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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

Trinity County Grand Jury • 2001-2002

Trinity County Behavioral Health Services Department

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Findings and Recommendations 8 findings

F1 Page 18
TCBHS Advisory Board agrees moral was low in the department at the time of the investigation.
No recommendations for this finding
F2 Page 11
Under the initial contract, the County paid Kings View an addi- tional $12,000 for training and setup services. Kings View training of County employees has been at best inadequate. At 21/2 years into the contract’s 3-year initial term, no training manuals have been made available. The Grand Jury finds that inadequate train- ing, and the lack of implementation of that training through appli- cable policies and procedures, is an underlying cause of the numer- ous compliance issues.
No recommendations for this finding
F3 Page 11
The TCBHS staff occupies office space at several locations around Weaverville. The former General Services building at the edge of the airport was recently renovated and accommodates the TCBHS ADDS functions and Adult Services clinicians, along with other County entities. However the walls at this facility are not suffi- ciently soundproofed to provide the necessary audio suppression during confidential client sessions. The same problem also exists at the Hayfork clinic, as was noted in a State On-Site Review in July 2001.
No recommendations for this finding
F4 Page 11
As noted in item 3 of the General Finding section, the computer- ized information management/accounting system has frequently failed. These malfunctions can, and have caused tardy or incom- plete billing, resulting in reduced State reimbursements. Also, the lack of a reliable email system has hindered communications within the department, as well as with external organizations (other County organizations, Kings View, State, etc.)
No recommendations for this finding
F5 Page 12
The Grand Jury received allegations that the Kings View informa- tion system failed for a period of four to six months. We also re- ceived allegations that numerous Medi-Cal billings were never sub- mitted, and that the total Medi-Cal reimbursement losses may have exceeded $100,000. Both the Mental Health Director and the Ex- ecutive Director indicated during interviews that some funds may have been lost due to errors or late billing, but the amounts were insignificant in their eyes, and certainly not of this magnitude. Given what the Kings View information management service is to provide contractually (refer to the Background section), and in an attempt to shed some light on these allegations, the Grand Jury initiated a test of the current information system. We requested fi- nancial information for fiscal year (FY) 2000-01 and FY 2001-02 to date, broken down by month, and including total revenue, Medi- Cal billings, and Medi-Cal reimbursements. We also requested, over the same time periods, and by month, the total numbers of clients, and the Medi-Cal client subset. During the same visit, the Grand Jury also requested copies of all State reviews, inspections, and audits involving TCBHS, from January 2001 to date. We also re- quested copies of the current State/County mental health provider contract, including any memorandaof-understanding (MOU), ad- denda, or any other documents that modify the initial contract. The Grand Jury did not obtain this information the day it was re- quested, nor on the following workday when Grand Jury members returned. It was two weeks later before we obtained the bulk of the material requested. The Grand Jury notes that industry standards normally require audit information be made available by the end of the workday on which it is requested. The Grand Jury did eventually receive the monthly Medi-Cal bill- ings and reimbursements for FY 1999-00, 2000-01, and 2001-02 through December. Given the Medicare/Medi-Cal reimbursement rate of 51.25 percent and the amounts billed and received, one can determine the potential “fully compliant” reimbursements, assum- ing no disallowance by the State, and consequently the revenue forfeited by the County for a lack of compliance. The following table illustrates these results, in which the numbers on the top two rows were provided by TCBHS, while those figures on the lower three rows were derived by the Grand Jury. FY 1999-2000 FY 2000-2001 FY 2001- Dec. Amount Billed $600,700. $805,856. $430,620. Amount Received $215,503. $307,384. $184,958. Fully Compliant $307,859. $413,001. $220,693. Reimbursement Forfeited Revenue $92,356. $105,617. $35,735. Reimbursement 70% 74% 84% Achievement Rate