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									                    Integrated Quality Assurance Review
                                 Tanana Chiefs Conference, Inc.

                                  August 30-September 3, 1999

                                        Fairbanks, Alaska

                                      Site Review Team:
Sam Bush, Community Member                     Jeri Lanier, Community Member
Christine Butler, Community Member             Jane Franks, Peer Reviewer
Linda Hurley, Peer Reviewer                    Vicki Thayer, Peer Reviewer
Connie Greco, Lead DMHDD QA Staff              Pam Miller, DMHDD QA Staff
Jane Atuk, ILP Technical Assistance Staff      John Havrilek, Facilitator
Sherry Modrow, Co-Facilitator

Introduction
The Site Review Team conducted a review of state-funded Infant Learning, Developmental
Disabilities and Counseling Center services at Tanana Chiefs Conference from August 30 to
September 3, 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 includes a limited administrative
review. The report 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 Quality Assurance staff conducted the Clinical Record Review and provided that section
of this report.

Description of Tanana Chiefs Conference, Inc.
Tanana Chiefs Conference, Inc. (TCC) is a nonprofit tribal organization representing 42 tribal
governments in Interior Alaska. TCC incorporated as a nonprofit organization in 1972. It serves and
represents approximately 14,000 Alaska Natives residing in an area of 235,000 square miles,
covering 39% of the state. The corporation provides services through state grants and federal
contracts and grants to Alaska Natives and non-native residents of small communities along the
Yukon, Tanana, Koyukuk and Kuskokwim Rivers and their tributaries.
TCC’s organizational history reflects the importance of balancing traditional Native values with the
modern demands facing indigenous peoples. The organization provides specially tailored programs
to its constituents in health, employment, education, economic development and general family
services.
Tanana Chiefs Conference’s member tribal organizations elect a 43-person Board of Directors and
a nine-member Executive Board. The full Board elects the president, who serves as the CEO of the
corporation. TCC administers over 40 programs through seven regional offices. The corporate
administration is located in Fairbanks.



                                                 1
In 1998, TCC was recognized as one of the 60 largest employers in the state of Alaska, with more
than 600 full-time and part-time staff distributed between the regional office in Fairbanks, seven
subregional district offices, and more than 30 communities.
TCC manages approximately $65 million annually. The organization completes an annual
independent audit.



Services Reviewed
Infant Learning Program: 3 FTE staff, 43 children receiving services in 20 villages
Infant Learning Specialists work as a team with families, other providers and contract specialists to
provide family-centered services, which respect the cultural differences and community values of
rural Alaska. The Fairbanks-based staff members travel regularly, attempting to visit each family
approximately every 5 weeks to evaluate, plan services, and provide or facilitate special instruction,
advocacy and specialized therapy.
Developmental Disabilities Program: 1 FTE staff, 42 individuals in 21 villages active on respite
caseload, 10 individuals on waitlist
This program offers assistance for families of children with developmental disabilities primarily by
providing vouchers for respite care. The program’s sole staff member provides limited case
management, advocacy and referral and helps families to develop individual plans of service based
on a child’s needs and family preferences. From the Fairbanks office, the Family and Community
Services Specialist uses telephone and fax to stay in contact with individuals and tribal
coordinators in the villages. The program provides vouchers to families, who hire their respite
providers. The relationship between consumers and respite providers is a contractual agreement
in which TCC has no involvement beyond voucher payments. The program does not supervise or
provide funding for training respite provider. Although there is a travel budget, the staff person has
no back-up coverage for office functions, so is only rarely able to visit the villages where most of
the consumer families live.
Counseling Center: 6 FTE staff, 40 clients in case management, coverage in all TCC villages and
Fairbanks
The TCC Counseling Center, located in the Fairbanks Memorial Hospital building, provides mental
health services and support to Alaska Natives and American Indians. Residents of Interior villages
fly to Fairbanks at TCC’s expense for regular appointments for psychiatric evaluation and
medication management, case management, referral and information, intake and crisis intervention
services. The Counseling Center offers crisis intervention and information and refers clients to
outpatient services by contracting with Fairbanks-area mental health professionals. The Paul
Williams House also provides services for crisis respite. The Institutional Discharge Program and
Community Support Program provide case management services to the chronically mentally ill
from the villages and Fairbanks.




