Performance audit, Department of Economic Security, Division of Developmental Disabilities

              PERFORMANCE AUDIT

Report to the Arizona Legislature

By the Auditor General

DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities

DOUGLAS R. NORTON, CPA

AUDITOR GENERAL

STATE OF ARIZONA

OFFICE OF THE

AUDITOR GENERAL

DEBRA K. DAVENPORT, CPA

DEPUTY AUDITOR CFNERPL

March 30, 1993

Members of the Arizona Legislature

The Honorable Fife Symington, Governor

Mr. Charles E. Cowan, Director

Department of Economic Security

Transmitted herewith is a report of the Auditor General, A Performance

Audit of the Department of Economic Security, Division of Developmental

Disabilities. This report is in response to a December 13, 1991,

resolution of the Joint Legislative Oversight Committee.

This is the second in a series of reports to be issued on the Department

of Economic Security. We found the Division of Developmental

Disabilities has made significant improvements in its fiscal and program

management. Our report offers additional recommendations to strengthen

client assessment, case management, facility licensing, contract

management, and protection of clients.

My staff and I will be pleased to discuss or clarify items in the report.

This report will be released to the public on March 31, 1993.

Sincerely,

~ o u w sR. Norton

Auditor General

2700 NORTH CENTRAL AVENUE - SUITE 700 1 PHOENIX, ARIZONA 85004 l ( 6 0 2 ) 255- 4385 1 FAX ( 6 0 2 ) 255- 1251

SUMMARY

The Office of the Auditor General has conducted a performance audit of

the Arizona Department of Economic Security, Division of Developmental

Disabi l ities pursuant to a December 13, 1991 resolution of the Joint

Legislative Oversight Committee. This performance audit, the second in a

series on the Department of Economic Security ( DES), was conducted as

part of the Sunset Review set forth in Arizona Revised Statutes ( A. R. S.)

0941- 2951 through 41- 2957.

The Division of Developmental Disabi l it ies ( DDD) provides services and

programs to individuals with developmental disabilities and to their

families. Individuals with severe, chronic disabilities caused by mental

retardat ion, cerebral palsy, epi lepsy, or autism may qua1 i fy for Division

services. Approximately 11,400 clients are currently participating in

the Division's service system. To the extent possible, services are

provided at home or in community- based settings rather than in

institutions. Both State and Federal monies ( received through the Title

XIX- funded Arizona Long- Term Care System) support Division programs.

1

lrn~ lernent Its Policies

For Assessina And Plannina Individual

Client Services ( See pages 9 through 15)

Consultants hired to assist us in evaluating the Division's services

concluded that the assessment and service planning process was not

functioning properly. Due in large part to poor case management, the

Division has not conducted al l necessary assessments for some

individuals, a process vitally important for both understanding clients'

abilities and meeting their individual needs. In 18 of the 30 case files

reviewed by the consultants, additional assessments were needed but had

not been conducted. For example, a young man living at home had

difficulty communicating, and was experiencing medical problems,

including seizures. Despite these problems and the challenges his

behavior presented to his family, case records indicated he had not

received a neurological examination, nor had his communication,

psychological, vocational, or educational needs been assessed.

The Division's Case Manaaement

Svstem Cannot Effectively

Service Clients

( See pages 17 through 25)

Although good case management is crucial to the success of i t s service

system, the Division's case management system is overburdened and unable

to perform effectively. Both clients and case managers expressed

significant dissatisfaction with the current system. Families reported

that case managers are often inexperienced, poorly trained, d i f f i c u l t to

contact, and have l i t t l e knowledge of clients. Case managers we surveyed

complained that because of excessive demands and high case loads, they

are often unable to effectively service their clients. Some case

managers told us they see clients as infrequently as once a year.

Due in part to Federal funding requirements, case managers are buried in

paperwork. We identified over 100 forms and reports that case managers

at any given time are responsible for. These paperwork requirements can

be streamlined to allow case managers more time with clients.

In addition, case manager case loads should be reduced. Case managers

average 47 cases each, with some having case loads of 70 clients or

more. However, experts in the f i e l d and practices in other states

suggest that case loads should average about 30 cases per worker. High

case loads make i t d i f f i c u l t for case managers to adequately f u l f i l l a l l

assigned responsibilities, and also contribute to high turnover, which

further weakens the Division's case management system.

The Division Can lm~ rove

Its Svstem For lnvestiaatinq

Client Abuse And Nealect

( See pages 27 through 33)

The Division's system for investigating allegations of client abuse and

neglect can be strengthened. The Division's clients are particularly

vulnerable due to their d i s a b i l i t i e s and must rely on the Division's

incident reporting system for protection. However, this system exhibits

several weaknesses. Some incidents that warrant investigation are not

reported or are reported too late. Reported incidents are not always

investigated adequately or by the appropriate authorities. Final ly,

response to some incidents has not been adequate.

The Division is taking several steps to improve i t s reporting and

investigations system. For example, a new policy with investigation

guidelines has been developed, and a new computer tracking system is

being piloted. The Division should also consider strengthening Central

Office oversight over incidents of a more serious nature, reassigning the

s t a f f t o the oversight function, and improving staff training.

Licensina Inspections Need

To Be More Timelv And

Enforcement Should Be St ren~ thened

( See pages 35 through 42)

Severaj operational deficiencies within the Division's licensing function

need to be addressed. The Division is routinely late in conducting both

i n i t i a l inspections and i t s relicensing inspections. In addition,

six- month monitoring v i s i t s have not been timely, and fol low- up actions

in response to violations have been inadequate. As a result, licensing

inspections have identified numerous repeat violations at some

f a c i l i t i e s . For example, six inspections since 1986 at one group home

found numerous health and safety hazards, many of which were repeat

violations from previous inspections. Three inspections found that toxic

substances were not properly locked up.

The Division Needs To Continue And Extend

Efforts To Strenathen Its

Contract ina Process

( See pages 43 through 50)

The Division should continue efforts to improve i t s contracting process.

Since most of the Division's services are contracted out to private

providers, a sound procurement process i s v i t a l . The Division has

strengthened the Central Office's role in negotiating and overseeing

contracts; however, we found that more oversight over d i s t r i c t

procurement practices is needed. A limited review of contract f i l e s

disclosed several weaknesses, such as limited review of provider

financial information and questionable evaluations of provider proposals.

Inadequate review of provider financial information and insufficient

auditing have been particularly costly to the Division and i t s clients.

A recent set of nine financial reviews ordered by the Division's

assistant director identified over $ 2.1 million in questionable or

excessive costs that had not been previously identified. For example,

auditors found several instances in which compensation paid to executive

staff was excessive. The president of one provider agency received over

$ 417,000 in bonuses between June 1990 and June 1991.

TABLE OF CONTENTS

INTRODUCTION AND BACKGROUND. . . . . . . . . . . . . . . . . . .

FINDING I: THE DIVISION NEEDS TO

YORE ADEQUATELY IUPLEUENT ITS

POLICIES FOR ASSESSING AND PLANNING

INDIVIDUAL CLIENT SERVICES . . . . . . . . . . . . . . . . .

The Service Planning Process . . . . . . . . . . . . . . . .

A l l Necessary Assessments

AreNot BeingDone. . . . . . . . . . . . . . . . . . . . .

Procedures For Conducting Planning

Meetings AreNot Always Followed . . . . . . . . . . . . . .

Breakdowns Occur Within

The Case Management System . . . . . . . . . . . . . . . . .

Recommendations. . . . . . . . . . . . . . . . . . . . . . .

FINDING I I : M E DIVISION'S CASE MANAGEMENT

SYSTEM CANNOT EFFECT I VELY

SERVICE CLIENTS. . . . . . . . . . . . . . . . . . . . . . .

Case Management Is Essential,

But Inadequate A t DDD. . . . . . . . . . . . . . . . . . . .

Various Factors Hamper DDD's

A b i l i t y To Provide Good

CaseManagement. . . . . . . . . . . . . . . . . . . . . . .

Changes Are Needed . . . . . . . . . . . . . . . . . . . . .

Recommendations. . . . . . . . . . . . . . . . . . . . . . .

FINDING I l l : THE DIVISION CAN

IMPROVE ITS SYSTEM K) R

INVESTIGATING CLIENT ABUSE AND NEGLECT . . . . . . . . . . .

Reports, Investigation Required For

Protection Of Vulnerable Clients . . . . . . . . . . . . . .

The Division Has Not Adequately

Resolved Some Incidents. . . . . . . . . . . . . . . . . . .

Several Factors Contribute

ToFailures . . . . . . . . . . . . . . . . . . . . . . . . .

Division Is Trying To Improve

But NeedsToDoMore. . . . . . . . . . . . . . . . . . . .

Recommendations. . . . . . . . . . . . . . . . . . . . . . .

Page

1

TABLE OF CONTENTS ( Con ' t )

Page

FINDING IV: LICENSING INSPECTIONS NEED TO

BE YORE TlYELY AND ENFWEENT SHOUU) BE

STRENGTHENED . . . . . . . . . . . . . . . . . . . . . . . . 35

The Division's Licensing Process Has

Been Inconsistent and Inefficient. . . . . . . . . . . . . . 36

Licensing Process Could Be Streamlined

And Administered More Consistently . . . . . . . . . . . . . 39

Recommendation . . . . . . . . . . . . . . . . . . . . . . . 42

FINDING V: THE DIVISION NEEDS TO CONTIWE AND EXTEND

EFMTS TO STRENGTHEN ITS CONTRACTING PROCESS. . . . . . . . 43

Most Division Services

AreContractedOut . . . . . . . . . . . . . . . . . . . . . 43

Central Office Role

HasBeenLimited . . . . . . . . . . . . . . . . . . . . . . 44

Weak Financial Review And

Oversight Has Been Costly. . . . . . . . . . . . . . . . . . 46

The Division Needs To Continue I t s Efforts

To Strengthen The Contracting Process. . . . . . . . . . . . 48

Recommendations. . . . . . . . . . . . . . . . . . . . . . . 50

OTHER PERTINENT INFOIWATION. . . . . . . . . . . . . . . . . . . 51

TABLES

TABLE 1 Department Of Economic Security

Long- Te rm Care System Budget ( ALTCS)

Statement Of FTEs And Actual And Budgeted Expenditures

Fiscal Years 1990- 91, 1991- 92, And 1992- 93

( unaudited) . . . . . . . . . . . . . . . . . . . . . . 4

TABLE 2 Department Of Economic Security

Developmental Disabi l i t ies Budget ( State Funded Only)

Statement Of FTEs And Actual And Budgeted Expenditures

Fiscal Years 1990- 91, 1991- 92, And 1992- 93

( unaudi ted) . . . . . . . . . . . . . . . . . . . . . . 5

TABLE 3 Sufficiency Ratings Of Currently Delivered Services

Reported By Clients, Families, Service Providers

And Case Managers

( For Services Rated Least Sufficient) . . . . . . . . . 52

INTRODUCTION AND BACKGROUND

The Office of the Auditor General has conducted a performance audit of

the Arizona Department of Economic Security, Division of Developmental

D i s a b i l i t i e s , pursuant to a December 13, 1991 resolution of the Joint

Legislative Oversight Committee. This performance audit, the second in a

series on the Department of Economic Security, was conducted as part of

the Sunset Review set forth in Arizona Revised Statutes ( A. R. S.)

§ § 41- 2951 through 41- 2957.

Backqround

The Division o f Developmental D i s a b i l i t i e s i s one of nine divisions

within DES. The Division's purpose is to provide services and programs

to individuals with developmental d i s a b i l i t i e s and to t h e i r families.

Approximately 11,400 persons with developmental d i s a b i l i t i e s are

currently receiving services through the Division. As defined in statute

( A. R. S. $ 36- 5511, developmental d i s a b i l i t y means either

... a strongly demonstrated potential that a chi Id under the age

of six years is developmentally disabled or w i l l become

developmentally disabled as determined by a test performed

pursuant to A. R. S. $ 36- 694 or by other appropriate tests, or a

severe chronic d i s a b i l i t y which: ( a) i s a t t r i b u t a b l e to mental

retardation, cerebral palsy, epilepsy, or autism, ( b) i s

manifest before age eighteen, ( c) is l i k e l y t o continue

i n d e f i n i t e l y , ( d l results in substantial functional I imitation

in three or more of the following areas of major l i f e a c t i v i t y

( self- care, learning, mobility, receptive/ expressive language,

self- direction, economic self- sufficiency, or capacity for

independent l i v i n g ) , ( e l reflects the need for a combination and

sequence o f i n d i v i d u a l l y planned or coordinated special,

interdisciplinary or generic care, treatment, or other services

which are of l i f e l o n g or extended duration.

