May 2000

A Performance Audit of Group Home Oversight

A Performance Audit

of the Commonwealth's Oversight of Group Homes

for the Mentally Retarded

in Western Pennsylvania

 

Pennsylvania Department of the Auditor General

Auditor General Robert P. Casey, Jr.

Letter to Governor Ridge

Introduction

Background

Objectives, Scope, and Methodology

Chapter One - Staffing Issues that Affect the Health and Welfare of Group Home Residents

Chapter Two - Unexpected Deaths of Group Home residents; Incidents of Abuse

Chapter Three - Quality of Service to Group Home Residents

Chapter Four - Physical Condition of Group Homes

DPW's Response to Audit Findings
Reprinted is the entire text of DPW's Response to the Department of the Auditor General with the exception of four attachments. These attachments include the "Pennhurst Longitudinal Study," the "Somerset Evaluation/Assessment Project Report," the "Report on the Closure of Laurelton State Mental Retardation Center," and the "Health Futures Report." It should be noted that - in the body of our audit report - we have repeated sections of DPW's response as they apply to specific conclusions, followed by our counter response.

Appendices

Distribution List


  May 8, 2000

The Honorable Thomas J. Ridge
Governor
Commonwealth of Pennsylvania
Room 225 Capitol
Harrisburg, Pennsylvania 17120

Dear Governor Ridge:

This report contains the results of the Department of the Auditor General's performance audit of the Commonwealth's oversight of group homes for persons with mental retardation. Specifically, the audit reviewed your Department of Public Welfare's (DPW) oversight of eight group homes in Western Pennsylvania for the period from July 1, 1994 through June 30, 1999. The audit was conducted pursuant to Section 402 of The Fiscal Code and in accordance with Government Auditing Standards issued by the Comptroller General of the United States.

Group homes are currently the subject of intense public interest, especially in Western Pennsylvania with the closure of Western Center and the transfer of its residents to group homes in residential neighborhoods. It is important to note that this audit does not evaluate the closing of Western Center; rather, it was conducted to evaluate the state's oversight concerning issues that affect the health and safety of group home residents.

Our audit findings have raised a number of serious concerns. As a result, we have offered 47 recommendations to improve your administration's oversight of group homes and, ultimately, the quality of care provided to group home residents.

In Chapter One, we found that DPW had allowed staff with criminal backgrounds to care for group home residents, and that staff training requirements were woefully inadequate to ensure the health and safety of residents.

In Chapter Two, we found that DPW failed to promptly investigate allegations of abuse and unexpected deaths of group home residents.

In Chapters Three and Four, we found that DPW failed to ensure that services were provided in a way that enhanced the health and well-being of residents, and that not all eight group homes we sampled were clean and safe.

Your administration's Department of Public Welfare, while entirely professional and cooperative throughout this process, appeared in its management response to have difficulty acknowledging the deficiencies we identified. Specifically, in the introduction to its response, DPW makes the incorrect statement that our report "does not find that the health and safety of any individual in the homes selected was in jeopardy, nor did the report find fault with the quality of care provided to the individuals in the homes." To the contrary, our audit found serious deficiencies that threaten the health and safety of group home residents, including allegations of abuse and unexpected deaths that were not investigated promptly, direct care workers with criminal backgrounds, and inadequately trained caregivers.

Those examples and the tone of DPW's written response cause us added concern. Further, it is disingenuous for DPW to suggest in its response that we did not provide enough supporting "comprehensive detail" from our auditors' work papers in order for DPW to confirm or correct our conclusions, or that its "short response time" was prohibitive. Not only did we provide DPW with all the information it asked for, but we also allowed DPW to have the response time it requested.

DPW's response is incorporated into the report under the applicable sections; the response also appears in its entirety in the appendices. In addition, the contents of this audit report were discussed with DPW management.

DPW has the authority and responsibility to implement the recommendations in this report to protect the health and safety of group home residents. Those residents, their families, and taxpayers deserve nothing less.

  Sincerely,
 
 
Robert P. Casey, Jr.
Auditor General

 

Introduction

Understanding
Mental Retardation

 

 

According to the American Association on Mental Retardation (AAMR), individuals with mental retardation are those individuals who, since childhood, have had and always will have an intelligence quotient (IQ) below 70-75 and who experience significant limitations in two or more adaptive skill areas. Adaptive skills are those daily living skills needed in order to live, work, and socialize in the community. Adaptive skills include, but are not limited to, communication, self-care, home living, social skills, and functional academics. The AAMR estimates that one in ten American families includes a person with mental retardation.

Mental retardation results from any condition which impairs the brain's development before birth, at birth, or throughout early childhood. The three leading causes of mental retardation are:

  • Down's syndrome, a chromosomal disorder;

  • fetal alcohol syndrome; and

  • fragile X syndrome, a single gene disorder located on the X chromosome and the leading inherited cause of mental retardation.

Mental retardation can also result from some childhood diseases or an accident that results in a severe injury to a child's head.

As is true for any medical condition or developmental disability, the overall effects of mental retardation on an individual's life vary from person to person. Research promoted by the AAMR indicates that approximately 87 percent of all Americans with mental retardation are affected only slightly, resulting in a slower than average ability to learn new information or skills. The other 13 percent of Americans diagnosed with mental retardation are found to have IQs below 50 that limit their overall functioning and, thus, pose significant--yet not necessarily insurmountable--challenges to achieving independence.

 

 

Mental Retardation Services in Pennsylvania

Individuals with mental retardation in Pennsylvania have a vast array of services available to them. Some individuals receive services to meet their health, social, and daily living needs in state centers for the mentally retarded. However, more and more Pennsylvanians with mental retardation are being discharged from state institutions to face the challenges of everyday living, finding employment, and building social relationships in supported, yet more independent, community-based living arrangements. Such settings include community homes for people with mental retardation, also known as "group homes," the subject of this audit.

Group homes serve eight or fewer individuals and are licensed and regulated by DPW. Approximately 9,000 individuals with mental retardation live in group homes in Pennsylvania.

Mental retardation services in Pennsylvania are largely classified into three broad categories of service:

  • Institutional Services;

  • Community-Based Mental Retardation Services; and

  • Early Intervention Services for children up to age two.

Institutional Services include residential programs that are either operated by the state--known as State Centers--or by private institutions supported by public funds--known as Intermediate Care Facilities for the Mentally Retarded (ICF/MR). Pennsylvania operates seven state centers for the mentally retarded and one mental retardation unit at a state mental hospital.1  During the 1999-2000 fiscal year, the Commonwealth expects 1,823 individuals with mental retardation to reside in state centers and 3,000 individuals to reside in one of the state's 221 ICF/MRs. Pennsylvania appropriated approximately $231 million to care for these individuals during the 1999-2000 fiscal year.

Community-Based Mental Retardation Services are either residential services or day programs within the community, which include employment, recreation, or other training activities to help individuals with mental retardation function and thrive in the community. In addition, such individuals and their families may be eligible for case management, adult day care, and other services to support their daily living. Pennsylvania appropriated nearly $534 million for community residential and other support services during the 1999-2000 fiscal year.

Individuals with mental retardation who live outside of an institutional setting and who are not living directly with their own family may reside in a single apartment, an apartment with a roommate, a family living home, or a group home. A family living home, which is licensed by the Department of Public Welfare (DPW), is a private home in which the homeowner provides residential services to one or two persons with mental retardation.

 

Deinstitutionalization: Challenges and Opportunities

Pennsylvania's Mental Health and Mental Retardation Act of 1966 requires the provision of community services to individuals with mental retardation and their families. In 1971, the General Assembly appropriated funds for community living arrangements and family support services. This funding played a role in the shift from the larger state-operated institutional settings-from over 13,000 persons with mental retardation living in state centers in 1967 to approximately 1,800 in fiscal year 1999-2000.

Although deinstitutionalization is a growing practice both in Pennsylvania and nationwide, it has been controversial. The controversy stems from debates about the rights of individuals with mental retardation to determine their own futures and the increasing public costs of institutional care.

The efforts to help individuals with mental retardation escape the perceived and actual boundaries of state-run institutions have resulted in several high profile court cases. These court cases have placed greater emphasis on the removal of barriers preventing an individual's transition to community living. For example, the recent U.S. Supreme Court decision in Olmstead v. L.C. requires states, under certain conditions, to place persons with mental disabilities in community settings rather than in institutions. The plaintiffs in the Olmstead case were two Georgia women with mental retardation who had resided for years in a state institution even though their doctors eventually concluded that the women could receive appropriate care in community settings outside of their institution. 2 

Following the Olmstead decision, the U.S. Department of Health and Human Services notified state Medicaid directors on January 14, 2000, of the federal government's continued commitment to deinstitutionalization. The letter stated in part: "[N]o one should have to live in an institution or a nursing home, if they can live in the community with the right support. Our goal is to integrate people with disabilities into the social mainstream, promote equality of opportunity, and maximize individual choice."

The letter recommended that states develop comprehensive plans to strengthen their community service systems, actively involve people with disabilities, use available technical assistance from the federal government, and inform the government of questions and ideas regarding assistance that would be helpful.

While the prospect of living outside of an institution means independence and rewards for some, there are many other individuals with mental retardation and their families for whom such a transition brings fears, challenges, and even crises. These individuals do not necessarily welcome deinstitutionalization, even when state and local officials promise intensive community supports. It is not surprising then that some families resist actions that will disrupt a level of comfort and familiarity that has taken years to achieve.

As the Commonwealth and others promote greater independence for the mentally retarded, it must ensure that residents discharged from institutions are not only capable of leaving such care, but also able to thrive in the community because the discharge is in their best interest and supported with intensive community supports. To the extent that residents move to group homes, it is our hope that this performance audit will assist in the promotion of their safety and well-being in those settings.

 

 

Background

In Pennsylvania and across the nation, human services organizations-especially those that are publicly funded-are restructuring their delivery of services to vulnerable individuals. In the field of mental retardation, an increasing emphasis is being placed on allowing mentally retarded adults and their loved ones a greater role in deciding how, where, and with whom they should live. At the same time, a growing number of residential and community supports for the mentally retarded are providing alternatives to institutional care.

Since the 1960s, many states, including Pennsylvania, have moved thousands of individuals with mental retardation out of institutions and into group homes in residential neighborhoods. In 1989, a class action lawsuit was brought against the Commonwealth on behalf of residents of Western Center. Western Center is a state center for the mentally retarded located in Canonsburg, Washington County.

In 1992, a resolution to the class action lawsuit was eventually achieved and approved by the federal court. At the time of this consent decree, 359 individuals were residing in Western Center. In 1998, DPW began the process of discharging residents into community living settings, including group homes. DPW officially announced its intention to close Western Center and discharge all residents-including the most severely challenged-into the community by June 30, 1999.

Following this decision, several trustees and family members of current and former residents of Western Center expressed concerns to the Department of the Auditor General about the treatment and well being of group home residents in Western Pennsylvania. In particular, they alleged that "forced outplacements of Western Centers residents [to private group homes] have resulted in numerous tragedies, including documented cases of abuse, neglect, abandonment and unexplained or avoidable deaths." The trustees and family members also told us that outplacements had sometimes occurred without the appropriate and required pre-discharge evaluations being performed, in opposition to the expressed concerns of residents and families, and without the full participation of residents and families in the decision-making process.

The source and substance of these allegations raised very serious concerns. Therefore, pursuant to his audit authority and his commitment to Pennsylvania families, Auditor General Robert P. Casey, Jr., in May 1998 launched a performance audit survey of the process by which Western Center residents had been placed into community living arrangements. As part of this survey, auditors examined certain DPW procedures for monitoring the care, support, and treatment provided to individuals with mental retardation in group homes supported by state funds.

We completed our survey in January 1999. The results of our work, which we communicated to DPW, showed that DPW did conduct pre-discharge evaluations of Western Center residents prior to their placement in group homes or other community living facilities. However, it did not appear that decisions regarding whether residents should be discharged in community settings were made based on individual evaluations of each resident's needs as required by the federal consent decree. We did not pursue whether DPW's evaluation process complied with the decree because this issue would be settled definitively by the federal court.

We found that 52 percent of the families expressed no objection to community placement, 14 percent expressed concerns or reservations, 23 percent objected to community placement, and 3  We were unable to conclude, however, whether families were permitted the level of involvement provided for under the consent decree. We refrained from pursuing this issue because it would be resolved by the federal court.

Finally, regarding the allegations of abuse that families and guardians told us resulted from what they considered to be forced community placements, we found that the rates of alleged and substantiated abuse incidents in group homes were significantly higher than the rates of alleged and substantiated abuse at Western Center.

Because our survey raised sufficient concerns regarding the quality of care being provided to former Western Center residents, Auditor General Casey launched a performance audit of the Commonwealth's oversight of eight group homes for the mentally retarded in Western Pennsylvania.

Fieldwork for this audit began on February 19, 1999, and was completed nine months later on November 12, 1999. Our sample included five counties, eight provider agencies (companies that operate more than one home), and eight homes (one home per provider agency). The provider agencies in our sample were based in Allegheny, Beaver, Fayette, Washington, and Westmoreland counties.

Our sample also included 35 individuals whose mental retardation ranged from mild to profound. Some of those individuals could walk on their own, while others could not. Some had severe physical disabilities, while others did not. One of the 35 held a part-time job, another held a job with the assistance of a "job coach," several others worked in controlled settings, and the others attended day programs. A profile of each resident is included in the appendices.

DPW, through its headquarters in Harrisburg and its Western Regional Office in Pittsburgh, is ultimately responsible for monitoring the provider agencies operating group homes in Western Pennsylvania, reviewing the counties' oversight of the agencies and homes through county Offices of Mental Health/Mental Retardation (MH/MR), and ensuring the health and safety of group home residents. Chapter 6400 of Title 55 of the Pennsylvania Code contains DPW's regulations applicable to group homes and their provider agencies. DPW ensures compliance with these requirements through its licensing inspection process. Areas addressed include individual rights, staffing, physical site, fire safety, individual program planning, individual health, and medications.

The health and welfare of mentally retarded individuals is monitored through DPW's Health Risk Assessment Initiative, a system to collect health care information about people who had moved or were in the process of moving from state-operated facilities into community settings. In addition, health and welfare issues are monitored by each county though case management services. County oversight is further defined through written contracts between counties and provider agencies.

Each year, the Commonwealth of Pennsylvania directs hundreds of millions of dollars to mental retardation services. This financial investment and, more importantly, the needs and concerns of clients and their families, underscores the importance of vigilant state oversight of group homes for the mentally retarded.

There is no question about the magnitude of the challenge to ensure the safety and well-being of group home residents. As with any vulnerable group-children, older persons in nursing homes, and those incapacitated by illness-there are serious risks of abuse, neglect, and poor quality care.

The report that follows presents the findings of our performance audit of the state's oversight of group homes in Western Pennsylvania for the period July 1, 1994 through June 30, 1999. This audit was conducted in accordance with Government Auditing Standards issued by the Comptroller General of the United States.

 

 

 

 

 

Objectives,
Scope, and
Methodology

Our performance audit focused on group home staffing issues, deaths and abuse incidents, service provision, and physical environment.

 

Specifically, the audit intended to determine whether:

  • residents were provided clean and safe homes;
  • abuse and death incidents were thoroughly investigated and reported and safeguards were implemented to prevent future occurrences;
  • resident needs, including ongoing health care, vocational and special therapies, medication regimens, and case management services, were properly provided;
  • group home staff members possessed appropriate backgrounds and were properly trained to support the residents; and
  • staffing ratios and turnover rates in group homes were maintained at levels which assured continuity and stability in the care received by residents.

To assess quality of care in group homes and to determine the adequacy of DPW and county oversight, we:

  • reviewed state regulations and applicable guidelines to determine minimum standards regarding group home operations and DPW oversight responsibilities;
  • selected a sample of eight provider agencies and group homes;
  • reviewed documents, conducted interviews, and observed general operating procedures in the selected provider agencies to assess regulatory compliance; and
  • compared DPW inspection records, case manager records, and county contracts with the audit results to assess the efficacy of DPW and county oversight procedures.

The sample of reviewed provider agencies and group homes included former residents of Western Center and other institutions, as well as residents placed from their family homes. The sample was also designed to produce a mix of homes based on these additional attributes:

  • provider agency size, based on the number of group homes operated by the provider;
  • reported abuse rates, based on DPW's unusual incident database; and
  • number of residents in the home.

The final sample included one home from each of eight provider agencies in five western Pennsylvania counties. The attributes are detailed on the following page.

 

Attributes of the Eight Group Homes Selected for Our Sample

 

Total number of homes operated by provider agency

Home's residential capacity

Former Western Center residents at the home?

Home 1

51

3

Yes

Home 2

106

3

No

Home 3

68

5

Yes

Home 4

48

3

Yes

Home 5

68

4

Yes

Home 6

27

3

Yes

Home 7

45

3

Yes

Home 8

43

6

No

Notes about this table:

 

Chapter One

Staffing
Issues that
Affect the
Health and
Welfare of
Group Home
Residents

Caregivers who
have been
convicted of serious
crimes were
employed in group
homes, working
directly with
vulnerable
residents.

The provider agencies that operate group homes employ direct care staff to care for the health, safety, and well-being of the residents of the homes. The provider agencies must recruit, hire, train, and retain qualified personnel to ensure that residents receive the highest level of service. Individuals with mental retardation, whether receiving partial or full-time care, deserve to have their needs met by staff who are trained, experienced, compassionate, and consistent in providing care.

The background of caregivers is especially critical because of the vulnerability of group home residents. The homes' provider agencies must make every effort to minimize the risk of exposing individuals to direct care workers who have demonstrated criminal tendencies. Comprehensive and timely criminal history background checks are an important part of this process.

The abilities of caregivers are also critical. For both the resident and the caregiver, provider agencies must do all they can to ensure that their direct care workers support their residents' needs and have the training to help them. Residents with specific nutritional needs, for example, require caregivers who are knowledgeable about relevant feeding techniques.

Finally, in order to avoid disruption in residents' lives, provider agencies must strive to provide a consistent direct care staff. The resident-caregiver relationship can be much like that of a family, and high staff turnover rates can interrupt familiarity and impede progress in habilitation and therapy.

DPW plays a vital role in ensuring the quality of the direct care staff. The primary tool in this effort is the licensing inspection process, through which DPW monitors provider agencies to ascertain their compliance with DPW regulations related to staffing issues.

 

 

Objectives and Methodology for Chapter One

Our audit intended to assess the quality of care in group homes by determining whether:

  • provider agencies effectively conducted criminal background screenings of prospective employees in a timely manner;
  • state law and regulations regarding criminal history background checks can adequately safeguard group home residents;
  • DPW oversight adequately protected residents against the employment of direct care workers convicted of serious crimes;
  • direct care worker turnover rates were conducive to consistent resident care;
  • direct care worker-to-resident ratios were within mandated limitations and allowed for the level of care specified in each resident's annual assessment;
  • mandated training requirements ensured that direct care workers were properly prepared to support group home residents; and
  • DPW inspections ensured that direct care workers met regulatory training requirements.

To complete the assessment, we:

  • reviewed state requirements regarding group home staff employment and training;
  • visited eight provider agencies that operate group homes and obtained past and present direct care worker personnel records;
  • reviewed provider agency personnel records to assess the existence, timing, and results of employee criminal history background checks; summarized staff turnover information; and determined whether staff were adequately trained to support residents;
  • assessed whether existing law and regulations regarding criminal history background checks can adequately safeguard group home residents;
  • interviewed Pennsylvania Department of Aging (PDA) and DPW personnel to determine the existence and nature of training regarding state requirements governing the employment and retention of persons convicted of crimes;
  • correlated staff turnover information with residents' quality of care;
  • assessed whether provider agency training programs adequately prepared direct care workers to support residents;
  • obtained DPW inspection records to assess oversight; and
  • interviewed DPW personnel to determine the policies and procedures for group home licensure.

Conclusions 1, 2, and 3 discuss the issue of criminal history background checks for group home employees. According to DPW and PDA, the criminal history background check provisions of the Older Adults Protective Services Act (OAPSA)4--a state law aimed at protecting older Pennsylvanians in certain facilities--apply to residential programs serving the mentally retarded, including group homes. However, there is currently some debate as to whether OAPSA applies to group homes because OAPSA does not expressly designate group homes as a type of facility subject to its provisions.

 

 

Conclusion 1:

State law and regulations requiring criminal history background checks for prospective group home employees are not sufficiently stringent to protect group home residents.

Provider agencies must consider the previous employment, education, and experience of prospective employees in order to ensure that those individuals are informed about the needs of persons with mental retardation and that their knowledge and commitment will lead to consistent and compassionate quality of care. However, an evaluation of a prospective employee's experience and employment record is by no means sufficient to provide greater protections for individuals with mental retardation, whose vulnerability may be heightened due to intellectual or physical impairment.

Therefore, a key component for the evaluation of prospective employees is a thorough and timely understanding of prospective employees' criminal backgrounds. Whether a resident of a group home is entirely care-dependent or has the ability to pursue life activities outside of the group home, provider agencies, residents' families, and the Commonwealth must ensure that individuals with mental retardation are not victimized by those charged with their care.

We reviewed criminal history records for a sample of 5  who were either "current"6  or former employees of group homes operated by the eight provider agencies selected for our audit. Six of the 48 current employees, as well as 17 of the 158 former employees, had been convicted of various felony, misdemeanor, and summary offenses.7  The frequency and nature of the crimes are depicted in tables on the next two pages.8 

One employee was a direct care worker from September 1997 until early 2000. His criminal history background check revealed that he had been alternately imprisoned, fined, and placed on state and/or county probation for 27 convictions, including assault/solicitation to commit sodomy, prostitution, theft, forgery, writing bad checks, receiving stolen property, and several felony and misdemeanor drug offenses. As discussed in Conclusion 3, the provider agency's retention of this employee at the group home violated the Older Adults Protective Services Act.

In 1993, the same provider agency hired a person previously imprisoned for aggravated assault, violation of state firearms laws, criminal attempt/robbery, and assault by a prisoner. This person was dismissed only after he was reincarcerated in 1996.

