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                           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


A review of the Mental Health services provided by Fairbanks Community Mental Health Center
(FCMHC) 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.
DMHDD (Division of Mental Health and Developmental Disabilities of the State of Alaska) Quality
Assurance staff conducted the Clinical Record Review and provided that section of this report.

Peculiar to 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); the Case Management Unit,
connecting consumers with resources including special services for the addicted chronically
mentally ill; the Intensive Residential Services Unit, a residential unit with capacity for eleven; the
Northern Door Clubhouse Unit, a psychosocial rehabilitation source for members with a focus on
community integration; the Residential Service Unit with a 10 tenant apartment building, four 2
bedroom houses and the Adult Group Home; the Vocational Unit composed of an entrepreneurial
business (Alaska Rag Company) and a Supported Employment Program; the Medical Unit which
includes the psychiatrist, medical director (also a psychiatrist) and nursing staff; the 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

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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, 5
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.


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
NAMI (National Alliance for the Mentally Ill) 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: DFYS (Division of Family and Youth Services for the State of Alaska), the
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 regards 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 CMI (Chronically Mentally Ill) adults or 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

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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.


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 MICA (Mentally Ill Chemically Addicted of 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.


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


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

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    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 FY 98 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.


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
+ 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
- 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


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

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     “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 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.”)

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

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-   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
-   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)


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


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

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  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

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

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

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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

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, areas needing improvement: too large a caseload in emergency services to be
effective, 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

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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
    demograhic 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

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

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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”.


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 file 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).


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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 and credentialing,
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.

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.

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.

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

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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.

                                    STATISTICAL SUMMARY GRAPH
                            100%      93%
                                                    85%         86%

                            60%                                               50%
                             0%    ASSESSMENTS   TREATMENT     PROGRESS    TREATMENT
                                                   PLANS         NOTES    PLAN REVIEWS
                                            MEDICAL NECESSITY AREAS


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
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

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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; the legalities of adulthood regardless of diagnosis; role loss and
    role confusion and 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
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.

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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.

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).

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.

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