Los Angeles County Grand Jury
2006-2007
From the annual report
The consolidated year-end volume. The individual investigations it contains are listed separately below.
📑 Year-End Report
The full consolidated volume; individual reports are listed below.
Individual reports (19)
Findings and recommendations not yet extracted.
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Findings & Recommendations
4 findings
F1:
DHS central staff Directors have established spheres of influence when working with the Hospitals, but they lack formal authority relationships and audit functions Current relationships are built on trust and collegiality and judicious use of staff authority. The authority has not encompassed all the oversight provisions included in the Job Specification for the Director, Pharmacy Services. The Director, Pharmacy Services, reports to the Departmental Chief Medical Officer. The Director, Pharmacy Services, participates in and provides staff support for major committees, including the DHS Core Pharmacy and Therapeutics Committee, the DHS Pharmacy Director’s Committee, and the DHS Pharmacy Information Systems Committee. The incumbent has been effective in funding and generating agreement about implementation of new technology. This assignment of responsibility and chain of command through the Chief Medical Officer appropriately reflects the need for central direction for the Hospitals. Nevertheless, the Hospitals do not share the full reports of all Medication Errors, which are essential for the Director to understand overall Pharmacy Performance and needed interventions. In addition, there is no formally developed Audit Schedule to review conformance with Departmental policies associated with ordering, distributing, and administering medication.
F2:
Investments in technology can result in significant reductions in medication error risks. Automated medication dispensing cabinets have proven themselves to be a good, if substantial, investment. Where they have been put into use, Hospital staff members report that errors have fallen, and the dispensing process has become more efficient. Similar results are projected for pharmacy medication carousels. Bar coding systems offer the prospect of a new level of patient medication safety that has heretofore been unavailable. A pre-requisite for the success of these systems is the implementation of standards for bar code systems across the industry. IV Smart Pumps also add a new level of medication error reduction by highlighting delivery rates or concentrations that fall outside standard parameters. Smart Pumps allow for programming of standard concentrations of IV medications, removing the burden of the unit nursing staff having to calculate flow rates, thereby eliminating an additional potential source of error. The implementation of new technology has rendered information technology staff ever more vital to Hospital operations. The medication use systems assessed here are highly dependent on contractors and internal staff members for installation, staff training, and system maintenance. The systems are expanding in both scope and complexity. DHS is aware of this issue. DHS’s Chief Information Officer (CIO) has prepared a business plan that outlines the resource needs he expects to face immediately and for several years into the future. Work remains to gain the funding needed to offer competitive salaries and deploy staff at the Hospitals.
F3:
Olive View Medical Center processes appear to be incompatible with realization of ADC benefits. Olive View’s description of its plans to install ADCs is not consistent with the approaches used by other Hospitals. Its current systems include pneumatic tube distribution of medications. Citing space limitations on the floors, Olive View staff members are designing plans that limit access to the ADCs, which limits its advantage of allowing nursing staff complete access to regular medications while maintaining controls over controlled substances. During the site visit to Olive View, it was not conclusively demonstrated that patients’ identities are always recorded on medical records before medical orders are written. There was some evidence that the patient’s last name was being written by hand on the initial order sets and then covered with a printed label. This is not a best practice, and it affords a clear opportunity for medication error, as it is possible for the order to refer to the wrong patient. When questioned about the practice, Olive View staff denied that this was the case. The denial, in fact, is more disturbing than the practice itself, since it suggests a defensiveness that could cover other errors or weaknesses. A single site visit should not be considered conclusive, and is not in itself sufficient grounds for action. It is, however, sufficient to support a review of current medication orders, dispensing, and administration to ensure that the Hospital is fully prepared to implement a more automated pharmacy system.
F4:
Electronic Health Records (EHRs) and Computerized Physician Order Entry, when properly implemented, are best practices to reduce medication error. Computerized Physician Order Entry (CPOE) has been successfully implemented in several regional hospitals. It is difficult and expensive to do. It requires extensive planning, a significant investment, and careful building of internal acceptance. Executive management must make the commitment to CPOE and consistently let people know that it will be implemented – especially when thorny issues arise or the system shows difficult growing pains. A pre-requisite for its success is the implementation of EHRs, which are currently being planned in DHR. CPOE, difficult as it is to implement, is worth the trouble. It eliminates a transcription step that generates errors. It eliminates illegible orders and unapproved abbreviations. Wrong dose and wrong drug errors are reduced. Data can be easily collected for evidence-based clinical paths, considered a best practice. Physician orders, including medication orders, can be transmitted to the responsible parties instantly. Medical records can be shared between facilities and programs, making it much faster and easier to assess patients accurately, and all but eliminating the “shopping” of medical services by patients. Productivity, quality of care, and patient safety all advance. DHS has been wise in the order of technology implementation. The technologies described in this report are well-proven innovations that impact patient safety. After the installation of Automated Pharmacy Systems, assignment of Clinical Pharmacists, acquisition of IV Smart Pumps and bar coding of medications are complete, EHRs and CPOE appear to be the next major steps in reducing the risk of medication errors.
Additional Recommendations
11
Not linked to specific findings.
R1:
The Director, Pharmacy Services, should be entrusted with the authority to carry out medication error risk and performance audits and business process reviews. Given the level of human risk and dollars involved, DHS requires a centralized approach to auditing medication errors and processes. These reviews should be coordinated with the Department of Auditing and Compliance. To avoid any potential conflict of interest, Audit staff must have direct access to the DHS top management, up to the Director, DHS. In addition, copies of the audit recommendations should be given to the Director, DHS. Audit recommendations should include proposals for standardization and process improvements in all medication-related functions. The Director, Pharmacy Services, should establish these functions as formal, centralized responsibilities. Along with the audit responsibilities should be an established schedule for performing process and performance audits annually at each Hospital. While this function will require additional staff, process improvements and technological enhancements should cover the costs of this function. In addition, the Director, Pharmacy Services, should have access to all medication error reports.
R2:
DHS should invest in medication management technology improvements, using life cycle costing that accounts for acquisition, installation, and maintenance of equipment. Funding for these investments should be drawn in part from medication cost savings such as those attributable to improved acquisition management. The Technology plan being implemented deserves full funding. Major technology improvements to be implemented include: IV Smart Pumps at all facilities Complete implementation of Automated Dispensing Cabinets at all Hospitals Integration of the ADC system with the Pharmacy System Medication Barcode Carousels Pharmacy Barcode Prepackaging Electronic Health Records While these systems are expensive, it is a prudent decision to implement them. County staff members are proud of their efforts to improve patient safety, and investments in technology reinforce the County’s commitment to their efforts. Furthermore, the County’s investment in best practices in patient safety will help prevent harm to patients, and are evidence of sincere interest in the event of litigation. 2006-2007 County of Los Angeles Civil Grand Jury 32 In calculating the total costs of the system, DHS should employ the best practice of life-cycle cost accounting, which provides resources for operation and maintenance for the equipment during its life and for replacement when its useful life is completed. It is especially important when acquiring the equipment to ensure that there is sufficient staffing to program and test before implementing, because medical staff depend on the accuracy of the information and technology systems. The Director, Pharmacy Services, has been vigilant in keeping down the costs of medication. Last year, by negotiating carefully with the primary medication wholesaler and instituting prudent cost saving programs, savings of more than $150,000 each month have been realized. Careful attention to Formulary management has also led to using cost-effective medications. After years of escalating medication costs, in Fiscal Year 2006/2007 DHS is projected to avoid more than $6 million in pharmaceutical costs, devoting a significant portion of these savings to technology improvements. The ability to apply savings to further improvements is a positive incentive and should continue.
R3:
As part of the implementation of ADCs at Olive View, DHS should review the complete medication order, delivery, and administration process to ensure that both the baseline process and the plan to strengthen it with ADC technology are sound. As stated in the finding supporting this recommendation, it is not clear that the processes at Olive View are as strong as those in place at sister County Hospitals. It is an axiom of technology implementation that, if the underlying processes are not completely sound, the application of technology may well make matters worse rather than better. As part of the implementation of the ADC System, the in-patient medication processes at Olive View, from prescription through 2006-2007 County of Los Angeles Civil Grand Jury 33 ordering, dispensing, and administration should be subject to a thorough peer review. This peer review should: Redesign processes as necessary Ensure that Olive View has adopted best practices used elsewhere in the County Establish processes that ensure low levels of medication error are in place and in practice.
R4:
DHS should begin now to plan for the implementation of CPOE and EHRs. DHS should convene an inter-disciplinary team charged with: a) researching current technology, b) developing specifications and cost estimates, and c) designing implementation plans for CPOE systems that will one day serve all County medical facilities. The team should set milestones to complete research, identify preferred technologies, address implementation issues, identify offsetting savings, and submit budget requests. This is a multi-year, multi-million dollar effort. There may be physician resistance within the Hospitals that needs to be addressed and overcome. There will also be training and retraining issues. There are several interim steps that are being taken that will support the development of DHS-wide systems. Currently, Lab Directors are standardizing nomenclature across the Department for common tests in anticipation of the need to be able to share test results for a patient that visits multiple hospitals. 2006-2007 County of Los Angeles Civil Grand Jury 34
R5:
The Jury recommends that DHS have a system of tracking and interface between hospitals and outpatient clinics to maintain a continuity of care. Information technology should be used to facilitate this process. A similar tracking and interaction should be established between all County departments providing health and social services for the citizens of Los Angeles County, including the Jails. 2006-2007 County of Los Angeles Civil Grand Jury 18
R6:
24-hour Pharmacist coverage is DHS should immediately establish a 24-hour important to Patient Safety. Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication.
R7:
It is a common practice to conduct pre- The County should implement pre- employment drug testing among staff employment drug screening and should involved in the health care professions. develop a targeted program to provide for DHS does not do this. early identification and treatment of substance abuse among staff with access to controlled medications.
R8:
A “Safe and Just” culture is essential to DHS should strengthen its “Safe and Just” accurate self-reporting of errors – culture. including medication errors – as well as to the rapid and effective response to error trends.
R9:
elaborates on process changes required to implement changes to sharing these reports. 2006-2007 County of Los Angeles Civil Grand Jury 31 TECHNOLOGY
R10:
The number of minor errors causing no DHS should consider establishing Nurse patient harm (Category A - C in “Naïve Observation” auditing to reduce University HealthSystem Consortium – dependency on self-reporting for medication the Patient Safety Net) is less than errors. expected, and raises the possibility that they are not fully self-reported.
R11:
DHS does not have a regular practice DHS should recognize best practices of replicating the best practices implemented at one facility, and replicate implemented from one facility to them system-wide. another. II – HISTORY AND BACKGROUND HOSPITALS’ BACKGROUND The Los Angeles County Department of Health Services (DHS) operates four major hospitals, Harbor-UCLA Medical Center (Harbor-UCLA), Los Angeles County+USC Medical Center (LAC+USC), Rancho Los Amigos Rehabilitation Center (RLA), and Olive View Medical Center (Olive View). Together, they provide more than 300,000 patient days of care annually. Table 2: Size of Hospitals # of Beds Hospital Average Daily Census Licensed Budgeted Los Angeles County+USC Medical Center 1022 685 628 Harbor–UCLA Medical Center 570 332 355 Rancho Los Amigos Rehabilitation Center 395 147 140 Olive View Medical Center 377 195 196 The Centers provide a wide variety of services: LAC+USC is the largest single provider of health care in Los Angeles County, providing a full spectrum of emergency, inpatient and outpatient services. LAC+USC provides the community with more than 28% of its trauma care. It operates one of three burn centers in the County and one of the few Level III Neonatal Intensive Care Units in Southern California. It provides care for one-half of both AIDS patients and sickle cell anemia patients in Southern California. RLA is one of the largest comprehensive rehabilitation centers in the United States. Harbor-UCLA is a Level 1 Trauma Center with an NIH-funded General Clinical Research Center. The 72-acre facility is composed of the 8-story Hospital, and a 52,000 square foot Primary Care and Diagnostic Center. Olive View is an acute care Hospital. Table 3 includes the list of services provided at each Center. 2006-2007 County of Los Angeles Civil Grand Jury 23 Table 3: Specialty Services Provided Hospital ER OR Oncology ICU Neo-Natal Los Angeles County+USC Medical X X X X X Center Harbor – UCLA Medical Center X X X X X Rancho Los Amigos Rehabilitation X X Center Olive View Medical Center X X X X X MEDICATION ERRORS Medication errors are classified according to severity by the standards established by the University HealthSystem Consortium – the Patient Safety Net (UHC PSN). They include: No patient harm categories: Category A – Unsafe conditions Category B1 – No harm, near miss because of chance alone Category B2 – No harm, near miss because of active recovery Category C – No harm, and does not require increased patient monitoring More serious but no permanent harm to patient categories: Category D – Required increased monitoring to ensure no harm to patient Category E – Temporary harm to patient, which does not require treatment or intervention Category F – Temporary harm to patient which requires intervention Most severe categories: Category G – Permanent patient harm Category H – Intervention required to sustain life Category I – Patient death Undetermined Category X – Cannot assess harm at the time of error evaluation Incidents of lasting harm or deaths attributable to medication error reported by the Hospitals are rare. The goal, as always, is to minimize medication errors that actually reach patients. Responsibility for the safe prescription, dispensing and administration of medications in a hospital is shared. Physicians, Physicians’ Assistants, and Nurse Practitioners are authorized to prescribe medications. Pharmacists are responsible for acquiring, storing, reviewing prescribed medications; compounding some medications; and providing medications to the floors. Nurses, and in some cases Physicians, are responsible for administering medications to patients. At each step in the process, medications and medication orders are reviewed to ensure patient safety. 2006-2007 County of Los Angeles Civil Grand Jury 24 III – PURPOSE OBJECTIVES AND SCOPE The objective of the investigation was to review existing inpatient medication use processes at four Los Angeles County Hospitals, identify areas that pose the greatest risks of medication error, and offer recommendations that would reduce that risk. The CGJ also sought best practices at each Hospital and at medical centers outside the County that should be adopted throughout the system. The following Hospitals were reviewed: Los Angeles County+USC Medical Center Harbor-UCLA Medical Center Rancho Los Amigos Rehabilitation Center Olive View Medical Center Harbor-King was not included in this review for several reasons. As the evaluation was being developed, there were only 25 beds in the hospital, and it was in transition from being independent to being managed by Harbor-UCLA. The review included processes associated with prescription, dispensing, and administration of in- patient medications, and focused on risk of error, as contrasted with investigation of actual errors. IV – INVESTIGATION
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Findings & Recommendations
4 findings
F1:
DHS central staff Directors have established spheres of influence when working with the Hospitals, but they lack formal authority relationships and audit functions Current relationships are built on trust and collegiality and judicious use of staff authority. The authority has not encompassed all the oversight provisions included in the Job Specification for the Director, Pharmacy Services. The Director, Pharmacy Services, reports to the Departmental Chief Medical Officer. The Director, Pharmacy Services, participates in and provides staff support for major committees, including the DHS Core Pharmacy and Therapeutics Committee, the DHS Pharmacy Director’s Committee, and the DHS Pharmacy Information Systems Committee. The incumbent has been effective in funding and generating agreement about implementation of new technology. This assignment of responsibility and chain of command through the Chief Medical Officer appropriately reflects the need for central direction for the Hospitals. Nevertheless, the Hospitals do not share the full reports of all Medication Errors, which are essential for the Director to understand overall Pharmacy Performance and needed interventions. In addition, there is no formally developed Audit Schedule to review conformance with Departmental policies associated with ordering, distributing, and administering medication.
F2:
Investments in technology can result in significant reductions in medication error risks. Automated medication dispensing cabinets have proven themselves to be a good, if substantial, investment. Where they have been put into use, Hospital staff members report that errors have fallen, and the dispensing process has become more efficient. Similar results are projected for pharmacy medication carousels. Bar coding systems offer the prospect of a new level of patient medication safety that has heretofore been unavailable. A pre-requisite for the success of these systems is the implementation of standards for bar code systems across the industry. IV Smart Pumps also add a new level of medication error reduction by highlighting delivery rates or concentrations that fall outside standard parameters. Smart Pumps allow for programming of standard concentrations of IV medications, removing the burden of the unit nursing staff having to calculate flow rates, thereby eliminating an additional potential source of error. The implementation of new technology has rendered information technology staff ever more vital to Hospital operations. The medication use systems assessed here are highly dependent on contractors and internal staff members for installation, staff training, and system maintenance. The systems are expanding in both scope and complexity. DHS is aware of this issue. DHS’s Chief Information Officer (CIO) has prepared a business plan that outlines the resource needs he expects to face immediately and for several years into the future. Work remains to gain the funding needed to offer competitive salaries and deploy staff at the Hospitals.
F3:
Olive View Medical Center processes appear to be incompatible with realization of ADC benefits. Olive View’s description of its plans to install ADCs is not consistent with the approaches used by other Hospitals. Its current systems include pneumatic tube distribution of medications. Citing space limitations on the floors, Olive View staff members are designing plans that limit access to the ADCs, which limits its advantage of allowing nursing staff complete access to regular medications while maintaining controls over controlled substances. During the site visit to Olive View, it was not conclusively demonstrated that patients’ identities are always recorded on medical records before medical orders are written. There was some evidence that the patient’s last name was being written by hand on the initial order sets and then covered with a printed label. This is not a best practice, and it affords a clear opportunity for medication error, as it is possible for the order to refer to the wrong patient. When questioned about the practice, Olive View staff denied that this was the case. The denial, in fact, is more disturbing than the practice itself, since it suggests a defensiveness that could cover other errors or weaknesses. A single site visit should not be considered conclusive, and is not in itself sufficient grounds for action. It is, however, sufficient to support a review of current medication orders, dispensing, and administration to ensure that the Hospital is fully prepared to implement a more automated pharmacy system.
F4:
Electronic Health Records (EHRs) and Computerized Physician Order Entry, when properly implemented, are best practices to reduce medication error. Computerized Physician Order Entry (CPOE) has been successfully implemented in several regional hospitals. It is difficult and expensive to do. It requires extensive planning, a significant investment, and careful building of internal acceptance. Executive management must make the commitment to CPOE and consistently let people know that it will be implemented – especially when thorny issues arise or the system shows difficult growing pains. A pre-requisite for its success is the implementation of EHRs, which are currently being planned in DHR. CPOE, difficult as it is to implement, is worth the trouble. It eliminates a transcription step that generates errors. It eliminates illegible orders and unapproved abbreviations. Wrong dose and wrong drug errors are reduced. Data can be easily collected for evidence-based clinical paths, considered a best practice. Physician orders, including medication orders, can be transmitted to the responsible parties instantly. Medical records can be shared between facilities and programs, making it much faster and easier to assess patients accurately, and all but eliminating the “shopping” of medical services by patients. Productivity, quality of care, and patient safety all advance. DHS has been wise in the order of technology implementation. The technologies described in this report are well-proven innovations that impact patient safety. After the installation of Automated Pharmacy Systems, assignment of Clinical Pharmacists, acquisition of IV Smart Pumps and bar coding of medications are complete, EHRs and CPOE appear to be the next major steps in reducing the risk of medication errors.
Additional Recommendations
11
Not linked to specific findings.
R1:
The Director, Pharmacy Services, should be entrusted with the authority to carry out medication error risk and performance audits and business process reviews. Given the level of human risk and dollars involved, DHS requires a centralized approach to auditing medication errors and processes. These reviews should be coordinated with the Department of Auditing and Compliance. To avoid any potential conflict of interest, Audit staff must have direct access to the DHS top management, up to the Director, DHS. In addition, copies of the audit recommendations should be given to the Director, DHS. Audit recommendations should include proposals for standardization and process improvements in all medication-related functions. The Director, Pharmacy Services, should establish these functions as formal, centralized responsibilities. Along with the audit responsibilities should be an established schedule for performing process and performance audits annually at each Hospital. While this function will require additional staff, process improvements and technological enhancements should cover the costs of this function. In addition, the Director, Pharmacy Services, should have access to all medication error reports.
R2:
DHS should invest in medication management technology improvements, using life cycle costing that accounts for acquisition, installation, and maintenance of equipment. Funding for these investments should be drawn in part from medication cost savings such as those attributable to improved acquisition management. The Technology plan being implemented deserves full funding. Major technology improvements to be implemented include: IV Smart Pumps at all facilities Complete implementation of Automated Dispensing Cabinets at all Hospitals Integration of the ADC system with the Pharmacy System Medication Barcode Carousels Pharmacy Barcode Prepackaging Electronic Health Records While these systems are expensive, it is a prudent decision to implement them. County staff members are proud of their efforts to improve patient safety, and investments in technology reinforce the County’s commitment to their efforts. Furthermore, the County’s investment in best practices in patient safety will help prevent harm to patients, and are evidence of sincere interest in the event of litigation. 2006-2007 County of Los Angeles Civil Grand Jury 32 In calculating the total costs of the system, DHS should employ the best practice of life-cycle cost accounting, which provides resources for operation and maintenance for the equipment during its life and for replacement when its useful life is completed. It is especially important when acquiring the equipment to ensure that there is sufficient staffing to program and test before implementing, because medical staff depend on the accuracy of the information and technology systems. The Director, Pharmacy Services, has been vigilant in keeping down the costs of medication. Last year, by negotiating carefully with the primary medication wholesaler and instituting prudent cost saving programs, savings of more than $150,000 each month have been realized. Careful attention to Formulary management has also led to using cost-effective medications. After years of escalating medication costs, in Fiscal Year 2006/2007 DHS is projected to avoid more than $6 million in pharmaceutical costs, devoting a significant portion of these savings to technology improvements. The ability to apply savings to further improvements is a positive incentive and should continue.
R3:
As part of the implementation of ADCs at Olive View, DHS should review the complete medication order, delivery, and administration process to ensure that both the baseline process and the plan to strengthen it with ADC technology are sound. As stated in the finding supporting this recommendation, it is not clear that the processes at Olive View are as strong as those in place at sister County Hospitals. It is an axiom of technology implementation that, if the underlying processes are not completely sound, the application of technology may well make matters worse rather than better. As part of the implementation of the ADC System, the in-patient medication processes at Olive View, from prescription through 2006-2007 County of Los Angeles Civil Grand Jury 33 ordering, dispensing, and administration should be subject to a thorough peer review. This peer review should: Redesign processes as necessary Ensure that Olive View has adopted best practices used elsewhere in the County Establish processes that ensure low levels of medication error are in place and in practice.
R4:
DHS should begin now to plan for the implementation of CPOE and EHRs. DHS should convene an inter-disciplinary team charged with: a) researching current technology, b) developing specifications and cost estimates, and c) designing implementation plans for CPOE systems that will one day serve all County medical facilities. The team should set milestones to complete research, identify preferred technologies, address implementation issues, identify offsetting savings, and submit budget requests. This is a multi-year, multi-million dollar effort. There may be physician resistance within the Hospitals that needs to be addressed and overcome. There will also be training and retraining issues. There are several interim steps that are being taken that will support the development of DHS-wide systems. Currently, Lab Directors are standardizing nomenclature across the Department for common tests in anticipation of the need to be able to share test results for a patient that visits multiple hospitals. 2006-2007 County of Los Angeles Civil Grand Jury 34
R5:
The Jury recommends that DHS have a system of tracking and interface between hospitals and outpatient clinics to maintain a continuity of care. Information technology should be used to facilitate this process. A similar tracking and interaction should be established between all County departments providing health and social services for the citizens of Los Angeles County, including the Jails. 2006-2007 County of Los Angeles Civil Grand Jury 18
R6:
24-hour Pharmacist coverage is DHS should immediately establish a 24-hour important to Patient Safety. Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication.
R7:
It is a common practice to conduct pre- The County should implement pre- employment drug testing among staff employment drug screening and should involved in the health care professions. develop a targeted program to provide for DHS does not do this. early identification and treatment of substance abuse among staff with access to controlled medications.
R8:
A “Safe and Just” culture is essential to DHS should strengthen its “Safe and Just” accurate self-reporting of errors – culture. including medication errors – as well as to the rapid and effective response to error trends.
R9:
elaborates on process changes required to implement changes to sharing these reports. 2006-2007 County of Los Angeles Civil Grand Jury 31 TECHNOLOGY
R10:
The number of minor errors causing no DHS should consider establishing Nurse patient harm (Category A - C in “Naïve Observation” auditing to reduce University HealthSystem Consortium – dependency on self-reporting for medication the Patient Safety Net) is less than errors. expected, and raises the possibility that they are not fully self-reported.
