INTEGRATED QUALITY ASSURANCE REVIEW

FAIRBANKS COMMUNITY MENTAL HEALTH AGENCY

September 14, 1999 to September 17, 1999

Fairbanks, Alaska

 

Site Review Team:

Connie Greco, DMHDD QA Lead Staff Member               Kendra Parker, Community Member

Dan Weigman, DMHDD QA Staff Member                       Cheryl Wheat, Community Member

Pam Miller, DMHDD QA Staff Member                            Dona Rule, Community Member

Bill Hogan, Peer Reviewer                                             Barbara Price, Facilitator

                                    Suzanne Price, Facilitator-in-Training

 

INTRODUCTION

 

A review of the Mental Health services provided by Fairbanks Community Mental Health Center (FCMHC) FCMFwas conducted from Tuesday, September 14, 1999, to Friday, September 17, 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 Quality Assurance staff of the Division of Mental Health and Developmental Disabilities (DMHDD), State of Alaska conducted the Clinical Record Review and provided that section of this report.

 

Noteworthy in this review is the fact that some of the “weaknesses” pointed out by those interviewed, while of a serious nature and worthy of remedy, are beyond the scope of this agency’s mandate or require the participation of other agencies or groups.  Those items are so identified in the Areas Requiring Response and indicated by an *.  They are included because of the impact of these items on the every day lives of consumers and because they affect the “outcomes” that this review is designed to examine.

 

The services provided by Fairbanks Community Mental Health Center are extensive and include the Community Support Program for adults diagnosed with a chronic mental illness including a special program provided in collaboration with the Regional Center for Alcohol and Other Addictions (RCAOA; a program of Fairbanks Native Association). Other programs include the Case Management Unit, connecting consumers with resources including special services for the addicted chronically mentally ill.  There is the Intensive Residential Services Unit which is a residential unit with capacity for eleven and the Northern Door Clubhouse Unit, a psychosocial rehabilitation source for members with a focus on community integration, and the Residential Service Unit with a 10 tenant apartment building, four 2 bedroom houses.  There is also the Adult Group Home, and the Vocational Unit composed of an entrepreneurial business (Alaska Rag Company) and a Supported Employment Program. There is the Medical Unit which includes the psychiatrist, medical director (also a psychiatrist) and nursing staff; Emergency Services and Specialized Programs offer emergency/crisis respite, two dedicated crisis respite beds available 24 hrs. a day, crisis intervention therapy and serve all requests from those not qualifying for CSP (Community Support Program) or SED (Severely Emotionally Disturbed) services; Specialized Children’s Services for SED youth and their families.

 

In FY 2000, the agency’s budget is $5,811,901 with 53% of those funds coming from state grants including pass through funds for state building maintenance, crisis line and non-crisis respite.

 

The agency is governed by an eleven member executive board.  Of the occupied seats, five represent Fairbanks, three represent Delta, and two represent Healy. As FCMHC has responsibilities to serve not only the greater Fairbanks area, but also outlying regions, the board feels that representation from outlying areas is vital if the board is to comply with the requirement to have a governing body that represents the areas served.

 

DESCRIPTION OF REVIEW

 

This review was conducted over the course of four days and included interviews of 15 to 45 minutes’ duration conducted by telephone or in person at the main office of FCMHC or in the Clubhouse building.  DMHDD requested 15 consumer interviews and provided FCMHC with 40 randomly selected case numbers for this purpose.  Of the 40 cases provided, 18 consumers were available and willing to be interviewed as of Monday, September 13, the day prior to the review. As some consumers did not appear for their appointments, the result was that 10 of those consumers interviewed were from the random list. There was careful documentation of the results of all 40 approaches and the reasons why appointments could not be made.  The president of the local National Alliance for the Mentally Ill (NAMI) chapter requested that two additional consumer interviews be conducted and those were also scheduled.  In addition, one consumer contacted the team by telephone during the review and requested to be included and one consumer requested an interview in person.  Four consumers were interviewed as a group at their request; all other consumer interviews were individual ones.