                                                  2
Description of Review:
The Integrated Quality Assurance Site Review Team met for five days in Fairbanks. The team
consisted of three community representatives, three peer providers, two facilitators, two DMHDD
staff and an ILP staff person. The team reviewed individual ILP and DD consumer files and
program and agency materials, and interviewed 24 consumers of TCC services and 14 staff
members. The review also included interviews with 12 individuals from the following related
service agencies: Public Health Nursing, Fairbanks Correctional Center, Adult Learning Programs
of Alaska, TCC Head Start, University of Alaska Rural Programs, Division of Family and Youth
Services, Public Defender Agency, Fairbanks Resource Agency, ACCESS Alaska and Yukon Flats
School District. Interviews lasted between 30 minutes and an hour.
It must be noted that the team performed its duties admirably under complex conditions. In order
to do justice to the ILP portion of the review, part of the team traveled to Delta, some 75 miles
distant, to complete interviews. The team’s crucial orientation/training session the first morning
was interrupted by an evacuation of the TCC building for a two hour period, the team was often
divided by the varying locations of services within Fairbanks and the team’s final report
preparations were complicated by needing to provide the Counseling Center with a separate exit
interview during the final report preparation period. The sudden illness of the MH director left the
crucial overview of the agency to a staff member recruited at the last minute for this function, and
one whose reluctance to perform the task left the team insufficiently briefed for all they would
encounter.
Monitoring and reporting the quality of life and the quality of services for individuals and families
make significant contributions to the State of Alaska’s understanding of the effectiveness of
program services and supports. The review team’s findings are reported below.
The report includes TCC’s responses to the previous action plan; related service agency
comments; an administrative review; consumer responses to the Quality of Life Standards. The
report also includes recommended improvements and tables of consumer satisfaction and file
reviews.


Open Forum: TCC staff advertised an Open Forum by distributing a flier in Fairbanks and in each
village. The flier was posted in several locations in the TCC building in Fairbanks and was provided
to other community agencies. The flier included prominent notice of a toll-free telephone number
for people outside the Fairbanks area to call to provide their comments. A meeting room was
provided in the Fairbanks North Star Borough’s Noel Wien Library. No one attended or called.




                                                   3
Mental Health Program Findings
Progress Since Previous Review: As this was the first site review under the Integrated Quality
Assurance system, there was no previous review available for comparison or response.
It must be noted here that the site review team felt their review of TCC’s mental health services
was inadequate, resulting in the findings of “insufficient data” repeatedly in the sections below. The
core of the measure of outcomes in the lives of consumers is based on consumer interviews.
Generally, in an agency with this level of state funding, 15 consumers would be included, thus
providing a significant sample and one from which conclusions may be drawn. Unfortunately,
TCC’s MH program could only offer five consumers in a residential facility to be interviewed and
those chosen were not able to be completely available, emotionally and cognitively, for an
interaction of this sort. Therefore the team cannot claim that the findings below present either an
adequate or an accurate picture of TCC’s MH services.
Given the above facts, the team recommends that another review be scheduled that would include
a sufficient number of consumer interviews to present a balanced picture of the satisfaction of TCC
consumers with their services and their lives.


CHOICE AND SELF DETERMINATION
The team identified the following strengths under Choice and Self Determination for people
receiving MH services from TCC:
                                   INSUFFICIENT DATA
The team identified the following weaknesses under Choice and Self Determination for people
receiving MH services from TCC:
-   There is a long wait-list for seeing a psychiatrist.
-   There is a perceived lack of therapeutic services: “We need a therapist that does therapy.”--
    consumer


DIGNITY, RESPECT AND RIGHTS
The team identified the following strengths under Dignity, Respect and Rights for people receiving
MH services from TCC:
+ Consumers and other agencies recognize the respect with which consumers are treated:
 “I would rather work with TCC than other providers. They give us prompt, up-to-date info. and
they care about their clients.”—related service agency
Consumers reported they feel extremely respected.
+ Case managers reflect their respect and concern for the consumers by their hard work. They are
a recognized strength of the program: “Case managers are working their tails off; they’re
awesome.”--consumer
The team identified the following weaknesses under Dignity, Respect and Rights for people
receiving MH services from TCC:



                                                    4
-   Three of the five consumers interviewed had not signed the release of information provided.
-   Some related agencies would like more collaborative efforts and communication with TCC.