Division philosophy focuses on providing services to meet an i n d i v i d u a l ' s

needs at home or in other community- based settings rather than in

i n s t i t u t i o n s . To accomplish i t s mission, the Division d i r e c t l y provides,

and also contracts with, individuals and agencies. Services are provided

to e l i g i b l e individuals based on the person's needs, State and Federal

guidelines, and available funding. Examples of services provided include:

Case management

Residential room and board

Foster care for children

Early intervention f o r children

Recreation/ socialization programs

Vocational- related assistance

Non- emergency transportation

H a b i l i t a t i o n

Acute care

Personal care

Respite care

Day care

Homemaker

Home health aide

Therapies

Physician visits/ nursing

The State's a b i l i t y to provide services for persons with developmental

d i s a b i l i t i e s was greatly expanded with the implementation of the Federal

Medicaid ( T i t l e XIX) program in Arizona. Until 1989, essentially a l l

services provided to individuals by DDD were funded solely with State

appropriations. In late 1988, DDD entered into an agreement with the

Arizona Health Care Cost Containment System ( AHCCCS) to provide both

acute and long- term care to persons with developmental d i s a b i l i t i e s . For

t h i s to occur, AHCCCS negotiated with the Federal Health Care Financing

Administration ( HCFA) for a five- year demonstration ( research) project to

allow the State to provide long- term care, medical services, and case

management to AHCCCS- eligible developmentally disabled persons. The

program i s referred to as the Arizona Long- Term Care System ( ALTCS) and

is funded by Federal Medicaid monies and matching State appropriations.

Individuals who are e l i g i b l e for services through the Division may also

be e l i g i b l e for services through ALTCS i f they are determined to be at

r i s k of i n s t i t u t i o n a l i z a t i o n . ALTCS provides both acute medical services

and medically necessary home- and community- based services. As a result

of new Federal funding, approximately 6,000 more persons are receiving

some services.

Oraanization And Staffinq

Headed by an assistant director, the Division is composed of six regional

d i s t r i c t s , approximately 46 local offices, and a Central Office located

in Phoenix. Services are coordinated through, and in some areas d i r e c t l y

provided by, DDD s t a f f located in the d i s t r i c t s ( e. g., State- operated

group homes). Each d i s t r i c t has a d i s t r i c t program manager, area program

managers, case managers, and various other program and operations s t a f f .

The Central Office provides for administration, business operations,

program functions ( di rects the T i t l e XIX Long Term- Care and State- funded

programs and manages comp l i ance w i th Federal fund i ng and program

requirements), and managed care operations ( directs the administration of

a l l medical and long- term care services with an emphasis on cost

containment). In total, the Division has an authorized ful I- time

employee staffing level of 1,468 for Fiscal Year 1992- 93 ( see Tables 1

and 2, pages 4 and 5).

Funding

Funding is provided primarily through State appropriations and T i t l e XIX

of the Social Security Act ( Medicaid). With the implementation of the

ALTCS program, the Federal government funds approximately 62 percent of

the expenses for persons qualifying for that program, with the State

paying the balance. As a result of this new program, developmental

d i s a b i l i t y resources were s p l i t into two program budgets. Clients

e l i g i b l e for Federal assistance are primarily funded from the Long- Term

Care System budget program ( see Table 1, page 4). All other clients

receiving assistance are funded through the 100 percent " State- funded"

program, referred to as Developmental Disabilities program budget ( see

Table 2, page 5). For Fiscal Year 1992- 93, DDDts total budget is over

$ 184 million.

TABLE 1

DEPARTMENT OF ECONOMIC SECURITY

LONG- TERM CARE SYSTEM BUDGET ( ALTCS)

STATEMENT OF FTEs AND ACTUAL AND BUDGETED EXPENDITURES

FISCAL YEARS 1990- 91, 1991- 92, AND 1992- 93

( unaudited)

FTE Positions

EXPENDITURES

Operating:

Personal Services

Employee Related

A l l Other Operating

OPERATING SUBTOTAL

Special Line Items:

Acute Care

Fee for Service

Foster Care

Purchase of Care

Stipends 81 Allowances

SPECIAL LINE ITEM

SUBTOTAL

1990- 91 1991- 92 1992- 93

( Actual 1 ( Actual 1 ( A~~ roved)

( a) O f these t o t a l expenditures, amounts funded by T i t l e X I X ( and t o a s i g n i f i c a n t l y

lesser e x t e n t , o t h e r funding sources) and State appropriations t o t a l e d the f o l l o w i n g :

FY 1990- 91 FY 1991- 92 FY 1992- 93

( Actual ) ( Actual) ( Approved)

State Appropriations $ 45,954,900 $ 57,025,900 $ 56,186,900

T i t l e X I X & Other 69,223,600 78,767,300 86,293,400

$ 115,178,500 $ 135,793.200 $ 142,480.300

Source: Department of Economic Security, Office of Budget, Financial

Management and Control System Reports for Fiscal Years 1990- 91

and 1991- 92 and the State of Arizona, Appropriations Report

for Fiscal Year 1992- 93.

TABLE 2

DEPARTMENT OF ECONOMIC SECURITY

DEVELOPMENTAL DISABILITIES BUDGET ( STATE FUNDED ONLY)

STATEMENT OF FTEs AND ACTUAL AND BUDGETED EXPENDITURES

FISCAL YEARS 1990- 91, 1991- 92, AND 1992- 93

( unaudited)

1990- 91 1991- 92 1992- 93

( Actual ( Actual ) ( Ap~ roved)

FTE Positions 702 545 489

EXPENDITURES

Operating:

Personal Services $ 14,237,100 $ 11,650,600 $ 10,600,700

Employee Related 3,713,900 3,259,600 2,923,600

A l l Other Operating 3,397,200 2,535,200 2.115.800

OPERATING SUBTOTAL 21,348,200 17.445.400 15,640.100

Special Line Item:

ASH Community Placement

Assistance to Families

Foster Care

Housekeeping Payments

Out- of- District

P l acemen t

Purchase of Care

Stipends and Allowances

Voc Rehab Contracts

SPECIAL LINE ITEM

SUBTOTAL

TOTAL

Source: Department of Economic Security, Office of Budget, Financial

Management and Control System Reports f o r Fiscal Years 1990- 91

and 1991- 92 and the State of Arizona, Appropriations Report

for Fiscal Year 1992- 93.

Audit Scope

I n l a t e 1991 when t h i s audit was authorized and i n i t i a t e d , there were

numerous l e g i s l a t i v e concerns about the Division's operations. However,

during our audit, a new assistant director was appointed who has

aggressively pursued changes in both fiscal and programmatic areas.

Throughout t h i s report, our findings and recommendations acknowledge and

bu i l d upon the many changes that have been spearheaded by the ass i s tan t

di rector.

Our report presents findings and recommendations in f i v e areas:

The extent to which individual needs are being adequately assessed

and services properly planned

The need for changes in the Division's case management system to

better enable case managers to provide effective case management to

c l ients

The adequacy of the Division's system of investigating c l i e n t abuse

and neglect

The efficiency and effectiveness of the Division's licensing process

The need for DDD to continue and expand i t s e f f o r t s at improving i t s

contracting process

To help us determine how well DDD has assisted persons with developmental

d i s a b i l i t i e s , we contracted with the consulting firm of Conroy &

Feinstein Associates ( CFA) of Wynnewood, Pennsylvania, noted experts in

the f i e l d of developmental d i s a b i l i t i e s . We asked them to assess the

Division's performance in three main areas: ( 1) determination of

e l i g i b i l i t y for services and assessment of individual needs, ( 2) e f f o r t s

at planning appropriate services for meeting i d e n t i f i e d needs, and ( 3)

a b i l i t y to secure adequate and quality services. The consultant's

research consisted mainly of completing in- person surveys with c l i e n t s

and their fami lies/ caregivers, and phone interviews with case managers

for 219 randomly selected persons; conducting 30 detailed case f i l e

reviews; c l i n i c a l l y analyzing 10 cases; holding focus group meetings with

Division administrators and case managers, family members, and services

providers; and reviewing and evaluating DDD policies and procedures. Due

to funding limitations, only ALTCS- eligible consumers were studied; those

e l i g i b l e for State- funded services only were not.

Finding I summarizes their concIusions regarding the Division's

performance in assessing needs and planning services f o r individuals. A

summary of the consultant's conclusions regarding the overall q u a l i t y and

a v a i l a b i l i t y of services can be found on page 51.

The audit was conducted in accordance with government auditing standards.

The Auditor General and s t a f f express appreciation to the Director and

s t a f f of the Arizona Department of Economic Security, and the Assistant

Director and s t a f f of the Division of Developmental D i s a b i l i t i e s for

their cooperation and assistance during the audit.

FINDING I

THE DIVISION NEEDS TO MORE ADEQUATELY

IMPLEMENT ITS POLICIES FOR ASSESSING AND PLANNING

INDIVIDUAL CLIENT SERVICES

The Division is not consistently following established procedures in

assessing needs and planning individual c l i e n t services. Our consultants

found that appropriate c l i e n t assessments are not always completed prior

to the development of written service plans required for a l l c l i e n t s . I n

addition, planning meetings are not always appropriately conducted and

monitoring and adjustment of plans i s sometimes lacking. While Division

policies and procedures for assessing c l i e n t needs and developing plans

were found to be state of the a r t by our consultants, they are not being

consistently followed by Division case managers.

The Service Planninq Process

A l l services provided to Division c l i e n t s are developed and authorized

through a formal planning process. This process begins a f t e r c l i e n t s are

determined e l i g i b l e for Division services. F i r s t , c l i e n t needs are

assessed by case managers and, as appropriate, by outside professional

specialists. After assessments are completed, an interdisciplinary team

meets, often with c l i e n t s and family members p a r t i c i p a t i n g , to formally

plan c l i e n t goals and services. Additional assessments may be requested

by the team. A written Individual Program Plan ( IPP) i s prepared

following these meetings. Plans are updated annually, or more frequently

i f necessary. For example, a formal review of service plans for most

T i t l e XIX clients must take place every 90 days. These reviews can

result in changes or modifications to the c l i e n t ' s IPP.

All Necessarv Assessments

Are Not Beina Done

Our consultants found that a l l assessments that should be completed on

some clients are not being done prior to the IPP meetings. General

assessments of c l i e n t functioning that are routinely done for a l l c l i e n t s

are not always completed by the time the team meets, and some special

assessments needed are not being done at al I . As a resu l t , many of the

services and goals established at the IPP meetings are not based on

formal, documented assessments of client needs.

Tvpes of assessmentg - The first critical step in assisting a person with

developmental disabilities in obtaining needed services and supports

involves the assessment of the person's abilities and disabilities, and

strengths and weaknesses. Assessment results are crucial to developing

appropriate plans to assist individuals in achieving more independence

and a better quality of life. Two primary categories of assessments are

typically administered:

General functional ability - The Division uses an assessment package,

the Inventory for Client and Agency Planning ( ICAP) to evaluate the

client's overall functional level. The ICAP is generally completed

on an annual basis by the Division's case managers with the

assistance of individuals who know the client well. ICAP results

provide a basic overview of functional abilities in such areas as

eating, dressing, and grooming. Results also help identify levels of

supervision the cl ient may require, chal lenging behaviors ( such as

agg ress i veness ) , and the need for add i t i ona l assessments , se rv i ces ,

and supports. According to our consultants, the Division's ICAP is a

valid and appropriate package for use in assessing general functional

abilities, and is especially appropriate for adults. It is not

necessarily appropriate, however, for assessing the abilities and

needs of infants and young chi ldren.(')

S~ ecial assessments - Additional assessments may be required to

determine an individual's special needs. For example, the ICAP

cannot reveal the extent to which a client may need physical or

occupational therapy. Separate assessments by appropriate

professionals need to be administered, and are essential to

developing a comprehensive understanding of individual abilities and

needs. Typically, these additional assessments are requested by case

managers .

( 1) The consultants found 6 children, ages 5 years and younger, f o r whom an ICAP was

i nappropri ate1 y administered by the Division. Because of t h i s , the consultants

recomnended a l t e r n a t i v e assessments more appropriate f o r young children, such as the

Denver Developmental Screening Instrument, the Sl osson I n t e l 1 i gence Test, and the

Bayley Scales of I n f a n t Development. According to the Division, however, a l l of i t s

d i s t r i c t s have been u t i 1 i zing various standardized and national 1 y recognized

assessments f o r young children f o r several years, such as the Denver and the Bayley.

ICAPs not timely - Although the ICAP is a valid and appropriate

instrument, i t is not always administrated in a timely manner. Our

consultants found that, in some cases, the ICAP was not completed u n t i l

after the IPP team had met. When this occurs, important information

which should be considered by the team in developing goals is not

available since a service plan has not been completed. The team needs

ICAP results to help i t s members understand an individual's functional

needs. It is unlikely this information would be available elsewhere.

S~ ecial assessments - Moreover, the Division has not ensured that a l l

necessary additional assessments of individuals have been conducted. Our

consultants f e l t that additional assessments were necessary for 18 of the

30 individuals whose Division maintained case f i l e s they reviewed. While

the consultants realize that a l l types of assessments are not always

necessary, some circumstances dictate that formal assessments be

conducted. For example, some f i l e s contained a reference that a

particular service, such as physical therapy, was needed; however, there

was no indication that an assessment was done. The consultants further

commented that the failure to conduct necessary assessments is

unacceptable and inconsistent with practices in other states that they

have reviewed. In these states, they found that the assessment process

was clear, routine, and " practically never misses any important area."