R11:
DHS does not have a regular practice DHS should recognize best practices of replicating the best practices implemented at one facility, and replicate implemented from one facility to them system-wide. another. II – HISTORY AND BACKGROUND HOSPITALS’ BACKGROUND The Los Angeles County Department of Health Services (DHS) operates four major hospitals, Harbor-UCLA Medical Center (Harbor-UCLA), Los Angeles County+USC Medical Center (LAC+USC), Rancho Los Amigos Rehabilitation Center (RLA), and Olive View Medical Center (Olive View). Together, they provide more than 300,000 patient days of care annually. Table 2: Size of Hospitals # of Beds Hospital Average Daily Census Licensed Budgeted Los Angeles County+USC Medical Center 1022 685 628 Harbor–UCLA Medical Center 570 332 355 Rancho Los Amigos Rehabilitation Center 395 147 140 Olive View Medical Center 377 195 196 The Centers provide a wide variety of services: LAC+USC is the largest single provider of health care in Los Angeles County, providing a full spectrum of emergency, inpatient and outpatient services. LAC+USC provides the community with more than 28% of its trauma care. It operates one of three burn centers in the County and one of the few Level III Neonatal Intensive Care Units in Southern California. It provides care for one-half of both AIDS patients and sickle cell anemia patients in Southern California. RLA is one of the largest comprehensive rehabilitation centers in the United States. Harbor-UCLA is a Level 1 Trauma Center with an NIH-funded General Clinical Research Center. The 72-acre facility is composed of the 8-story Hospital, and a 52,000 square foot Primary Care and Diagnostic Center. Olive View is an acute care Hospital. Table 3 includes the list of services provided at each Center. 2006-2007 County of Los Angeles Civil Grand Jury 23 Table 3: Specialty Services Provided Hospital ER OR Oncology ICU Neo-Natal Los Angeles County+USC Medical X X X X X Center Harbor – UCLA Medical Center X X X X X Rancho Los Amigos Rehabilitation X X Center Olive View Medical Center X X X X X MEDICATION ERRORS Medication errors are classified according to severity by the standards established by the University HealthSystem Consortium – the Patient Safety Net (UHC PSN). They include: No patient harm categories: Category A – Unsafe conditions Category B1 – No harm, near miss because of chance alone Category B2 – No harm, near miss because of active recovery Category C – No harm, and does not require increased patient monitoring More serious but no permanent harm to patient categories: Category D – Required increased monitoring to ensure no harm to patient Category E – Temporary harm to patient, which does not require treatment or intervention Category F – Temporary harm to patient which requires intervention Most severe categories: Category G – Permanent patient harm Category H – Intervention required to sustain life Category I – Patient death Undetermined Category X – Cannot assess harm at the time of error evaluation Incidents of lasting harm or deaths attributable to medication error reported by the Hospitals are rare. The goal, as always, is to minimize medication errors that actually reach patients. Responsibility for the safe prescription, dispensing and administration of medications in a hospital is shared. Physicians, Physicians’ Assistants, and Nurse Practitioners are authorized to prescribe medications. Pharmacists are responsible for acquiring, storing, reviewing prescribed medications; compounding some medications; and providing medications to the floors. Nurses, and in some cases Physicians, are responsible for administering medications to patients. At each step in the process, medications and medication orders are reviewed to ensure patient safety. 2006-2007 County of Los Angeles Civil Grand Jury 24 III – PURPOSE OBJECTIVES AND SCOPE The objective of the investigation was to review existing inpatient medication use processes at four Los Angeles County Hospitals, identify areas that pose the greatest risks of medication error, and offer recommendations that would reduce that risk. The CGJ also sought best practices at each Hospital and at medical centers outside the County that should be adopted throughout the system. The following Hospitals were reviewed: Los Angeles County+USC Medical Center Harbor-UCLA Medical Center Rancho Los Amigos Rehabilitation Center Olive View Medical Center Harbor-King was not included in this review for several reasons. As the evaluation was being developed, there were only 25 beds in the hospital, and it was in transition from being independent to being managed by Harbor-UCLA. The review included processes associated with prescription, dispensing, and administration of in- patient medications, and focused on risk of error, as contrasted with investigation of actual errors. IV – INVESTIGATION
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Findings & Recommendations
79 findings
F1:
Patient and Family Handbook; Rancho Los Amigos
F2:
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Summary Report on Medication Error Related Events, February 2007
F3:
Inpatient Pharmacist Interventions; March 2007
F4:
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Medication Errors Reported per 1,000 Doses Dispensed August 2003 – February 2007
F5:
Clinical Pharmacists are effective in reducing medication error risks. Clinical Pharmacists spend time as part of patient care teams, consulting with Physicians and the remainder of the team on the units and during rounds. They provide drug information, recommend dosage adjustments, respond to questions from nursing staff, and make suggestions regarding initiation of drug therapy. All of these activities relieve stress on the Physicians and other clinicians who must sometimes make rapid decisions about patient care in difficult circumstances. This improves the quality and speed of the decisions and reduces the likelihood of medication errors.
F6:
24-hour Pharmacist coverage is important to Patient Safety. A Pharmacist is needed on-site for in-patient care on a 24/7 basis, particularly for acute patients. If a Pharmacist is not available, a comparatively slow and cumbersome process of faxes and telephone calls to Pharmacists at home is required. A “night locker” must be maintained, under the control of a Senior Nurse. If a medication is needed that is not in the night locker, a Pharmacist must be called in from home to open the main pharmacy and dispense it. The primary disadvantage of the process is that it is not fast, and the circumstances that give rise to overnight medication orders are likely to demand prompt action. There are also evident weaknesses in the processes for the checking of medications against orders. Finally, tired Pharmacists are expected to perform their day shifts, even when their sleep is interrupted. In all professions, errors usually increase when people become sleep-deprived. Some smaller hospitals cannot support a 24-hour pharmacy. These hospitals are adopting the capabilities of automated prescription transmission, which involves scanning medication orders to a Pharmacist for verification and approval. The Pharmacist can then release the medication from the ADC at the smaller facility. 2006-2007 County of Los Angeles Civil Grand Jury 36
F7:
It is a common practice to conduct pre-employment drug testing among staff involved in the health care professions. DHS does not do this. Drug screening and random drug testing are common means of ensuring security and safety in a wide variety of sensitive business and government operations. A number of hospitals use them. Failure to conduct screening and testing exposes patients to a potential risk of not receiving prescribed medication (if an addicted employee substitutes a placebo for the particular drug), and increases the potential risk of medication errors when impaired staff members prescribe, approve, distribute, and administer medications. This is a known risk in an environment where staff members sometimes work long hours, and where there is ample knowledge of the “right” mix of drugs to take to stay alert.
F8:
A “Safe and Just” culture is essential to accurate reporting of errors – including medication errors – as well as to the rapid and effective response to error trends. A survey undertaken by DHS in December 2005 showed disturbingly high levels of concern among both Nurses and attending Physicians that errors would be held against them. Nurses also expressed high levels of concern that errors would be kept in their personnel files. Some of this concern may be traced to a long-standing policy in which managers close out reports of all types of medication errors by indicating that an employee was “counseled about the incident”. That is the first step in the County’s standard progressive discipline process. In that process, managers are advised to keep a permanent record of the counseling action for use as needed in ensuing sanctions for further errors. In April 2006, DHS engaged a contractor to deliver a training workshop, entitled “Patient Safety and the Just Culture”. It appears to have been intended to address the issue of a punitive culture by advocating a culture in which acknowledgement that errors are human and inevitable is balanced by a strong sense of professionalism and “zero tolerance” for medication errors. Before punitive actions are taken when a rule is broken or mistake is made, a Just Culture would consider: Whether the employee knowingly violated the rule (cid:104) Whether there was a compelling reason to violate the rule (cid:104) Whether the employee had a good faith but mistaken belief that the violation (cid:104) was justified or insignificant Whether the source of the error resided within the system or was behavioral. (cid:104) Based on answers to such questions, the response would vary from counseling to training to revising procedures. Perceptions of an unjust culture are crippling to any attempt to encourage the self-reporting of Category A, B and C errors, in which no measurable harm comes to a patient. If Physicians and Nurses fear retribution, they will be significantly less likely to self-report errors that have little measurable impact. DHS’s efforts to counter them are laudable, but it seems likely that they have not been sufficient. Further surveys were not available, but anecdotal evidence suggests that negative perceptions have proved to be persistent.
F9:
There is insufficient consistent, Department-wide medication error trend analysis. The identification of trends within overall medication error rates is key to reducing them. The Hospitals do some analysis now, although they do not all follow the same guidelines; and their analysis appears to be limited at times by a lack of formal training for some Hospital Risk Management staff members. For the past year-and-a-half, data have been gathered in a nationwide system run by the University HealthSystem Consortium, which permits sophisticated analysis of errors. There has been insufficient consistent reporting and analysis to take advantage of that capability. While some errors occur only within one Hospital, others may be related to overall policies, training regimens, or technology systems across the County. These error trends should be identified and corrected; this can only be done if errors are reported and analyzed consistently across the County. In addition, such a function will serve to protect the Hospitals against the possibility that a medication error trend may be missed at the Hospital level. Recently, DHS has developed a “Report Card” which tracks high level trend data. It is a good beginning, but needs additional development.
F10:
The number of errors in UHC-PSN Categories A-C is less than expected, and raises the possibility that they are not fully self-reported. A review of reported errors shows few reported errors in the A and B1 categories for all four Hospitals in the six months ending March 31, 2007. The total errors reported for “no patient harm” categories (A, B1, B2, C) were low, considering there were over 300,000 patient days at Harbor-UCLA, Olive View, and RLA, where many patients have multiple medications. Given the number of reported errors in other categories over the same period, this does not appear logical. It is understandable that staff members who make lower category errors are sometimes reluctant to report them. Even in a non-punitive atmosphere, it is easy to see that a staff member would be reluctant to report a minor mishap, such as picking up an improper medication from a shelf, noticing it immediately, and replacing it before gathering up a proper medication. This is how major trends are identified that lead to, for example, separating look alike/sound alike medications. For errors in Categories B1 and B2, the patient receives no improper medications. Self-reporting is the only source of data. Responsible staff noted that the system used to track medication errors and pharmacy interventions is very cumbersome to use, further discouraging reporting of errors. This possible underreporting is important, because identifying errors that do not result in patient harm can point the way to weaknesses in the system that pose the potential for more serious adverse events.
F11:
DHS does not have a regular practice of replicating the best practices implemented from one facility to another. As an example, Harbor-UCLA has implemented Structured Physician Order Forms for admissions and transfers requiring the use of block lettering to reduce cases of illegibility. These forms significantly reduce a broad range of medication order errors, including illegible orders, unapproved abbreviations, dosage errors, and “wrong drug” errors. The Structured Physician Order Forms are considered successful where they are now used. The balance of DHS facilities does not use block lettering on these forms. As another example, Olive View does not recognize the same medications as high risk as the other Hospitals. These are examples of processes that are low-cost and can be relatively easily implemented, as contrasted with implementation of ADCs and bar coding technology.
F12:
Patient Safety and the Just Culture: County of Los Angeles DHS
F13:
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
F14:
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
F15:
Rancho Los Amigos National Rehabilitation Center; Department of Nursing Administrative Policy and Procedure: a. Orientation: Nursing b. Competency Program: Management and Assessment, Initial and Ongoing c. Medication Management Guidelines d. Medication Administration Documentation e. Order Transcription, Recopying of Flow Sheets and Verification of Medication Administration Record f. Supplemental Blood Glucose Medication and Treatment Record g. Pyxis System Access and Responsibility h. Medication Error and Near Miss Reporting i. Competency Program: Management and Assessment, Initial and Ongoing j. Intravenous Therapy: Guidelines for Administration k. Waived testing
F16:
UHC Patient Safety Net On-Site Administration Report – Rancho Los Amigos Sample pie chart Report of Harm Score Distribution and Event Sub-type Distribution
F17:
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 43
F18:
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F19:
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F20:
LAC+USC Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F21:
LA County DHS - Nursing Registry Usage FY 2007-07 a. Harbor UCLA b. Rancho Los Amigos c. LAC+USC d. Olive View
F22:
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F23:
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
F24:
Proposed Medication Management Automation Solution, LA DHS 1/2007
F25:
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
F26:
Pharmacy Utilization Report for FY 2006-2007
F27:
DHS Outpatient Pharmacy Automation Installation Plan: Expected Order of Installation Status – May 2007
F28:
The Just Culture Algorithm 29. “Medication Errors – A Nurse’s Worst Nightmare” Working Nurse Magazine, April 9- 30, 2007 30. “Med Errors = Bad Outcomes”, Nurse Week, April 2007
F31:
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
F32:
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
F33:
Managing Medication Related Events: PowerPoint Presentation
F34:
Medication Management Process in Valley Care – PowerPoint Presentation
F35:
LAC+USC Chemotherapy Physicians Orders
F36:
LAC+USC Daily Physicians Orders – Adult Critical Care
F37:
LAC+USC Neonate Continuous Infusion Orders
F38:
LAC+USC Neonate Continuous Infusion Recipes
F39:
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
F40:
LAC+USC Adult Inpatient Rasburicase Physician Order Form
F41:
LAC+USC Pharmacy Department Policy and Procedure Manual a. Inpatient Prescribing/Ordering General Practices
F42:
LAC+USC Department of Nursing Services Policy a. Medication Administration System b. High Alert Medications c. General Medication Policies
F43:
LAC+USC HealthCare Network Policy: Medication Usage
F44:
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
F45:
List of High-Alert Medications
F46:
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 44
F47:
LAC+USC Drug Bulletin June 2006
F48:
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
F49:
Intervention Summary Report
F50:
Harbor-UCLA – Patient Safety Bulletin October/November 2006
F51:
Harbor-UCLA – Patient Safety Bulletin July/August 2006
F52:
Harbor-UCLA – Patient Safety Bulletin May/June 2006
F53:
Harbor-UCLA – Patient Safety Bulletin January/February 2004
F54:
Harbor-UCLA – Patient Safety Bulletin November/December 2003
F55:
Harbor-UCLA – Patient Safety Bulletin October 2003
F56:
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
F57:
Los Angeles County DHS Lipid Management Algorithm
F58:
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
F59:
Wikepedia: Medical Error
F60:
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
F61:
JCAHO Front Line – Admitting Pharmacists usher in big improvements
F62:
UHC Patient Safety Net Categories a. Pharmacist Review b. Medication Error Event Details Questions c. Adverse Drug Reaction Event Details Questions d. Event Type
F63:
Harbor-UCLA MAR Sample
F64:
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
F65:
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
F66:
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
F67:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
F68:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
F69:
Flow Chart: Medication-use Process for Hospital and Long-Term Care
F70:
Unlabeled Articles/Chapters a. Medication Errors: Prevention Strategies b. Action Agenda for Health Care Organizations c. Medication Errors: Incidence Rates
F71:
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
F72:
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
F73:
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
F74:
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
F75:
LA County DHS Class Specification; Director of Pharmacy Services
F76:
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
F77:
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 45
F78:
DHS Pharmacy Leadership Program description
F79:
DHS Outpatient Report Card: Medication Use Performance Metric 2007
F80:
DHS Pharmacy Leadership Program proposal
F81:
DHS Report Card: Medication Use Performance Metrics 2007 2006-2007 County of Los Angeles Civil Grand Jury 46 JUVENILE CUSTODIES - ARE WE PAYING TWICE? EXECUTIVE SUMMARY State law requires that whenever a minor is in custody in a juvenile hall or other county juvenile facility for thirty consecutive days, the county welfare agency needs to be informed. The law requires that the welfare department determine whether these minors are part of a family receiving cash aid benefits and, if so, make reductions in the family’s aid payments to reflect the period of time the minor received care in the facility. Yet, there appears to be no liaisons between these agencies to share information and to stop the cash aid. The Los Angeles County Probation Department handles over 20,000 custodies annually with a staff of 5,800 and budget of $630 million. Costs of an individual minor in custody are approaching $200 a day. The Department does a financial screening of the parents or other responsible relative and bills for the cost of care. If the family is receiving financial assistance, the family is not billed; this information should be sent to the welfare agencies. The welfare agencies in Los Angeles County are the Department of Public Social Services and the Department of Children and Family Services. DPSS has over a million clients and over 13,000 employees. There is no direct supervision of the individuals receiving the cash aid and the agency relies on self reporting to find out when a child is no longer residing in the home. DCFS monitors families directly and should have knowledge of where a child is residing. Recent legislation prohibits simultaneous or duplicative case management or services provided by the county probation department and the child welfare services department. The recommendations are designed to co-ordinate county agencies so that they will be in compliance with state law. The lack of communication between the Probation Department and the public assistance agencies may result in replicated support for the same minor. If there is no “Stop Order” issued in a timely manner, or not issued at all, it may take months for funding to be halted and realize that substantial taxpayer funds may be wasted. DPSS, DCFS and Probation need to work together and implement an information sharing process. Probation needs to inform the child support agencies when a minor is in custody for thirty days. A protocol needs to be developed to avoid replicate funding. If payments are not discontinued or unjustified payments are made, attempts should be made to recover such overpayments. The Probation Department’s responsibility is to expeditiously complete the financial screening of the family and communicate this information to the appropriate agencies. HISTORY The Los Angeles County Probation Department handles over 20,000 custodies annually with a staff of 5,800 and a budget of $6301 million. The size and transient nature of the custodies underscores the responsibility and diverse services required of the Department while adhering to the myriad federal, state and local laws. Within this oversight they must provide medical care, mental health, education, behavioral rehabilitation and be involved with any other agency 2006-2007 County of Los Angeles Civil Grand Jury 47 providing care for a minor’s custody. Within this area lies a responsibility to report to the supportive agencies (DPSS and DCFS) to prevent replication of costs for those minors adjudicated and sentenced to juvenile hall, camps or probation group homes. California’s Welfare and Institutions Codes Sections 900-914 covers the above issues. With the cost of maintaining a minor in custody spiralling upwards, approaching $200 a day1, there is a need to address the lack of communication and oversight between supportive services and the Probation Department. Due to the layering of department and service providers, it is difficult to pinpoint who is charged with this reporting and at what point the information should be submitted. There is no statistical data available for the numbers of minors coming from DCFS funded units, group homes and foster care, or from DPSS comprised of CALWORKS funded units. Along with DPSS funding is the availability of food stamps, medical care, housing assistance and childcare, all of which is based on the number of individuals residing in the unit. PURPOSE In accordance with California Welfare and Institution Codes Sections 900-914 when minors are placed in the custody of the Juvenile Probation Department for thirty days or more, any agency providing funding for that minor must be notified so as to terminate funding for that minor. This notification ensures that the taxpayers are not paying twice for the minor’s care and support while being held. The investigation attempted to: • Determine what mechanism is in place to avoid funding of minors in custody when their homes are simultaneously receiving support from various social service agencies. • Identify the appropriate mechanism to be implemented to stop the replication of funding. • To determine what agencies are involved and who is responsible for triggering that mechanism. • Recover any monies that have been inappropriately paid, creating a duplicated taxpayer support of the minor in custody. • Make sure measures are in place to aggressively seek reimbursement of overpaid funding. Probation Department, Administrative Services, 5/1/07 2006-2007 County of Los Angeles Civil Grand Jury 48
Additional Recommendations
11
Not linked to specific findings.
R1:
Federal, state and local law and policy issues Some other California counties have had better success in information sharing. Los 2006-2007 County of Los Angeles Civil Grand Jury 57 Angeles County has recently adopted an interagency Memorandum of Understanding stating that DCFS and DHS will develop protocols to improve data sharing.
R2:
Information technology issues Existing systems within DCFS and DHS do not enable information sharing. Development of new systems that could facilitate this sharing is lagging.
R3:
Interdepartmental collaboration, information sharing and the HUB clinics While such limited approaches as multidisciplinary teams (combining several technical and social workers) and HUB clinics (specializing in services for abused and neglected children) have represented some improvement in care, there is a need for enhanced management oversight of the two departments coordination and information sharing.
R4:
Public health nurses Public Health Nurses represent an improvement in the care of some children, but their effectiveness is limited by the inadequate access to patient records and the fact that their management is divided (half report to the Department of Public Health, half to the Department of Children and Family Services).
R5:
0: DHS should expand the number of Clinical Pharmacists, institute a Clinical Coordinator position at each Hospital, and use Tech-Check-Tech processes to free Pharmacists to perform other pharmaceutical duties
R6:
DHS should immediately establish a 24-hour Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication. Olive View Medical Center is of sufficient size and structure to warrant a 24-hour pharmacy. While they recognize the advantages of 24/7 coverage, staff at Olive View cite the difficulty of hiring Pharmacists to work this demanding shift. It is a hurdle to be overcome rather than an insurmountable obstacle, and Olive View should work with Department of Human Resources staff to develop incentives sufficient to attract night shift pharmacists or retain pharmacists when night shifts become a requirement. Olive View is too far removed from other medical facilities to seriously consider a partnering solution. Its patient census and the existence of an emergency room indicate that there is sufficient demand for constant staffing. Rancho Los Amigos, as a rehabilitation facility, has a different patient profile, and has historically seen fewer demands for after-hours pharmacy. This may be changing. DHS should monitor off-hours pharmacy demands on a regular basis, and consider partnering with other DHS facilities or other plans to ensure coverage.
R7:
The County should implement pre-employment drug screening and should develop a targeted program to provide for early identification and treatment of substance abuse among staff with access to controlled medications Pre-employment screening will reduce the risk of hiring individuals who are addicted to narcotics or other drugs. In addition, a program should be developed, modeled on best practices, that include training managers to recognize problems associated with drug abuse, referrals to Employee Assistance Programs, development of reporting mechanisms that identify patterns of abuse, and testing for drugs with a lower threshold of evidence than for other County staff. The program should be modeled on best practices which provide for confidentiality of results, automatic retesting of positive results, counseling, and, where needed, recovery programs. This program is not, at heart, different from ensuring that medical staff members do not have chronic infectious diseases. 2006-2007 County of Los Angeles Civil Grand Jury 37
R8:
0: DHS should strengthen its “Safe and Just” culture.
R9:
0: DHS should analyze medication error trends, share aggregated information with Departmental and Facility leadership, and allow central review of medication error reports.
R10:
DHS should consider establishing Nurse “Naïve Observation” auditing to reduce dependency on self-reporting for medication errors. In this practice, at random intervals Nurses observe other Nurses administering medications. Afterwards, the observing Nurse checks the Medical Administration Record (MAR) and patient records to determine whether any errors were made. A 2002 study comparing methods of detecting medication errors found independent observation by Nurses to be the most efficient and accurate method of doing so.18 18 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities” American Journal of Health-System Pharmacy, Vol 59 2006-2007 County of Los Angeles Civil Grand Jury 40
R11:
DHS should recognize best practices implemented at one facility, and replicate them system-wide. The best practice of Structured Physician Order Forms with block lettering spaces, currently in place at Harbor/UCLA Medical Center, should be implemented at all County Hospitals. Introducing these forms system-wide is a low-cost and low-risk item for DHS. In addition, if one or more Hospitals identify a certain medication as high risk, all Hospitals should similarly categorize that medication as high risk absent a compelling reason to the contrary. Successful best practice programs often include regular reporting on best practices at senior staff meetings, and development of tracking mechanisms for implementation of the changes.
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Findings & Recommendations
79 findings
F1:
Patient and Family Handbook; Rancho Los Amigos
F2:
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Summary Report on Medication Error Related Events, February 2007
F3:
Inpatient Pharmacist Interventions; March 2007
F4:
Rancho Los Amigos National Rehabilitation Center Quality Resource Management Department; Medication Errors Reported per 1,000 Doses Dispensed August 2003 – February 2007
F5:
Clinical Pharmacists are effective in reducing medication error risks. Clinical Pharmacists spend time as part of patient care teams, consulting with Physicians and the remainder of the team on the units and during rounds. They provide drug information, recommend dosage adjustments, respond to questions from nursing staff, and make suggestions regarding initiation of drug therapy. All of these activities relieve stress on the Physicians and other clinicians who must sometimes make rapid decisions about patient care in difficult circumstances. This improves the quality and speed of the decisions and reduces the likelihood of medication errors.
F6:
24-hour Pharmacist coverage is important to Patient Safety. A Pharmacist is needed on-site for in-patient care on a 24/7 basis, particularly for acute patients. If a Pharmacist is not available, a comparatively slow and cumbersome process of faxes and telephone calls to Pharmacists at home is required. A “night locker” must be maintained, under the control of a Senior Nurse. If a medication is needed that is not in the night locker, a Pharmacist must be called in from home to open the main pharmacy and dispense it. The primary disadvantage of the process is that it is not fast, and the circumstances that give rise to overnight medication orders are likely to demand prompt action. There are also evident weaknesses in the processes for the checking of medications against orders. Finally, tired Pharmacists are expected to perform their day shifts, even when their sleep is interrupted. In all professions, errors usually increase when people become sleep-deprived. Some smaller hospitals cannot support a 24-hour pharmacy. These hospitals are adopting the capabilities of automated prescription transmission, which involves scanning medication orders to a Pharmacist for verification and approval. The Pharmacist can then release the medication from the ADC at the smaller facility. 2006-2007 County of Los Angeles Civil Grand Jury 36
F7:
It is a common practice to conduct pre-employment drug testing among staff involved in the health care professions. DHS does not do this. Drug screening and random drug testing are common means of ensuring security and safety in a wide variety of sensitive business and government operations. A number of hospitals use them. Failure to conduct screening and testing exposes patients to a potential risk of not receiving prescribed medication (if an addicted employee substitutes a placebo for the particular drug), and increases the potential risk of medication errors when impaired staff members prescribe, approve, distribute, and administer medications. This is a known risk in an environment where staff members sometimes work long hours, and where there is ample knowledge of the “right” mix of drugs to take to stay alert.