HEALTH, SAFETY AND SECURITY
The team identified the following strengths under Health, Safety and Security for people receiving
MH services from TCC:
+ TCC psychiatric staff does an excellent job of medication management.
The team identified the following weaknesses under Health, Safety and Security for people
receiving MH services from TCC:
-   Budget cuts are perceived as negatively affecting staffing and service levels.


RELATIONSHIPS
The team identified the following strengths under Relationships for people receiving MH services
from TCC:
+ One of the Counseling Center staff’s strong points is their longevity. Stable staff can build
professional relationships with consumers.
+ The staff model healthy relationships: TCC fosters teamwork among case managers: “We have
great teamwork.”—direct service staff
The team identified the following weaknesses under Relationships for people receiving MH
services from TCC:
                                  INSUFFICIENT DATA


COMMUNITY PARTICIPATION
The team identified the following strengths under Community Participation for all people receiving
MH services from TCC:
                                  INSUFFICIENT DATA


The team identified the following weaknesses under Community Participation for all people
receiving MH services from TCC:
                                  INSUFFICIENT DATA




                                                  5
Consumer Satisfaction Chart *
    MH                         Choice N=5       Dig&Res. N=5         Hth,Saf,Sec N=5     Relatns. N=5          Com.Par. N=5


    Outcome                    Yes   No          Yes       No         Yes    No           Yes    No            Yes   No
     Person/Parent/guardian      3    2           4        1           5                   4     1              5
    Staff Performance
     Person/Parent/guardian      5                3        2           5                   4     1              5

* As only five consumers in a residential facility were interviewed from this extensive program and
since those interviewed were unable to respond to all of the necessary questions, the team does
not claim that this chart adequately reflects the life situations of TCC MH consumers as a group.
.

Staff Interviews
The staff were extremely supportive of consumers and their ability to work together as a team, but
were concerned about budget cuts.

Collateral Agency Interviews
Agencies were very supportive of TCC services, but would like more collaborative efforts in the
Community Support Program, in the Institutional Discharge Program and in crisis intervention.


Administrative and Personnel Narrative
TCC overall has strong administrative policies and procedures. In an organization of this size, input
of consumers in small programs may not be reflected in the agency’s overall processes.
Consequently, the Counseling Center does not meet Administrative and Personnel Standards
numbers 6, 12, 14,and 22. (See Areas Requiring Response)
Program Management
Budget cuts appear to have negatively affected staffing and service levels.

QA Clinical Chart Review
 INTRODUCTION - The clinical chart review was conducted for the purpose of determining the
agency’s training needs in order to provide 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) to
determine 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. The number of charts to be
reviewed was determined by a Range Table based on the total number of cases supplied by DMA. There
were fifteen (15) Medicaid charts reviewed, ten (10) adult charts and five (5) child charts.
 STRENGTHS- One of the most noteworthy strengths of this agency is their desire for information.
The clinical director has expressed a desire to have training in areas of Medicaid billing and documentation
requirements. In the area of documentation, the charts reflect assessments that are well written, and do a
great job in supporting the given diagnoses. Overall, progress notes were well documented
WEAKNESSES- If psychiatric assessments are used as comprehensive assessments, please
make sure they include all the components required by regulations and standards. It appears that the
agency puts more time into the assessment process than is being reflected in the billings. There appears to


