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									                         INTEGRATED QUALITY ASSURANCE REVIEW
                                   Maniilaq Association
                                     April 18-20, 2000
                                    Kotzebue, Alaska

                                       SITE REVIEW TEAM
                                 LeRoy White, Community Member
                             Ken Roberts, Mental Health Peer Reviewer
                       Terri Firor, Developmental Disabilities Peer Reviewer
                               Robyn Henry, Mental Health Facilitator
                       John Havrilek, Developmental Disabilities Facilitator
                             Connie Greco, DMHDD QA Staff Member
                             Dan Weigman, DMHDD QA Staff Member


                                         INTRODUCTION

A review of Mental Health (MH) Counseling Services and Developmental Disabilities (DD) Services
provided by the Maniilaq Association was conducted April 18 - 20, 2000, using the Integrated
Quality Assurance Review process.

The contents of the report is the summation of the impressions of the 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.

Description of Program services

The Maniilaq Association is a non-profit Alaska Native association (PL 93638) serving the state’s
Northwest Arctic Region. The region size is equivalent to the State of Indiana and includes eleven
Native villages and the city of Kotzebue. The Association also serves the village of Point Hope in
the North Slope Borough. The Association provides direct and preventative medical and health
services to the entire region.

The MH services provided by Maniilaq Association through their Counseling Services include
psychotherapy; counseling for adults and adolescents; play therapy for children; marital and family
therapy; 24 hour a day on-call crisis intervention services; grief counseling; hospital assessments;
court screenings. Itinerant counselors provide support to each village with monthly visits.

The DD services provided by the Maniilaq Association include residential treatment in the
program’s Lake Street House in Kotzebue, emergency placement services and in-home support in
Kotzebue and the villages.

A 12-member Board of Directors, which includes one community member from each village,
governs the overall Association. Individual Tribal Governments appoint representatives to be
members of the Board.


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Description of the process

To conduct this review, an interview team consisting of two facilitators, one community
representative, and two peer reviewers conducted 29 interviews over three days in Kotzebue,
Alaska. Consumer interviews included people who receive services from both the MH and the DD
programs. Four of the six MH consumers scheduled were interviewed. Eight consumers from the
DD program were interviewed. Seven interviews were conducted with related service professionals
and ten interviews were with program staff. Although two interviews were scheduled with
Association Board members, neither person appeared. Interviews lasted from 15 minutes to an
hour and were held in person, at Maniilaq Association’s offices, in the community and by
telephone.

The interview team members also reviewed seven personnel files, the Association’s staff
orientation plan and the Association’s and programs’ Policy and Procedure Manuals. After
gathering the information, all the team members met to review the data and draft the report that
was presented to the administrative staff on the final day of the visit.

During this same period of time, two members of the DMHDD Quality Assurance Unit did a review
of randomly selected clinical records. A report of these findings was provided under separate
cover.

Open Forum

An open forum was held in Kotzebue at the elementary school at 7:00 P.M. on April eighteenth.
The Maniilaq Association advertised the event by posting flyers throughout the community and by
announcing it on the local radio station. No one attended.

                                            FINDINGS

Progress Since Previous Review

This is the first review of the MH program using these program standards. Therefore there is no
previous action plan for comparison.

The DD program was reviewed in January, 1998. That site review team made several
recommendations, most of which have yet to be addressed. Two recommendations (one regarding
staff training and one addressing the incorporation and use of vouchers) have been implemented.
The following recommendations still need to be addressed:

1. The team suggests the DD Program either re-institute an Advisory Board with consumer
   representation or have representation on the present Maniilaq Board of Directors to meet state
   DD standards and provide advocacy for the DD Program. (1.3.2)

2. Develop plans with input from consumers and other key people in areas of program
   development and habilitation. (1.4.1, 1.5.1, 1.5.2)



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3. The team recommends the program come up with a locally and culturally appropriate way to
   get systematic consumer satisfaction feedback from consumers and family members. (1.5.3)

4. Develop plans and work with consumers and their families, schools, DVR, and the community
   on employment and subsistence options for those on your case load who have made this
   choice. (5.1.1)

5. A combined culturally sensitive and informal/formal assessment should be implemented, i.e.,
   the coordinator could phone to talk with parents/guardians and fill out assessments based on
   that input. (6.1.1) (6.1.2) (6.2.1)

6. The team did not see any formal advertising, other than the state DD brochure and informal
   word of mouth is the primary procedure. We suggest the newspaper, T. V. scanner, newsletter,
   etc. be used. (6.4.1)

7. Develop Futures plans with consumers and family members and related agencies to meet
   present and upcoming needs. (7.1.1)

8. The team recommends that planning occur in close collaboration with family and other
   community members with careful attention to individual family and cultural values as guidelines
   for planning. (7.1.4)