 

 

Criminal Convictions of Direct Care Workers

9 

Convictions of 6 of 48 direct care workers sampled

Frequency

Number convicted of crimes

6

Number who disclosed crime(s) on application

1

   

Convictions:

 
 

Drugs (felony)

5

 

Drugs (misdemeanor)

4

 

Assault/solicitation to commit sodomy (felony)

2

 

Prostitution and related offenses

4

 

Robbery with accomplice or while armed or by violence

 
 

(felony)

1

 

Forgery

2

 

Receiving stolen property

5

 

Theft by unlawful taking

1

 

Bad checks

3

 

Retail theft (summary offense)

3

 

Public drunkenness

2

 

Driving under the influence of liquor or drugs

 
 

(misdemeanor)

1

 

Counterfeiting - inspection/license/title/permit (felony)

1

     
 

Total convictions of direct care workers

34

Notes: (1) We included the type of offense-felony, misdemeanor, summary-for those cases in which that information was included in the file during fieldwork.

(2) Of the 34 convictions summarized, 27 were attributable to one employee who was employed, not by one of the eight group homes that we audited, but rather by a different group home operated by one of the provider agencies that we audited.

(3) Ultimately, the convictions of the majority of these 6 direct care workers would not have prohibited the employees hiring or retention under OAPSA, but the provider agencies could not have known that fact during the provisional period or the delay that followed.

 

 

Criminal Convictions of Former Direct Care Workers in Eight Group Homes

 

Convictions of 17 former direct care workers of 158 sampled

Frequency

Number convicted of crimes

17

Number who disclosed crime(s) on application

4

   

Convictions:

 
 

Aggravated assault (felony)

2

 

Assault by prisoner (felony)

1

 

Simple assault (misdemeanor)

1

 

Firearms (misdemeanor)

1

 

Drugs

1

 

Harassment (summary offense)

3

 

Criminal attempt/robbery

1

 

Retail theft (summary offense)

9

 

Theft by deception (misdemeanor)

1

 

Disorderly conduct (misdemeanor)

1

 

Public drunkenness (summary offense)

1

 

Unsworn falsification to authorities (summary offense)

1

 

Driving under the influence of alcohol or controlled

4

 

substance (misdemeanor)

 
 

Driving while privilege is suspended or revoked

1

     
 

Total convictions of former direct care workers

28

Notes: (1) We included the type of offense-felony, misdemeanor, summary-for those cases in which that information was included in the file during fieldwork.

(2) Ultimately, the convictions of the majority of these 17 direct care workers would not have prohibited the employees hiring or retention under OAPSA, but the provider agencies could not have known that fact during the provisional period or the delay that followed.

 

 

DPW regulations form the principal basis for the licensing inspection checklist (called the Licensing Inspection Instrument) used by DPW group home inspectors. The regulations require only that an application for a criminal history background check must be submitted to the Pennsylvania State Police for prospective employees within five working days after the hiring date; an application for a Federal Bureau of Investigation (FBI) check must also be submitted for nonresidents.10  The regulations are silent regarding what should happen if the background check reveals a criminal history.

Effective July 1, 1998, all new applicants for group home employment-and employees hired after July 1, 1997-must have no history of those disqualifying convictions listed in OAPSA.11  Employment is prohibited when the background check reveals a felony drug conviction, convictions of certain other state crimes (including criminal homicide, aggravated assault, kidnapping, rape, sexual assault, prostitution, burglary, robbery, forgery, and crimes against children), and/or similar federal or out-of-state convictions.

OAPSA requires facilities to require job applicants to submit with their employment application a criminal history report from the Pennsylvania State Police. Facilities must require nonresident applicants to submit a report from the FBI as well. However, OAPSA also provides for "provisional" employment, meaning that a prospective employee can be hired for a trial employment period even though his or her background has not yet been checked for a criminal history. The provisional employment period may not exceed 30 days for Pennsylvania residents and 90 days for nonresidents.

OAPSA allows such provisional employment only if all of the following conditions are met:

  • The provisional employee has applied for the criminal history background check and has provided a copy of the appropriate completed request forms to the facility administrator;
  • The facility administrator has no knowledge of a disqualifying conviction in the applicant's background;
  • The applicant swears/affirms in writing that he or she is not disqualified from employment under OAPSA;
  • The applicant will immediately be fired if the criminal history background check reveals disqualification from employment; and
  • PDA develops guidelines for supervising provisional employees.

The last condition for provisional employment under OAPSA has not yet been satisfied. Although PDA has recently proposed OAPSA regulations12 -which we have been told by PDA will constitute the required "guidelines"-those proposed regulations have not yet been issued in final form. Because there currently are no guidelines or regulations, it appears from the language of OAPSA that provisional employment should not be permitted at the present time. However, DPW apparently allows provisional employment regardless.

 

The aforementioned DPW regulations are far less restrictive than OAPSA. Yet OAPSA itself is not sufficient to protect the safety and well-being of group home residents because its authorization of a provisional employment period-when it becomes valid upon PDA's issuance of final OAPSA regulations-is dangerous.

For example, the requirement that an applicant affirm in writing that he or she is not disqualified from employment under OAPSA is an ineffective safeguard because few job applicants will freely admit to a conviction of a type of crime that they know will disqualify them from employment. Seventeen of the 23 applicants we reviewed who were convicted of crimes-nearly 75 percent-stated on their applications that they had not been convicted of a criminal offense, even when nearly all of the application forms noted explicitly that criminal offenses included any felony, any misdemeanor, or any summary offense. In short, the 17 applicants misrepresented their backgrounds and were hired.

That caregivers with serious criminal backgrounds can work directly with vulnerable men and women for any time period is indefensible. Pennsylvania has already recognized the wisdom of prohibiting persons with certain criminal histories from having contact with vulnerable populations by enacting legislation more restrictive than OAPSA for applicants seeking employment with school children. Pennsylvania law and regulations require school entities to require a criminal history background check prior to hiring an applicant or accepting the services of a contractor who would have direct contact with children, without an allowance for provisional employment. Such employment should not be allowed for those who care for the mentally retarded.

Our audit of the criminal histories and personnel records of 206 then-current and former employees revealed that six employees failed to apply for their criminal history background checks within five working days of hire as required by DPW regulations. We further studied this issue by reviewing criminal history reports for 186 employees hired by the eight group home provider agencies after November 1991 whose applications for criminal history background checks were submitted within five working days of hire as required by DPW's regulations.

On average, the provider agencies received those criminal history reports 25 days after the 186 direct care employees were hired. But the actual timing ranged from as early as the date of hire to 143 days afterward. Over one-fourth of the reports-54 of the 186-arrived at the provider agencies more than 30 days after the date of hire, effectively rendering OAPSA's provisional period irrelevant.13 

Therefore, even when applications for criminal history background checks are submitted within five working days of hire as required by DPW's regulations, the results frequently are not received until well after OAPSA's 30-day provisional employment period.

Provider agencies were far less likely to receive criminal history reports on a timely basis for those provisional employees with criminal convictions than those without criminal convictions. A total of 61 percent-or 14 of the 23 newly hired employees who had a criminal history-were still on the job beyond the 30-day provisional period before their criminal history reports were received. On average, the reports for those 23 caregivers arrived at the group home's provider agency 41 days after the hire date.

Ultimately, the convictions of the majority of those 23 caregivers would not have prohibited the employees' hiring or retention under OAPSA, but the provider agencies could not have known that fact during the provisional period or the delay that followed.

We note that 25 employees in our sample submitted their criminal history reports along with their employment applications. Provider agencies cannot make informed decisions about their prospective employees without the benefit of such reports. Therefore, we recommend the elimination of the provisional employment period. Yet the process for obtaining the report from the Pennsylvania State Police and the FBI must also be expedited so as not to adversely impact the hiring needs of the homes. Until the provisional employment period is eliminated, DPW should protect group home residents by requiring providers to notify families when their loved ones' caregivers are provisionally employed. DPW should also incorporate into its licensing determinations evaluations of whether homes retain individuals beyond the 30-day provisional employment period without having received their criminal history reports.

In addition to requiring criminal history background checks, consideration should also be given to requiring child abuse background checks of prospective direct care workers in certain group homes. The Child Protective Services Law (CPSL) requires all prospective employees of "child care services," which include mental health, mental retardation, and early intervention services for children, to submit to both types of background checks.14  However, DPW's MR Bulletin #6000-88-02 interprets the CPSL requirement of child abuse background checks to only apply to prospective employees in facilities in which more than 50 percent of the residents are children. DPW's group home regulations also limit the requirement to prospective employees in homes serving primarily children.15 

During our audit, we visited one group home that served children. The home's population of children was less than 50 percent of its capacity during the majority of the time period covered by the audit. Although the direct care workers employed at the home had undergone a child abuse background check, DPW should consider revising its bulletin and regulations in order to eliminate the inconsistency with the CPSL. The revisions should ensure that all direct care staff working with children-whether there is a single child or multiple children in the group home-first undergo a child abuse background check.

 

 

 

Recommendations:

DPW and PDA should recommend to the General Assembly that it amend OAPSA to eliminate the provisional period of employment for applicants.

DPW should enhance protections for group home residents through revised group home regulations; DPW should not include a provisional employment period in those regulations.

As long as the provisional period remains in effect, DPW should protect residents during the provisional employment period by requiring family notification of a caregiver's provisional status and by incorporating into its licensing determinations evaluations of whether homes retain individuals beyond the 30-day provisional employment period without having received their criminal history reports.

The Ridge Administration and the General Assembly should evaluate and remove any barriers to an expedited process for conducting the criminal history background checks.

DPW should consider requiring all direct care staff working with children-whether there is a single child or multiple children in the group home-to first undergo a child abuse background check.

DPW's Response:

This conclusion extends beyond a determination of the Department's compliance with current statutes and regulations. The DPW applies and enforces the Older Adults Protective Services Act (OAPSA) adopted by the General Assembly in 1996. When a licensed home complies with the requirements of the law, residents of the home can be assured that employees meet the legal requirements of the OAPSA. The provisional period of employment provided for in the statute is useful to Pennsylvania citizens who have never been convicted of a crime and are seeking employment. In addition, this provision allows the many types of agencies covered by the law to employ staff to provide the necessary critical care and services to people until the criminal history background checks are returned.

As part of the employment application, potential employees are required to respond to questions concerning prior criminal charges and convictions. This self-reporting is a screening process, which would cause the applicant to withdraw if an affirmative response was given.

There are three methods available to the public to obtain criminal history background reports. The methods are the PATCH system, direct mail, and contracting with an agency that provides this service. The PATCH system is an on-line automated system used by 850 agencies to obtain criminal history reports. These agencies get a same-day response when no record is available to match the name, date of birth, and/or Social Security number. A "no record" report is an indication that the potential employee has no convictions in the database. Overnight mail packages containing fewer than six applications are processed within a week. Regular mail applications are processed and returned within a month. The State Police are constantly improving this system and have made several enhancements since the passage of the OASPA. Additional improvements are under development. The third option is to contract with an agency that charges a fee to obtain criminal history reports. Processing time is similar to agencies using PATCH.

When the DPW's current regulations for mental retardation residential services were last revised in 1991, there was no statutory basis for prohibiting the employment of individuals based on their criminal history. In the absence of such an absolute prohibition, DPW regulations required providers to obtain criminal and child abuse histories in order to expose the histories of applicants that might then be considered by the employer. The OAPSA requirements exceed the current regulations, and providers are required to be in compliance with the OAPSA. The DPW will incorporate the new requirements into its program regulations when they are revised in the future.

The DPW has reviewed the charts concerning the criminal record checks conducted on current and former employees against the provisions of the OAPSA and its application. Of the 34 convictions identified for six in the sample of 48 employees, 27 convictions were associated with one individual who was not employed at any one of the eight homes that were chosen for the audit. The facts about this employee, who worked at another location, were voluntarily provided to the auditors by the agency's executive director. The individual is no longer employed at the agency. (Appendix B incorrectly identifies the employee as working at one of the eight homes reviewed.) Of the same 34 convictions identified for six in the sample of 48 employees, 14 convictions would not disqualify individuals from employment under the OAPSA, even if the employees were not grandfathered under the law.

Concerning 17 of 158 former employees identified, 14 of the 28 offenses would not have disqualified applicants from employment.

Finally, the OAPSA allowed for the grandfathering of employees hired before July 1, 1997. Since the hiring dates for the employees were excluded from the audit report, the DPW is unable to determine the number of employees who would be grandfathered into their current positions.

The AG cites inconsistencies between the DPW bulletin regarding background checks on applicants for employment in programs serving children and the Child Protective Services Law (CPSL), which requires all prospective employees to have both a Criminal History Background Check and a Child Abuse Background Check. The statute takes precedence over mental retardation bulletins, which will be revised to be consistent with the law. In addition, protections for children are further enforced through the DPW's recently-published Chapter 3800, Child Residential and Day Treatment Facilities regulations, effective June 12, 1999, which incorporates the requirements of the CPSL to conduct child abuse and criminal history checks on applicants.

 

Department of the Auditor General's Response:

DPW states that "[t]his conclusion extends beyond a determination of the Department's compliance with current statutes and regulations." Our audit, however, was a performance audit which, by its very nature, goes beyond a compliance audit and offers recommendations that will improve oversight rather than ensure compliance alone. Our recommendations, if implemented, can help DPW ensure that group home residents receive the best possible quality of care by going beyond the standard rules and regulations.

Contrary to DPW's assertion that it "applies and enforces the Older Adults Protective Services Act (OAPSA)," the audit disclosed at least one violation of OAPSA. One agency hired an employee in September 1997 and retained that employee until early 2000 despite the fact that he had been convicted of 27 serious crimes, many of which disqualify him from employment by OAPSA. Although DPW conducted a full inspection of that home in October 1999, the inspection did not document or correct this violation of OAPSA.

DPW correctly states in its response that the facts about the employee at issue were voluntarily provided to us by the agency's executive director. DPW also correctly states that the employee at issue was not employed at any of the eight homes that we audited. However, he was employed at a different group home operated by one of the eight provider agencies that we audited. While we have added an explanatory footnote to the chart on page 19 and in Appendix B, the seriousness of this situation required follow-up on our part and disclosure in the audit report.

DPW states, "Of the same 34 convictions identified for six in the sample of 48 employees, 14 convictions would not disqualify individuals from employment under the OAPSA, even if the employees were not grandfathered under the law." DPW continues its response, "Concerning 17 of 158 former employees identified, 14 of the 28 offenses would not have disqualified applicants from employment." The charts on pages 19 and 20 present a list of all criminal convictions of group home employees in our sample, not only those convictions that would disqualify one from employment under OAPSA. More important is the fact that, according to DPW's data, 20 of the 34 convictions for current employees and 14 of the 28 offenses for former employees would disqualify applicants from employment.

Although DPW notes in its response that "three methods are available to the public to obtain criminal history background reports," we found that each of the eight audited provider agencies utilized the slowest of the three available methods; i.e., the direct mail method. Our findings also contradict DPW's contention that "regular mail applications are processed and returned within a month." Over one-fourth of the audited 186 criminal history reports arrived at the provider agencies more than 30 days after the date of hire. Two of the regular mail applications were processed and returned to the provider agency 143 days after the date of hire.

DPW maintains that it will incorporate OAPSA's "requirements into its program regulations when they are revised in the future." However, we found that OAPSA is not sufficient to protect the safety and well-being of group home residents because its authorization of a provisional employment period is dangerous. Furthermore, we disagree with DPW's assertion that the effect of the provisional employment period is mitigated by the self-reporting requirement, in light of our finding that nearly 75 percent of our sample of job applicants who had criminal convictions were hired based on misrepresentations about their criminal backgrounds.

We note that, in response to our audit, DPW has agreed to revise its mental retardation bulletins to require all prospective employees to submit to both a criminal history background check and a child abuse background check. However, DPW should also revise its own regulations, as noted in the conclusion.

DPW also asserted that, because we did not include employees' hire dates in our report, it was unable to determine the number of employees grandfathered into their current positions. However, DPW did not ask us for those dates, all of which were included in our work papers.

 

 

 

Conclusion 2:

DPW failed to provide guidance to provider agencies regarding compliance with OAPSA's requirements of criminal history background checks.

Our review of current employment disclosure statements and interviews of human resource personnel in the eight provider agencies revealed that six of the eight agencies did not incorporate the requirements of OAPSA in their employment processes. Several of the staff members interviewed explicitly said that they were unaware that OAPSA addresses criminal history background checks and related hiring/retention practices.

DPW has not issued a Mental Retardation (MR) Bulletin to communicate guidelines for compliance with OAPSA. The employment disclosure statements of the aforementioned six provider agencies generally utilized the guidelines detailed in the two most recently issued MR Bulletins that address criminal history background checks of prospective employees in various fields, including mental retardation services. Yet those guidelines, contained in MR Bulletin #6000-88-02 (January 1988) and MR Bulletin #00-88-07 (June 1988), are far less restrictive than the OAPSA requirements.

According to DPW, it has trained only its own personnel regarding the criminal history background check provisions of OAPSA. DPW has not specifically trained county Offices of Mental Health and Mental Retardation (MH/MR) or provider agencies. Although PDA (through the Temple University Institute on Aging) sponsored 30 training sessions for a variety of attendees during 1998 and 1999, administrators from six of the eight provider agencies in our sample did not receive any such training. We are concerned about the apparent lack of coordination between DPW and PDA with regard to providing training to the regulators and the regulated.

DPW's failure to provide formal guidance and comprehensive training regarding the criminal history background check provisions of OAPSA to provider agencies increases the probability that such providers will violate OAPSA's employment requirements, thereby placing vulnerable individuals at risk. For example, as discussed in Conclusion 3, one of the aforementioned six untrained provider agencies employed and retained-for more than two years-a direct care worker who had been convicted of 27 serious crimes.

 

Recommendations:

DPW should issue formal guidelines for compliance with the hiring/retention practices mandated by OAPSA.

DPW should work with PDA to expedite the issuance of PDA's final form regulations providing guidance for compliance with the hiring/retention practices mandated by OAPSA.

In the meantime, DPW and PDA should issue a joint MR Bulletin providing guidance for compliance with the hiring/retention practices mandated by OAPSA.

DPW should sponsor or conduct training seminars regarding OAPSA for all group home providers and county MH/MR offices who impact hiring/retention decisions.

 

DPW's Response:

The Pennsylvania Department of Aging (PDA) is the lead agency responsible for implementation of the OASPA. As noted in the AG's report, following adoption of the OASPA, which was effective December 1997, the PDA sponsored 30 training sessions that were delivered by Temple University in 1998 and 1999. In addition, the PDA has also developed a web site for "On-Line Training for Mandatory Abuse Reporting and Criminal Background Checks," and this information is being given to providers by the licensing staff as part of the annual inspection exit interview. The web site is xtbase.galaxyscientific.com/pde/index_ie.asp.

In addition, the DPW is working with PDA on the development of regulations to implement the law. Upon adoption of the regulations, DPW will also issue a policy bulletin to all licensed entities required to comply with OASPA and will provide training to County MH/MR Programs and provider agencies.

 

Department of the Auditor General's Response:

No response necessary.

 

Conclusion 3:

DPW's licensing process does not protect residents of group homes from the employment of individuals with serious criminal histories.

Section 505 of OAPSA states that the "Commonwealth agency or Commonwealth agencies which license the facilities have jurisdiction to determine violations" of OAPSA's criminal background check provisions. DPW has failed to fulfill this responsibility in group homes because its record sampling methods, content, and documentation of group home inspections are inadequate with regard to reviewing the criminal histories of employees.

According to DPW personnel, licensing inspectors limit their review of criminal history reports to only a sample of those direct care workers hired since the date of the provider agency's last full inspection. DPW has not established specific guidelines regarding the absolute or relative size of the sample of new hire records to be inspected. Furthermore, the inspectors select that sample from a list furnished by the employer. Few, if any, safeguards exist to prevent the employer from omitting the record of an employee with an egregious criminal past.

Thus, some employees' criminal history reports are not reviewed by DPW at all. Equally troubling is the fact that even those reports that are reviewed are inspected only to see if the applicants requested a criminal history background check within five working days of hire as required by DPW regulations. According to our interviews with DPW licensing personnel, DPW's practice does not include checking the records to see if employees have convictions that would have prevented their employment in the first place-or their continued retention.

Still another inadequacy exists because DPW licensing personnel do not retain documentation of the new hire records reviewed during an inspection. The worksheets prepared by the licensing inspectors are discarded after the provider's license is issued.

 

 

The sole documentation of the specific employee records that were reviewed consists of the initials of any employee who was found not to have applied for the criminal history background check as required.

The record sampling, content, and documentation flaws of DPW inspections have resulted in DPW failures to detect noncompliance with both DPW regulations and OAPSA. Our audit of the criminal histories and personnel records of 206 then-current and former employees of the eight provider agencies disclosed that six employees failed to apply for their criminal history clearances within five working days after the date of hire as required by DPW's regulations. DPW inspections failed to detect any of the six violations.

More important, three DPW inspections since September 1997 failed to detect and, thus, failed to discourage the continued employment of the direct care worker who was convicted of the 27 crimes, including serious sexual and drug offenses. As discussed in Conclusion 1, DPW's regulations fail to specify what actions providers should take upon the receipt of an employee's criminal history. However, according to the interpretation of OAPSA followed by DPW and PDA, this employee became subject to OAPSA's criminal background check requirement on July 1, 1999. We communicated information about his criminal history to the provider agency in May 1999 and to DPW several times beginning in May 1999. It is our understanding that DPW took action which led to the termination of this employee in February 2000.

However, OAPSA would have required the termination of this employee no later than July 1, 1999. The employee could not have been entitled to OAPSA's 30-day provisional employment period, as the provider agency was aware of his disqualifying convictions. The provider agency had such knowledge because a criminal history background check had been requested for this employee within five working days of hire as required by DPW's regulations! The provider agency received his criminal history report in October 1997 and could have-and should have-terminated his employment at that point instead of waiting two years.

 

 

Recommendations:

DPW should require its licensing inspectors to review the criminal history reports of all currently employed direct care workers hired since the date of a provider agency's last full inspection.

DPW should establish licensing inspection procedures to safeguard against a provider agency's omission of the records of new hires with serious criminal histories. For example, DPW inspectors should, in all cases, cross-check an agency's listing of new hires against employee payroll records and/or employee schedules.

DPW should require its licensing inspectors to review criminal history reports specifically to ensure compliance with both OAPSA and DPW's regulations.

DPW should retain the documentation regarding the new hire records reviewed during a licensing inspection.

 

DPW's Response:

The DPW disagrees that there are significant deficiencies in the procedures in place to safeguard residents of group homes. The DPW has a comprehensive licensing process that enforces each provider's compliance with statutes and regulations designed to protect individuals. Consistent with the Department's licensing process, sampling is used to review employees' records during annual inspections. Sampling is a valid and accepted tool used to determine compliance with regulations in many types of organizations. Sampling of records is utilized in all types of facilities including hospitals, nursing homes, and ICFs/MR and is, in fact, a standard auditing practice.