Keep in mind that the “forfeited revenue” figures are the difference between the “fully compliant reimbursement” (assuming full com- pliance with Federal and State requirements, resulting in no Medi- care/Medi-Cal disallowance) and the actual “amount received” by the County. The “reimbursement achievement rate” is simply the ratio of actual reimbursements “amounts received”) to the “fully compliant reimbursements”, and illustrates management’s effective- ness. While the Grand Jury realizes that, as a practical matter, achiev- ing 100 percent compliance is highly unlikely, we believe management’s goal should be reimbursement achievement rates of over 95 percent. Although the recent trend is in the right direction, management still has much to rectify. While the loss of potential revenue is staggering and adds credence to the original allegations, it does not constitute proof as to the remaining allegations. For example, it does not address the asser- tion that a significant number of billings were not submitted that would add significantly to reimbursement to the County. Because the Grand Jury could not either validate or dismiss all of the allega- tions, and because the Grand Jury lacks the resources necessary to conduct thorough financial and management audits, the Grand Jury finds that such audits should be performed to identify and correct any related problems. When the Grand Jury reviewed the State/County contract, we noted under Exhibit B - Payments Provisions, section 4 - Amounts Pay- able, that the State was to pay TCBHS an allocation amount of $126,096 for FY 2001-02. We had not received any documentation that modified this allotment, nor assigned it to another source. Since we had not been provided this figure during our interviews with the directors, we asked the Executive Director to explain this omis- sion. Initially, he was unable to explain it, and wanted a copy (in effect, a copy of a copy originally obtained from TCBHS). Several days later the Executive Director stated he believed this funding was a portion of the realignment funds listed in the County budget associated with Medi-Cal managed care reconciliation. The Grand Jury queried the State contract representative from the Department of Mental Health, and he informed us the allocation was direct fund- ing for the contract. Consequently the Grand Jury is still uncertain as to the real funding source and any restrictions associated with this revenue, and just where it resides in the funding explanations provided to us for the Background section. Examples such as these tend to erode the Grand Jury’s confidence in the Department’s man- agement. In summary, the Grand Jury finds that the Kings View information management system, as implemented at TCBHS, does not measure up to industry accounting standards. The Grand Jury believes that the type of fiscal information we requested should already have been available as printed monthly reports, but at the very least, should have been readily available from the computerized infor- mation system. The Grand Jury also finds that any prudent depart- ment manager should have had accounting reports provided monthly (as noted above) in order to verify and oversee the client informa- tion and costs being reported to the State, and for comparison with the reimbursements returned from the State. Any disallowance should have been a flag to management indicating a problem that required inquiry and solution, in order to maximize revenue return. A management information system can be a superb tool for manag- ers to properly execute their managerial duties and responsibilities, but only if properly utilized. As stated in the opening paragraph of this Finding #5, both the Mental Health Director and the Executive Director indicated dur- ing interviews that some funds might have been lost due to errors or late billing, but the amounts were insignificant in their eyes. This Grand Jury finds that the funds lost due to management negli- gence are not insignificant in our eyes, and believes that further investigations are warranted.
No recommendations for this finding
F6 Page 13
Given the numerous problems that have arisen in the Department during the transition to contract services with Kings View, and managed care medical delivery service in general, including the compliance issues identified during the State audits, the Grand Jury finds that the leadership and oversight has not been commensurate with the task. We recognize that the Mental Health Director is also the County Auditor and the interim CAO, in addition to other du- ties that he has been assigned. Overall, he can only devote about 30 percent of his time overseeing the TCBHS Department operations.