F8:
A “Safe and Just” culture is essential to accurate reporting of errors – including medication errors – as well as to the rapid and effective response to error trends. A survey undertaken by DHS in December 2005 showed disturbingly high levels of concern among both Nurses and attending Physicians that errors would be held against them. Nurses also expressed high levels of concern that errors would be kept in their personnel files. Some of this concern may be traced to a long-standing policy in which managers close out reports of all types of medication errors by indicating that an employee was “counseled about the incident”. That is the first step in the County’s standard progressive discipline process. In that process, managers are advised to keep a permanent record of the counseling action for use as needed in ensuing sanctions for further errors. In April 2006, DHS engaged a contractor to deliver a training workshop, entitled “Patient Safety and the Just Culture”. It appears to have been intended to address the issue of a punitive culture by advocating a culture in which acknowledgement that errors are human and inevitable is balanced by a strong sense of professionalism and “zero tolerance” for medication errors. Before punitive actions are taken when a rule is broken or mistake is made, a Just Culture would consider: Whether the employee knowingly violated the rule (cid:104) Whether there was a compelling reason to violate the rule (cid:104) Whether the employee had a good faith but mistaken belief that the violation (cid:104) was justified or insignificant Whether the source of the error resided within the system or was behavioral. (cid:104) Based on answers to such questions, the response would vary from counseling to training to revising procedures. Perceptions of an unjust culture are crippling to any attempt to encourage the self-reporting of Category A, B and C errors, in which no measurable harm comes to a patient. If Physicians and Nurses fear retribution, they will be significantly less likely to self-report errors that have little measurable impact. DHS’s efforts to counter them are laudable, but it seems likely that they have not been sufficient. Further surveys were not available, but anecdotal evidence suggests that negative perceptions have proved to be persistent.
F9:
There is insufficient consistent, Department-wide medication error trend analysis. The identification of trends within overall medication error rates is key to reducing them. The Hospitals do some analysis now, although they do not all follow the same guidelines; and their analysis appears to be limited at times by a lack of formal training for some Hospital Risk Management staff members. For the past year-and-a-half, data have been gathered in a nationwide system run by the University HealthSystem Consortium, which permits sophisticated analysis of errors. There has been insufficient consistent reporting and analysis to take advantage of that capability. While some errors occur only within one Hospital, others may be related to overall policies, training regimens, or technology systems across the County. These error trends should be identified and corrected; this can only be done if errors are reported and analyzed consistently across the County. In addition, such a function will serve to protect the Hospitals against the possibility that a medication error trend may be missed at the Hospital level. Recently, DHS has developed a “Report Card” which tracks high level trend data. It is a good beginning, but needs additional development.
F10:
The number of errors in UHC-PSN Categories A-C is less than expected, and raises the possibility that they are not fully self-reported. A review of reported errors shows few reported errors in the A and B1 categories for all four Hospitals in the six months ending March 31, 2007. The total errors reported for “no patient harm” categories (A, B1, B2, C) were low, considering there were over 300,000 patient days at Harbor-UCLA, Olive View, and RLA, where many patients have multiple medications. Given the number of reported errors in other categories over the same period, this does not appear logical. It is understandable that staff members who make lower category errors are sometimes reluctant to report them. Even in a non-punitive atmosphere, it is easy to see that a staff member would be reluctant to report a minor mishap, such as picking up an improper medication from a shelf, noticing it immediately, and replacing it before gathering up a proper medication. This is how major trends are identified that lead to, for example, separating look alike/sound alike medications. For errors in Categories B1 and B2, the patient receives no improper medications. Self-reporting is the only source of data. Responsible staff noted that the system used to track medication errors and pharmacy interventions is very cumbersome to use, further discouraging reporting of errors. This possible underreporting is important, because identifying errors that do not result in patient harm can point the way to weaknesses in the system that pose the potential for more serious adverse events.
F11:
DHS does not have a regular practice of replicating the best practices implemented from one facility to another. As an example, Harbor-UCLA has implemented Structured Physician Order Forms for admissions and transfers requiring the use of block lettering to reduce cases of illegibility. These forms significantly reduce a broad range of medication order errors, including illegible orders, unapproved abbreviations, dosage errors, and “wrong drug” errors. The Structured Physician Order Forms are considered successful where they are now used. The balance of DHS facilities does not use block lettering on these forms. As another example, Olive View does not recognize the same medications as high risk as the other Hospitals. These are examples of processes that are low-cost and can be relatively easily implemented, as contrasted with implementation of ADCs and bar coding technology.
F12:
Patient Safety and the Just Culture: County of Los Angeles DHS
F13:
Rancho Los Amigos New RN/ LVN Graduate Program Outline (for re-entry nurses and new graduates
F14:
Rancho Los Amigos National Rehabilitation Center; Job Description for Staff/Relief Nurse
F15:
Rancho Los Amigos National Rehabilitation Center; Department of Nursing Administrative Policy and Procedure: a. Orientation: Nursing b. Competency Program: Management and Assessment, Initial and Ongoing c. Medication Management Guidelines d. Medication Administration Documentation e. Order Transcription, Recopying of Flow Sheets and Verification of Medication Administration Record f. Supplemental Blood Glucose Medication and Treatment Record g. Pyxis System Access and Responsibility h. Medication Error and Near Miss Reporting i. Competency Program: Management and Assessment, Initial and Ongoing j. Intravenous Therapy: Guidelines for Administration k. Waived testing
F16:
UHC Patient Safety Net On-Site Administration Report – Rancho Los Amigos Sample pie chart Report of Harm Score Distribution and Event Sub-type Distribution
F17:
PowerPoint Presentation – In-Patient Unit Nursing Orientation Program on Medication Management 2006-2007 County of Los Angeles Civil Grand Jury 43
F18:
Harbor/UCLA Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F19:
Olive View Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F20:
LAC+USC Medical Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F21:
LA County DHS - Nursing Registry Usage FY 2007-07 a. Harbor UCLA b. Rancho Los Amigos c. LAC+USC d. Olive View
F22:
Rancho Los Amigos Rehabilitation Center Department of Nursing Productivity Report; April 2007 with Staffing Levels by unit
F23:
Overview: DHS Medication Events October 2006 – March 2007 – PowerPoint Presentation
F24:
Proposed Medication Management Automation Solution, LA DHS 1/2007
F25:
Medication Safety: The Basics: PowerPoint Presentation from Amy Gutierrez
F26:
Pharmacy Utilization Report for FY 2006-2007
F27:
DHS Outpatient Pharmacy Automation Installation Plan: Expected Order of Installation Status – May 2007
F28:
The Just Culture Algorithm 29. “Medication Errors – A Nurse’s Worst Nightmare” Working Nurse Magazine, April 9- 30, 2007 30. “Med Errors = Bad Outcomes”, Nurse Week, April 2007
F31:
Institute for Safe Medication Practices: Medication Safety Alert; Survey on High Alert Medications; May 17, 2007
F32:
LAC+USC Health Care Network Quality Management PowerPoint – Review of the Chemotherapy Medication Use Process
F33:
Managing Medication Related Events: PowerPoint Presentation
F34:
Medication Management Process in Valley Care – PowerPoint Presentation
F35:
LAC+USC Chemotherapy Physicians Orders
F36:
LAC+USC Daily Physicians Orders – Adult Critical Care
F37:
LAC+USC Neonate Continuous Infusion Orders
F38:
LAC+USC Neonate Continuous Infusion Recipes
F39:
LAC+USC Adult Insulin Continuous Infusion for Hyperglycemia in Critical Patients
F40:
LAC+USC Adult Inpatient Rasburicase Physician Order Form
F41:
LAC+USC Pharmacy Department Policy and Procedure Manual a. Inpatient Prescribing/Ordering General Practices
F42:
LAC+USC Department of Nursing Services Policy a. Medication Administration System b. High Alert Medications c. General Medication Policies
F43:
LAC+USC HealthCare Network Policy: Medication Usage
F44:
LAC+USC Adverse Drug Reaction & Medication Event Information Flow Diagram
F45:
List of High-Alert Medications
F46:
List of Look-Alike Sound-Alike Drugs 2006-2007 County of Los Angeles Civil Grand Jury 44
F47:
LAC+USC Drug Bulletin June 2006
F48:
Medication Reconciliation: JCAHO’s National Patient Safety Goal and Sentinel Event Alert 1/06 PowerPoint Presentation
F49:
Intervention Summary Report
F50:
Harbor-UCLA – Patient Safety Bulletin October/November 2006
F51:
Harbor-UCLA – Patient Safety Bulletin July/August 2006
F52:
Harbor-UCLA – Patient Safety Bulletin May/June 2006
F53:
Harbor-UCLA – Patient Safety Bulletin January/February 2004
F54:
Harbor-UCLA – Patient Safety Bulletin November/December 2003
F55:
Harbor-UCLA – Patient Safety Bulletin October 2003
F56:
Los Angeles County DHS Pamphlet – Adult Dyslipidemia Formulary Pocket Guide 20063
F57:
Los Angeles County DHS Lipid Management Algorithm
F58:
Journal on Quality and Patient Safety – Volume 32, #2; February 2006: “How Many Hospital Pharmacy Medication Dispensing Errors go Undetected?
F59:
Wikepedia: Medical Error
F60:
JCAHO – Identifying Risks I the Medication Use Process – Strategies for Pharmacists
F61:
JCAHO Front Line – Admitting Pharmacists usher in big improvements
F62:
UHC Patient Safety Net Categories a. Pharmacist Review b. Medication Error Event Details Questions c. Adverse Drug Reaction Event Details Questions d. Event Type
F63:
Harbor-UCLA MAR Sample
F64:
Harbor-UCLA Adult Medical Admission Orders Sample – Blank
F65:
Harbor-UCLA Adult Medical Admission Orders Sample – Completed
F66:
LA County DHS Adult Inpatient Anticoagulation Physician’s Orders
F67:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications
F68:
Medication Administration Guidelines: Table of Drugs: Standard IV Medications (Chemotherapy Drugs)
F69:
Flow Chart: Medication-use Process for Hospital and Long-Term Care
F70:
Unlabeled Articles/Chapters a. Medication Errors: Prevention Strategies b. Action Agenda for Health Care Organizations c. Medication Errors: Incidence Rates
F71:
Harbor-UCLA Department of Pharmacy Process Flows: Current State as of Thursday, March 16, 2006
F72:
American Journal of Health-System Pharmacy, Vol 59 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities”
F73:
Order of Adoption: Board of Pharmacy California Code of Regulations Change to Title 16, Division 17: Requirements for Pharmacies Employing Pharmacy Technicians
F74:
American Journal of Health-System Pharmacy, Vol 64 “Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
F75:
LA County DHS Class Specification; Director of Pharmacy Services
F76:
DHS Clinical Pharmacy Strategic Plan – July 2006 Final
F77:
Draft DHS Decision Grid: Pharmaceutical Procurement 2006-2007 County of Los Angeles Civil Grand Jury 45
F78:
DHS Pharmacy Leadership Program description
F79:
DHS Outpatient Report Card: Medication Use Performance Metric 2007
F80:
DHS Pharmacy Leadership Program proposal
F81:
DHS Report Card: Medication Use Performance Metrics 2007 2006-2007 County of Los Angeles Civil Grand Jury 46 JUVENILE CUSTODIES - ARE WE PAYING TWICE? EXECUTIVE SUMMARY State law requires that whenever a minor is in custody in a juvenile hall or other county juvenile facility for thirty consecutive days, the county welfare agency needs to be informed. The law requires that the welfare department determine whether these minors are part of a family receiving cash aid benefits and, if so, make reductions in the family’s aid payments to reflect the period of time the minor received care in the facility. Yet, there appears to be no liaisons between these agencies to share information and to stop the cash aid. The Los Angeles County Probation Department handles over 20,000 custodies annually with a staff of 5,800 and budget of $630 million. Costs of an individual minor in custody are approaching $200 a day. The Department does a financial screening of the parents or other responsible relative and bills for the cost of care. If the family is receiving financial assistance, the family is not billed; this information should be sent to the welfare agencies. The welfare agencies in Los Angeles County are the Department of Public Social Services and the Department of Children and Family Services. DPSS has over a million clients and over 13,000 employees. There is no direct supervision of the individuals receiving the cash aid and the agency relies on self reporting to find out when a child is no longer residing in the home. DCFS monitors families directly and should have knowledge of where a child is residing. Recent legislation prohibits simultaneous or duplicative case management or services provided by the county probation department and the child welfare services department. The recommendations are designed to co-ordinate county agencies so that they will be in compliance with state law. The lack of communication between the Probation Department and the public assistance agencies may result in replicated support for the same minor. If there is no “Stop Order” issued in a timely manner, or not issued at all, it may take months for funding to be halted and realize that substantial taxpayer funds may be wasted. DPSS, DCFS and Probation need to work together and implement an information sharing process. Probation needs to inform the child support agencies when a minor is in custody for thirty days. A protocol needs to be developed to avoid replicate funding. If payments are not discontinued or unjustified payments are made, attempts should be made to recover such overpayments. The Probation Department’s responsibility is to expeditiously complete the financial screening of the family and communicate this information to the appropriate agencies. HISTORY The Los Angeles County Probation Department handles over 20,000 custodies annually with a staff of 5,800 and a budget of $6301 million. The size and transient nature of the custodies underscores the responsibility and diverse services required of the Department while adhering to the myriad federal, state and local laws. Within this oversight they must provide medical care, mental health, education, behavioral rehabilitation and be involved with any other agency 2006-2007 County of Los Angeles Civil Grand Jury 47 providing care for a minor’s custody. Within this area lies a responsibility to report to the supportive agencies (DPSS and DCFS) to prevent replication of costs for those minors adjudicated and sentenced to juvenile hall, camps or probation group homes. California’s Welfare and Institutions Codes Sections 900-914 covers the above issues. With the cost of maintaining a minor in custody spiralling upwards, approaching $200 a day1, there is a need to address the lack of communication and oversight between supportive services and the Probation Department. Due to the layering of department and service providers, it is difficult to pinpoint who is charged with this reporting and at what point the information should be submitted. There is no statistical data available for the numbers of minors coming from DCFS funded units, group homes and foster care, or from DPSS comprised of CALWORKS funded units. Along with DPSS funding is the availability of food stamps, medical care, housing assistance and childcare, all of which is based on the number of individuals residing in the unit. PURPOSE In accordance with California Welfare and Institution Codes Sections 900-914 when minors are placed in the custody of the Juvenile Probation Department for thirty days or more, any agency providing funding for that minor must be notified so as to terminate funding for that minor. This notification ensures that the taxpayers are not paying twice for the minor’s care and support while being held. The investigation attempted to: • Determine what mechanism is in place to avoid funding of minors in custody when their homes are simultaneously receiving support from various social service agencies. • Identify the appropriate mechanism to be implemented to stop the replication of funding. • To determine what agencies are involved and who is responsible for triggering that mechanism. • Recover any monies that have been inappropriately paid, creating a duplicated taxpayer support of the minor in custody. • Make sure measures are in place to aggressively seek reimbursement of overpaid funding. Probation Department, Administrative Services, 5/1/07 2006-2007 County of Los Angeles Civil Grand Jury 48
Additional Recommendations
11
Not linked to specific findings.
R1:
Federal, state and local law and policy issues Some other California counties have had better success in information sharing. Los 2006-2007 County of Los Angeles Civil Grand Jury 57 Angeles County has recently adopted an interagency Memorandum of Understanding stating that DCFS and DHS will develop protocols to improve data sharing.
R2:
Information technology issues Existing systems within DCFS and DHS do not enable information sharing. Development of new systems that could facilitate this sharing is lagging.
R3:
Interdepartmental collaboration, information sharing and the HUB clinics While such limited approaches as multidisciplinary teams (combining several technical and social workers) and HUB clinics (specializing in services for abused and neglected children) have represented some improvement in care, there is a need for enhanced management oversight of the two departments coordination and information sharing.
R4:
Public health nurses Public Health Nurses represent an improvement in the care of some children, but their effectiveness is limited by the inadequate access to patient records and the fact that their management is divided (half report to the Department of Public Health, half to the Department of Children and Family Services).
R5:
0: DHS should expand the number of Clinical Pharmacists, institute a Clinical Coordinator position at each Hospital, and use Tech-Check-Tech processes to free Pharmacists to perform other pharmaceutical duties
R6:
DHS should immediately establish a 24-hour Pharmacy at Olive View Medical Center, and monitor Rancho Los Amigos Rehabilitation Center off-hours demands for medication. Olive View Medical Center is of sufficient size and structure to warrant a 24-hour pharmacy. While they recognize the advantages of 24/7 coverage, staff at Olive View cite the difficulty of hiring Pharmacists to work this demanding shift. It is a hurdle to be overcome rather than an insurmountable obstacle, and Olive View should work with Department of Human Resources staff to develop incentives sufficient to attract night shift pharmacists or retain pharmacists when night shifts become a requirement. Olive View is too far removed from other medical facilities to seriously consider a partnering solution. Its patient census and the existence of an emergency room indicate that there is sufficient demand for constant staffing. Rancho Los Amigos, as a rehabilitation facility, has a different patient profile, and has historically seen fewer demands for after-hours pharmacy. This may be changing. DHS should monitor off-hours pharmacy demands on a regular basis, and consider partnering with other DHS facilities or other plans to ensure coverage.
R7:
The County should implement pre-employment drug screening and should develop a targeted program to provide for early identification and treatment of substance abuse among staff with access to controlled medications Pre-employment screening will reduce the risk of hiring individuals who are addicted to narcotics or other drugs. In addition, a program should be developed, modeled on best practices, that include training managers to recognize problems associated with drug abuse, referrals to Employee Assistance Programs, development of reporting mechanisms that identify patterns of abuse, and testing for drugs with a lower threshold of evidence than for other County staff. The program should be modeled on best practices which provide for confidentiality of results, automatic retesting of positive results, counseling, and, where needed, recovery programs. This program is not, at heart, different from ensuring that medical staff members do not have chronic infectious diseases. 2006-2007 County of Los Angeles Civil Grand Jury 37
R8:
0: DHS should strengthen its “Safe and Just” culture.
R9:
0: DHS should analyze medication error trends, share aggregated information with Departmental and Facility leadership, and allow central review of medication error reports.
R10:
DHS should consider establishing Nurse “Naïve Observation” auditing to reduce dependency on self-reporting for medication errors. In this practice, at random intervals Nurses observe other Nurses administering medications. Afterwards, the observing Nurse checks the Medical Administration Record (MAR) and patient records to determine whether any errors were made. A 2002 study comparing methods of detecting medication errors found independent observation by Nurses to be the most efficient and accurate method of doing so.18 18 “Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities” American Journal of Health-System Pharmacy, Vol 59 2006-2007 County of Los Angeles Civil Grand Jury 40
R11:
DHS should recognize best practices implemented at one facility, and replicate them system-wide. The best practice of Structured Physician Order Forms with block lettering spaces, currently in place at Harbor/UCLA Medical Center, should be implemented at all County Hospitals. Introducing these forms system-wide is a low-cost and low-risk item for DHS. In addition, if one or more Hospitals identify a certain medication as high risk, all Hospitals should similarly categorize that medication as high risk absent a compelling reason to the contrary. Successful best practice programs often include regular reporting on best practices at senior staff meetings, and development of tracking mechanisms for implementation of the changes.
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Findings & Recommendations
1 findings
F5:
Prevention and Data Sharing DCFS is currently enhancing its resources and services directed to child abuse (cid:137) and neglect prevention activities and intend to continue to do so in the future. The Department implemented a pilot Point of Engagement program in 2004 that provides for more community-based services for families who are experiencing problems, are assessed as low risk of future instances of child abuse and neglect and are willing to make changes and improvements. Team Decision Making is one aspect of this program that provides a multidisciplinary team approach to supporting these families. The Board of Supervisors directed County staff in 2006 to expand prevention (cid:137) efforts with a “holistic, integrated approach to services” that address root causes of child abuse or neglect. While the motion and resulting DCFS concept paper on the topic does not specifically address health services, the paper does establish healthy communities as one outcome target for the Department’s prevention efforts and recommends that the County’s Chief Administrative Office assume responsibility for interdepartmental coordination. The move toward coordinated interdepartmental services as part of child (cid:137) maltreatment prevention services speaks to the need for well orchestrated information and data sharing between DCFS and DHS particularly for families who may need health services as part of their family improvement plan. As DCFS proceeds with plans to expand its prevention efforts, the importance of well managed information and data sharing with DHS should be included as a program objective, with outcome measures established to ensure that it is occurring. Current Child Maltreatment Prevention Efforts at DCFS DCFS’s prevention efforts are relatively new. The Department began implementing a pilot program called Point of Engagement (POE) in 2004. POE, which is being implemented in the Compton and Wateridge (South Los Angeles) offices, is a preventive, family-centered approach that makes maximum use of community based organizations in its response to family needs. It is designed to support the Department’s goals of safety, reducing detentions and increasing permanency. In late 2006, the Children and Families Research Consortium (CFRC) conducted an evaluation of the POE79. This evaluation, which was a comprehensive qualitative analysis, provides a 79 According to its website, the Children and Families Research Consortium is a group formed by DCFS and the Interuniversity Consortium (IUC). The IUC is a group of five local universities engaged in providing training services to DCFS. The CFRC is focused on “enhancing DCFS capacity to analyze and 2006-2007 County of Los Angeles Civil Grand Jury 112 detailed background about POE, its relationship to State of California policy initiatives, and the results from 17 interviews and three focus groups with staff and administrators from the Compton and Wateridge offices, as well as a focus group with representatives from Shields for Families, a key community-based nonprofit organization which has been collaborating with DCFS on POE. According to the CFRC report, POE is consistent with the State of California’s Child Welfare Services Redesign Plan developed in 2003. In this plan, there are three paths that could be used effectively in serving families that come to the attention of the child welfare system as follows: “Path 1: Community Response is used when a family is experiencing problems but the situation does not meet statutory definitions of abuse or neglect. Instead of being turned away without any assistance, families are linked to services in the community through partnerships with local organizations. Path 2: Child Welfare and Community Response may be used when the report meets statutory definitions of abuse and neglect. County staff assess that the child is safe and at low to moderate risk of future harm and the family is likely to make changes and mitigate risk voluntarily. The county agency works with the family and community-based organizations to identify strengths and needs. If the family is unwilling to make needed improvements or the situation deteriorates, endangering the child, the case would be re-referred to the child welfare agency. Path 3: Child Welfare Services Response is used when the child is not safe and is at moderate to high risk of continued abuse or neglect. Actions may be taken with or without the family’s consent, court orders may be sought and criminal charges may be filed. Social workers seek to engage families more fully and to work with other county agencies to provide focused services. This path is most similar to the child welfare system’s traditional response.” DCFS’s POE pilot has focused on “evaluated out” and “inconclusive” referrals, i.e., allegations regarding a family that are called into the DCFS Hotline. Some calls to the DCFS Hotline are “evaluated out” when, according to a systematic assessment by the Hotline telephone worker, the referral does not meet “California Department of Social Services guidelines” for an in-person response. If a referral is forwarded to the SPA/District Office, an Emergency Response worker may, after systematically investigating it, deem it to be “inconclusive”, i.e., evidence is insufficient to “substantiate” the allegation. Both of these situations trigger a POE case for the Compton and Wateridge offices during the pilot, which is still ongoing, partially funded by a grant from First 5 L.A. Once POE is triggered, the family is referred to local community services. To date, many of these services have been provided by Shields for Families, which is the actual recipient of the First 5 L.A. funds. One of the main goals of POE is to “prevent a referral from becoming a use data to support planning and decision-making, developing research priorities and a long term research agenda, and facilitating partnerships with universities and other research organizations to expand knowledge about public child welfare.” 2006-2007 County of Los Angeles Civil Grand Jury 113
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Findings & Recommendations
1 findings
F5:
Prevention and Data Sharing DCFS is currently enhancing its resources and services directed to child abuse (cid:137) and neglect prevention activities and intend to continue to do so in the future. The Department implemented a pilot Point of Engagement program in 2004 that provides for more community-based services for families who are experiencing problems, are assessed as low risk of future instances of child abuse and neglect and are willing to make changes and improvements. Team Decision Making is one aspect of this program that provides a multidisciplinary team approach to supporting these families. The Board of Supervisors directed County staff in 2006 to expand prevention (cid:137) efforts with a “holistic, integrated approach to services” that address root causes of child abuse or neglect. While the motion and resulting DCFS concept paper on the topic does not specifically address health services, the paper does establish healthy communities as one outcome target for the Department’s prevention efforts and recommends that the County’s Chief Administrative Office assume responsibility for interdepartmental coordination. The move toward coordinated interdepartmental services as part of child (cid:137) maltreatment prevention services speaks to the need for well orchestrated information and data sharing between DCFS and DHS particularly for families who may need health services as part of their family improvement plan. As DCFS proceeds with plans to expand its prevention efforts, the importance of well managed information and data sharing with DHS should be included as a program objective, with outcome measures established to ensure that it is occurring. Current Child Maltreatment Prevention Efforts at DCFS DCFS’s prevention efforts are relatively new. The Department began implementing a pilot program called Point of Engagement (POE) in 2004. POE, which is being implemented in the Compton and Wateridge (South Los Angeles) offices, is a preventive, family-centered approach that makes maximum use of community based organizations in its response to family needs. It is designed to support the Department’s goals of safety, reducing detentions and increasing permanency. In late 2006, the Children and Families Research Consortium (CFRC) conducted an evaluation of the POE79. This evaluation, which was a comprehensive qualitative analysis, provides a 79 According to its website, the Children and Families Research Consortium is a group formed by DCFS and the Interuniversity Consortium (IUC). The IUC is a group of five local universities engaged in providing training services to DCFS. The CFRC is focused on “enhancing DCFS capacity to analyze and 2006-2007 County of Los Angeles Civil Grand Jury 112 detailed background about POE, its relationship to State of California policy initiatives, and the results from 17 interviews and three focus groups with staff and administrators from the Compton and Wateridge offices, as well as a focus group with representatives from Shields for Families, a key community-based nonprofit organization which has been collaborating with DCFS on POE. According to the CFRC report, POE is consistent with the State of California’s Child Welfare Services Redesign Plan developed in 2003. In this plan, there are three paths that could be used effectively in serving families that come to the attention of the child welfare system as follows: “Path 1: Community Response is used when a family is experiencing problems but the situation does not meet statutory definitions of abuse or neglect. Instead of being turned away without any assistance, families are linked to services in the community through partnerships with local organizations. Path 2: Child Welfare and Community Response may be used when the report meets statutory definitions of abuse and neglect. County staff assess that the child is safe and at low to moderate risk of future harm and the family is likely to make changes and mitigate risk voluntarily. The county agency works with the family and community-based organizations to identify strengths and needs. If the family is unwilling to make needed improvements or the situation deteriorates, endangering the child, the case would be re-referred to the child welfare agency. Path 3: Child Welfare Services Response is used when the child is not safe and is at moderate to high risk of continued abuse or neglect. Actions may be taken with or without the family’s consent, court orders may be sought and criminal charges may be filed. Social workers seek to engage families more fully and to work with other county agencies to provide focused services. This path is most similar to the child welfare system’s traditional response.” DCFS’s POE pilot has focused on “evaluated out” and “inconclusive” referrals, i.e., allegations regarding a family that are called into the DCFS Hotline. Some calls to the DCFS Hotline are “evaluated out” when, according to a systematic assessment by the Hotline telephone worker, the referral does not meet “California Department of Social Services guidelines” for an in-person response. If a referral is forwarded to the SPA/District Office, an Emergency Response worker may, after systematically investigating it, deem it to be “inconclusive”, i.e., evidence is insufficient to “substantiate” the allegation. Both of these situations trigger a POE case for the Compton and Wateridge offices during the pilot, which is still ongoing, partially funded by a grant from First 5 L.A. Once POE is triggered, the family is referred to local community services. To date, many of these services have been provided by Shields for Families, which is the actual recipient of the First 5 L.A. funds. One of the main goals of POE is to “prevent a referral from becoming a use data to support planning and decision-making, developing research priorities and a long term research agenda, and facilitating partnerships with universities and other research organizations to expand knowledge about public child welfare.” 2006-2007 County of Los Angeles Civil Grand Jury 113
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Additional Recommendations
27
Not linked to specific findings.