                                                       6
be few rehab services indicated for children, and some of the charts reflected only substance abuse issues.
A review of the billing allowances and contents required for assessment (comprehensive and psychiatric)
and medication management might be helpful. Some charts do not contain treatment plans and others
contain goals that were not recommended in the assessment material. In some treatment plans, problems
were identified (mostly clinical) that were not recommended for treatment. If the agency only offers
psychiatric and case management, they should document outside referral for other treatment modalities.
Please include the specific goal being addressed during service episodes and the client progress toward the
goal. The practice of clearly stating active interventions can be more consistent. In some charts, there were
discrepancies in the progress notes between the amount of time reflected for the session and the amount
that was billed to and paid by Medicaid. This resulted in less revenue being paid than was indicated in the
progress note. If there is not a system in place to track billing follow-up, it is recommended that one be
implemented. Some charts did not contain treatment review documents.
SUMMARY- The file review should identify areas of documentation that need more attention in
order to reflect good clinical practice. These areas can be the focus of training for the agency. In this
review, the strengths of the documentation process are reflected in assessment and progress notes. The
psychiatric notes are very good, however there appears to be a shortage of clinical services delivered by
other than a psychiatrist. This could reduce needed services to the client and be a burden on the
psychiatrist’s time, which is generally at a premium. The treatment plans and treatment plan reviews
reflected the most need for documentation training. You are encouraged to arrange for training in areas of
billing and documentation and to refer to the Integrated Standards (Oct. 98) and/or to the provider-
approved standardized clinical record forms for the required components. The Mental Health File Review
Checklist in the Integrated Standards discusses the components required and the timelines for assessments,
treatment plans, progress notes, and treatment plan reviews. The standardized forms are available in hard
copy and on disk (instructions are included). While the forms are optional, the components of the forms
are mandatory, in order to meet all the requirements of the Medicaid Regulations and Integrated Standards.



                                         TCC COUNSELING CENTER

                                  100%      81%                       80%
               COMPLLIANCE RATE




                                  80%
                                  60%                     47%
                                  40%                                                  31%
                                  20%
                                   0%    ASSESSMENTS   TREATMENT    PROGRESS      TREATMENT
                                                         PLANS        NOTES      PLAN REVIEWS
                                                  MEDICAL NECESSITY AREAS




                                                           7
Developmental Disabilities Program Findings
Progress Since Previous Review:
Previous Recommendation: “The team recommends that, in the absence of a designated
representative, the program explore effective ways to inform the TCC Executive Board of the
program’s accomplishments and needs as well as the issues and level of satisfaction of its
consumers.”
      Action Taken: The consumer survey has been completed; results will be given to the
administration and board. Staff plans to join a related program in forming an advisory board. Each
year the program’s annual report is presented to the Executive Board.
Previous Recommendation: “The team recommends that a clear process of appeals be developed
for the DD program and made available to all consumers of the program’s services.”
      Action Taken: The program has a grievance process in place; the grievance policy is
provided to families in the respite packet.

Choice and Self Determination
The team identified the following strengths under Choice and Self Determination for people
receiving DD services from TCC:
+ The DD program maintains a strong focus on consumer choice: “Amanda has been my best
resource.”-- consumer
+ TCC provides families with a service that allows them to define respite according to their needs,
interests and individual respite needs: “I don’t know what I would have done without TCC. I was
lost, frustrated; they gave me guidance.”--consumer

The team identified the following weaknesses under Choice and Self Determination for people
receiving DD services from TCC:
- Staff should be prepared to consistently provide information and assist families in making
    referrals to other resources.
- There is a larger case load than one staff person can accommodate.

Dignity, Respect and Rights
The team identified the following strengths under Dignity, Respect and Rights for people receiving
DD services from TCC:
+ The respite program is community based: “This respite provider really knows what we are going
through.”--consumer
+ DD staff are very responsive to consumer needs.

The team identified the following weaknesses under Dignity, Respect and Rights for people
receiving DD services from TCC:
- Consumers said they would benefit from more visits in the villages from the DD staff person;
    respite providers also expressed a need for training and more on site visits from the staff.

Health, Safety and Security
The team did not have enough information to identify strengths under Health, Safety and Security
for people receiving DD services from TCC:




                                                 8
The team identified the following weaknesses under Health, Safety and Security for people
receiving DD services from TCC:
- The program lacks a training component for respite providers

Relationships
The team identified the following strengths under Relationships for people receiving DD services
from TCC:
+ Respite providers function as a natural extension of family life in the village.

