Modoc County Grand Jury Fy 2005-2006 Report

Additional Recommendations 3

These recommendations are not explicitly linked to specific findings.

• R3
  Requires further analysis or study. In such case, the law requires a detailed outline of the analysis and time frame not to exceed six (6) months. Further, the complete analysis or study must be submitted to the officer, director or governing board of the entity being investigated.
• R4
  Will not be implemented because it is either unwarranted or unreasonable with an explanation(s) and supporting facts. Timing of Responses and Actions to Findings and Recommendations: As stated in Penal Code Section 933(c), for 45 days after the end of the term, the Grand Jury foreperson or designees shall, upon reasonable notice, be available to clarify recommendations in the report. No later than 90 days after the grand jury submits a final report on the operations of any public agency, the governing body of any public agency subject to grand jury reviewing authority, shall comment to the presiding judge of the superior court on findings and recommendations. Every elected official or agency head for which the grand jury has responsibility shall comment to the judge of the superior court with a copy sent to the Board of Supervisors. Grand Jury Reports EDUCATION Areas of Study: • Modoc County Charter School • Modoc County Office of Education • Modoc Joint Unified School District • Surprise Valley Joint Unified School District • Tulelake Joint Unified School District General Report: Members of the Grand Jury interviewed the Superintendents of each school district as well as the head administrator of the Charter School. Jurors discussed funding sources, technology plans, maintenance plans, drug testing, test scores, and future improvements. Issues: No complaints were received regarding any district. There are issues of concern by the Jurors.
• R30-06
  MOU between Modoc County and the UPEC Loca1 792 (Medical Unit). Detailed notes were written for all interviews. The Grand Jury analyzed these notes to identify issues. Issues: Six (6) separate complaints were received during the tenure of the 2005-2006 Modoc Grand Jury. One (1) complaint was dropped after 7 months of investigation. One (1) complaint will be held over for next years Grand Jury. Issues identified in the complaints are: • Unlawful Discharge of employees • Staff working outside their scope of work • Volunteers working outside their scope of work. • Current CEO does not meet qualification for the position as defined by the Board of Supervisor’s policy and bylaws. • TB Skin test for entire staff done at the same time • MMC Employee Fund • Exempt Status of Employees • On Call Time • Billing Fraud • New Plan for Ambulance Services • No Maintenance Plan for Ambulance Service • Disputed property ownership • Management is not responsive to requests from employees to obtain a copy of their personnel file or prompt return of personal items, following termination of employment • Policy and Procedure manual is outdated and obsolete • Staff are not trained in following the Policy and Procedure manual • Inadequate inventory control Findings: Commendations 1. The hospital staff has continued to provide quality service and show compassion with all patients and families. 2. The County Health Officer should be commended for his loyal devotion to the medical profession and community during a very trying time. 3. X-ray personnel should be commended for doing patient follow-ups on mammograms, for notifying patients of when its time for the annual test and providing the results. 4. The Hospital Lab is run effectively, and is neat and clean. 5. Renovation of the Warnerview Skilled Nursing Facility dining area is a true asset for MMC, with new windows, lighting fixtures, and furniture, and adding a patio where patients can plant flowers in raised beds or enjoy the outdoors with access from the dining room. Much of the credit goes to the former CEO and the Rural Indian Health Clinic for getting the project off the ground. 6. The Warnerview unit is clean and pleasant. 7. The ambulance staff continues to perform at a high standard and garners numerous compliments on their professionalism and quick response to the needs of the community. 8. Care at the Medical Clinic and the Warnerview Skilled Nursing Facility is much improved. 9. Billing is slowly improving. 10. The MMC is closer to meeting Department of Health Services (DHS) standards. 11. The MMC has in place a continuing education program for employees. 12. Very recently, the following was reported to the Modoc Grand Jury. A local patient had a medical emergency that required urgent transport to Reno. The patient called 911. Within minutes the Rural Fire Dept (volunteers) arrived. Very soon the ambulance arrived. For medical reasons the patient had to go to MMC ER before getting into the aircraft that was on its way. At the ER, the patient was immediately greeted by an RN and a paramedic. They took excellent care of him; then the on-call MD arrived to confirm the medical situation. The facilities were adequate. Each of the medical personnel was polite, skilled, professional and efficient. The patient was very favorably impressed with the whole ER function. Board of Supervisors 1. The Board of Supervisors did not comply with Board of Supervisors policy in hiring the current CEO. (See Addendum below titled Article III, Section 1 Administration, ). 