INTEGRATED QUALITY ASSURANCE REVIEW

VALDEZ COUNSELING CENTER

NOVEMBER 8-10, 1999

VALDEZ, ALASKA

 

SITE REVIEW TEAM

Pam Miller, DMHDD QA Lead Staff Member

Helen McCollum, Peer Reviewer

Debs Campbell, Community Member

Dave Woodmancy, Community Member

Barbara Price, Facilitator

 

INTRODUCTION

A review of the Mental Health (MH) services provided by Valdez Counseling Center (VCC) was conducted from Monday, November 8, 1999, through Wednesday, November 10, 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 Quality Assurance staff conducted the Clinical Record Review and provided that section of this report.

 

Valdez Counseling Center has provided MH services for twenty years, substance abuse treatment services (separately funded by the Division of Alcoholism and Drug Abuse) for seventeen years and family preservation services (separately funded by the Division of Family and Youth Services) for the last four years. This latter service is embodied in the Young Parents Empowerment Group (YPEP), an active educational, support and referral system.  The City of Valdez provides matching funds.   While this review is specific to the MH program, the provision of multiple services is a benefit to the community and especially to consumers who may find additional services on site.

 

From its inception until early 1997, the City of Valdez operated the center; formal interim management was provided by Providence Health Systems for a six month period after which VCC became part of the Valdez Regional Health Authority (VRHA) which then encompassed the hospital, home health and VCC services.  Billing, accounting and personnel services are provided by VRHA. The VRHA board serves as the governing board while a nine member advisory board serves VCC exclusively.  A member of the advisory board represents the interests of VCC on the governing board.

 

In FY 98 and FY 99, VCC also provided twenty-six hours per week of MH services in the schools.  For the current fiscal year, the school has added a full time school counselor, convinced of the need and efficacy of counseling services in the school setting.  VCC currently provides liaison services to the school district for MH services.

 

Valdez Counseling Center provides 24 hr a day/ 7 day a week crisis outreach services, coordinating with both the police department and the hospital according to Memoranda of Agreement.  Services are provided to VCC clients and non-clients alike.  The Valdez Police Department recently sponsored a VCC therapist to receive forensic training in order to assist police officers in their investigation of cases involving children.  Services are also provided within the jail.

 

The center is described by a community member as “a real comfortable, clean, dependable place.”  Services include play therapy; group therapy; individual, couple and family counseling; case management; juvenile attendant care; supervision of parent-child visitations; and home based services.  The clinical staff of four, aided by the director, an intern and the support staff member, serves approximately 160 people each year, of which some ten percent are chronically mentally ill adults.

 

“We’re lucky to have this place.” - consumer

 

DESCRIPTION OF REVIEW

This review was conducted over the course of three days. It included interviews of 15 to 60 minutes’ duration conducted in person or, in one case, by telephone, at the main office of VCC.  DMHDD requested 5 consumer interviews and provided the agency with randomly selected case numbers.  Seven consumers were interviewed as well as 4 staff members of related agencies (State court, police department, DFYS and Valdez Native Tribe), a VCC/VRHA board member, 7 VCC direct service staff and two administrators from VRHA.  All of the interviews requested by the regional program staff are included in the above.

 

OPEN FORUM

The open forum was scheduled as requested for the first night of the review.  The forum was advertised by posters and in the local weekly newspaper.  The forum was held in a meeting room in the hospital and was attended by four citizens.

 

The issues raised at the open forum were: 1) questions about the degree of collaboration between the Valdez Police Department and VCC based on a particular case that had been highlighted in the local newspaper; the concern was with the incarceration of a presumed consumer of MH services; 2) questions regarding how friends of an adult MH consumer could provide information to direct service providers, could be included in the treatment plan as natural supports and could learn more about mental illness; 3) the need for the community to understand what services are offered, especially to counteract the impression that VCC only provides court ordered substance abuse services.

 

FINDINGS

 

MODEL PRACTICES

Beginning in FY 00, DMHDD has asked that site review teams highlight those practices, if any, that an agency provides which are exemplary to the point that they should be used as models for other programs.  That is, an activity, a style, an innovation or the like, that could serve as a model for state MH programs.  Needless to say, not all agencies, however capable, can be seen as exemplary in this manner.  Those few that do are the gold medal winners of the site review world and VCC is one of them.