 

The initial interview for purposes of this review was with DMHDD regional program staff, Steve Emerson and Michelle Arnold.  At that time, the team was requested to include interviews with the following agencies: Division of Family and Youth Services for the State of Alaska (DFYS),  Fairbanks school district, Alaska State Troopers, Fairbanks Police Department, Fairbanks Memorial Hospital, Fairbanks Correctional Center, Women in Crisis Counseling Assistance (WICC), The Rescue Mission, NAMI, Public Health, the State Division of Vocational Rehabilitation, the court system, Family Centered Services, Tanana Chiefs Conference (TCC), RCAOA, Alaska Psychiatric Institute and Love, Inc. (a consortium of churches offering assistance to those in need).  Also, an interview of the board president, a consumer group representing the Clubhouse and the new director of the CSP program were requested.  In regard to grant compliance, the team was asked to review medical records, the agreement with RCAOA, the five session cap on services to consumers not qualifying for services as Chronically Mentally Ill (CMI) adults or Severely Emotionally Disturbed (SED) youth and, finally, emergency services.  While all of these appointments were set by FCMHC, the team was unable to contact the school district, Fairbanks Correctional Center or TCC at the appointed times and in subsequent attempts.  All other contacts were made and all items listed for particular review were completed.

 

The result of the team’s efforts was 14 interviews with staff (12 direct service staff, 2 managers) and 1 with the Executive Director; 17 interviews with the staff of other related agencies; 20 consumer interviews (16 direct consumers, 4 parents of consumers) and 1 with the board president.  In addition, at the request of NAMI, the team attended a regular NAMI meeting where 11 consumers and parents/guardians of consumers were present and shared their impressions from 7:00 PM to 9:20 PM the second night of the review.  Those 64 contacts in addition to the 25 contacts at the Open Forum described below provided the team with the data from which to produce this report.

 

 

OPEN FORUM

 

FCMHC scheduled an open forum, as requested, on the first night of the review.  It was held at the DeNardo Center, the site of the group home.  The cost of a more neutral, public location was prohibitive. The agency advertised with posters at their facilities, by mail to 38 agencies and 6 individuals and advertised the forum in the Fairbanks Daily News Miner on the fifth, eighth, twelfth and fourteenth of September.

 

The forum lasted from 7:00 PM to 8:45 PM and informal contacts continued until 9:00 PM.  The 25 audience members self-identified as an agency representative, parents/foster parents/friends of consumers, a physician, a legislator and several consumers.  Concerns focused on barriers to treatment: limited psychiatric care through FCMHC, the limited number of psychiatrists with hospital admitting privileges, a lack of cooperative care between the agency and the private psychiatrists who currently have hospital admitting privileges, a lack of communication among agencies including law enforcement, the hospital, DFYS and FCMHC; limited care for those not qualifying for CSP; the consumers’ obligation to come to treatment when outreach or aid with transportation is unavailable; the waiting list for services; high expectations for parental involvement in place of services and a consumer concern that "too high a level of functioning is required to access care.”

 

Friends of a Mentally Ill Chemically Addicted (MICA) dually diagnosed  consumer described in detail a three week odyssey of attempting to access care for their friend’s deteriorating condition, the barriers encountered including the advice “Your only option is to have him arrested.”  Several comments from parents of consumers and consumers themselves echoed this experience.  More than one suggested that services are more readily available when legal action is threatened.

 

Other comments from the forum are incorporated into the sections that follow.

 

 

FINDINGS

 

PROGRESS SINCE PREVIOUS REVIEW

 

This is the first review of the agency using the Integrated Quality Assurance Review process, therefore, there is no prior review for comparison.

 

 

MODEL PRACTICES

 

1)       The RCAOA/FCMHC Dual Diagnosis Collaboration Project, formalized on the fifteenth of May of last year, deserves special commendation and should serve as a model for merging substance abuse and mental health treatment services in the state of Alaska.  The stated goal of this project is “to improve the quality of services provided dually diagnosed persons as evidenced by fewer relapses, hospitalizations and incarcerations.”  This collaboration extends to assessment, intervention, stabilization, treatment, continuing care and cross training.