In response to the report's suggestions to modify the inspection protocol, the DPW will consider including a review of the criminal history checks for all new hires since the last inspection as part of the annual inspection process, informing the CEO of the agency and the Regional Program Manager of any criminal history checks that reveal a violation of the OAPSA, and retaining all working papers from the inspection as part of the record for a period of two years.

 

Department of the Auditor General's Response:

Despite DPW's implication to the contrary, we do not dispute the validity and value of sampling as a tool to determine compliance. Instead, the conclusion challenges the effectiveness of DPW's licensing inspection process regarding criminal history background checks. Both the source of the records reviewed during an inspection and the failure of DPW inspectors to explicitly review the convictions to determine the propriety of employee hire or retention undermine the effectiveness of DPW inspections.

DPW's licensing process failed to detect and prevent the continued employment, in violation of OAPSA, of the direct care worker convicted of 27 crimes. DPW inspections also failed to detect the regulatory violation for each of the six employees who failed to apply for their criminal history clearances within five working days after the date of hire.

Our conclusion further recommends that licensing inspectors review the criminal history reports of all currently employed direct care workers hired since the date of the provider agency's last full inspection. We are encouraged by DPW's stated intent to consider implementing our recommendation.

 

Conclusion 4:

Excessive turnover resulted in a lack of consistent direct care for group home residents.

Although the staff levels at each of the eight group homes accommodated the required levels of direct care noted in each of the residents' annual assessments and met the minimum staff-to-resident ratios mandated by DPW's regulations, the group homes varied in the levels of consistent, educated, and experienced care.

We first examined the eight group homes individually to determine the length of employment of each direct care worker. Then, by charting the tenure for all of that home's workers, we determined the median tenure for each home. For all eight homes, the shortest median tenure was not quite four months; the longest was about four years.

We then used each of the 42 median tenures (representing the direct care workers16  from all eight homes) to determine that the median tenure of that staff for the eight homes overall17  was one year. That figure is significantly less than that of the nation's general workforce in February 1998, 3.6 years, and also of the nation's social service industry at that same date, 2.7 years.18 

The 1998 overall crude separation rates19  for the eight homes-another way to measure turnover-was 98 percent, indicating a much higher turnover rate than that for psychiatric aides in the state's mental health/mental retardation institutions (8.6 percent)20  and for aides in child day care centers (51 percent).21 

 

 

Employment and Wage Figures for the Eight Group Homes

 

This table shows that, per home, employees stayed the shortest time at Home #7 and the longest at Home #6. The range of tenure shows shortest and longest length of employment of individual workers at each home.

 

Number of Years Home Has Operated

Median Tenure

(in years)

Range of Tenure

(in years)

Home 1

4 years

1.9

0.0 - 4.5

Home 2

16 years

3.2

0.1 - 6.3

Home 3

3 years

0.5

0.0 - 3.3

Home 4

11 years

0.8

0.2 - 9.8

Home 5

5 years

1.2

0.7 - 2.1

Home 6

5 years

4.0

0.3 - 4.6

Home 7

4 years

0.3

0.1 - 0.6

Home 8

4 years

3.6

0.3 - 4.7

Overall:

 

1.0

0.0 - 9.8

 

 

This table shows that the highest percentage of employees left Home #7 in both 1997 and 1998; the lowest percentage of employees left Home #8, which also had no employees leave in 1997.

Group Home Crude Separation Rate

 

1998

1997

Home 1

20%

100%

Home 2

25%

50%

Home 3

80%

80%

Home 4

100%

114%

Home 5

80%

80%

Home 6

43%

43%

Home 7

329%

271%

Home 8

20%

-

Overall rate:

98%

100%

 

 

This table shows that the three reviewed group homes with the greatest median tenure of the current direct care staff (i.e., Homes #2, #6, and #8) also paid the three greatest average wage rates.

 

Average Wage Rate

Range of Wage Rates

Home 1

$7.02

($6.75 - $7.31)

Home 2

$7.92

($7.05 - $8.70)

Home 3

$7.21

($7.00 - $7.64)

Home 4

$6.82

($6.57 - $8.05)

Home 5

$6.19

($5.86 - $6.41)

Home 6

$7.66

($6.25 - $8.01)

Home 7

$6.75

($6.75)

Home 8

$7.30

($6.75 - $7.86)

Overall:

$7.08

($5.86 - $8.70)

 

A 1998 study of workers in community residential settings for persons with developmental disabilities found that higher turnover rates tend to be associated with lower pay.22  The same study also indicated that younger employees, low staff/client ratios, and urban locations contributed to high turnover in such settings. Additionally, variables such as benefits and supervisory style influenced turnover rates.

The salaries of 93 percent, or 39 of the 42 non-supervisory direct care workers employed in the eight group homes during the period of our audit fieldwork, were less than the July 1999 federal poverty level for a family of four, which was $16,700 annually.23  The average hourly wage rate in July 1999 for the 42 employees was $7.08, which is less than half of the 1998 average hourly wage for all private industry workers in Pennsylvania who are covered by unemployment insurance/compensation, $14.96. Finally, the $7.08 wage is also less than half of the 1998 average hourly wage for covered employees in the services industry in Pennsylvania, $14.17.24 

Legislation is currently pending in the Pennsylvania General Assembly that would create a minimum entry-level annual wage of $18,000-which is $8.65 per hour-for direct care workers in publicly funded mental retardation programs. Legislation is also pending that would designate a percentage of tobacco litigation master settlement agreement funds for this purpose.

Recommendation:

DPW should consider policies that will enhance wages and other economic incentives for group home direct care workers in order to reduce the turnover of such employees.

 

DPW's Response:

The AG's report acknowledges that at "each of the eight homes reviewed, staff levels met the requirements in each of the residents' annual assessments and met the minimum staff-to-resident ratios required in the regulations.."

The Department agrees that stability of core direct care staff is an important element in the delivery of quality services to residents of group homes. In the audit sample of homes, seven of the eight homes had staff working in the home for more than two years. Crude separation rates, while one measurement of turnover, fail to factor the presence and impact of core staff who continue to work, according to the report, from a minimum of 2.1 years to 9.8 years.

In addition, a turnover of direct care staff is related to more than salary. A Legislative Budget and Finance Committee (LBFC) study, entitled Salary Levels and Their Impact on Quality of Care of Client Workers in Community-Based MH/MR Programs, released in February 1999, reported a weak correlation between direct care worker salaries and turnover rates. Consistent with other studies "which typically find that salaries are only one of the many factors affecting employee turnover, studies of workers in institutions and community residential settings for persons with disabilities have found that higher turnover rates tend to be associated with lower pay, younger employees, more residents per staff member, and urban locations. Variables such as benefits, supervisory style, and local economic conditions are also important."

In fact, the LBFC study shows that 32 percent of the 19,759 direct care workers, or 6,323, had less than one-year employment with their current organization. This means that 68 percent of the direct care workers, or 13,436, had one or more years of employment with their current organization.

The report overlooks the overall experience of direct care staff working in the eight homes. In fact, the report so narrowly focuses on the length of time the employees worked at a particular home, it disregards any and all experience an employee may have had at another home with the same organization working with individuals with similar conditions as those in the home in which the employee was working at the time of the review. Furthermore, no consideration was given to the previous employment of the direct care staff of the group homes at other similar provider agencies.

The omission of such information fails to provide a fair and complete picture of the direct care staff's overall experience, knowledge, and skill that they bring to the job of providing care to the residents of the homes.

The DPW has considered the pressures on provider recruitment of employees created by the current economic climate. The Governor's initiative to expand services for the waiting list has been funded at a level that recognizes the cost of providing services. The DPW will negotiate with each county to determine that proper level. Counties have been encouraged to seek administrative efficiencies that can be channeled into salary adjustments. In addition, the DPW is implementing recommendations from the LBFC report to increase federal funding and to reduce categorical allocations, thus giving local communities more flexibility to fund programs.

 

Department of the Auditor General's Response:

DPW has misinterpreted the major thrust of this conclusion. The conclusion documents the excessive turnover in the eight group homes and the attendant impact on the consistency of direct care provided to the residents, as opposed to the experience of direct care workers. Consistency is clearly compromised by the departure of any staff member, regardless of the existence of a "core staff." High turnover rates negatively impact the continuity and stability in group home residents' lives regardless of the experience levels of the direct care staff. Furthermore, the conclusion documents that only 12 of the 47 then-current employees in the eight group homes had previous experience working with people with developmental disabilities.

We are encouraged by DPW's acknowledgement of the importance of economic factors that challenge provider agencies' abilities to recruit and retain qualified staff.

DPW states that employee turnover is affected by other variables in addition to wages. We agree with DPW's assertion. In fact, the conclusion cites several such variables found by a 1998 study of workers in community residential settings for persons with developmental disabilities.

 

 

Conclusion 5:

DPW regulations are not stringent enough to ensure that direct care staff are adequately trained.

The educational levels of the direct care staff employed in the eight group homes during the period of our audit fieldwork varied considerably. Twenty-five of the 47 direct care workers had high school diplomas alone; 16 of the 47 had some college coursework; and the remaining 6 had bachelor's degrees. Only 12 of the 47 employees had previous experience working with people with developmental disabilities.

Staff training and competence are key elements in achieving quality care for group home residents. DPW's regulations establish timing requirements and the general nature of training for direct care workers in Pennsylvania group homes. Those requirements include the following:

  • Before working directly with residents, direct care workers must receive training in fire safety and first aid techniques and an orientation regarding the home's operation, policies, and procedures. Expert fire safety training must be updated annually.
  • Within 30 calendar days after, or 12 months prior to, initial employment, direct care workers must receive training in the areas of mental retardation, the principles of normalization, rights, and program planning and implementation.
  • Within six months of employment and annually thereafter, direct care workers must receive certified training in first aid, cardio-pulmonary resuscitation (CPR), and Heimlich techniques.
  • Prior to administering medications, direct care workers must pass DPW's Medications Administration Course. In order to continue to administer prescription medications, direct care workers must pass DPW's Medications Administration Course Practicum annually.
  • Direct care workers who are employed for more than 40 hours per month must receive at least 24 hours of training relevant to human services annually.

In addition to being mandatory, training is important because it enables staff members to develop the knowledge, skills, and attitudes necessary to perform their job responsibilities.

Our review of the training records of then-current direct care workers in the eight group homes disclosed the following deficiencies in training:

  • the training failed to address specific needs of group home residents;
  • courses were not offered in a timely manner; and
  • agencies committed multiple violations of the training requirements specified in DPW regulations.

The residents of the eight group homes possessed special physical and/or behavioral characteristics that were outlined in their annual assessments. Direct care staff must be trained to recognize, manage, and/or accommodate the residents' characteristics and needs in order to provide quality care.

Neither DPW's regulations nor its Licensing Inspection Instrument specifies that direct worker training must address the specialized needs of the residents as identified in the annual assessments. Accordingly, DPW's regulations failed to ensure that the direct care staff of the eight group homes received necessary specialized training. Furthermore, the regulations failed to ensure the timeliness of the training that was actually received.

 

Several residents in each of the eight group homes had been diagnosed with seizure disorders. More specifically, 18 of the 27 then-current residents and 5 of the 11 former residents of the reviewed group homes had seizure disorders. Yet in two of the homes, we found no evidence that any of the then-current direct care workers had received formal training in seizure recognition and treatment during the periods that we audited. In the other six homes, we found that with regard to 27 of the 32 then-current workers for whom first-year training records were available who received such training, the training occurred an average of 249 days after the initial date of unsupervised direct care work.25 

Some then-current and former residents in seven of the eight group homes either had been placed on specialized feeding regimens to reduce the risk of choking, or they had exhibited behaviors in which they repeatedly attempted to ingest foreign objects. Yet, five of 40 then-current workers in the seven homes had not received training in CPR or Heimlich techniques as of the beginning date of our audit fieldwork. The remaining 35 workers received such training an average of 121 calendar days after the first date of unsupervised direct care. Overall, the timing of training ranged from before unsupervised direct care was given to 739 days after the initial date of unsupervised direct care.

The regulatory requirement that direct care workers must receive CPR and Heimlich techniques training within six months of hire is not sufficiently rigorous. It is an indefensible risk that an untrained worker could be employed for any time period to care for a resident susceptible to choking.

The annual assessments for 12 then-current residents in five of the eight group homes indicated tendencies for maladaptive or aggressive behaviors and/or the required usage of anti-psychotic medications. Yet our review of employee and client records showed that 14 of 28 then-current employees in these five homes had not received crisis prevention training to deal with the aforementioned maladaptive or aggressive behaviors as of the beginning date of audit fieldwork. The remaining 14 workers received such training an average of 161 days after the first date of unsupervised direct care. None of the then-current employees received crisis prevention training for one group home in which the assessments for three of the six residents indicated a necessity for such training. The provider agency's failure to train such workers in crisis prevention decreases the likelihood that the group home environment will be conducive to the emotional well-being of both the residents and the direct care workers.

A resident of one of the eight group homes suffered from profound bilateral deafness. The individual's annual assessment noted that, in order for her to be successful in the community, she would need to be cared for by staff members who knew and used sign language. Yet none of the eight workers employed at the home during the period of our audit fieldwork had received formal training in sign language as of the beginning date of our audit fieldwork, and we saw no documentation to indicate that any of those staff members had received such training previously or had such abilities in the absence of formal training.

 

Recommendations:

DPW should require all direct care staff in group homes to be trained to address the special needs of residents as defined in their annual assessments.

DPW should require that all such training occur prior to each employee's unsupervised direct care work.

 

DPW's Response:

The DPW strongly believes that its regulations ensure that direct care staff are adequately trained. The regulations recognize the type of training that is critical prior to working directly with individuals. In addition, the regulations recognize the need for continuing training throughout employment. As such, the regulations are more stringent than even the federal ICF/MR certification requirements.

DPW regulations specify training that must be delivered prior to the staff person working directly with residents, and specific training that must occur throughout the first year, including within 30 days, of working with individuals. Within six months of employment, the regulations require training in CPR, First Aid, and the Heimlich technique. Direct care staff must complete and pass the DPW's medications administration course prior to administering medications. Annually thereafter, they must complete and pass the medications administration course practicum. Finally, the regulations require that those working 40 hours or more per month must receive 24 hours of training annually.

The report is incorrect in the assertion that seizure management and crisis prevention are required training. The regulations do not require that all employees receive training in these areas. In cases where seizure management is required, each situation is unique, demanding interventions designed exclusively for that individual, and typically developed by the person's physician and communicated directly to staff. This training would be documented in the individual's record, rather than the employee's training record.

The DPW believes that the regulations related to the use of restrictive procedures go well beyond a requirement for crisis prevention. Each person's program plan is individually designed. In homes that serve individuals whose behavior requires intervention, an individual plan is designed. Should the plan require any restriction of a person's freedom of movement, access to personal possessions, or involvement in preferred activity, a restrictive procedure committee must review the plan. Chemical restraint, mechanical restraint, and seclusion are prohibited.

The regulations require that the provider agency must demonstrate the necessity of any restrictive intervention. Situations that call for the use of physical restraint have limits placed on the use of that restraint. Furthermore, staff who employ the intervention ".must experience use of the specific technique or procedures directly on themselves." (Ch. 6400.191-206) The regulations further require a written record of each and every use of restrictive procedures. These particular regulations governing the use of restrictive procedures have been effective in reducing the use of restrictive procedures in group homes. Coupled with the extensive training and technical assistance provided to counties and providers, the DPW has succeeded in improving environmental conditions, mental health treatment interventions and supports that reduce negative behavior, and, more importantly, supports positive behavior.

Additionally, the Community Homes Regulations, Pa. Code Chapter 6400, regarding use of restrictive procedures, are more stringent than those of the ICF/MR certification requirements.

 

Department of the Auditor General's Response:

The purpose of this performance audit was to make recommendations that would improve DPW's oversight of group homes in Pennsylvania, and not solely to determine DPW compliance with current regulations. The regulatory requirement that direct care workers must receive CPR and Heimlich techniques training within six months of hire is not sufficiently rigorous, particularly in those group homes in which individuals susceptible to choking reside.

Despite DPW's claim to the contrary, the conclusion does not assert that seizure management and crisis prevention are required training. In fact, the conclusion emphasizes the importance of requiring training to address the specialized needs of group home residents diagnosed with seizure disorders or maladaptive behaviors. Our review of both employee training records as well as the residents' records noted the absence of documented evidence of the consistent or timely provision of such specialized training.

DPW states that it "believes that the regulations related to the use of restrictive procedures go well beyond a requirement for crisis prevention." But restrictive procedures relate more to crisis management than to crisis prevention. According to information from one of the provider agencies, effective crisis prevention training incorporates training in de-escalation (pre-crisis) techniques, redirection techniques, reinforcement of positive behaviors, and the use of vigilance and verbal praise.

 

 

 

 

Conclusion 6:

DPW did not ensure that direct care workers met regulatory training requirements.

Our review of training records found that 24 of the 47 direct care workers employed by the eight provider agencies during the period of our audit fieldwork had 67 violations of the training requirements included in DPW's regulations. The following chart outlines the violations of the then-current direct care staff from their individual dates of hire to the beginning date of audit fieldwork.26  DPW inspectors failed to cite any of the 67 violations.27 

Training Requirement Not Satisfied

Number of Violations

Annual requirement for 24 hours of human services training

4

   

Training in the areas of mental retardation, normalization, client rights, and program planning and implementation within 30 calendar days after hire or within 12 months prior to hire

 

1

   

Certified training in CPR and Heimlich techniques within 6 months after hire

6

   

Annual requirement for certified training in CPR and Heimlich techniques

20

   

Certified training in first aid within 6 months after hire

6

   

Annual requirement for certified training in first aid

8

   

Annual requirement for successful completion of DPW's Medications Administration Course Practicum

22

Total

67

 

 

 

DPW did not employ adequate sampling methods in its selection of group homes and staff records to be inspected. As a result, the adequacy of the number of group homes and staff records reviewed is questionable.

DPW's regulations do not require DPW to inspect each group home on an annual basis. Instead, each provider agency operating one or more homes serving eight or fewer individuals shall have at least a sample of its homes inspected by DPW on an annual basis.28  According to DPW personnel, the annual sample of homes that receive a full inspection includes each of an agency's new homes in their first year of operation and 25 percent of its other (existing) homes. Therefore, except for new homes in their first year of operation, group homes generally receive a full licensing inspection only once every fourth year.

Critical to the frequency of group home full inspections is the number of inspectors and the associated number and variety of entities other than group homes that must be licensed and inspected. In this regard, DPW group home inspectors are responsible for inspecting three additional types of facilities that serve persons with mental retardation. Yet in 1998 DPW employed just 20 licensing inspectors across the Commonwealth. 29 

Here is a breakdown of the facilities that fell under DPW's jurisdiction and that require some form of inspection, also using 1998 figures:

  • 2,566 group homes operated by 198 agencies;
  • 683 family living homes operated by 80 agencies;
  • 206 adult training facilities; and
  • 179 vocational facilities.
 

According to DPW personnel, licensing inspectors review the training records of a limited number of an agency's direct care staff during a full inspection. The Licensing Inspection Instrument, employed during full inspections, directs licensing personnel to review a minimum of one staff record for each home that is inspected. DPW personnel assert that inspectors frequently review the training records for 20 percent of a group home's employee complement, meaning that reviews are carried out typically for just one or two employees in each home. But even a full inspection only reviews the training records for the most recent training year.

DPW did not employ formal methods to ensure the randomness of the sample of employee training records. In fact, we found that DPW personnel often asked the group home's provider agency to make its own selection of a specified number of training records to be reviewed. No explicit measures exist to prevent agencies from manipulating samples selected in such a manner to include only those records in regulatory compliance. Furthermore, DPW licensing personnel did not retain documentation of the training records reviewed during an inspection. Thus, the risk of reviewing the same employee files during sequential inspections is increased.

 

Recommendations:

DPW should evaluate and formally revise its inspection sample selection methods for group homes and staff records in order to increase the probability of detecting regulatory violations.

DPW should evaluate the sufficiency of its licensing inspector staff levels to review its sample selection of employee training records and increase staff levels if necessary.

DPW should require the retention of documentation regarding the training records reviewed during a licensing inspection.

 

DPW's Response:

The DPW disagrees with this conclusion. DPW licensing inspectors review staff training records as a normal part of all annual licensing inspections. While the sampling methodology requires that a minimum of one staff record be reviewed for each home, inspectors routinely inspect several records for each home. Across the total number of homes under inspection, licensing inspectors target the records of newly hired employees, staff from different shifts and different positions, and staff with differing lengths of employment. Typically, as part of a normal annual inspection, licensing staff reviews a minimum of two staff records in each small community home. This sample consists of one newly hired employee and one from the other target groups previously noted.

The DPW believes that the sample used during the licensing inspection process is adequate. It requires that, at minimum, all new homes, and no less than 25 percent of all existing homes, be inspected annually. The sample for a full inspection most typically exceeds 25 percent and, with 100 percent of all homes inspected each year for compliance with fire safety requirements, all homes are reviewed through the DPW licensing inspection process annually.

The AG's report suggests that the DPW evaluate the sufficiency of its licensing inspector staff levels. The report identified 20 licensing inspectors, but overlooked that four licensing administrators also perform licensing inspections. Further, the reorganization and expansion of the OMR has added two licensing inspectors, which brings the total to 26 rather than 20. The DPW's OMR has also added a Bureau of Quality Improvement and Policy, and is instituting a management information system that will integrate databases from various monitoring systems to allow for analysis of findings. In addition, the Office of Licensing and Regulatory Management, which reports directly to the Secretary of Public Welfare, has been established to provide training to licensing inspectors, manage the regulatory review process for human service licensing regulations, and to develop a Human Services Licensing Information System.

Licensing inspectors review staff training records for compliance with all training topics, and for compliance with minimum number of training hours required by the regulations. Licensing inspectors also review this information for completion within the training year that is established by the providers. If there are any serious concerns regarding compliance with the regulations, additional staff training records are reviewed.

The DPW does not believe that the report provides sufficient cause to deviate from its established sampling methodology.

 

Department of the Auditor General's Response:

DPW's response concludes that it "does not believe that the report provides sufficient cause to deviate from its established sampling methodology" regarding the inspection of staff training records. As discussed in the conclusion, we identified 67 violations of the training requirements included in DPW's regulations. DPW inspectors failed to cite any of the 67 violations.