The team identified the following weaknesses under Relationships for all people receiving DD
services from TCC:
- Staff turnover appears to have been a problem: “In my three and a half years receiving TCC
    services, there have been three different staff people.”--consumer

Community Participation
The team identified the following strengths under Community Participation for all people receiving
DD services from TCC:
+ The respite program is community based.

The team did not identify weaknesses under Community Participation for people receiving DD
services from TCC.


Consumer Satisfaction Chart
  DD                          Choice N=10      Dig&Res. N=10       Hth,Saf,Sec N=10    Relatns. N=10    Com.Par. N=10
 Outcome                      Yes    No        Yes       No        Yes    No           Yes   No         Yes      No
   Person/Parent/guardian      5     5           9       1          8      2            8     2             8    2
 Staff Performance
   Person/Parent/guardian      9     1          10                  8      2            9     1             10




Staff Interviews
With a caseload of 42 and 10 on waitlist, the single DD specialist needs additional staff, and has
requested a three-quarter position. Current staffing limits the ability of the specialist to travel since
that would leave the office without coverage. Additional staff would allow for production of a respite
booklet with training information about general disabilities to send respite providers and families.
Staff would like funding to link respite providers to basic CPR and First Aid training that are
periodically available.
TCC provides staff with an atmosphere of creative freedom, trust and support.

Collateral Agency Interviews
Agencies were very supportive of TCC services and Amanda. They request more training for
respite providers and more travel to the villages from the Fairbanks office.


                                                     9
Administrative/Personnel Narrative
TCC overall has strong administrative policies and procedures. In an organization of this size, input
of consumers in small programs may not be reflected in the agency’s overall processes, although
Amanda has surveyed all consumers, with a very high return of surveys. This is being used to
direct program-level decision-making. The program does not, however, meet Administrative and
Personnel Standards #6 (See Areas Requiring Response)


Program Management
In the past, frequent staff turnover has been a difficulty. The caseload is extraordinarily large for
the single staff person.

File Review
The DD files reviewed were well organized and fairly thorough. However, several files needed to
have case notes inserted or updated.




                                                   10
Early Intervention/Infant Learning Program Findings

Progress Since Previous Review:
Previous Recommendation: “Develop written orientation manual for families.”
      Action Taken: The new orientation sheet and parents rights have been in use since the
beginning of 1999.
Previous Recommendation:” Assure that all team members contribute information to evaluation
reports.”
      Action Taken: All suggestions are incorporated into the evaluation report.
Previous Recommendation: “Include criteria, procedures and timelines with each outcome
statement.”
      Action Taken: Training was received from State ILP. This is an area for continued
improvement.
Previous Recommendation: “Include statement of specific services needed in the IFSP.”
      Action Taken: All services are listed, whether available or not.
Previous Recommendation: “Expand MOAs with local service providers.”
      Action Taken: There are current MOAs with school districts and Head Starts; this needs to be
a continuing effort with expansion to additional local service providers.
Previous Recommendation: ”Emphasize family needs in the transition planning process.”
      Action Taken: ILP staff is actively advocating in this area.
Previous Recommendation: “Individualized timelines in written transition plans.”
      Action Taken: Transition plans are more detailed and families are involved.
Previous Recommendation: “Review and revise program policies to conform to ILP standards.”
      Action Taken: Policy Manual has been updated to meet standards.
Previous Recommendation: “Make salaries competitive with school districts.”
      Action Taken: This continues to need additional action.
Previous Recommendation: “Improve program planning and collaboration.”
      Action Taken: Program staff collaborate in more activities with other agencies.
Previous Recommendation: “Give families input in the planning process. Utilize information from
family in developing programs and priorities.”
      Action Taken: Parent survey results incorporated into program planning.
Previous Recommendation: “Assure family participation in hiring process.”
      Action Taken: This is ongoing.
Previous Recommendation: “Include more involvement of local supports to increase family visits.”
      Action Taken: MOAs are in place with local Head Starts and program is working closely with
Head Start programs.