2. The Board of Supervisors has not complied with County recruitment and hiring policy in filing vacant positions at MMC. 3. The Board of Supervisors disbanded the MMC Board of Trustees and by doing so lost extensive knowledge of the issues at MMC. 4. The Board of Supervisors has not required MMC staff to provide Board of Supervisors with briefing materials in advance of meetings. Personnel Management 1. The Hospital CEO and management staff do not have a clear policy on, or understanding of, how to terminate employees, including how employees are to collect personal items. No proper exit interview policy is in place. 2. All terminations were within the guidelines stated in the MOU between the Hospital and the union. 3. A volunteer at MMC has been working outside the legitimate scope of volunteer duties. Volunteers should never give direction to employees, make personnel decisions, advise the Board of Supervisors, or have access to any hospital records. According to testimony before the Grand Jury, a volunteer has been given access to patient charts and other records in violation of federal law and Health Insurance Portability and Accountability Act of 1992 (HIPPA). Her authority has been extended to directing nurses and staff, including an instance in which she directed nurses and staff to provide obstetrics while the hospital was not licensed to do so. These testimonies during a Grand Jury interview raise significant concerns about violation of State of California DHS rules. Her presence and actions are found to negatively impact the morale of employees, and subject the County to unnecessary liability. 4. Law requires that all staff have TB test yearly and having staff tested at the same time is common practice and is not out of line. 5. A complaint was filed with the City of Alturas Police Department with regard to funds of the MMC employees association. This Jury could not confirm the details of this case. The case is currently under investigation and the matter will be referred to the 2006-2007 Grand Jury for follow-up. Employees of MMC no longer make contributions to this fund directly from their paychecks. 6. The Hospital union and the Board of Supervisors do not have clear written definition of the exempt status of all employees as well as clear job descriptions indicating that status. 7. On call time has been addressed and will be included in the next Hospital MOU. 8. A reference library of approved methods of coding and billing for state and federal reimbursement has not been developed. Questions regarding billing fraud have not been addressed using state and federal billing fraud hotlines. Employees are either unaware of these hotlines or feel that due to the small workforce confidentiality will be compromised. 9. The MMC does not have an active Injury Illness Prevention Plan (IIPP) and does not take an active role in the safety of the its employees. When the Modoc Grand Jury questioned a range of employees on this subject none recognized or were aware of any IIPP plan. 10. The ambulance maintenance plan is unclear and reactive rather than precise and proactive. Continued work with the ambulance employees is needed to ensure a top- quality ambulance service, because the ambulance crew is often the first contact for the hospital and a well-run ambulance reflects well on MMC. Review of Prior Year Grand Jury Recommendations The 2005-2006 Grand Jury has reviewed the recommendations from the previous year’s Grand Jury and found that there are a number of issues on which MMC has made improvements. • Management has been changed. A CFO was hired and then named CEO at a later date. • Registry provider use has been cut significantly. • A new write-off policy is in place. • Outside consultants have been hired and have given recommendations. Hazardous materials alleged in previous Grand Jury Report were not found, and current management is following current state approved guidelines for hazardous material handling. Here are some items that are still in question: • The Board of Supervisors dissolved the Board of Trustees. • The Board of Supervisors has not established what medical services are to be provided by MMC. • The Policy and Procedures manual has not been updated to comply with the California State and Federal Government laws and codes. • The MOU with the Medical Center employees still differs from the General Unit’s or the Sheriff’s Office’s MOUs in significant areas. • Nurses and staff are still working outside their licensure and certifications. For example, a member of the staff was asked to act in capacity of respiratory therapist when that position was no longer under contract. • The MMC departments do not cross-train their own staff. Cross-training is needed in part because of employee turnover. Several consultants have emphasized this. Recommendations: 1. The Board of Supervisors is responsible to the county for the management and oversight of the full spectrum of county business. Managing the hospital, as a governing board is time- consuming, particularly in that it requires specialized knowledge. Re-establishing a Hospital Board of Trustees is an option that should be considered in order to free the Board of Supervisors to carry out all its responsibilities effectively. The Board of Trustees members can be selected so that their cumulative knowledge and experience covers the full array of hospital administration and operation. 2. The Modoc Medical Center should clearly enforce a volunteer policy that establishes guidelines and roles of volunteers. Every volunteer should have a written agreement clearly describing duties and responsibilities. The Modoc Grand Jury finds that the misuse of volunteer status undermines the work of the management and staff at the MMC. Volunteers should never give direction to employees, make personnel decisions, advise the Board of Supervisors, or have access to any hospital records. 