In Pennsylvania, for example, formal written plans cannot be developed

without evidence that a l l essential assessments have been conducted.

Because assessments were not always done, some clients have not received

services and supports they may need . ( ' I For examp l e:

A medically fragi le 2- year- old g i r l had worn hearing aids for a

period of time. According to the consultantts review of her case

f i l e , her hearing was somehow determined adequate for speech, and the

hearing aids were discontinued. However, a speech evaluation was not

completed u n t i l over one year after the decision was made to

discontinue use of the hearing aids.

( 1) The case examples cited here are based on the consultant's review of Division case

f i l e s , c l i e n t v i s i t s , and case manager interviews. The consultants strong1 y be1 ieve

that a l l important information about a c l i e n t should be documented i n Division records

and available to the case manager, who i s responsible f o r the c l i e n t s ' day- to- day

support.

A young man l i v i n g with his family has d i f f i c u l t y communicating and

presents behavioral problems that are challenging to them. He also

experiences medical problems, including seizures. Although he

receives some services, the consultants found no current neurological

assessments or physician's notes in the Division's case f i l e . In

addition, he has not had his communication, psychological,

vocational, or educational needs assessed. The consultants concluded

that the young man has not received comprehensive functional

assessments i n a l l needed areas, and when assessments have been

completed, they have not been conducted in a timely or coordinated

manner .

Plans not S U D D O ~- ~ B~ e~ ca use a1 1 necessary assessments are not always

done p r i o r t o the IPP meeting, goals have been established and services

authorized that are not based on an assessed need. This can result in

the delivery of costly services that may be unnecessary or excessive.

During their review of case f i l e s , our consultants found no evidence of

an assessed need for approximately 43 percent of goals contained in

planning documents. During the IPP meetings, goals are established for

c l i e n t s , such as learning how to eat or dress, or increasing social

interaction. Services are then developed to help meet these goals.

However, our consultants often could not determine how or why many goals

were set. They stress that accurately determining a c l i e n t ' s needs is

paramount for ensuring an effective and e f f i c i e n t service system.

Procedures For Conducting

Plannina Meetinas Are Not

Always Followed

Some planning meetings are not conducted according to established

procedures, and follow up between annual planning meetings is sometimes

lacking. Teams do not always include a l l appropriate individuals who

should be involved and some c r i t i c a l information, in addition to

assessment results, is lacking when the IPP team meets. Monitoring of

c l i e n t progress is also weak in some cases and plan revisions are not

always made when appropriate.

Team com~ osition - According to our consultants, professional personnel

and others who should be involved in the IPP team meeting are often l e f t

out. In fact, in their review of 30 case f i l e s , the consultants found

only one case in which there was a properly constituted interdisciplinary

team present during the c l i e n t ' s annual IPP review. In most cases the

teams consisted of the c l i e n t , case manager, and family members. In a

few cases, residential and day program providers were involved. However,

the consultants believe that residential and day program representatives

should be more involved in the planning process. Furthermore, i f

important assessments w i l l not be available for the planning meeting,

various other professionals who interact with the c l i e n t should at least

be ava i lab l e , given the complex needs of many i nd i v i dua l s who have

developmental d i s a b i l i t i e s . According to the consultants, these

individuals, including medical specialists, physical and occupational

therapists, teachers, and speech/ language professionals, were rarely

involved in planning in the cases they reviewed.

Information lacking - In addition to assessment results, other c r i t i c a l

information is also not available when some IPP teams meet. I n t h e i r

case f i l e review, the consultants found that medical records, laboratory

test results, and c l i e n t plans developed by other agencies were sometimes

lacking. They noted that this makes i t impossible for appropriate

planning to occur.

The consultants also did not find any comprehensive lPPs that encompassed

assessment results from other agencies working with the c l i e n t ,

especially for clients over f i v e years of age. For example, local school

d i s t r i c t s develop Individual Educational Plans ( IEPs) for developmental ly

disabled youth who reside in their d i s t r i c t s . In addition, adult c l i e n t s

may have an employment- related plan developed through the DES, Division

of Vocational Rehabilitation ( DVR). When plans are not integrated, the

result is often poor coordination of service delivery and inconsistency

in e f f o r t s to address service needs.

Monitorina and ~ l a n adjustment - The consultants also i d e n t i f i e d

weaknesses in the monitoring of c l i e n t progress and adjusting of c l i e n t

plans. Although the ICAPs are completed, results are not used to

benchmark functional a b i l i t i e s and measure progress over time. According

to the consultants, ICAPs appear to be completed " simply because they are

required,'' and are often forgotten once completed.

In addition, teams often do not reconvene when appropriate to adjust

c l i e n t plans. Plans may need to change between annual IPP meetings i f no

progress i s being made, or i f new problems or other needs arise. For

example, in one case reviewed, an individual had experienced 14

behavioral episodes between July and October 1992. The team did not meet

to examine the possible causes for the increased number of behavioral

incidents nor to discuss a plan of action. The consultants f e l t that the

c l i e n t would have benefited greatly had the IPP team reconvened to

address the c l i e n t ' s problems. In only one of 30 cases reviewed did the

IPP team reconvene between annual meetings.

Breakdowns Occur Within

The Case Management System

Weaknesses in the Division's case management system appear to be the

principal cause of problems with the assessment and planning process.

The consultants found Division policies and procedures were appropriate.

However, because of poor communication and lack of training, case

managers were not uniformly fol lowing these policies and procedures in

the f i e l d . For example, the consultants learned that assessments were

often not requested because the case manager believed the assessments

were not e l i g i b l e for T i t l e X I X funding. In fact, one case manager

admitted that none of the 44 c l i e n t s in the case manager's case load has

had any assessments other than the ICAP. The case manager saw no point

in requesting assessments that would not be funded. Division

administrators explained, however, that such assessments could be funded

with T i t l e X I X monies. Our consultants concluded that Division policies

have not been f u l l y explained to case managers, and as a result are

simply not being consistently followed.

Finding I I ( page 17) addresses in more detail other problems, such as

excessive paperwork, high case loads, and s t a f f turnover, which may also

adversely impact the Division's a b i l i t y to adequately assess needs and

create effective service plans.

RECOMMENDATIONS

1. The Division should adequately t r a i n case managers and others

involved in the assessment process in proper procedures for

conducting assessments, and should i n s t i l l a clear understanding of

the importance of f u l l and consistent implementation of i t s policies

and procedures.

2. The Division should ensure that a more appropriate tool is

consistently used for assessing the functional a b i l i t i e s of young

chi ldren.

3. The Division should ensure that comprehensive assessment information

is available to planning teams when goals are set and services are

author i zed.

4. The Division should ensure that case managers involve a l l appropriate

personnel in the IPP planning process.

5. To strengthen i t s planning a b i l i t y , the Division should take steps to

ensure that a l l information essential to the planning process, such

as medical examination and laboratory test results, assessments, and

information prepared by other agencies, i s contained in c l i e n t case

f i l e s .

6. In cases involving multiple agencies, the Division should attempt to

develop integrated plans that are comprehensive and consistent with

plans developed by these other agencies.

FINDING II

THE DIVISION'S CASE MANAGEMENT SYSTEM

CANNOT EFFECTIVELY SERVICE CLIENTS

The Division's case management system i s overburdened and poorly

administered. This i s p a r t i c u l a r l y disturbing because case management i s

a c r i t i c a l element in the system that delivers services to persons with

developmental d i s a b i l i t i e s . However, excessive paperwork, high case

loads, and other factors make i t d i f f i c u l t for DDD's case managers to

carry out t h e i r r e s p o n s i b i l i t i e s . Although the Division recognizes that

problems exist and some improvements are planned, further e f f o r t s are

needed.

Case Manaaement Is Essential,

But lnadeauate At DDD

Quality case management i s important to successful c l i e n t development,

yet the case management system at DDD i s lacking. Case managers perform

many important functions, and fostering strong personal relationships

through frequent contact with clients and their families is among the

most crucial. However, both DDD case managers and c l i e n t s feel that

DDD's case management is not responsive to c l i e n t s ' needs.

Good case manaqement i s necessary - DDD's case managers are the key

contact within the system for persons wanting to access services.

Specifically, case managers are responsible for determining whether a

person is e l i g i b l e for Division- funded services, and i f so, ensuring

necessary assessments are conducted to determine the individual's needs.

For example, the case manager may need to address issues such as which

type o f residential placement would most benefit a c l i e n t , which

therapies are needed, and which programs could assist the individual in

developing new s k i l l s and a b i l i t i e s . Case managers also determine

whether the c l i e n t ' s family has any special needs. Based on these

assessments, the case manager, along with others involved with the

c l ient , plans and coordinates the del ivery of services through a network

of providers. The case manager also monitors services received by the

c l i e n t and assesses the c l i e n t ' s progress in achieving goals.

In addition to accurately assessing a person's needs and coordinating

services, case managers need to develop close personal relationships with

c l i e n t s and their families. Building such a relationship i s often

accomplished by frequently v i s i t i n g and talking with c l i e n t s and their

families. By doing t h i s , case managers can increase their opportunities

for ensuring the c l i e n t ' s needs have been accurately determined and that

services are reaching and benefiting the c l i e n t . Furthermore, many

persons with developmental d i s a b i l i t i e s have severe physical

limitations. Some c l i e n t s are non- verbal, or cannot walk or even stand.

Others may be dependent on ventilators for breathing. Many c l i e n t s are

also vulnerable to such things as s e l f - i n f l i c t e d injury, physical neglect

or abuse, or exploitation. Frequent case manager contact w i t h c l i e n t s

helps to ensure their safety and may help reduce c r i s i s situations.

Effective case manaqement ham~ ered - Although case management i s v i t a l l y

important to successful c l i e n t development, neither case managers nor

clients are satisfied with the current system. We surveyed, by mail, a l l

246 case managers employed by DDD during July 1992; 130 responded to our

survey. Those who responded estimated they currently spend about ten

percent o f t h e i r time in direct contact with c l i e n t s , but f e l t , on

average, that they should spend nearly one- quarter o f t h e i r time in this

manner. Many reported that excessive demands on their time have greatly

impacted their a b i l i t y to know their c l i e n t s and perform their jobs

e f f e c t i v e l y . Several case managers we spoke with see some of their

clients as l i t t l e as once a year.

Families of persons with developmental d i s a b i l i t i e s have also expressed

dissatisfaction with the case management services their family members

are receiving. More than two dozen parents voiced their concerns during

a Joint Legislative Committee hearing in November 1991. Some parents

stated that case managers are generally inexperienced, poorly trained,

d i f f i c u l t to contact, and have l i t t l e knowledge of the individual for

whom they are coordinating services. Parents questioned whether case

managers were properly prepared to identify and meet the needs of their

children. In addition, some family members surveyed by our consultants,

or who contacted Auditor General s t a f f d i r e c t l y during the audit, also

expressed their unhappiness with DDD's case management system. Problems

they noted include high case manager turnover, lack of case management

services, and unknowledgeable and uninformed case managers.

Various Factors Hamper DDD's

Abilitv To Provide Good

Case Manaaement

Several aspects of DDD's current system have rendered case managers

unable to provide clients with quality case management. Excessive

paperwork requirements demand much of the case managers' time. Adding to

this is high client- to- case manager ratios. High turnover and poor

training also make i t d i f f i c u l t , i f not impossible, for case managers to

f u l f i l l their responsibilities.

Considerable paperwork required - Case managers responding to our survey

noted that a reduction in paperwork would be the one change that would

most improve their jobs. In some cases, the problem i s that case

managers have to complete various types of reviews and complete paperwork

on those reviews too often, while in other instances, the paperwork they

complete i s often duplicative.

We i d e n t i f i e d over 100 forms and reports which case managers may have to

f i l l out, depending on Division requirements and c l i e n t needs. Some of

these forms, and the type and amount of information contained within them

may not be necessary, at least to some degree. Recently, for instance,

two internal studies both concluded that the forms and paperwork required

for most case management functions contain duplicative information and

that the tasks expected of case managers are excessive and redundant.

Both reports recommended that procedures and paperwork need to be

simplified. Consultants hired by the Auditor General also noted that

case managers seem to be burdened with an inordinate amount of

paperwork. They recommend that duplicative tasks be reduced, and that

case aides or other s t a f f be responsible for some of the paperwork.

To i l l u s t r a t e one impact of high paperwork requirements, we found that

whi le accompanying a case manager to a group home where several of her

c l i e n t s lived, she spent only a few minutes with each of her c l i e n t s

during the 2- and 1/ 2- hour v i s i t . She spent the remaining time s o l i c i t i n g

information from the group home administrator and completing paperwork.

