Northern Community Resources
P. O. Box 7034, Ketchikan, Alaska 99901
(907) 225-6355 FAX 225-6354
Site Review Team
Gina Frickey, Community Member
The site review team met in Juneau at the main office of REACH, Inc., to conduct a review of the Developmental Disabilities (DD) and Early Intervention/Infant Learning Program (EI/ILP) services provided by REACH. The review was conducted from November 27 to November 30, 2000 using the Integrated Quality Assurance Review process.
This report is the summation of the impressions of a community team after interviewing consumers, staff members, board 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.
REACH, Inc. serves 460 consumers in the communities of Juneau, Skagway, Haines, Yakutat, Sitka, Ketchikan, Hoonah and, when the need arises, Tenakee Springs. In addition to these communities, the EI/ILP serves Petersburg and Wrangell.
REACH provides early intervention services for 120 children annually, with a current enrollment of between 50 and 55 infants and toddlers to 3 years of age with assessment, therapy, respite, and group and individual activities.
REACH DD programs include care coordination, respite, foster care, family support, supported living and vocational services.
The agency serves several individuals with dual diagnosis in DD and mental health, but none has a primary MH diagnosis. Agency management feels REACH does not currently have a staffing pattern that would support expansion into MH services. Under their DVR contract, Juneau Works serves people with a wide variety of disability types.
“REACH is a gift to parents.” -- consumer
The team particularly observed the following: people in the community and individuals receiving services value services at REACH; REACH has a history and strong reputation for providing quality services; services typically are provided by caring and dedicated staff; REACH has established long-standing trusting relationships with families and individuals receiving services that are helping to carry them through a period of reorganization that began a year and a half ago.
Description of
Process
A team of seven conducted the consumer-centered site review. The team included three Juneau community members, two peer reviewers and a facilitator. For two days of the review, an EI/ILP Technical Assistant assisted with the review as well.
Over the course of the four-day review the team conducted 55 interviews, including 2 Board members, 9 representatives of related agencies, 19 DD consumers or their parents or guardians, 9 EI/ILP families, 8 direct service staff, 1 volunteer interviewee (see below), 6 combination direct service/administrative staff, and one administrator.
Consumers were randomly selected from those who receive services from REACH. One EI/ILP family scheduled for an interview declined to participate during the site review and one was unavailable for a scheduled telephone call.
The interviews lasted from 15 minutes to one and one-half hours and were conducted by telephone or in person, in private homes or at the agency.
Open Forum
Agency staff planned and advertised an open forum at the Juneau Library for the first night of the review. One person arranged a telephone call in lieu of attending. No one attended the forum.
Progress Since Last
Review
The previous review of DD services was conducted in April 1999. The following items were identified as needing attention from the organization:
1. Assure that individual goals are measurable and objective. There is evidence of continuous activity to improve. Standard met.
2. Assure that all individuals have current plans. Files reviewed included current plans. Standard met.
3. Assure that REACH gives timely notification to consumers of opportunities to be involved in decisions that affect their family members’ services. Notification appears to be timely. Standard met.
4. Refine your grievance procedure to more effectively provide consumers opportunities for resolution of their concerns. Consumers should be informed of the grievance procedure at times of admission and when plans of care are revised (with signed copies in the files) and the procedure should be posted. This has not been accomplished. Standard not met.
5. Reword your mission statement using language that describes “persons with disabilities”. (Standard #1) The agency's revised mission statement includes this language. Standard met.
6. Assure that the public and consumers are notified of Board meetings (Standard # 8). It is not clear to board members that these standards require board meetings to be open to the public and to consumers. Standard partially met.
7. Build on recent gains in working with other community entities to maximize the availability and service delivery (Standard #17). Standard met.
8. Develop a procedure to incorporate consumer input into hiring and evaluating of direct service providers (Standard #22) Procedures are in place. Standard met.
9. Develop a policy and improve procedures that facilitate the development or strengthening of people’s natural support networks (Standard # 26). The agency appears to be consistently working to facilitate non-paid relationships. Standard met.
10. Assure that REACH obtains informed consent from consumers whenever there is a change or modification in service. (Standard # 27) Standard met.
