Summary
1. Introduction
2. Business description – special conditions
3. Implementation
4. What audit covered
5. Findings
6. Business management
7. Regulations
8. Document Stands
9. Participants at the audit
This report describes the discrepancy and remarks were pointed out in the audited areas. System audit covered the following areas:
- start-up phase – availability, handling of new inquiries and surveys of needs
- Implementation phase – from plans, individual plans, decisions and resolutions for specific services and initiatives.
- Follow-up phase – monitoring of recipients, reassessment of needs and any adjustments to services.
The audit was conducted in Orland municipality – Mental health is organized in Family Centre, Unit for Health and Welfare, and Rustjenesten organized in Nav. Both services are organized in health and welfare. The municipal services in NAV office is part of the service health and welfare in Orland municipality.
Orland municipality has planned a reorganization of 01/01/2016, which means that Rustjenesten will be moved from Nav to Family Centre. It is not made any analysis of any risks and / or vulnerabilities associated with the planned reorganization.
The audit was conducted with the system audit that method, 9 people were interviewed and 18 patient records were reviewed.
Orland municipality has not established a system to ensure that mental health and Rustjenesten cooperates for the performance of services to recipients with ROP disorders. The audit shows that it is not paved the way for a systematic and coordinated effort to ensure holistic services and to assess the extent of services for recipients with ROP disorders.
The municipality does not have an electronic quality and missing a comprehensive internal control system. The electronic deviation system appears not known, and there is no culture for reporting discrepancies.
During the audit it was revealed one (1) deviation.
Variance
Orland municipality does not ensure that people with concurrent substance abuse and mental disorders receive proper coordinated services.
Date: 8 December 2015
Ingrid Karin Hegvold
audit manager
Lars Wikdahl and Bente Hustad
auditor
The report was prepared by a system audit in Orland municipality in the period 23 June 2015 – 5th November 2015. The revision is part of the County’s planned oversight activities in the current year.
The county governor is given the authority to oversee the health and care services under the Act on Supervision of Health Care § 2.
The purpose of the system audit is to assess whether the business caters to different requirements in the legislation through its internal control.
A system audit carried out by examining documents, the interviews and other research.
The report deals deviations and remarks that have been uncovered during the audit and therefore provides no comprehensive condition assessment of the agency’s operations in the areas covered Authority.
- Variance is a lack of compliance with the requirements imposed by or pursuant to law or regulation
- Note are conditions that are not contrary to the requirements established by or pursuant to statute or regulation, but where the supervisory authority finds reason to point out the opportunity for improvement
Orland municipality has approximately 5200 inhabitants. The municipality is organized in a tonivåmodell – Chief (with municipal managers) and unit managers. Municipal managers have delegated fully chief administrative officer responsible in their fields, and are both in organizing and delegating part of alderman.
In Orland municipality’s services to people with substance abuse organized in Nav. Services for people with mental disorders are organized in Family Centre, which is organized under the Health and Welfare. It is planned a reorganization of 01/01/2016, which means that rustjenesten will be organized under the Family Centre of Health and Welfare. Mental health has three employees. All three have college education, two of which have continuing education in mental health. Rustjenesten currently has 5 authorized positions. There are both resource base, Rustjenesten and Ungdomslos. It is a job title that operates direct monitoring of drug abusers. The other driver prevention work, environmental work and projects. All the employees have college education. Both Mental Health and Rustjenesten have staffing in the daytime. The rest of the day receives patients possible offer of home care, as well as emergency contact on evenings, nights and weekends.
The municipality established in spring 2014 a coordinating unit. Adjacent to the coordinating unit is established a decision-making team that has an advisory role in the proceedings, and that it should be the authority in the municipality that processes applications for services that require decisions,. Health and care law and Public Administration.
The municipality has routines to make decisions for the services performed by Mental Health and Rustjenesten. Coordinating Unit (decision team) resolves services of Mental Health. Nav fatter per today’s decision concerning services to individuals with substance abuse. From the 1.1.2016 shall coordinating unit make decisions on all the services.
Orland municipality has a “Ruspolitisk strategic plan for municipalities Ørland and Bjugn 2011 to 2014″. There is a note, dated 05/15/2015, on rollover of the strategic plan. Orland municipality has an overall competence plan. The municipality participates in KS its national learning network – “good patient care in the municipalities for patients with mental illness and / or addictions.”
The municipality does not have an overall quality. There are binders with procedures, but this is not systematized in an internal control system. The municipality has quality system under consideration. Mental health uses Gerica as documentation system. Nav currently has its own documentation system “Welfare” but rustjenesten should also take Gerica from 01.01.2016. The municipality has used mapping system “User Plan”.
System audit covered the following activities:
Audit Warning: sent on 23 June 2015
Pre-assessments: It was held a joint preparatory meeting for four municipalities 11. September 2015.
Opening meeting: held on 4 November 2015
Interviews: 9 people were interviewed
It was not conducted inspections.
Final Meeting: held on 5 November 2015.
Overview of business documents has been submitted in connection with the audit and which were reviewed during the audit visit, is given in chapter Document Substrates.
The aim of the audit is to determine whether, and if so how, the municipality complies with regulatory requirements in different phases of service execution to the target group. Through the audit, we want to look into safeguarding the three phases:
- start-up phase – availability, handling of new inquiries and surveys of needs
- Implementation phase – from plans, individual plans, decisions and resolutions for specific services and initiatives.
- Follow-up phase – monitoring of recipients, reassessment of needs and any adjustments to services.
In all phases, cooperation between municipal entities and competence for personnel in the service examined.
It was revealed one (1) deviation. It was not given notices.
Deviation:
Orland municipality does not ensure that people with concurrent substance abuse and mental disorders receive proper coordinated services.
Deviations from the following statutory requirements:
Law on health services § 4-1, § 3-1, § 3-2 and § 5-10
Act on ways in administrative matters § 2, cf. . Chapters 4 and 5
Law on patient and user rights § 2-7
Regulations on Internal Control in Health Care
Regulations regarding patient.
The deviation based on the following:
- The audit shows that it is not paved the way for a systematic and coordinated effort to ensure holistic services and to assess the scope for recipients with ROP disorders.
– There are no system which ensures that the two departments consult each other for the performance of services to recipients with ROP disorders.
– There will be a survey of the recipient’s needs when applying for services, including the use of recommended mapping. The result of the survey indicated, however, not of the recipient’s journal.
– Mental health has weekly meetings with Fosen team, GPs and “Fast mental health care,” but rustjenesten in Nav has no procedures for how contact with GPs and Fosen team should previous.
– It is stated under interview that evaluation be made along the way, along with user, but the evaluation process is not systematized.
– There are no procedures or established practice, to terminate services.
– It is not clear that it considered the need for individual emergency plans. - Orland municipality uses both paper records and electronic journal (Gerica and Welfare). The audit was lodged records for 18 recipients that the staff believes has ROP disorders. Only for an service recipients were presented journal of both service areas.
- Journal The review of recipients by rustjenesten in Nav (Welfare) showed that the documentation does not meet the requirements laid journal Regulations:
– Commencement of service is not documented.
– Completed medical assessments and meetings are not documented in NAV its journal.
– The re are no status reports / evaluations of service recipient’s needs and effectiveness of services.
– There are long periods without any form of documentation in the journal.
– It is found in small degree mapping and IP. - Journal The review of recipients by mental health (Gerica) showed that:
– There are no procedures for closing journal access after services are completed.
– The re are no status reports / evaluations of service recipient’s needs and effect of services. - Orland municipality lacks a comprehensive internal control system:
– The units have binders with procedures in paper. It is not appointed responsible for maintenance procedures and procedures have not been audited and any. Continued.
– The municipality’s electronic system deviation appears not known and there is no culture for reporting any deviation. It is not clear what should be defined as a deviation.
– Procedures and exception handling is not part of the staff meetings.
– The municipality does not have procedures for utilizing deviations / incidents in their improvement efforts.
> – There is no systematic survey of user experiences.
All organizations that provide health care should ensure that health legislation met through systematic management and continuous improvement. The requirements for internal control shall ensure that daily tasks are planned, organized, conducted and improved in accordance with the requirements laid down in or pursuant to the health legislation.
Orland municipality has planned a reorganization of 01/01/2016. Rustjenesten, which are currently under Nav, will be organized under the Family Centre of Health and Welfare. It is not made any analysis of any risks and / or vulnerabilities associated with the planned reorganization.
Orland municipality lacks a comprehensive internal control system. There are binders with sometimes outdated procedures. Individual work is underway to develop procedures, but there is no system for approval and revision procedures. There are seldom established procedures for systematic and comprehensive effort to ensure adequate services.
The decision on services for the part of the provision of services which the audit covered. Fylkesmannen nevertheless utilizes this opportunity to emphasize that it must decision is made on health services provided within the home and that goes over one whose duration. Health care in the home (home care) is rooted in health and care Act § 3-2 no.6 letter a, including psychiatric nursing. Health & Rights Act § 2-7 stipulates that the decisions taken for such services “which is expected to last longer than two weeks.” This means that the decisions taken also for calls in the home, if they runs over a period of two weeks.
The municipality has not ensured that recordkeeping and information system in business is justifiable, ref. the requirement of health and care services law § 10.5 and § 16 of the Health Personnel, on the organization of facilities providing health services. Rustjenesten have limited access to the electronic records system from their place of employment and must migrate to Nav its premises in order to document the service recipient’s journal. The documentation is performed by Rustjenesten, does not satisfy the requirements laid journal Regulation.
For the part of the provision of services which the audit covered, there is no culture for reporting any deviation. The electronic system deviation is not known. Events documented in the patient record, but not in such a way that the management get an overview of the scope and content of the deviations. It is further not procedures for reviewing and closing nonconformities. Exception handling is not part of the staff meetings.
- Law on Supervision of health and care services
- Law on health services in the municipalities
- Law on patient and user rights
- Health Personnel Act
- Act relating to procedure in cases concerning public
- Regulations regarding patient
- Regulations on Internal Control in Health Care
- Regulation on quality of nursing and care services
- A regulation on habilitation and rehabilitation, individual plans and coordinator
The organization’s own documentation related to the daily operations and other matters of significance that were submitted during the preparation of the audit:
- Report from the User Plan 2015 psychiatry
- Report from the User Plan 2015 rus
- Ruspolitisk strategic plan for municipalities Orland and Bjugn2011-2014
- Note regarding rollover of ruspolitiske strategic 05.15.15
- Mandate leader coordinating unit / team decision and policy team in Orland municipality
- Procedures / checklist in conjunction with the new demands for services in health and welfare
- Delegation Regulations of councilman to municipal managers, revised 02/13/15
- Strategic development of Orland, proposed Municipal Plan 2014-2026 social element
- Interdisciplinary prevention team; mandate, role and tasks for Interdisciplinary prevention teams in Orland municipality
- Resource Team intoxication, mental health and prevention; mandate, role and tasks for Resource Team intoxication, mental health and prevention in Orland municipality
- Improvement Team, substance abuse and mental health – coordinated mapping
- Ungdomslos; mandate, role and tasks
- Guidelines, checklists and procedures:
-Revidert routine description rustjenesten and prevention efforts, including ROP
– Mapping Scheme
– Signals in adolescents (13-18)
– Signals in young Adults (18-23)
– Children relatives
– Checklist for inspection / evaluation in relation to children as dependents
– Procedure for assessment of coercion by law on municipal health and care services
– Assessment about Decision of tiltrå enforcement - Participation in KS learning network
Minutes of meetings:
– Invitation to work-shop dated 05/08/15
– Priorities for work-shop – meeting in improvement team dated 06/16/15
> – Minutes of the meeting of the Resource Team substance abuse and mental health dated 02/12/14
– Minutes of the meeting of the steering committee dated 08/18/15
– Minutes of the meeting of the reconstruction of drug abuse dated 08.24.15 - Organization Chart
Documentation were reviewed during the audit visit:
- 18 journals to recipients
Correspondence between the business and the County:
- Letter from the County of Sør-Trøndelag with notification of oversight, dated 06/23/2015
- Letter from Orland municipality received 02.09.2015, enclosed div. documentation
- Mail from the County in Oslo with final program for supervision days, dated 02.11.2015.
The table below provides a list of participants at the opening meeting and final meeting, and which people were interviewed.
| Name
| Function / position
| Opening meeting
| Interview
| End Meeting
|
|---|---|---|---|---|
| Sigrun Klausen
| Discipline leader; Rustjenesten NAV
| X
| X
| X
|
| Toril Røstad
| Discipline leader; Mental health
| X
| X
| X
|
| Rune Aune
| Ruskonsulent / ungdomslos; Rustjenesten NAV
| X
| X
| X
|
| Sissel Round Maute
| Nurse; Home Care
| X
| X
| X
|
| Hanne Berg Habrekke
| Occupational Therapist; Mental health
| X
| X
| X
|
| Heidi Sæther
| Nurse; Home Care
| X
| X
| X
|
| Atle Hestnes
| local medical officer
| X
| X
| X
|
| Karin Helen Størseth
| Head of Department; Family Center
| X
| X
| X
|
| Marit Knutshaug Ervik
| Kommunalsjef health and welfare
| X
| X
| X
|
| Solvor D. Brandvik
| Ruskonsulent / Ungdomslos; Rustjenesten NAV
| X
| ||
| Liv Marit Røstad
| Director NAV
| X
| X
|
From the County attended:
Senior Adviser Ingrid Karin Hegvold (audit manager)
Senior Adviser Lars Wikdahl
Adviser Bente Hustad
Adviser Trude Søreng (Observer
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