 

Valdez Counseling Center achieves maximum utilization of the talents, skills and resources found among the staff, local residents, agencies and consumers to the benefit of the entire community.  It is the opinion of the site review team that enthusiastic, compassionate creativity results from the free flow of information and ideas in an atmosphere of respectful listening and mutual acceptance.  It is clear that, unique among MH agencies, the staff, consumers and other members of this coalition hold each other in very high personal and professional regard.

 

 

PROGRESS SINCE PREVIOUS REVIEW

Since this is the first review of this agency using the Integrated Quality Assurance Review approach, there is no prior review to compare to the one performed at this time. However,  DMHDD has conducted yearly consumer chart reviews prior to the integrated review approach. The regional program specialist stated that no complaints regarding VCC have ever been received and that the agency, to his knowledge, was performing well.

 

CHOICE AND SELF-DETERMINATION 

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

 

+Services are available 24 hours per day, 7 days per week and consumers can access service or visit the center as needed as well as at appointment times.

+ The team treatment approach increases the availability and depth of services.

+ Treatment planning is consumer-driven.

+ The sliding fee scale makes services affordable to a wide range of people.

 

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

 

-         Consumers request more frequent psychiatric services.

 

DIGNITY, RESPECT AND RIGHTS

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

 

+ The individual consumer’s perceptions are respected.

+ Services are consumer-driven.  

+ Confidentiality is reported as being rigorously maintained.

+ The center has a relaxed, comfortable environment.

+ The staff frequently accompany consumers to court appearances to provide support.

+  The staff frequently visits consumers at the jail to provide ongoing support.

+ The center represents a refuge and a resource for consumers.

 

                “You’re always welcome here.” – consumer

                The staff is “non-judgmental and willing to listen.” – consumer

                “You forget you’re a patient here.” - consumer

               “(Peggy) has a lot of good ideas.” – consumer

                “I just need someone to talk to so I come and talk.” – consumer

               “People trust (Ginny).” – consumer

               “If I didn’t have this place, I’d be like a fish out of water.” – consumer

 

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

 

HEALTH, SAFETY AND SECURITY

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

 

+ The central location of the center provides easy access to necessary services (including pharmacy, store, post office and hospital).

+ Consumers are provided with effective education on medications verbally, in writing and through use of a web site.

+ The center actively collaborates with DFYS, the police department, the hospital, State court, Advocates for Victims of Violence and the schools.

 

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

 

-         Consumers express concern about the infrequency of psychiatric visits.

-         Consumers express concern about the brief duration of psychiatric appointments.

 

“I like (VCC) because they saved my life.” – consumer

“They try to make me feel safe.” – consumer

“Some days I come in I’m so mad I can’t see straight.  Then when I leave here it’s a whole    

different situation.” – consumer

 

RELATIONSHIPS  

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

 

+ Consumers describe genuinely warm, caring relationships with service providers.

+ The agency provides staff to supervise parent-child visitations.

+ Consumers report improved relationship skills.

+ Consumers recognize the generosity of staff who use personal time to interact with and support consumers.

 

“They are dedicated, spending time after hours and on weekends so I can see my daughter.” - consumer

In comparison to other agencies, “This is more fun.  You really get to connect.” - consumer

Getting services from VCC “has been a wonderful experience.”- consumer

 

The team did not identify weaknesses under Relationships for people receiving MH services from VCC.

 

COMMUNITY PARTICIPATION

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

 

+ Case management is focused on linking consumers with community opportunities.     

+ Consumers report increased participation in the community.

+ The center models community participation by entering a center/consumer-created float in the Gold Rush Days parade and by participating in the community health fair.

+ Agency open houses comfortably include consumers, agency representatives, center staff and other community members.

 

Valdez is “tolerant of people who are different.” –community member

 

The team did not identify weaknesses under Community Participation for people receiving MH services from VCC.

 

STAFF INTERVIEWS

The seven staff interviews yielded a picture of a creative, supportive work environment where a diverse and mutually supportive staff forms a “holistic team.”  This apparently cohesive group easily utilizes the treatment team approach to serves consumers.

 

Staff report feeling that their performance evaluations are fair and helpful.  The availability of resources to meet training needs is appreciated.  No concerns were expressed regarding benefits or salaries.

 

Two clinicians share the 24-hr/ 7 day a week after hours crisis response.  All service providers report working past the regular workday and workweek.