Choice and Self Determination
The team identified the following strengths under Choice and Self Determination for people
receiving ILP services from TCC:
+ Most related service providers reported strong collaborative efforts: “Michelle is really good. If
there’s any questions, I can ask her.” “They are our eyes and ears.”
+ Parents are given options and choice of family service coordinator when possible.
The team identified the following weaknesses under Choice and Self Determination for people
receiving ILP services from TCC:
- Some families were not aware they could get respite services.


                                                  11
-   Some Public Health Nurses expressed the need for stronger communication about the types of
    services available in ILP.
-   Some Public Health Nurses reported that residents and service providers did not understand
    the Infant Learning services and program.

Dignity, Respect and Rights
The team identified the following strengths under Dignity, Respect and Rights for people receiving
ILP services from TCC:
+ Parents report high satisfaction with services received: “We were pleased with all the services
we’ve had so far.”
+ Parents feel the staff does a good job: “They were right on the ball.” “ILP staff have always
been great to work with.”
+ Staff are aware of the agency mission and are respectful of family and community cultural norms.

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

Health, Safety and Security
The team identified the following strengths under Health, Safety and Security for people receiving
ILP services from TCC:
+ ILP staff have developed a process for ChildFind utilizing the “Ages and Stages” questionnaire
that could be a model for rural communities in Alaska.

The team did not identify weaknesses under Health, Safety and Security for people receiving ILP
services from TCC.


Relationships

The team noted the following strengths under relationships for people receiving ILP services from
TCC:
+ The team found that the ILP staff assisted families in making connections with support
networking.
+ The staff fosters relationships between siblings and infants.

The team did not note specific weaknesses under Relationships for people receiving ILP services
from TCC.

Community Participation
The team noted the following strengths under community participation for people receiving ILP
services from TCC:
+ The ILP staff supports families to become active members of the community in culturally relevant
activities through use of assistive technology and other methods.
+ The ILP staff assist children to participate in their natural environment and activities in their
home and community.




                                                12
The team did not note specific weaknesses under Community Participation for people receiving ILP
services from TCC.


Consumer Satisfaction Chart
  ILP                          Choice N=9       Dig&Res. N=9        Hth,Saf,Sec N=9      Relatns. N=9         Com.Par.N=9
 Outcome                       Yes    No        Yes        No        Yes    No           Yes    No            Yes   No
   Person/Parent/guardian       6     3           7        2          6      3            6      3             6    3
 Staff Performance
   Person/Parent/guardian       9                 9                   7      2            7      2             8    1




Staff Interviews
ILP goals are several years old, and family involvement has been limited for changing the program
goals. Staff asked if funds could be made available to bring program participants to Fairbanks
annually to perform a group discussion about ILP goals and program changes.
Staff report that reliable evaluation and survey information are difficult to obtain.
Staff would like to facilitate participation of families in the process of hiring direct service providers.
(Administrative and Personnel Standard #22) Suggestions include: A supervisor could ask parents
for some questions they would like to have asked during an interview for a new staff member. A
supervisor could take a finalist for a position to one or more villages on several home visits as the
final step in the hiring process, thereby giving families real involvement in the decision.
Staff would like to see staffing levels adequate to provide on-going programming in the villages.
The belief was expressed that visits in intervals of five weeks or longer seriously underserve the
intent of ILP and the needs of children and families. The current system sets up family expectations
that ILP will have an appreciable impact on a child’s development, but the level of program activity
and funding are not sufficient to make those expectations realistic.
More than one staff person expressed anger about a job classification that occurred two years ago:
“I am not a Tech II; ever since that happened, I have been really angry.” “The agency doesn’t
acknowledge the professionalism of staff. I don’t know why.” The Program Director acknowledged
agency-wide concerns about job classifications, and said it is being worked on. An individual
grievance procedure does exist.

Collateral Agency Interviews
Related agencies expressed that they like the services from ILP, but they feel there is a need for
more frequent visits and a need to explain ILP services at community-wide meetings.
There was concern that three staff people are not enough to serve an area this large.


Administrative/Personnel Narrative
TCC overall has strong administrative policies and procedures. However, there is no mechanism
for membership of ILP consumers on the Board.