11. Assure that employees receive timely performance appraisals and a staff development plan based on those appraisals (Standards # 28, #29, #31, #32). These standards are not implemented systematically or agency-wide.
The previous review of EI/ILP services was conducted in April 1997. The following items were identified as requiring response:
1. Develop “child-find” activities for families who are not in the health or social service system. Standard met.
2. Implement better documentation of responses back to referral sources. In progress, see EI/ILP file review report.
3. Develop better documentation of the reasons for not meeting timelines. Standard met.
4. Assure that families are not over-served and frequency is not more than families want. Standard met.
5. Improve documentation of updated status of goals on the IFSP. Standard met.
6. The team recommends that staff use increased sensitivity in obtaining personal/family information, and review the need to know. Standard met.
7. Take measures to insure the privacy and confidentiality of consumer records. Standard met.
8. Consider sharing information on family rights on a recurring basis. REACH is working on this; see EI/ILP file review report.
9. Develop written complaint and/or grievance policies. Not met; see EI/ILP file review report.
10. Continue to refine the customer satisfaction survey, use it regularly and administer it rigorously to make the information useful as part of the annual program evaluation process. Standard met.
11. Develop a policy and mechanism for meaningfully involving consumers in hiring and evaluating agency personnel. Standard met for EI/ILP.
Both Juneau Works and Infant Learning are exemplary programs at REACH. Strong service delivery models and strong staff characterize both. Both programs are meeting the needs of the people they serve. “They are crown jewels of the agency” in the words of a related service agency.
The Infant Learning Program has well-trained, caring staff who have been with the agency for many years. The high level of program continuity contributes to quality programming and family satisfaction.
Juneau Works exemplifies empowerment and growth of individual consumers. The program offers individualized jobs that provide freedom, enhance skills and independence, and include vocational future planning, career exploration and job development. REACH received a grant to provide benefits counseling training region-wide for REACH and other agencies. They have been working closely with employers, the Juneau School District and other agencies. The philosophy of Juneau Works moves people toward inclusionary settings.
The team identified the following strengths under Choice and Self Determination for those receiving EI/ILP services:
+“Staff help coordinate and put it all together.”-- EI/ILP and Juneau Works consumers
+ Families and individuals report high satisfaction with the
quality of choices.
+ Options are presented in a manner that helps parents learn how to make
positive and healthy choices.
+ Staff present many choices.
+ Choice is a strength of Early Intervention services.
+ Options are given but staff are there when people need help.
The team did not identify any weaknesses in this area.
The team identified the following strengths under Dignity, Respect and Rights for those receiving EI/ILP services:
+ Consumers feel “totally respected”. --family members
+ “They're wonderful.”-- related agency and a family member
+ “They hold us in
high regard” --. family member
+ “Family is in the lead”. --staff member
+ Family choices are respected.
+ “Staff listen.” – family member
The team did not
identify any weaknesses in this area.
The team identified the following strengths under Health, Safety and Security for those receiving EI/ILP services:
+ “No matter what our health and safety concern was, ILP staff helped us find information.” -- parent
+ The team heard repeatedly about interagency collaboration and sharing of knowledge that help promote individual health and safety.
+ ILP staff help families find resources in addition to
regular funding.
+ Families can access information by using the Internet at REACH.
+ Staff help families negotiate medical systems and facilitate between
physicians and consumers, for best services.
The team did not identify any weaknesses in this area.
The team identified the following strengths under Relationships for those receiving EI/ILP services:
+ “ILP has totally alleviated the stress and isolation.” -- parent
+ “Services have touched family lives beyond the individual receiving the services.” -- parent
+ “The best of all is the ILP provider coming to the home”. -- parent
+ “The hardest part will be leaving; she [provider] has helped us become a better family.” -- parent
+ Staff seek to promote positive relationships between parents and children.
+ “REACH staff listen
to concerns, validate and form a triad with the parent, child and provider.” --
staff member
+ “Staff seem to promote positive
relationships between family and children.”
+ EI/ILP helped a family's child to communicate: “Before, we used to give him what we thought
he wanted, but now we can respond to what he's really asking for.”