9. The team recommends that agency services be driven by the plans. (7.1.5, 7.1.4, 7.1.2)

10. The team suggests that an independent review committee comprised of community members
    (e.g., the NWABSD Special Education Director, Maniilaq Health Center Social Worker) be
    created to review behavior plans when needed. (8.2.3) (8.2.4)
.
Life Domains

Choice and Self-determination
The team identified the following strengths under Choice and Self-Determination for those
receiving services from Maniilaq:
+ One person reported that services helped them overcome a lot of anger and that since they
    have come to therapy their outlook has changed and they are much happier. (MH)
+ Most people reported that the goals that are worked on are ones they have chosen. (MH)
+ Several people reported that their therapist helps them solve their problems. (MH)
+ One person indicated that they often recommend counseling services to others that need help.
    (MH)
The team identified the following weaknesses under Choice and Self-Determination for those
receiving services from Maniilaq:
- One person reported that they “know what to choose, but no one is there (to help).” (DD)
- One person reported that they had no choice in having their child placed out-of-home
    and out-of-state. They were not part of that decision. (DD)
- One guardian reported that the plan for the person for whom they were responsible was
    changed without their notice or their participation and that they have not been able to get
    a copy of the new plan. (DD)


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- Many consumers interviewed were not aware of the service options available. (DD)
- The team is very concerned about the overall lack of DD services to people who are not in the
  residential program. (DD)

Dignity, Respect and Rights
The team identified the following strengths under Dignity, Respect and Rights for those receiving
services from Maniilaq:
+ Most people interviewed said they felt respected by the staff and the clinicians. (MH and DD)
+ Several people indicated that staff were flexible about services. (MH)
The team identified the following weaknesses under Dignity, Respect and Rights for those
receiving services from Maniilaq:
- A couple of people interviewed stated that, while they felt respected and valued, they did not
    feel they had access to information regarding their illness and treatment. (MH)
- One person indicated that they had not signed a release of information form for
    the interview or at any other time in the past. (MH)
- One person interviewed indicated that they had requested services but no one had ever called
    back. (DD)

Health, Safety, Security
The team identified the following strength under Health, Safety and Security for those receiving
services from Maniilaq:
+ Most people interviewed indicated that, overall, they felt safe and secure in their current
   situation and that there were no problems in this area. (MH and DD)
The team identified the following weaknesses under Health, Safety and Security for those receiving
services from Maniilaq:
- One person interviewed, who is a relative of a person receiving services, indicated that they
     have serious health problems and they have been given no support for accessing out of town
     treatment (i.e. transportation to Anchorage) (medical services issue) (DD)
- One person who is homeless indicated that they had been given no support with housing and
     were told they had to work on getting housing on their own. (DD)
- One person reported that other family members were stealing from them when they visited and
     no one would help them with this issue. (DD)
- Two person reported that a consumer was held down/restrained on the floor for an hour and
     they felt this was an inappropriate action. (DD)
- Two village members interviewed indicated that the only service they have received from the
     program is help with rides from the airport to the hospital. (DD)
- The mental health program appears to provide support with either once a month village home
    visits or once a week office visits in Kotzebue, except in the case of an emergency. This limited
    service provision is of concern when supporting people with serious and persistent mental
    illness who may need more regular community based support.

Relationships
The team identified the following strengths under Relationships for those receiving services from
Maniilaq:
+ Most people reported being happy with the relationships they have with others. (MH and DD)
+ Several people reported that they were satisfied with the level of support they receive with
    building and maintaining relationships. (MH and DD)


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+ Two consumers in the residential program reported (and records substantiated) frequent
   contact with family members. (DD)
The team identified the following weakness under Relationships for those receiving services from
Maniilaq:
- Several people reported that staff had limited knowledge of their natural support system. (MH
   and DD)

Community Participation
The team identified the following strengths under Community Participation for those receiving
services from Maniilaq:
+ Most people interviewed were happy with their level of community participation (MH and DD)
+ Most MH people interviewed have regular full time jobs that are satisfying
+ One DD client interviewed reported they had a job they liked in the community.
+ Staff members take Lake St. House residents into the community on a regular basis including
    facilitating participation in subsistence and other outdoor activities.
The team identified the following weakness under Community Participation for those receiving
services from Maniilaq:
- The team is concerned about the level of community participation for people who are eligible
     and funded for services but are not receiving services (MH and DD)

Staff Interviews

The team interviewed 10 staff from the MH and DD programs. It should be noted that only one staff
member interviewed had been with the agency longer than a year. The staff member who had
been with the agency the longest said that they felt the agency had been improving and that things
were more organized.