Related Recommendations (1)
R00-01
Page 17
(kv) Total Units 49,168 532,284 25,425 22,070 628,947 Paid Units 44,145 320,381 11,012 15,305 390,843 32.98% Rate/Unit - Published 1.33 1.71 3.18 2.57 Paid M/C Revenue $ 58,713 547;852 35,018 .39,334 680,916 37.03% RECOMMENDATION #5 No opinion. The state periodically audits the Department now. An independent audit may be redundant. FINDING #6 NA RECOMMENDATION #6 NA FINDING #7 r.e. Director The original Kings View contract called for an Executive Di- rector and a management information system. Both Kings View and the County entered into that agreement in good faith. What has been learned over that three year contract is that there are three specific skill sets that are necessary to adequately run a small county managed care mental health and alcohol and drug program: 1. Program and political expertise The ability to work with a di- verse group of staff from front office support staff to psycholo- gists and psychiatrists in a variety of settings. The ability to work collaboratively with other agencies towards common goals such as children’s system of care and CaIWORKS. The ability to work with a local county government structure and be respon- sive to the Board of Supervisors, Advisory Boards, and a variety of local agencies (both public and private) and special interest groups and interface with other counties, the state and federal gov- ernment. The ability to make and communicate decisions as to who can be served and who can’t based upon available resources, man- dates and regulations. 2. Fiscal Administration The ability to manage a budget composed of multiple funding sources, legislative mandates, cost report- ing systems and fiscal oversight bodies including complex systems such as the Medicaid system. 3. Quality Improvement The ability to develop, implement and monitor a medical model quality improvement process that assures the development and oversight of compliance standards and pro- cedures (this is even more important then ever before due to HIPAA requirements), proper documentation, client grievance pro- cedures, treatment authorization procedures, etc Four years ago, the County was not able to recruit a qualified Mental Health Director. Through Kings View, a Director that meets the qualifications of the State has been hired. During the past five years, the County has not been able to recruit or retain quali- fied people in the latter two areas described above. Many of the problems described in the Grand Jury report are directly related to the County’s inability to recruit and retain qualified Fiscal Administrative personnel and Quality Assurance personnel. It is only in the past 6 months - as a result of an amendment to the Kings View contract that shifted all of the above responsibilities to Kings View - that these issues have begun to be resolved. Cur- rently, via the Kings View contract, a highly qualified fiscal ad- ministrator with over 30 years experience (who has already increased revenues by identifying areas that Trinity County has never billed in the past) and a highly qualified Quality Improve- ment Coordinator with a similar level of experience are fulfilling the responsibilities that are bringing the Department into com- pliance, increasing revenues and improving the care of the cli- ents of Trinity County. The fundamental issue is that Trinity County, like every other county in the State agreed to become the managed care provider of mental health services. This decision was made in the mid nine- ties. While most other counties spent the next four or five years learning how to do managed care (including going through similar struggles as has been experienced over the past two years in Trinity County), Trinity County Behavioral Health resisted that responsibility. The County was unable to recruit or retain not only a Director, but, as mentioned above, a qualified fiscal administra- tor or a Quality Improvement Coordinator. Had the County been able to hire its own people in these positions, the Department would still have gone through exactly the same issues as it has recently been going through. RECOMMENDATION #7 A. I strongly disagree for the reasons mentioned above. It would not be in the County, the clients or the State’s best interest to ter- minate the Kings View contract. B. I agree that quality mental health services to our community must remain a top priority. I also agree that organizational changes will result in improved service delivery. Recommendations have been made to accomplish this and are included in the County Salary Study and in the proposed Kings View contract. FINDING #8 r.e. Advisory Board The roles, responsibilities and makeup of the Mental Health Advi- sory Board are clearly set forth in regulation. Besides attending all Advisory Board meetings, the Department management staff meets with the Advisory Board Executive Committee monthly and makes available to the Advisory Board all management staff at the Advisory Board’s request. To the extent that resources are avail- able, all informational requests of the Advisory Board receive a response.
F7 Page 13
Throughout most of its history, a single director has headed the County mental health organization. Now, under the Kings View contract, the organization’s management includes a Mental Health Director, an Executive Director, and a Deputy Director, in addition to the section/team leaders. As indicated in the background section and reported findings, both the Mental Health Director and Deputy Director hold other managerial appointments with separate respec- tive duties. The Executive Director, a Kings View employee, re- sides outside of Trinity County. In addition, the team leaders (es- sentially first-line supervision) have reduced some of their clinical duties, thus either impacting client services, or adding to the bur- den of the remaining clinical staff. The Grand Jury has found that the duties and responsibilities of the Mental Health Director and Executive Director are not well delin- eated and are inexorably intertwined. At times they overlap, at times they seem not to cover fully all the Department’s requirements, and, above all, are confusing to both departmental employees and outside observers. The Grand Jury finds that Kings View has not achieved the original contractual goal of clinical efficacy, cost efficiency, nor full com- pliance with State requirements. The Grand Jury finds that the post of Executive Director is extraneous, provided the Board of Super- visors accepts the previous recommendation for a full-time County Mental Health Director.