+ EI/ILP groups help children discover relationships with
other children and adults.
+ Parents report high satisfaction with EI/ILP group activities.
+ REACH staff provide reassurance about children's development within a continuum of progress.
The team did not identify any weaknesses in this area.
The team identified the following strengths under Community Participation for those receiving EI/ILP services:
+ A parent whose son felt welcomed by the community said, “Juneau loves my son; he is a gift to the community.”
The team did not identify any weaknesses in this area.
The team identified the following strengths under Choice and Self Determination for those receiving DD services:
+ “Staff help coordinate and put it all together.” -- consumers
+ “I volunteer at the Salvation Army; I have lots of choices about what I do.” -- consumer
+ Families and individuals report high satisfaction with the
quality of choices.
+ Staff present many choices.
+ Family choices are respected.
+ Juneau Works encourages people by giving options, work
opportunities, job sampling, and job shadowing; the staff help when needed, but
do not enable.
+ Options are given but staff are there when people need help.
The team identified the following weaknesses under Choice and Self Determination for those receiving DD services:
- Staff turnover negatively impacts the way consumers feel about the services they receive; individuals express concern about constantly changing staff.
- Several families and individuals receiving services stated opinions about shortage of qualified and appropriate people to work, limiting their choices for caregivers and amounts of care.
The team identified the following strengths under Dignity,
Respect and Rights for those receiving DD services:
+ Consumers feel “totally respected.”
+ “They're wonderful.” -- related agency and a family member
+ “We've always been really happy with REACH services, except respite.” - parent
+ Family choices are respected, as reported by consumers.
+ “Staff listen.” -- consumers
The team identified the following weaknesses under Dignity, Respect and Rights
for those receiving DD services:
- There is an inconsistency in the way some care
coordinators and Individual and Family Support staff offer supports. The team
heard many good things about what IFSS staff are doing, while also hearing
about several staff that seem to have their own agenda and seem not to be
listening to what consumers want. The team heard these concerns from a
significant number of people receiving services (or their family members) as
well as from other agencies in Juneau. In a parent's words, “It feels different at REACH, like a general
drop in quality.”
- Several family members feel that since the agency’s reorganization, less importance is placed on consumers' rights. Families report instances when staff have told them they do not have the right to direct the activities of caregivers in the family's home and do not have recourse within REACH for changing care coordinators.
The team identified the following strengths under Health, Safety and Security for those receiving DD services:
+ The team heard
repeatedly about interagency collaboration and sharing of knowledge that help
promote individual health and safety.
+ Families can access information by using the Internet at REACH.
+ Staff help families negotiate medical systems and facilitate between
physicians and consumers, for best services.
+ REACH connects consumers to nutrition, dental and medical services, with particular care to individual needs. An example of this is an individual receiving DD services whose nutritional program has visual keys to quantities and types of food.
The team identified the following weaknesses under Health, Safety and Security
for those receiving DD services:
- Some consumers report inconsistencies in the quality of direct service staff hired by REACH. Families and individuals are concerned about REACH hiring “just warm bodies,” and state that background checks and fingerprints are not enough to assure adequate quality in new hires. Families expressed strong feelings about needing direct service staff to have good work habits and appropriate training for working with people who experience developmental disabilities. Several family members said they would like to be invited to present information during staff training about living with and caring for people with developmental disabilities.
- Because requests for Prior Authorizations for Medicaid services are so delayed, months can pass during which no response arrives from the State. While this is out of the control of the agency, consumers nonetheless feel that REACH is not taking action, which may be due to inadequate communication with families about the health and safety issues related to their requests for funding.
The team identified the following strengths under Relationships for those receiving DD services:
+” Services have touched family lives beyond the individual receiving the services.” -- consumer
+ Staff seek to promote positive relationships among family, children and community.
+ “They [staff] are like family; if I need to talk, I can call.” -- consumer
+ Many individuals commented enthusiastically about the Friday socials and groups.
The team identified the following weakness under Relationships for those
receiving DD services:
- Loneliness was reported by some consumers who live independently.