Hiah case loads - Case managers have d i f f i c u l t y finding enough time to

adequately service a l l c l i e n t s on their case loads. We found that in

June 1992, DDD case managers were assigned an average of 47 c l i e n t s each,

with some having upwards of 70 c l i e n t s or more. High case loads can

l i m i t a case manager's abi l i t y t o perform e f f e c t i v e l y , as we1 l as his or

her opportunity to v i s i t clients and personally monitor their progress.

It has also forced some case managers into " p r i o r i t i z i n g " individuals in

their case loads, causing a disparity in the equitable provision o f case

management among c l i e n t s .

Nearly everyone involved with case management at DDD agrees that case

loads are too high. Case managers and case manager supervisors we

surveyed indicated that the average case load size should be reduced to a

maximum of 33 c l i e n t s .

Case managers average about 50 percent more c l i e n t s than experts say

should be assigned t o t h e i r case loads. Our consultants explained that

current best practice dictates that one case manager be involved in

supporting about 30 individuals. We also spoke with several other

consultants who specialize in the f i e l d . They told us that a case load

size of 20 to 30 is generally reasonable to ensure quality case

management. In addition, Michigan and New Hampshire, two states

i d e n t i f i e d to us as having model DD programs, reported average case load

sizes of 24 and 25 c l i e n t s , respectively, per case manager.

Because of system requi rements and the compl icated needs of many

individuals with developmental d i s a b i l i t i e s , a reasonable case load size

is c r u c i a l . E f f e c t i v e l y servicing even one c l i e n t can take a

considerable amount of time and e f f o r t . To i l l u s t r a t e t h i s point, case

managers are required to ensure that, for many c l i e n t s , w r i t t e n plans

outlining the c l i e n t ' s services are reviewed quarterly and that other,

more formal reviews occur once or twice a year. This process alone can

necessitate discussions with parents, guardians, and others involved with

the individual, and arranging and preparing for meetings with medical

specialists, therapists, and other professionals. The case manager must

also document the results both manually and on the Division's computer

system. I f changes in services or other supports are determined to be

needed, the case manager i s then responsible for coordinating these

changes for the c l i e n t . In addition, case managers with c l i e n t s in

foster care must prepare a variety of reports for the foster care review

board and the courts, as well as participate in court hearings. Also

absorbing part of a typical case manager's work week i s travel time to

and from c l i e n t planning meetings, meetings with providers, and v i s i t s

with c l i e n t s .

The Division has realized i t s need for more case managers in an e f f o r t to

handle both new c l i e n t growth and reduce high case loads. Division

o f f i c i a l s told us they have requested additional case manager positions

in recent years. Although some case manager and related support

positions were added as a result o f these requests, mostly f o r servicing

Long- Term Care System ( ALTCS) c l i e n t s , DDD management acknowledges more

case managers are needed to allow for manageable case loads.

While i t i s clear that smaller case loads should be the norm at DDD,

various factors, such as c l i e n t type and the intensity of the person's

needs, would need to be considered to most e f f e c t i v e l y determine

appropriate case loads for individual case managers.

Other factors also im~ act - Case manager knowledge of c l ients and thei r

a b i l i t y to ensure c l i e n t needs are met is further impacted by high

turnover and inadequate training.

Turnover - Although we were unable to accurately calculate DDD's

turnover rate for case managers, Central Office case management s t a f f

estimate i t to be between 25 and 35 percent, approximately double the

average turnover rate for several states i d e n t i f i e d as having model

DD programs and s i g n i f i c a n t l y greater than the 10 percent turnover

rate for case managers employed by Child Protective Services. High

turnover negatively impacts case management in several ways.

According to experts in the f i e l d of developmental d i s a b i l i t i e s , the

case manager's value grows with experience, often taking years for

the case manager to develop necessary s k i l l s . We found, however,

that more than 50 percent of DDD's case managers have worked in the

Division fewer than two years.

Turnover also reduces the c l i e n t ' s opportunities to develop a

continuing relationship with his or her case manager. Turnover also

adds to al ready high case loads for remaining case management s t a f f ,

including case manager supervisors. F i n a l l y , training and

recruitment a c t i v i t i e s are costly.

Accord i ng to case managers and superv i sors we surveyed , as we l l as some

we interviewed, the high rate of turnover among DDD case managers i s due

in large part to r e l a t i v e l y low salaries. Currently, DDD's entry- level

case manager earns an annual salary of $ 17,755. The base salary for case

managers working for Maricopa County Long- term Care i s about 25 percent

more, while case managers in Child Protective Services earn about 20

percent more and those contracting with the Office f o r the Seriously

Mentally I l l earn nearly 10 percent more. According to a Division

representative, in an e f f o r t to make i t s case managers' salaries more

competitive, DDD contacted the Department of Administration to conduct a

Classification Maintenance Review ( a position/ salary reclassification

analysis) for Fiscal Year 1992- 93. However, DOA declined to perform such

a review because the Division had no funding allocation i d e n t i f i e d to

support any resulting reclassification. S t i l l , the Division should

continue i t s e f f o r t s to improve case manager salaries, when possible to

do so.

Training - DDD i s not providing case managers with adequate

training. According to the results of our case manager survey, 40

percent of the case managers responded that DDD training was

i n s u f f i c i e n t and nearly 20 percent believe i t has not been

beneficial. Further, according to a recent study commissioned by the

Division, consultants found that only 12 of 181 case managers

included in the analysis have had training on a l l topics necessary to

perform their jobs e f f e c t i v e l y . We also found that DDD has f a i l e d to

provide t r a i n i n g t o new case managers on a timely basis.

The training program is not s u f f i c i e n t l y standardized or properly

monitored. The absence of written standards or guidelines on how to

develop a training course has resulted in more than 100 d i f f e r e n t

training packages in use statewide. Also, the adequacy of case manager

training i s affected by poor monitoring. For example, though DDD spent

more than $ 130,000 for the development of a competency- based training

system in 1990, which was designed to guarantee case managers received

appropriate training and periodic monitoring by Central Office, i t never

f u l l y implemented the system.

During their review, our consultants also expressed concern about case

manager training. They concluded that DDD's training curriculum has not

been implemented. As a result, and as evidenced through the records

review and other work they performed, they feel strongly that key areas

of competence have not been clearly achieved.

Changes Are Needed

Much needs to be done to develop an effective case management system.

DDD is taking some steps to improve the system, such as strengthening

Central Office's role and redesigning the case manager training program.

However, a number of critical issues, including case load size, have yet

to be addressed in any significant way.

DDD workina toward improvement - DDD management recognizes that

deficiencies exist and appears to be committed to improving its case

management system. Recently, the assistant director selected a group of

DDD managers and staff to analyze the Division's operations and practices

in the wake of considerable criticism from clients and their families,

legislators, and staff. Case management was one of the five functional

areas studied by the group. The group identified a number of

inefficiencies within the case management system. Management is now

deciding what actions to take to create a stronger case management system

statewide.

The Division is also beginning to address the issue of excessive

paperwork. For instance, DDD has identified about 20 processes and

corresponding forms it believes could either be consolidated or

eliminated entirely, such as consolidation of the Individual Program Plan

( IPP) document with the Service Plan. The assistant director has also

obtained AHCCCS' approval to complete formal reviews for some clients

less frequently than is currently the case.

DDD is also in the process of developing a stronger and more uniform

training program. The Division recently hired a consulting group to work

with Division staff in assessing the Division's training programs,

especially as they relate to case managers. As a result, DDD is

developing guidelines for training new case managers that combine formal

classroom training with supervised on- the- job t r a i n i n g . Classroom

training i s expected to emphasize basic case management functions as well

as specialty areas, such as mental health and medical needs assessments.

More chanaes w i l l be needed - Although DDD is t r y i n g t o e f f e c t some

changes, more changes w i l l be needed. For examp l e , even a f t e r the

proposed changes, case managers w i l l continue to be overburdened by

excessive and duplicative paperwork.

Once case manager paperwork requirements have been minimized, the

Division needs to develop a policy on case load size. DDD should assess

case manager duties to determine the time case managers need to f u l f i l l

each of their tasks. DDD w i l l then need to establish a plan, which could

include reorganizing or redeploying existing s t a f f . Only after these

steps have been taken should the Division consider requesting more case

manager positions from the Legislature.

Due to budget constraints, State funds may not be immediately available

to hire additional case managers. However, i f DDD wants to improve the

quality of i t s case management services, case load sizes w i l l have to be

reduced. The problems of turnover and low salaries w i l l also need to be

addressed. U n t i l Division case managers are paid s i m i l a r l y to case

managers in other Arizona agencies, high turnover w i l l continue.

1. DDD should continue i t s e f f o r t to further reduce excessive paperwork

requirements and related tasks.

2. Once paperwork requirements are adequately addressed, DDD should

analyze remaining case manager a c t i v i t i e s and develop an appropriate

case manager- to- client r a t i o .

3. DDD should analyze the relationship between high turnover among case

managers and such issues as low salaries. DDD may want to request

the Department of Administration to study restructuring the salary

c l a s s i f i c a t i o n for i t s case managers, when budgetary guidelines and

funding make i t possible to do so.

4. DDD should continue to revise i t s case manager training program to

ensure case managers have the s k i l l s they need. S p e c i f i c a l l y , DDD

should develop a training curriculum for new and experienced case

managers, properly standardize and monitor case manager t r a i n i n g , and

provide t r a i n i n g t o new case managers on a timely basis.

FINDING Ill

THE DIVISION CAN IMPROVE ITS SYSTEM

FOR INVESTIGATING

CLIENT ABUSE AND NEGLECT

The Division's system for reporting, investigating, and acting upon

incidents of c l i e n t abuse and neglect can be strengthened. Many people

who rely on DDD for services must also rely on DDD to protect them, as

they cannot protect themselves. However, DDD does not always conduct

adequate investigations into allegations of abuse and neglect or take

appropriate action to safeguard c l i e n t s . Several factors contribute to

this f a i l u r e . Although DDD has recently taken some steps to address the

problem, further action must occur.

*

Reports, lnvestiaation Reauired For

Protection Of Vulnerable Clients

The physical and mental limitations that make people e l i g i b l e for DDD

services also make them p a r t i c u l a r l y vulnerable to abuse and neglect.

Many c l i e n t s cannot speak, so cannot protest or t e l l others when they are

mistreated. Others have physical impairments that prevent them from

defending themselves or running away. Some lack the a b i l i t y to recognize

abusive situations. Furthermore, DDD c l i e n t s cannot simply find a new

home, a new job, or a new school i f they become victims, but must depend

on others to help them change their circumstances.

Whenever c l ient abuse or neglect is observed, al leged, or suspected, DDD

division management must be n o t i f i e d by means of an Unusual Incident

Report ( UIR). Licensing regulations ( R6- 6- 1601) require contract agency

employees to report to DDD via the observing employee's supervisor. The

D i v i s i o n ' s p o l i c i e s and procedures require DDD employees to verbally

inform a supervisor immediately upon learning about the problem from the

agency, a c l i e n t , the public, or by their own observation, and to prepare

a written UIR within 24 hours. Investigation of a UIR i s mandatory in

a l l cases of c l i e n t abuse and neglect.(') UlRs and investigation reports

a l e r t management to problems, provide a written h i s t o r y f o r spotting

trends, and supply information needed to determine actions to correct

problems and prevent their recurrence.

The Division Has Not Adeauately

Resolved Some Incidents

Our review of over 100 UIRS(*) and other records revealed several

weaknesses in the Division's system f o r protecting c l i e n t s . Some

incidents did not result in UIRs, some UlRs were slowly or inadequately

investigated or were inappropriately turned over to provider agencies for

investigation, and some investigations did not lead to appropriate

action. In at least two cases, complainants were i d e n t i f i e d to the

subjects of the compiaints, in v i o l a t i o n o f regulations. Of the 19 cases

we chose for review of d i s t r i c t records, 6 were investigated by the

provider instead of by DDD, and 5 were not investigated at a l l . We found

investigation s t a r t and completion dates for 13 of the 19 cases;

investigations started up to 47 days after the incident was reported

( average 8 days), and the investigations took from 1 to 107 days to

complete ( average 24 days).

( 1 ) Other examples of unusual i n c i d e n t s i n c l u d e c l i e n t death, medication e r r o r s , missing

c l i e n t s , t h e f t of c l i e n t property, serious c l i e n t i l l n e s s o r i n j u r y , community

disturbances i n v o l v i n g c l i e n t s , non- routine damage t o State and p r o v i d e r p r o p e r t y , and

community complaints regarding r e s i denti a1 s e t t i n g s . Current1 y, DOD has about 450 to

500 UIRs per month. DDO management estimates approximate1 y t e n percent o f these UIRs

are s e r i o u s .