 

2)       The Alaska Rag Company is an entrepreneurial business located in downtown Fairbanks currently employing 14 people and holding 15 contracts for shop rags, manufacturing handwoven rag rugs and housing art works from more than 80 Alaska artists.  Art by local consumers is also on display.  In FY98, the company provided training to 21 individuals with severe chronic mental illness and 5 of those individuals graduated into community placements.  This project combines prevocational training, vocational training, a creative outlet and a showcase for the successes of local consumers.

 

 

CHOICE AND SELF-DETERMINATION

 

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

+ Consumers actively participate in treatment planning (They listen “to my goals, my ideas.

   They give me choices.” –parent of a consumer)

+ The agency respects and supports the Declaration for Mental Health Treatment by which

   consumers state their choices regarding treatment including medications

+ Consumers can choose their roommates when in residential care and those choices are

   respected

+ Consumers can and have successfully requested a change in their case manager or physician

+ Consumers can and do exercise their options for participating in Clubhouse activities

+ Consumers can exercise choice regarding services

+ Consumers can choose not to be medicated

+ Consumers can participate in the decision as to which medication may be used

 

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

-     There are limited opportunities for psychiatric care

-         There is a limit to the number of sessions available to consumers who are not priority populations as defined by the state

-         There are limited resources for SED youth in regards to respite care, psychiatric care and placement

-         There are limited resources for youth who are transitioning out of programs at age 18

-         There are limited resources for higher functioning chronically mentally ill adults who are not defined as a priority population by the state

-         There is a lengthy waiting list for some services

 

DIGNITY, RESPECT AND RIGHTS

 

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

+   Consumers are well informed regarding their rights and those rights are respected by staff

      “They sat me down and told me my rights!” – consumer)

+   Consumers are treated as worthy and valuable persons by staff  (“Dr. Kletti was really

     helpful. He treated me like a person.” – consumer) (A consumer reported in some detail

     the interest that the Executive Director had shown in him, calling him by name,

     encouraging him and aiding him to learn of opportunities to enhance his skills.)  (“Sharon

     has helped to make my life 100% better.”-- consumer)  (“People (at FCMHC) are nice

     to me.” – consumer)

+   Consumers are treated as whole people by staff and are not labeled by staff

+   Recent improvement in the treatment of consumers by receptionists reinforces the dignity of

     consumers

+   Consumers describe the staff as professional and genuinely caring  (“I can’t say enough

     good things about Fahrenkamp…”  They work together with the family because

     “They care about me too.” – parent of a consumer)

+   The Clubhouse is governed by an Executive Committee of consumer-members

 

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

-         In recent years, some staff at residential facilities were unavailable while on duty, unaware of consumer rights and unresponsive to consumer needs

-         Staff do not always respect or courteously receive the opinion of the parents of consumers (“They have to learn to care more and listen better.” – parent of a minor consumer)

-         Consumers express a desire to receive services in a building wholly occupied by mental health (“I would put the MHC in a building by itself and make it private.” – consumer)

-         Staff may at times be abrupt in expressing themselves regarding their roles and limits (A

       consumer quotes a staff member as saying in response to a request “We don’t get paid to

       do visits at the hospital.”  Parents of adult consumers report staff as responding to their

       requests with “That’s not my job.”  “That’s not my responsibility.”)

 

HEALTH, SAFETY AND SECURITY

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

+   Waiting room guidelines that exclude those who are under the influence and those persons

      who are not consumers, provide safety to consumers

+   Clubhouse staff who accompany consumers on outings are trained in first aid and CPR

+   Mandt training is required for many staff and encouraged and made available to all staff

+   Residential options allow for progress or for return to a living arrangement with more

     supervision in order to provide safe and appropriate housing

+   Consumers are well educated regarding medications and their side effects

      (“I would not be alive if it weren’t for Mental Health.”—consumer)

 

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

-         Many consumers have need for extensive dental services that are no longer provided through Medicaid. 

