Submittal to the Board of Supervisors County of Riverside, State of California Submittal Date:*

through supervisor meetings and at program meetings - encouraging staff interested in promotions to submit their resumes to the county's Resumix system and to make sure any existing applications are still active. Senior management not monitoring morale indicators such as stress leave, 1.e. frequent unscheduled time off, unexpected resignations or retirements, and transfer requests. Response: Respondent disagrees wholly with the finding. Managers review each leave of absence request, and monitor worker's compensation claims and excess time off. Patterns of leave are discussed with both program supervisors and Human Resources on an individual basis. In several cases, program supervisors adjusted workloads in order to reduce the workload stress on staff. In addition, staff were asked if they wanted to take leave time in order to relieve the stress. Managers monitor resignations, leaves of absence, unplanned time off and transfer requests. As a result, in several cases, managers have been able to identify patterns of leave requests and/or time off that are related to supervisory efforts to improve the employees' work performance to standard. Resignations not linked to performance concerns have usually been associated with employees' decisions to relocate out of the area, promotional opportunities, and/or career changes. Following county personnel practices and policies, the department has terminated some employees. For privacy reasons, management does not report employee terminations to the work force and recognizes that they may have been perceived as unexpected resignations. Finding Number 2: Personnel in some clinics denied knowing, or were unaware of, the existence of written safety protocols for their clinics. Safety inspection reports were not uniformly followed. 2.a. Response: Respondent disagrees partially with the finding. The department responds to all safety reports and develops plans of correction. If the department does not plan to act on a recommended change, the decision is communicated to the Safety Office. The Safety Office and the department work toward consensus to resolve any outstanding safety The department recognizes that due to staff shortages, concerns. implementation of safety recommendations have, at times, exceeded the planned implementation timeline. 2.b. The reception areas do not provide full visibility to clinic staff. This is important as the clinics deal with mentally ill persons. Response: Respondent disagrees partially with the finding. Three of four facilities have reception areas with full visibility. The department has attempted to improve visibility as part of an ongoing effort to provide a more welcoming environment for consumers. Visibility improves overall safety for any business operation, not just those serving persons with a mental The department plans to evaluate redesign options for the fourth illness. facility as part of the program expansion and reorganization related to new Mental Health Services Act programs. Not all clinics are equipped with panic buttons. Some buttons are not 2.c. operational or staff members were unaware of their location and use. Response: Respondent agrees with the finding. The department has provided alarms when clinics requested them. In clinics which are not equipped, alternative safety protocols are being developed. Finding Number 3: 3.a. Clinics do not have designated training officers. Response: Respondent disagrees partially with the finding. The department has a designated training officer; however, there is no policy that each clinic have a training officer. The training officer receives regular input regarding training needs from managers, supervisors and program staff. 3.b. In some clinics, proper documentation in a client's chart, in terms of assessment, case notes and other actions (including appropriate reimbursement billing notations), is handled by untrained clerical personnel. Clerical staff is unable to handle workloads due to their personal injuries. Clinics are unable to secure replacement staffing through the county's Temporary Assistance Program (TAP). Response: Respondent disagrees partially with the finding. Proper documentation, including appropriate billing notations is solely the responsibility of clinical provider staff, not clerical personnel. Two clerical staff at one program location were on temporary medical leave • for several weeks in November-December, 2005. Operational issues have been linked to their absence, to program operational procedures, and individual performance concerns for a number of staff at the facility. The program has been able to secure replacement staff via TAP whenever funding was available for such staffing. 3.c. There was no evidence that each clinic regularly scheduled and participated in drill procedures for fire or other emergency situations. Response: Respondent disagrees wholly with the finding. A review of emergency drills found that all programs have conducted and recorded dates for emergency drills. Records of safety meetings were also The department also found that due to recent staff vacancies, found. replacement safety officers scheduled to attending training were unable to attend due to class cancellation or personnel issues. The transition impacted recent drill schedules. Finding Number 4: 4.a. The Regional Mental Health Services Manager volunteered for and assumed additional duties, thus resulting in dilution of overall effectiveness. Response: Respondent disagrees partially with the finding. The regional manager assumed additional duties to provide temporary coverage while a new manager was recruited. The assumption of temporary extra duties is standard procedure used to minimize disruption to program operations during the recruitment process. During the past year, all members of the management team assumed and received additional assignments in order to assist with the Mental Health Services Act planning process. This required a restructuring of workload priorities. 4.b. Employee performance evaluations are not accomplished in a timely manner. Some employees have not received written evaluations for as long as seven years. Response: Respondent disagrees partially with the finding. The department acknowledges that some employee evaluations have not been provided in a timely manner. A performance evaluation training module is being developed by our HR Team, and this will be implemented in January