 

Staff identifies their primary needs as the addition of at least one clinician, an additional support staff member, additional psychiatric consultation, upgraded computers and additional equipment for play therapy. 

 

We’re “all working on the same page.” – staff member

 

COLLATERAL AGENCY INTERVIEWS

Valdez Counseling Center is a member of the Valdez Community Partnership for Healthy Families, an interagency group which includes Valdez Community Hospital, Advocates for Victims of Violence, Valdez Police Department and Division of Family and Youth Services.  This group meets regularly to discuss community needs.

 

Interagency case conferences occur within the carefully observed guidelines of confidentiality. School representatives, guardians ad litem, attorneys and others are included in person or by teleconference as appropriate. gencyagency representatives note that they are “getting a lot of service from a small group”, find services at VCC much improved in recent years, describe VCC staff as “very tenacious in finding resources”, but express concern that the staff may be overextended. Agency representatives recommend expansion to include ASAP provider certification, a batterers’ program and services for the homeless.

 

Three of the four agencies interviewed have high praise for VCC and report benefit from their interactions.  The Valdez Court routinely directs treatment to occur as part of sentencing and reduced recidivism among substance abusers.  There seems to be a cultural or communication gap between the Native community and VCC/VRHA.  An increased knowledge of the Valdez Native community may increase the effectiveness of counseling services.

 

“They run a professional organization here.” 

The “credibility of the agency has improved in the last two to three years.”

 “I think they are very much underappreciated.”

 

ADMINISTRATIVE AND PERSONNEL NARRATIVE

Of the current 34 administrative and personnel standards set by the DMHDD for community mental health center, VCC fully meets the expectations of 27 of them.  VCC partially complies with Standard #4 “Budget controls, record keeping and staff training support good business practices and conform to state requirements.”  Budgetary controls are in place but not all are formalized.      The separation of the center’s funds might allow for a clearer financial picture for the center director and better inform the advisory board.

 

VCC does not comply with Standard #11: “All facilities and programs operated by the agency provide equal access to all individuals.”  The center is currently on the second floor of a building without an elevator.  The Policy and Procedure Manual states that consumers will be seen at their homes should the stairs inhibit access.  Signage is not in Braille.  There is no accommodation for the hearing impaired.  The VRHA is currently considering construction of a new building that could include VCC.  This building would be fully accessible.

 

VCC partially complies with Standard #12: “The agency actively solicits and carefully utilizes consumer and family input in agency policy setting and program delivery.”  The agency does have a consumer satisfaction survey instrument but it has not been widely utilized recently.  It is the team’s belief that the standard is met informally.  The recommendation is to formalize and document this process.

 

VCC partially complies with 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.”  As stated above.

 

VCC partially complies with Standard #14: “The agency develops annual goals and objectives in response to consumer, community and self-evaluation activities.”  As stated above.

 

VRHA partially complies with 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.”   Of the 5 personnel files reviewed at VRHA, 3 did not contain reference checks.  Two were files of employees whose hire predated the VRHA takeover of services.  One file of a recently hired person lacked documentation of reference checks. No file reviewed contained documentation of background and criminal checks.  As the direct service staff has access to and authority over vulnerable populations, fingerprinting is advised.  Fingerprinting should be submitted both to the Alaska State Troopers and to the FBI.

 

VCC and VRHA partially comply with 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 laws), cultural diversity issues and potential work related hazards associated with serving individuals with severe disabilities.”  The Policy and Procedure Manual includes documentation of all direct service staff having been made aware of its contents.  The contents include most of the above and in staff interviews, employees evidenced knowledge of them.  Safety and health issues are addressed in the training required by the VRHA and documentation of that training is provided in the personnel files.  Cultural diversity issues remain to be effectively addressed. 

 

 

 

PROGRAM MANAGEMENT     

Members of the community and related service providers repeatedly pointed out the improved quality of services during the last two to three years. The current director took her post two and a half years ago and all but one provider is relatively new to the agency.  It is clear that the fine environment of Valdez Counseling Center is largely the creation of this dedicated director.

 

VRHA is aware of the marketing aspect of services and had developed a marketing plan that was completed in August of this year.  Its recommendations are consistent with observations expressed at the open forum, by a board member and by an agency representative: that the community is insufficiently informed of the array and quality of services at VCC.  VRHA is interested in a wellness and outreach approach and, in conjunction with VCC, efforts have been made in this area.