( 2 ) We reviewed 103 UIRs a t Central Office, based on a judgmental sample of i n c i d e n t s

l i s t e d i n the Central O f f i c e database f o r January and one- half of February 1992. The

i n c i d e n t s selected involved community complaints, c l i e n t neglect or abuse o r death,

unexplained i n j u r y , t h e f t or misuse of c l i e n t money, o r medication e r r o r s , and

appeared t o be p o t e n t i a l l y serious and/ or preventable. When the Central O f f i c e f i 1 es

contained a d d i t i o n a l UIRs f o r the same c l i e n t s noted i n the judgmental sample, we

reviewed those UIRs as we1 1 .

Although we cannot project how frequently they occur, the serious nature

of the problems we discovered, as i l l u s t r a t e d by the following case

examples, make clear the need to improve DDD's system for responding to

incidents of abuse and neglect.

Police were called r e ~ e a t e d lf~ or runawav client. no UlRs written -

One c l i e n t had many incidents but no UlRs u n t i l Child Protective

Services got involved. The police called CPS to report that the

c l i e n t was running away from his group home one to two times a day,

and police had been called eight times in a two- year period to help

find him. Police records showed the c l i e n t had broken his arm in a

f a l l during one incident, and another time he returned to the home

with a bicycle o f unknown o r i g i n . Group home s t a f f n o t i f i e d DDD via

incident reports or phone c a l l s to the case manager.

These incidents clearly signal a problem at the group home that

needed resolution. In addition, they should have been considered in

making license renewal decisions. Without UIRs, however, those who

make the decisions and resolve the problems do not learn about the

incidents.

Group home manaaement implicated in alleqations but DDD did not

investiaate - A former employee of a group home made several

allegations regarding abuse and neglect of c l i e n t s at the home. The

nature of some of the allegations implicated management of the

contract agency that operated the home. However, instead of

beginning an independent investigation, the DDD d i s t r i c t wrote to the

agency to request investigation. In t h i s l e t t e r , the d i s t r i c t

i d e n t i f i e d the complainant by name and enclosed a copy of the UIR,

although Rule R- 6- 6- 120 prohibits disclosure of the complainant

without his or her written permission. A b r i e f investigation by the

agency director confirmed that at least some of the allegations were

true. Furthermore, the agency director's response revealed that he

had previous knowledge of some of the incidents but had not reported

them to DDD. The d i s t r i c t chose to take no action on t h i s matter,

stating that the agency had adequately addressed the problem when the

agency director counseled the home supervisor to follow the rules.

Several Factors Contribute

To Failures

DDD's UIR system has several weaknesses that prevent i t from e f f e c t i v e l y

protecting c l i e n t s . Although Central Office oversight of UlRs i s

important for several reasons, DDD's decentralized system f a i l s to keep

Central Office informed. In addition, we found DDD f i l e s regarding UlRs

to be incomplete, making i t less l ikely that a case manager or other DDD

employee w i l l identify and resolve an ongoing problem. Furthermore, the

Central Office unit responsible for UIRs is inadequately staffed to

handle the high volume of incidents. Finally, few DDD staff have any

training in investigative methods.

Central Office receives inadeauate information for effective oversiaht -

Central oversight and tracking of UlRs is necessary for several reasons,

but DDD's Central Office does not receive the information i t needs.

Central oversight permits licensing inspectors to consider UlRs in making

license renewal decisions, discloses patterns of injury, abuse, and

neglect, and f a c i l i t a t e s sharing of solutions to complex problems. A t

DDD, however, although policy requires d i s t r i c t s to send a copy of a l l

UlRs and investigation reports to Central Office, we found the Central

Office f i l e s to be so incomplete as to be unusable. Virtually a l l

non- death investigation reports were missing, and DDD s t a f f t o l d us some

UlRs were never sent to Central Office.

Files are incom~ lete - We also found that d i s t r i c t f i l e s did not maintain

UIR information and references in a consistent manner. In some cases,

UlRs and related information were scattered haphazardly among other

documents in client f i l e s . Many case note references to incidents were

not supported by a copy of a UIR or a cross- reference to other f i l e s .

Without the important information contained in UlRs and investigation

reports accessible to case managers, i t is hard to imagine how they can

make c r i t i c a l decisions about clients' needs. Licensing f i l e s also lack

complete information about UIRs, and the Department of Health Services'

recent audit report on DDD licensing criticized the Division's failure to

keep adequate UIR information in those f i l e s .

Central Office s t a f f insufficient - A t i t s Central Office of Compliance

Review, DDD lacks adequate staff to effectively manage UIRs. The office

has only one administrative assistant and one- half of one manager's time

to monitor, review, f i l e , and track a l l the Division's UIRs, and to

handle any incidents and investigations that are too sensitive to be l e f t

up to the d i s t r i c t . With 450 to 500 UlRs every month, this is clearly an

impossible task.

Staff who conduct investiaations lack training - DDD's d i s t r i c t o f f i c e s

handle most UIR investigations. Most d i s t r i c t s , however, do not have

s t a f f who specialize in investigations, or who have received any training

in investigation methods. In a January 1991, report evaluating DDD's

Quality Assurance System, the Human Services Research I n s t i t u t e ( HSRI)

stated that " There i s unanimity among key informants that UIR

investigations are of poor quality and are conducted by poorly trained or

untrained personnel." Although HSRl expected improvement after DDD

completed some planned training sessions and hired f u l l - t i m e

investigators in two d i s t r i c t s , we found that only one of the d i s t r i c t s

had hired investigators and the planned training had been canceled due to

lack of funds. The problems noted in that two- year- old report have s t i l l

not been addressed. Only a few Division s t a f f have received

investigative training, and they are concentrated in D i s t r i c t 2 ( Pima

County) because one of their employees attended a week- long session out

of state and returned to share what she learned with the d i s t r i c t ' s s t a f f .

Division Is Trvina To Improve

But Needs To Do More

DDD is taking some steps to remediate i t s UIR handling system, but

additional steps are needed. Other government e n t i t i e s have processes

that DDD could adopt to improve i t s a b i l i t y to respond to incidents of

abuse and neglect.

DDD's recent e f f o r t s for improving i t s performance include:

A new and clearer UIR policy, currently i n d r a f t form, that includes

guidelines for investigations;

A new computer tracking system, currently in the p i l o t stage, that

w i l l provide more complete information about each UIR so patterns can

be i d e n t i f i e d ;

Review of every abuse and neglect UIR by the Assistant Director of

DDD, to give him a better feel for the problems and to identify areas

where top- level management can make system- wide improvements; and

Planning to coordinate investigative t r a i n i n g with the assistance of

the Attorney General and DES's Office of Internal A f f a i r s , at some

time after the new tracking system is f u l l y implemented.

In addition, D i s t r i c t 2, headquartered in Tucson, has implemented some

innovative techniques to improve i t s quality assurance as a whole,

including UIRs. I t s unique Quality Advocacy Unit reviews the program

manager's recommendations, oversees investigations conducted by others,

and conducts investigations into serious incidents. The D i s t r i c t ' s Human

Rights Committee has also taken an active role in ensuring adequate

follow up on UIRs. As noted e a r l i e r , D i s t r i c t 2 has some s t a f f who have

received training regarding investigative methods.

DDD could adopt some techniques used by other government e n t i t i e s that

manage UIRs d i f f e r e n t l y :

In Connecticut, abuse, neglect, and serious injury are treated

separately from minor incidents. Eighteen liaisons statewide conduct

investigations and maintain d a i l y communication with Central Office

regarding serious incidents, while minor incidents are handled at the

local level. Separating the types of incidents t h i s way could reduce

the burden on Central Office s t a f f .

Maricopa County has 14 investigators who specialize in various

incident types.

Arizona State Hospital uses a duplicate- style UIR form. The person

who f i l l s i t out gives one copy to his or her supervisor, and gives

the other d i r e c t l y to the hospital's Quality Assurance Office. This

ensures that Central Office is informed more quickly, and also

prevents any censoring of the report before i t reaches Central Office.

Adopting these methods of separating serious from minor incidents, using

s t a f f who have been specially trained in investigation techniques, and

using control techniques to improve reporting could strengthen DDD's

a b i l i t y to e f f e c t i v e l y investigate, monitor, and respond to c l i e n t abuse

and neglect.

RECOMMENDATIONS

1. DDD should improve the quality of i t s investigations by:

Giving p r i o r i t y to developing comprehensive investigation training

and providing i t to a l l s t a f f who conduct investigations of c l i e n t

abuse and neglect;

Considering using s t a f f who report d i r e c t l y to the Central

O f f i c e o f Compliance Review to conduct a l l investigations into

serious incidents; and

Investigating a l l abuse and neglect incidents d i r e c t l y instead

of requesting provider agencies to conduct investigations.

2. DDD should more e f f e c t i v e l y address reported problems by:

Analyzing and d i s t r i b u t i n g information from the new computer

tracking system to improve problem solving and trend

i d e n t i f i c a t i o n ; and

Maintaining complete records of reported incidents and

investigations i n f i l e s accessible to licensing s t a f f and case

managers, and noting cross- references to those f i l e s in the

appropriate licensing and c l i e n t f i l e s .

3. DDD should improve Central Office oversight of serious incidents by:

Enforcing i t s requirement that d i s t r i c t s submit information about

incidents and investigative reports to Central Office. DDD may

consider using two- part forms where one copy goes d i r e c t l y t o

Central Office while the other goes through supervisory channels.

Considering establishing a two- tier system, where serious

incidents such as abuse and neglect are handled separately from

minor incidents

Increasing the number of Central Office s t a f f assigned to duties

associated with the tracking and monitoring of c l i e n t abuse and

neglect reports

FINDING IV

LICENSING INSPECTIONS NEED TO BE MORE TIMELY

AND ENFORCEMENT SHOULD BE STRENGTHENED

Action needs to be taken to improve the current licensing process so that

i t more adequately safeguards the c l i e n t s ' health, safety, and f a i r

treatment. The Division has not conducted timely licensing inspections

and repeat violations have not been e f f e c t i v e l y addressed. In addition,

the l i cens i ng process i s cumbersome and d i sorgan i zed and has not been

implemented uniformly throughout the State.

The licensing process i s important in protecting c l i e n t health and safety

rights, and ensuring c l i e n t programs are properly developed and

implemented. The vulnerable nature and medical problems of many DDD

clients mandates the use of the licensing process. Residential

f a c i l i t i e s are not just places to l i v e , but important components of

c l i e n t h a b i l i t a t i o n programs.

DDD licenses residential f a c i l i t i e s under contract with the Division, and

also c e r t i f i e s intermediate care f a c i l i t i e s for the mentally retarded

( ICF/ MRs) and State- operated group homes.(') Faci I i t ies sat i s f a c t o r i ly

passing an inspection receive a one- year regular license or c e r t i f i c a t e ,

which indicates the faci l i t y ' s compl iance with l icensing standards. This

inspection, conducted by Central Office licensing s t a f f , should occur

before the expiration of the current regular license or c e r t i f i c a t e so

the f a c i l i t y can correct violations and have the corrections v e r i f i e d by

d i s t r i c t monitoring s t a f f before the license or c e r t i f i c a t e expires.

Midyear monitoring v i s i t s by d i s t r i c t monitors are expected to ensure

ongoing compliance with standards. According to Division information, in

Fiscal Year 1991- 92, 364 privately operated group homes, 25

State- operated group homes ( SOGHs) , and 14 I CF/ MRs were ope rat i ng under

DDD licenses and c e r t i f i c a t e s .

( 1) DDD does not l i c e n s e f a c i l i t i e s which only provide r e s i d e n t i a l services t o

private- pay c l i e n t s .

The Division's Licensina Process Has

Been Inconsistent And lneff icient

The licensing process has not been consistently and e f f i c i e n t l y

administered by DDD. DDD has routinely fai led to inspect, i n i t i a l l y

license, and relicense residential f a c i l i t i e s in a consistent and timely

manner. Also, DDD failed to e f f e c t i v e l y follow up on licensing

v i o l a t i o n s , r e s u l t i n g in repeat violations among licensees and allowing

underlying problems to go unchecked.

DDD i s routinelv late i n i n s ~ e c t i n a , i n i t i a l l y licensina, and relicensing

residential f a c i l i t i e s - Our review of 50 randomly selected licensing

f i l e s found that DDD routinely f a i l e d to inspect, i n i t i a l l y license, and

relicense f a c i l i t i e s u n t i l months after a f a c i l i t y had opened or the

current license had expired.(') Further, to cover inspection and

licensing delays, DDD inappropriately issued provisional licenses and

backdated both regular and provisional licenses. A review of both

State- operated and contracted group homes indicated that DDD, on average:

lssued a 6- month provisional license( 2) 32 days after the regular

license expired, backdated to the expiration date of the regular

license ( obscuring the 32- day period of operating without a license)

Inspected group homes 87 days after the regular license expired or

55 days after provisional license had been issued

lssued an inspection report 35 days after the inspection had been

completed or 122 days after the regular license had expired

Issued a regular license 31 days after the provisional license had

expired or 213 days after the previous regular license had expired,

backdated to show the expiration date of the provisional license

( again, disguising a 31- day period of operation without any type of

l i cense 1

( 1 ) We reviewed information contained i n 1 icensing f i l e s f o r inspections conducted during

the time period of January 1990 through A p r i l 1992.