3. The exit interview system must be revamped. It is recommended that an exit interview plan be developed that includes the following features: • Confidentiality, • A standard form, • An employee option to include a union representative if interviewed, • Completed interviews submitted by employee to 3rd-party human resource specialist for purposes of compiling the information provided by exiting employees and preparing analysis for Board of Supervisors review. The exit interview plan must be designed to provide the union and the Board of Supervisors with workplace information, trends in causes for losing employees, and ways to improve the workplace and retention. Exiting employees should be able to keep a copy of the interview form and get a copy of their personnel file on request. 4. The Modoc Medical Center should update and establish an Injury Illness and Prevention Plan (IIPP) that has been approved by the County Risk Management team. All employees must have training in all areas of safety and have regular documented safety meetings. Every employee must know about, and where to find, the Injury Illness and Prevention Plan. 5. The Modoc Medical Center should continue working with the two new ambulance managers to maintain and improve ambulance maintenance. The Program must be designed to be proactive and not reactive. Ambulance maintenance should be a top priority for any hospital, particularly in a rural setting. 6. The Modoc Medical Center should develop an accurate and comprehensive inventory control and property plan. The MMC currently has no clear inventory controls and it is therefore not clear what property is MMC’s, what is personal to an employee, or what belongs to another agency. This has led to at least one legal dispute and such disputes can be avoided in the future. Clear guidelines must be in place that gives direction on the purchase, loaning out, or receipt of inventory items, and disposition of property no longer meeting the needs of the MMC. 7. In the future, the board of Supervisors should pursue recruitment of hospital CEOs that meet the job description and standards established by Board of Supervisors policy. (See Addendum below titled Article II, Section 1 Administration, ). 8. The Modoc Medical Center still looks outdated and old. Emphasis on maintenance must be a priority and budgeting for internal and external appearance must be taken seriously. Appearance and presentation goes a long way in the public eye. A positive example is the notably improved appearance of the Clinic under its new manager. A short term and long term maintenance plan needs to be established and publicly announced to help promote change. 9. As emphasized by consultants, agencies such as the MMC and Clinic must pay close attention to state and federal billing laws to avoid major liability Respondents: Modoc County Board of Supervisors Modoc Medical Center CEO/CFO ADDENDUM -Board of Supervisors Policy ARTICLE III ADMINISTRATION SECTION 1 – ADMINISTRATOR The Governing Board shall select and appoint an Administrator. This will be done through a panel interview process. The Administrator shall be the Governing Board’s representative in the management of the Hospital. The Governing Board and Title 22 shall qualify the Administrator. Candidates for the position of Administrator must meet the following criteria. a. Education: Graduation from a recognized college with a Master’s Degree, preferably in hospital and /or business administration. (Two years of additional responsible healthcare administration experience with a Bachelor’s degree may be substituted for the Master’s Degree. b. Experience: Two years of experience as an administrator in charge of a general hospital or as an assistant administrator of a hospital, or four years experience in healthcare administration (additional healthcare experience or background may be considered.) c. Knowledge of: Principles and methods of hospital administration and management; standards of medical service, budgetary planning and fiscal control, personnel management; regulations pertaining to hospital operations; the organization and maintenance of records. d. Ability to: Plan and execute large-scale administrative programs including preparing budgets and controlling large expenditures; establish and maintain cooperative relationships with the general public, with medical and other professional groups, and with other public agencies and departments of government, communicate effectively in oral and written form. The State Department of Health Services shall be notified in writing whenever a change in administration occurs. The Administrator shall be given the necessary authority and responsibility to operate the Hospital in all its activities and departments, subject to the provisions of Modoc County Ordinances, policies adopted by the Governing Board and applicable Federal and State laws and regulations. The Administrator shall act as the duly authorized representative of the Governing Board in all matters in which the Governing Board has not formally designated some other person to act. LAW ENFORCEMENT Areas of Study: • Required Annual Inspection of Devil's Garden Conservation Camp • Required Annual Inspection of Modoc County Jail • 911 System • Complaints received from citizens Devil's Garden Conservation Camp Members of the Grand Jury inspected the Devil's Garden Conservation Camp. The camp is jointly operated by the California Department of Forestry and Fire and the California Department of Corrections. During 2005 crews provided the local communities with 37,016 hours of conservation work, State agencies with 13,522 hours, Federal agencies with 36,240 hours (BLM 11,096, US Forest Service 14,000 and US Fish and Wildlife 10,392). In addition crews responded to 32 fires and provided 44,241 hours