-         The inconsistent supervision of medication monitoring in the residence facilities may present a danger to the consumer

-         Medical oversight of non-mental health issues is inconsistent for consumers in residential units  (The agency responds that consumers are urged to obtain a primary care physician and that the agency facilitates that connection.)

-         Some low income housing in Fairbanks (not operated by FCMHC) may be unsafe

-         High functioning consumers who self-monitor their illness lack opportunities to check in with staff as they are not a priority population as defined by the state

-         The use of locum tenens doctors causes consumers anxiety with each adjustment to a new provider

-         Consumers are sometimes incarcerated rather than receiving treatment

-         Incarcerated consumers may experience disruption in their medication

-         Consumers feel unjustly charged with assault on staff in some instances

-         Parents of adult consumers question the staff’s ability to identify the early signs of decompensation and feel that staff do not honor the parent’s assessment of those signs

-         A lack of coordination among FCMHC, Fairbanks Memorial Hospital, law enforcement and the private psychiatrists having hospital admitting privileges results in inadequate continuity of care (“The shuffling needs to stop.” –parent of adult consumer)

 

RELATIONSHIPS

 

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

+   The entire Clubhouse program enhances relationship skills and provides the opportunity for

      relationships  (“The Clubhouse is a vital part of a lot of people’s lives.” -- consumer)

+   There is agency support for education at local schools and for work in community businesses

     where new relationships may be built

+   The staff model genuine, caring relationships

+   The Fahrenkamp Center helps children develop social skills and encourages their participation

 

The team identified the following weaknesses under Relationships for people receiving MH services from FCMHC:

-         The staff are discouraged from contact with consumers outside of the work place or after hours when not on call; while there are ethical concerns with such contact, some consumers desire the participation of staff in some major life events (marriage, graduation, etc.)

-         Parents experience confusion and hostility as their child transitions to adult services and legal parental control ceases

 

COMMUNITY PARTICIPATION

 

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

+   Educational opportunities are encouraged by staff

+   Church attendance is facilitated by staff

+   Employment opportunities exist due to good job coaches

+   Residential units are spread throughout the community and blended into the neighborhoods

+   The Clubhouse offers catering services at community events

+   Consumers are offered volunteer opportunities, for example at Denali Center

+   Consumers are aided in attending recreational and community events; consumers mentioned

      going to the movies, bowling, fishing, camping and other activities      

+   There is considerable community acceptance of chronically mentally ill adults

 

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

-         A shortage of winter-ready vans for transporting consumers limits travel

-         There are limited opportunities for barber and beautician visits and training in hair care, makeup and other self esteem enhancing services

 

It should be noted that during the course of the review several compliments were received regarding staff.  Some are included as quotes in the above sections.  Also singled out for praise by consumers or their parents were Jackie Sunnyboy, “counselor Mark” and “nurse Debbie”.

 

Consumer Satisfaction Chart

MH	Choice   N=20			Dig&Res. N=20			Hth,Saf,Sec N=20			Relatns. N=20			Com.Par. N=20
Outcome	Yes	No		Yes	No		Yes	No		Yes	No		Yes	No
Person/Parent/guardian	16	4		17	3		14	6		16	4		18	2
Staff Performance
Person/Parent/guardian	15	5		16	4		15	5		14	6		16	4

 

Staff Interviews

 

One outstanding characteristic of the interviews with staff was what was not said.  Uncharacteristic of community mental health centers in Alaska, in none of the 14 staff interviews were there complaints regarding poor pay, poor benefits, poor communication, staff burnout or agency instability and in only one was there a reference to ”too much paper work”.  But then, as a staff member notes, “This is paradise compared to other mental health centers.” And “The purpose here is more important than the pay.” And “I absolutely love working here.” And “This is the best place I have ever worked.”

 

FCMHC seems to offer an extraordinary environment in which to work.  Staff feel valued, listened to, able to shape their work environment, supported by leave and training policies, rewarded when appropriate and given genuine opportunities for professional and personal growth.  One staff member notes that the agency “has given me the flexibility to continue to grow.”  And another says “You have the freedom here to be an individual.”  And another that “they allow you to be creative.”