Many people interviewed indicated that they worked a lot of over-time hours. Several people
indicated they have gotten good training while one person felt they did not get enough training.
Several people specifically identified the lack of orientation/training in addressing cultural issues.
This was problematic for making the adjustment to working in the village. One person reported that
the orientation session was “hostile” and that the speaker indicated to the new hires that, if they
could, they would replace them with a Native person.

Two people interviewed indicated that they did not want to answer many of the questions because
they had not been with the agency long and did not want to get anyone angry with them, explaining
“I like my job and I want to keep it”. One person expressed mistrust for the organization indicating
there is “…no stability from the top;…the organization can be toxic”. Staff morale seemed very low.

Collateral Agency Interviews

Seven people from collateral agencies were interviewed including representatives from DFYS, the
local police, Family Services, the Kotzebue Children’s home, the school district, the substance
abuse program and a local judge. The overall responses from the agencies were mixed. Most
people interviewed indicated that the programs were very good at following up with referrals.




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One person interviewed expressed great concern for system issues such as the lack of leadership
in working with people who “fall through the cracks”. They also indicated that they felt there needed
to be more collaboration among agencies especially when looking at cultural issues with youth in
the villages. They stated that once a month visits to the village were not enough. Also cited was
the lack of any services addressing FAS/FAE.

Specific issues identified relevant to current services included the lack of good DD services outside
of the Lake Street House and the lack of “village helpers” for both DD and MH. Several agencies
reported that communication regarding mutual clients was not always good, but two people said
that it had gotten better in the last six months. Several people identified the need for more
preventative/outreach services. One community service agency identified the need for more MH
training in their own program to help them better deal with MH clients.

Administrative/Personnel Narrative

The Administrative and Personnel Checklist is included at the end of this report. It includes 34
items, 21 of which are completely met by Maniilaq Association. Those standards not fully met
include:

1. The agency’s governing body includes significant membership by consumers (DD, MH) or
   consumer family members (ILP), and embraces their meaningful participation. (Standard #6)
While the Association’s Board of Directors includes members from each village being served, the
Board does not include MH and DD consumer membership.

2. The agency actively solicits and carefully utilizes consumer and family input in agency policy
    setting and program delivery. (Standard #12)
The agency does not formally solicit MH and DD consumer and family input in setting policy or
program delivery.

3. The agency systematically involves consumers, staff and community in annual agency
    planning and evaluation of programs, including feedback from its current and past users about
    their satisfaction with the planning and delivery of services. (Standard #13)
While the association apparently does have a process for visiting villages annually for the purpose
of getting feedback regarding health services, there is no systematic means for specifically
involving MH and DD consumers in that process.

4. The agency develops annual goals and objectives in response to consumer, community and
     self-evaluation activities. (Standard #14)
Again, there is no systematic means for involving MH and DD consumers in the agency goal
setting process.

5. The agency actively participates with other agencies in its community to maximize resource
     availability and service delivery. (Standard #17)
Related agency staff interviewed reported that they would like stronger and more frequent
collaboration in this area.




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6. The organization has and utilizes a procedure to incorporate consumer choice into the hiring
    and evaluation of direct service providers, and to ensure that special individualized services
    (e.g. foster care, shared care, respite care providers) have been approved by the family or
    consumer. (Standard #22)
Families using respite services hire their own providers, but other consumers do not have input into
the hiring and evaluation of staff.

7. The agency provides new staff with a timely orientation/training according to a written plan, that
    includes, as a minimum, agency policies and procedures, program philosophy, confidentiality,
    reporting requirements (abuse, neglect, mistreatment laws), cultural diversity issues, and
    potential work related hazards associated with serving individuals with severe disabilities.
    (Standard #25)
The agency provides new staff with orientation to the Association, but staff interviews indicated a
strong need for cultural orientation, especially to village life, as a major component of orientation.

8. The program obtains and documents informed consent from consumers (or ILP family
    members) before services are initiated and when services are changed or modified. (Standard
    #27)
A guardian, a staff member and a consumer reported instances where informed consent had not
been requested or given.

9. The agency evaluation system provides performance appraisal and feedback to the employee
    and an opportunity for employee feedback to the agency. (Standard #28)
10. A staff development plan is written annually for each professional and paraprofessional staff
    person. (Standard #29)
11. The agency identifies available resources to meet the assessed training needs of staff.
    (Standard #30)
12. The performance appraisal system adheres to reasonably established timelines. (Standard
    #31)
13. The performance appraisal system establishes goals and objectives for the period of appraisal.
    (Standard #32)

While the Association has a comprehensive system for evaluating staff annually which meets the
Standards, Standards 28-32 are not being met as evidenced by a review of the only two eligible
employee files. Neither had an evaluation in the file.

Program Management

There appears to be a large gap between the MH/DD program staff and the Association
leadership. The MH/DD programs seem to lack ability/authority to work autonomously and
effectively in the midst of the large bureaucracy of the Association.