We recommended that DPW evaluate the sufficiency of its licensing inspector staff levels. DPW's response disputes the number of licensing inspectors identified in the report. The conclusion cites 20 inspectors, while DPW contends that there are 26 inspectors. DPW includes four licensing administrators who conduct inspections and two inspectors added since DPW provided us with the data included in the conclusion. DPW's response, however, does not adequately address our recommendation that DPW evaluate the sufficiency of the complement. The fact that we found 67 training violations that were not cited during DPW inspections indicates the need to evaluate the sufficiency of inspector staff levels.

 

 

 

 

Chapter Two

Unexpected Deaths of Group Home Residents; Incidents of Abuse

Three unexpected deaths were not investigated adequately, and several abuse incidents were not reported in a timely manner.

There were five deaths among the residents of the eight group homes in our sample, as well as 32 allegations of abuse, six of which were substantiated.

For this section of the audit, we examined the records of 35 people who lived in the eight group homes for various periods beginning in 1994, 1995, and 1996, and ending on June 30, 1999. Of the five deaths, four were unexpected. Two of the four unexpected deaths occurred at the same home.

When a group home resident is alleged to have been abused, DPW regulations require the group home to begin an investigation and send an unusual incident report to both the county and DPW within 72 hours after the alleged abuse occurs.30  Furthermore, the home must submit a final report to the county and DPW at the conclusion of the investigation.31 

DPW's regulations define abuse as "an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements set forth in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals." 32 

Of the 32 abuse allegations, one of the eight homes had none, while another had 14 such allegations. The tables on the next page illustrate the number, determination, and time period of review for abuse allegations at all eight homes.

 

 

 

Incidents of Alleged Abuse in Eight Groups Homes in Western Pennsylvania

 

 

Group Home

 

Residential Capacity

 

 

Period Reviewed

Number of

Alleged Abuse

Incidents

Number of

Incident

Reports*

Number of

Founded

Abuse

Incidents

Home #1

3

1/1/95 - 6/30/99

3

9

0

Home #2

3

7/1/94 - 6/30/99

0

0

0

Home #3

5

6/27/96 - 6/30/99

3

3

0

Home #4

3

7/1/94 - 6/30/99

14

14

3

Home #5

4

7/1/94 - 6/30/99

1

1

1

Home #6

3

7/1/94 - 6/30/99

7

9

0

Home #7

3

7/10/95 - 6/30/99

3

5

2

Home #8

6

12/16/94 - 6/30/99

1

1

0

Totals

32

42

**6

*More than one report may have been written for each incident if more than one resident was involved.

**Refer to page 65 for a breakdown of the six founded abuse incidents.

Group Home (continued)

 

Number of Allegations of General Abuse

Number of Founded Allegations

of General Abuse

Number of Allegations of

Financial Abuse

Number of

Founded

Allegations

of Financial Abuse

Number of

Allegations of Sexual

Abuse

Number of

Founded

Allegations

of Sexual Abuse

Home #1

1

0

2

0

0

0

Home #2

0

0

0

0

0

0

Home #3

2

0

0

0

1

0

Home #4

12

3

0

0

2

0

Home #5

1

1

0

0

0

0

Home #6

6

0

1

0

0

0

Home #7

3

2

0

0

0

0

Home #8

1

0

0

0

0

0

Totals

26

6

3

0

3

0

Note: Of the 32 incidents, seven incidents of abuse allegedly occurred at the residents' day programs or parental homes rather than in the group homes. The seven incidents included all of the allegations of sexual abuse, the founded allegation of general abuse (Home #5), an unfounded allegation of general abuse (Home #6), an unfounded case of general abuse (Home #3), and the unfounded allegation of general abuse (Home #8). All of the allegations of financial abuse were listed as unfounded on the Office of Mental Retardation's database. The agencies were not able to determine what happened to the residents' money but reimbursed the affected residents.

 

 

DPW's Western Regional Office of Mental Retardation maintains a database of unusual incidents, including allegations of abuse. Abuse allegations are categorized as either general (which includes acts or omissions of acts that cause physical or emotional harm to the residents), financial, sexual, or client right violations.

 

Objectives and Methodology for Chapter Two

Our broad objective was to determine how unexpected deaths were investigated. In addition, we determined the frequency of abuse incidents and the adequacy of actions and measures adopted by group homes to prevent, report, and investigate incidents of abuse. Additionally, for deaths and abuses, we reviewed DPW and the counties' oversight.

In order to accomplish the above objectives, we:

  • reviewed provider agency, county, and DPW documentation regarding each death incident at the selected homes within the designated time periods to determine the existence and content of investigations and to determine the propriety of corrective actions to prevent future incidents;
  • reviewed DPW regulations and county and provider agency policies and procedures regarding the prevention, reporting, and management of unusual incidents;
  • interviewed DPW, county, and provider agency personnel;
  • reviewed provider agency, county, and DPW documentation regarding each abuse incident at the selected homes within the designated time periods to assess adherence to reporting guidelines, the quality of investigations conducted, and the propriety of corrective actions;
  • reviewed DPW licensing inspection summaries to determine whether DPW noted violations of reporting requirements; and
  • reviewed provider agency records to determine the sufficiency of caregiver training in abuse prevention.

 

Conclusion 1:

DPW did not investigate three of four unexpected deaths at the time they occurred and, in two cases, uncovered serious problems later.

Of the five deaths that occurred during the period of our review of the eight group homes, four were deemed to be unexpected. Yet DPW failed to conduct timely and adequate investigations into three of the deaths, thereby compromising the protection of the remaining residents.

Group homes are required to notify the county and DPW within 24 hours after an unusual or unexpected death occurs. The home is required to conduct an investigation,33  but there are no such regulatory requirements for the county or DPW. Instead, the county or DPW may conduct investigations.

According to our interviews with DPW personnel, DPW's practice since early 1999 has been to collect certain information from the provider agencies, including the following:

  • death certificate listing the official cause of death, and autopsy report if applicable;
  • documentation of the provider agency's review of death;
  • lifetime medical history for the resident, including the most recent annual health assessments and physical examination results;
  • discharge summaries from the resident's hospitalizations in the past 12-month period; and
  • non-routine health notations made by staff in the past six-month period.

The following are summaries of the three unexpected deaths for which DPW failed to conduct timely and adequate investigations.

 

Unexpected Death: Resident #1

This woman died of pneumonia but had no history of respiratory problems. Neither DPW, the county, nor the provider agency investigated for two years. An investigation was finally made after three other deaths had occurred at group homes operated by this agency in a two-year period.

Resident #1 entered the group home in June 1994 at the age of 33 after previously living at home with her family. Approximately six months later, in January 1995, she was admitted to a hospital with a diagnosis of pneumonia. Eight days later, while still in the hospital, she died.

Neither the group home's provider agency, the county, nor DPW investigated at that time to determine whether or not the group home provided adequate health care to the woman prior to her admission to the hospital. It was not until two years after the woman's death that DPW directed the county to investigate the deaths of four group home residents-including the woman-that had occurred in homes operated by the same provider agency between February 1995 and January 1997.

 

 

Unexpected Death: Resident #2

Following a man's death, the group home's provider agency and the county investigated but found nothing inappropriate. The county conducted a second investigation three months later. Finally, one year after the man's death, DPW investigated and found that the man had died following an incident at his day program site where he stopped breathing after receiving food that was chopped rather than pureed as required.

Resident #2 entered the group home in June 1994 at age 37 after his discharge from a state institution. In October 1996, while the man was attending his day program, he stopped breathing after he finished eating. The nurse at the day program administered CPR, and the man was transported to the hospital. He died there the next day.

At the time of the man's death, the executive director of the day program, along with a county representative, investigated the death. The investigation concluded that the cause of the cardiopulmonary arrest could not be determined and that the day program staff acted in an appropriate manner at the time of the incident. Records at the group home, however, were not reviewed.

Approximately three months after the initial death investigation, the death was again investigated as part of the county review noted previously for Resident #1. During this second review, the records at the group home were reviewed as well as the records from the day program. This time something amiss was found. In August 1996 after the resident had been hospitalized, discharge instructions had been issued that he be given only pureed foods because of his swallowing difficulties. There was no documentation to show that the group home ever conveyed those instructions to the day program personnel, who continued to feed the resident chopped foods instead of pureed.

The following year, in 1997, two DPW investigators from Ebensburg Center reviewed the man's death as part of an investigation into the deaths of ten former state institution residents, including Resident #2. The new review found that the man had died because his food at the day program had not been the proper consistency (i.e., pureed).

In addition, the county's investigation resulted in recommendations that written procedures must be developed and maintained to ensure that health care information is transferred among residential and day treatment providers as needed, and that investigators of serious incidents and deaths should review records and conduct interviews with all staff involved in an individual's care.

The county in this case subsequently developed policies and procedures to document changes in diets and medications and to ensure that the changes are exchanged with applicable providers. We note that, as of November 1999, this system had not been adopted by the other four counties in our review. We also note that we saw no documentation to show that DPW informed the other counties about the recommendations.

 

 

Unexpected Death: Resident #3

A man died after choking on food. The provider agency did not investigate, explaining later that they deferred to the county. Although the county did investigate immediately, it did not reconcile contradictory information, nor did DPW follow up at the time. Two years later, DPW investigated and suggested that the provider was negligent.

Resident #3 entered a group home in June 1994 at age 29 after previously residing in a state institution. Less than a year later-in April 1995-the man died.

The man had a severe cleft palate. This condition required that his food be chopped and moistened, and that he be offered adequate liquid with all foods and after each bite of food. The autopsy report listed the cause of death as asphyxiation secondary to food obstructing the pharynx.

In this case, the county investigated. The county's report indicated that the deputy coroner determined the death to be accidental by asphyxiation from food particles in the pharynx.

We noted numerous deficiencies surrounding the investigation of this man's death:

  • DPW did not conduct an investigation at the time of death.
  • DPW did not follow up on questions that, according to our review, the county left unanswered.
  • The group home's provider agency did not conduct an internal investigation.
  • The county investigator did not interview the direct care workers who were on duty prior, during, and subsequent to the death. As such, there were no signed statements from direct care workers.
  • The county investigator did not review pertinent agency documents, including direct care charts, nursing journals, and daily logs.
  • The county investigator failed to review and/or reconcile contradictory evidence. Agency documentation indicated that the resident was to be repositioned at two-hour intervals at night, and the group home's direct care staff maintained a chart to document the required repositioning at those intervals. However, not only did the applicable employee on duty fail to initial the chart on the night the man died, but provider agency officials subsequently indicated that there were no set time frames or routines to reposition the man. There is no evidence to show that the county's investigator attempted to review the direct care charts to either note or reconcile the discrepancy.
  • In yet another contradiction, the Pennsylvania Protection and Advocacy organization reviewed records and noted that there were differences in the reports of two group home staff members about the man's sleeping patterns in the week prior to his death. The first employee-who worked at two jobs each day-reported that the resident had slept soundly on the nights he was on duty. The second employee-who worked only at the group home-reported contrary circumstances, saying that when he was on duty that week the man suffered from a cold and did not sleep well. The county investigator did not attempt to reconcile the contradiction but only noted its existence in a letter to DPW.
  • The man's case manager had made notes-which the county investigator reviewed-indicating that the resident was awake and had been given toast at approximately 10:30 p.m. on the night of his death. In spite of the feeding instructions for the resident, the investigator did not question whether improper feeding techniques might have contributed to the resident's choking death.
  • The county investigator did not review training records to determine whether the involved direct care workers were properly trained in the resident's plan of care, including his feeding techniques and night routines.
  • The group home's provider agency did not discipline any of its direct care workers for breaches of established procedures regarding feeding and documenting the repositioning of the resident.

Although DPW officials questioned the county's final report and, in fact, wrote to the county with questions about some discrepancies, we could find no evidence that either DPW or the county followed up further other than to obtain the autopsy report.

The review by the DPW Ebensburg team, discussed previously, was conducted approximately two years later. This team found that the resident had apparently died due to being given the dry toast to eat without following the proper feeding techniques.

Also troubling were the Ebensburg team's notations that the man's autopsy indicated that he had weeping bedsores at his death, that he had not received a bath during one four-week span, and that his plan of care for personal hygiene was extensive to avoid skin breakdown while maintaining the skin's integrity.

But the DPW team's findings and recommendations were not conveyed either to the group home's provider agency or to county officials, and the personal hygiene issues were not even mentioned in the county's death investigation report.

Finally-in January 1998-more than two and a half years after the death of the resident, DPW's Deputy Secretary for Mental Retardation issued an internal memorandum restating the man's cause of death and the problems with the resident's personal hygiene. The letter suggested that death may have occurred due to provider negligence, directed that a referral be made to the Office of the Attorney General, and requested that a determination be made on the home's compliance with licensing regulations. Although DPW did refer the case to the Attorney General, DPW informed us that such a review had not been undertaken by the Attorney General as of November 1999. DPW program and licensing personnel did conduct an unannounced visit of the group home in February 1998 and determined that it complied with licensing regulations and that the health and safety of the current occupants were assured.

If DPW and the agency had conducted an investigation at the time of the man's death, it is possible that more could have been done to identify precursors to the incident, opportunities for prevention, areas of risk, possible deficiencies in training group home staff regarding individuals' health needs, or inadequacies in caregiving.

DPW's actions in these three examples were deficient. In the case of Resident #1, DPW did not investigate for two years, certainly untimely by reasonable standards. In the case of Resident #2, DPW did not ensure that the home conducted a thorough investigation, nor did DPW follow up in a timely manner. In the case of Resident #3, DPW's investigation was both ineffective and late. It is patently obvious that, when DPW does not immediately oversee, investigate, or review cases of abuse, unexpected death, or other serious issues, DPW compromises its responsibility to the residents, families, and all who expect state government to carry out its public mission with efficiency, effectiveness, and compassion.

In conclusion, DPW should ensure that investigations of unexpected deaths are begun immediately. It should not tolerate delays, nor should it delay its own investigations. DPW should direct that interviews be conducted as soon as possible in the investigation process, and by trained investigators who should not allow information to become stale or forgotten. Investigations should be thorough, contradictory information should be evaluated, and conclusions should be determined when information is complete.

 

Recommendations:

DPW should evaluate current regulatory requirements to ensure that they promote efficient and timely investigations of unexpected deaths at group homes.

DPW should consider enhancing its regulations to determine whether additional safeguards should be instituted into the licensing of facilities.

DPW should oversee or perform the investigation of any unexpected death of a resident in a group home. In addition, it should conduct interviews promptly and perform timely reviews of documents.

DPW should ensure that death investigations are performed by individuals who have adequate experience and training; if necessary, DPW should establish investigative standards and procedures.

DPW should develop best practices to promote the quality of care and safety of residents. DPW should institute a mechanism to disseminate and train counties and providers of such best practices.

 

DPW's Response:

While the DPW is in the process of significantly revising and improving its reporting requirements and investigation procedures of unusual incidents and deaths, the DPW disagrees that the investigations of these three deaths were untimely. In the case of the three deaths identified in the AG's report, the DPW received and reviewed reports from the providers and counties at the time of, and following, the deaths. Not every incident or death requires the same level of review or investigation. An essential component of risk management systems is the targeting of resources to areas or issues that are most problematic, incidents that occur with the most frequency, and/or put vulnerable individuals at most risk.

In the case of the deaths included in the AG's report, all were reported and reviewed by the provider, the county, and the DPW in a timely fashion. The DPW conducted follow-up investigations either because there were additional questions, new information was received, there was dissatisfaction with the final reports, or as an exercise to evaluate the existing investigation procedures.

Individual Identified #1

A death from pneumonia in a person with a weakened health condition, which occurred after eight days of hospitalization, would not typically require a full investigation at the time of death. The information provided to the auditor revealed that the individual had significant health-related issues that received constant attention by agency and medical staff. Specifically relevant to the issue was the diagnosis and monthly blood monitoring of the individual for leukopneia. This condition is manifested by a significantly reduced white blood cell count, a precursor to infection. This condition, coupled with the individual's sedentary lifestyle, colostomy, rectal abscess, and urinary tract infection, contributed to the provider agency and county decision to forego a formal investigation of the death. In point of fact, the absence of a history of pneumonia reflected the high level of care provided to the individual in preventing infection. The investigation conducted some months later was part of a regular review process and not prompted by specific concerns. Suggesting that because "this woman.had no history of respiratory problems," her death was not only unexpected but unexplained, is grossly misleading. There was no question about the care provided in two different community hospitals. Family members maintained constant watch over this individual until the time of her death. While the death may not have been expected at that specific time, it was by no means unanticipated.

Individual Identified #2

The individual was discovered unconscious on October 28, 1996. The next day, the legal guardian directed that life support be withdrawn and the individual then expired. On October 30, 1996, the county began a follow-up investigation. The agency's final report of their findings and conclusions was issued to the county on January 17, 1997, and the final county report with corrective actions was accepted by the DPW on April 21, 1997. On March 5, 1998, as part of further follow-up, the DPW requested additional documentation in regard to improving communication between agencies.

The DPW's review of the incident concluded that a change in the individual's diet two months earlier was not conveyed to the day program that was responsible for providing the lunch meal. The review conducted by the DPW supports the contention that the probable cause for the respiratory arrest and subsequent cardiac arrest was the noon meal. However, because an autopsy was not approved by the immediate family, the actual cause of death could not be definitively determined. However, with the likelihood that food consistency contributed to the individual's death, the county took positive steps to insure appropriate communication among the agencies providing services.

Through both licensing reviews and waiver monitorings, attention to the sharing of critical information among providers is addressed through measuring compliance with regulations that require the recording of information in the medical section of the individual's record.

Individual Identified #3

The death occurred on April 5, 1995, at which time the DPW was notified. A review by the county case management agency was conducted the same day. The county initiated a formal investigation on April 27, 1995 and submitted their report to the DPW on May 8, 1995.

The DPW conducted a review of the report and requested additional information on June 8, 1995, and again on June 16, 1995. The autopsy report was made available to the DPW on September 20, 1995, and the review by the DPW was completed on October 24, 1995.

The documentation reviewed by the auditor substantiated the existence of diagnostic and training procedures relevant to the physical disabilities presented by this individual. As noted, extensive documentation also exists regarding sleep preferences and eating patterns and habits. Specifically, on April 3, 1995, representatives from the county, who had been conducting monitoring visits, noted a problem with regard to the positioning of the individual during sleep. Documentation supports their recommendation that cessation of the positioning routine should be "with medical consent or knowledge."

As part of a systems review, the DPW team conducted a follow-up review on June 26, 1997 and reported a possible Act 28 violation to the Office of Attorney General on January 5, 1998.

The DPW is currently redesigning the system and the requirements for managing unusual incident reports, including deaths. Included will be standard definitions, standards for conducting investigations, developing and requiring training for those who conduct investigations, and maintaining information to allow for analysis of incidents over time to detect trends and patterns that require intervention.

 

Department of the Auditor General's Response:

We are encouraged that DPW is in the process of significantly revising and improving its reporting requirements and investigation procedures of unusual incidents and deaths. The following responses relate to the three individuals identified in the finding:

Resident #1 - DPW's explanation and its conclusion that "[w]hile the death may not have been expected at that specific time, it was by no means unanticipated" make the presumption that it was unnecessary to investigate the unexpected death of this 33-year-old woman because she was going to die eventually anyway. Such a cavalier presumption is irresponsible and completely without regard for life itself. It also sends the message that this woman with mental retardation is not worthy of the state's attention because her unexpected death was coupled with her "weakened health condition," her history of "significant health-related issues that received constant attention by agency and medical staff," and her "sedentary lifestyle, colostomy, rectal abscess, and urinary tract infection." Further, contrary to DPW's implication that we questioned the care provided in two different community hospitals, we at no time in our audit report questioned the care provided in those hospitals. Instead, we specifically questioned the absence of an investigation at the time of death by the group home's provider agency, the county, and DPW to determine whether or not the group home provided adequate health care to the woman prior to her admission to the hospital. There can be no defensible reason to raise questions only after two years passed and three more deaths occurred at group homes operated by the same provider agency.

Resident #2 - Once again, DPW does not directly address its delay in investigating this unexpected death. Indeed, DPW acknowledges that it accepted a "final report" by the county (approximately six months after the unexpected death). As the response from DPW shows, more than a year passed until DPW requested additional information as "part of further follow-up.in regard to improving communication between agencies." Most important, it should not have taken over a year for DPW to determine that the resident's death was caused by food being improperly prepared.

DPW states that its review "supports the contention that the probable cause for the respiratory arrest and subsequent cardiac arrest was the noon meal." The conclusion notes that the executive director of the day program, along with a county representative, investigated the death and could not determine the cause of cardiopulmonary arrest; we further note that the agency and county investigation determined-without even reviewing the records at the group home-that the day program staff acted in an appropriate manner at the time of the initial incident.

Resident #3 - DPW's review of a county report and an autopsy report is not the same as DPW investigating an unexpected death itself. Yet DPW relied solely on the reports of others until, two years later, it conducted an investigation. As the conclusion states, the provider agency conducted no investigation, and there were numerous deficiencies and contradictions regarding the county's investigation. Most glaring, perhaps, was that the county investigator neither reviewed pertinent documents nor interviewed the direct care workers who were on duty prior, during, and subsequent to the death. DPW should have addressed these problems through a timely and effective investigation and follow-up. Therefore, DPW's oversight of the county and the provider agency was ineffective as well as untimely.

 

 

 

Conclusion 2:

DPW allowed staff of group homes' provider agencies to perform abuse investigations even if they had no special training to do so.

During the course of our audit, staff from provider agencies and county MH/MR offices asserted that it was difficult to substantiate abuse allegations made by or on behalf of group home residents. The following example illustrates some of the problems brought to our attention regarding abuse investigations and their conclusions:

A resident suffered scrapes on his elbows and knees as a result of an incident involving a group home staff member. The resident accused the staff member of having "nabbed" him and put him "in a headlock." The accused staff member stated that the resident "lost his balance and fell." A staff member who witnessed the incident said the accused staff member placed the resident in a headlock and pushed him to the ground. Still another staff member-who did not witness the incident-said that the accused staff member told her he "had tried to put a hold" on the resident.

The final report concluded that it was not clear if the resident had been improperly restrained or pushed. The abuse allegation was therefore deemed to be unsubstantiated. Such an inability to reach a definitive conclusion becomes unfortunate for all parties involved-residents who were actually abused are not adequately protected and, conversely, improperly accused abusers are not irrefutably cleared. This incident illustrates the importance of having investigators adequately trained in interviewing and investigation techniques.