 

It is clear that the staff are treated with the same dignity, respect and concern that staff are expected to exhibit toward consumers and that this is equally true of all employees. The agency is described as “conscientious in its commitment to its employees.”

 

The ease with which staff describe how their agency enhances the five life domains for consumers reflects their assurance of equal worth as professionals within this agency.  In fact, “the single focus of this agency is the best interests of the clients.” When asked to describe the consumers with whom he works, a staff member answers “Receptive.  They are open and good with each other and good with the staff.”  Another adds “I tell the clients that I work for them.”  And another that consumers have “unrealized potential, unrealized by them, especially in the workplace.  And our goal is their pride in themselves.”

 

This singularly effective and humane work place owes much, according to its staff, to the Executive Director in whom they express faith and toward whom they express a sort of amused affection.

 

In those areas in which the team approach predominates, staff express feelings of efficacy and collegiality.  Staff describe a workplace where communication flows in all directions, where supervision is customary and helpful, where flexibility is a work style and where authoritarian practices are so foreign that one employee noted with glee “You can disagree with the Director AND keep your job!”  An example of the openness of the communications was provided by one interviewee who noted that the management team posts the minutes of their meetings for staff to review.

 

Interestingly, staff reflect an understanding of the agency budget and the restraints imposed by it.  While the desirability of expanded health insurance (for eye care and dental services) is acknowledged, so is the high cost of that coverage.

 

Staff complimented their co-workers as well as the Executive Director for the positive changes he has made and for his accessibility.  And in children’s services “We have been BLESSED by Frank and then by Ken.”

 

As a further indication of the openness with which staff express themselves, they offered, unsolicited, as an area needing improvement, that there is too large a caseload in emergency services to be effective. Other areas include Medicaid regulations that impede work, a lack of sufficient structure in IRS, the need for more home based services, and opposition to the five-session limit for some consumers.  The latter was vehemently described as “inadequate and disrespectful.”

 

Collateral Agency Interviews

 

The team’s interviews included 17 representatives of 14 agencies.  The summary of the responses to the uniform questions asked is attached at the end of this report.

 

Agency responses are generally positive, note improvement in recent years and single out certain staff for particular praise: Doug, Wayne, Randy, Sharon, Ernie, Julie and the family advocate.  Other positive comments were

1.       The guardianship program is very effective

2.       Emergency room visits by mental health consumers have decreased

3.       Length of stay by mental health consumers in the hospital has decreased

 

Difficulties experienced by some providers include

1.       The packet to be filled out for admission to children’s services was described as “overwhelming” and “foreboding” and a “barrier to services” by a seasoned provider

2.       The waiting list for services for children

3.       The need for outreach

4.       The need to improve communication with some agencies

5.       The incarceration of consumers

6.       The lack of coordination with the hospital and other medical providers

7.       The need for FCMHC staff to have hospital privileges

8.       The need for a single, full time psychiatrist

 

Administrative and Personnel Narrative

 

The Administrative and Personnel Checklist is included at the end of this report.  It includes 34 items, 29 of which are completely met by FCMHC.  The additional 5 standards are partly met.  Those standards not fully met are:

1.       The inclusion of direct consumers on the board.  There are family members of consumers on the board.  The board has sponsored two consumers to receive board training and one currently attends the meetings but not as a member.  The board, with the assistance of NAMI, is currently trying to recruit consumers willing to become board members. (Standard #6)

2.       While the agency evidences planning and evaluation based on consumer, staff and community input and does survey consumer satisfaction, that effort is not systematic. (Standard #13)

3.       While, in the past, the agency has developed annual goals and objectives and has used consumer, community and staff opinion in that process, this has not occurred within the last two years.  (Standard #14)

4.       While FCMHC interacts with many agencies, the team did not feel that the interaction resulted in “maximizing resource availability and service delivery.”  (Standard #17)