R1:
(3) Meetings with Director and Medical Director
R2:
Meeting with Representatives from District Attorney Office Domestic Violence
R3:
(3) Meetings with ICAN
R4:
Meeting with Deputy Planning and Oversight, DHS,
R5:
Visited Eastlake Juvenile Facility
R6:
(2) Meetings with CIO LA County and Information Technology personnel
R7:
(3) Interviews with Social workers, including Emergency Response Supervisor
R8:
(2) Interview, Presiding Judge and others, Edelman Children’s Court DOCUMENTS REVIEWED
R9:
DCFS – Prevention Plan (2002)
R10:
Judge Michael Nash’s Standards for Social Workers’ Court Reporting The Superior Court, Juvenile Division, January 9, 2003
R11:
ICAN – Death Review Report 2005
R12:
ICAN Annual Report on Child Abuse & Neglect 2005
R13:
ICAN/National Center on Child Fatality Review Program “Suspicious Child Death and severe non-fatal injury review -California and Regional Training, October 25, 2006, Universal Sheraton.
R14:
ICAN Child Abuse and Neglect Protocol, June 8, 2006
R15:
Information presented by City Attorney
R16:
Data on child deaths provided by ICAN
R17:
DCFS Medical Directors report to Grand Jury January 11, 2007 SPEAKERS from Los Angeles County
R18:
Presiding Judge, Edelman Children’s Court
R19:
Deputy Director, Probations
R20:
Director, Human Relations Commission
R21:
Civil Rights activist, gang violence
R22:
Community Services & Seniors
R23:
District Attorney PARTICIPATION
R24:
Day of Mentoring Children in Foster Care – Pierce College
R25:
Department of Public Social Services Toy Loan Program
R26:
Attendance NEXXUS/ICAN “Child Fatality Death Review Conference”– Universal City
R27:
Pat Brown Institute, Symposium “Health and Violence”, California State University, LA. 2006-2007 County of Los Angeles Civil Grand Jury 119
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Additional Recommendations
27
Not linked to specific findings.
R1:
(3) Meetings with Director and Medical Director
R2:
Meeting with Representatives from District Attorney Office Domestic Violence
R3:
(3) Meetings with ICAN
R4:
Meeting with Deputy Planning and Oversight, DHS,
R5:
Visited Eastlake Juvenile Facility
R6:
(2) Meetings with CIO LA County and Information Technology personnel
R7:
(3) Interviews with Social workers, including Emergency Response Supervisor
R8:
(2) Interview, Presiding Judge and others, Edelman Children’s Court DOCUMENTS REVIEWED
R9:
DCFS – Prevention Plan (2002)
R10:
Judge Michael Nash’s Standards for Social Workers’ Court Reporting The Superior Court, Juvenile Division, January 9, 2003
R11:
ICAN – Death Review Report 2005
R12:
ICAN Annual Report on Child Abuse & Neglect 2005
R13:
ICAN/National Center on Child Fatality Review Program “Suspicious Child Death and severe non-fatal injury review -California and Regional Training, October 25, 2006, Universal Sheraton.
R14:
ICAN Child Abuse and Neglect Protocol, June 8, 2006
R15:
Information presented by City Attorney
R16:
Data on child deaths provided by ICAN
R17:
DCFS Medical Directors report to Grand Jury January 11, 2007 SPEAKERS from Los Angeles County
R18:
Presiding Judge, Edelman Children’s Court
R19:
Deputy Director, Probations
R20:
Director, Human Relations Commission
R21:
Civil Rights activist, gang violence
R22:
Community Services & Seniors
R23:
District Attorney PARTICIPATION
R24:
Day of Mentoring Children in Foster Care – Pierce College
R25:
Department of Public Social Services Toy Loan Program
R26:
Attendance NEXXUS/ICAN “Child Fatality Death Review Conference”– Universal City
R27:
Pat Brown Institute, Symposium “Health and Violence”, California State University, LA. 2006-2007 County of Los Angeles Civil Grand Jury 119
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Findings & Recommendations
7 findings
F1:
Are patients asked if they have any coverage when they receive care?
F2:
Are patients sent a bill for services rendered?
F3:
If so, is there follow-up on outstanding bills?
F4:
If not, is there an effort to encourage patients to pay for at least a fraction of the services? Our preliminary investigation revealed that the Department not only does all of the above, but has a system in place to provide assistance to people in order to obtain Medi-Cal coverage. The Department furthermore utilizes the services of collection agencies which are paid on the basis of the amounts collected. 2006-2007 County of Los Angeles Civil Grand Jury 133
F5:
Comprehensive Health Center Urgent Care Center $ 65.
F6:
County Hospital Emergency Rooms $100.
F7:
Outpatient Surgery Clinics $300. Problems with Emergency Room Payments Los Angeles County has four hospitals with emergency departments. All patients entering these departments are medically screened and provided with the appropriate medical stabilizing treatment before any inquiry is made about their ability to pay. Individuals with immediate life threatening symptoms such as bleeding or an obstruction in the airway are classified as category 1 and are seen immediately by medical staff. The method of providing medical treatment first and then inquiring about the patients ability to pay is governed by legislation in the “Emergency Medical Treatment and Active Labor Act”(EMTALA). This Law was enacted by Congress in 1986 and final regulations were issued in1994. EMTALA is a federally unfunded mandate and imposes stiff fines and penalties on a hospital or physician not following its regulations. 2006-2007 County of Los Angeles Civil Grand Jury 135 Los Angeles County is in the process of updating electronic records. In the past six months the Harbor UCLA complex has upgraded its system making it possible to obtain information from the associated clinics. This upgrade provides information about previous treatments and methods of payment for patients, and would make it possible for immediate billing. The other three hospitals have yet to complete this process. Financial Considerations in Clinics With the passage of EMTALA in 1986, emergency rooms turned into de-facto clinics; treating a wide variety of ailments, many not actually emergencies. This practice of treating many uninsured, nonpaying patients resulted in creating a fiscal burden on emergency rooms that forced many of them to close. One answer to the problem was the creation by the County of comprehensive health centers and clinics, whose mission is to provide a wide range of services in a culturally sensitive manner. These clinics provide a wide range of health services. These health centers and clinics are required by County policy to charge for services rendered, and may ask patients about payment on entry. Patients may apply for an Ability to Pay Plan (“ATP”) for all or part of the medical or dental services provided. This process includes the filling out of a form and an interview to determine their share of payment primarily based on their income. They are evaluated for ATP at every admission and after 30 days if hospitalized. They are also evaluated every six months to confirm their continuing ATP coverage. People with Medi-Cal (or Medi-Cal qualified), Medicare or other medical insurance may enroll in the Community Health Plan and will not incur additional charges. If patients do not bring money with them, they are given an envelope with instructions to remit the amount owed within seven days. Other Counties have found that if a timely reminder is sent, more money may be recouped. Patients are requested to provide the following to register: Clinic card Drivers license Address verification Medi-Cal or Medicare card (if applicable) Telephone number Birthdate Follow-up to Unpaid Bills for Medical Services
Additional Recommendations
7
Not linked to specific findings.
R1:
The Board of Supervisors should study ways for Probation and DCFS to develop and evaluate up to 5 pilot projects designed to prevent and reduce the number of new dependents and wards in the system. The standard approaches to prevention are general public education and intervention in high-risk homes (when they can be identified). Successful prevention strategies in both delinquency and dependence cases is likely to require a multi-faceted approach. The Board has previously provided funding to the Service Integration Board (SIB) and some projects are underway in the District Attorney, CAO, and other departmental offices to mitigate some of the factors that effect the generation of new cases. Both Probation and DCFS need to study how to best accomplish this priority and participate effectively in the important integration efforts. The purpose of this recommendation is to challenge the Departments to experiment with and propose new ideas.128 Such innovation should be accomplished by bringing together multidisciplinary teams from within and outside the Departments to develop new prevention strategies on a pilot basis. Relevant nonprofit organizations, community groups, academicians, and professional consultants should also be involved. The pilot projects should include a strong evaluation component with assessments at the end of two years; at which time, the County determines the level of success of the pilots and the viability for sustaining or replicating these pilots elsewhere. The County should undertake at least 5 pilots to increase the chances of developing and implementing effective solutions quickly. One of the key parts of the effort, led by the County Auditor-Controller, should be the development of an estimate of what an average child entering the system costs. The estimate should include all potential cost components, including: a) lost productivity over a life-time as a result of a negative life trajectory and b) the explicit “out of pocket” costs while these children are in the child welfare, juvenile justice, and possibly adult justice and welfare systems. This estimate will help the Board make its “investment in prevention” decision once the pilots identify the most effective prevention strategies.
R2:
Probation and DCFS should develop more sophisticated approaches to evaluate, monitor, and measure success. The Departments should establish holistic evaluation approaches that consider both quantitative and qualitative components.
R3:
DCFS should implement new treatment models that are evidence-based and proven to be successful.
R4:
Develop a system of associated urgent care clinics where patients can be directed, rather than utilizing emergency rooms. 2006-2007 County of Los Angeles Civil Grand Jury 137 TABLE OF CONTENTS PREFACE....................................................................................................................................140 I EXECUTIVE SUMMARY ……………………………………...............……………141 II. HISTORY AND BACKGROUND......................................................................................144 III. PURPOSE.............................................................................................................................154 IV. INVESTIGATION...............................................................................................................155 V. FINDINGS...........................................................................................................................156 VI. RECOMMENDATIONS.................................................................................................... VII. CONCLUSIONS..................................................................................................................187 APPENDICES A – Acronyms.......................................................................................................................190 B – Quantitative Fact-Finding and Analysis C – Group Home Quantitative Findings D – Qualitative Fact-Finding: Site Visits and Interviews E – References 2006-2007 County of Los Angeles Civil Grand Jury 138 TRIPLE JEOPARDY: ABANDONED, NEGLECTED, AND ABUSED CHILDREN OF LOS ANGELES COUNTY PREFACE This investigation by the 2006-2007 Civil Grand Jury (CGJ) revealed that a review of group homes was not a simple matter. The term “group home,” though commonly used, has many different interpretations due to the range of services and quality of care provided, from minimal to comprehensive. The CGJ has redefined the term “group homes” and refers to them as “congregate-care facilities” (see diagram below). Moreover, the authorities concerned with the care of children who are the County’s wards and dependents differ dramatically in their judgments of these congregate-care facilities. The range of quality of care provided varies from truly excellent to abysmal. This situation is compounded by the fact that State funding levels for congregate-care facilities have not changed in many years. This affects the ability to hire qualified staff, establish reasonable staffing ratios, provide aftercare services, and deliver other programs necessary to provide quality services. Beyond the complex evaluation of these facilities lie the uneven, conflicting, and inconsistent efforts made by the Department of Children & Family Services (DCFS) and Probation Department. These Departments manage their assigned children’s cases, including their initial placement, monitoring and tracking them over time, and developing their exit plans (e.g., end-result reporting and outcomes). The State licenses congregate-care facilities. It has established a Rate Classification System (RCL) assigning the level of “residential-based services” provided in the facility. It is the County’s responsibility, however, to guarantee the quality of care provided. This report includes information from on-site visits made by the CGJ to a selected sampling of congregate-care facilities. It explores the changes that DCFS and Probation should be making to improve the quality of care provided and asks the questions: Which of these facilities are inappropriate for placement? Which of these facilities are underutilized? CHILDREN’S PLACE OF RESIDENCE IN-HOME/ CONGREGATE-CARE LOCK-DOWN FOSTER FAMILY RE-UNIFICATION FACILITIES FACILITY Least Most Restrictive Restrictive HOME FACILITY RESIDENTIAL-BASED FACILITIES • Small (<10 beds) • Campus-like settings • Stand alone • Multi-faceted agencies, which include campus-like settings and other services • Multi-faceted agencies with central administrative facility and multiple home facilities • Agency-operated with multiple residential facilities 2006-2007 County of Los Angeles Civil Grand Jury 139 I – EXECUTIVE SUMMARY Jackie’s Story Jackie, a thirteen year old girl was removed from her heroin-addicted birth mother at age 4 after she and her brother were sexually abused by her mother’s boyfriend and slapped and beaten by her mother as a means of discipline. In the first foster home, she suffered more abuse. In the second foster home over a nine year period, she became defiant, suspended from school for fighting, ran away and ended up in a temporary homeless shelter on skid row. In the current residential based facility, she has been found to be intelligent although guarded, has low self esteem, and displays inappropriate affect, unrealistic fear, excessive guilt, anger, mood swings, and depression. She has been described as delusional, suicidal with bizarre thinking, paranoid, and depressed, and self-destructive. She was not on psychotropic medication and was listed as "non compliant”. One medical examination indicated that she was “mentally retarded”, yet another psychological evaluation indicated “cognitive ability - high average”. Although she has a 2.94 grade average (in 9th grade) and wants to be a nurse, she has an inability to focus on her studies. She had formed an attachment to her former foster mother where her brother resides, and reunification is being pursued. CGJ 2006-2007 encountered this case during a site visit. As a result of this case, complaints to the Ombudsman, the Auditor-Controller’s reports, and the findings of previous CGJ reports, the 2006-2007 CGJ decided to investigate the use of congregate care for children in the child welfare and juvenile justice systems. Much of the previous literature refers to “group homes” as an all encompassing category, which does not reflect the breadth of congregate-care facilities and services rendered. The effects of congregate-care settings are confounded with type of facility, quality of facility and staff, staffing levels, severity of problems of children placed, prior placements, services rendered, and other variables. In the County of Los Angeles, children in the juvenile justice system are called wards assigned to the Probation Department; they can be placed in lock-up in camps or Juvenile Hall or in congregate-care settings, typically group homes. Only a few are assigned to live at home or with relatives. A variety of options is available to children, called dependents, in the child welfare system under the DCFS. Dependents are generally placed at home, with relatives, with foster families, or at congregate-care facilities. Probation views congregate-care facilities as less restrictive and a preferred option compared to the two lock-up options. DCFS views congregate- care facilities as the least preferred option for placement of their children. DCFS and Probation are currently using 238 group homes that are licensed by the State of California. The group homes range in size from 5 to 143 beds. The State license determines the monthly fees paid based on the level and type of services provided. The fees range from $2,589 to $6,371 per child per month. DCFS and Probation have approximately 1,500 dependents and 1,300 wards respectively placed in group homes, representing 4% and 23 % of the 38,000 and 5,700 children in the two systems. Within the broad category of congregate-care facilities, the CGJ has developed its own classifications: Residential-based facilities 2006-2007 County of Los Angeles Civil Grand Jury 140 Campus-like settings with a range of services – treatment centers, schools, and transitional programs Multi-faceted agencies, which include campus-like settings and foster family services, adoption services, and residential facilities Multi-faceted agencies with central administrative facility and multiple group home facilities Agency-operated with multiple residential facilities Stand-alone, small group facilities (<10 beds) The trend in the literature and emerging best practices indicate the reliance on group homes should be curtailed. The implication is that group homes are inferior to placement in a foster home because of a lack of a parental authority figure on a 24/7 basis. Dependents and wards need continuity, unconditional love, emotional support, and boundaries needed by children to thrive. The group home environment makes the transition more complicated when a child is reunified with his/her family. In contrast, within the CGJ’s classifications, the CGJ found differences in practice: With appropriate placement, children needing RCL-6 through RCL-10 residential-based services can do well in stand-alone, small group facilities. A number of residential-based facilities have remarkable success with the children in their care. Some had particularly impressive transition programs that provide job and housing support when a child emancipates or ages out of the system. They help them to become young, responsible adults with a solid foothold in the community. Because congregate-care facilities are only a component of a larger system of care for dependents and wards, the investigation’s conclusions go beyond group homes and address systems, organizational, and program issues in the Departments. Specifically: New prevention programs with specific reduction goals are required to staunch the flow of children entering the systems. The Departments, in addition to evaluating the intermediate effectiveness of specific programs, need to follow up on children after they leave the systems and collect longitudinal data to measure the real impact of the systems on a child’s life trajectory. The information systems need to be improved, automated, and integrated to ensure that accessible and comprehensive information is maintained on each child. Team decision-making, involving all the caregivers involved with the child, and where confidential information can be shared, should be the norm to ensure optimal decisions are made for the child. Stability and continuity is important for a child’s well-being. Both systems need to minimize the turnover of Children Social Workers (CSWs); DCFS must reduce the number of placements of their dependents. The Departments should set goals of one case worker throughout the child’s stay in the system and one placement per child. An organizational review is needed to address the current staffing levels in both Departments. New and more realistic case ratios are required and should be related to the complexity of 2006-2007 County of Los Angeles Civil Grand Jury 141 the cases assigned. A higher-level position of case manager should be considered for the more complex cases. The development of new systems, technology, and equipment that provide better information in real time should be part of the review. To support the stability goals, a new comprehensive placement assessment protocol is needed to ensure that each child is: a) assigned a CSW or Deputy Probation Officer (DPO), who are trained caseworkers with the appropriate skills, and b) then placed appropriately. More foster families need to be recruited and new classes of highly trained foster family caregivers are required to reduce the number of children inappropriately placed in congregate-care facilities. Children should not be placed in congregate-care facilities if the facilities are not able to provide high quality, comprehensive services. Improved educational strategies are needed to help many of the children achieve at or above their grade levels and improve their life trajectory. To avoid potentially negative peer influences, DCFS dependents and Probation wards should never be assigned to the same group facility. Some congregate-care facilities raise significant funds in the community to support and enrich their programs and services but overall most are under-funded, given the services they are required to provide. Wraparound Services – that provide supports to families to prevent children from being removed and supports after they are returned or permanently placed elsewhere – are valuable but the efficacy of delegating this to a third-party is questionable because of fragmentation and coordination problems. There is little contact and sharing of information between congregate-care facilities and other care providers or across County departments. Annual forums for sharing successful programs, best practices, and strategies could lead to improved system-wide performance. Children entering both systems are still in their formative years. Many are damaged and vulnerable. Program and system improvements are needed to help more of them attain better life trajectories than they face when they enter the child welfare or juvenile justice systems. The current goals are excellent: a) achievement of permanent placement, including reuniting with parents as fast as possible, and b) placement in the least restrictive accommodation. These goals need to be tempered by practical considerations and the needs of the child. An early removal that negatively disrupts the child’s schooling for instance should be avoided. Despite the current views and best practice research, there will likely always be a subset of children who cannot or should not be placed permanently with their family or relatives. These children thrive better in a comprehensive structured program offered by some of the larger congregate-care facilities that provide care in campus settings. Wards who have been entangled in gangs and children who have substance abuse problems are two examples. This CGJ investigation makes recommendations to: a) ensure the placement of children in congregate-care facilities is appropriate; b) improve their care and potential life trajectories; and c) maintain and improve the support of those congregate-care facilities who are currently successful with the children they are assigned. 2006-2007 County of Los Angeles Civil Grand Jury 142 II – HISTORY AND BACKGROUND NATIONAL TRENDS IN RESIDENTIAL CARE The Child Welfare League of America (CWLA) defines Residential-Based Services (RBS) as: Resident group care encompasses a broad array of services for children with pronounced special needs. Residential services are highly flexible and provide for varying lengths of stay, based on the client’s needs. Lengths of stay may range from a short respite due to tense family situations, to long-term therapy for problems such as drug or alcohol addiction. Although long-term stays in family-like community-based group homes best serve some children’s individual needs, residential group care is usually a temporary placement. Many children in residential care have emotional or physical conditions that require intensive, on-site therapy[;] others receive services from day treatment programs in their communities. Residential care programs are highly flexible and are designed to meet each child’s individual needs.80 RBS can involve a broad array of residential options for children living out-of-home, including half-way homes, campus-based homes, emergency shelters, self-contained settings, and staff- secured settings.81 Child welfare systems attempt to work with children and families in the least restrictive environment (e.g., biological, kinship, or foster family home). When such environments are unavailable or insufficient in meeting the needs of individuals, child welfare systems place dependents into more restrictive settings. Current laws and policies require that children be placed in the least restrictive setting to meet their needs. Relatives or kin are given priority in placement decisions wherever possible. Other family settings include family foster care. Placement priorities are to keep the child: 1) In the home if they are not endangered 2) With relatives 3) In a foster family 4) In congregate-care facilities In some cases, children entering out-of-home care are temporarily placed into an emergency foster care setting, which may be either a family, or a group setting. Of the 500,000 dependents in foster care in the United States, approximately 20% live in a group home or other residential institution.82 Within the social service continuum of care, congregate- care facilities are less restrictive than in-patient psychiatric clinics and juvenile detention centers, but more restrictive than foster family care.83 In all instances, the continuum is building blocks toward reunification with one’s family if possible. Child Welfare League of America (CWLA): Child Welfare, Residential Group: www.cwla.org/programs/groupcare/groupcareaboutpage.htm 81 Curtis, Alexander, & Lunghofer, 2001, CWLA, 2005. Administration for Children and Families, 2003; Jonson-Reid & Barth, 2000a, 2000b. Handwerk, Friman, Mott, & Stairs, 1998. 2006-2007 County of Los Angeles Civil Grand Jury 143 Group facilities are used in a variety of social service settings, including child welfare, mental health, and juvenile justice. Group facilities tend to be: Smaller than other residential facilities, consisting of a medium-size homes capable of housing between 8 and 12 adolescents in a community-based setting Staff secured as opposed to a locked facility Staffed with employees who work 24 hours/day Reliant on the public schools to educate their assigned children Group homes are one of the most expensive placements options for child welfare systems, given the staffing ratios. In 2000, 43% of all substitute care dollars in the State of California were associated with group home placements.84 Because the majority of children never enter a congregate-care setting, and the lengths of stay within these settings is significantly shorter than traditional foster family placements, the high costs and overall proportion of the budget allocated to such placements requires that agencies assess the viability of such placements. Children in group homes stay an average of 10 to 20 months.85 Children from California group homes and foster homes have the lowest median lengths of stay (12 and 13 months, respectively), in comparison with California treatment foster care and kinship care, which have the highest medians (25 and 20 months, respectively).86 Characteristics of Children Served In Congregate-Care Settings Across the nation, approximately 20% of child welfare placement cases enter congregate-care settings because some dependents are better suited to enter such facilities or no other placement options are available. As compared to traditional or specialized foster care homes, children living in congregate-care settings are more likely to be: older, male, minority, experiencing a range of socio-emotional and behavioral problems, and previously involved with the juvenile justice system.87 Congregate-Care Placements A healthy debate exists regarding the effectiveness of congregate-care settings. Central to this debate is the issue of peer groups and the socialization of adolescents living in congregate-care settings. Those supportive of congregate-care placements argue that youth can be influenced by positive peer behaviors. Those advocating the termination of such placements argue that congregate-care institutions generally serve high-risk children in close confines, thus, increasing the chances for reinforcing negative attitudes, values, and beliefs. A chart summarizing studies of the positive and negative effects of residential group settings is on the following page. CA Department of Social Services Research and Development Division (RADD), 2001. CA RADD, 2001. Chamberlain (1998). Berrick, Courtney, & Barth, 1993; Curtis et al., 2001; Knapp, Baines, Bryson, & Lewis, 1987; Mech, Ludy-Dobson, & Hulseman, 1994. 2006-2007 County of Los Angeles Civil Grand Jury 144 Residential Group Care Settings Positive Effects Negative Effects A number of studies have identified positive • In a well-publicized study,92 peer group outcomes: interventions might increase adolescent behavior problems and negative life outcomes in adulthood. ● A study of children diagnosed with conduct disorder in residential care – caregivers’ • On the basis of two experimental studies, the high- concerns decreased between admission and risk youth, compared with low-risk youth, were discharge and six months, one year, and two particularly vulnerable to peer aggregations. years after post-discharge.88 • In part, the potential problems associated with ● A retrospective study of 200 children served in group home placements stem from the ties that group homes in the Midwest – as adults, 70% are often severed between group home youth and had completed high school, 27% had some other more positive role models (peers and college or vocational training, and 14% received adults). public assistance.89 • Group homes often cut juveniles off from their ● A Canadian study of 40 children in resident care non-delinquent and pro-social peers and keep – the majority of the children were functioning them with youth who often are delinquent or have at severely impaired levels at admissions, emotional and behavioral problems (including moderately impaired at discharge, and normal conduct disorders and Attention- one- to three-years post-discharge.90 Deficit/Hyperactivity Disorder (ADHD) in a congregated setting for 24 hours a day.93 A specific clinical model – positive peer culture (PPC) – for youth in the juvenile corrections system • Group care is not safe, does not promote healthy and housed in residential settings found that:91 development, is not stable, exceeds the cost of other types of care, and is not cost efficient.94 • Juveniles are capable of establishing and reinforcing socially acceptable behaviors. • Children from group care report seeing family members less than children in kinship care, are • Juveniles not only take responsibility for their less likely to be reunified, and are more likely to behaviors, but for the behaviors of the entire return to group care, especially children aged 6 to group. 