 

 

The table below identifies the positions held by those persons

deemed to be abuse investigators at each provider agency, as well as the investigation training received by each person. We note here that, according to our review, none of the investigators attended more than one training seminar regarding abuse investigations for the period of our audit.

 

 

Agency

Agency Staff Members who Conduct

Investigations

Number of

Training Hours

Date of Training

Agency 1

Residential Program Director*

Asst. Residential Program Director*

0

0

n/a

n/a

Agency 2

Program Manager*

Assistant Program Manager*

CEO

Residential Supervisor

Program Specialist

Risk Manager

0

0

2

8

0

16

n/a

n/a

11/97

9/94

n/a

1998

Agency 3

Residential Services Director*

Residential Services Supervisor*

Client Services Director*

Executive Director

7

18

19

18

1/96

8/97

1/96

6/90

Agency 4

Executive Director*

10

6/99

Agency 5

Director of Administrative Services*

CEO*

0

16

n/a

11/93

Agency 6

Director, Adult MR Services, S. Region*

Director, Adult MR Services, N. Region*

VP Program Administration*

Supervisor Adult MR Services

0

0

0

0

n/a

n/a

n/a

n/a

Agency 7

Program Specialist*

Residential Program Director*

CEO

0

0

0

n/a

n/a

n/a

Agency 8

Program Specialist*

Program Specialist*

0

0

n/a

n/a

*Indicates primary investigators of abuse at each agency.

 

Note: The investigators at Agencies 6 and 8 received training regarding what constitutes abuse, but the training did not focus on abuse investigations.

 

 

Interviews conducted with provider agency, county, and DPW personnel indicated that DPW provided no standardized abuse investigation training to staff of provider agencies during the period of our audit. One of the five sample counties offered abuse investigation training to its agencies but, in the five counties combined, training for investigators was highly variable. In some cases, in fact, there is no training at all. Contributing to this dearth is the fact that DPW's regulations contain no training or certification requirements for investigators, nor do the five counties mandate any such requirements.

By not requiring training or certification for the conduct of investigations, DPW cannot be assured that investigators have the expertise and experience for such critical work. Furthermore, work habits and investigative techniques are bound to differ from person to person. On the other hand, investigators trained uniformly in effective interviewing techniques and critical analysis skills are more likely to ascertain vital information from victimized residents, accused abusers, and wary witnesses. By addressing this issue, DPW would better facilitate the credibility of conclusions and corrective actions attendant to abuse investigations.

We note that, in 1985, DPW laid a foundation for acting on this problem when it developed an abuse investigation manual that included guidelines for securing evidence, conducting and documenting interviews, and preparing final reports. Unfortunately, DPW did not distribute these manuals to counties or provider agencies.34  If DPW were to direct counties and provider agencies to follow these written guidelines, there would be some assurance that at least minimum procedures would be set forth for investigations.

One county has already acted on its own in this regard. The county that offered abuse training to its investigators (as mentioned on the preceding page) also developed its own written guidelines to assist its group homes' provider agencies in conducting investigations. Furthermore, through its contracts with the agencies, the county required each agency to follow established procedures for the conduct of abuse investigations.

 

Recommendations:

DPW should require that all investigators of abuse incidents receive training and/or certification with periodic updates in order to ensure credible investigations, conclusions, and corrective actions.

DPW should distribute investigation standards to all counties and to the provider agencies of group homes, and should require that those standards be followed.

 

DPW's Response:

This finding is consistent with the DPW's assessment. The DPW has identified the need for such training, and is currently in the process of developing a system for managing unusual incidents that will include a training curriculum for abuse investigation for OMR, county, and provider staff. Once the curriculum is developed, training will be required; training sessions will be sponsored by the DPW and offered throughout the state.

 

Department of the Auditor General's Response:

No response necessary.

 

 

 

Conclusion 3:

DPW did not require county officials or any other independent officials to be directly involved in abuse investigations.

Just as the individual background and training of abuse investigators varied from provider agency to provider agency, the policies for local government oversight of abuse incidents differed from county to county. There was, however, one commonality: four of the five counties allowed group homes' provider agencies to investigate themselves at least some-if not most-of the time. The table below indicates the role assumed by each county in conducting investigations.

 

County

Summary of Each County's Role During Abuse Investigations

County 1

Generally, the group homes' provider agencies exclusively conducts the investigation. County officials then review the investigation report. The county may conduct investigations in conjunction with the agency depending upon the severity of the incident.

County 2

The county conducts most investigations in the presence of provider agency management personnel. In cases where the provider agency solely conducts the investigation, the report is reviewed by county personnel.

County 3

County personnel decide if the provider agency should solely conduct the investigation or if a team of trained investigators (including county personnel and community support agencies) will assist the provider agency. If the provider agency solely conducts the investigation, the report is reviewed by the county. If the team assists in conducting the investigation, the team reviews the provider agency's final report and then prepares a separate report.

County 4

Typically, the provider agency exclusively conducts the investigation. County officials then review the investigation report. In some cases-depending on the severity of the incident-the county conducts investigations in conjunction with the provider agency.

County 5

The county and the provider agency jointly conduct investigations. Final reports by the agency are reviewed by county personnel.

 

 

DPW has established no criteria to identify cases that require direct county involvement in the conduct of investigations; in the five counties we reviewed, county involvement was generally determined on a case-by-case basis. As a result, there was little consistency from one county to another. For example, one county did not become involved in the interviews and review of documents during an investigation as serious as sexual abuse, while another county chose to participate directly in an arguably less serious investigation, that of verbal abuse.

When an investigation of possible abuse-whether sexual, verbal, financial, or emotional-is carried out by the provider agency that employs the accused abuser, there is at least the appearance if not the reality of a conflict of interest. The direct involvement of an independent party should be required.

 

Recommendations:

DPW should require officials from the county MH/MR offices to be directly involved in abuse investigations instead of allowing provider agencies to investigate their own homes with no such independent involvement.

DPW should consider instituting a multidisciplinary review team within each county that incorporates, at a minimum, the expertise of officials from the county MH/MR offices, law enforcement, and medical personnel to evaluate allegations of abuse and in certain cases conduct the investigation.

 

DPW's Response:

DPW regulations require the licensed agency to initiate an initial investigation of all alleged abuse. Conducting investigations of events that occur in its own facility is standard practice in all care giving entities, including hospitals, nursing homes, and state institutions. It is generally considered an essential management function. It is the facility itself that is the first to become aware of incidents, and facility staff must act immediately to secure evidence, interview witnesses, and establish a clear record of findings. All reports of abuse and investigations of events in community mental retardation programs must be submitted to the County MH/MR Program and to the DPW. After review, a determination is made on whether further investigation is necessary. In general, agencies act promptly to assure an individual's safety and to take appropriate action against the person who has committed abuse.

County MH/MR Programs and the DPW have the responsibility for conducting investigations of alleged abuse, and do so whenever there are questions about an agency's investigation, findings, or follow-up actions. The revised Unusual Incident Management System will specify the types of incidents that will require the involvement of independent officials in an investigation, including County MH/MR Programs.

 

Department of the Auditor General's Response:

As the conclusion states, DPW has established no criteria to identify abuse allegations that require direct county involvement in the conduct of the investigations. While it is important that agencies conduct internal investigations, certain allegations are worthy of an investigation by county officials or other independent officials. We are encouraged that DPW's revised Unusual Incident Management System will specify the types of incidents that will require the involvement of independent officials in an investigation.

 

 

 

Conclusion 4:

DPW did not require county or group home officials to report abuse investigation information that is critical to DPW's oversight.

MR Bulletin #6000-88-04 states that DPW is responsible for ensuring that counties fulfill their "responsibilities for the prevention, management and reporting of unusual incidents." These responsibilities include ensuring that "proper investigation, analysis, and corrective changes" are made.

All of the eight provider agencies in our sample had policies for the prevention, management, and reporting of unusual incidents, including alleged abuse. Two of the eight agencies formally distinguished between levels of abuse and explicitly identified the progressive disciplinary measures associated with each defined level. But the final reporting to DPW was another matter.

Final reports of abuse investigations should provide DPW with the means to carry out the oversight responsibilities with which it is charged. Yet DPW did not require the counties or homes to report certain information critical to oversight. For example, final investigation reports frequently did not include the following:

  • summary of corrective personnel actions;
  • recommendation(s) regarding related agency procedures;
  • summary of investigative procedures;
  • summary of evidence gathered;
  • identities and credentials of the investigators; or
  • signatures of the county personnel who reviewed the report.

During interviews, DPW personnel noted that final reports from provider agencies must incorporate only two elements: (1) they must be on provider agency letterhead and (2) they must include the investigation's conclusion regarding the alleged abuse. DPW's Licensing Inspection Instrument checklist that is used during full inspections, however, says something different. That checklist directs DPW licensing inspectors to verify that each final report from an agency utilizes either (1) DPW's standard unusual incident report form or (2) agency letterhead on which "the findings, evidence to support the findings, and if founded, corrective actions taken" are included.

The following example illustrates how the lack of critical information can hinder DPW's oversight:

One provider agency, following its investigation of an incident in which a resident's leg was broken, prepared an internal report complete with summary, conclusions, and corrective actions. The internal report noted that the resident's leg was broken when a direct care worker violated agency policy by lifting the resident from his wheelchair without the assistance of another direct care worker. The report also noted that the worker received a written disciplinary warning and was re-trained in agency policy and procedures. In addition, two other workers received written disciplinary warnings and re-training because they did not tell a supervisor that the resident's "right foot extended to the right of his right leg," to quote the internal investigation report.

The internal report went even further in detailing the inadequate actions of workers. Still another employee observed symptoms that could signify a problem while the resident was awaiting an unrelated examination by a gastroenterologist. Yet that employee, too, did not relay her observation to the doctor, nor was the employee disciplined for that failure.

 

 

In spite of all this detailed information in the provider agency's internal report, the final report to both the county and DPW was glaringly incomplete and alarmingly misleading. It said only that the abuse was unfounded and that the broken leg most likely occurred when the resident was "transferred from a couch to his wheelchair."

With the provider agency's omission of significant information about the violations of policy, the failure to notify a supervisor or physician, and the administration of written warnings and re-training, DPW would have had no real reason to question the adequacy of the agency's actions. On the other hand, DPW could have raised serious questions if it had required the final report to be more detailed.

As noted previously, there were 32 allegations of abuse among the eight group homes during the period of our review. Two of those allegations of abuse-neither of which occurred at the group home itself-were investigated by the county's district attorney and Children and Youth Services agency. Remaining, then, were 30 alleged abuse incidents for which the provider agency of each group home submitted a final report to DPW:

  • For 19 of those 30 investigations, the final reports included no summary of investigation procedures used or of evidence gathered.
  • In four of the 11 unfounded incidents, the reports to DPW did not include actions that the provider agencies had taken to prevent future abuses, information that DPW would need in order to know that residents would be adequately protected.
  • In no cases did county officials sign the final reports from the provider agencies, thereby leaving DPW without a critical detail that could signify whether the county actually reviewed and agreed with the report.
  • In one of the six founded cases of abuse, the report to DPW did not include personnel actions taken by the provider agency-information that DPW would need in order to determine if the group home's residents were reasonably safe from danger.
 

Although we could not conclude that DPW was proactive in ensuring or reviewing corrective actions by group homes, we found that the provider agencies in all six cases of founded abuse had taken corrective measures that appeared appropriate. The table below indicates the nature of the six incidents and the associated actions.

 

Provider

Description of Incident

Corrective Action(s)

Home 4

A staff person slapped a resident on the hand.

Employment was terminated.

Home 4

Two staff persons used seclusion as a restrictive procedure to manage a resident's behaviors.

The employees received written warnings and retraining in accordance with agency policy.

Home 4

A direct care worker utilized unnecessary force while "redirecting" a resident. A coworker who witnessed the abuse reported the abuse 15 days after the incident.

The direct care worker who exercised unnecessary force received a written warning and retraining in "redirection techniques." The worker who failed to report the abuse within 24 hours received a written reprimand in accordance with agency policy.

Home 5

The incident occurred at the day program. A day program employee stuck his foot in the mouth of a resident and made disparaging remarks to the resident.

The employee was suspended without pay until his resignation became effective.

Home 7

While smoking outside of the home, a direct care worker left a resident unattended in the bathtub. Additionally, three direct care workers failed to follow proper procedures and evacuate the residents when the fire alarm sounded.

Employment for the direct care worker who left the resident unattended was terminated. Each of the remaining two employees was suspended for two days. All agency employees were retrained in fire safety procedures.

Home 7

A direct care worker slapped a resident while attempting to block the resident's attempts to scratch and pinch the worker.

The employee was suspended for three days during the investigation. She also received a written warning in accordance with agency policy.

 

 

Final decisions for such corrective actions are the responsibility of the provider agency, but DPW and the county can make recommendations. In order for DPW to make recommendations based on complete information, however, it must require more details in the final reports.

DPW has taken a first step in that direction by developing a recommended comprehensive format for final investigation reports, but it has not mandated that the specific format be used. Only one of the five counties in our sample required agencies under its purview to use the format recommended by DPW. Of the remaining four counties, only one required that the report include a summary of the investigation. DPW must do more to ensure that its oversight actually fulfills its mandate to ensure the health and well-being of group home residents with mental retardation.

 

Recommendations:

DPW should require final investigation reports to conform to a uniform format that includes summaries of investigative procedures, evidence gathered, and corrective actions.

DPW should require county officials to sign all final investigation reports, indicating their review and agreement or disagreement with the conclusion and corrective actions.

 

DPW's Response:

The DPW disagrees with this conclusion. The DPW requires that all investigations comply with the current regulatory requirements and that information be provided using the standard Unusual Incident Report form. These Unusual Incident Reports and follow-up investigations are reviewed by the DPW and additional information is regularly requested from provider agencies. These requests ask for information such as personnel, corrective, and preventative actions taken or to be taken.

Improvements to the system for managing unusual incidents will more completely prescribe what is to be reported.

The DPW is pleased to have its assertion that group homes are safe places confirmed by the AG's report, which found that "the provider agencies in all six cases of founded abuse had taken corrective measures that appeared appropriate" and would prevent future abuse.

 

Department of the Auditor General's Response:

DPW states that it disagrees with our conclusion but does not directly respond to it. Instead, DPW states what it requires in theory but not what occurred in practice in the cases we reviewed. Although DPW notes that "improvements to the system for managing unusual incidents will more completely prescribe what is to be reported," we encourage DPW not only to prescribe what is to be reported but also to ensure that such reporting is done.

DPW states that it "is pleased to have its assertion that group homes are safe places confirmed by the AG's report, which found that 'the provider agencies in all six cases of founded abuse had taken corrective measures that appeared appropriate' and would prevent future abuse." We have not asserted and we do not assert that group homes are necessarily safe places. We assert only that, in the six sampled cases of founded abuse which we reviewed, the provider agencies took corrective measures that appeared to be appropriate. Moreover, the six provider agencies appear to have implemented these corrective measures in spite of DPW's lack of oversight.

 

 

Conclusion 5:

DPW did not ensure that abuse investigations were completed and that its database was updated.

After receiving an initial report about alleged abuse, DPW staff enters information about the incident into a database. Included are the name of the resident, the type of alleged abuse, and the date of the incident. An incident is considered open until DPW receives and reviews a final report and conclusion (founded or unfounded) from a group home's provider agency, and until any necessary follow-up questions35  have been answered. Only then does DPW record the conclusion and deem the incident to be closed.

As of November 1999, the database records for the previously discussed 32 allegations of abuse disclosed that six of the 32 incidents showed no final determinations or closing dates. Three of those six incidents occurred in 1997. The following chart lists the dates of the unclosed incidents and the reasons that they were not closed on the database.

 

Date of Incident

Reason that the determination was not entered on the database

2/12/97

The final report was received by DPW; the data was not entered on the database.

7/22/97

The final report was received by DPW; the data was not entered on the database.

8/19/97

No final report was found at the provider agency, county, or DPW.

9/9/98

The final report was received by DPW; the data was not entered on the database.

1/16/99

The group home's provider agency did not prepare a final report.

5/3/99

The group home's provider agency did not prepare a final report.

 

 

No regulation states when an agency must send a final investigation report to the county and DPW. Moreover, DPW has not established policies and procedures regarding the time period within which its program personnel must contact agencies to determine the status of those investigations for which no final report has been received. In at least three of six incidents listed in the preceding table, DPW would be unable to assess the propriety of final conclusions or corrective actions because it would be unaware of them. Its oversight of such investigations must therefore be considered untimely and inadequate.

 

Recommendation:

DPW should develop and enforce time frames for agencies to submit final investigation reports after completion of investigations and also time frames and procedures for DPW's own staff to follow when provider agencies' final reports are late.

 

DPW's Response:

The DPW acknowledges this conclusion and the need to establish a timeframe in which a final investigative report must be submitted.

The AG's report acknowledges that DPW follow-up to final investigations do, in fact, take place via telephone in most cases. However, DPW staff does not always record information from follow-up contacts in the file. The Department will develop a policy requiring that follow-up conversations be documented in writing by DPW staff.

As part of the annual licensing inspections, the inspectors review all reports and investigations of founded abuse. All corrective actions taken to address the abuse are also reviewed at this time.

 

Department of the Auditor General's Response:

No response necessary.

 

 

Conclusion 6:

DPW did not ensure that all allegations of abuse were reported in the required time frames.

DPW regulations require group homes to orally report allegations of abuse to the appropriate county and DPW regional office within 24 hours after the suspected abuse occurs.36  The home must initiate an investigation and send copies of the associated unusual incident report to the county and DPW within 72 hours after the alleged incident occurs.37  In addition, in cases in which the alleged victim of abuse is age 17 or younger, the home must immediately report the incident to ChildLine, which is the state's central registry for child abuse and neglect cases.38 

According to our review of the records for the 32 alleged abuse incidents that occurred among the eight agencies sampled, there were eight instances in which the provider agency did not make an oral report to DPW within 24 hours. In some of those cases, the agency made no oral report at all. In addition, our review found four cases in which a written report was not filed within 72 hours, as well as four cases in which ChildLine was not immediately notified as required. Yet DPW cited violations in only three of the 16 instances when abuse was not reported as required.

 

 

Violation

Number

of Violations

Number of Associated Citations

     

Requirement to orally report alleged abuse within 24 hours

8

2*

Requirement to send written report of abuse allegation within 72 hours

4

1*

Requirement to immediately report suspected child abuse to ChildLine

4

0

*One alleged abuse incident occurred after the agency's most recent inspection by DPW. Documentation disclosed that the agency had violated both the requirements to orally report the incident within 24 hours and to submit a written report within 72 hours.

 

According to DPW licensing personnel, the annual inspections of provider agencies typically do not include reviewing when all alleged abuse incidents for all of the agency's group homes were reported (since the prior inspection) unless the provider agency maintains the records for all such incidents in a central file within the agency. Moreover, even though the provider agencies are reviewed annually, only about one-quarter of agencies' group homes are inspected each year. Furthermore, only a few of the abuse incidents are studied during those inspections to determine if they were reported as required. That means that for agencies with no central file of abuse incidents, far fewer than one-quarter of abuse incidents would be reviewed to determine if reporting occurred within the required time frames.

Reviewing just a fraction of abuse incidents to see if they were reported on time is inadequate by itself. But even worse is DPW's practice of waiting until its next annual provider agency inspection to take action against the untimeliness. According to our interviews, when DPW provides its licensing staff with information about cases of untimely abuse reporting, the licensing staff cites the provider agency during the next inspection rather than immediately. The interval between the licensing staff's knowledge of the violation and its citation of it might well be an entire year-a counterproductive delay that undermines rather than enforces the importance of timely reporting.

 

Recommendations:

DPW should ensure that all abuse incidents that occurred since the previous home inspection are reviewed during the subsequent inspection.

DPW should enforce regulatory time frames for reporting abuse by citing noncompliant group home provider agencies as soon as the violations become known to DPW.

DPW's Response:

The DPW disagrees with this conclusion. Prior to a licensing inspection, the licensing inspectors obtain a report of all unusual incidents reported to the DPW since the last inspection. The DPW licensing inspectors review reports of alleged abuse at all homes in which a full inspection is conducted during all annual inspections for compliance with the regulations. A full inspection is also conducted at any home that has a founded abuse report.

DPW licensing inspectors and program staff conduct unannounced inspections as follow-up to abuse investigations. If the provider agency is in violation of the regulations, a plan of correction is required to be submitted to the regional office.

The Department does not wait until the annual inspection to act on noncompliance with the regulations when the violation is likely to require some type of licensing action, such as issuance of a provisional license or a revocation.

 

Department of the Auditor General's Response:

While DPW's response discusses processes and policies that are in place and that should be followed, it does not discuss the process that actually was followed and that resulted in the actual violations we identified. As the conclusion states, 8 of 32 alleged abuse incidents were not orally reported to DPW in a timely manner, and only two of these incidents were cited by DPW licensing personnel. We also found that DPW cited only two of four cases where written reports of alleged abuse cases were not filed in a timely manner. While DPW may believe that licensing inspectors are effectively reviewing reports and ensuring that agencies report the incidents in a timely manner because there are policies and procedures in place, the evidence shows otherwise.

 

 

Conclusion 7:

DPW did not ensure that direct care workers received adequate training in abuse prevention.

Newly hired direct care workers in group homes frequently had no experience working with individuals with mental retardation. The responsibility is great and the job is challenging, but it can also be stressful and exhausting. Training is needed not only for orientation but also for continuing education to help direct care workers cope with unfamiliar situations that might lead them to commit abuse themselves.

The training offered at the eight provider agencies can be summarized as follows:

  • Six agencies did not offer a comprehensive course in abuse to newly hired employees.
  • Seven agencies offered no formal abuse training as part of the continuing education for existing employees.
  • Five agencies provided no annual abuse training, even on an informal basis, to existing employees as part of their continuing education.
  • Six agencies offered new staff members a review of the agencies' policies relating to abuse and, in some instances, a discussion of actions that constitute abuse. Emphasis was placed on the recognizing and reporting of abuse rather than on preventing and managing abuse.
  • Each of the eight provider agencies had developed policies and procedures for the prevention, reporting, and management of abuse incidents.