                                                      13
Program policies and procedures have been recently updated and are beginning to be
implemented.
It was reported that staff do not feel a good level of administrative support within the agency.
Examples cited included the job classification and lack of support to implement the new Childfind
process.
Present ILP staffing is insufficient to serve the caseload adequately or meet goals laid out in the
IFSPs. The two vacant ILP positions need to be filled as soon as possible by qualified staff.
Distances and the demands of travel impact the Fairbanks-based program staff negatively. A
suggestion was made that the program should look at hiring and supporting paraprofessional staff
to work out of each subregional center with appropriate support from professional staff.
The program does not fully meet Administrative and Personnel Standards #6, #20, #39, #41 (See
Areas Requiring Response).


Program Management
The classification of these staff positions as Tech II has been a source of real concern. While TCC
has procedures for individuals to file appeals to their job classifications, the ILP staff feel their
concern needs to be handled for the entire group rather than individually.


File Review
Review of ILP files indicates gaps in documentation, but conversations with consumers and related
service agencies shows general satisfaction with services and rapid follow-up on referrals. On-
going level of services is not documented well.
One file example: Part C eligible child
       Only one entry in contact log, blank direct service reports; only evidence of contacts is:
             Eval                    5/ 6/97
             IFSP                  10/28/97
             Language eval           2/27/98
             Exit form               4/23/99
           (Were there only 4 contacts in 2 years?)
Overall the case notes and home visit forms (Direct Service Forms) were very hard to follow
because dates were frequently incomplete (day or year missing) and very inconsistent. Four of the
files reviewed had very limited case notes of any sort.
       IFSP is a critical document. It is required for enrollment and drives the services. It is the legal
document showing services agreed to by the family and program. Only one of the six files reviewed
contained a current IFSP, and that one was not complete (missing was the summary of the child’s
development).
       Evaluation reports were in all files; parent consent forms were signed and in files for all six
cases reviewed. Four files had appropriate exchange of information forms signed by parents. The
files are generally organized in the same order. Completion of basic program documentation is a
major concern.




                                                   14
Areas Requiring Response
1. The agency’s governing body does not include the memberships of consumers or of the family
    members of consumers. (Administrative and Personnel Standard #6) Consider the creation of
    advisory boards or the restructuring of the governing board to allow for consumer and family
    member participation.
2. The agency’s collection and utilization of consumer and family opinion in the development of
    policies and the provision of services is not consistent through all programs. (Administrative
    and Personnel Standard #12) Broaden efforts to gather and use the opinions of consumers
    and their families in the development of policies and in the provision of services.
3. The agency does not uniformly and annually develop goals and objectives that are in response
    to consumers, community opinion and self evaluation. (Administrative and Personnel Standard
    #14) Regularize the gathering of opinions and evaluation and the application of this
    information in developing annual goals and objectives.
4. Regarding ILP: The agency does not maintain a system for the regular review and revision of
    job descriptions. (Administrative and Personnel Standard #20) Given the dissatisfaction
    expressed by the staff in regard to their classification, consider implementing a regular review
    and revision of job descriptions.
5. Regarding MH: The program does not have a procedure by which consumers can exercise
    choice in the hiring and evaluation of providers. (Administrative and Personnel Standard #22)
    Consider the adoption of policies to allow for a consumer voice in the hiring and evaluation of
    direct service providers.
6. The agency only partially complies in its efforts to foster consumer relationships with other
    community members in a social setting. (Administrative and Personnel Standard #26)
    Strengthen efforts to facilitate consumer relationships and community involvement.
7. Regarding ILP: Staffing levels are insufficient to properly serve the children and their families in
    need of these services. (Administrative and Personnel Standard #39) Implement staffing
    changes and/or program design in order to provide the services agreed to in the IFSP.
8. Regarding ILP: There is a need for a greater number of specialized staff to provide IFSP
    services. (Administrative and Personnel Standard #41) Seek additional staff and/or additional
    training for staff and/or MOA’s to meet this standard.
9. Regarding MH: Consumers are negatively impacted by long delays in receiving psychiatric
    services. Consider staffing or program changes that would alleviate this difficulty. Document
    these attempts.
10. Regarding MH: Consumers express the need for direct therapeutic services. Consider staffing
    or program changes that would allow for increased therapeutic services.
11. Regarding MH: Given respect for the rights of consumers and the ever present legal concerns,
    systematize the use of releases of information.
12. Regarding MH: Develop collaborative policies with related agencies especially for the complex
    and critical needs of consumers in the IDP, CSP and crisis intervention programs.
13. Regarding DD: The case load far outpaces the staffing in this program. This is reflected
    directly in the consumer requests for more frequent visits and for training for respite providers
    and indirectly in the stated need for additional information and referrals. Consider staffing or
    program changes that would alleviate this important difficulty and allow for consumer needs to