12.95 • Decisions regarding the progression of treatment • As compared with children in specialized foster (e.g., recreational rewards, level movements, care, adolescents living in group care are more family visitation) are made collectively. likely to suffer from extreme behavioral and • As a group, juveniles learn to trust, respect, and social adjustment difficulties, including sexual take responsibility for the actions of others; acting out, developmental disabilities, suicidal norms can be established that not only extinguish ideation and attempts, self-induced injuries, anti-social conduct, but more importantly 88 Day, Pal, & Goldberg, 1994, cited in CWLA Position Statement on Resident Services, pp. 1-2. Alexander & Huberty, 1993, cited in CWLA Position Statement on Resident Services, pp. 2. Blackman, Eustace, & Chowdhury, 1991, cited in CWLA Position Statement on Resident Services, p. 1. Vorrath and Brentro, 1985. Dishion et al., 1999. Osgood & Briddell, 2006. Barth, 2002. Barth, 2002; Wulczyn, Hislop, & Goerge, 2001. 2006-2007 County of Los Angeles Civil Grand Jury 145 Residential Group Care Settings Positive Effects Negative Effects reinforce pro-social attitudes, beliefs, and eating disorders, substance abuse, and behaviors. aggression.96 • Children in group care have fewer opportunities to practice real life tasks.97 • Children in group homes also have more academic problems. Compared with youth in family foster care, dependents in group homes received mostly C or below grades in school, have truancy problems, enroll in remedial classes, and attain lower levels of education.98 Considerable evidence suggests that: a) group care programs increase the likelihood of negative outcomes, and b) detaining children in congregate residential settings may exacerbate delinquency through exposure to deviant peers. Mitigating Factors. The effects of placements may vary by individual, that is, an interaction may exist between congregate-care placements and the characteristics of the individual. The negative effects of living in congregate care is likely to be a function of: Self-identity and influence of other factors (e.g., the developmental status of the child, the interactions of the other children who live there, and the context in which the intervention is provided). Children who are firmly grounded in their identity may be more likely to resist peer temptation. Defiant influences and tendencies (e.g., level of deviance a peer has upon entrance into a facility, the number of deviant peers present, and the length and amount of deviant peer exposure). A child who is moderately deviant may be more susceptible to become involved in delinquent friendships. Educational problems may be more prevalent for those in group care because of children’s limited opportunity for individual development and involvement in extra-curricular activities, which help to promote well-being and self-confidence. Group home facilities may also impede learning and studying because of resource shortages (e.g., lack of adequate study areas and staff to help with homework). Unfortunately little is known about which youth are most likely to succeed in congregate-care programs. To date, no evaluations exist that focus specifically on PPC models within the context of the child welfare system. Few studies have looked at factors which contribute to resilience among young people in congregate care facilities. Resilience is defined as an individual’s ability to cope in a successful manner in adverse circumstances. This skill is not a psychological trait, rather it is a set of protective factors and risks that modify the individual’s response to the 96 Berrick et al., 1993. Barth, 2002. Berrick et al., 1993; Festinger, 1983; Knapp et al., 1987; Mech et al., 1994. 2006-2007 County of Los Angeles Civil Grand Jury 146 situation and occur at critical transition points99. Resilient children in out-of- home care had: 1) high quality relationships with caregivers and friends, 2) received consistent encouragement and support to foster self esteem, and 3) experienced interventions which strengthened social abilities and social connections100 . Emancipated foster youth who were successful in attending a four- year college experienced stable school attendance, a challenging high school curriculum, considerable social support, and participation in prosocial organizations and groups. However, these youth still experienced financial difficulties, psychological distress, and a lack of health insurance and access to health services101.
R10-13:
Years 7,769 20.5 73 5.3
R14-15:
Years 4,670 12.3 431 31.2
R16-17:
Years 4,576 12.0 813 59.0 18 Years and Older 1,930 5.1 61 4.5 Age Total 37,979 100.0 1,378 100.0 Ethnicity Hispanic 19,347 50.9 804 58.3 African-American 12,039 31.7 432 31.3 2006-2007 County of Los Angeles Civil Grand Jury 150
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Findings & Recommendations
7 findings
F1:
Are patients asked if they have any coverage when they receive care?
F2:
Are patients sent a bill for services rendered?
F3:
If so, is there follow-up on outstanding bills?
F4:
If not, is there an effort to encourage patients to pay for at least a fraction of the services? Our preliminary investigation revealed that the Department not only does all of the above, but has a system in place to provide assistance to people in order to obtain Medi-Cal coverage. The Department furthermore utilizes the services of collection agencies which are paid on the basis of the amounts collected. 2006-2007 County of Los Angeles Civil Grand Jury 133
F5:
Comprehensive Health Center Urgent Care Center $ 65.
F6:
County Hospital Emergency Rooms $100.
F7:
Outpatient Surgery Clinics $300. Problems with Emergency Room Payments Los Angeles County has four hospitals with emergency departments. All patients entering these departments are medically screened and provided with the appropriate medical stabilizing treatment before any inquiry is made about their ability to pay. Individuals with immediate life threatening symptoms such as bleeding or an obstruction in the airway are classified as category 1 and are seen immediately by medical staff. The method of providing medical treatment first and then inquiring about the patients ability to pay is governed by legislation in the “Emergency Medical Treatment and Active Labor Act”(EMTALA). This Law was enacted by Congress in 1986 and final regulations were issued in1994. EMTALA is a federally unfunded mandate and imposes stiff fines and penalties on a hospital or physician not following its regulations. 2006-2007 County of Los Angeles Civil Grand Jury 135 Los Angeles County is in the process of updating electronic records. In the past six months the Harbor UCLA complex has upgraded its system making it possible to obtain information from the associated clinics. This upgrade provides information about previous treatments and methods of payment for patients, and would make it possible for immediate billing. The other three hospitals have yet to complete this process. Financial Considerations in Clinics With the passage of EMTALA in 1986, emergency rooms turned into de-facto clinics; treating a wide variety of ailments, many not actually emergencies. This practice of treating many uninsured, nonpaying patients resulted in creating a fiscal burden on emergency rooms that forced many of them to close. One answer to the problem was the creation by the County of comprehensive health centers and clinics, whose mission is to provide a wide range of services in a culturally sensitive manner. These clinics provide a wide range of health services. These health centers and clinics are required by County policy to charge for services rendered, and may ask patients about payment on entry. Patients may apply for an Ability to Pay Plan (“ATP”) for all or part of the medical or dental services provided. This process includes the filling out of a form and an interview to determine their share of payment primarily based on their income. They are evaluated for ATP at every admission and after 30 days if hospitalized. They are also evaluated every six months to confirm their continuing ATP coverage. People with Medi-Cal (or Medi-Cal qualified), Medicare or other medical insurance may enroll in the Community Health Plan and will not incur additional charges. If patients do not bring money with them, they are given an envelope with instructions to remit the amount owed within seven days. Other Counties have found that if a timely reminder is sent, more money may be recouped. Patients are requested to provide the following to register: Clinic card Drivers license Address verification Medi-Cal or Medicare card (if applicable) Telephone number Birthdate Follow-up to Unpaid Bills for Medical Services
Additional Recommendations
7
Not linked to specific findings.
R1:
The Board of Supervisors should study ways for Probation and DCFS to develop and evaluate up to 5 pilot projects designed to prevent and reduce the number of new dependents and wards in the system. The standard approaches to prevention are general public education and intervention in high-risk homes (when they can be identified). Successful prevention strategies in both delinquency and dependence cases is likely to require a multi-faceted approach. The Board has previously provided funding to the Service Integration Board (SIB) and some projects are underway in the District Attorney, CAO, and other departmental offices to mitigate some of the factors that effect the generation of new cases. Both Probation and DCFS need to study how to best accomplish this priority and participate effectively in the important integration efforts. The purpose of this recommendation is to challenge the Departments to experiment with and propose new ideas.128 Such innovation should be accomplished by bringing together multidisciplinary teams from within and outside the Departments to develop new prevention strategies on a pilot basis. Relevant nonprofit organizations, community groups, academicians, and professional consultants should also be involved. The pilot projects should include a strong evaluation component with assessments at the end of two years; at which time, the County determines the level of success of the pilots and the viability for sustaining or replicating these pilots elsewhere. The County should undertake at least 5 pilots to increase the chances of developing and implementing effective solutions quickly. One of the key parts of the effort, led by the County Auditor-Controller, should be the development of an estimate of what an average child entering the system costs. The estimate should include all potential cost components, including: a) lost productivity over a life-time as a result of a negative life trajectory and b) the explicit “out of pocket” costs while these children are in the child welfare, juvenile justice, and possibly adult justice and welfare systems. This estimate will help the Board make its “investment in prevention” decision once the pilots identify the most effective prevention strategies.
R2:
Probation and DCFS should develop more sophisticated approaches to evaluate, monitor, and measure success. The Departments should establish holistic evaluation approaches that consider both quantitative and qualitative components.
R3:
DCFS should implement new treatment models that are evidence-based and proven to be successful.
R4:
Develop a system of associated urgent care clinics where patients can be directed, rather than utilizing emergency rooms. 2006-2007 County of Los Angeles Civil Grand Jury 137 TABLE OF CONTENTS PREFACE....................................................................................................................................140 I EXECUTIVE SUMMARY ……………………………………...............……………141 II. HISTORY AND BACKGROUND......................................................................................144 III. PURPOSE.............................................................................................................................154 IV. INVESTIGATION...............................................................................................................155 V. FINDINGS...........................................................................................................................156 VI. RECOMMENDATIONS.................................................................................................... VII. CONCLUSIONS..................................................................................................................187 APPENDICES A – Acronyms.......................................................................................................................190 B – Quantitative Fact-Finding and Analysis C – Group Home Quantitative Findings D – Qualitative Fact-Finding: Site Visits and Interviews E – References 2006-2007 County of Los Angeles Civil Grand Jury 138 TRIPLE JEOPARDY: ABANDONED, NEGLECTED, AND ABUSED CHILDREN OF LOS ANGELES COUNTY PREFACE This investigation by the 2006-2007 Civil Grand Jury (CGJ) revealed that a review of group homes was not a simple matter. The term “group home,” though commonly used, has many different interpretations due to the range of services and quality of care provided, from minimal to comprehensive. The CGJ has redefined the term “group homes” and refers to them as “congregate-care facilities” (see diagram below). Moreover, the authorities concerned with the care of children who are the County’s wards and dependents differ dramatically in their judgments of these congregate-care facilities. The range of quality of care provided varies from truly excellent to abysmal. This situation is compounded by the fact that State funding levels for congregate-care facilities have not changed in many years. This affects the ability to hire qualified staff, establish reasonable staffing ratios, provide aftercare services, and deliver other programs necessary to provide quality services. Beyond the complex evaluation of these facilities lie the uneven, conflicting, and inconsistent efforts made by the Department of Children & Family Services (DCFS) and Probation Department. These Departments manage their assigned children’s cases, including their initial placement, monitoring and tracking them over time, and developing their exit plans (e.g., end-result reporting and outcomes). The State licenses congregate-care facilities. It has established a Rate Classification System (RCL) assigning the level of “residential-based services” provided in the facility. It is the County’s responsibility, however, to guarantee the quality of care provided. This report includes information from on-site visits made by the CGJ to a selected sampling of congregate-care facilities. It explores the changes that DCFS and Probation should be making to improve the quality of care provided and asks the questions: Which of these facilities are inappropriate for placement? Which of these facilities are underutilized? CHILDREN’S PLACE OF RESIDENCE IN-HOME/ CONGREGATE-CARE LOCK-DOWN FOSTER FAMILY RE-UNIFICATION FACILITIES FACILITY Least Most Restrictive Restrictive HOME FACILITY RESIDENTIAL-BASED FACILITIES • Small (<10 beds) • Campus-like settings • Stand alone • Multi-faceted agencies, which include campus-like settings and other services • Multi-faceted agencies with central administrative facility and multiple home facilities • Agency-operated with multiple residential facilities 2006-2007 County of Los Angeles Civil Grand Jury 139 I – EXECUTIVE SUMMARY Jackie’s Story Jackie, a thirteen year old girl was removed from her heroin-addicted birth mother at age 4 after she and her brother were sexually abused by her mother’s boyfriend and slapped and beaten by her mother as a means of discipline. In the first foster home, she suffered more abuse. In the second foster home over a nine year period, she became defiant, suspended from school for fighting, ran away and ended up in a temporary homeless shelter on skid row. In the current residential based facility, she has been found to be intelligent although guarded, has low self esteem, and displays inappropriate affect, unrealistic fear, excessive guilt, anger, mood swings, and depression. She has been described as delusional, suicidal with bizarre thinking, paranoid, and depressed, and self-destructive. She was not on psychotropic medication and was listed as "non compliant”. One medical examination indicated that she was “mentally retarded”, yet another psychological evaluation indicated “cognitive ability - high average”. Although she has a 2.94 grade average (in 9th grade) and wants to be a nurse, she has an inability to focus on her studies. She had formed an attachment to her former foster mother where her brother resides, and reunification is being pursued. CGJ 2006-2007 encountered this case during a site visit. As a result of this case, complaints to the Ombudsman, the Auditor-Controller’s reports, and the findings of previous CGJ reports, the 2006-2007 CGJ decided to investigate the use of congregate care for children in the child welfare and juvenile justice systems. Much of the previous literature refers to “group homes” as an all encompassing category, which does not reflect the breadth of congregate-care facilities and services rendered. The effects of congregate-care settings are confounded with type of facility, quality of facility and staff, staffing levels, severity of problems of children placed, prior placements, services rendered, and other variables. In the County of Los Angeles, children in the juvenile justice system are called wards assigned to the Probation Department; they can be placed in lock-up in camps or Juvenile Hall or in congregate-care settings, typically group homes. Only a few are assigned to live at home or with relatives. A variety of options is available to children, called dependents, in the child welfare system under the DCFS. Dependents are generally placed at home, with relatives, with foster families, or at congregate-care facilities. Probation views congregate-care facilities as less restrictive and a preferred option compared to the two lock-up options. DCFS views congregate- care facilities as the least preferred option for placement of their children. DCFS and Probation are currently using 238 group homes that are licensed by the State of California. The group homes range in size from 5 to 143 beds. The State license determines the monthly fees paid based on the level and type of services provided. The fees range from $2,589 to $6,371 per child per month. DCFS and Probation have approximately 1,500 dependents and 1,300 wards respectively placed in group homes, representing 4% and 23 % of the 38,000 and 5,700 children in the two systems. Within the broad category of congregate-care facilities, the CGJ has developed its own classifications: Residential-based facilities 2006-2007 County of Los Angeles Civil Grand Jury 140 Campus-like settings with a range of services – treatment centers, schools, and transitional programs Multi-faceted agencies, which include campus-like settings and foster family services, adoption services, and residential facilities Multi-faceted agencies with central administrative facility and multiple group home facilities Agency-operated with multiple residential facilities Stand-alone, small group facilities (<10 beds) The trend in the literature and emerging best practices indicate the reliance on group homes should be curtailed. The implication is that group homes are inferior to placement in a foster home because of a lack of a parental authority figure on a 24/7 basis. Dependents and wards need continuity, unconditional love, emotional support, and boundaries needed by children to thrive. The group home environment makes the transition more complicated when a child is reunified with his/her family. In contrast, within the CGJ’s classifications, the CGJ found differences in practice: With appropriate placement, children needing RCL-6 through RCL-10 residential-based services can do well in stand-alone, small group facilities. A number of residential-based facilities have remarkable success with the children in their care. Some had particularly impressive transition programs that provide job and housing support when a child emancipates or ages out of the system. They help them to become young, responsible adults with a solid foothold in the community. Because congregate-care facilities are only a component of a larger system of care for dependents and wards, the investigation’s conclusions go beyond group homes and address systems, organizational, and program issues in the Departments. Specifically: New prevention programs with specific reduction goals are required to staunch the flow of children entering the systems. The Departments, in addition to evaluating the intermediate effectiveness of specific programs, need to follow up on children after they leave the systems and collect longitudinal data to measure the real impact of the systems on a child’s life trajectory. The information systems need to be improved, automated, and integrated to ensure that accessible and comprehensive information is maintained on each child. Team decision-making, involving all the caregivers involved with the child, and where confidential information can be shared, should be the norm to ensure optimal decisions are made for the child. Stability and continuity is important for a child’s well-being. Both systems need to minimize the turnover of Children Social Workers (CSWs); DCFS must reduce the number of placements of their dependents. The Departments should set goals of one case worker throughout the child’s stay in the system and one placement per child. An organizational review is needed to address the current staffing levels in both Departments. New and more realistic case ratios are required and should be related to the complexity of 2006-2007 County of Los Angeles Civil Grand Jury 141 the cases assigned. A higher-level position of case manager should be considered for the more complex cases. The development of new systems, technology, and equipment that provide better information in real time should be part of the review. To support the stability goals, a new comprehensive placement assessment protocol is needed to ensure that each child is: a) assigned a CSW or Deputy Probation Officer (DPO), who are trained caseworkers with the appropriate skills, and b) then placed appropriately. More foster families need to be recruited and new classes of highly trained foster family caregivers are required to reduce the number of children inappropriately placed in congregate-care facilities. Children should not be placed in congregate-care facilities if the facilities are not able to provide high quality, comprehensive services. Improved educational strategies are needed to help many of the children achieve at or above their grade levels and improve their life trajectory. To avoid potentially negative peer influences, DCFS dependents and Probation wards should never be assigned to the same group facility. Some congregate-care facilities raise significant funds in the community to support and enrich their programs and services but overall most are under-funded, given the services they are required to provide. Wraparound Services – that provide supports to families to prevent children from being removed and supports after they are returned or permanently placed elsewhere – are valuable but the efficacy of delegating this to a third-party is questionable because of fragmentation and coordination problems. There is little contact and sharing of information between congregate-care facilities and other care providers or across County departments. Annual forums for sharing successful programs, best practices, and strategies could lead to improved system-wide performance. Children entering both systems are still in their formative years. Many are damaged and vulnerable. Program and system improvements are needed to help more of them attain better life trajectories than they face when they enter the child welfare or juvenile justice systems. The current goals are excellent: a) achievement of permanent placement, including reuniting with parents as fast as possible, and b) placement in the least restrictive accommodation. These goals need to be tempered by practical considerations and the needs of the child. An early removal that negatively disrupts the child’s schooling for instance should be avoided. Despite the current views and best practice research, there will likely always be a subset of children who cannot or should not be placed permanently with their family or relatives. These children thrive better in a comprehensive structured program offered by some of the larger congregate-care facilities that provide care in campus settings. Wards who have been entangled in gangs and children who have substance abuse problems are two examples. This CGJ investigation makes recommendations to: a) ensure the placement of children in congregate-care facilities is appropriate; b) improve their care and potential life trajectories; and c) maintain and improve the support of those congregate-care facilities who are currently successful with the children they are assigned. 2006-2007 County of Los Angeles Civil Grand Jury 142 II – HISTORY AND BACKGROUND NATIONAL TRENDS IN RESIDENTIAL CARE The Child Welfare League of America (CWLA) defines Residential-Based Services (RBS) as: Resident group care encompasses a broad array of services for children with pronounced special needs. Residential services are highly flexible and provide for varying lengths of stay, based on the client’s needs. Lengths of stay may range from a short respite due to tense family situations, to long-term therapy for problems such as drug or alcohol addiction. Although long-term stays in family-like community-based group homes best serve some children’s individual needs, residential group care is usually a temporary placement. Many children in residential care have emotional or physical conditions that require intensive, on-site therapy[;] others receive services from day treatment programs in their communities. Residential care programs are highly flexible and are designed to meet each child’s individual needs.80 RBS can involve a broad array of residential options for children living out-of-home, including half-way homes, campus-based homes, emergency shelters, self-contained settings, and staff- secured settings.81 Child welfare systems attempt to work with children and families in the least restrictive environment (e.g., biological, kinship, or foster family home). When such environments are unavailable or insufficient in meeting the needs of individuals, child welfare systems place dependents into more restrictive settings. Current laws and policies require that children be placed in the least restrictive setting to meet their needs. Relatives or kin are given priority in placement decisions wherever possible. Other family settings include family foster care. Placement priorities are to keep the child: 1) In the home if they are not endangered 2) With relatives 3) In a foster family 4) In congregate-care facilities In some cases, children entering out-of-home care are temporarily placed into an emergency foster care setting, which may be either a family, or a group setting. Of the 500,000 dependents in foster care in the United States, approximately 20% live in a group home or other residential institution.82 Within the social service continuum of care, congregate- care facilities are less restrictive than in-patient psychiatric clinics and juvenile detention centers, but more restrictive than foster family care.83 In all instances, the continuum is building blocks toward reunification with one’s family if possible. Child Welfare League of America (CWLA): Child Welfare, Residential Group: www.cwla.org/programs/groupcare/groupcareaboutpage.htm 81 Curtis, Alexander, & Lunghofer, 2001, CWLA, 2005. Administration for Children and Families, 2003; Jonson-Reid & Barth, 2000a, 2000b. Handwerk, Friman, Mott, & Stairs, 1998. 2006-2007 County of Los Angeles Civil Grand Jury 143 Group facilities are used in a variety of social service settings, including child welfare, mental health, and juvenile justice. Group facilities tend to be: Smaller than other residential facilities, consisting of a medium-size homes capable of housing between 8 and 12 adolescents in a community-based setting Staff secured as opposed to a locked facility Staffed with employees who work 24 hours/day Reliant on the public schools to educate their assigned children Group homes are one of the most expensive placements options for child welfare systems, given the staffing ratios. In 2000, 43% of all substitute care dollars in the State of California were associated with group home placements.84 Because the majority of children never enter a congregate-care setting, and the lengths of stay within these settings is significantly shorter than traditional foster family placements, the high costs and overall proportion of the budget allocated to such placements requires that agencies assess the viability of such placements. Children in group homes stay an average of 10 to 20 months.85 Children from California group homes and foster homes have the lowest median lengths of stay (12 and 13 months, respectively), in comparison with California treatment foster care and kinship care, which have the highest medians (25 and 20 months, respectively).86 Characteristics of Children Served In Congregate-Care Settings Across the nation, approximately 20% of child welfare placement cases enter congregate-care settings because some dependents are better suited to enter such facilities or no other placement options are available. As compared to traditional or specialized foster care homes, children living in congregate-care settings are more likely to be: older, male, minority, experiencing a range of socio-emotional and behavioral problems, and previously involved with the juvenile justice system.87 Congregate-Care Placements A healthy debate exists regarding the effectiveness of congregate-care settings. Central to this debate is the issue of peer groups and the socialization of adolescents living in congregate-care settings. Those supportive of congregate-care placements argue that youth can be influenced by positive peer behaviors. Those advocating the termination of such placements argue that congregate-care institutions generally serve high-risk children in close confines, thus, increasing the chances for reinforcing negative attitudes, values, and beliefs. A chart summarizing studies of the positive and negative effects of residential group settings is on the following page. CA Department of Social Services Research and Development Division (RADD), 2001. CA RADD, 2001. Chamberlain (1998). Berrick, Courtney, & Barth, 1993; Curtis et al., 2001; Knapp, Baines, Bryson, & Lewis, 1987; Mech, Ludy-Dobson, & Hulseman, 1994. 