Related Recommendations (1)
R00-01
Page 17
(kv) Total Units 49,168 532,284 25,425 22,070 628,947 Paid Units 44,145 320,381 11,012 15,305 390,843 32.98% Rate/Unit - Published 1.33 1.71 3.18 2.57 Paid M/C Revenue $ 58,713 547;852 35,018 .39,334 680,916 37.03% RECOMMENDATION #5 No opinion. The state periodically audits the Department now. An independent audit may be redundant. FINDING #6 NA RECOMMENDATION #6 NA FINDING #7 r.e. Director The original Kings View contract called for an Executive Di- rector and a management information system. Both Kings View and the County entered into that agreement in good faith. What has been learned over that three year contract is that there are three specific skill sets that are necessary to adequately run a small county managed care mental health and alcohol and drug program: 1. Program and political expertise The ability to work with a di- verse group of staff from front office support staff to psycholo- gists and psychiatrists in a variety of settings. The ability to work collaboratively with other agencies towards common goals such as children’s system of care and CaIWORKS. The ability to work with a local county government structure and be respon- sive to the Board of Supervisors, Advisory Boards, and a variety of local agencies (both public and private) and special interest groups and interface with other counties, the state and federal gov- ernment. The ability to make and communicate decisions as to who can be served and who can’t based upon available resources, man- dates and regulations. 2. Fiscal Administration The ability to manage a budget composed of multiple funding sources, legislative mandates, cost report- ing systems and fiscal oversight bodies including complex systems such as the Medicaid system. 3. Quality Improvement The ability to develop, implement and monitor a medical model quality improvement process that assures the development and oversight of compliance standards and pro- cedures (this is even more important then ever before due to HIPAA requirements), proper documentation, client grievance pro- cedures, treatment authorization procedures, etc Four years ago, the County was not able to recruit a qualified Mental Health Director. Through Kings View, a Director that meets the qualifications of the State has been hired. During the past five years, the County has not been able to recruit or retain quali- fied people in the latter two areas described above. Many of the problems described in the Grand Jury report are directly related to the County’s inability to recruit and retain qualified Fiscal Administrative personnel and Quality Assurance personnel. It is only in the past 6 months - as a result of an amendment to the Kings View contract that shifted all of the above responsibilities to Kings View - that these issues have begun to be resolved. Cur- rently, via the Kings View contract, a highly qualified fiscal ad- ministrator with over 30 years experience (who has already increased revenues by identifying areas that Trinity County has never billed in the past) and a highly qualified Quality Improve- ment Coordinator with a similar level of experience are fulfilling the responsibilities that are bringing the Department into com- pliance, increasing revenues and improving the care of the cli- ents of Trinity County. The fundamental issue is that Trinity County, like every other county in the State agreed to become the managed care provider of mental health services. This decision was made in the mid nine- ties. While most other counties spent the next four or five years learning how to do managed care (including going through similar struggles as has been experienced over the past two years in Trinity County), Trinity County Behavioral Health resisted that responsibility. The County was unable to recruit or retain not only a Director, but, as mentioned above, a qualified fiscal administra- tor or a Quality Improvement Coordinator. Had the County been able to hire its own people in these positions, the Department would still have gone through exactly the same issues as it has recently been going through. RECOMMENDATION #7 A. I strongly disagree for the reasons mentioned above. It would not be in the County, the clients or the State’s best interest to ter- minate the Kings View contract. B. I agree that quality mental health services to our community must remain a top priority. I also agree that organizational changes will result in improved service delivery. Recommendations have been made to accomplish this and are included in the County Salary Study and in the proposed Kings View contract. FINDING #8 r.e. Advisory Board The roles, responsibilities and makeup of the Mental Health Advi- sory Board are clearly set forth in regulation. Besides attending all Advisory Board meetings, the Department management staff meets with the Advisory Board Executive Committee monthly and makes available to the Advisory Board all management staff at the Advisory Board’s request. To the extent that resources are avail- able, all informational requests of the Advisory Board receive a response.
F8 Page 13
The number of compliance issues cited during the State Oversight Review in January dumbfounded the TCBHS Advisory Board. Though they meet monthly (some times more frequently) with the Executive Director, they were perplexed by the large number of deficiencies. The Mental Health Director is present at some of these meeting as well. When the Grand Jury interviewed the TCBHS directors (separately), each downplayed any problem or issues we introduced, be they from citizens complaints, or issues we had uncovered during our investigation. The Advisory Board has apparently been satisfied by similar assurances. The contract with Kings View states that the selection of the Ex- ecutive Director shall be subject to the approval of the County. The Grand Jury assumes that the “approval of the County” involves review and advice from the Advisory Board. Yet the Advisory Board was simply informed about Kings View Executive Director appoint- ments after the fact, and was not part of the process.