 

 

Recommendations:

DPW should require agencies to conduct comprehensive training regarding abuse both during orientation and on an annual basis. The training should include the following:

  • A review of agency policies and procedures including those regarding abuse recognition, reporting, management, and associated disciplinary actions.
  • Thorough training on abuse prevention. New employees should be trained in methods to recognize and manage potentially volatile situations.
  • Diverse instructional methods to reinforce and clarify agency policies and procedures regarding abuse, e.g., role-playing exercises, pertinent videos, and written tests.
  • A requirement that each employee sign a statement asserting that he or she received training and understands the policies.

 

DPW's Response:

Current regulations state that the agency ".shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home, and policies and procedures of the home.." In addition, regulations require that all direct service workers have training in client rights within 30 calendar days of employment. [Ch. 6400.46(e)] The first of the client rights listed in the regulations is: "An individual may not be neglected, abused, mistreated or subjected to corporal punishment." [Ch. 6400.33(a)]

As noted in the report, "six of the eight provider agencies offered new staff members a review of the agency's policies relating to abuse and, in some instances, a discussion of actions that constitute abuse." The report also states that "each of the eight provider agencies had developed policies and procedures for the prevention, reporting, and management of abuse incidents."

In addition, the regulations governing community homes have extensive requirements related to client rights and the use of restrictive procedures. Abuse frequently occurs with individuals who have behavior that is difficult to manage. Therefore, the requirements for behavioral program planning, staff training in the plan, and the application of alternate interventions before restrictive procedures are applied, all serve to reduce situations and employee behavior that lead to abuse.

The DPW agrees that abuse prevention training is critical to ensure the health and safety of the individual and that it should be part of the annual training for all employees, as well as part of the orientation process. As regulations are revised, provisions that will serve to prevent abuse will be considered as part of the training requirements.

 

Department of the Auditor General's Response:

We note that DPW agrees that "abuse prevention training is critical to ensure the health and safety of the individual and that it should be part of the annual training for all employees, as well as part of the orientation process."

Unfortunately, DPW did not address some of our concerns relative to newly hired direct care workers. We found that six of the eight agencies did not offer a comprehensive course in abuse. While having policies and reviewing them is important, a more comprehensive and formal training course should be offered to new employees.

Again, this was a performance audit, which goes beyond compliance with rules and regulations. Improving the training given to new direct care employees in the area of abuse prevention would improve the care provided to these most vulnerable individuals and could possibly prevent future tragedies.

 

 

 

 

Chapter Three

Quality of
Service to
Group Home
Residents

DPW fell short in
ensuring that group
home residents of
all eight sampled
agencies were
provided service in
a timely manner
that did not
compromise their
health and well-being.

 

Every group home resident receives services according to a written plan based on his or her specific needs. The written plan is known as an assessment, and each resident has a program specialist who coordinates the assessment process.

Information collected and documented about each resident during the initial assessment includes the following:

  • disability, including functional and medical limitations;
  • lifetime medical history;
  • ability to perform personal needs with and without assistance;
  • functional strengths and weaknesses;
  • likes, dislikes, and interests; and
  • need for specific areas of training, programming, and services.
 

Using the assessment, a team from various disciplines develops resident goals that are outlined in written, individual support plans. The program specialist monitors the resident's progress and also updates the plan at least every three months. Then, once a year, the interdisciplinary team conducts a comprehensive review of the plan and updates it as necessary.

Services that residents require vary with each resident but include, for example, the arrangement of employment, transportation, and other activities; assistance with personal needs; the procurement of medical care, including routine care, emergency care, and therapeutic care; and the administration of medications. Typically, the group home's provider agency arranges for these services, and the county MH/MR office provides direct oversight through its case management responsibilities. Written contracts between the county and the agency provide for the county's oversight and define performance expectations. DPW monitors the overall provision of services through its licensing and inspection process.

 

Objectives and Methodology for Chapter Three

To assess how well services were coordinated and provided, we:

  • reviewed applicable state regulations and guidelines to determine the existence of mandated services and to ascertain the oversight responsibilities of DPW and the county MH/MR offices;
  • visited eight agencies and reviewed individual support plans to determine what services were prescribed for each of the residents;
  • reviewed agency documents to determine if services were provided as prescribed; and
  • reviewed DPW inspection records, case manager records, and county contracts to assess the oversight of services provided.

We reviewed agency documentation for a total of 35 group home residents over various periods based on the term of residence up to five years and/or the date on which a particular home began operating. There were three to six residents in each home at any one time during our review.

Specifically, we intended to determine whether:

  • physical health assessments were comprehensive and timely;
  • all individuals had a comprehensive emergency medical plan in place;
  • medications were administered as prescribed and, if not, whether medication errors were properly documented;
  • individuals received all services in accordance with their individual support plans;
  • county case managers provided adequate oversight and support to individuals residing in group homes; and
  • DPW provided adequate oversight regarding service provision to group home residents.

Overall, we found that provider agencies for the most part provided adequate and timely services regarding physical health assessments, day programming, and specialized therapies, and that county case managers in most cases provided adequate oversight. However, there were several areas in which the services provided were deficient. Those areas are addressed in the four conclusions on the following pages.

 

 

 

Conclusion 1:

DPW has ensured that the eight group homes met minimum requirements in developing emergency medical plans for residents, but it has not provided direction to go beyond those minimal requirements.

To ensure individual well-being in the event of a medical emergency, DPW's regulations require that all individuals have written emergency medical plans. DPW requires the plans to list (1) the hospital or source of health care that will be used in an emergency, (2) the method of transportation to be used, and (3) an emergency staffing plan.39 

Of the 35 resident files that we reviewed, we found that emergency medical plans had been prepared in all cases in compliance with these requirements. The emergency medical plans are intended to provide pertinent information about the resident, along with specific instructions for staff to follow in emergency situations.

One group home went beyond DPW's requirements, as evidenced by a single comprehensive plan per resident rather than the segregated plans maintained by the other seven homes. A single document contained the individual's comprehensive medical history, including diagnoses, parent or guardian contact, medical insurance, current medications, advice about potential drug interactions, immunization history, and other pertinent health information (such as seizure disorders, communicable diseases, and allergies). Several of the other homes maintained a separate document addressing health insurance information of the residents. Several homes also used a separate policy and procedures manual to address hospital information, emergency transportation methods, and staffing procedures.

 

 

Neither DPW nor the county (via the contract between the provider agencies and the county) specify that the emergency plans be contained in a single document. But although all eight homes complied with the regulations, the direct care workers in seven of the homes would undoubtedly spend more time gathering necessary information from a variety of sources during a medical emergency than the direct care workers in the home with the single comprehensive plan. A comprehensive, single document would allow immediate access to all vital information, freeing the direct care worker to quickly focus on the emergency needs of the resident.

 

Recommendations:

DPW should encourage county MH/MR offices to require the provider agencies of group homes to develop and implement comprehensive, single-document emergency medical plans. The completed plans should be reviewed and approved by qualified county staff.

DPW should develop guidelines to aid group homes and their provider agencies in developing and implementing comprehensive, single-document emergency medical plans.

 

DPW's Response:

DPW licensing inspectors ensure that all agencies meet the current regulatory requirements regarding the development of emergency medical plans during the annual inspections. As noted in the AG's report, all of the emergency medical plans reviewed were in compliance with current regulations. As part of annual licensing inspections, inspectors make recommendations to provider agencies that go beyond the regulations, directed at ways to improve overall services. These recommendations are optional, since they go beyond the current regulations.

The AG's report also "found that provider agencies for the most part provided adequate and timely services regarding physical health assessments, day programming, and specialized therapies, and that county case managers in most cases provided adequate oversight."

Contrary to the AG's assertions, the DPW has an extensive and proactive program committed to improving the planning and care of individuals. The DPW has sponsored statewide training in many areas of best practices, including managing health needs, as well as treating individuals with mental health diagnoses, including the use of psychopharmacology and environmental/psycho-social interventions, and best practices in person-centered planning.

 

Department of the Auditor General's Response:

Again, this performance audit offers recommendations that may go beyond compliance with rules and regulations. We found that the eight group homes had the required emergency medical plans on file. Our recommendation asks DPW to encourage and support the development of emergency medical plans which are contained in a single comprehensive document, such as the one found at one of the group homes. This practice would allow immediate access to all vital information, freeing the direct care worker to quickly focus on the emergency needs of the resident.

 

 

 

Conclusion 2:

DPW has not implemented a system to inform all group homes of extra safety precautions used by other group homes for medication administration.

The majority of residents in the eight group homes were administered physician-prescribed medications. In many cases, because of the nature of their disabilities, group home residents cannot safely self-administer their medications. To help ensure residents' safety in this regard, all direct care workers receive comprehensive training and must pass a practical medication administration test before they are permitted to administer medications.

Our review disclosed that the eight group homes differed in their practices and precautions concerning the administration of medication. It should be noted that each of the eight homes followed procedures dictated by its provider agency and, therefore, may typify the practices of the other homes operated by that agency.

  • Five of the eight homes performed medication counts both before and after administration to a resident, thereby increasing the likelihood that correct dosages were followed.40  This practice contrasts sharply with that of another home that performed medication counts only twice per week. The latter practice could allow improperly administered dosages to go unnoticed for several days.
  • One of the eight homes received all medications weekly from a central pharmacy that also packed its pills individually (in "blister packs") for easier dispensing and counting. A home that receives weekly prescriptions has less medicine on hand than a home receiving its medications less frequently, thereby reducing the potential for errors. Several of the other homes also received blister-packed medications from central pharmacies, but the prescriptions were not filled weekly.
  • One home staggered the medication administration schedules to ensure that only one resident would receive medications at a time, thereby reducing the chance for errors or mix-ups.
  • One of the eight homes was subject to its provider agency's written, comprehensive policies and procedures that clearly defined medication errors.
  • Two homes established progressive medication error disciplinary procedures that use retraining and re-testing to prevent recurrence of mistakes.

Regarding actual errors in medication administration and related disciplinary policies, we found the following:

  • Two homes failed to report six and seven medication errors, respectively, during a one-month period.
  • One home reported 26 medication errors over a twelve-month period but did not report to agency administrators the identity of the person or persons responsible for the errors. Consequently, in spite of the provider agency's progressive, written medication error disciplinary policy for the re-training and re-testing for the errant employees, no employees were ever re-trained or re-tested.
  • The provider agency of one of the homes, rather than establishing written medication error disciplinary procedures, chose to consider actions on a case-by-case basis. The staff of the provider agency indicated that this policy allowed consideration of the error's severity and the employee's history. While this policy may be reasonable, we noted that it did not appear effective in correcting the deficiencies of at least one employee who was responsible for seven medication errors over a two-month period. The errors ranged from improper documentation to failure to administer medications, and the disciplinary action included only written warnings.

While our review disclosed that none of the above medication errors resulted in hospitalization or emergency treatment for the residents involved, the risk for serious medical consequences is great nonetheless. Residents of group homes would benefit if all provider agencies developed comprehensive written policies to ensure proper administration of medication, complete reporting of errors, and strict disciplinary measures when errors result.

DPW has not established criteria or guidelines that assist provider agencies in developing such policies, nor do the counties require such policies in their contracts with the provider agencies. At the very minimum, the provider agencies and their homes would benefit from information about effective practices and policies of other group homes.

 

Recommendations:

DPW should develop guidelines that would aid group homes in developing and implementing comprehensive medication administration and error policies along with effective progressive disciplinary guidelines.

DPW should establish a system to communicate effective practices to all provider agencies and the group homes they operate.

DPW should direct county MH/MR offices to require provider agencies to develop and implement comprehensive medication administration and error policies along with effective progressive disciplinary guidelines. The completed policies should be reviewed and approved by qualified county staff.

 

DPW's Response:

The DPW has an active program to achieve best practices in health care among provider agencies. We believe the structured approach of monitoring, training, and technical assistance described below will provide more consistent outcomes than the issuance of guidelines for medication administration, error policies, and discipline action. The mechanism typically used to share best practices is training and professional association conferences.

The DPW, along with the Temple University School of Nursing, continually evaluates and upgrades the Medications Administration Course, which is required for those training direct care staff to administer medications. The improvements address all practices and procedures related to the administration of medications.

The creation of HCCUs referenced in the Introduction will ensure that proper health assessments are completed, that agencies have adequate policies and procedures for managing the health of individuals and securing good medical care, and that agencies receive the training and technical assistance needed to improve practice and care.

 

 

Department of the Auditor General's Response:

DPW responds that it "has an active program to achieve best practices in health care among provider agencies." Unfortunately, we did not see evidence of this "active program." We found that the eight group homes had different practices and precautions concerning the administration of medication. While DPW may believe that best practices are being communicated, we found no such evidence.

DPW also states that "[t]he mechanism typically used to show best practices is training and professional association conferences." However, as discussed in several prior conclusions, we found flaws in the training provided to employees and DPW's oversight of training.

We hope that DPW's plan to create Health Care Coordination Units (discussed in the introduction section of DPW's response) will improve this process.

 

 

 

 

Conclusion 3:

DPW has not established guidelines to aid group homes in ensuring that they convey their residents' critical health and medical needs to outside caregivers.

As noted in Chapter Two, a group home resident died unexpectedly in 1996 when he was in the care of people outside of his home. His death was linked to the home's failure to communicate a critical health change to the people caring for him.

The circumstances surrounding the death of this resident illustrate a group home's grave obligation to ensure that its residents' most current health and medical needs are conveyed to all outside caregivers. The majority of the eight homes in our audit updated residents' needs by telephone or facsimile ("fax") machine or by face-to-face visit. However, there is enormous risk for error-based on misunderstanding or poor recall-when such important issues are communicated verbally. Even transmittal by fax machine carries with it the risk of omission if assurances are not in place that the intended caregiver has actually received the message.

A change form should include, at a minimum:

  • effective change date;
  • prescribing physician (if applicable);
  • specific nature of the change; and
  • day program, group home, and county representative signatures acknowledging the change.

We noted during our audit that DPW had provided no guidelines to aid group homes and their provider agencies in ensuring that critical health and medical changes were conveyed to outside caregivers. We also noted that the county MH/MR contracts did not require provider agencies to utilize specific procedures in this matter.

One of the eight provider agencies in our audit sample took the step of implementing formal policies and establishing a comprehensive written notification system for its group homes to use in communicating with outside caregivers. DPW should recognize that initiative and communicate it to other provider agencies as a commendable practice in ensuring the well-being of group home residents.

 

Recommendations:

DPW should develop standardized guidelines that would aid group homes in developing and implementing comprehensive health and medical change policies and forms.

DPW should direct county MH/MR agencies to require provider agencies that operate group homes to develop and implement comprehensive health and medical change policies and forms. The finalized forms should be reviewed and approved by qualified county staff.

 

DPW's Response:

The DPW acknowledges that standardized information exchange requirements are not in place. The DPW agrees that communication between all caregivers of the individuals is of the utmost importance. The residential regulations and adult training facility regulations require that medical information pertinent to diagnosis and treatment in case of an emergency be part of the physical examination that is part of the individual's record at the provider agency.

The process of developing an individual plan will be standardized across the county programs in the future. This standardization will compel the sharing of all pertinent information in the future.

 

Department of the Auditor General's Response:

No response necessary.

 

 

Conclusion 4:

DPW has not appeared to take actions that would strengthen case management efforts by county MH/MR offices.

The progress and well-being of group home residents are monitored primarily through case management services by county MH/MR offices or their third-party contractors. Case managers are required to visit group home residents at least three times each quarter-one time at the group home, one time at the resident's day program outside the home, and one time at a site agreeable to the resident. All counties in our audit sample prepared written narratives to document the site visits results and, although there are no standard requirements detailing specific areas to review, four of the five counties developed comprehensive checklists outlining site visit content. Examples of questions on the checklists include the following:

  • Is the individual receiving all services specified? If not, list services not received.
  • Are adequate staff available to provide the needed services at the rate and frequency described in the individual's health plan?
  • Are the necessary medical and dental appointments being scheduled and kept?
  • Does documentation show that the individual is taking medication as prescribed?
  • Is the setting, including grounds, reasonably clean and well maintained?
  • Have there been any unusual incidents involving the individual since the last monitoring visit?

 

 

Although the site visits and their documentation are intended to ensure that county oversight ensures the good health and well-being of group home residents, we found numerous incidents in which county efforts were deficient. In our review of the records for the 35 residents served by the eight group homes, we found the following examples of deficiencies:

  • Even though the site visits are required to be "face-to-face," one visit was conducted without the individual present, and three site visits were conducted by telephone.
  • The intervals between quarterly site visits were not always reasonably spaced. We found four cases in which a resident had been visited on consecutive days-with each visit counting toward one of the three quarterly visits. In two other instances, 90 days passed between visits.
  • Three counties failed to perform the minimum quarterly visits in ten cases. Five of the 10 cases involved the same resident.
  • One individual was not visited at his day program for 258 days.
  • A resident was placed on a special diet to reduce her weight and cholesterol level. While the diet effectively reduced the resident's weight, the cholesterol levels increased. The resident's case manager took no action even though the problem was documented in a therapist's memorandum.

Some of these problems may stem from DPW's lack of active involvement and evaluation, as well as an absence of specificity in certain areas. For example, DPW's MR Bulletin #00-92-23 addresses county case management but does not ensure timely oversight. The bulletin establishes that the frequency of a case manager's contact with residents should ensure that the resident's health and well-being are reasonably safeguarded. In addition, as discussed above, the visits must be face-to-face, and there must be three such visits each quarter (at the residence, the day program, and a place agreeable to the resident).

But the bulletin does not establish acceptable time intervals between each visit. Therefore, a case manager could visit a resident on six consecutive days-for example, the last three days of one quarter and the first three days of the next-and still satisfy the requirements for two quarters. Even worse, the next quarterly visit could be nearly six months later. Surely this is not the intention-and we did not find evidence that it was accepted practice-but better oversight and support by DPW would address some of the problems we found.

One county, in addition to its case manager site visits, regularly conducted unannounced residential visits to assess group home operations.41  In these visits, the county observed and documented both strengths and weaknesses and then communicated the findings in written reports to the applicable provider agency, which was then asked to respond to the county's reports in writing. This practice appeared not only reasonable but also beneficial to all parties involved: the unannounced visit allowed the county to see real-life settings; the county recognized strengths in addition to weaknesses; the agency's feedback was solicited; and, most important, the residents were provided with an additional level of oversight to protect their health and well-being.

 

 

Recommendations:

DPW should revise MR Bulletin #00-92-23 to establish acceptable time intervals between case manager site visits.

DPW should require all counties to develop comprehensive site visit checklists to ensure that all aspects of the individual's well-being are confirmed.

DPW should consider requiring county MH/MR personnel to conduct unannounced residential visits to assess group home operations.

 

DPW's Response:

Monitoring by county case management occurs in many different ways, not only through the three face-to-face meetings that are required by MR Bulletin #00-92-23. Ongoing phone communications with residential day program staff allow case managers to monitor the wellbeing of individuals. In addition, case managers accompany individuals on outings, trips to the doctor, and other such activities.

Not only are monitoring activities documented on the Monitoring Report Form, but they are also documented in the daily logs, progress notes, and activity logs kept by the case manager. In the audit report, there is no mention that these other sources of documentation were ever reviewed as part of the performance audit. As such, a major source of evidential material to support the ongoing monitoring efforts of case managers may have been overlooked.

While currently not a requirement, county case managers use a standard monitoring tool. In addition, there are monthly Waiver coordinator meetings conducted by the DPW that facilitate the dissemination of "best practices" to all counties. In addition, in 1999, training was conducted for all county case management staff regarding Waiver monitoring and best practices.

 

Department of the Auditor General's Response:

DPW does not address the deficiencies that we noted-numerous instances in which the three required face-to-face meetings were not held or were not held in a timely manner. Instead, DPW responds that "[m]onitoring by county case management occurs in many different ways, not only through the three face-to-face meetings that are required by MR Bulletin #00-92-23." While we agree with DPW that other methods-including telephone calls-can indeed be used as part of case management, we emphasize that those other methods should supplement the required face-to-face meetings, not replace them.

DPW also states that county case managers currently use a standard monitoring tool to assist in monitoring the progress of individuals. However, we found that such was not the case in one of the eight counties in our audit sample.

 

 

 

Chapter Four

Physical
Condition of
Group
Homes

Not all group
homes were clean
and safe.

The persons with mental retardation who reside in group homes are supported by various state protections related not only to the staffing, abuse, and service issues discussed in the previous three chapters, but also to the physical environment of the residences. The most basic such protection is that group homes must be clean and safe, and they must adequately accommodate residents' disabilities. The responsibility is not a small one, as evidenced by the fact that, in 1998, Pennsylvania had 2,566 group homes operated by 198 provider agencies.

Both the state and the county are responsible for overseeing the physical condition of the group homes-the state through DPW and each county through its Office of Mental Health and Mental Retardation. Both DPW and the county MH/MR offices-in addition to the provider agencies themselves-are responsible for ensuring that the physical environment of group homes meets minimum standards. These standards are monitored in the following ways:

  • DPW licenses and inspects all provider agencies annually, and it inspects all individual group homes before persons can reside there. After group homes have opened, DPW inspects them only on a sample basis or possibly in response to complaints.

  • County case managers visit the individual group homes to observe conditions on an ongoing basis.
  • Provider agencies conduct annual self-assessments of each group home they operate.

DPW conducts its inspections by using its comprehensive checklist, the Licensing Inspection Instrument, which identifies certain criteria that each provider agency and its homes must meet. Initial inspections occur prior to a provider agency's licensure. If the homes and the provider agency comply with the criteria on the checklist, the provider agency is issued a certificate of compliance (i.e., a license) that extends to each of the individual homes. A certificate of compliance is typically valid for one year, but it can also be issued on a provisional basis if certain criteria are not met.

During subsequent licensing periods, DPW conducts a full inspection of each provider agency on a yearly basis, but not of each group home. DPW inspects the group home annually only to evaluate whether fire safety conditions are met, and such visits-while critical-are typically brief. On the other hand, to evaluate a home's quality of care and physical environment annually, DPW would need to conduct lengthier inspections, which we will refer to as full licensing inspections. Instead, DPW conducts such inspections annually only on a 25 percent sample of the group homes operated by each provider agency. Therefore, if an entity operates 40 group homes, only 10 of them will undergo a full licensing inspection yearly-and they will be afforded preparation time by receiving notification in advance.42 

A supplement to DPW's limited oversight of a group home's physical condition might be provided when county MH/MR case managers visit with each resident at least once quarterly. Those visits, however, are intended primarily for case managers to assess the resident's care rather than to inspect for physical deficiencies of the residence.