The team identified the following strengths under Community Participation for those receiving DD services:
+ Staff excel at collaborating in Juneau to develop jobs
throughout the community.
+ REACH collaborates with and supports consumers' participation in ORCA and
consumers place a high positive value on these activities.
+ REACH staff work at all levels to prepare consumers for jobs: transitional
school students, employers and other agencies work together for great outcomes.
+ Individuals working in the community love their jobs.
+ Staff work to connect families to resources in the community, and use the community for a variety of activities.
The team identified the following weakness under Community Participation for those receiving DD services:
- Continue to seek and develop more inclusive living
arrangements than are offered by assisted living homes, while assuring options
to alleviate loneliness.
Staff Interviews
+ Direct service staff try to focus on finding people's preferences and presenting options. “It's great here; you get to work directly with people,” one staff member said.
+ Staff report a team approach to problem solving with families.
+ Care coordinators hold periodic parent meetings at REACH, at which they explain differences between types of supports and types of funding; similar discussions are held in staff meetings.
-- Some staff
members indicate there is confusion and overlap within the agency about the
roles of intake and care coordination staff.
-- Staff have concerns about how difficult it is to obtain financing for necessary services. One said “Clients can wait months for a Prior Authorization, and that's out of our control.”
-- Several employees express difficulty finding and retaining qualified entry-level employees; one said “Finding qualified staff is a problem -- there's not a very big resource pool of trained people.” Others think there are plenty of people available for jobs, particularly those who wish to work with children, and that the only challenge is ensuring the right fit between staff and consumers.
-- Most employees indicated that a grievance procedure exists for consumers, but no one could locate one.
+ “REACH outperforms other agencies that provide similar services, by far.” -- related agency
+ “If there's a choice
of jobs at different agencies, people choose to work at REACH,” was what
one person said about the agency.
+ Strong interaction between Juneau Works and the school
district's transition program is seen by several people as a particularly
strong link in the community. One
person said, “They collaborate whether or
not a consumer receives services from REACH.”
+ “Their staff take time to answer my questions and empower us to understand processes and consumer needs.”-- related agency
+ Benefits trainings received praise.
+ Most of the people at other agencies see REACH as operating in a collaborative mode. One said: “There isn't enough money for all of us to do everything; there have to be more seamless services. REACH asks us how they can help.”
- Some people at other agencies said they have heard from consumers about the inflexible attitudes of some REACH staff. For example, a REACH staff member reportedly told a consumer, “This is what we have,” rather than operating in a problem-solving mode.
- Some people at related agencies indicate that roles do not seem to be clearly defined for people who work in the central office at REACH.
The team's review of Administrative & Personnel Standards suggests the need for a systematic and agency-wide approach to implementation of staff evaluations, consumer rights, and agency planning that incorporates consumer, community and staff involvement. Specific standards that need to be addressed include:
#8 -- It is not clear to board members that these standards require board meetings to be open to the public. Board meeting notices are not posted or published.
#12 -- ILP performs a consumer survey and utilizes it in a systematic manner to plan programs. Other programs have varying amounts of consumer and family input. This activity is not agency-wide and is not implemented on a consistent or timely basis throughout the agency.
#13 -- This standard is also not systematic or agency-wide, although REACH is moving in the direction of annual agency planning that, if applied consistently, will bring the agency up to standards in this respect.
#14 -- REACH does not have a process of developing annual goals and objectives with consumer, community and self-evaluation activities.
#19 -- REACH partially meets the requirement that all staff have appropriate training, experience and supervision, but there are inconsistencies in hiring, training and supervision.
#28 – While self, peer, and informal ongoing evaluations occur, and some supervisors implement consistent annual performance appraisals, there is not an agency-wide system of written employee evaluations conducted on a regular basis.
#29 -- Staff development plans are not written annually for each professional and paraprofessional.
#31 -- Performance appraisals are not conducted on a regular schedule agency-wide.
#32 -- Performance appraisals are not systematically implemented, so formal goals are not written for many employees.
Program Management
The REACH management team has been together through a recent period of growth and agency reorganization and has carefully prepared for the imminent retirement of a key player, the Administrative Director.