in fire fighting. (2005 was a slow fire season) The camp still sponsors a bike-refurbishing project and maintains its sign shop. The camp is commended for all the community services it provides. Recommendations: None Respondents: None Modoc County Jail Members of the Grand Jury toured the Modoc county Jail operated by the Modoc County Sheriff’s Office. The capacity of jail is 52 inmates. The jail averages 35 to 38 inmates with about ten percent being females. Facilities offered to inmates include a library, recreation area and laundry room. Inmates are assigned to do the cooking, laundry, etc. The jail is staffed 24 hours a day with three officers assigned to the facility during the day (0700-1500), during the mid-day shift (1500-2300) two officers and during the evening (2300-0700) two officers. The jail is running efficiently. Based on an inspection by the State of California's Corrections Standards Authority in September of 2005 a number of issues were pointed out, particularly those pertaining to procedures and manuals. The Sheriff's Office has put together the documentation to comply. Recommendation: The Sheriff's Office to continue to follow up on the State of California's Corrections Standard Authority’s recommendations. Respondents: Modoc County Sheriff's Office 911 System The 911 system is complete with all residences in the county identified. All residential 911 calls come to the Sheriff s Office with cell phone 911 calls going to Susanville. Recommendation: None Respondents: None Complaints Received from Citizens Issues: Six separate complaints were received during the tenure of the 2005-2006 Grand Jury. 1. Mistreatment by a Sheriffs Deputy. 2. Speeding in Adin. 3. Deputy's use of foul language. 4. Deputy publicly divulging sensitive information. 5. Deputy's favoritism. 6. Domestic dispute not handled properly. Findings: The Grand Jury interviewed Sheriff Mix and the complainant regarding complaint No. 1, and found that there was no validity to the complaint, notifying the complainant of such action. Complaint No. 2, speeding in Adin, after interviewing the Sheriff, a member of the Highway Patrol and the Alturas Chief of Police, the speed limit in Adin has not been surveyed for an official speed limit by the State of California, nor has many other small communities in the county including some streets in Alturas. Because of this, unless the speeding is excessive, officers do not issue citations since the court will not uphold them. As to complaints 3, 4, and 5 the Sheriff's Office is aware of these complaints and has been working on them to get matters solved. There was a report of a domestic dispute and it was found there was no court order specifying the issues concerning the complaint. Therefore, the officer had no jurisdiction. Recommendations: None Respondents: None SPECIAL DISTRICTS/AUDITS Areas of Study: • Audits for Special Districts • Conflict of Interest Laws for Special Districts Audits for Special Districts Background: Special districts are required by law to be audited each year by the County Auditor if no other proper audit is filed with the Auditor (Government Code 26909). Costs are to be borne by each district. The audit may be done every two years if unanimously requested by the district board and unanimously approved by the Board of Supervisors, or every five years if the district’s budget does not exceed an amount specified by the Board. Districts also file annual financial reports with the State Controller (Government Code 53890). Issues: The required audits of special districts have not been forthcoming. Findings: 1. Few special districts have been audited and none have been filed with the County Auditor. 2. The County Auditor now estimates that each audit by a CPA would cost about $ 1,500.00. It may be possible to reduce the cost if the audits are performed at the same time or on a schedule convenient to the CPA. 3. Many of the small special districts are staffed by volunteers and have insufficient funds. The cost of audits is a significant burden for them. 4. Government Code 29009 does not address non-payment of audit costs by a district, but most districts have tax funds through the County and can be charged for the audit. 5. The County Auditor maintains the tax funds of most districts and pays bills on presentation of the invoice by the district. Many small districts work entirely though the Auditor. Many provide the original invoice for such bill payments. The Auditor could also handle donated or outside monies. For districts whose monies and original invoices are handled by the Auditor, the audit process would be much easier and presumably less costly. 6. Dependent districts are covered by the annual County audit. 7. The County Auditor is the initiator of the audits absent action by the districts (Government Code 26909(a)). 8. The County Auditor has been doing the annual financial reports to the State Controller for the districts (Government Code 53890). 