5.       While FCMHC does submit regular quarterly reports to DMHDD and does submit clinical and demographic MIS data on all consumers, it is not able to provide the “identifier” information on the 60% of consumers who chose not to sign a release of this data.  That identifying information in those cases is the only information not provided to the state at this time.  FCMHC vigorously defends its actions in this regard and the issue is the subject of legal review.  Consequently, the team felt that the response of “partial” was appropriate.  (Standard #18)

 

That having been said, it should be noted that the compliance with these standards for community mental health centers in Alaska has been approximately at the 60% level to date.  FCMHC’s unparalleled level of compliance with the state’s Administrative and Personnel standards is deserving of special recognition.  One particular strength was the most comprehensive  and consumer oriented employee orientation packet viewed by this facilitator to date.

 

Program Management

 

A major concern for this agency and the focus of a recent DMHDD investigation is the difficulty of providing a continuum of care for consumers who are in need of hospitalization.  Staff, consumers, parents and friends of consumers and agency representatives all note deficits in this process.  To its credit, FCMHC has responded to these difficulties by developing a Memorandum of Understanding Regarding Coordination of Care for the Patients of the Fairbanks Community Mental Health Center.  This agreement, signed in May of this year, is an agreement between FCMHC and Fairbanks Memorial Hospital “to provide for cooperative efforts to improve the coordination and quality of care for patients who are currently active outpatients of the Fairbanks Community Mental Health Center and who present to FMH for admission for emergent or routine inpatient care for mental health or other medical conditions.”  Further progress has been made with the organization of Emergency Services under the direction of Sharon Bullock.

 

There remains the issue of psychiatric care within the hospital, the agency’s inability to recruit a full time psychiatrist for its staff and a system that too often finds consumers in jail.  This difficulty cannot be construed as the total responsibility of FCMHC.  It is rather the system that surrounds the provision of emergency mental health services that is flawed.  A solution to these difficulties therefore, must be system wide.  Although one player may be a catalyst for change, there must be cooperation and collaboration among all parties.

 

Another area of concern, focused on by the DMHDD regional staff, has been CSP services.  There is considerable confidence expressed in the new director of CSP services, Wayne McCollum.  The interview with the CSP director revealed:

1)       Residential staff have been encouraged to spend time at the Clubhouse in order to get to know the residents of their unit outside of the residential setting.

2)       An emphasis on the residential program as a treatment program, not a stopping place, and the expectation of progress for consumers through this system and beyond it.

3)       Within just the 4 months of the new director’s arrival, there has been an accelerated number of consumers who have moved to independence.

4)       There is increasing structure to the program in the residential units.

 

The 17 consumer files reviewed were complete, up to date, evidenced consumer and family involvement, notification of client rights, education as to medications, medical oversight of medication and side effects, treatment plans that contained clear, measurable goals and that were revised regularly.  The medical records were identified externally only by number. The records department staff were organized, professional and clear guardians of confidentiality.

 

The limitation of 5 sessions for non-priority clients as set by the state is a restriction uniformly decried by consumers, staff, family members, other agencies and the Executive Director himself.  The latter referred to this limit as a budgetary necessity based on required changes to emergency services, but a major professional concern, one creating “ethical friction”.

 

QA CLINICAL CHART REVIEW

 

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 audit for the Division of Medical Assistance (DMA). This audit determines 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 chart review consisted of a review of four areas, Assessments, Treatment Plans, Progress Notes, and Treatment Plan Reviews.  The team reviewed a total of  (27) charts, twenty (20) Medicaid charts (6 youth/14 adults) and  (7) non-Medicaid charts (3 youth/4 adults).