2006-2007 County of Los Angeles Civil Grand Jury 144 Residential Group Care Settings Positive Effects Negative Effects A number of studies have identified positive • In a well-publicized study,92 peer group outcomes: interventions might increase adolescent behavior problems and negative life outcomes in adulthood. ● A study of children diagnosed with conduct disorder in residential care – caregivers’ • On the basis of two experimental studies, the high- concerns decreased between admission and risk youth, compared with low-risk youth, were discharge and six months, one year, and two particularly vulnerable to peer aggregations. years after post-discharge.88 • In part, the potential problems associated with ● A retrospective study of 200 children served in group home placements stem from the ties that group homes in the Midwest – as adults, 70% are often severed between group home youth and had completed high school, 27% had some other more positive role models (peers and college or vocational training, and 14% received adults). public assistance.89 • Group homes often cut juveniles off from their ● A Canadian study of 40 children in resident care non-delinquent and pro-social peers and keep – the majority of the children were functioning them with youth who often are delinquent or have at severely impaired levels at admissions, emotional and behavioral problems (including moderately impaired at discharge, and normal conduct disorders and Attention- one- to three-years post-discharge.90 Deficit/Hyperactivity Disorder (ADHD) in a congregated setting for 24 hours a day.93 A specific clinical model – positive peer culture (PPC) – for youth in the juvenile corrections system • Group care is not safe, does not promote healthy and housed in residential settings found that:91 development, is not stable, exceeds the cost of other types of care, and is not cost efficient.94 • Juveniles are capable of establishing and reinforcing socially acceptable behaviors. • Children from group care report seeing family members less than children in kinship care, are • Juveniles not only take responsibility for their less likely to be reunified, and are more likely to behaviors, but for the behaviors of the entire return to group care, especially children aged 6 to group. 12.95 • Decisions regarding the progression of treatment • As compared with children in specialized foster (e.g., recreational rewards, level movements, care, adolescents living in group care are more family visitation) are made collectively. likely to suffer from extreme behavioral and • As a group, juveniles learn to trust, respect, and social adjustment difficulties, including sexual take responsibility for the actions of others; acting out, developmental disabilities, suicidal norms can be established that not only extinguish ideation and attempts, self-induced injuries, anti-social conduct, but more importantly 88 Day, Pal, & Goldberg, 1994, cited in CWLA Position Statement on Resident Services, pp. 1-2. Alexander & Huberty, 1993, cited in CWLA Position Statement on Resident Services, pp. 2. Blackman, Eustace, & Chowdhury, 1991, cited in CWLA Position Statement on Resident Services, p. 1. Vorrath and Brentro, 1985. Dishion et al., 1999. Osgood & Briddell, 2006. Barth, 2002. Barth, 2002; Wulczyn, Hislop, & Goerge, 2001. 2006-2007 County of Los Angeles Civil Grand Jury 145 Residential Group Care Settings Positive Effects Negative Effects reinforce pro-social attitudes, beliefs, and eating disorders, substance abuse, and behaviors. aggression.96 • Children in group care have fewer opportunities to practice real life tasks.97 • Children in group homes also have more academic problems. Compared with youth in family foster care, dependents in group homes received mostly C or below grades in school, have truancy problems, enroll in remedial classes, and attain lower levels of education.98 Considerable evidence suggests that: a) group care programs increase the likelihood of negative outcomes, and b) detaining children in congregate residential settings may exacerbate delinquency through exposure to deviant peers. Mitigating Factors. The effects of placements may vary by individual, that is, an interaction may exist between congregate-care placements and the characteristics of the individual. The negative effects of living in congregate care is likely to be a function of: Self-identity and influence of other factors (e.g., the developmental status of the child, the interactions of the other children who live there, and the context in which the intervention is provided). Children who are firmly grounded in their identity may be more likely to resist peer temptation. Defiant influences and tendencies (e.g., level of deviance a peer has upon entrance into a facility, the number of deviant peers present, and the length and amount of deviant peer exposure). A child who is moderately deviant may be more susceptible to become involved in delinquent friendships. Educational problems may be more prevalent for those in group care because of children’s limited opportunity for individual development and involvement in extra-curricular activities, which help to promote well-being and self-confidence. Group home facilities may also impede learning and studying because of resource shortages (e.g., lack of adequate study areas and staff to help with homework). Unfortunately little is known about which youth are most likely to succeed in congregate-care programs. To date, no evaluations exist that focus specifically on PPC models within the context of the child welfare system. Few studies have looked at factors which contribute to resilience among young people in congregate care facilities. Resilience is defined as an individual’s ability to cope in a successful manner in adverse circumstances. This skill is not a psychological trait, rather it is a set of protective factors and risks that modify the individual’s response to the 96 Berrick et al., 1993. Barth, 2002. Berrick et al., 1993; Festinger, 1983; Knapp et al., 1987; Mech et al., 1994. 2006-2007 County of Los Angeles Civil Grand Jury 146 situation and occur at critical transition points99. Resilient children in out-of- home care had: 1) high quality relationships with caregivers and friends, 2) received consistent encouragement and support to foster self esteem, and 3) experienced interventions which strengthened social abilities and social connections100 . Emancipated foster youth who were successful in attending a four- year college experienced stable school attendance, a challenging high school curriculum, considerable social support, and participation in prosocial organizations and groups. However, these youth still experienced financial difficulties, psychological distress, and a lack of health insurance and access to health services101.
R10-13:
Years 7,769 20.5 73 5.3
R14-15:
Years 4,670 12.3 431 31.2
R16-17:
Years 4,576 12.0 813 59.0 18 Years and Older 1,930 5.1 61 4.5 Age Total 37,979 100.0 1,378 100.0 Ethnicity Hispanic 19,347 50.9 804 58.3 African-American 12,039 31.7 432 31.3 2006-2007 County of Los Angeles Civil Grand Jury 150
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Additional Recommendations
14
Not linked to specific findings.
R4:
The CEO needs to assist DCFS and Probation in developing a comprehensive and integrated information system.
R5:
The CEO should immediately commission an organizational review to assess the CSW and DPO structure, staffing levels, and compensation. From this CGJ investigation, the Departments had insufficient staffing and funding to care adequately for their dependents and wards. The staffing ratios of 50-55 wards per DPO in Probation and 30-35 dependents per CSW in DCFS speak for themselves. Average rates do not tell the whole story. Best practices recognize that a tiered approach linked to the type of case is optimal. In some types, a ratio of 4-8 cases per CSW may be appropriate. CWLA131 recommends the following caseloads per social worker: Initial assessment: 12 active cases per month Ongoing case: 17 active families per month and no more than 1 new case for every 6 open cases 131 CWLA Standards of Excellence for Services or Abused or Neglected Children and their Families, Revised 1999 (www.cwla.org). 2006-2007 County of Los Angeles Civil Grand Jury 180 Combined cases: 10 active on-going and 4 active investigations Foster family care: 12-15 cases Supervisors: 1 for every 5 social workers Probation also has structural problems, which make it more difficult to fill current vacancies (25 DPO vacancies in March 2007). There are a variety of staffing models to evaluate, including staggered hours, work from home, and longer but fewer shifts that might attract more recruits to this position. After the initial assessment, it is a ‘best practice’ to have the assigned CSW or DPO remain with the child throughout the child’s stay in the system. Children who have multiple CSWs and DPOs tend to develop trust issues with adults and the system. Staffing, remuneration, and organizational supports should be set at levels that optimize the attainment of this continuity goal. The County should create a more highly skilled case manager position for the children with the most complex and difficult problems, such as those who are currently placed in an RCL- 12 level or higher. Realistic staffing levels should also be developed for the after-hours requirements of the DCFS Command Post.
R6:
In consultation with the congregate-care facilities’ staff, DCFS and Probation management should develop and implement comprehensive assessment tools for making placement and exit decisions. Poor initial placement decisions can often result in many changes of residence. This destabilization of the child’s environment can have serious negative impacts, as statistically proven in this CGJ investigation. Other children exit the system without well-thought through transition plans or before they are ready.
R8:
The CEO should ensure that DCFS and Probation’s current practice of assigning dependents and wards to the same facilities ceases immediately. This CGJ investigation has discussed the potentially adverse impact of congregate-care facilities on children’s increased propensity to commit crimes. According to senior officials in both Departments, separation of dependents and wards will provide more appropriate environments for the children. This recommendation will cause disruption, particularly for group home facilities. Some of the excess capacity may be taken up by Probation. Some capital support may be required to help congregate-care facilities accommodate the shift to being an all-Probation or all-DCFS group facility. But nevertheless, dependents and wards should be served in different facilities.
R9:
DCFS and Probation should strategically use congregate care facilities that meet quality assurance standards and provide awards for achieving meaningful outcomes. DCFS and Probation should retain its relationships with the high-quality, congregate-care facilities that they currently have, as long as those settings meet quality assurance standards and are the least restrictive for specific dependents and wards to thrive. Other congregate-care facilities should be phased out – either because of the poor quality or because of reduced demand for their services with the new treatment models to be implemented. The transition may take 2 to 5 years. During this period, there will be disruptions, spare capacity, and other operating problems. To ensure that congregate-care performance does not deteriorate over this period, the Board should consider extra funding support.
R10:
DCFS and Probation should meet at least annually with congregate- care providers to share best practices. DCFS and Probation should establish their own separate annual or semi-annual meetings with all congregate-care providers to exchange best practices, share successful outcomes, act as an educational forum, and deal with common issues. Awards can be given out to: a) successful outcomes at congregate-care facilities and b) DCFS and Probation employees who have made extra efforts to transform children’s lives. County recognition of special efforts and ideas would go a long way with those that do provide exceptional service and make super efforts on behalf of the children. DCFS and Probation management should communicate with each other and share the results, information, and recommendations formulated during these conferences. DCFS also needs to establish better, consistent, and scheduled communication with providers.
R11:
The CEO should establish an inter-departmental task force charged with implementing these recommendations and the shift outlined in its Foundation white paper. Well-intentioned managers and professionals currently have good ideas and intensions, which often do not get implemented because those involved are too busy with their day-to-day duties to carry out the intense work of creating real change in the system. DCFS, Probation, and DMH should create an interdepartmental task force whose sole responsibility is to develop and launch these recommendations and other new child-focused programs. This task force should also collect and analyze factors related to resilience and educational success of former youth in congregate care facilities. If the system is to be effective in its role as a custodian for wards and dependents, it needs to move beyond correcting deficiencies to a focus on systematically nurturing the strengths and talents of those children served by Los Angeles County. This task 2006-2007 County of Los Angeles Civil Grand Jury 185 force would enable a group of experienced, dedicated people to focus all of their attention on shifting the child welfare system in Los Angeles County to the new model. VII – CONCLUSIONS DCFS, Probation Department, and congregate-care facility staff members are hard-working and dedicated to the well-being of the children in their charge. The number of children who annually enter the child welfare and juvenile justice systems is staggering. Many are victims of unfortunate family or environmental situations. Each of these young lives is precious. More must be done to ensure these assets do not become community liabilities. Even more disappointing is the estimate by Probation officials that 40% of the wards that enter their system were once dependents in the child welfare system. This is a poor outcome, given the dedication and hard work of all involved. It draws into question the efficacy of the County’s current programs and methods of care for these children. Regardless of one’s parenting philosophy or views on the relative responsibility of the child for his/her actions, most agree these children are at great disadvantage mainly because of circumstances largely beyond their control (family, environmental, educational, or mental health). While some may be lost, most children have remarkable resiliency if given the right nurturing. The County can make a difference in their life trajectory in three ways: Prevention and Early Intervention – Intervene early to minimize the number of children who enter the system Permanency – Provide exemplary programs that stabilize the children, help them learn and thrive, and get them permanently placed or prepared for emancipation Continuous Improvement – Provide follow-up services to maintain and enhance the gains PREVENTION AND CONTINUOUS EARLY INTERVENTION: IMPROVEMENT: Follow Minimize the number of up, maintain the gains, children entering the and make needed system improvements PERMANENCY: For those in the system, stabilize children and find permanent placements for them or enable them to achieve self-sufficiency once emancipated On the basis of these findings, DCFS and Probation have some key opportunities to address to improve the current system: 2006-2007 County of Los Angeles Civil Grand Jury 186 Introduce prevention and early intervention initiatives and measures that will reduce the number of children that enter the system each year Focus the system to measure both the on-going activities and also the actual long-term impact these activities and programs are having on the life trajectories of the children; use data, trends, and outcomes to make empirically based decisions Improve the staffing, information systems, and information sharing across County departments involved in health and social support services (i.e., DCFS, Probation, Department of Health Services (DHS), and Department of Public Social Services (DPSS) and with congregate-care facilities Phase out over time congregate-care facilities that are not providing full services, ensure that children (particularly dependents) placed in group home facilities can benefit from such a setting as the least restrictive environment for them; and maintain and improve the programming and effectiveness of congregate-care services during the transition Develop stronger and integrated communication mechanisms across the system, which will not only improve efficiency but effectiveness of serving children Collaborate more with the schools to ensure that children can complete their school terms, earn high school diplomas, and have complete, implemented, monitored, and updated IEPs Focus on the total needs of the child – emotional, social, educational, and mental Reduce the DCFS and Probation caseloads 2006-2007 County of Los Angeles Civil Grand Jury 187
R40:
*61.1 tnemecalp emoh puorG 29.0
R42:
**45.- naisA 50.2 50. *27. 48.1
R50:
*02.- tnemecalp tcelgeN 71.2
R58:
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R60:
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R70:
*55. naciremA-nacirfA 2006-2007 County of Los Angeles Civil Grand Jury 196 4 ledoM 3 ledoM 2 ledoM 1 ledoM 71.1
R80:
70.- stnemecalp 2 09.0
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Full Details →
Additional Recommendations
14
Not linked to specific findings.
R4:
The CEO needs to assist DCFS and Probation in developing a comprehensive and integrated information system.
R5:
The CEO should immediately commission an organizational review to assess the CSW and DPO structure, staffing levels, and compensation. From this CGJ investigation, the Departments had insufficient staffing and funding to care adequately for their dependents and wards. The staffing ratios of 50-55 wards per DPO in Probation and 30-35 dependents per CSW in DCFS speak for themselves. Average rates do not tell the whole story. Best practices recognize that a tiered approach linked to the type of case is optimal. In some types, a ratio of 4-8 cases per CSW may be appropriate. CWLA131 recommends the following caseloads per social worker: Initial assessment: 12 active cases per month Ongoing case: 17 active families per month and no more than 1 new case for every 6 open cases 131 CWLA Standards of Excellence for Services or Abused or Neglected Children and their Families, Revised 1999 (www.cwla.org). 2006-2007 County of Los Angeles Civil Grand Jury 180 Combined cases: 10 active on-going and 4 active investigations Foster family care: 12-15 cases Supervisors: 1 for every 5 social workers Probation also has structural problems, which make it more difficult to fill current vacancies (25 DPO vacancies in March 2007). There are a variety of staffing models to evaluate, including staggered hours, work from home, and longer but fewer shifts that might attract more recruits to this position. After the initial assessment, it is a ‘best practice’ to have the assigned CSW or DPO remain with the child throughout the child’s stay in the system. Children who have multiple CSWs and DPOs tend to develop trust issues with adults and the system. Staffing, remuneration, and organizational supports should be set at levels that optimize the attainment of this continuity goal. The County should create a more highly skilled case manager position for the children with the most complex and difficult problems, such as those who are currently placed in an RCL- 12 level or higher. Realistic staffing levels should also be developed for the after-hours requirements of the DCFS Command Post.
R6:
In consultation with the congregate-care facilities’ staff, DCFS and Probation management should develop and implement comprehensive assessment tools for making placement and exit decisions. Poor initial placement decisions can often result in many changes of residence. This destabilization of the child’s environment can have serious negative impacts, as statistically proven in this CGJ investigation. Other children exit the system without well-thought through transition plans or before they are ready.
R8:
The CEO should ensure that DCFS and Probation’s current practice of assigning dependents and wards to the same facilities ceases immediately. This CGJ investigation has discussed the potentially adverse impact of congregate-care facilities on children’s increased propensity to commit crimes. According to senior officials in both Departments, separation of dependents and wards will provide more appropriate environments for the children. This recommendation will cause disruption, particularly for group home facilities. Some of the excess capacity may be taken up by Probation. Some capital support may be required to help congregate-care facilities accommodate the shift to being an all-Probation or all-DCFS group facility. But nevertheless, dependents and wards should be served in different facilities.
R9:
DCFS and Probation should strategically use congregate care facilities that meet quality assurance standards and provide awards for achieving meaningful outcomes. DCFS and Probation should retain its relationships with the high-quality, congregate-care facilities that they currently have, as long as those settings meet quality assurance standards and are the least restrictive for specific dependents and wards to thrive. Other congregate-care facilities should be phased out – either because of the poor quality or because of reduced demand for their services with the new treatment models to be implemented. The transition may take 2 to 5 years. During this period, there will be disruptions, spare capacity, and other operating problems. To ensure that congregate-care performance does not deteriorate over this period, the Board should consider extra funding support.
R10:
DCFS and Probation should meet at least annually with congregate- care providers to share best practices. DCFS and Probation should establish their own separate annual or semi-annual meetings with all congregate-care providers to exchange best practices, share successful outcomes, act as an educational forum, and deal with common issues. Awards can be given out to: a) successful outcomes at congregate-care facilities and b) DCFS and Probation employees who have made extra efforts to transform children’s lives. County recognition of special efforts and ideas would go a long way with those that do provide exceptional service and make super efforts on behalf of the children. DCFS and Probation management should communicate with each other and share the results, information, and recommendations formulated during these conferences. DCFS also needs to establish better, consistent, and scheduled communication with providers.
R11:
The CEO should establish an inter-departmental task force charged with implementing these recommendations and the shift outlined in its Foundation white paper. Well-intentioned managers and professionals currently have good ideas and intensions, which often do not get implemented because those involved are too busy with their day-to-day duties to carry out the intense work of creating real change in the system. DCFS, Probation, and DMH should create an interdepartmental task force whose sole responsibility is to develop and launch these recommendations and other new child-focused programs. This task force should also collect and analyze factors related to resilience and educational success of former youth in congregate care facilities. If the system is to be effective in its role as a custodian for wards and dependents, it needs to move beyond correcting deficiencies to a focus on systematically nurturing the strengths and talents of those children served by Los Angeles County. This task 2006-2007 County of Los Angeles Civil Grand Jury 185 force would enable a group of experienced, dedicated people to focus all of their attention on shifting the child welfare system in Los Angeles County to the new model. VII – CONCLUSIONS DCFS, Probation Department, and congregate-care facility staff members are hard-working and dedicated to the well-being of the children in their charge. The number of children who annually enter the child welfare and juvenile justice systems is staggering. Many are victims of unfortunate family or environmental situations. Each of these young lives is precious. More must be done to ensure these assets do not become community liabilities. Even more disappointing is the estimate by Probation officials that 40% of the wards that enter their system were once dependents in the child welfare system. This is a poor outcome, given the dedication and hard work of all involved. It draws into question the efficacy of the County’s current programs and methods of care for these children. Regardless of one’s parenting philosophy or views on the relative responsibility of the child for his/her actions, most agree these children are at great disadvantage mainly because of circumstances largely beyond their control (family, environmental, educational, or mental health). While some may be lost, most children have remarkable resiliency if given the right nurturing. The County can make a difference in their life trajectory in three ways: Prevention and Early Intervention – Intervene early to minimize the number of children who enter the system Permanency – Provide exemplary programs that stabilize the children, help them learn and thrive, and get them permanently placed or prepared for emancipation Continuous Improvement – Provide follow-up services to maintain and enhance the gains PREVENTION AND CONTINUOUS EARLY INTERVENTION: IMPROVEMENT: Follow Minimize the number of up, maintain the gains, children entering the and make needed system improvements PERMANENCY: For those in the system, stabilize children and find permanent placements for them or enable them to achieve self-sufficiency once emancipated On the basis of these findings, DCFS and Probation have some key opportunities to address to improve the current system: 2006-2007 County of Los Angeles Civil Grand Jury 186 Introduce prevention and early intervention initiatives and measures that will reduce the number of children that enter the system each year Focus the system to measure both the on-going activities and also the actual long-term impact these activities and programs are having on the life trajectories of the children; use data, trends, and outcomes to make empirically based decisions Improve the staffing, information systems, and information sharing across County departments involved in health and social support services (i.e., DCFS, Probation, Department of Health Services (DHS), and Department of Public Social Services (DPSS) and with congregate-care facilities Phase out over time congregate-care facilities that are not providing full services, ensure that children (particularly dependents) placed in group home facilities can benefit from such a setting as the least restrictive environment for them; and maintain and improve the programming and effectiveness of congregate-care services during the transition Develop stronger and integrated communication mechanisms across the system, which will not only improve efficiency but effectiveness of serving children Collaborate more with the schools to ensure that children can complete their school terms, earn high school diplomas, and have complete, implemented, monitored, and updated IEPs Focus on the total needs of the child – emotional, social, educational, and mental Reduce the DCFS and Probation caseloads 2006-2007 County of Los Angeles Civil Grand Jury 187
R40:
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R42:
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R50:
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R58:
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R60:
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Findings & Recommendations
5 findings
F1:
That the prime cause(s) of the overflow of January 15, 2006 came about due to the malfunctions of circuitry which were beyond the control of and not included within the maintenance programs of The Districts.
F2:
That The Districts’ responses to the overflow situation were timely, effective, competent and innovative, and in the process developed new protocols in beach sanitation treatment which are currently available to other local, state and federal agencies.
F3:
That the proposed major financial liability assessment of almost $4.7 million against The Districts was unreasonable, and not fully justified under the circumstances, which eventually resulted in a greatly reduced Settlement assessment which by its terms retained the vast bulk of the ultimate payment amount for uses and purposes located within Los Angeles County.
F4:
That the Settlement also precluded liability assessments against The Districts in 92 other potential overflow cases.
F5:
That the Management and Staff of The Districts at all times relevant to the primary matter under investigation acted professionally, promptly, in a scientifically visionary manner, and are deserving of the highest approbation. 2006-2007 County of Los Angeles Civil Grand Jury 235
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Findings & Recommendations
5 findings
F1:
That the prime cause(s) of the overflow of January 15, 2006 came about due to the malfunctions of circuitry which were beyond the control of and not included within the maintenance programs of The Districts.
F2:
That The Districts’ responses to the overflow situation were timely, effective, competent and innovative, and in the process developed new protocols in beach sanitation treatment which are currently available to other local, state and federal agencies.