Other than DPW's initial inspection of group homes prior to their accepting residents, the only requirement for a full licensing inspection each subsequent year falls to the licensee itself. Known as self-assessments, these inspections are performed in large part by the staff of the provider agency-and in some cases by the staff of the homes themselves. Whoever performs the self-assessment-whether provider agency officials or group home staff-the inspector is required to use the same comprehensive checklist used by DPW during its full licensing inspections.

DPW requires that self-assessments be conducted three to six months before the agency's certificate of compliance expires. In theory, this timing should discourage the practice of delaying repairs until a home is chosen for sample inspection, which tends to be every four years. In fact, even though DPW reviews each home's self-assessment results when visiting every home's provider agency each year, there is no guarantee that the self-assessments are accurate without actually confirming the results firsthand. In short, annual evaluations of group homes are entrusted to the people who are being evaluated.

 

Objectives and Methodology for Chapter Four

To test whether DPW and the counties ensured that group homes provided safe and healthy group home environments for residents, we determined whether:

  • DPW conducted required inspections prior to issuing certificates of compliance;
  • DPW oversight was adequate to ensure that each provider agency complied with the regulations concerning the ongoing physical condition of the individual group homes;
  • each provider agency conducted self-assessments of each group home three to six months before the agency's certificate of compliance expired; and
  • county case managers adequately assessed the physical condition of group homes during quarterly face-to-face visits with residents.

 

To accomplish the objectives, we:

  • reviewed state regulations to determine group home certification requirements;
  • interviewed DPW employees and reviewed relevant manuals to determine licensing policies and procedures;
  • reviewed the most recent certificates of compliance to determine that the provider agencies possessed current certificates of compliance and that the homes did not exceed the maximum capacity;
  • toured eight group homes-one from each of the eight provider agencies;
  • obtained and reviewed the group homes' most recent self-assessments to determine whether they occurred three to six months prior to the expiration date of the agencies' pertinent certificates of compliance;
  • reviewed the most recent support plan and assessment for each resident to ascertain whether the physical environment met the individual needs noted in the plan;
  • reviewed the licensing inspection summaries for the two most recent inspections of each of the eight homes to determine whether DPW inspected them prior to the certificate of compliance expiration and whether areas of non-compliance were corrected in a timely manner; and
  • reviewed case manager monitoring notes to assess the effectiveness of county case manager visits in ensuring safe and clean physical environments.

 

Conclusion 1:

DPW failed to ensure that one of eight group homes we reviewed was clean and safe, and that another of the eight group homes was safe.

During our tour of the eight group homes, we found that six appeared clean and safe, one appeared clean but had toxic cleaning supplies accessible to residents, and one was obviously dirty and-in our judgment-poorly maintained.

The home with the improperly stored cleaning supplies had failed to adequately secure them to prevent residents from accessing them. Since records of the residents indicated they could not safely distinguish between hazardous and non-hazardous substances, the provider agency violated DPW's regulation that poisonous materials must be "locked or made inaccessible to individuals" under such circumstances.43  The danger inherent to such an unsafe practice is heightened by the fact that one resident of the home was diagnosed with a propensity to exhibit behaviors that included repeated attempts to ingest foreign objects.

During a tour of the unclean group home, we found soiled and worn carpet in both the living and dining rooms, stained walls, and damaged corners on doorways. In addition, prescription medicines were stored in an unlocked filing cabinet, there were flies in the bathroom, and the front porch housed three full and open garbage containers emitting foul odors.

Even more troubling is that DPW licensing inspectors had visited that home just four weeks prior to our tour. Even though the DPW visit was made to inspect for fire safety only, the unclean condition of the home should have been obvious. Yet the inspectors failed to make note of it.

In addition, case managers from the county MH/MR office also visited the home only four days prior to our tour-and on at least two other separate occasions as close as six weeks before our tour and four weeks after it. After each of their visits, the case managers reported that the residential setting was reasonably clean and well maintained.

DPW's regulations seems to allow little argument: clean and sanitary conditions must be maintained in the home,44  and floors, walls, ceilings and other surfaces must be in good repair.45  An area of worn carpet is not only in need of repair; it might also be dangerous if someone trips on it and injures himself. A stained wall is not just unsightly; it might well be unclean. A damaged doorway not only needs repair, but also illustrates a lack of ongoing maintenance. DPW should direct its inspectors to exercise reasonable judgment concerning these issues and, when questions arise, to do what is best for the residents. DPW should also convey this directive-through training sessions or written communication-to county case managers and provider agency personnel.

 

Recommendations:

DPW should provide training sessions or written communications for licensing inspectors, county case managers, and group home administrators to communicate expectations regarding obvious cleanliness and good repair of group homes.

DPW should expand its annual fire safety inspection checklist to include notation of obvious areas of non-compliance concerning cleanliness, sanitary conditions, and good repair of floors, walls, ceilings, and other surfaces.

 

DPW's Response:

The DPW disagrees with this conclusion, which refers to two homes operated by the same agency, both of which were visited by the auditors because the individuals under review had recently moved from the first to the second home. The report fails to reflect this fact.

The DPW conducted the annual inspection of each of these provider agency homes on June 21-23, 1999, prior to the visit by the auditors on July 23, 1999. A full inspection was conducted at one home, and a fire safety inspection was conducted at the second home. Both of these inspections require a physical site inspection. During the inspection, it was noted that garbage cans were on the front porch and that the carpet in one home was worn, but not hazardous. There were no food stains on the walls and no flies were observed. It is useful to note that several individuals who live in this home use wheelchairs, which contribute to rapid wear of the carpet.

A citation for not locking or making poisonous material inaccessible to individuals was given, and the materials were subsequently removed. DPW licensing staff enforced and cited the applicable regulations during the time of their inspection.

A follow-up inspection of both of these homes on April 10th and 14th, 2000 revealed no areas of noncompliance. Both homes were clean, sanitary, and had no hazardous conditions. Poisonous materials were locked and inaccessible to individuals in both homes. Additionally, the worn carpet had been replaced, walls painted, and garbage cans had been removed from the porch and were located at the side of the home.

 

Department of the Auditor General's Response:

From June 21-23, 1999, DPW conducted a full inspection of the one home in which we found improperly stored cleaning supplies. The resulting licensing inspection summary, however, did not mention improperly stored cleaning supplies.

During the same period, DPW also conducted a fire safety inspection of the unclean home. The licensing inspection summary cited the provider agency for poisonous materials in the garage which were not locked or made inaccessible to individuals. However, the summary failed to document garbage cans on the front porch, worn carpets, or prescription medication stored in an unlocked file cabinet.

During our tour of the unclean home approximately one month after the DPW inspection, we noted open trash cans in front of the house, worn and soiled carpeting, stained walls, flies in the bathroom, damaged doorways, and medications in an unlocked file cabinet. We notified the appropriate county MR administrators of the above concerns during an informal exit conference on August 11, 1999. A county administrator visited the site on August 24, 1999, and concurred with most of our observations. The provider agency subsequently replaced the carpet in the dining room, cleaned the carpet in the living room, and painted the dining room walls. The provider agency also purchased insect repellant devices. Perhaps such corrective measures may be the reason why DPW's follow-up inspection in April 2000, while it was reviewing a draft of this report, found no areas of noncompliance.

 

 

 

 

Conclusion 2:

DPW did not ensure that group home self-assessments were carried out within required time frames.

We also found that three of the eight group homes did not undergo self-assessments by their provider agency within three to six months of certificate expiration as required.46  When provider agencies either delay or ignore this requirement, and when DPW does not ensure that the requirements for self-assessment are followed, the physical condition of group homes may deteriorate with no official notice or intervention.

This conclusion is particularly noteworthy because DPW reviews the self-assessment documentation as a part of its annual inspection of the provider agencies. However, DPW inspection records did not reflect the noncompliance of the three group homes whose inspections were late.

 

Recommendation:

DPW should enforce timing requirements regarding group home self-assessments to ensure that homes are maintained throughout the year.

 

DPW's Response:

The DPW disagrees with this conclusion. DPW licensing records indicate that a self-assessment was completed according to the timeframes required in the regulations during the most recent annual inspection of all group homes identified in the AG's report.

Untimely self-assessments are cited by DPW licensing staff when found during annual inspections, and are not a significant threat to health and safety.

Department of the Auditor General's Response:

We disagree with DPW's claim that self-assessments were completed within the required time frames. We found that there were three instances in which the provider agencies did not complete the self-assessments within the required time frames and were not cited by DPW licensing inspectors.


 

The Honorable Robert P. Casey, Jr.
Auditor General
229 Finance Building
Harrisburg, Pennsylvania 17120

Dear Mr. Casey:

This is in response to your letter of March 24, 2000, whereby you transmitted the advance copy of the final draft report of your office's Performance Audit of the Commonwealth's Oversight of Group Homes for the Mentally Retarded in Western Pennsylvania for the period July 1, 1994 through June, 30, 1999. Following the Introduction section are our comments to the conclusions contained in the audit report.

 

INTRODUCTION

The Department of Public Welfare (DPW) is pleased to respond to the Auditor General's (AG's) report entitled, "A Performance Audit of the Commonwealth's Oversight of Group Homes for the Mentally Retarded in Western Pennsylvania."

The AG's report recognizes that the Commonwealth's Mental Health and Mental Retardation Act of 1966 requires "the provision of community services to individuals with mental retardation and their families." Funding for such services began with an appropriation from the General Assembly in 1971. "This funding played a role in the shift from the larger state-operated institutional settings - from over 13,000 persons with mental retardation living in state centers in 1967 to approximately 1,800 in Fiscal Year 1999-2000." The experience in Pennsylvania parallels the national trend. Nationally, less than a third as many residents live in state-operated MR centers as resided in such facilities in 1967.

A number of studies, beginning with the Pennhurst Longitudinal Study in 1985, have established through research the gains that individuals with mental retardation make when they move from institutions to the community. Included as appendices are: The Pennhurst Longitudinal Study 1985; the Somerset Evaluation/Assessment Project Report 1997; the Report on the Closure of Laurelton State Mental Retardation Center, issued by Pennsylvania Protection and Advocacy, Inc. in 1998; and Healthy Futures, a report on the health risk assessment of Pennsylvanians with mental retardation published in 1999.

As the AG's report states, "The efforts to help individuals with mental retardation escape the perceived and actual boundaries of state-run institutions have resulted in several high profile courts cases. These court cases have placed greater emphasis on the removal of barriers preventing an individual's transition to community living." Intensifying that emphasis is the recent U.S. Supreme Court decision in Olmstead v. L.C, along with the U.S. Department of Health and Human Services' (DHHS) letter to State Medicaid Directors recommending that states develop comprehensive plans to place qualified persons with disabilities in the most integrated setting appropriate and a waiting list that moves at a reasonable pace not controlled by a state's objective of keeping its institutions fully populated."

Today, over 69,000 people, or 97 percent of those served, receives services in Pennsylvania's community service system. Of the total number of people served, more than 18,000 people are living in 3,650 licensed residential facilities. Strengthening the infrastructure of the system to improve the management and supervision of the program, and to assure the health and safety of the people receiving services, has been a major commitment and accomplishment of the Ridge administration and the DPW. Building on the recommendations of the Multi-Year Plan developed by all of the stakeholders in the mental retardation system, community services have expanded for people leaving institutions and for those on community waiting lists, and significant program improvements are in various stages of development.

While the AG's report is critical of the DPW's oversight functions and activities related to the eight homes audited, the report does not find that the health and safety of any individual in the homes selected for review was in jeopardy, nor did the report find fault with the quality of care provided to the individuals in the homes. We are pleased that the AG shares the DPW's interest in assuring the health and safety of individuals with mental retardation who live in the community.

The AG's recommendations are consistent with the DPW's recent initiatives to strengthen the management of the community mental retardation residential system in order to assure the health and safety of individuals receiving services. Many of the Department's initiatives, however, go beyond basic health and safety assurances; they are directed at implementing the most promising practices and achieving the highest level of quality. Ultimately, providing consumers and families with more control over major decisions about services will have a significant impact on quality.

With attention to health and safety, the Department has funded, and is assisting in the development of, two new entities in County MH/MR Programs. The primary functions of these entities are to monitor and improve the quality of services.

The first is the creation of Independent Monitoring Teams. The boards of these organizations must consist of a majority of consumers and families. The teams that conduct the reviews of programs must also be primarily consumers and families. The review process is designed to be consistent across counties, and data from these reviews will be available to the county program and to the DPW for analysis and follow-up in the areas of safety, consumer and family satisfaction, and consumer outcomes.

The second of these entities is Health Care Coordination Units (HCCUs). These entities, made up primarily of trained medical personnel, will oversee the management of health care by providers in the county program. Standardized health risk assessments will be conducted on each individual receiving residential services. A Health Risk Assessment (HRA) tool has been developed. It has been piloted in the Western Region and validated through research. Findings have been published in Healthy Futures, 1999. The HRAs will be used, as they were in the pilot, as the basis for improving care to individuals, but also as the basis for training and technical assistance that HCCUs will deliver to providers of service. In addition, HCCUs will maintain a working relationship with Medicaid managed care programs to improve access and build capacity within the medical community.

In addition, the Department is currently redesigning the system to manage more effectively unusual incidents for both the community and state center program. This redesign and development will include clear definitions for unusual incidents, reporting requirements and procedures, standards for conducting investigations, minimum training requirements, as well as required follow-up actions.

Pennsylvania has taken a lead role in the development of the National Core Indicators Project. This project is a multi-state collaboration aimed at developing and implementing performance and outcome indicators that will measure the effectiveness of state mental retardation service systems in achieving mission-critical goals and objectives. The areas of measurement include consumer outcomes; system performance areas, such as service coordination; access; and resource utilization. Other domains address health, rights, and service system strength and stability. Each state will be able to benchmark its performance against other states, against the state's own previous performance, and in Pennsylvania, we will to do the same across County MH/MR Programs.

Training is among the most effective strategies for continually improving the quality of services. The DPW sponsors, through Temple University, basic training, such as the medication administration training, and also training in best practices. Among best practices, the DPW is a leader in the development and delivery of training to serve people with the dual diagnosis of mental illness and mental retardation. Individuals with this combination of disabilities are among the most challenging to serve and are also the most vulnerable to abuse, receiving poor treatment, and institutionalization. Through classroom approaches, such as extended Clinical Institutes enhanced with direct technical assistance to providers and counties, the DPW is rapidly building the capacity of the community system to support and treat individuals with these diagnoses.

As an overarching initiative, the DPW is developing an information system that is client-based. This new system will enable the DPW to integrate and analyze data provided by Independent Monitoring Teams, HCCUs, the unusual incident tracking system, the National Core Indicators Project, and the DPW's licensing system. It will enhance the DPW's monitoring of county compliance with the grant agreement, to not only measure and assure health and safety, but also to continuously improve the quality of services.

Recognizing that consumers and families play an important role in monitoring and improving services, the DPW will use Internet web-based technology to make information available to consumers, families, advocates, and all interested parties on services, as well as provider, county, and system performance.

Lastly, the administration recently approved a reorganization of, and staff enhancements in, the Office of Mental Retardation (OMR), which are designed to strengthen our ability to assure health and safety and improve quality. The addition of the Office of Medical Director and a Bureau of Quality Improvement and Policy increase staff resources at the senior level in order to design and manage systems that will measure performance and make improvements in the system. The addition of 33 positions in the OMR over a two-year period has not only allowed the creation of the two new units in the organization, but more importantly, has increased the number of staff available in the four regional field offices to conduct licensing inspections, investigations, and to monitor services in the community system.

The Department wishes to commend the AG and his audit staff who completed their fieldwork with professionalism and respect for the individuals receiving services, their families, the provider agencies, and County MH/MR Programs.

The DPW has five general concerns regarding the presentation of the audit. We believe our response and comments will help to clarify the conclusions and recommendations. Without complete information, the conclusions in the report may be misunderstood, the conclusions inappropriately generalized as systemic, and the recommendations improperly evaluated.

First, this report, in some cases, summarizes information that has been gathered over an eight-month period. Supporting detail in work papers were not provided to the Department during the two-week review period. Given the short response time and the absence of comprehensive detail, the Department's response in some instances cannot confirm or correct conclusions reached by the auditors.

Second, we notified your Office at the time of the original survey that there were problems with the analysis of statistical information about abuse incidents collected by the auditors. A summary conclusion is drawn and stated about the number of abuse reports in the mental retardation system. It does not take into consideration other factors that significantly affect the data, such as the reporting behavior of caregivers and the way events are interpreted by caregivers who must determine whether abuse has occurred.

In the background section of the audit report, survey conclusions are linked to concerns regarding quality of care. Monitoring and assessing quality of care must go well beyond abuse prevention. The Core Indicators Project is a national effort to identify indicators that track system performance and outcomes. While the project does include indicators for measuring safety from abuse, neglect, and injury, it measures many other things in order to arrive at balanced conclusions regarding quality of care. Examples include:

Third, references are made in the audit to the use of sampling as a way to collect information. In some cases, it appears that the audit recognizes sampling as a valid methodology, while in other cases it is criticized. The DPW believes sampling is an accepted approach to gather information in both program and financial reviews. It is commonly used in licensing and certification processes, as well as auditing.

Fourth, in considering the findings, conclusions, and recommendations of the audit, a distinction must be made between what existing laws and regulations require, and what the AG thinks should be required. The conclusions in Chapter 3 of the audit measure performance against standards that the AG believes should be in place, rather than those that are in place. In an audit forum, recommendations to change laws and regulations exceed the measurement of compliance with laws and regulations. While it may be valuable to raise such issues and inform public officials, performance should be measured against existing standards.

Fifth, the audit fails to acknowledge improvements continually being implemented throughout the mental retardation system by the DPW, County MH/MR Programs, and providers of service to ensure quality, health, and safety in community programs. These improvements grew from recommendations presented to the DPW by the OMR Planning Advisory Committee in the Multi-Year Plan, and, as such, represent the consensus of those who receive, provide, manage, and monitor services in the Commonwealth.

The specific conclusions in the AG's report are constructive to our ongoing monitoring and assurances. The DPW will take appropriate actions to correct deficiencies at these eight sites or in the procedures for oversight of these programs. However, generalized audit conclusions taken out of context can unnecessarily frighten people and cast an inaccurate picture of the provision of community mental retardation services in Pennsylvania.

 


CHAPTER ONE

Staffing Issues that Affect the Health and Welfare of Group Home Residents

Conclusion 1:  State law and regulations requiring criminal history background checks for prospective group home employees are not sufficiently stringent to protect group home residents.

This conclusion extends beyond a determination of the Department's compliance with current statutes and regulations. The DPW applies and enforces the Older Adults Protective Services Act (OAPSA) adopted by the General Assembly in 1996. When a licensed home complies with the requirements of the law, residents of the home can be assured that employees meet the legal requirements of the OAPSA. The provisional period of employment provided for in the statute is useful to Pennsylvania citizens who have never been convicted of a crime and are seeking employment. In addition, this provision allows the many types of agencies covered by the law to employ staff to provide the necessary critical care and services to people until the criminal history background checks are returned.

As part of the employment application, potential employees are required to respond to questions concerning prior criminal charges and convictions. This self-reporting is a screening process, which would cause the applicant to withdraw if an affirmative response was given.

There are three methods available to the public to obtain criminal history background reports. The methods are the PATCH system, direct mail, and contracting with an agency that provides this service. The PATCH system is an on-line automated system used by 850 agencies to obtain criminal history reports. These agencies get a same-day response when no record is available to match the name, date of birth, and/or Social Security number. A "no record" report is an indication that the potential employee has no convictions in the database. Overnight mail packages containing fewer than six applications are processed within a week. Regular mail applications are processed and returned within a month. The State Police are constantly improving this system and have made several enhancements since the passage of the OASPA. Additional improvements are under development. The third option is to contract with an agency that charges a fee to obtain criminal history reports. Processing time is similar to agencies using PATCH.

When the DPW's current regulations for mental retardation residential services were last revised in 1991, there was no statutory basis for prohibiting the employment of individuals based on their criminal history. In the absence of such an absolute prohibition, DPW regulations required providers to obtain criminal and child abuse histories in order to expose the histories of applicants that might then be considered by the employer. The OAPSA requirements exceed the current regulations, and providers are required to be in compliance with the OAPSA. The DPW will incorporate the new requirements into its program regulations when they are revised in the future.

The DPW has reviewed the charts concerning the criminal record checks conducted on current and former employees against the provisions of the OAPSA and its application. Of the 34 convictions identified for six in the sample of 48 employees, 27 convictions were associated with one individual who was not employed at any one of the eight homes that were chosen for the audit. The facts about this employee, who worked at another location, were voluntarily provided to the auditors by the agency's executive director. The individual is no longer employed at the agency. (Appendix B incorrectly identifies the employee as working at one of the eight homes reviewed.) Of the same 34 convictions identified for six in the sample of 48 employees, 14 convictions would not disqualify individuals from employment under the OAPSA, even if the employees were not grandfathered under the law.

Concerning 17 of 158 former employees identified, 14 of the 28 offenses would not have disqualified applicants from employment.

Finally, the OAPSA allowed for the grandfathering of employees hired before July 1, 1997. Since the hiring dates for the employees were excluded from the audit report, the DPW is unable to determine the number of employees who would be grandfathered into their current positions.

The AG cites inconsistencies between the DPW bulletin regarding background checks on applicants for employment in programs serving children and the Child Protective Services Law (CPSL), which requires all prospective employees to have both a Criminal History Background Check and a Child Abuse Background Check. The statute takes precedence over mental retardation bulletins, which will be revised to be consistent with the law. In addition, protections for children are further enforced through the DPW's recently-published Chapter 3800, Child Residential and Day Treatment Facilities regulations, effective June 12, 1999, which incorporates the requirements of the CPSL to conduct child abuse and criminal history checks on applicants.

Conclusion 2:  DPW failed to provide guidance to provider agencies regarding compliance with OAPSA's requirements of criminal history background checks.

The Pennsylvania Department of Aging (PDA) is the lead agency responsible for implementation of the OASPA. As noted in the AG's report, following adoption of the OASPA, which was effective December 1997, the PDA sponsored 30 training sessions that were delivered by Temple University in 1998 and 1999. In addition, the PDA has also developed a web site for "On-Line Training for Mandatory Abuse Reporting and Criminal Background Checks," and this information is being given to providers by the licensing staff as part of the annual inspection exit interview. The web site is xtbase.galaxyscientific.com/pde/index_ie.asp.

In addition, the DPW is working with PDA on the development of regulations to implement the law. Upon adoption of the regulations, DPW will also issue a policy bulletin to all licensed entities required to comply with OASPA and will provide training to County MH/MR Programs and provider agencies.

