 6/97

                  IFSP                       10/28/97

                  Language eval          2/27/98

                  Exit form                   4/23/99

              (Were there only 4 contacts in 2 years?)

Overall the case notes and home visit forms (Direct Service Forms) were very hard to follow because dates were frequently incomplete (day or year missing) and very inconsistent. Four of the files reviewed had very limited case notes of any sort.

         IFSP is a critical document. It is required for enrollment and drives the services. It is the legal document showing services agreed to by the family and program. Only one of the six files reviewed contained a current IFSP, and that one was not complete (missing was the summary of the child’s development).

         Evaluation reports were in all files; parent consent forms were signed and in files for all six cases reviewed. Four files had appropriate exchange of information forms signed by parents. The files are generally organized in the same order. Completion of basic program documentation is a major concern.                                                                                   

 

Areas Requiring Response

 

1.       The agency’s governing body does not include the memberships of consumers or of the family members of consumers. (Administrative and Personnel Standard #6)  Consider the creation of advisory boards or the restructuring of the governing board to allow for consumer and family member participation.

2.       The agency’s collection and utilization of consumer and family opinion in the development of policies and the provision of services is not consistent through all programs. (Administrative and Personnel Standard #12)  Broaden efforts to gather and use the opinions of consumers and their families in the development of policies and in the provision of services.

3.       The agency does not uniformly and annually develop goals and objectives that are in response to consumers, community opinion and self evaluation. (Administrative and Personnel Standard #14)  Regularize the gathering of opinions and evaluation and the application of this information in developing annual goals and objectives.

4.       The agency only partially complies in its efforts to foster consumer relationships with other community members in a social setting.  (Administrative and Personnel Standard #26)  Strengthen efforts to facilitate consumer relationships and community involvement.

5.       Regarding MH: Consumers are negatively impacted by long delays in receiving psychiatric services.  Consider staffing or program changes that would alleviate this difficulty.  Document these attempts.

6.       Regarding MH: Consumers express the need for direct therapeutic services.  Consider staffing or program changes that would allow for increased therapeutic services.

7.       Regarding MH: Given respect for the rights of consumers and the ever-present legal concerns, systematize the use of releases of information.

8.       Regarding MH: Develop collaborative policies with related agencies especially for the complex and critical needs of consumers in the IDP, CSP and crisis intervention programs.

9.       Regarding MH: The program does not have a procedure by which consumers can exercise choice in the hiring and evaluation of providers.  (Administrative and Personnel Standard #22) Consider the adoption of policies to allow for a consumer voice in the hiring and evaluation of direct service providers.

10.   Regarding DD: The caseload far outpaces the staffing in this program.  This is reflected directly in the consumer requests for more frequent visits and for training for respite providers and indirectly in the stated need for additional information and referrals.  Consider staffing or program changes that would alleviate this important difficulty and allow for consumer needs to be met.  These needed changes may alleviate the further concern regarding turnover of these key staff positions.

11.   Regarding DD: The quality of respite care is dependent on the training received by the providers.  Consider ways in which to educate and supervise respite providers. In the light of health and safety issues, consider providing CPR and First Aid training to respite providers or link respite providers with community based health aides for support and guidance.  Additional types of  training for developmental disabilities are also necessary.

12.   Regarding DD: Case notes must be complete and current.

13.   Regarding ILP: The agency does not maintain a system for the regular review and revision of job descriptions. (Administrative and Personnel Standard #20)  Given the dissatisfaction expressed by the staff in regard to their classification, consider implementing a regular review and revision of job descriptions.

14.   Regarding ILP: Staffing levels are insufficient to properly serve the children and their families in need of these services.  (Administrative and Personnel Standard #39) Implement staffing changes and/or program design in order to provide the services agreed to in the IFSP.

15.   Regarding ILP: There is a need for a greater number of specialized staff to provide IFSP services.  (Administrative and Personnel Standard #41)  Seek additional staff and/or additional training for staff and/or MOA’s to meet this standard.

16.   Regarding ILP: Continue the improvement of outcome statements as per the last site review.

17.   Regarding ILP: Continue to expand the scope of MOA’s as per the last site review.

18.   Regarding ILP: Attempt to improve the salaries to a competitive level as per the last site review.

19.   Regarding ILP: Increase efforts to educate your communities in the services you offer, to whom, why and how.

20.   Regarding ILP: Facilitate the hiring needed to fill the two vacant positions appropriately and seek to increase staffing levels.

21.   Regarding ILP: Documentation does not meet standards.  Case notes and home visit forms (Direct Service Forms) are very hard to follow because the dates were frequently incomplete and inconsistent.  IFSP’s are not current nor are they complete.  Seek technical assistance in this important area. Improved staffing or revised program design could allow for the essential time to put the training into practice.

22.   Regarding ILP: Improve communication with Public Health Nurses.  Document your efforts.

 

 

 

Suggestions and Comments

 

Note: The team found that because of limited staffing in both the DD and ILP programs services are provided at very minimal, basic levels.  The programs deliver these basic services well but the consumer, DD and ILP staff along with the review team realize the need for more services to consumers, more onsite visits, training and related support services.

 

1.        The ILP staff has a real need to know that they are supported by their administrators.  The needed support is both personal (valuing their vital work) and professional (aiding in the implementation of the new Childfind process).

2.       Distances and the demands of travel impact the Fairbanks-based program staff negatively.  A suggestion was made that the program should look at hiring and supporting paraprofessional staff to work out of each subregional center with appropriate support from professional staff.

3.       The ILP staff wish to obtain reliable evaluation and survey information.  Technical assistance from within the agency or elsewhere may be helpful.

4.       The ILP staff would like to facilitate participation of families in the process of hiring direct service providers.  Suggestions include: A supervisor could ask parents for some questions they would like to have asked during an interview for a new staff member.  A supervisor could take a finalist for a position to one or more villages on several home visits as the final step in the hiring process, thereby giving families real involvement in the decision.

5.       The ILP staff would like to see staffing levels adequate to provide on-going programming in the villages.  The belief was expressed that visits in intervals of five weeks or longer seriously underserve the intent of the ILP and the needs of children and families.  The current system sets up family expectations that ILP will have an appreciable impact on a child’s development, but the level of program activity and funding are not sufficient to make those expectations realistic.

6.       It is recommended that DMHDD’s QA staff conduct training on clinical documentation for the MH staff of TCC.

7.       It is also recommended that the consumer interview portion of the MH review is conducted again with a more representative sampling of consumers.

 

 

Closing Comments

 

The team expresses appreciation to the MH, ILP and DD staffs for their assistance in the review. The TCC staff’s caring attitudes and dedication to clients and families are particularly notable.

You will receive the official copy of this report in approximately 30 days, with an overview of TCC’s compliance with the Integrated Quality Assurance Standards. TCC, in collaboration with state ILP and DMHDD, will develop plans for program responses to items identified in the review that need further action.