( 2 ) I s s u i n g p r o v i s i o n a l licenses t o group homes t o compensate f o r delays i n the

inspection process i s inappropriate because, by d e f i n i t i o n , a p r o v i s i o n a l 1 icense

permi t s a f a c i l i t y t o operate w h i l e c o r r e c t i n g d e f i c i e n c i e s a f t e r a l i c e n s i n g

inspection has been completed. However, DDD issued a t 1 east one i nappropri ate

p r o v i s i o n a l l i c e n s e t o each contracted group home i n our sample.

Allowed new group homes to operate for up to three months under a

provisional license and without the benefit of an i n i t i a l inspection

Failed to inspect State- operated f a c i l i t i e s annually as required by

statute. In two cases reviewed, the last inspection conducted

previous to 1992 was in 1987. Further, when State- operated

f a c i l i t i e s were inspected, the inspection process was not often

completed since reports were not issued, corrective action plans

were not required, and follow- up v i s i t s were not performed.

Finally, DDD failed to conduct monitoring v i s i t s on a consistent and

timely basis. Although the Arizona Administrative Code ( R6- 6- 107)

requires DDD to conduct a monitoring v i s i t no more than 6 months after

the previous licensing inspection, DDD f i l e s lacked documentation of

these v i s i t s for 45 percent of the cases reviewed. In addition, f o r the

monitoring v i s i t s that did occur, our review showed that these v i s i t s

took place, on average, 7 months after the previous inspection.

DDD appears to b; addressing some of these issues. According to the

licensing manager, the unit is now conducting inspections of new group

homes p r i o r t o allowing clients to be placed in these settings. He also

told us that a l l State- operated group homes have been inspected as of

early November 1992.

DDD fai Is to e f f e c t i v e l y follow UD on licensina violations - Our review

of the 50 licensing f i l e s found that 29 licensees were cited for the same

violation during two or more inspections or monitoring v i s i t s . ( ' ) Some

repeated the same violation as many as four times, and several had repeat

citations for up to eight standards. This history of repeated violations

suggests that problems associated with licensees are not being

addressed. The following examples i l l u s t r a t e the problem of repeat

violations.

( 1 ) Our review focused on approximately 113 of 320 t o t a l l i c e n s i n g standards used by DDD

i n conducting inspections. These 113 mandatory 1 icensing standards are those deemed

most c r i t i c a l by DDD f o r ensuring the h e a l t h , s a f e t y , and proper treatment o f c l i e n t s

i n r e s i d e n t i a l f a c i l i t i e s .

Ex- le 1 - This group home received i t s f i r s t formal inspect ion in

1986. DDD has inspected t h i s home 7 times since i t s opening,

discovering from 6 to 23 violations of mandatory standards during

each inspection, including:

- Six inspections found the premises to be unclean with numerous

health and safety hazards. Three inspections found that toxic

substances were not locked up. It was also noted during three

inspections that various items in the house did not work, such

as the swamp cooler and lighting.

- Four inspections found f i r e d r i l l s not conducted as required.

Two inspections discovered that f i r e inspections by the

appropriate f i r e authority had not been conducted and one

inspection noted that f i r e extinguishers had not been serviced.

- Five inspections found that c l i e n t medication treatment plans

were improperly maintained or could not be located, or that the

medication log was incorrect, or not properly signed or

i n i t i a l l e d .

- Six inspections found that documentation verifying formal f i r s t

aid, CPR, and additional s t a f f training was not on f i l e for

d i f f e r e n t employees in each inspection.

- Fingerprint clearances were not on f i l e for eight employees

across two inspections.

Exanwle 2 - This group home opened in 1986 and received i t s f i r s t

regular license on January 1, 1987. DDD has inspected the home

seven times since i t s opening, discovering up to ten violations of

mandatory standards during each inspection, including:

- Three inspections found that f i r e d r i l l s were not conducted as

required, especially during the night when c l i e n t s are asleep.

Two inspections discovered that f i r e inspections by the

appropriate f i r e authority had not been conducted and a

separate inspection noted that f i r e extinguishers had not been

serviced.

- Three inspections found that toxic substances were not properly

locked in storage.

- Documentation verifying formal f i r s t aid and CPR training was

not on f i l e for different employees during two inspections.

- Fingerprint clearances were not on f i l e for four employees

across two inspections.

There are several reasons why DDD follow up is inadequate, leading to

frequent cases of repeat violations among licensees. F i r s t , DDD did not

require corrective action plans ( CAPS) for approximately one- half of the

inspections we reviewed, even though licensing procedures require a CAP.

DDD waived t h i s requirement when i t s inspections were too late to enable

licensees to prepare a CAP and make necessary corrections before

expiration of the provisional license.

Second, DDD does not always conduct the required follow- up v i s i t s to

ensure required corrections are implemented. Files lacked documentation

of these v i s i t s in 18 percent of the cases reviewed which required follow

UP

Finally, DDD addresses specific incidents rather than the systemic

problem that created the incident, thus treating the symptoms of the

problem rather than the problem i t s e l f . The Department of Health

Services, in i t s report on a recent audit of DDD licensing, stated that

" CAP'S addressed only specific instances or examples. There was no

indication o f how the f a c i l i t y would correct systematic problems."

DDD recently took license revocation action against four group homes

known to have multiple repeat violations in c r i t i c a l areas. However, the

high number of licensees with repeat violations indicates that DDD should

strengthen i t s e f f o r t s in this area.

Licensinq Process Could Be Streamlined

And Administered More Consistentlv

In addition to being i n e f f i c i e n t , the licensing process is cumbersome,

disorganized, and lacks statewide uniformity. F i r s t , many licensing

standards are vague and subject to interpretation. Second, the licensing

process i s not uniformly administered, resulting in a fragmented approach

to inspection and monitoring. Third, s t a f f turnover and lack of training

leads to timeliness problems and inconsistent application of standards.

The Division should streamline and consolidate i t s licensing standards

and process.

Licensina standards are vaque and subiective - The licensing standards

DDD has used are vague and subject to interpretation, which has

contributed to the lack of understanding among group home providers and

licensing inspectors of what i s expected for compliance. A task force

led by the Human Services Research lnst i tute ( HSRI ), which i s studying

and making recommendations to the Governor's Council on Developmental

D i s a b i l i t i e s regarding DDD's licensing standards and process, noted the

subjectiveness in the licensing process. The task force, which includes

representatives of providers, c l i e n t s , and d i v i s i o n s t a f f , recommends

reducing licensing standards to an essential core of standards which lend

themselves to only " yes" or " no" interpretat ions. The task force further

recommends simplifying the licensing process by l i m i t i n g i t to basic

health and safety standards only.

We witnessed the vagueness and s u b j e c t i v i t y of licensing standards while

observing a training exercise at a statewide licensing meeting, i n which

inspectors and monitors were asked t o i d e n t i f y which standards were

violated i n scenarios based on actual events. For each scenario,

licensing s t a f f and monitors i d e n t i f i e d several d i f f e r e n t standards which

they thought were violated and applied to each scenario.

A l l were correct. A DDD licensing supervisor agreed that the d i v i s i o n ' s

current approach to licensing is based on subjective interpretations of

standards, not objective application of clear standards. Also, nearly

one- half of the respondents to our survey of group home providers(')

reported that licensing standards are open to interpretation and that

licensing standards have been applied d i f f e r e n t l y t o t h e i r own settings

in d i f f e r e n t locations. Other providers t o l d us that some of their homes

had been rated out of compliance for standards which were not applied to

those same homes i n p r i o r years.

The vagueness of DDD's l icensing standards may be addressed, to some

extent, as a result of recent l e g i s l a t i o n . House B i l l 2487, which became

law on October 1, 1992, established a committee to examine a l l Federal

and State statutes, rules, and standards relating to the licensure of

community residential settings in order to determine their effectiveness

( 1 ) Auditor General s t a f f surveyed a l l 38 group home p r o v i d e r agencies by m a i l .

T h i r t y - t h r e e p r o v i d e r agencies ( 86.8 percent) responded t o the survey.

in protecting the clients' health, welfare, and safety. A report is due

from the committee by October 31, 1993 and during this examination

period, DDD licensing is restricted to using only those standards that

appear in statutes and rules for licensure of group homes. DDD licensing

spent the month of October 1992 revising their licensing process to

reflect this b i l l ' s intent. However, DDD licensing management feels the

standards identified in the statutes and rules are even more vague than

the previous standards, and further revisions are needed to compile an

adequate and appropriate set of licensing standards.

Licensina Drocess is not uniformly administered - The licensing process

has not been uniformly administered, resulting in a fragmented approach

to inspection and monitoring. DDD's Iicensing inspectors report to a

centralized licensing section; but u n t i l recently, monitors, who are

d i s t r i c t employees, reported to d i s t r i c t management with the licensing

section having no clear authority over them. However, in late 1992,

licensing reached an agreement with d i s t r i c t management regarding the use

of staff for monitoring. In most d i s t r i c t s , monitors w i l l continue to

report to d i s t r i c t management and have other responsibilities besides

monitoring, but licensing expects to have a more active role in how

monitors u t i l i z e their time. D i s t r i c t 1 ( Maricopa County) monitors w i l l

now report directly to licensing and are considered full- time monitors.

These changes, i f properly implemented, could help strengthen the

inspection and monitoring functions.

S t i l l , d i s t r i c t monitors do not have clear guidelines to follow or

definitions of their licensing responsibilities.

Staff turnover and lack of training contributes to DDD's licensing

problems - Staff turnover and lack of staff training contributes to the

timeliness problems and inconsistent application and interpretation of

standards. Staff turnover probably has the greatest impact on the timely

completion of inspections. According to the licensing manager, the

turnover rate for licensing inspectors was about 17 percent during

calendar year 1992, and 33 percent during 1991.

Limited training for new licensing inspectors and monitors contributes to

inconsistencies and delays. The majority of training for licensing

inspectors is on the job, as new staff accompany experienced staff on

inspections. Training for d i s t r i c t monitors is v i r t u a l l y nonexistent.

Although licensing management has encouraged monitors to attend the

training sessions that are conducted for Iicensing inspectors, and to

accompany inspectors on inspections, monitors' other duties, assigned by

d i s t r i c t s , have l e f t l i t t l e time to take advantage of these opportunities.

RECOMMENDATION

The Division should improve i t s licensing process by:

Conducting inspections and monitoring v i s i t s in a timely manner;

Discontinuing the improper use of provisional licenses;

Modifying and, consolidating the Iicensing standards so they are

properly and consistently interpreted and applied by licensing staff

and understood by licensees;

Changing the I icensing process and procedures to ensure that

underlying systemic problems that prevent compliance with Iicensing

standards are properly addressed and corrected;

Evaluating the effectiveness of placing D i s t r i c t 1 monitors under

Central Office licensing authority, and i f successful, expanding this

practice statewide; and

Providing training to the licensing inspectors and d i s t r i c t monitors.

FINDING V

THE DIVISION NEEDS TO

CONTINUE AND EXTEND EFFORTS

TO STRENGTHEN ITS CONTRACTING PROCESS

The Division has taken significant steps to improve i t s contracting

process, but more can be done to ensure that sound procurement practices

are followed statewide. The Division's Central Office has not

effectively overseen and controlled d i s t r i c t contracting practices which,

at times, have been weak and deficient. For example, rate negotiations

have been poorly handled by some d i s t r i c t s , resulting in significant

overpayments to some contractors. The Division has strengthened the

Central Office's role in negotiating contractor rates, but more can be

done to enhance the Central Office's oversight and support role.

Most Division Services

Are Contracted Out

1

Good procurement practices and procedures are important to the Division

because i t expends a significant amount of funds for the purchase of

care. According to the Division's Business Operations Manager, the

Division spent over $ 150 mi l l ion on contracted services. Furthermore,

the Division accounts for the most procurement a c t i v i t y among the DES

divisions, awarding about 800 contracts and almost 500 individual service

agreements annually. Contractors provide a variety of services,

including room and board, day treatment and training, therapy, home

health services, and respite care.

Current structure - Responsibility for contracting is shared by the

Division's Central Office and the d i s t r i c t s . The Central Office has a

contracts management unit staffed by five employees: the unit manager,

two contracts specialists, and two clerical s t a f f . The Central Office is

responsible for developing and updating policies and procedures, and

preparing the Division's annual solicitation for services ( a

comprehensive request for proposals which is issued annually to a l l

providers statewide). In addition, the unit i s responsible for

processing contracts after they are negotiated and submitted for approval

by the d i s t r i c t s . Although the Central Office played a more significant

role this year negotiating provider contracts, in the past the d i s t r i c t s

have reviewed and evaluated proposals submitted for most services,

negotiated rates, and selected providers in their regions. Contracts

specialists in the d i s t r i c t s work with other employees temporarily

assigned to review proposals and select providers.

