YELLOW SHEET
Office of the State Auditor of Missouri
Claire McCaskill
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YELLOW SHEET Office of the State Auditor of Missouri |
Report No. 2006-62
October 2006
The following findings were included in our audit report on the Department of Mental Health, Joplin Regional Center.
The Joplin Regional Center (JRC) has not taken adequate steps to ensure clients receive the best care possible. Unsatisfactory living conditions were observed during a April 4, 2006, visit to two individualized support living (ISL) homes. We found it quite disturbing that service coordinators' case notes from visits to the homes on March 16, 2006, contained no mention of these concerns. The Auditor's Office notified the JRC of our concerns in a letter dated April 7, 2006. The JRC subsequently took steps to move the three clients from the homes. We also noted that in February 2004, a service coordinator identified poor living conditions in a client's natural home and requested immediate funding for home repairs. The JRC received funding to repair the home in April 2004; however, the work was not completed until October 2004.
Our visits to three placement facilities noted numerous problems related to the facilities' management of client funds including: balances exceeding maximum limits, inadequate documentation to support some disbursements, client ledgers not reconciled to checking account balances, untimely deposits, inadequate tracking of client activity, and accounts with negative balances.
The JRC spent over $19 million in fiscal year 2005 to care for its clients. The regional center could better manage costs by monitoring service providers' actual and past costs of operation and by reviewing rates for consistency. Regional center personnel do not periodically review documentation to support the amounts billed by approximately 72 service providers or vendors for client services, and contracts with various day habilitation service providers were unclear. We noted providers used vague descriptions for service provided and were unable to provide adequate documentation to support some amounts billed. Additionally, the JRC has not established adequate procedures to ensure client budgets prepared by service coordinators are accurate.
The JRC provided funding in excess of the maximum allowed by the community support waiver and did not obtain approval from the Division of Mental Retardation and Developmental Disabilities (MRDD) Director for the additional funding. For example,
day habilitation services costing $29,617 were provided to one client between February 2005 and December 2005, and approval for the additional funding was not obtained. These services are limited to $20,000 based on Department of Mental Health (DMH) guidelines. We also noted two other instances where excess funding was provided and approval was not obtained.
The regional center does not adequately control, review, monitor, and procure day habilitation services provided exclusively by one provider to regional center clients with autism. This provider was paid over $1 million during the two years ended June 30, 2005, for services provided to the Southwest Project, which includes the Joplin and Springfield regional centers. On a statewide basis, the DMH paid this vendor over $4.3 million during the two years ended June 30, 2005. This provider is given complete autonomy to determine which regional center clients receive services and the type and amount of services provided. The quality management team does not perform any type of quality assurance review of this provider, and the regional center does not review services provided. Neither the regional center nor DMH personnel monitor the number of hours provided statewide or in each region or the costs of those services. Further, an annual services report prepared by the provider indicated 45 percent of services were provided to clients over the telephone. When questioned by our office, the provider lowered this to 23 percent. The JRC has had a contract with this same provider since 1994.
The JRC has not taken adequate steps to ensure Medicaid reimbursements from Targeted Case Management (TCM) services are maximized. The DMH has established a standard that provides that service coordinators are to log 106 direct service hours to the TCM system monthly, or 1,272 hours each year. However, we found 14 service coordinators in 2005 and 19 service coordinators in 2004 did not meet the 106 direct hour standard when we compared the total direct hours logged by service coordinators, and this resulted in the JRC losing an estimated $200,000 in potential reimbursements. Additionally, TCM billings are not adequately reviewed to ensure Medicaid billings include the correct number of units and are supported by adequate documentation in the case notes.
The JRC expended more than $107,600 from its specific appropriations for operating costs of the Bellefontaine Habilitation Center. In addition, the regional center purchased postage and requested Choices for Families funding in advance of the need to use state appropriations that would have otherwise lapsed at year-end. Further, the JRC contracted with two former DMH employees to provide services without any consideration of other individuals or firms, and payments made to these individuals were not supported by adequate documentation.
The audit also includes comments related to background check procedures, Senate Bill 40 boards, management of donations, non-appropriated funds system procedures, Choices for Families, payroll policies and procedures, and the employee relations committee. The center should consider and take appropriate corrective action to implement the recommendations in these and all other areas discussed in the report.