The office structure of the clinics is not conducive to meeting the physical and 6.a. emotional needs of the majority of the clients. Response: Respondent disagrees partially with the finding. Two locations are faced with significant space challenges. The department is planning to relocate all or part of the staff from these locations. In the interim, program supervisors have worked to organize available office space in a manner that is respectful of client needs. All programs meet ADA requirements in accordance with state and federal requirements. The Corona/Norco area, with a population of nearly 200,000, has no locally 6.b. available multipurpose mental health service clinic, so clients must travel to Riverside. Response: Respondent agrees with the finding. The department requested and received Board of Supervisor approval in November 2005 to identify a new location for West Clinic Adult in Riverside to relocate to the Corona/Norco area. In order to improve access for clients, the department adopted the goal of establishing services in the Corona/Norco Relocation has been delayed due to shortage of space area in 2004. available for lease; however, several tentative locations have been identified. There is inadequate office space to assure client confidentiality. 6.c. Response: Respondent disagrees wholly with the finding. Every program location provides confidential offices for client meetings. In programs with limited or shared worker space, private interview offices are set aside for client meetings. Additionally, the workforce is routinely out in the field. Their offices are also available for confidential interviews should the need arise. 6.d. There are insufficient personnel trained to deal effectively with dual diagnosis (mental illness plus alcohol and/or drug addiction) that afflict seventy to eighty percent of service consumers. Response: Respondent disagrees partially with the finding. Programs in Western Region do have a number of providers trained and providing treatment of co-occurring mental health and substance abuse disorders. The department recognizes the need to improve the skills of all providers to assist clients with dual disorders and has recently trained 27 mental health staff in a best practice model of intervention. A standardized model of intervention is being developed for introduction to all provider staff working with clients with co-occurring disorders. 6.e. Reception personnel are not trained to deal with the clinics' difficult mental health service clients. Response: Respondent disagrees wholly with the finding. The department has sponsored training for office support staff in dealing with consumers. The most recent was in May 2006. Additional training for the clerical staff is being planned. 6.f. The City of Riverside has initiated eminent domain proceedings, with condemnation of two facilities currently contracted by the county to provide housing for Department of Mental Health clients. This action will exacerbate the shortage of bed space for these clients. Response: Respondent agrees with the finding. The City of Riverside initiated eminent domain proceedings on one licensed residential care facility; the property owner then sold it to a developer prior to eminent domain action. The City of Riverside is pursuing eminent domain on a second similar facility as part of ongoing redevelopment efforts. These Z. facilities are not under contract with the county, but are used on a referral basis. Combined, these two private facilities provide housing for 108 clients. This represents 25% (of 435 beds) of countywide capacity for adults ages 18- The department is working with prospective vendors and State Social 59. Services-Community Care Licensing to encourage new facilities in the county. If this effort is not successful, clients will be staying longer at higher cost facilities or being sent to facilities in other surrounding counties. Finding Number 7: 7.a. Quality Improvement audits of clinics are not conducted quarterly as the procedure manual dictates. Response: Respondent disagrees wholly with the finding. The Quality Improvement Manual does not require quarterly reviews. Reviews are generally conducted quarterly but no less often than every six months. 7.b. A function of Quality Improvement is to collect data for Medi-Cal disallowances. This data is used in discussions with clinic supervisors, but is not disseminated to senior management. Response: Respondent disagrees wholly with the finding. Quality Improvement initiated the practice of providing audit results to managers of program services last year. Adequate information regarding billing procedures is not collected. There are 7.c. no indicators to alert management to billing deficiencies. Response: Respondent disagrees wholly with the finding. The existing database tracks and reports unclaimed services on a monthly basis. Additionally, within the last year, the department developed new audit policies, procedures and audit tools for supervisors to use during chart reviews. The policy includes forms and procedures for supervisors to report their findings to management. 7.d. Information collected is not always reported to the department program manager, assistant director or director. Response: Respondent disagrees partially with the finding. As indicated in 7b above, Quality Improvement reports all audit findings to Senior management receives audit results related to regional managers. significant or re-occurring findings.

Services-Community Care Licensing to encourage new facilities in the county. If this effort is not successful, clients will be staying longer at higher cost facilities or being sent to facilities in other surrounding counties. Finding Number 7: 7.a. Quality Improvement audits of clinics are not conducted quarterly as the procedure manual dictates. Response: Respondent disagrees wholly with the finding. The Quality Improvement Manual does not require quarterly reviews. Reviews are generally conducted quarterly but no less often than every six months. 7.b. A function of Quality Improvement is to collect data for Medi-Cal disallowances. This data is used in discussions with clinic supervisors, but is not disseminated to senior management. Response: Respondent disagrees wholly with the finding. Quality Improvement initiated the practice of providing audit results to managers of program services last year. Adequate information regarding billing procedures is not collected. There are 7.c. no indicators to alert management to billing deficiencies. Response: Respondent disagrees wholly with the finding. The existing database tracks and reports unclaimed services on a monthly basis. Additionally, within the last year, the department developed new audit policies, procedures and audit tools for supervisors to use during chart reviews. The policy includes forms and procedures for supervisors to report their findings to management. 7.d. Information collected is not always reported to the department program manager, assistant director or director. Response: Respondent disagrees partially with the finding. As indicated in 7b above, Quality Improvement reports all audit findings to Senior management receives audit results related to regional managers. significant or re-occurring findings.