9. Sound accounting, audits, filing of audits, and public review of the audits is important to efficient and proper government. Recommendations: The 2005-2006 Grand Jury recommends as follows: 1. The County Auditor should proceed expeditiously to audit all special districts that have not provided audits. The Grand Jury recommends the following elements for the audits: a. Notify all independent special districts that they are required to participate in an audit as per Government Code 26909: 1. They must make and file a proper audit with the Auditor by date certain, or 2. They must provide all original invoices and other financial paperwork as specified by the Auditor by date certain. They can achieve this by: a. keeping all of their accounts with the County and always submitting original invoices with payment warrants, b. or by submitting the paperwork before their scheduled audit date. The districts will be charged for the audit by the Auditor (a fixed amount or rate should be specified). Future audit expense can be reduced by submitting a request to the Board of Supervisors for a two or five year audit schedule that is unanimously approved by the district’s governing board as per Government Code 26909(f). Also some cost reduction might be achieved as above. b. Contract with a CPA to do all of the district audits, or hire a part-time or temporary audit staff member. At the estimated $ 1,500.00 per audit and 30 audits, that is $ 45,000.00. From the reports to the State Controller, the Auditor and CPA might negotiate a lower bulk contract based on size of district budgets. Negotiating the audit schedule for the convenience of the CPA or doing all of the audits at one time might lower the cost. c. Consider including the district audits in the annual County audit contract if it would reduce the cost. The two and five year audits could be scheduled with a certain number each year. d. The first audit should cover the past five years or back to the last filed audit whichever is the lesser. Future audits or audit filing would occur annually, or every two or five years if a 26909(f) schedule is approved. 2. The County Board of Supervisors should proceed expeditiously to establish five year and two year audits under Government Code 26909(f): a. Pass a resolution specifying maximum annual budget for the five year audit class. b. Develop a list of districts, which the Board would approve for the five or two year audits. c. Unanimously approve applications from the approved districts upon their proper request. Do the above as soon as possible and notify the County Auditor of the five year qualification amount and the approved five and two year list, so that the audits may proceed faster. Absent these steps, annual audits are required by law. Respondents: County Auditor County Board of Supervisors Conflict of Interest Laws for Special Districts Background: Special districts are subject to California conflict of interest laws and regulations. Government Code Title 9 prohibits public officials from using their official position to influence a decision in which they have a financial interest (GC 87100), requires them to disclose financial interests that might be affected by their official actions (GC 87200), and districts must adopt and file a Conflict of Interest Code (GC 87300). Additionally, AB1234 requires that any kind of compensation or reimbursement to district officials must be by a written policy and filed expense reports (GC 53232), and the officials must take a two hour “ethics training” every two years (GC 53235). Issues: Many of the small special districts are staffed by volunteers. The disclosure filing is intimidating. The Conflict of Interest Code filing is confusing and time consuming. The new compensation and ethics training law is another time and financial burden. Findings: 1. Special districts have complied with the financial disclosure requirement (Form 700). Some potential candidates have chosen not to serve because the filing is public and otherwise private matters must be disclosed, and some because of a misunderstanding of the requirements. The County Clerk is the “filing officer” for special district Form 700s. 2. Many small districts were exempted from filing Conflict of Interest Codes by Board of Supervisors resolution 95-08, however this exemption may no longer be valid (Fair Political Practices Commission Regulation 18751). 95-08 also provides that the list may be amended by the Board. 3. Some districts have not filed and received approval of their Conflict of Interest Codes. The County Board of Supervisors is the code reviewing body (Government Code 82011(b) and 87303). The filed codes may further limit or add to the types of disclosures required by Form 700 and therefore affect (1) above. 4. AB1234 ethics courses are being developed for in-person, on-site, or on-line use, and most involve costs and fees. AB1234 also requires a written reimbursement and compensation policy, and keeping of public records thereof. Retention of ethics training records is also required. 5. The County has general welfare responsibility and the special districts provide necessary services. Recommendations: The 2005-2006 Grand Jury recommends as follows: 1. That the County Clerk prepare a general guide document for Form 700 that points to or quotes the sections that describe what does not need to be reported, and is more specific about requirements for each specific district type when an approved Conflict of Interest Code applies. 2. That the Board of Supervisors review and update resolution 95-08 to include Canby Fire and other small districts. This should include verification that exemptions can still be granted under current law. 3. That the Board of Supervisors order the non-exempt districts to submit a Conflict of Interest Code (Government Code 87304), and work with them in preparing and approving the codes. A prototype could be developed for use by the small but numerous districts such as cemetery and fire protection, if they can no longer be exempted under FPPC Regulations. Provisions of the Conflict of Interest Codes could specify disclosure requirements that might ameliorate candidate concerns about Form 700. While the districts could appeal to the Fair Political Practices Commission for this help, that might not serve the interests of Modoc County. 4. The County should include the special districts in its plans for AB1234 Ethics training. Respondents: County Clerk County Board of Supervisors