The MH and DD programs seem to be in a continual state of flux. Staff turnover was identified on
many occasions as a major challenge for both programs. Only two staff in the MH program had
been there more than one year and all of the staff in the DD Program had been there less than a
year including both program managers. It does appear that the recent changes to the programs
have been positive.


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Areas Requiring Response

1. The team suggests the DD Program either re-institute an Advisory Board with consumer
   representation or have representation on the present Maniilaq Board of Directors to meet state
   DD standards and provide advocacy for the DD Program. (1.3.2) (Prior review and Standard
   #6; should include a MH advisory board as well)

2. Develop plans with input from consumers and other key people in areas of program
   development and habilitation. (1.4.1, 1.5.1, 1.5.2) (Prior review)

3. The team recommends the program come up with a locally and culturally appropriate way to
   get systematic consumer satisfaction feedback from consumers and family members. (1.5.3
   (Prior review)

4. Develop plans and work with consumers and their families, schools, DVR, and the community
   on employment and subsistence options for those on your case load who have made this
   choice. (5.1.1) (Prior review)

5. A combined culturally sensitive and informal/formal assessment should be implemented, i.e.,
   the coordinator could phone to talk with parents/guardians and fill out assessments based on
   that input. (6.1.1) (6.1.2) (6.2.1) (Prior review)

6. The team did not see any formal advertising, other than the state DD brochure and informal
   word of mouth is the primary procedure. We suggest the newspaper, T. V. scanner, newsletter,
   etc. be used. (6.4.1) (Prior review)

7. Develop Futures plans with consumers and family members and related agencies to meet
   present and upcoming needs. (7.1.1) (Prior review)

8. The team recommends that planning occur in close collaboration with family and other
   community members with careful attention to individual family and cultural values as guidelines
   for planning. (7.1.4) (Prior review)

9. The team recommends that agency services be driven by the plans. (7.1.5, 7.1.4, 7.1.2) (Prior
   review)

10. The team suggests that an independent review committee, comprised of community members
    (e.g., the NWABSD Special Education Director, Maniilaq Health Center Social Worker) be
    created to review behavior plans when needed. (8.2.3) (8.2.4) (Prior review)

11. The agency needs to develop a process to formally solicit consumer and family input in setting
    policy and program delivery. (Standard #12)

12. The agency needs to develop a process for formally involving consumers in both DD and MH
    program planning and evaluation, including feedback from consumers about their satisfaction
    with services. (Standard #13)


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13. The agency needs to develop annual goals and objectives in response to consumer,
    community and self-evaluation activities. (Standard #14)

14. The agency need to work on stronger collaborative efforts with other agencies, especially with
    the idea of designating a lead person or advocate to follow through on mutual clients where
    several agencies are involved. This would help keep clients from falling through the cracks.
    (Standard #17)

15. The agency needs to develop a process to involve consumers in the hiring and evaluation of
    program staff. (Standard #22)

16. Consistently require and obtain consumer/parent/guardian consent and input before starting or
    changing services. (Standard #22)

17. Provide a timely orientation/training to new staff according to a written plan that includes at
    least the minimal content as per the Standard. (Standard #25)

18. Systematically obtain and document informed consent from consumers before initiating or
    modifying services. (Standard #27)

19. Systematically provide performance appraisals and feed back to employees and an opportunity
    for employee feedback to the agency. (Standard #28)

20. The evaluation system needs to be completed and documented on an annual basis. (Standard
    #29)

21. The agency needs to systematically identify available resources to meet the assessed training
    needs of staff. (Standard #30)

22. The performance appraisal system should be systematic and adhere to reasonably established
    timelines. (Standard #31)

23. The performance appraisal system should systematically establish goals and objectives for the
    period of appraisal. (Standard #32)

24. The organization needs to develop a comprehensive cultural orientation process for new staff
    that would include a focus on how to work with people in the village setting.


Other Recommendations

1. Work with the Division of Mental Health and Developmental Disabilities to increase the use of
   Mental Health Medicaid funds as a resource to increase your program/staff capacity including
   the use of paraprofessionals to provide support.




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2. The organization could work with current village residents to identify people who live in the
   village who could provide support to others. Consider increasing the use of the UAF Rural
   Human Services training program for these paraprofessionals.

Closing

The team wishes to thank the staff of Maniilaq Association for their cooperation and assistance in
the completion of this review. A process such as this can be very disruptive to the office
environment and your hospitality was much appreciated by all of the team members.
.
The final draft of this report will be prepared within 30 days and sent to you along with a Plan of
Action. You will then have 30 days in which to complete the Plan of Action and return it to Northern
Community Resources. NCR will review your response and forward it to DMHDD.

Attached: Administrative and Personnel Checklist; Questions for Related Agencies (tallied), Report
Card (tallied)




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