Related Recommendations (1)
R00-01
Page 17
(kv) Total Units 49,168 532,284 25,425 22,070 628,947 Paid Units 44,145 320,381 11,012 15,305 390,843 32.98% Rate/Unit - Published 1.33 1.71 3.18 2.57 Paid M/C Revenue $ 58,713 547;852 35,018 .39,334 680,916 37.03% RECOMMENDATION #5 No opinion. The state periodically audits the Department now. An independent audit may be redundant. FINDING #6 NA RECOMMENDATION #6 NA FINDING #7 r.e. Director The original Kings View contract called for an Executive Di- rector and a management information system. Both Kings View and the County entered into that agreement in good faith. What has been learned over that three year contract is that there are three specific skill sets that are necessary to adequately run a small county managed care mental health and alcohol and drug program: 1. Program and political expertise The ability to work with a di- verse group of staff from front office support staff to psycholo- gists and psychiatrists in a variety of settings. The ability to work collaboratively with other agencies towards common goals such as children’s system of care and CaIWORKS. The ability to work with a local county government structure and be respon- sive to the Board of Supervisors, Advisory Boards, and a variety of local agencies (both public and private) and special interest groups and interface with other counties, the state and federal gov- ernment. The ability to make and communicate decisions as to who can be served and who can’t based upon available resources, man- dates and regulations. 2. Fiscal Administration The ability to manage a budget composed of multiple funding sources, legislative mandates, cost report- ing systems and fiscal oversight bodies including complex systems such as the Medicaid system. 3. Quality Improvement The ability to develop, implement and monitor a medical model quality improvement process that assures the development and oversight of compliance standards and pro- cedures (this is even more important then ever before due to HIPAA requirements), proper documentation, client grievance pro- cedures, treatment authorization procedures, etc Four years ago, the County was not able to recruit a qualified Mental Health Director. Through Kings View, a Director that meets the qualifications of the State has been hired. During the past five years, the County has not been able to recruit or retain quali- fied people in the latter two areas described above. Many of the problems described in the Grand Jury report are directly related to the County’s inability to recruit and retain qualified Fiscal Administrative personnel and Quality Assurance personnel. It is only in the past 6 months - as a result of an amendment to the Kings View contract that shifted all of the above responsibilities to Kings View - that these issues have begun to be resolved. Cur- rently, via the Kings View contract, a highly qualified fiscal ad- ministrator with over 30 years experience (who has already increased revenues by identifying areas that Trinity County has never billed in the past) and a highly qualified Quality Improve- ment Coordinator with a similar level of experience are fulfilling the responsibilities that are bringing the Department into com- pliance, increasing revenues and improving the care of the cli- ents of Trinity County. The fundamental issue is that Trinity County, like every other county in the State agreed to become the managed care provider of mental health services. This decision was made in the mid nine- ties. While most other counties spent the next four or five years learning how to do managed care (including going through similar struggles as has been experienced over the past two years in Trinity County), Trinity County Behavioral Health resisted that responsibility. The County was unable to recruit or retain not only a Director, but, as mentioned above, a qualified fiscal administra- tor or a Quality Improvement Coordinator. Had the County been able to hire its own people in these positions, the Department would still have gone through exactly the same issues as it has recently been going through. RECOMMENDATION #7 A. I strongly disagree for the reasons mentioned above. It would not be in the County, the clients or the State’s best interest to ter- minate the Kings View contract. B. I agree that quality mental health services to our community must remain a top priority. I also agree that organizational changes will result in improved service delivery. Recommendations have been made to accomplish this and are included in the County Salary Study and in the proposed Kings View contract. FINDING #8 r.e. Advisory Board The roles, responsibilities and makeup of the Mental Health Advi- sory Board are clearly set forth in regulation. Besides attending all Advisory Board meetings, the Department management staff meets with the Advisory Board Executive Committee monthly and makes available to the Advisory Board all management staff at the Advisory Board’s request. To the extent that resources are avail- able, all informational requests of the Advisory Board receive a response.

Additional Recommendations 20

These recommendations are not explicitly linked to specific findings.