Central Office Role

Has Been Limited

The Division needs to strengthen the Central Office's support and

oversight role to ensure that d i s t r i c t s follow proper procurement

procedures uniformly and consistently. In a limited review of d i s t r i c t

contract records, we found several problems, such as poor or nonexistent

documentation, inadequate evaluations of proposals, and superficial

analysis of financial information submitted by providers.

The role of the Division's contracts management unit has primarily been

limited to a support function -- i t is neither structured nor equipped to

oversee and control d i s t r i c t procurement practices. The Division's

Central Office contracts manager stated that she does not review d i s t r i c t

contracting practices. Although i t desires to provide more oversight,

the Central Office is not set up to take on this responsibility easily.

F i r s t , the contracts manager does not have direct authority over d i s t r i c t

personnel involved in the contracting process. These personnel, l i k e the

contracts manager, report directly to the Division's business operations

manager or to the d i s t r i c t program managers. Second, the Central Office

does not have adequate staff to review d i s t r i c t procedures. According to

the contracts manager, her two contracts specialists are too busy

preparing the annual s o l i c i t a t i o n and processing the approximately 800

contracts awarded annually to take on additional tasks. Finally, contract

records that would require review are maintained in the d i s t r i c t s ,

further inhibiting the u n i t ' s a b i l i t y to examine d i s t r i c t practices.

While the Central Office maintains copies of current contracts, time

logs, and related correspondence, other documentation important to the

procurement process, such as provider proposals, proposal evaluation

forms, and negotiation notes are maintained by the d i s t r i c t s .

D i s t r i c t ~ roblems - More oversight over d i s t r i c t practices is needed to

ensure that proper procurement procedures are consistently and uniformly

followed. We conducted a limited review of 11 provider contract f i l e s ,

examining both Central Office and d i s t r i c t records avai lable at the time

of our audit . ( ' I We reviewed both the contract award ( which may have

occurred in Fiscal Year 1990- 91 or 1991- 92) as well as any subsequent

renewals or amendments to the contract. While the results of this review

are not necessarily indicative of a widespread problem, weaknesses we

identified indicate a need for more extensive oversight over d i s t r i c t

contracting practices.

The problems we identified also suggest that the Central Office needs to

provide more effective technical support to d i s t r i c t personnel. Training

of d i s t r i c t personnel has been limited, and policies and procedures have

not been updated and compiled into an easily accessible and useful manual.

The following are problems we identified that collectively can undermine

the integrity, fairness, and competitiveness of the procurement process.

These problems could also result in costly administrative or legal

challenges to the Division's procurement decisions.

Limited review of financial information - Some contract f i l e s showed

l i t t l e analysis and use of financial information submitted by

providers. In several cases, there was no evidence of any

systematic or detailed review of agency budgets. Rates for some

contracts appear to have been derived by dividing the provider's

proposed budget by the number of total client units, suggesting that

the provider's proposed budget was accepted without detailed

review. In three cases, rates accepted and contained in final

contracts were actually higher than rates originally proposed by the

( 1) Our i n i t i a l , exploratory sample of contracts was selected to represent a d i v e r s i t y of

services across d i s t r i c t s . It also included two contracts to one provider awarded by

a u n i t i n the Central Office. We intended to eventually review a larger sample of

contracts; however, the Division was slow i n assembling and sometimes unable to make

available to us complete records f o r the i n i t i a l sample within our audit time frame.

Therefore, we were unable to expand our sample size.

providers without j u s t i f i c a t i o n as to why. In some cases, while

there was documentation that costs were discussed in negotiating

sessions with providers, there was l i t t l e evidence that detailed

review of costs was conducted or that costs and budget information

was independently verified.

Questionable evaluations - Some proposal evaluations were poorly

done. In one case, di fferent evaluators appl ied c r i t e r i a

inconsistently, resulting in discrepancies in point deduct ions. In

other cases, evaluators rated one service proposed by the provider,

then copied the evaluation and used i t for a l l other services

proposed. ( Large provider agencies typical ly offer a variety of

services, a l l of which are required to be evaluated independently.)

We also examined evaluation forms which had more than one rating

number circled for the same evaluation item, i l l e g i b l e entries, and

mathematical errors.

Noncom~ liance with procedures - D i s t r i c t practices did not always

comply with the Division's policies and procedures governing the

contracting process. In one case, proposals were received and

accepted up to seven days after the publicly noticed submittal

deadline. There was no documentation that the deadline had been

extended. In two other cases contracts were awarded to providers

that did not appear to receive the highest ratings.

Inadequate and incom~ lete documentation - Several f i l e s lacked

important documentation. For example, two f i l e s had no documentation

of the evaluation of the provider's proposal. Four contracts

contained no documented j u s t i f i c a t i o n for contract rate increases

that were granted through contract amendments.

Weak Financial Review And

Oversiqht Has Been Costly

Inadequate review of some provider budgets and costs has been costly to

the Division and the clients i t serves. A recent series of financial

audits of major provider agencies disclosed that some providers have been

overpaid and spent service dollars in questionable ways.

Recent audits ordered - In May 1992, the Division hired an independent

accounting firm, KWG Peat Marwick, to conduct a financial review of

service providers. The financial reviews, initiated by the Division's

Assistant Director, were intended to examine provider expenditures and to

determine the reasonableness and allowability of costs. Service

providers selected for review were those receiving the largest amounts of

funding from the Division.

At the same time the Division was procuring an independent firm to review

providers, the DES Office of Internal Audit completed a similar review of

another major service provider. This audit was ordered after a letter

alleging questionable financial practices was received from the Regional

Office of the Inspector General of the U. S. Department of Health and

Human Services. The independent financial reviews conducted by the KPMG

and the Department's internal audit were the first such in- depth

financial examinations ever conducted involving Division service

providers.

Siclnificant amounts auestioned - The independent financial reviews and

the DES internal r audit identified a total of over $ 2.1 mi l lion in

questioned and/ or excessive costs for eight of the nine providers

examined. For two providers, total amounts questioned and/ or determined

to be excessive exceeded $ 500,000. Examp Ies of costs questioned or

determined excessive included the following:

$ 417,566 in bonuses paid in three installments from June 1990 to

June 1991 to the president of the agency. The bonuses were paid in

addition to the president's salary of $ 44,000. Funds were also used

to pay for the president's athletic club membership and for his

monthly chi Id care expenses.

$ 40,867 i n con t r i but i ons and enter ta i nmen t expenses spent by the

same provider. Entertainment expenses included charges for food and

beverages, lodging for management retreats, and floral arrangements

for various occasions.

$ 347,506 paid in compensation in 1991 to another provider.

$ 186,013 in excessive professional fees paid by the same provider

for accounting services.

A $ 35,000 bonus paid to the executive director of an agency, a

$ 32,000 bonus paid to the assistant director of the entity, and a

$ 5,000 bonus paid to a former off ice manager in 1991 and 1992. The

assistant director's bonus nearly doubled her base salary.

The nature and amount of the questioned and/ or excessive costs

demonstrate a clear need for a detailed, substantive, and meaningful

review of provider budgets and financial information. Financial

statement information reviewed by the independent auditors showed that

one provider realized net earnings of almost $ 1.3 mi I l ion in Fiscal Year

1990- 91. The provider had received about $ 9.6 million in service funds

from the Division. In another case, the independent auditors found a

mathematical error of over $ 10,000 in computing the provider's service

budget for professional specialty services. In an attempt t o v e r i f y

average hourly costs, the firm also found discrepancies between actual

average costs and hourly costs u t i l i z e d by the provider in i t s proposal.

For example, for personal care services, costs proposed were 38 cents per

hour higher than the average hourly costs calculated by the firm.

The Division Needs To Continue Its

Efforts To Strenathen The Contractina Process

The Division has taken significant steps to address weaknesses in the

contracting process. These efforts need to be expanded to ensure that

d i s t r i c t contracting practices are appropriate and properly documented

and that provider agencies are adequately monitored.

Efforts to improve - The Division took several actions in Fiscal Year

1991- 92 to strengthen the Central Office's role in the contracting

process. F i r s t , the Central Office led negotiations ( with the assistance

of several d i s t r i c t s t a f f ) of the 38 largest value contracts, those

representing $ 700,000 or more. These 38 contracts represent about

two- thirds of the Division's total dollars spent on purchase of care. An

outside firm was hired to assist the Central Office in i t s negotiations.

More detailed financial and budgetary information was requested from the

provider agencies, and more emphasis was placed on in- depth review of

provider costs. As a result of this e f f o r t , the Division estimates i t

saved approximately $ 5 million in contractor costs for Fiscal Year

1992- 93.

Second, as noted earlier, the Division hired an independent accounting

firm to conduct a financial review of eight providers. The Division is

currently pursuing recovery of questioned or excessive costs identified

by the financial reviews. In addition, a financial settlement was

reached with the provider audited by the Department's Office of Internal

Audit. This settlement has resulted in a payback to the State of an

undisclosed portion( 1) of the over $ 500,000 in costs questioned by the

internal audit.

The Division has initiated other efforts as well. For example, i t has

promulgated directives to promote more consistent procedures for

negotiating contracts in the d i s t r i c t s . It is also streamlining the

provider payment system by developing " blended rates" for contractors

that operate multiple programs, for example, group homes, a t d i f f e r e n t

sites. This would reduce the number of individual rates that have to be

negotiated with each provider.

Additional steps need& - The Division needs to continue and expand i t s

efforts. F i r s t , as noted earlier, i t needs to update procedures and i t s

contracts manual for d i s t r i c t personnel. The Central Office developed a

" Guide to Contracting" in April 1991. According to the Division's

contracts manager, the Guide is s t i l l in effect but needs to be updated

and reformatted for easier future revisions. In addition, numerous

directives have been issued to the d i s t r i c t s , on an ad hoc basis, by the

Division director and the Department's Contracts Management Section.

Directives are not compi led into a manual to al low for easy access and

reference.

In addition, more training needs to be offered. Some s t a f f t o l d us they

had no previous experience handling contracts and f e l t ill- prepared to

take on the contracting responsibilities they were assigned. The

d i s t r i c t s u t i l i z e program personnel to help in the contracting process,

but l i t t l e training has been offered to them. These personnel specialize

in service delivery, not fiscal control and accountability. The

contracts manager provided some training in 1992 to about 40 personnel,

but not a l l staff involved in contracting attended. Moreover, the

( 1) Under the terms of the settlement, both parties agreed not to disclose d e t a i l s of the

settlement. According to the Assistant Attorney General who hand1 ed the matter, t h i s

was done, i n part, to protect the State's position i n possible settlements with other

providers.

training focused s t r i c t l y on the negotiation process. No comprehensive

training has been provided.

Monitoring of contractors also needs to be strengthened. Currently,

financial monitoring is performed on a very limited basis. Contractors

receiving over $ 50,000 annually f i l e quarterly financial reports with the

Central Office, but l i t t l e is done with these reports. U n t i l t h i s past

year, there has been l i t t l e auditing of providers, nor have the d i s t r i c t s

focused on financial accountability. Further, d i s t r i c t contract monitors

focus primarily on programmatic rather than financial issues.

Finally, to strengthen accountability, the Division needs to continue i t s

efforts to c l a r i f y responsibility and authority on contracting matters.

As noted earlier, for example, the contracts manager had overal l

responsibility for the division's contracting process, but had no line

authority over the numerous D i s t r i c t personnel involved in the

contracting process. This made i t d i f f i c u l t for her to ensure and

enforce statewide compliance with the Division's contracting policies and

procedures.

RECOMMENDATIONS

The Division should continue i t s efforts to strengthen the Central

Office's role in the contracting process.

To supplement i t s current efforts, the Division should also consider:

Compiling a policies and procedures manual on contracting for

D i s t r i c t personnel,

Providing more extensive training to d i s t r i c t staff on

contracting policies and procedures,

Strengthening financial monitoring of contractors,

Clarifying responsibility and authority shared between the

Central Office and the d i s t r i c t s ,

Reviewing d i s t r i c t contracting practices on a regular basis to

ensure compliance with Division procedures, and

Ensuring that documentation of the contracts process is adequate

and consistently maintained.

OTHER PERTINENT INFORMATION

During the course of the audit, we developed information regarding the

adequacy and avai l a b i l i t y of services provided by the Division.

Peop l e w i t h deve l opmen ta I d i sab i I i t i es do not a l ways rece i ve adequate and

sufficient services. Overal I, our consultants described services

provided by the ALTCS program as " borderline acceptable" when compared to

other states' programs ( see the Introduction and Background, page 6, for

information on our consultants.) The consultants base their conclusion,

in part, on survey and interview results. Specifically, individuals

receiving services, and those persons providing direct care to

individuals ( including families and service providers), reported that

about 25 percent of a l l services being received were, on average, of less

than s u f f i c i e n t quality or that individuals were not receiving enough of

a certain service to meet their needs. They rated occupational therapy,

recreational therapy, speech therapy, and physical therapy as being most

inadequate. Division case managers reported about 19 percent of a l l

services currently provided to those same clients to be less than f u l l y

sufficient. Case managers rated community s k i l l s training and recreation

therapy the lowest.(') Table 3, page 52 l i s t s those service categories

with the lowest sufficiency ratings as identified by both groups.