Turnover in direct service and administrative entry level positions appears to have a negative impact on the lives of some families and individuals receiving DD services. Consumers report a shortage of qualified direct service staff, including limited access to people who sign.
Individual and Family Support Services staff are not consistently person-centered. Consumers and families report that in some cases staff have their own ideas about what families need. An example of that is a family that did not want an additional level of respite care services, but their care coordinator wrote it into the plan anyway.
Care coordinators are not responsible for leading the person-centered planning; this is creating confusion, as reported by families, as to who is doing what. Collaborating agencies reported lack of clarity about structure and roles within the organization in the past year. The high level of regard for REACH within the Juneau community has helped to carry people through the confusion, and families trust that REACH will work through it.
Areas Requiring
Response
1.From the prior DD and EI/ILP reviews: Refine your grievance procedure to more effectively provide consumers opportunities for resolution of their concerns. Consumers should be informed of the grievance procedure at times of admission and when plans of care are revised (with signed copies in the files) and the procedure should be posted. (Also see this item in EI/ILP file review report)
2.From the prior DD review: Assure that the public and consumers are notified of Board meetings (Standard #8). It is not clear to board members that these standards require board meetings to be open to the public and to consumers. The team recommends posting notices or placing them in the newsletter, as a start.
3, 4, 5, 6. From the prior review, all services: Assure that employees receive timely performance appraisals and a staff development plan based on those appraisals (Standards # 28, 29,31,32). These standards should be implemented systematically and agency-wide.
7.From the prior EI/ILP review: Implement better documentation of responses back to referral sources. In progress; see EI/ILP file review report.
8.From the prior EI/ILP review: Consider sharing information on family rights on a recurring basis. REACH is working on this; see EI/ILP file review report.
9.DD services: Continue seeking to reduce staff turnover; improve screening systems for new hires and include parent presentations in training of entering staff to assure that qualified and appropriate people work with consumers. (Standard #19)
10.DD services: Clarify structure and roles under the new organizational plan, especially regarding intake, care coordination, respite -- and communicate that information to families, staff and other agencies to reduce confusion, overlap and inconsistencies.
11.DD services: Continue to seek and develop more inclusive living arrangements than are offered by assisted living homes, while assuring options to alleviate loneliness with people living in supported or independent arrangements.
12, 13, 14. All services: REACH should implement systematic, agency-wide feedback for consumers, staff and community, and use that information in planning policies and programs and setting agency goals. (Standards #12, #13, #14)
15 through 23. EI/ILP services: See the additional recommendations made in the EI/ILP file review report, attached.
Other Recommendations
1.People in the community and within the consumer population feel there is not adequate funding for necessary services for DD and Infant Learning. Consumers want for REACH what they ask for themselves: “It would be nice for REACH to have better funding; they give so much, it would be good for them to get sometimes,” was the way one consumer said it.
2.It is critical for agencies to work within a system of timeliness for approval and renewal of Prior Authorizations for Medicaid-funded services. Delays extending into many months result in widespread feelings of disempowerment and anger on the part of consumers and caregivers, with an increased financial strain on overburdened agencies.
3.The State of Alaska should continue to refine the role of care coordination, and adequately fund it.
4.The site review team believes it would be helpful to have State guidelines and explanation of expectations regarding development of non-paid relationships to assist agencies in their service delivery planning and to clarify requirements for site review reports.
Closing Note
The site review team thanks the REACH staff for particularly gracious hospitality. Thank you for great snacks, flexibility and lots of help.
The final draft of this report will be sent to Northern Community Resources for final review. You will receive the final report within approximately thirty days, including a Plan of Action form, listing the Areas Requiring Response. You will then have an additional 30 days to complete the Plan of Action. The directions on how to proceed from there will be included in a cover letter you will receive with the final report and Plan of Action form.
NCR will review the completed Plan of Action and will send it to the DMHDD Quality Assurance Section. The QA Section will then contact you to develop collaboratively a plan for change.
Attachments: REACH EI/ILP File Review, EI File and Individual Family Service Plan Review (tallied), Administrative and Personnel Checklist, Interview Form for Staff of Related Agencies (tallied), Score Sheets (averaged)