 

STRENGTHS

An overview of ASSESSMENT MATERIAL indicates that each year the intake and psychiatric assessments are better developed.  Overall, diagnoses are very well supported, prognosis statements are thorough, and assessments are generated on time.  The inclusion of consumer statements reflects the agency's priority on consumer participation. SED Children assessments have a good eligibility statement. An overview of TREATMENT PLANS indicates improvement in writing of goals and a better relationship between problems identified in assessments and the goals written in the treatment plan. Other noted improvements are the signing with credentials, consumer participation, and timeliness of treatment plans.  Frequency, duration and person responsible are dependably found in treatment plans. An overview of TREATMENT PLAN REVIEWS indicates that reviews are consistently present in the file and that consumers are participating in the process.  Treatment plans and treatment plan reviews are much more comprehensive than in previous years.  An overview of PROGRESS NOTES show that notes were found in charts for the Medicaid billings, dates and units are being included, signing and credentialing is occurring.

 

AREAS FOR IMPROVEMENT

A continuing area of concern in ASSESSMENTS, although there has been improvement, is the need for clear identification of mental health problems.  Recommendations contained in some assessments refer to programs rather than services. I.e. "Recommend all CSP services" vs. skills building, case management… Adult assessments need to address eligibility.  In TREATMENT PLANS, not all goals are measurable or observable. The objectives in some plans appeared to be strategies rather than actual treatment objectives.  Correction of the objectives might improve the measurability of the goals.  Interventions were not always present or clear in the planning process.  Adult plans reflected programs and the children plans often referred to service modalities. The greatest areas of concern of the four (4) areas reviewed were found in PROGRESS NOTES.  Residential and Clubhouse PSD notes were missing interventions.  Notes were not being written per service episode.  The service delivered was often hard to determine and which goals being addressed were not evident.  In some cases the progress notes did not relate well to the treatment plan.  The notes reflected goals that were not identified in treatment plans. In TREATMENT PLAN REVIEWS, the greatest areas of concern were the absence of the identification of new mental health problems and the absence of making recommendations for change to treatment plan.  Identifying progress towards goals in treatment plans was generally global instead of specific or documented progress toward service areas such psychiatric needs, case management, etc. instead of specified treatment goals.

 

COMMENTS:

The newer Standards require that the problems identified in assessments be written in a clear written summary with treatment recommendations.  It is important to verify that all assessments, including those accepted from other agencies, contain all of the components required in the Standards. Do not use white out or write with pencils on your documentation.

 

 

 

SUMMARY:

This agency continues to improve in most areas of charting.  A review of the charts indicated that the agency is very responsive to recommendations from prior reviews. The method of review has been modified and a comparison of statistical information from previous years does not produce a good comparison between the past and present year.  However, a review of the Plan of Improvement from previous years provides strong indicators of progress.  The area of greatest improvement is the assessment, both psychiatric and comprehensive (intake).  The treatment plans are much improved and although there were areas in the treatment plan reviews that resulted in lower scores, the number of review plans and the timeliness of these reviews is greatly improved.  Although the progress notes in the following graph appear to represent an area of strength, this area is in need of agency-wide attention. Please refer to the recommendations for improvement in this year’s report.

 

 

AREAS REQUIRING RESPONSE

 

1.       Intensify efforts to include consumers on the governing board. (Administrative Standard # 6).  Consider creative solutions to this issue.  (Suggestions from the team include the possibility of having 2 or 3 consumers share a single board seat, offering support for each other or consider the use of a mentor to support the consumer’s participation and reinforce the board training received.)

2.       Systematize annual agency planning using consumer, community and staff opinions. (Administrative Standard #13)  As this already occurs informally or situationally, the need is for a policy describing a formal process and its implementation.

3.       Formalize the setting of annual goals.  (Administrative Standard # 14).  As this currently takes place as part of the budget process, the need is for a policy requiring a formal process and its implementation, possibly as part of the board’s required long range planning.

4.       * Work toward fuller cooperation with other provider agencies in order to provide a continuum of care.   (Administrative Standard # 17)  As FCMHC has been an energetic participant in regional planning efforts in the past, since FCMHC has created a model program in its collaboration with RCAOA and has created an agreement with the hospital for the first time ever, the agency appears to have the skill and the will to expand these efforts to include, for example, providers of services to marginalized populations (youth runaway shelter, WICCA, Rescue Mission, Senior Services).  Even the deadlock regarding physician care in the hospital, while complex and long standing, appears to be resolvable through cooperation and collaboration.