 

The advisory board is also adapting to its role in relationship to VRHA and to the governing board of that parent organization.  The board is concerned about the recent and impending changes.  Of equal concern is limited funding and the board is taking steps to locate alternative funding sources.  The board currently sees its role as providing support to the staff and as advocating for VCC services within the community.

 

“VCC is the best it’s ever been.” – community member

“ (VCC) is a much more user friendly” place. – Community member

 

QA CLINICAL CHART REVIEW

 

 STRENGTHS

There has been apparent progress made since the time of the last file review in Feb. 1998. The comprehensive assessment format appears to have included required items such as consumer statements, areas of strength and prognosis. Most comprehensive assessments were current. All but one file contained current treatment plans evidencing a marked improvement from the last chart review. Another strength is that there is clear progress being made in treatment plans in the area of documenting goals that are more measurable, observable, and achievable.

 

AREAS IN NEED OF IMPROVEMENT

Although the statistical summary bar graph below does not appear to support this finding, progress notes continue to be an area in need of improvement for VCC.  While service modalities, such as individual, group, and/or family therapy, client support services, etc. were documented in the majority of reviewed notes, interventions conducted by staff were rarely documented. Progress notes need to contain all other items required by the Division Standards adopted in Oct. 1998.There were no treatment review documents found in any of the charts. This has been an ongoing problem since the 1997 review.

 

RECOMMENDATIONS

It is recommended that VCC receive a follow up training, technical assistance and a desk-top chart review in approximately six months to ensure the addition of treatment plan reviews occurring and the continuation of progress the agency has already made.

 

* For more detailed information of the chart review findings, please refer to the Medical Necessity Review Report dated 11-8-99. This report will be attached to the official site review report.

 

AREAS REQUIRING RESPONSE

1.       Formalize budget procedures to comply with state requirements including purchasing policies and clarification of financial status for VCC.  This is the responsibility of VRHA.  Standard #4

 

2.       Verify that the planning for the future site of VCC includes equal access to all individuals (the responsibility of VRHA) and continue to seek accommodations for special needs in the interim (the responsibility of VCC).  Standard #11

 

3.       Formalize the gathering of consumer and family input and its utilization in policy setting and program delivery.  Standard #12

 

4.       Formalize the gathering of consumer, staff and community input and its utilization in an annual agency planning and evaluation process.  This should include consumer satisfaction survey information.  Standard #13

 

5.       Formalize the development of annual goals and objectives based on the information gathered in the above.  Standard #14

 

6.       Include background and criminal checks of direct service providers.  Document all reference checks.  This is the responsibility of VRHA.  Standard #24

 

7.       Seek assistance with cultural diversity issues including therapeutic approaches best suited to the Native community.  Standard #25

 

OTHER RECOMMENDATIONS

1.       Consistent with the marketing study and with the recommendations of community members, continue to advertise VCC’s mission and contribution to the community.  The advisory board may be of assistance with this task.

 

2.       Given the concerns of consumers and staff, consider using nursing services for medication checks and medication education to free up psychiatric time.  This might be provided through collaboration with the hospital.

 

3.       Given the need expressed by other service providers, consider ASAP certification. 

 

4.       Given the need expressed by other service providers, consider seeking funding for a batterers’ program.

 

5.       Given the need expressed by other service providers, support the creation of a local therapeutic foster home, possibly through the Valdez Community Partnership for Healthy Families.

 

6.       Investigate sources for funding at least one additional clinical position consistent with staff’s and related service providers’ concerns.

 

7.       Prioritize the hiring of an additional support staff member consistent with staff concerns.

 

8.       Consider providing a workshop for the police department on the special circumstances of MH consumers.

 

9.       Consider educating the community as to the effective support of MH consumers and including natural support networks in treatment plans if appropriate.

 

10.   Seek funding for computer and play therapy equipment in consideration for staff needs.

 

 

CLOSING COMMENTS

The team wishes to thank the staff of VCC for their cooperation and assistance in the completion of this review.   VCC’s hospitality extended to the site review team did not go unnoticed.

 

Attachments: DMHDD Key Indicators of Provider Performance and Unmet Needs List (tallied), Questions for Related Service Agencies (tallied), Administrative and Personnel Standards