Conclusion 3:  DPW's licensing process does not protect residents of group homes from the employment of individuals with serious criminal histories.

The DPW disagrees that there are significant deficiencies in the procedures in place to safeguard residents of group homes. The DPW has a comprehensive licensing process that enforces each provider's compliance with statutes and regulations designed to protect individuals. Consistent with the Department's licensing process, sampling is used to review employees' records during annual inspections. Sampling is a valid and accepted tool used to determine compliance with regulations in many types of organizations. Sampling of records is utilized in all types of facilities including hospitals, nursing homes, and ICFs/MR and is, in fact, a standard auditing practice.

In response to the report's suggestions to modify the inspection protocol, the DPW will consider including a review of the criminal history checks for all new hires since the last inspection as part of the annual inspection process, informing the CEO of the agency and the Regional Program Manager of any criminal history checks that reveal a violation of the OAPSA, and retaining all working papers from the inspection as part of the record for a period of two years.

Conclusion 4:  Excessive turnover resulted in lack of consistent direct care staff for group home residents.

The AG's report acknowledges that at "each of the eight homes reviewed, staff levels met the requirements in each of the residents' annual assessments and met the minimum staff-to-resident ratios required in the regulations.."

The Department agrees that stability of core direct care staff is an important element in the delivery of quality services to residents of group homes. In the audit sample of homes, seven of the eight homes had staff working in the home for more than two years. Crude separation rates, while one measurement of turnover, fail to factor the presence and impact of core staff who continue to work, according to the report, from a minimum of 2.1 years to 9.8 years.

In addition, a turnover of direct care staff is related to more than salary. A Legislative Budget and Finance Committee (LBFC) study, entitled Salary Levels and Their Impact on Quality of Care of Client Workers in Community-Based MH/MR Programs, released in February 1999, reported a weak correlation between direct care worker salaries and turnover rates. Consistent with other studies "which typically find that salaries are only one of the many factors affecting employee turnover, studies of workers in institutions and community residential settings for persons with disabilities have found that higher turnover rates tend to be associated with lower pay, younger employees, more residents per staff member, and urban locations. Variables such as benefits, supervisory style, and local economic conditions are also important."

In fact, the LBFC study shows that 32 percent of the 19,759 direct care workers, or 6,323, had less than one-year employment with their current organization. This means that 68 percent of the direct care workers, or 13,436, had one or more years of employment with their current organization.

The report overlooks the overall experience of direct care staff working in the eight homes. In fact, the report so narrowly focuses on the length of time the employees worked at a particular home, it disregards any and all experience an employee may have had at another home with the same organization working with individuals with similar conditions as those in the home in which the employee was working at the time of the review. Furthermore, no consideration was given to the previous employment of the direct care staff of the group homes at other similar provider agencies.

The omission of such information fails to provide a fair and complete picture of the direct care staff's overall experience, knowledge, and skill that they bring to the job of providing care to the residents of the homes.

The DPW has considered the pressures on provider recruitment of employees created by the current economic climate. The Governor's initiative to expand services for the waiting list has been funded at a level that recognizes the cost of providing services. The DPW will negotiate with each county to determine that proper level. Counties have been encouraged to seek administrative efficiencies that can be channeled into salary adjustments. In addition, the DPW is implementing recommendations from the LBFC report to increase federal funding and to reduce categorical allocations, thus giving local communities more flexibility to fund programs.

Conclusion 5:  DPW regulations are not stringent enough to ensure that direct care staff are adequately trained.

The DPW strongly believes that its regulations ensure that direct care staff are adequately trained. The regulations recognize the type of training that is critical prior to working directly with individuals. In addition, the regulations recognize the need for continuing training throughout employment. As such, the regulations are more stringent than even the federal ICF/MR certification requirements.

DPW regulations specify training that must be delivered prior to the staff person working directly with residents, and specific training that must occur throughout the first year, including within 30 days, of working with individuals. Within six months of employment, the regulations require training in CPR, First Aid, and the Heimlich technique. Direct care staff must complete and pass the DPW's medications administration course prior to administering medications. Annually thereafter, they must complete and pass the medications administration course practicum. Finally, the regulations require that those working 40 hours or more per month must receive 24 hours of training annually.

The report is incorrect in the assertion that seizure management and crisis prevention are required training. The regulations do not require that all employees receive training in these areas. In cases where seizure management is required, each situation is unique, demanding interventions designed exclusively for that individual, and typically developed by the person's physician and communicated directly to staff. This training would be documented in the individual's record, rather than the employee's training record.

The DPW believes that the regulations related to the use of restrictive procedures go well beyond a requirement for crisis prevention. Each person's program plan is individually designed. In homes that serve individuals whose behavior requires intervention, an individual plan is designed. Should the plan require any restriction of a person's freedom of movement, access to personal possessions, or involvement in preferred activity, a restrictive procedure committee must review the plan. Chemical restraint, mechanical restraint, and seclusion are prohibited.

The regulations require that the provider agency must demonstrate the necessity of any restrictive intervention. Situations that call for the use of physical restraint have limits placed on the use of that restraint. Furthermore, staff who employ the intervention ".must experience use of the specific technique or procedures directly on themselves." (Ch. 6400.191-206) The regulations further require a written record of each and every use of restrictive procedures. These particular regulations governing the use of restrictive procedures have been effective in reducing the use of restrictive procedures in group homes. Coupled with the extensive training and technical assistance provided to counties and providers, the DPW has succeeded in improving environmental conditions, mental health treatment interventions and supports that reduce negative behavior, and, more importantly, supports positive behavior.

Additionally, the Community Homes Regulations, Pa. Code Chapter 6400, regarding use of restrictive procedures, are more stringent than those of the ICF/MR certification requirements.

Conclusion 6:  DPW did not ensure that direct care workers met regulatory training requirements.

The DPW disagrees with this conclusion. DPW licensing inspectors review staff training records as a normal part of all annual licensing inspections. While the sampling methodology requires that a minimum of one staff record be reviewed for each home, inspectors routinely inspect several records for each home. Across the total number of homes under inspection, licensing inspectors target the records of newly hired employees, staff from different shifts and different positions, and staff with differing lengths of employment. Typically, as part of a normal annual inspection, licensing staff reviews a minimum of two staff records in each small community home. This sample consists of one newly hired employee and one from the other target groups previously noted.

The DPW believes that the sample used during the licensing inspection process is adequate. It requires that, at minimum, all new homes, and no less than 25 percent of all existing homes, be inspected annually. The sample for a full inspection most typically exceeds 25 percent and, with 100 percent of all homes inspected each year for compliance with fire safety requirements, all homes are reviewed through the DPW licensing inspection process annually.

The AG's report suggests that the DPW evaluate the sufficiency of its licensing inspector staff levels. The report identified 20 licensing inspectors, but overlooked that four licensing administrators also perform licensing inspections. Further, the reorganization and expansion of the OMR has added two licensing inspectors, which brings the total to 26 rather than 20. The DPW's OMR has also added a Bureau of Quality Improvement and Policy, and is instituting a management information system that will integrate databases from various monitoring systems to allow for analysis of findings. In addition, the Office of Licensing and Regulatory Management, which reports directly to the Secretary of Public Welfare, has been established to provide training to licensing inspectors, manage the regulatory review process for human service licensing regulations, and to develop a Human Services Licensing Information System.

Licensing inspectors review staff training records for compliance with all training topics, and for compliance with minimum number of training hours required by the regulations. Licensing inspectors also review this information for completion within the training year that is established by the providers. If there are any serious concerns regarding compliance with the regulations, additional staff training records are reviewed.

The DPW does not believe that the report provides sufficient cause to deviate from its established sampling methodology.

 


CHAPTER TWO

Unexpected Deaths of Group Home Residents; Incidents of Abuse

Conclusion 1:  DPW did not investigate three of four unexpected deaths at the time they occurred and, in two cases discovered serious problems later.

While the DPW is in the process of significantly revising and improving its reporting requirements and investigation procedures of unusual incidents and deaths, the DPW disagrees that the investigations of these three deaths were untimely. In the case of the three deaths identified in the AG's report, the DPW received and reviewed reports from the providers and counties at the time of, and following, the deaths. Not every incident or death requires the same level of review or investigation. An essential component of risk management systems is the targeting of resources to areas or issues that are most problematic, incidents that occur with the most frequency, and/or put vulnerable individuals at most risk.

In the case of the deaths included in the AG's report, all were reported and reviewed by the provider, the county, and the DPW in a timely fashion. The DPW conducted follow-up investigations either because there were additional questions, new information was received, there was dissatisfaction with the final reports, or as an exercise to evaluate the existing investigation procedures.

 

Individual Identified #1

A death from pneumonia in a person with a weakened health condition, which occurred after eight days of hospitalization, would not typically require a full investigation at the time of death. The information provided to the auditor revealed that the individual had significant health-related issues that received constant attention by agency and medical staff. Specifically relevant to the issue was the diagnosis and monthly blood monitoring of the individual for leukopneia. This condition is manifested by a significantly reduced white blood cell count, a precursor to infection. This condition, coupled with the individual's sedentary lifestyle, colostomy, rectal abscess, and urinary tract infection, contributed to the provider agency and county decision to forego a formal investigation of the death. In point of fact, the absence of a history of pneumonia reflected the high level of care provided to the individual in preventing infection. The investigation conducted some months later was part of a regular review process and not prompted by specific concerns. Suggesting that because "this woman.had no history of respiratory problems," her death was not only unexpected but unexplained, is grossly misleading. There was no question about the care provided in two different community hospitals. Family members maintained constant watch over this individual until the time of her death. While the death may not have been expected at that specific time, it was by no means unanticipated.

 

Individual Identified #2

The individual was discovered unconscious on October 28, 1996. The next day, the legal guardian directed that life support be withdrawn and the individual then expired. On October 30, 1996, the county began a follow-up investigation. The agency's final report of their findings and conclusions was issued to the county on January 17, 1997, and the final county report with corrective actions was accepted by the DPW on April 21, 1997. On March 5, 1998, as part of further follow-up, the DPW requested additional documentation in regard to improving communication between agencies.

The DPW's review of the incident concluded that a change in the individual's diet two months earlier was not conveyed to the day program that was responsible for providing the lunch meal. The review conducted by the DPW supports the contention that the probable cause for the respiratory arrest and subsequent cardiac arrest was the noon meal. However, because an autopsy was not approved by the immediate family, the actual cause of death could not be definitively determined. However, with the likelihood that food consistency contributed to the individual's death, the county took positive steps to insure appropriate communication among the agencies providing services.

Through both licensing reviews and waiver monitorings, attention to the sharing of critical information among providers is addressed through measuring compliance with regulations that require the recording of information in the medical section of the individual's record.

 

Individual Identified #3

The death occurred on April 5, 1995, at which time the DPW was notified. A review by the county case management agency was conducted the same day. The county initiated a formal investigation on April 27, 1995 and submitted their report to the DPW on May 8, 1995.

The DPW conducted a review of the report and requested additional information on June 8, 1995, and again on June 16, 1995. The autopsy report was made available to the DPW on September 20, 1995, and the review by the DPW was completed on October 24, 1995.

The documentation reviewed by the auditor substantiated the existence of diagnostic and training procedures relevant to the physical disabilities presented by this individual. As noted, extensive documentation also exists regarding sleep preferences and eating patterns and habits. Specifically, on April 3, 1995, representatives from the county, who had been conducting monitoring visits, noted a problem with regard to the positioning of the individual during sleep. Documentation supports their recommendation that cessation of the positioning routine should be "with medical consent or knowledge."

As part of a systems review, the DPW team conducted a follow-up review on June 26, 1997 and reported a possible Act 28 violation to the Office of Attorney General on January 5, 1998.

The DPW is currently redesigning the system and the requirements for managing unusual incident reports, including deaths. Included will be standard definitions, standards for conducting investigations, developing and requiring training for those who conduct investigations, and maintaining information to allow for analysis of incidents over time to detect trends and patterns that require intervention.

Conclusion 2:  DPW allowed staff of group home provider agencies to perform abuse investigations, even if they had no special training to do so.

This finding is consistent with the DPW's assessment. The DPW has identified the need for such training, and is currently in the process of developing a system for managing unusual incidents that will include a training curriculum for abuse investigation for OMR, county, and provider staff. Once the curriculum is developed, training will be required; training sessions will be sponsored by the DPW and offered throughout the state.

Conclusion 3:  DPW did not require county officials or any other independent officials to be directly involved in abuse investigations.

DPW regulations require the licensed agency to initiate an initial investigation of all alleged abuse. Conducting investigations of events that occur in its own facility is standard practice in all care giving entities, including hospitals, nursing homes, and state institutions. It is generally considered an essential management function. It is the facility itself that is the first to become aware of incidents, and facility staff must act immediately to secure evidence, interview witnesses, and establish a clear record of findings. All reports of abuse and investigations of events in community mental retardation programs must be submitted to the County MH/MR Program and to the DPW. After review, a determination is made on whether further investigation is necessary. In general, agencies act promptly to assure an individual's safety and to take appropriate action against the person who has committed abuse.

County MH/MR Programs and the DPW have the responsibility for conducting investigations of alleged abuse, and do so whenever there are questions about an agency's investigation, findings, or follow-up actions. The revised Unusual Incident Management System will specify the types of incidents that will require the involvement of independent officials in an investigation, including County MH/MR Programs.

The DPW is pleased to have its assertion that group homes are safe places confirmed by the AG's report, which found that "the provider agencies in all six cases of founded abuse had taken corrective measures that appeared appropriate" and would prevent future abuse.

Conclusion 4:  DPW did not require county or group home officials to report abuse investigation information that is critical to DPW's oversight.

The DPW disagrees with this conclusion. The DPW requires that all investigations comply with the current regulatory requirements and that information be provided using the standard Unusual Incident Report form. These Unusual Incident Reports and follow-up investigations are reviewed by the DPW and additional information is regularly requested from provider agencies. These requests ask for information such as personnel, corrective, and preventative actions taken or to be taken.

Improvements to the system for managing unusual incidents will more completely prescribe what is to be reported.

Conclusion 5:  DPW did not ensure that abuse investigations were completed and that its database was updated.

The DPW acknowledges this conclusion and the need to establish a timeframe in which a final investigative report must be submitted

The AG's report acknowledges that DPW follow-up to final investigations do, in fact, take place via telephone in most cases. However, DPW staff does not always record information from follow-up contacts in the file. The Department will develop a policy requiring that follow-up conversations be documented in writing by DPW staff.

As part of the annual licensing inspections, the inspectors review all reports and investigations of founded abuse. All corrective actions taken to address the abuse are also reviewed at this time.

Conclusion 6:  DPW did not ensure that allegations of abuse were reported in the required time frames.

The DPW disagrees with this conclusion. Prior to a licensing inspection, the licensing inspectors obtain a report of all unusual incidents reported to the DPW since the last inspection. The DPW licensing inspectors review reports of alleged abuse at all homes in which a full inspection is conducted during all annual inspections for compliance with the regulations. A full inspection is also conducted at any home that has a founded abuse report.

DPW licensing inspectors and program staff conduct unannounced inspections as follow-up to abuse investigations. If the provider agency is in violation of the regulations, a plan of correction is required to be submitted to the regional office.

The Department does not wait until the annual inspection to act on noncompliance with the regulations when the violation is likely to require some type of licensing action, such as issuance of a provisional license or a revocation.

Conclusion 7:  DPW did not ensure that direct care workers received adequate training in abuse prevention.

Current regulations state that the agency ".shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home, and policies and procedures of the home.." In addition, regulations require that all direct service workers have training in client rights within 30 calendar days of employment. [Ch. 6400.46(e)] The first of the client rights listed in the regulations is: "An individual may not be neglected, abused, mistreated or subjected to corporal punishment." [Ch. 6400.33(a)]

As noted in the report, "six of the eight provider agencies offered new staff members a review of the agency's policies relating to abuse and, in some instances, a discussion of actions that constitute abuse." The report also states that "each of the eight provider agencies had developed policies and procedures for the prevention, reporting, and management of abuse incidents."

In addition, the regulations governing community homes have extensive requirements related to client rights and the use of restrictive procedures. Abuse frequently occurs with individuals who have behavior that is difficult to manage. Therefore, the requirements for behavioral program planning, staff training in the plan, and the application of alternate interventions before restrictive procedures are applied, all serve to reduce situations and employee behavior that lead to abuse.

The DPW agrees that abuse prevention training is critical to ensure the health and safety of the individual and that it should be part of the annual training for all employees, as well as part of the orientation process. As regulations are revised, provisions that will serve to prevent abuse will be considered as part of the training requirements.

 


CHAPTER THREE

Quality of Service to Group Home Residents

The four conclusions in this chapter find that the DPW meets existing requirements and regulations, and makes recommendations to exceed current requirements. The comments and recommendations are directed toward improving services. To that end, the DPW refers again to the Introduction in the response, which reviews the DPW's integrated approach to improving quality, as well as assuring health and safety. These integrated initiatives include: independent monitoring teams; HCCUs; increased licensing staff; adoption of the National Core Indicators to measure system performance; an integrated management information system to allow for the ongoing analysis of findings from all reviews in order to plan improvements in the system; and the reorganization and staff enhancements in the OMR to manage the system for accountability and quality.

Conclusion 1:  DPW has ensured that the eight group homes met minimum requirements in developing emergency plans for residents, but it has not provided direction to go beyond those minimal requirements.

DPW licensing inspectors ensure that all agencies meet the current regulatory requirements regarding the development of emergency medical plans during the annual inspections. As noted in the AG's report, all of the emergency medical plans reviewed were in compliance with current regulations. As part of annual licensing inspections, inspectors make recommendations to provider agencies that go beyond the regulations, directed at ways to improve overall services. These recommendations are optional, since they go beyond the current regulations.

The AG's report also "found that provider agencies for the most part provided adequate and timely services regarding physical health assessments, day programming, and specialized therapies, and that county case managers in most cases provided adequate oversight."

Contrary to the AG's assertions, the DPW has an extensive and proactive program committed to improving the planning and care of individuals. The DPW has sponsored statewide training in many areas of best practices, including managing health needs, as well as treating individuals with mental health diagnoses, including the use of psychopharmacology and environmental/psycho-social interventions, and best practices in person-centered planning.

Conclusion 2:  DPW has not implemented a system to inform all group homes of extra safety precautions used by other group homes for medication administration.

The DPW has an active program to achieve best practices in health care among provider agencies. We believe the structured approach of monitoring, training, and technical assistance described below will provide more consistent outcomes than the issuance of guidelines for medication administration, error policies, and discipline action. The mechanism typically used to share best practices is training and professional association conferences.

The DPW, along with the Temple University School of Nursing, continually evaluates and upgrades the Medications Administration Course, which is required for those training direct care staff to administer medications. The improvements address all practices and procedures related to the administration of medications.

The creation of HCCUs referenced in the Introduction will ensure that proper health assessments are completed, that agencies have adequate policies and procedures for managing the health of individuals and securing good medical care, and that agencies receive the training and technical assistance needed to improve practice and care.

Conclusion 3:  DPW has not established guidelines to aid group homes in ensuring that they convey the residents' critical health and medical needs to outside caregivers.

The DPW acknowledges that standardized information exchange requirements are not in place. The DPW agrees that communication between all caregivers of the individuals is of the utmost importance. The residential regulations and adult training facility regulations require that medical information pertinent to diagnosis and treatment in case of an emergency be part of the physical examination that is part of the individual's record at the provider agency.

The process of developing an individual plan will be standardized across the county programs in the future. This standardization will compel the sharing of all pertinent information in the future.

Conclusion 4:  DPW has not appeared to take action that would strengthen case management efforts by county MH/MR offices.

Monitoring by county case management occurs in many different ways, not only through the three face-to-face meetings that are required by MR Bulletin #00-92-23. Ongoing phone communications with residential day program staff allow case managers to monitor the wellbeing of individuals. In addition, case managers accompany individuals on outings, trips to the doctor, and other such activities.

Not only are monitoring activities documented on the Monitoring Report Form, but they are also documented in the daily logs, progress notes, and activity logs kept by the case manager. In the audit report, there is no mention that these other sources of documentation were ever reviewed as part of the performance audit. As such, a major source of evidential material to support the ongoing monitoring efforts of case managers may have been overlooked.

While currently not a requirement, county case managers use a standard monitoring tool. In addition, there are monthly Waiver coordinator meetings conducted by the DPW that facilitate the dissemination of "best practices" to all counties. In addition, in 1999, training was conducted for all county case management staff regarding Waiver monitoring and best practices.

 


CHAPTER FOUR

Physical Condition of Group Homes

Conclusion 1:  DPW did not ensure that all group homes were clean and safe.

The DPW disagrees with this conclusion, which refers to two homes operated by the same agency, both of which were visited by the auditors because the individuals under review had recently moved from the first to the second home. The report fails to reflect this fact.

The DPW conducted the annual inspection of each of these provider agency homes on June 21-23, 1999, prior to the visit by the auditors on July 233 1999. A full inspection was conducted at one home, and a fire safety inspection was conducted at the second home. Both of these inspections require a physical site inspection. During the inspection, it was noted that garbage cans were on the front porch and that the carpet in one home was worn, but not hazardous. There were no food stains on the walls and no flies were observed. It is useful to note that several individuals who live in this home use wheelchairs, which contribute to rapid wear of the carpet.

A citation for not locking or making poisonous material inaccessible to individuals was given, and the materials were subsequently removed. DPW licensing staff enforced and cited the applicable regulations during the time of their inspection.

A follow-up inspection of both of these homes on April 10th and 14th, 2000 revealed no areas of noncompliance. Both homes were clean, sanitary, and had no hazardous conditions. Poisonous materials were locked and inaccessible to individuals in both homes. Additionally, the worn carpet had been replaced, walls painted, and garbage cans had been removed from the porch and were located at the side of the home.

Conclusion 2:  DPW did not ensure that group home self-assessments were carried out within required time frames.

The DPW disagrees with this conclusion. DPW licensing records indicate that a self-assessment was completed according to the timeframes required in the regulations during the most recent annual inspection of all group homes identified in the AG's report.

Untimely self-assessments are cited by DPW licensing staff when found during annual inspections, and are not a significant threat to health and safety.

I would like to thank you for the opportunity to respond to this audit report.

Sincerely,

 

Michael Stauffer

 

Attachments

cc: Mr. Harvey C. Eckert
  Mr. Peter Speaks
 

Appendix A