5.       Work toward resolution of the concerns regarding the submission of MIS data.  (Administrative Standard # 18) 

6.       *Support efforts to educate and support the entities involved in the emergencies that affect the lives of consumers: FMH, law enforcement, private physicians and others.  Consider additional agreements patterned on the successful agreements with the hospital and with RCAOA.  It is recognized that this is not the sole responsibility of this one agency.

7.       Make vigorous efforts to recruit at least one full time psychiatrist.  Resolution of the emergency care issues may create a more attractive climate for a potential hire.

8.       *Explore ways to offer outreach to non-CSP consumers and to expand outreach to other consumers and populations, including contact in the home.  (The team suggests use of the Compeer Program or other volunteer efforts.)  It is recognized that this is beyond the scope of this agency given the state’s definition of priority populations.

9.       Provide for the needs of families of consumers to understand not only the illness, but also the losses, grief and separation, and the legalities of adulthood regardless of diagnosis. Consumer need more awareness surrounding the role loss and role confusion that comes with adult status and the agency should offer particular support for the transition of consumers and their families during the consumer’s seventeenth year and beyond.

10.   *Aid in educating the community about the resources available for consumers, their limitations, their responsibilities, their guidelines.  Consider community workshops related to these topics sponsored in conjunction with other agencies.  It is recognized that only a portion of this responsibility lies with the agency.

11.   Maximize the use of educational materials within the agency, at other facilities like the Clubhouse and residences and specifically provide educational material to family members and consumers.

12.   *Continue to reduce emergency hospital admissions and incarceration of consumers as an alternative placement.  It is recognized that this effort must involve multiple providers and is not the sole responsibility of this agency.

13.   Continue to work to educate staff to the effects of ill considered speech and angry responses to family members and others involved with consumers.  While isolated events are not representative of this agency, such comments have left feelings of animosity among some consumers and family members.  (The team suggests that your fine staff newsletter is an excellent vehicle for this reminder.)

14.   Document efforts to reduce the waiting list.

15.   Continue the changes in the residential programs in the areas of increased structure, increasing staff involvement outside of the residences, careful monitoring of non-MH medical concerns and medication administration/supervision.

16.   *Explore means to obtain dental care for consumers in need.  It is recognized that this is beyond the mandate of this agency.

17.   Review the admission packet for children’s services to devise ways to make it less challenging for families and agencies or consider ways to find assistance for them in completing this task.

18.   *Search for ways to increase the number of resources for youth, possibly in conjunction with several other agencies.  It is recognized that this is not the sole responsibility of the agency, but rather lends itself to collaboration with other agencies and community groups including volunteers.

19.   *Reconsider the cap on services at 5 sessions and consider alternatives.  It is recognized that the agency itself considers this a tragic decision necessitated by funding limitations and priority populations, both under the control of the state.

20.   *Given the concerns with the safety of low income housing not maintained by FCMHC, consider training consumers in personal safety, if not already provided.

21.   Investigate the availability of transportation for consumers especially during the winter months.

 

OTHER RECOMMENDATIONS

1.       Seek private and corporate sources of funding to enhance services.

2.       Develop a foundation as a fund raising arm of the agency.

3.       Given the complexity of the grievance process for consumers, consider training volunteer consumers or others to assist the consumer in the process.

4.       Consider providing barber and beauty (including make up) services at the Clubhouse on occasion to aid consumers with self esteem and vocational preparation.

5.       Continue to educate the community to reduce the stigma surrounding mental illness, especially in the environs of the agency (main building lobby and elevators).

 

 

CLOSING COMMENTS

The team wishes to thank the staff of FCMHC for their cooperation and assistance in the completion of this review.  Special thanks to Lee Ann Amerson for her masterful scheduling and for all of the staff and members of the Clubhouse who endured our constant comings and goings with good grace and good food.

 

The final draft of this report will be prepared within 7 days and sent to DMHDD.  DMHDD will then contact FCMHC to develop collaboratively a plan for change.