F3:
That the proposed major financial liability assessment of almost $4.7 million against The Districts was unreasonable, and not fully justified under the circumstances, which eventually resulted in a greatly reduced Settlement assessment which by its terms retained the vast bulk of the ultimate payment amount for uses and purposes located within Los Angeles County.
F4:
That the Settlement also precluded liability assessments against The Districts in 92 other potential overflow cases.
F5:
That the Management and Staff of The Districts at all times relevant to the primary matter under investigation acted professionally, promptly, in a scientifically visionary manner, and are deserving of the highest approbation. 2006-2007 County of Los Angeles Civil Grand Jury 235
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Additional Recommendations
11
Not linked to specific findings.
R1:
Each department head shall be responsible for implementation of the Clean Fuels Policy within his/her department.
R2:
Whenever possible, new vehicle purchases will be clean fuel vehicles.
R3:
Implementation of the Clean Fuels Policy shall depend on the financial resources available to the County. Departments shall pursue funding available from a variety of sources and may work with other public/private agencies to share resources, coordinate efforts, and apply jointly for available 2006-2007 County of Los Angeles Civil Grand Jury 211 funds.
R4:
Departments shall report to the Board by March 1st each year on the composition of their fleet and the number of vehicles powered by clean fuels. RESPONSIBLE DEPARTMENT _______________________________________________________________ Internal Services Department Chief Administrative Office DATE ISSUED/SUNSET DATE _______________________________________________________________ Issue Date: January 10, 1995 Sunset Review Date: January 10, 2004 Review Date: February 19, 2004 Sunset Review Date: January 10, 2007 2006-2007 County of Los Angeles Civil Grand Jury 212 Clean Fuels Policy (CF 00-0157) In May of 2000, the City Council adopted a Clean Fuels Policy (CF 00-0157). This policy helps to implement alternative fuel applications by supporting programs and regulations that balance environmental benefits against operational concerns such as safety, efficiency, and cost effectiveness. Specifically, the City Council decided to: use and purchase vehicles which utilize clean fuels and/or electric propulsion based upon technology that has been determined to be reliable, durable, and cost-effective; support development of vehicle technologies that promote energy efficiency and clean operation; consider retrofit technologies for existing vehicles; promote development of alternative fuel infrastructure; support implementation of federal and state vehicle emission standards; and address health and safety issues and cumulative impacts of existing and alternative fuel technologies on all neighborhoods, particularly low income communities of color. Council member Mark Ridley-Thomas authored the Clean Fuels Policy and received a Clean Air Award from the South Coast Air Quality Management District (Leadership in Government Category) in 2001 for this legislative initiative. For further reading see: Mark Ridley Thomas' motion Environmental Quality and Waste Management Committee Report Council Action to Adopt Policy 2006-2007 County of Los Angeles Civil Grand Jury 213 LOS ANGELES CLEAN CITIES COALITION BACKGROUND In February 1996, the City of Los Angeles joined the United States Department of Energy (DOE) Clean Cities Program by forming the City of Los Angeles Clean Cities Coalition. In 2002, the City was approved for its 5 year renewal, indicating Los Angeles' continuing commitment to improving air quality. The Coalition supports the voluntary deployment of alternative fuel vehicles (AFVs) and construction of infrastructure to support AFVs and includes 18 Principal Stakeholders and 10 General Stakeholders, who may participate on a project per project basis. The Principal Stakeholders consist of key City departments. The General Stakeholders consist of government agencies, utilities, and non-profit organizations committed to improving air quality in the Los Angeles area. The goals of the City of Los Angeles Clean Cities Coalition are to: (cid:131) Work to increase the City’s overall AFV fleet inventory by 15%, as a target goal, each fiscal year (cid:131) Identify opportunities to maximize the deployment of AFVs in City fleets (cid:131) Encourage the adoption of policies that promote the use of AFVs (cid:131) Enhance the support for AFV use by facilitating the expansion and increased utilization of AFV refueling/recharging infrastructure in the City (cid:131) Support local job creation and economic development opportunities related to the AFV industry through efforts to deploy AFVs in City fleets and enhance AFV use in the City Between 1996 and 2001, the number of clean fuel vehicles in the City’s fleet increased from 279 to 807, an average increase of over 23% per year. During this time, the City also supported the installation of alternative fuel infrastructure, including a fast-fill compressed natural gas (CNG) refueling station in downtown Los Angeles, a liquefied natural gas (LNG) refueling station at Los Angeles International Airport (LAX), and approximately 400 electric vehicle (EV) charging stations throughout the Los Angeles area. In May 2000, the City Council adopted a Clean Fuels Policy (CF 00-0157) that encourages the use of alternative fuel applications in the City. In addition, the City is required by the Fleet Rules, adopted by the South Coast Air Quality Management District (SCAQMD) in 2000 and after to acquire alternative fuel vehicles in most City operations when adding or replacing vehicles in the fleet. Thus, it appears that AFVs will have a continued and increasing role in the City’s fleet. In 2004, the number of AFVs increased to 2071, an average of 37 percent per year from 2001 through 2004. As of June 2005, there were over 2400 alternative fuel vehicles in the City's fleet. 2006-2007 County of Los Angeles Civil Grand Jury 214 Participation in the Clean Cities Program provides the City with grant opportunities only available to Clean Cities Coalitions and provides national recognition for the innovative alternative fuel projects spearheaded by the City. Past DOE grants are listed at this link. Regarding recognition, the DOE awarded the City of Los Angeles as one of the Top Ten Clean Cities in 2000. In addition, the Los Angeles Coalition has been presented with several Clean Cities awards, including the Rainmaker Award for securing the most funding from grants and other sources (1999) and the Gold Star Award for adding the most AFV fueling stations (1999, 2000). In 2001, the Clean Cities Legal Eagle Award was received for Advancing AFV Legislation. In 2004, an Excellence in Advancing Propane award was received. In 1994, the DOE created the Clean Cities Program to serve several objectives, both locally and nationally, including: 1) progress toward attainment of federal and state air quality standards; 2) enhanced penetration of clean fuel vehicles; 3) energy security and resource conservation; and 4) economic stimulation in areas that have been heavily impacted by the economic recession and cutbacks. There are currently 88 Clean Cities Coalitions throughout the United States. DOE requires Clean Cities Coalitions to report regularly on activities and achievements and appoint a Clean Cities Coordinator. For information about the Clean Cities Program, please contact the Air Quality Division at heloise.froelich@lacity.org. If you are interested in contacting the National Clean Cities Program directly please call their Clean Cities Hotline at (800) 224-8437or (703) 934-3068 or via e-mail at ccities@nrel.gov 2006-2007 County of Los Angeles Civil Grand Jury 215 LAHSA – THE STRUGGLE TO SERVE After a troubled period, the Los Angeles Homeless Services Authority has now stabilized its operation---but it needs much more City and County involvement to do its crucial job 2006-2007 County of Los Angeles Civil Grand Jury 216 EXECUTIVE SUMMARY Homelessness has been a pervasive and continuing problem in the City and County of Los Angeles for many years. As the result of a lawsuit, the City and the County agreed to establish a joint powers authority, the Los Angeles Homeless Services Authority (LAHSA). This Authority was authorized to take over the distribution of grant funds from a variety of Federal, City and County sources to the private contractors who provided direct services to the homeless. Serious concern about LAHSA’s ability to function effectively developed in the years after it was given autonomy in 2001. These issues came to a head by 2005, prompting the City Controller and the County Auditor to intervene. LAHSA was then severely criticized for operational problems and inappropriate (though not fraudulent) handling of grant funds passed through to contractors servicing the homeless. Since that time, the Los Angeles Homeless Services Authority (LAHSA), with considerable outside support (extensive audits, procedural changes and significant interim financial oversight and management), has been able to perform more effectively as a pass-through agency for funds granted for care of the homeless. LAHSA, therefore, continues to perform a critical and necessary role in receiving funds from HUD, the City and the County of Los Angeles and other sources, and to distribute them to some 90 non-profit contractors who provide direct services to the homeless. However, in order to continue to properly carry out its charter (as originally established in 1993 by a Joint Agreement between the City and the County) LAHSA requires substantial staff upgrading and expansion and, especially, further support and increased oversight from both the City and the County. Starting with five simple contracts to service in 1993, and a staff of thirteen, the Authority now administers 200 complex contracts with a staff of 70. LAHSA’s financial control requirements have also greatly increased because of greater and more complicated requirements from the various funding sources. At the same time, until recently, LAHSA has continued to function without either an Executive Director or a qualified Chief Financial Officer on staff. In order to insure a sound foundation and the proper capability of carrying out its significant responsibilities, LAHSA requires: (cid:131) closer and stronger County and City oversight (cid:131) creation of a broader, stronger governance body (cid:131) an increase in staff (cid:131) an upgrade in key staff positions (cid:131) a review of some of the more time-consuming accounting requirements made by some funding sources (cid:131) a fully qualified Chief Financial Officer (cid:131) the addition of a Director to administer both the Financial and the Contract areas (cid:131) creation of a special section to continually monitor contract servicers 2006-2007 County of Los Angeles Civil Grand Jury 217 (cid:131) a Line of Credit to cover gaps between servicers’ requests and remittances from funding sources (cid:131) annual reviews of its operations by the City and County Controllers (cid:131) implementation of the Homeless Management Information System HISTORY Prior to 1993, the processing of funds from HUD and other sources for the care of the homeless was handled within Los Angeles County and City organizations. In acquiring these responsibilities, LAHSA thus became the “lead agency” for Los Angeles for distribution of federal funds, a HUD requirement for every large city. Until 2001 the County and the City continued to manage the accounting concerns of LAHSA’s operations. In that year this responsibility was turned over to the Authority itself, with County and City oversight greatly reduced. Starting with a staff of thirteen, the size and workload of LAHSA has grown as the processing of requests from servicers and the draws from funding sources has expanded dramatically in number and complexity. The staff has similarly grown to between 60 and 70. Funding in these years increased from the initial $5,000,000 to over ten times that amount in some years. Contracts being serviced increased from the original 5 to forty times that number. More rigid and complex restrictions on funding requests complicated the receipt of funds due service contractors, and the wide variety of service contractors involved led to a variety of problems in receiving and processing requests in a timely manner. This combination of conditions caused LAHSA to be frequently unable to receive funds within the time that contractors needed them, and led to LAHSA sometimes commingling funds from inappropriate grants to meet those needs. This situation resulted in LAHSA owing major amounts to servicers without having the funds available to pay them. The limitation on funds designated for LAHSA’s administrative expense and the occasional delays in transferring them resulted in LAHSA’s inability to meet payroll on occasion. As the challenging work load increased during these years, LAHSA’s staff was not sufficiently qualified in some instances to properly handle the more complicated requirements, particularly in the financial area. Necessary training, upgraded procedures, and improved operating policies were not able to be provided because of the complex work load. The lack of strong, positive management was a major factor contributing to LAHSA’s inability to cope with these increased demands. By mid-2005 the operations of LAHSA were in serious disarray, owing to the increased and more complex workload, the loss of the Executive Director and the Chief Financial Officer, and the limited 2006-2007 County of Los Angeles Civil Grand Jury 218 qualifications of some of the staff in key areas. Systems, policies and procedures had not been evolved to meet the greatly expanded work demands. A review by the Los Angeles Housing Department (LAHD) reported that servicers were not paid and monies needed from funding sources were not being requested in a timely manner. Over $5,000,000 owed at one point in early 2005 with only $700,000 on hand because of delays in requesting grant funds. Commingling of funds (funds being drawn from sources intended for and restricted to other purposes) was done at times to pay some of the servicers. The fiscal closing of the books had not been done for 2004 and 2005. An audit by Laura Chick’s office identified all of these problems, and indicated serious concerns about the capabilities of the existing staff. A report quoting these problems appeared in the Los Angeles Times. * To address these urgent problems an intensive and extensive examination was made by the County Auditor/Controller’s office along with the Blue Consulting firm to fully audit LAHSA, to install a senior consultant as acting CFO, and to cause extensive rewriting of operating policies and procedures. This work lasted from October, 2005, through March of 2006. As a result of this combined effort, and with the close involvement of the interim Chief Financial Officer provided by Blue Consulting, accounts were reconciled, new policies and procedures were implemented, and intensive training was done to better prepare key staff members to maintain the suggested improvements The Simpson and Simpson audit firm has since completed the work of closing the fiscal books for 2004 and 2005. * Los Angeles Times, July 23, 2005, Pg. B.3 Significantly, no instance of any fraud was found in any of the audits. One instance involving the misappropriation of three checks was immediately discovered and stopped by LAHSA itself. The problems that had occurred were produced by a combination of ineffective management, especially in the financial controls area, the rapid increase in volume and complexity of work, and the inadequate training and staffing that existed. However, serious challenges for LAHSA remain. 2006-2007 County of Los Angeles Civil Grand Jury 219 FUNDING SOURCES, DESIGNATED PURPOSES: LAHSA BUDGET 2006-07 * Sources of Funding L.A. City L.A. County State HUD Total Designated for: Housing $ 1,169,000 $ 1,975,386 $ 29,987,736 $ 33,132,122 Shelter 8,639,844 9,137,531 146,136 17,923,511 Other 6,187,959 351,007 6,538,966 LAHSA directly administered prog. 245,120 3,064,309 3,309,429 LAHSA administration 1,540,126 2,035,160 73,293 3,648,579 Funding Totals $ 17,782,049 $ 16,563,393 $ 146,136 $ 30,061,029 $ 64,552,607 * Figures summarized by primary source, purpose. The Los Angeles Times articles criticizing the operations of LAHSA, exposed by the Laura Chick audit, sparked the interest of the 2006-2007 Los Angeles County Civil Grand Jury and resulted in the formation of the LAHSA Committee. The underlying or primary concern was to investigate whether the homeless community meant to be serviced by the funds distributed by LAHSA was indeed receiving proper benefits. The investigation determined to understand and evaluate the following concerns: (cid:131) LAHSA’s financial control problems (cid:131) LAHSA’s operational problems (cid:131) LAHSA’s relationship to contract servicers (cid:131) LAHSA’s evaluation of the actual service made to the homeless (cid:131) the need to identify and recommend needed changes, upgrades, etc. (cid:131) the need to identify and recommend needed changes in the relationship of LAHSA to its sources of funding, to its contract servicers, and to the City and the County 2006-2007 County of Los Angeles Civil Grand Jury 220 INVESTIGATION
R5:
CHIEF FINANCIAL OFFICER LAHSA must have a fully qualified Chief Financial Officer. While this position is currently filled on an interim basis by an audit firm consultant, and while the search for a permanent replacement has been carried on for some time, the need continues. This person will be the key acquisition in the effective meeting of LAHSA’s fiscal responsibilities. This position is reported close to being filled.
R6:
LINE OF CREDIT LAHSA must secure a line of credit to fill the gap between servicers’ requests and the release of funds from funding sources. While at this point efforts are indeed being made to secure such a financial support for LAHSA, the need is permanent and substantial. Whether through a coordinated support from the City and the County, or from outside financial sources, this need must be met. 2006-2007 County of Los Angeles Civil Grand Jury 223
R7:
REVIEW OF STRINGENT FUND REQUEST ACCOUNTING Because of the extreme concern about the commingling of funds, stringent controls were imposed by LAHD on the request for funds. While entirely appropriate at the time, these controls, though recently eased, require substantial additional efforts by LAHSA’s staff to prepare fund requests on a timely basis. Similarly, the accrual adjustments required by the County Community Development Commission for their own accounting needs cause considerable extra effort on LAHSA’s staff. LAHSA should meet on a continuing basis with appropriate representatives from all funding sources to review the working relationships, the control requirements, and the possibility of moderating the stringent funding request requirements.
R8:
LAHSA CONTRACTOR MONITORING SECTION LAHSA should organize a section dedicated to continually monitor and make risk assessments for the service contractors funded by LAHSA. This is a requirement for HUD’s continued funding, but also provides validation that the funds being distributed are indeed properly reaching the Homeless, as intended. This section should also complete the 100% source documentation reviews of Department of Housing and Urban Development Supporting Housing Program contractors. This has been acknowledged by LAHSA’s proposed 2007 budget.
R9:
CENTRALIZED PROCESS FOR EXTERNAL AGENCY MONITORING REPORTS A centralized process should be developed by LAHSA to manage and follow up on external agency reports to LAHSA. These external monitoring findings and recommendations should be integrated into the LAHSA management process.
R10:
IMPLEMENT THE HOMELESS MANAGEMENT INFORMATION SYSTEM This system has not been able to be properly implemented by LAHSA because of its complexity and because of LAHSA’s more urgent work overload. However, this system, when implemented, will not only meet HUD requirements but can supplysignificant reports on shelter usage, client intake, homeless demographics and success rates of people moving out of homelessness. LAHSA should complete this installation promptly. 2006-2007 County of Los Angeles Civil Grand Jury 224
R11:
Until the time it can effectively audit the effectiveness of major contractors with its own designated staff, LAHSA should seek budget approval to hire an audit firm to perform this task CONCLUSION LAHSA, despite its past difficulties and ongoing concerns, remains the necessary vehicle for the proper and effective handling of the millions of dollars involved in contracting services for the homeless of Los Angeles City and County. Expanded training, revamped policies and procedures, particularly more efficient organization and review of certain demanding restrictions from fund sources are further needs. It requires the support itemized in the Recommendations listed to do its job more properly, dependably, and on a long term basis. 2006-2007 County of Los Angeles Civil Grand Jury 225
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Additional Recommendations
11
Not linked to specific findings.
R1:
Each department head shall be responsible for implementation of the Clean Fuels Policy within his/her department.
R2:
Whenever possible, new vehicle purchases will be clean fuel vehicles.
R3:
Implementation of the Clean Fuels Policy shall depend on the financial resources available to the County. Departments shall pursue funding available from a variety of sources and may work with other public/private agencies to share resources, coordinate efforts, and apply jointly for available 2006-2007 County of Los Angeles Civil Grand Jury 211 funds.
R4:
Departments shall report to the Board by March 1st each year on the composition of their fleet and the number of vehicles powered by clean fuels. RESPONSIBLE DEPARTMENT _______________________________________________________________ Internal Services Department Chief Administrative Office DATE ISSUED/SUNSET DATE _______________________________________________________________ Issue Date: January 10, 1995 Sunset Review Date: January 10, 2004 Review Date: February 19, 2004 Sunset Review Date: January 10, 2007 2006-2007 County of Los Angeles Civil Grand Jury 212 Clean Fuels Policy (CF 00-0157) In May of 2000, the City Council adopted a Clean Fuels Policy (CF 00-0157). This policy helps to implement alternative fuel applications by supporting programs and regulations that balance environmental benefits against operational concerns such as safety, efficiency, and cost effectiveness. Specifically, the City Council decided to: use and purchase vehicles which utilize clean fuels and/or electric propulsion based upon technology that has been determined to be reliable, durable, and cost-effective; support development of vehicle technologies that promote energy efficiency and clean operation; consider retrofit technologies for existing vehicles; promote development of alternative fuel infrastructure; support implementation of federal and state vehicle emission standards; and address health and safety issues and cumulative impacts of existing and alternative fuel technologies on all neighborhoods, particularly low income communities of color. Council member Mark Ridley-Thomas authored the Clean Fuels Policy and received a Clean Air Award from the South Coast Air Quality Management District (Leadership in Government Category) in 2001 for this legislative initiative. For further reading see: Mark Ridley Thomas' motion Environmental Quality and Waste Management Committee Report Council Action to Adopt Policy 2006-2007 County of Los Angeles Civil Grand Jury 213 LOS ANGELES CLEAN CITIES COALITION BACKGROUND In February 1996, the City of Los Angeles joined the United States Department of Energy (DOE) Clean Cities Program by forming the City of Los Angeles Clean Cities Coalition. In 2002, the City was approved for its 5 year renewal, indicating Los Angeles' continuing commitment to improving air quality. The Coalition supports the voluntary deployment of alternative fuel vehicles (AFVs) and construction of infrastructure to support AFVs and includes 18 Principal Stakeholders and 10 General Stakeholders, who may participate on a project per project basis. The Principal Stakeholders consist of key City departments. The General Stakeholders consist of government agencies, utilities, and non-profit organizations committed to improving air quality in the Los Angeles area. The goals of the City of Los Angeles Clean Cities Coalition are to: (cid:131) Work to increase the City’s overall AFV fleet inventory by 15%, as a target goal, each fiscal year (cid:131) Identify opportunities to maximize the deployment of AFVs in City fleets (cid:131) Encourage the adoption of policies that promote the use of AFVs (cid:131) Enhance the support for AFV use by facilitating the expansion and increased utilization of AFV refueling/recharging infrastructure in the City (cid:131) Support local job creation and economic development opportunities related to the AFV industry through efforts to deploy AFVs in City fleets and enhance AFV use in the City Between 1996 and 2001, the number of clean fuel vehicles in the City’s fleet increased from 279 to 807, an average increase of over 23% per year. During this time, the City also supported the installation of alternative fuel infrastructure, including a fast-fill compressed natural gas (CNG) refueling station in downtown Los Angeles, a liquefied natural gas (LNG) refueling station at Los Angeles International Airport (LAX), and approximately 400 electric vehicle (EV) charging stations throughout the Los Angeles area. In May 2000, the City Council adopted a Clean Fuels Policy (CF 00-0157) that encourages the use of alternative fuel applications in the City. In addition, the City is required by the Fleet Rules, adopted by the South Coast Air Quality Management District (SCAQMD) in 2000 and after to acquire alternative fuel vehicles in most City operations when adding or replacing vehicles in the fleet. Thus, it appears that AFVs will have a continued and increasing role in the City’s fleet. In 2004, the number of AFVs increased to 2071, an average of 37 percent per year from 2001 through 2004. As of June 2005, there were over 2400 alternative fuel vehicles in the City's fleet. 2006-2007 County of Los Angeles Civil Grand Jury 214 Participation in the Clean Cities Program provides the City with grant opportunities only available to Clean Cities Coalitions and provides national recognition for the innovative alternative fuel projects spearheaded by the City. Past DOE grants are listed at this link. Regarding recognition, the DOE awarded the City of Los Angeles as one of the Top Ten Clean Cities in 2000. In addition, the Los Angeles Coalition has been presented with several Clean Cities awards, including the Rainmaker Award for securing the most funding from grants and other sources (1999) and the Gold Star Award for adding the most AFV fueling stations (1999, 2000). In 2001, the Clean Cities Legal Eagle Award was received for Advancing AFV Legislation. In 2004, an Excellence in Advancing Propane award was received. In 1994, the DOE created the Clean Cities Program to serve several objectives, both locally and nationally, including: 1) progress toward attainment of federal and state air quality standards; 2) enhanced penetration of clean fuel vehicles; 3) energy security and resource conservation; and 4) economic stimulation in areas that have been heavily impacted by the economic recession and cutbacks. There are currently 88 Clean Cities Coalitions throughout the United States. DOE requires Clean Cities Coalitions to report regularly on activities and achievements and appoint a Clean Cities Coordinator. For information about the Clean Cities Program, please contact the Air Quality Division at heloise.froelich@lacity.org. If you are interested in contacting the National Clean Cities Program directly please call their Clean Cities Hotline at (800) 224-8437or (703) 934-3068 or via e-mail at ccities@nrel.gov 2006-2007 County of Los Angeles Civil Grand Jury 215 LAHSA – THE STRUGGLE TO SERVE After a troubled period, the Los Angeles Homeless Services Authority has now stabilized its operation---but it needs much more City and County involvement to do its crucial job 2006-2007 County of Los Angeles Civil Grand Jury 216 EXECUTIVE SUMMARY Homelessness has been a pervasive and continuing problem in the City and County of Los Angeles for many years. As the result of a lawsuit, the City and the County agreed to establish a joint powers authority, the Los Angeles Homeless Services Authority (LAHSA). This Authority was authorized to take over the distribution of grant funds from a variety of Federal, City and County sources to the private contractors who provided direct services to the homeless. Serious concern about LAHSA’s ability to function effectively developed in the years after it was given autonomy in 2001. These issues came to a head by 2005, prompting the City Controller and the County Auditor to intervene. LAHSA was then severely criticized for operational problems and inappropriate (though not fraudulent) handling of grant funds passed through to contractors servicing the homeless. Since that time, the Los Angeles Homeless Services Authority (LAHSA), with considerable outside support (extensive audits, procedural changes and significant interim financial oversight and management), has been able to perform more effectively as a pass-through agency for funds granted for care of the homeless. LAHSA, therefore, continues to perform a critical and necessary role in receiving funds from HUD, the City and the County of Los Angeles and other sources, and to distribute them to some 90 non-profit contractors who provide direct services to the homeless. However, in order to continue to properly carry out its charter (as originally established in 1993 by a Joint Agreement between the City and the County) LAHSA requires substantial staff upgrading and expansion and, especially, further support and increased oversight from both the City and the County. Starting with five simple contracts to service in 1993, and a staff of thirteen, the Authority now administers 200 complex contracts with a staff of 70. LAHSA’s financial control requirements have also greatly increased because of greater and more complicated requirements from the various funding sources. At the same time, until recently, LAHSA has continued to function without either an Executive Director or a qualified Chief Financial Officer on staff. In order to insure a sound foundation and the proper capability of carrying out its significant responsibilities, LAHSA requires: (cid:131) closer and stronger County and City oversight (cid:131) creation of a broader, stronger governance body (cid:131) an increase in staff (cid:131) an upgrade in key staff positions (cid:131) a review of some of the more time-consuming accounting requirements made by some funding sources (cid:131) a fully qualified Chief Financial Officer (cid:131) the addition of a Director to administer both the Financial and the Contract areas (cid:131) creation of a special section to continually monitor contract servicers 2006-2007 County of Los Angeles Civil Grand Jury 217 (cid:131) a Line of Credit to cover gaps between servicers’ requests and remittances from funding sources (cid:131) annual reviews of its operations by the City and County Controllers (cid:131) implementation of the Homeless Management Information System HISTORY Prior to 1993, the processing of funds from HUD and other sources for the care of the homeless was handled within Los Angeles County and City organizations. In acquiring these responsibilities, LAHSA thus became the “lead agency” for Los Angeles for distribution of federal funds, a HUD requirement for every large city. Until 2001 the County and the City continued to manage the accounting concerns of LAHSA’s operations. In that year this responsibility was turned over to the Authority itself, with County and City oversight greatly reduced. Starting with a staff of thirteen, the size and workload of LAHSA has grown as the processing of requests from servicers and the draws from funding sources has expanded dramatically in number and complexity. The staff has similarly grown to between 60 and 70. Funding in these years increased from the initial $5,000,000 to over ten times that amount in some years. Contracts being serviced increased from the original 5 to forty times that number. More rigid and complex restrictions on funding requests complicated the receipt of funds due service contractors, and the wide variety of service contractors involved led to a variety of problems in receiving and processing requests in a timely manner. This combination of conditions caused LAHSA to be frequently unable to receive funds within the time that contractors needed them, and led to LAHSA sometimes commingling funds from inappropriate grants to meet those needs. This situation resulted in LAHSA owing major amounts to servicers without having the funds available to pay them. The limitation on funds designated for LAHSA’s administrative expense and the occasional delays in transferring them resulted in LAHSA’s inability to meet payroll on occasion. As the challenging work load increased during these years, LAHSA’s staff was not sufficiently qualified in some instances to properly handle the more complicated requirements, particularly in the financial area. Necessary training, upgraded procedures, and improved operating policies were not able to be provided because of the complex work load. The lack of strong, positive management was a major factor contributing to LAHSA’s inability to cope with these increased demands. By mid-2005 the operations of LAHSA were in serious disarray, owing to the increased and more complex workload, the loss of the Executive Director and the Chief Financial Officer, and the limited 2006-2007 County of Los Angeles Civil Grand Jury 218 qualifications of some of the staff in key areas. Systems, policies and procedures had not been evolved to meet the greatly expanded work demands. A review by the Los Angeles Housing Department (LAHD) reported that servicers were not paid and monies needed from funding sources were not being requested in a timely manner. Over $5,000,000 owed at one point in early 2005 with only $700,000 on hand because of delays in requesting grant funds. Commingling of funds (funds being drawn from sources intended for and restricted to other purposes) was done at times to pay some of the servicers. The fiscal closing of the books had not been done for 2004 and 2005. An audit by Laura Chick’s office identified all of these problems, and indicated serious concerns about the capabilities of the existing staff. A report quoting these problems appeared in the Los Angeles Times. * To address these urgent problems an intensive and extensive examination was made by the County Auditor/Controller’s office along with the Blue Consulting firm to fully audit LAHSA, to install a senior consultant as acting CFO, and to cause extensive rewriting of operating policies and procedures. This work lasted from October, 2005, through March of 2006. As a result of this combined effort, and with the close involvement of the interim Chief Financial Officer provided by Blue Consulting, accounts were reconciled, new policies and procedures were implemented, and intensive training was done to better prepare key staff members to maintain the suggested improvements The Simpson and Simpson audit firm has since completed the work of closing the fiscal books for 2004 and 2005. * Los Angeles Times, July 23, 2005, Pg. B.3 Significantly, no instance of any fraud was found in any of the audits. One instance involving the misappropriation of three checks was immediately discovered and stopped by LAHSA itself. The problems that had occurred were produced by a combination of ineffective management, especially in the financial controls area, the rapid increase in volume and complexity of work, and the inadequate training and staffing that existed. However, serious challenges for LAHSA remain. 2006-2007 County of Los Angeles Civil Grand Jury 219 FUNDING SOURCES, DESIGNATED PURPOSES: LAHSA BUDGET 2006-07 * Sources of Funding L.A. City L.A. County State HUD Total Designated for: Housing $ 1,169,000 $ 1,975,386 $ 29,987,736 $ 33,132,122 Shelter 8,639,844 9,137,531 146,136 17,923,511 Other 6,187,959 351,007 6,538,966 LAHSA directly administered prog. 245,120 3,064,309 3,309,429 LAHSA administration 1,540,126 2,035,160 73,293 3,648,579 Funding Totals $ 17,782,049 $ 16,563,393 $ 146,136 $ 30,061,029 $ 64,552,607 * Figures summarized by primary source, purpose. The Los Angeles Times articles criticizing the operations of LAHSA, exposed by the Laura Chick audit, sparked the interest of the 2006-2007 Los Angeles County Civil Grand Jury and resulted in the formation of the LAHSA Committee. The underlying or primary concern was to investigate whether the homeless community meant to be serviced by the funds distributed by LAHSA was indeed receiving proper benefits. The investigation determined to understand and evaluate the following concerns: (cid:131) LAHSA’s financial control problems (cid:131) LAHSA’s operational problems (cid:131) LAHSA’s relationship to contract servicers (cid:131) LAHSA’s evaluation of the actual service made to the homeless (cid:131) the need to identify and recommend needed changes, upgrades, etc. (cid:131) the need to identify and recommend needed changes in the relationship of LAHSA to its sources of funding, to its contract servicers, and to the City and the County 2006-2007 County of Los Angeles Civil Grand Jury 220 INVESTIGATION
R5:
CHIEF FINANCIAL OFFICER LAHSA must have a fully qualified Chief Financial Officer. While this position is currently filled on an interim basis by an audit firm consultant, and while the search for a permanent replacement has been carried on for some time, the need continues. This person will be the key acquisition in the effective meeting of LAHSA’s fiscal responsibilities. This position is reported close to being filled.