While interview and survey results revealed concerns over the adequacy of

services received by some individuals, evidence gleaned from f i l e reviews

suggests that some clients are making developmental progress with

services currently received.

( 1) Due t o problems i n the needs assessment process, s e r v i c e p l a n n i n g process, and

process of moni t o r i ng progress toward achieving goal s current1 y i n place wi t h i n the

D i v i s i o n , the consultants cautioned t h a t service s u f f i c i e n c y r a t i n g s as reported may

be a r t i f i c i a l l y high.

TABLE 3

SUFFICIENCY RATINGS OF CURRENTLY DELIVERED SERVICES

REPORTED BY CLIENTS, FAMILIES, SERVICE PROVIDERS

AND CASE MANAGERS

( FOR SERVICES RATED LEAST SUFFICIENT)

Service

Occupational Therapy

Recreational Therapy

Speech Therapy

Physical Therapy

Psychotherapy

Cogn i t i ve

Community S k i l l s

Med i ca l

Case Management

Behavior Modification

Community S k i l l s

Recreation Therapy

Physical Therapy

Occupational Therapy

Behavior Modification

Percent Of Clients, Families,

And Service Providers Rat i ng

Service Sufficient

Percent Of Case Managers

Ratina Service Sufficient

Source: Auditor General summary of information contained in the

consultant's final report to the Auditor General, dated

November 1992.

In addition to problems with the quality and level of services actually

being received, some services are simply not available when needed.

Research we conducted revealed that demand for certain services cannot

be met because of the scarcity of some services. Survey and interview

information we developed indicated that gaps exist in services needed

for both T i t l e XIX e l i g i b l e and non- Title X I X e l i g i b l e persons

( State- funded only). Moreover, services are general ly less avai lable

for the non- Title XIX recipients, due largely to a lack of State

funding. I n t o t a l , for a l l clients, the results of various surveys and

interviews we conducted indicates that placement in Intermediate Care

F a c i l i t i e s , peer self- help assistance, and special therapies ( physical,

occupational, and speech) are generally unavailable for many clients.

Foster homes ( especial ly cultural ly appropriate homes ) ,

employment- related services, and individual provider services, such as

respite and personal care, were also described as being d i f f i c u l t to

obtain.

In a similar vein, our consultants were told during a focus group that

due to a dearth of therapists in d i s t r i c t s other than D i s t r i c t s 2 ( Pima

County) and 4 ( Yuma, La Paz, and Mohave counties), therapy services were

rarely, i f ever, prescribed even when i t would have been appropriate to

do so.

Reasons for lack of a v a i l a b i l i t y have been described as including: a

lack of providers for some services, particularly therapies; lack of

State funding ( for example, to pay for services T i t l e XIX does not pay

for and for development of new residential faci l i t ies); lack of Division

staff time to recruit individual providers; limitations resulting from

income requirements for foster homes; provider d i f f i c u l t i e s i n

contracting, b i l l i n g , and receiving payment from the State, and low pay

rates.

To improve a v a i l a b i l i t y i n these and other areas, those we interviewed

or who responded to our surveys made severa l suggest i ons , i nc l ud i ng : ( 1 )

consideration of a voucher system for paying individual providers and

therapists, which would be expected to increase the number of those

providing services and lessen payment problems, and ( 2) more aggressive

efforts by the Division in recruiting individual providers, therapists,

and foster homes.

The consultants concluded that the service system lacks innovation,

c r e a t i v i t y , and effective case management. Other than some creative

foster care situations, for example, CFA found l i t t l e evidence of

supported living arrangements or supervised apartments. In terms of day

program options, the consultants queried the focus groups about the

apparent lack of supported employment options, such as job coaches and

sheltered workshops, and were told by case managers that this service

was not fundable through T i t l e X I X . The consultants explained, however,

that many other states have found creative ways to f a c i l i t a t e supported

employment opportunities. Case management, described by the consultants

as a c r i t i c a l l y important service, was found to be ineffective in many

cases. Their research found case managers often lacking the necessary

competence and abi l i ty to per form good case management due to a var i ety

of factors, including inadequate training, high case loads, and too much

paperwork ( see Finding I I , page 17, for additional information on case

management . )

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

171 7 W. Jefferson - P. O. Box 61 23 - Phoenix, AZ 85005

Fife Symington Charles E. Cowan

Governor Director

MAR 2 6 1993

Mr. Douglas R. Norton, CPA

Auditor General

Office of the Auditor General

2700 N. Central Avenue, Suite 700

Phoenix, Arizona 85004

Dear Mr. Norton:

Thank you for the opportunity to review the Auditor General's Office

performance audit on the Division of Developmental Disabilities

( DDD).

We have enclosed three copies of our response to the Auditor

General's report. In many cases, the response updates information

provided in your office's report. We are pleased to have this

opportunity to respond and appreciate, as well, the courtesy

consistently displayed by your staff in the course of their review.

We believe that the recommendations contained in this report are

consistent with the direction that DDD has embarked upon under

new leadership. In our response, we demonstrate how the DDD has

already begun implementation of many of those recommendations.

If you have any questions or need additional information, please call

me. *

/

Enclosure

c:

Sam Thurmond

DIVISION OF DEVELOPMENTAL DISABILITIES

RESPONSE

TO AUDITOR GENERAL'S REPORT DRAFI'

Before responding to specific items in the Auditor General's draft report, we want to

establish the context in which this information, and the Division of Developmental

Disabilities ODD), must be viewed.

Arizona's Long Term Care System ( ALTCS) Title XIX program is unique in the

United States and meaningful comparisons with other State programs are difficult.

The Auditor General's report drew upon the analysis of an independent consultant firm,

Conroy and Feinstein ( CFA). Much of CFA's conclusions are subjective and derived

from perceptions at the " front linen, that is, case managers and families. These

perceptions are valuable, but this population has not felt the impact of the changes

which have been instituted in Central Office and which have not yet been fully

implemented Statewide.

The DDD recognizes and acknowledges many of the difficulties with this program.

The problems are of a long standing nature. The DDD went through a major

expansion in December 1988 when the DDD became the only agency in the United

States to start both a Long Term and an Acute Care system on the same day. The

ALTCS ( Title XIX) program increased not only the DDD's client population

dramatically but added to the DDD's reporting responsibilities.

Under the current Assistant Director, who has been in charge of the DDD for one year,

a series of principal changes have been instituted to address the problems identified in

the Auditor General's report. The DDD had already identified many of these same

problems in its General Systems Design analysis, and has developed - and in a number

of cases executed - plans to address them in a consistent and uniform manner while

abiding by budgetary restrictions. The DDD has created systems, procedures, and

training to resolve the problems, and is now reaching a stage where these changes are

beginning to become evident. Two very obvious examples are the creation of the

Statewide Policy and Procedures Manual, which, when published, will be available to

case management, and the case manager training program ( described by CFA as " state

of the art"), which is being implemented in March 1993.

We appreciate the recognition which the report gave to the leadership of the current

Assistant Director in pursuing changes in both fiscal and programmatic areas. The

Division is confident that future audits will show the culmination of those changes and

the resolution of many of the problems identified in the Auditor General's report.

The Division Needs to hlore Adequatelv Im lement its Policies for

Assessing and Planning Individual 8 lient Services

All Necessary Assessments Are Not Being Done

This section of the report contains many statements that can be characterized as

subjective.

The finding that all necessary assessments are not being done is based upon conclusions

reported by CFA. CFA examined case records and determined that, on the average,

31.9 percent of these cases showed " no evidence that assessment was performed"

DDD questions whether this means that no assessments were performed or that an

assessment which CFA felt should have been performed was not. The DDD and

ALTCS policy calls for assessments & in areas that are considered appropriate for

the client and the client's diagnosis.

Evidence that the CFA assessment findings may not be accurate is indicated by family

and consumer input. CFA asked families and consumers if they thought the Individual

Program Plan ( IPP) goals were appropriate. Of respondents, 85.9 percent reported that

goals were appropriate, 8.8 percent reported that goals were partially appropriate, and

5.3 percent reported that goals were not appropriate ( see pp 46 of the CFA report).

Fully 94.7 percent of the respondents believed that the IPPs contained appropriate or

partially appropriate goals. Clearly, the DDD is perceived to be addressing the right

goals by the families and consumers.

This is not to say, however, that DDD does not need to make improvements in this

area. The DDD has launched a number of initiatives that will bring about

improvements. Some of these are:

1. The new Individual Service and Program Plan ( ISPP) format and training for

case managers and provider staff. The ISPP combines the previously used

Individual Program Plan ( IPP) and the Service Plan. The format of the ISPP

specifically requires documentation of all needed assessments and provides a

check list for the team members to ensure that no area of assessment is

overlooked.

2. The Case Management core cumculum addresses the importance of

comprehensive assessments. The utility of this training is acknowledged by

CFA when they point out that " the case manager training materials are

definitely state of the art; if this training were fully implemented, Arizona's

problems with the assessment process would diminish sharply." @ p 40).

3. The DDD case management training and ISPP format emphasize the " person

centered planning" approach which is cited by CFA as a current best practice in

the field.

1. Training in person centered planning has been provided in four of the six

districts since 1990 through a contract with Patterson and Associates. Patterson

and Associates is now working with all districts through its Statewide contract

with the DDD.

5. The Individualized Family Senice Plans ( IFSP) approach is cited by CFA as a

example of a well integrated assessment and planning approach. The IFSP is

being field tested in two DDD districts before Statewide application is

approved. The DDD should be implementing this Statewide in FY 94.

ICAPs Not Done Timely

The new ISPP policy and training will address this issue.

Procedures for Conducting Planning Meetings Are Not Always Followed

The Auditor General's report @ p. 12) summarizes the CFA opinion that, " professional

personnel and others who should be involved in the IPP team meetings are often left

out" and "... only one case in which there was a properly constituted interdisciplinary

team present during the clients' annual IPP reviewn. It is neither cost efficient nor

necessary for all professional personnel to be included in all ISPP ( formerly IPP)

meetings. As a practical matter, physicians and therapists are not able to attend such

meetings. It is sufficient in most cases for their assessments and recommendations to

be available for the team meeting.

It is appropriate to involve medical specialists in the planning process for individuals

with identified medical needs. The DDD's Specialty Services Unit has been established

to provide medical nurse case management to individuals who are medically involved.

These nurses can and do provide assessment of individuals' medical needs. However,

to provide CFA's recommended level of involvement by medical personnel in the

planning process would require a ratio of one nurse for every 30- 50 individuals served

by the DDDIALTCS program. It is doubtful that this could be justified as cost-effective.

The report stated that critical information was not available when IPP teams met. CFA

did not find comprehensive IPPs that encompassed assessment results from other

agencies working with the client ( e. g., local school districts). If a DDD client is in

residential service, the provider would maintain medical records, lab results, etc., and

the case manager would not necessarily maintain copies in the case file. However, the

DDD agrees that this is an area in which they need to tighten their procedures and

document information.

CFA also notes that IPP teams " often do not reconvene when appropriate". The DDD

has instituted actions, such as an Administrative Directive clarifying the review of

ISPP, and addresses this concern in the Policy and Procedure Manual and in Case

Manager and ISPP training; DDD acknowledges, however, that more must be done and

is committed to taking stronger steps in that direction.

Breakdowns Occur Within the Case Management System

The Auditor General's report noted that the DDD's policies and procedures were

appropriate and that communication and lack of training are problems. These problems

are being addressed by the DDD through a comprehens~ vetr aining program.

1. Concur. The DDD has established a Statewide case management training

curriculum being implemented in March 1993.

2. Concur. The DDD is conducting a research project through the Arizona Early

Intervention Project ( AZEIP) field tests in Districts 11 and III to determine an

appropriate tool for this population that can be used Statewide. An assessment

tool has been selected for the field tests based upon a review of national best

practices.

3. Concur and addressed through new ISPP form.

4. Concur and being addressed in case management training and in ISPP training.

5. Concur, but may not always be possible. Site reviews will incorporate this as

an item for the monitoring of case files.

6. Concur. Individual Family Service Plan is addressed with a supplemental sheet

in the new ISPP. Policy and Procedures Manual addresses plan coordination.

The Division's Case Management System

Cannot Effectively Service Clients

The DDD generally concurs with the recommendations for improving case

management .

Case Management is Essential, but Inadequate at DDD

Case management is essential for a system in which services are dispersed and require

coordination. CM is also critical to meeting Title XIX, Foster Care, and Statutory

requirements. The introduction of Title XIX funded services in December 1988 placed

new responsibihties on case managers while none were taken away.

Over the past year, much has been done to institute consistent policies and to clarify

case management responsibilities. Administrative Directives were used to provide

rapid solutions to policy issues. These directives are now being incorporated into a

Statewide policy and procedures manual ( scheduled to be distributed in May 1993).

Additionall