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      be met. These needed changes may alleviate the further concern regarding turnover of these
      key staff positions.
14.   Regarding DD: The quality of respite care is dependent on the training received by the
      providers. Consider ways in which to educate and supervise respite providers. In the light of
      health and safety issues, consider providing CPR and First Aid training to respite providers or
      link respite providers with community based health aides for support and guidance. Additional
      types of training for developmental disabilities are also necessary.
15.   Regarding DD: Case notes must be complete and current.
16.   Regarding ILP: Continue the improvement of outcome statements as per the last site review.
17.   Regarding ILP: Continue to expand the scope of MOA’s as per the last site review.
18.   Regarding ILP: Attempt to improve the salaries to a competitive level as per the last site
      review.
19.   Regarding ILP: Increase efforts to educate your communities in the services you offer, to
      whom, why and how.
20.   Regarding ILP: Facilitate the hiring needed to fill the two vacant positions appropriately and
      seek to increase staffing levels.
21.   Regarding ILP: Documentation does not meet standards. Case notes and home visit forms
      (Direct Service Forms) are very hard to follow because the dates were frequently incomplete
      and inconsistent. IFSP’s are not current nor are they complete. Seek technical assistance in
      this important area. Improved staffing or revised program design could allow for the essential
      time to put the training into practice.
22.   Regarding ILP: Improve communication with Public Health Nurses. Document your efforts.



Suggestions and Comments
Note: The team found that because of limited staffing in both the DD and ILP programs services are
provided at very minimal, basic levels. The programs deliver these basic services well but the consumer,
DD and ILP staff along with the review team realize the need for more services to consumers, more onsite
visits, training and related support services.

1.    The ILP staff has a real need to know that they are supported by their administrators. The
      needed support is both personal (valuing their vital work) and professional (aiding in the
      implementation of the new Childfind process).
2.    Distances and the demands of travel impact the Fairbanks-based program staff negatively. A
      suggestion was made that the program should look at hiring and supporting paraprofessional
      staff to work out of each subregional center with appropriate support from professional staff.
3.    The ILP staff wish to obtain reliable evaluation and survey information. Technical assistance
      from within the agency or elsewhere may be helpful.
4.    The ILP staff would like to facilitate participation of families in the process of hiring direct
      service providers. Suggestions include: A supervisor could ask parents for some questions
      they would like to have asked during an interview for a new staff member. A supervisor could
      take a finalist for a position to one or more villages on several home visits as the final step in
      the hiring process, thereby giving families real involvement in the decision.
5.    The ILP staff would like to see staffing levels adequate to provide on-going programming in the
      villages. The belief was expressed that visits in intervals of five weeks or longer seriously



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    underserve the intent of the ILP and the needs of children and families. The current system
    sets up family expectations that ILP will have an appreciable impact on a child’s development,
    but the level of program activity and funding are not sufficient to make those expectations
    realistic.


Closing Comments

The team expresses appreciation to the MH, ILP and DD staffs for their assistance in the review.
The TCC staff’s caring attitudes and dedication to clients and families are particularly notable.
You will receive the final draft of this report within 30 days with an overview of TCC’s compliance
with the Integrated Quality Assurance Standards. TCC, in collaboration with state ILP and DMHDD,
will develop plans for program responses to items identified in the review that need further action.




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