R6:
LINE OF CREDIT LAHSA must secure a line of credit to fill the gap between servicers’ requests and the release of funds from funding sources. While at this point efforts are indeed being made to secure such a financial support for LAHSA, the need is permanent and substantial. Whether through a coordinated support from the City and the County, or from outside financial sources, this need must be met. 2006-2007 County of Los Angeles Civil Grand Jury 223
R7:
REVIEW OF STRINGENT FUND REQUEST ACCOUNTING Because of the extreme concern about the commingling of funds, stringent controls were imposed by LAHD on the request for funds. While entirely appropriate at the time, these controls, though recently eased, require substantial additional efforts by LAHSA’s staff to prepare fund requests on a timely basis. Similarly, the accrual adjustments required by the County Community Development Commission for their own accounting needs cause considerable extra effort on LAHSA’s staff. LAHSA should meet on a continuing basis with appropriate representatives from all funding sources to review the working relationships, the control requirements, and the possibility of moderating the stringent funding request requirements.
R8:
LAHSA CONTRACTOR MONITORING SECTION LAHSA should organize a section dedicated to continually monitor and make risk assessments for the service contractors funded by LAHSA. This is a requirement for HUD’s continued funding, but also provides validation that the funds being distributed are indeed properly reaching the Homeless, as intended. This section should also complete the 100% source documentation reviews of Department of Housing and Urban Development Supporting Housing Program contractors. This has been acknowledged by LAHSA’s proposed 2007 budget.
R9:
CENTRALIZED PROCESS FOR EXTERNAL AGENCY MONITORING REPORTS A centralized process should be developed by LAHSA to manage and follow up on external agency reports to LAHSA. These external monitoring findings and recommendations should be integrated into the LAHSA management process.
R10:
IMPLEMENT THE HOMELESS MANAGEMENT INFORMATION SYSTEM This system has not been able to be properly implemented by LAHSA because of its complexity and because of LAHSA’s more urgent work overload. However, this system, when implemented, will not only meet HUD requirements but can supplysignificant reports on shelter usage, client intake, homeless demographics and success rates of people moving out of homelessness. LAHSA should complete this installation promptly. 2006-2007 County of Los Angeles Civil Grand Jury 224
R11:
Until the time it can effectively audit the effectiveness of major contractors with its own designated staff, LAHSA should seek budget approval to hire an audit firm to perform this task CONCLUSION LAHSA, despite its past difficulties and ongoing concerns, remains the necessary vehicle for the proper and effective handling of the millions of dollars involved in contracting services for the homeless of Los Angeles City and County. Expanded training, revamped policies and procedures, particularly more efficient organization and review of certain demanding restrictions from fund sources are further needs. It requires the support itemized in the Recommendations listed to do its job more properly, dependably, and on a long term basis. 2006-2007 County of Los Angeles Civil Grand Jury 225
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Findings & Recommendations
8 findings
F1:
To hold initial interviews to identify a group of qualified and appropriate candidate audit firms so they can be subsequently considered, as needed, for possible audit projects in support of Investigation Committees that require certain professional expertise.
F2:
To advise and assist each Investigation Committee that does require the use of an audit firm in the preparation of a statement of project objectives, to be used by the candidate audit firms for developing project proposals.
F3:
To assist Investigation Committees by recommending, arranging, and participating in interviews with those audit firms determined to be best suited for use in a particular Investigation.
F4:
To assist the Investigation Committees in reviewing and approving the project proposals subsequently received from audit firms.
F5:
To assist the Investigation Committees in the process of getting approval of audit contracts by the Civil Grand Jury, by the County Counsel, and by the Supervising Judge.
F6:
To assist the Investigation Committees in monitoring the progress of audit firms in carrying out project plans, and to assist in resolving any problems in achieving correct and complete project results.
F7:
To approve billings from contracted audit firms as received and as consistent with project progress.
F8:
To update the Audit Committee section of the Civil Grand Jury Administrative Manual as appropriate based on the Jury’s experience. 2006-2007 County of Los Angeles Civil Grand Jury 263 REPORT OF THE CITIZEN COMPLAINTS COMMITTEE OF THE 2006-2007 LOS ANGELES COUNTY CIVIL GRAND JURY EXECUTIVE SUMMARY The Citizen Complaints Committee is a Standing Committee of the County of Los Angeles Civil Grand Jury, and one which is mandated by State Law. Its primary and essential function is to responsibly provide, in strictest confidence, unbiased, independent evaluations regarding complaints submitted by individuals with respect to County and City Governments, Agencies and Special Districts within the County of Los Angeles over which the Grand Jury has oversight jurisdiction, and to recommend appropriate actions to be taken by the entire Grand Jury and ultimately by the concerned recipients of its Final Report. Such oversight jurisdiction, however, does not include reviews of Judicial performance, Court actions (Civil or Criminal in nature), pending litigation, Federal or State functions, actions or personnel, or out- of-State matters. Procedurally, during the period of its tenure, the Citizen Complaints Committee evaluates each individual complaint and determines whether any one of the following actions should be undertaken, namely: 1) That no action be taken; 2) That there is no Jurisdiction over the Complaint subject-matter; 3) That there be a referral of the Complaint to an appropriate committee for further investigation and recommendations; or 4) To undertake some other appropriate disposition of the Complaint. Once the Citizen Complaints Committee as such has recommended a specific disposition of a particular Complaint, each case was then submitted to the entire Grand Jury for its review, evaluation and vote as to whether the Committee’s preliminary recommendation should be approved, amended as appropriate, referred back to Committee, or to otherwise determine that some alternative course of action should be pursued. At the conclusion of the Citizen Complaints Committee’s activities during the term of its existence, a Final Report is prepared, summarizing the cumulative results of its assigned responsibilities, which Final Report delineates the methodology utilized, and is herewith submitted. 2006-2007 County of Los Angeles Civil Grand Jury 264 METHODOLOGY FOR PROCESSING CITIZEN COMPLAINTS
Additional Recommendations
7
Not linked to specific findings.
R1:
From many of the Complaints received, it appears that many of the general public, including those in prison, have some serious misconceptions as to the nature of the role that the Civil Grand Jury can lawfully undertake regarding their Complaints. The best example of an unrealistic request, (probably prompted by fictionalized television crime dramas), is where the Civil Grand Jury is called upon to convene formal hearings, subpoena witnesses, take sworn testimony, and conduct what is tantamount to pre-trial discovery activities, all of which is apparently designed to help make the case for the Complainant in proving his allegations, whatever they might be. The recommendation, therefore, would be to provide sufficiently clear written information to a potential complainant as to just what the Civil Grand Jury can do, and in general what it cannot do.
R2:
Another common misconception is based upon the belief that the Civil Grand can somehow overturn allegedly wrongful convictions or penalty assessments of one sort or another, discipline State Prison officials and personnel, or to otherwise intervene in pending civil and/or criminal litigation which may not be going particularly well for the complainant. 2006-2007 County of Los Angeles Civil Grand Jury 266
R3:
While complainants are constitutionally entitled to petition their government for redress and relief in appropriate cases, the Civil Grand Jury is legally unable to conduct itself in the sometimes bizarre manners requested, nor does it have the resources nor the mandate to do so.
R4:
To preclude many inappropriate complaint submissions by those who utilize the current Citizen Complaint form, the recommendation is to have imprinted at the top of the face thereof, in bold type, something more definitive than “Please Review Complaint Guidelines”; that such language should plainly spell out that the Civil Grand Jury has no jurisdiction nor authority over issues involving California State entities, Federal agencies, Judges and other judicial officers, nor over past or pending Court cases, either civil or criminal in nature. Such notifications in bold type may not entirely stem the flow of non-jurisdictional matters, but might well serve to reduce inappropriate submissions to the Civil Grand Jury; that further, from a humanitarian standpoint, such information might very well preclude individuals from seeking personally unattainable expectations.
R5:
In developing the Options utilizations in corresponding with complainants, as outlined above, with particular reference to complaints dealing with out-of-state matters, it is recommended that an additional Option be added to the list, which essentially would read: “The subject-matter of your Complaint appears to involve either individuals or entities who are neither under the control of nor in the service of the County of Los Angeles, and we are therefore unable to take nor recommend any action in your case”.
R6:
Having had the benefit of an enlightening presentation to the entire Civil Grand Jury by the Los Angeles County Department Of Ombudsman, a recommendation is made that the services provided by that entity should be considered by Citizen Complaints Committees in appropriate matters.
R7:
Predicated upon a citizen’s complaint, a Committee investigation was undertaken regarding the manner in which illegal aliens were being processed by law enforcement Departments in the County. The Committee ascertained that on January 25, 2005, the County Board Of Supervisors had approved the entry into a Memorandum Of Understanding with the United States Department Of Homeland Security to perform certain immigration law enforcement functions, on a pilot program basis. It was further determined by the Committee’s investigation that since that Program appeared to be successfully functioning at this time, a recommendation is made that said pilot Program as outlined in said Memorandum Of Understanding be authorized to be continued on a permanent basis. 2006-2007 County of Los Angeles Civil Grand Jury 267 CONTINUITY COMMITTEE REPORT The Continuity Committee serves as a bridge between all Civil Grand Juries, prior, current and future ones. It is concerned with informing the current Civil Grand Jury of investigation reports done by prior juries, following up on the reports of last year’s Civil Grand Jury, and maintaining a continuous record of the successive Juries’ reports. • The Committee reviewed all of the reports published by the five preceding juries. This provided • An awareness of investigations recently completed to assist the current jury in avoiding unneeded duplications • An awareness of areas of the County or the Cities that had not been investigated recently • An appreciation of the style and content of reports The Committee also initiated two new efforts for Continuity Committees: • A review of responses from governmental entities after the 90 day period has elapsed. A letter was sent to those who did not respond reminding them of their legal responsibility. • A separate review of those responses received where specific commitments were made. A letter was sent to each such responder asking for a status of the commitments. The Continuity Committee developed a manual to assist future Civil Grand Juries. This document includes a spread sheet outlining each investigation from the prior five years, organized by general administrative area, and indicating the main thrust of the investigation and the basic response received. Another spread sheet lists all investigative reports from the preceding Civil Grand Jury and identifies each in terms of whether a response had been received or not, and whether a commitment to take certain actions was promised. The Continuity Committee serves to reinforce the role of the Civil Grand Jury, not only in preparing investigations and reports, but in ensuring that those reports are properly responded to, and that commitments made to the Board of Supervisors are met. 2006-2007 County of Los Angeles Civil Grand Jury 268 Purpose The Continuity Committee is a Standing Committee, created by each new Civil Grand Jury. Its functions are:
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Findings & Recommendations
8 findings
F1:
To hold initial interviews to identify a group of qualified and appropriate candidate audit firms so they can be subsequently considered, as needed, for possible audit projects in support of Investigation Committees that require certain professional expertise.
F2:
To advise and assist each Investigation Committee that does require the use of an audit firm in the preparation of a statement of project objectives, to be used by the candidate audit firms for developing project proposals.
F3:
To assist Investigation Committees by recommending, arranging, and participating in interviews with those audit firms determined to be best suited for use in a particular Investigation.
F4:
To assist the Investigation Committees in reviewing and approving the project proposals subsequently received from audit firms.
F5:
To assist the Investigation Committees in the process of getting approval of audit contracts by the Civil Grand Jury, by the County Counsel, and by the Supervising Judge.
F6:
To assist the Investigation Committees in monitoring the progress of audit firms in carrying out project plans, and to assist in resolving any problems in achieving correct and complete project results.
F7:
To approve billings from contracted audit firms as received and as consistent with project progress.
F8:
To update the Audit Committee section of the Civil Grand Jury Administrative Manual as appropriate based on the Jury’s experience. 2006-2007 County of Los Angeles Civil Grand Jury 263 REPORT OF THE CITIZEN COMPLAINTS COMMITTEE OF THE 2006-2007 LOS ANGELES COUNTY CIVIL GRAND JURY EXECUTIVE SUMMARY The Citizen Complaints Committee is a Standing Committee of the County of Los Angeles Civil Grand Jury, and one which is mandated by State Law. Its primary and essential function is to responsibly provide, in strictest confidence, unbiased, independent evaluations regarding complaints submitted by individuals with respect to County and City Governments, Agencies and Special Districts within the County of Los Angeles over which the Grand Jury has oversight jurisdiction, and to recommend appropriate actions to be taken by the entire Grand Jury and ultimately by the concerned recipients of its Final Report. Such oversight jurisdiction, however, does not include reviews of Judicial performance, Court actions (Civil or Criminal in nature), pending litigation, Federal or State functions, actions or personnel, or out- of-State matters. Procedurally, during the period of its tenure, the Citizen Complaints Committee evaluates each individual complaint and determines whether any one of the following actions should be undertaken, namely: 1) That no action be taken; 2) That there is no Jurisdiction over the Complaint subject-matter; 3) That there be a referral of the Complaint to an appropriate committee for further investigation and recommendations; or 4) To undertake some other appropriate disposition of the Complaint. Once the Citizen Complaints Committee as such has recommended a specific disposition of a particular Complaint, each case was then submitted to the entire Grand Jury for its review, evaluation and vote as to whether the Committee’s preliminary recommendation should be approved, amended as appropriate, referred back to Committee, or to otherwise determine that some alternative course of action should be pursued. At the conclusion of the Citizen Complaints Committee’s activities during the term of its existence, a Final Report is prepared, summarizing the cumulative results of its assigned responsibilities, which Final Report delineates the methodology utilized, and is herewith submitted. 2006-2007 County of Los Angeles Civil Grand Jury 264 METHODOLOGY FOR PROCESSING CITIZEN COMPLAINTS
Additional Recommendations
7
Not linked to specific findings.
R1:
From many of the Complaints received, it appears that many of the general public, including those in prison, have some serious misconceptions as to the nature of the role that the Civil Grand Jury can lawfully undertake regarding their Complaints. The best example of an unrealistic request, (probably prompted by fictionalized television crime dramas), is where the Civil Grand Jury is called upon to convene formal hearings, subpoena witnesses, take sworn testimony, and conduct what is tantamount to pre-trial discovery activities, all of which is apparently designed to help make the case for the Complainant in proving his allegations, whatever they might be. The recommendation, therefore, would be to provide sufficiently clear written information to a potential complainant as to just what the Civil Grand Jury can do, and in general what it cannot do.
R2:
Another common misconception is based upon the belief that the Civil Grand can somehow overturn allegedly wrongful convictions or penalty assessments of one sort or another, discipline State Prison officials and personnel, or to otherwise intervene in pending civil and/or criminal litigation which may not be going particularly well for the complainant. 2006-2007 County of Los Angeles Civil Grand Jury 266
R3:
While complainants are constitutionally entitled to petition their government for redress and relief in appropriate cases, the Civil Grand Jury is legally unable to conduct itself in the sometimes bizarre manners requested, nor does it have the resources nor the mandate to do so.
R4:
To preclude many inappropriate complaint submissions by those who utilize the current Citizen Complaint form, the recommendation is to have imprinted at the top of the face thereof, in bold type, something more definitive than “Please Review Complaint Guidelines”; that such language should plainly spell out that the Civil Grand Jury has no jurisdiction nor authority over issues involving California State entities, Federal agencies, Judges and other judicial officers, nor over past or pending Court cases, either civil or criminal in nature. Such notifications in bold type may not entirely stem the flow of non-jurisdictional matters, but might well serve to reduce inappropriate submissions to the Civil Grand Jury; that further, from a humanitarian standpoint, such information might very well preclude individuals from seeking personally unattainable expectations.
R5:
In developing the Options utilizations in corresponding with complainants, as outlined above, with particular reference to complaints dealing with out-of-state matters, it is recommended that an additional Option be added to the list, which essentially would read: “The subject-matter of your Complaint appears to involve either individuals or entities who are neither under the control of nor in the service of the County of Los Angeles, and we are therefore unable to take nor recommend any action in your case”.
R6:
Having had the benefit of an enlightening presentation to the entire Civil Grand Jury by the Los Angeles County Department Of Ombudsman, a recommendation is made that the services provided by that entity should be considered by Citizen Complaints Committees in appropriate matters.
R7:
Predicated upon a citizen’s complaint, a Committee investigation was undertaken regarding the manner in which illegal aliens were being processed by law enforcement Departments in the County. The Committee ascertained that on January 25, 2005, the County Board Of Supervisors had approved the entry into a Memorandum Of Understanding with the United States Department Of Homeland Security to perform certain immigration law enforcement functions, on a pilot program basis. It was further determined by the Committee’s investigation that since that Program appeared to be successfully functioning at this time, a recommendation is made that said pilot Program as outlined in said Memorandum Of Understanding be authorized to be continued on a permanent basis. 2006-2007 County of Los Angeles Civil Grand Jury 267 CONTINUITY COMMITTEE REPORT The Continuity Committee serves as a bridge between all Civil Grand Juries, prior, current and future ones. It is concerned with informing the current Civil Grand Jury of investigation reports done by prior juries, following up on the reports of last year’s Civil Grand Jury, and maintaining a continuous record of the successive Juries’ reports. • The Committee reviewed all of the reports published by the five preceding juries. This provided • An awareness of investigations recently completed to assist the current jury in avoiding unneeded duplications • An awareness of areas of the County or the Cities that had not been investigated recently • An appreciation of the style and content of reports The Committee also initiated two new efforts for Continuity Committees: • A review of responses from governmental entities after the 90 day period has elapsed. A letter was sent to those who did not respond reminding them of their legal responsibility. • A separate review of those responses received where specific commitments were made. A letter was sent to each such responder asking for a status of the commitments. The Continuity Committee developed a manual to assist future Civil Grand Juries. This document includes a spread sheet outlining each investigation from the prior five years, organized by general administrative area, and indicating the main thrust of the investigation and the basic response received. Another spread sheet lists all investigative reports from the preceding Civil Grand Jury and identifies each in terms of whether a response had been received or not, and whether a commitment to take certain actions was promised. The Continuity Committee serves to reinforce the role of the Civil Grand Jury, not only in preparing investigations and reports, but in ensuring that those reports are properly responded to, and that commitments made to the Board of Supervisors are met. 2006-2007 County of Los Angeles Civil Grand Jury 268 Purpose The Continuity Committee is a Standing Committee, created by each new Civil Grand Jury. Its functions are: