YELLOW SHEET Office of the State Auditor of Missouri Claire McCaskill

Report No. 2004-100

December 30, 2004

The following problems were discovered as a result of an audit conducted by our office of the Department of Mental Health, Kansas City Regional Center.

Kansas City Regional Center (KCRC) service coordinators provide Targeted Case Management (TCM) services to numerous clients.  These clients must be eligible for the state's Medicaid program and must also meet the eligibility requirements from the Division of Mental Retardation and Developmental Disabilities (MRDD).  Each time a service coordinator provides TCM services, they are required to log the duration and description of the services into the computer system.  The number of TCM hours is converted to units and billed to the Medicaid program each month.  Medicaid currently reimburses Department of Mental Health (DMH)$6.46 for every unit (five minutes) spent on TCM services.  During the year ended June 30, 2003, the Regional Center received approximately $2.9 million in reimbursements from the state's Medicaid program for TCM services.

The Regional Center has not taken adequate steps to maximize Medicaid reimbursements from the TCM program.  Medicaid billings are done by service coordinators, who are required by department operating regulations to log an average of 106 direct hours to the system monthly, or 1,272 hours each year.  KCRC has not developed adequate procedures to ensure each service coordinator is fulfilling the hourly logging requirement.  Potential reimbursements totaling over $430,000 were lost during calendar year 2003 due to numerous service coordinators' failure to log 1,272 hours of direct services.  Oversight and follow-up by KCRC management for the lack of direct hours were inadequate.  Auditors found that 53 percent of service coordinators did not meet the monthly standard in 2003. 

TCM billings are not adequately reviewed and approved by service coordinators' supervisors to ensure Medicaid billings include the correct number of units and are supported by adequate documentation in the case notes.  Additionally, no one from KCRC reviews monthly billings before submission to Medicaid.

Incident and injury reports which involve a vendor employee are required to be reported to the Incident and Injury Tracking System (IITS) and investigated. Our office reviewed 10 incident and injury reports which were not entered into the IITS and noted none of the reports contained any evidence of follow-up or action taken by the service coordinator or quality assurance personnel.  Nine of the ten files contained documents that were not signed by both the service coordinator and quality assurance personnel indicating their review of the incident.  Additionally, one of the reports we reviewed appeared to meet the abuse and neglect criteria requiring entry into the IITS.

Incident and injury reports meeting the abuse and neglect criteria are assigned to an investigator, who is required to complete an investigative report to be submitted to the Regional Center Director within 30 working days of the complaint filing.  Our review noted that abuse and neglect reports are not always filed with KCRC and recorded in the DMH database timely.  Additionally, investigative reports are not always completed within 30 working days of the filing of the complaint and the decision to substantiate the charge of abuse or neglect is not always decided upon within 10 working days after receiving the final investigative report, as required.

The KCRC contracts with approximately 178 Community Placement facilities.  Through the Community Placement (CP) Program, the facility purchases residential care in community-based facilities for clients who would otherwise require institutionalization.  KCRC does not have adequate oversight and supervision of placement facilities.  Some facilities visited did not reconcile the client ledgers to the checking account balance, or did not maintain documentation of such reconciliations, or did not maintain supporting documentation for numerous purchases made from client funds.   Additionally, one facility maintained a duplicate set of accounting records which did not contain consistent information and had two different balances recorded for the same date.  By maintaining a duplicate set of accounting record which are not consistent or accurate, the risk for manipulation, falsification, or alteration of records or supporting documents is increased. 

The Choices for Families (CFF) program provides financial assistance to eligible families so they can better meet the special needs of any developmentally disabled individuals which reside within their home.  The purpose of the program is to prevent or delay out-of-home placement of clients and to empower family members as the primary decision makers for obtaining the goods and services needed by the individual.  Each client qualifying for the program is limited to $3,600 in eligible expenditures each year. 

Our audit noted KCRC does not always follow the CFF policies developed by the department.  The Regional Center has implemented an unwritten maximum of $500 for respite care, although the department policy does not limit the amount that can be spent on respite care, other than the $3,600 maximum in eligible expenditures each year.  To ensure fair and consistent treatment among MRDD clients throughout the state, KCRC should follow the department policy for CFF or request a change to the policy that would apply to all clients throughout the state.  Also, Individual Habilitation Plans (IHP) are not always developed within 30 days after the client is eligible for services, as required by policy, and several families' IHPs included CFF funding in excess of the maximum amount allowed. Additionally, the number of days of respite care used by families in the CFF program was exceeded without documenting a good cause and without the approval of the Division Director.

The audit report also notes some other concerns related to capital asset procedures, vehicle logs, and non-appropriated funds system. 

Complete Audit Report