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Neither new nor experienced PAlPG employees have an adequate manual for reference when they encounter a situation that requires guidance. They ask senior deputies for advice which often is conflicting. Advice given by one deputy to another can perpetuate the same mistake. A functional manual as mandated by PA/PG or HHSA management would prevent this from occurring. Response: Disagree. A manual of policies & procedures is currently available as a reference document for employees and will continue to be updated as new processes are implemented. The last update of the manual was completed in December 2005.

The PAlPG staff is not adequately trained in the requirements to insure property for loss and liability, and the need for inventorying all property of the estate at the time of appointment by the court or within a reasonable time thereafter. Response: Disagree. PAlPG staff is adequately trained in the requirements to insure property. Further, it is department policy to insure real property upon appointment by the court.

The Grand Jury finds that the problems occurring in the estates given as examples were adirect result of inadequate supervision. Response: Disagree. This statement istoo general forresponse. RECOMMENDATIONS: The Grand Jury recommends that the San Diego County Board of Supervisors: Recommendation 06-42: Appoint an independent committee to review the Policy and Procedures Manual for consistency and relevance to the work performed. Response: This recommendation will not be implemented because it is not warranted. Because of their familiarity with staff duties andprogram requirements, HHSA and PA/PG management regularly review the policy andprocedures manual for consistency and relevance. Recommendation 06-43: Institute procedures that require regular supervisory review of the estates assigned to the PA/PG. Response: This recommendation will not be implemented because it is not warranted. The recommended procedures are already in place. Presently, supervisors meet with deputies on an ongoing basis to review estates and determine the best course of action. The PA/PG has also implemented aprocess to enhance this review. This includes a series of meetings to evaluate the sale of real property, securities, and medical decisions and to make referrals for investment/financial planning. The process also includes individual meetings with County Counsel, as well as Unit meetings to address case management issues. Recommendation 06-44: Require an immediate inventory ofall property as soon asthe PA/PG is appointed to administer an estate. Response: This recommendation will not be implemented because it is not warranted. The probate code requires an inventory and appraisal to be completed within 120 days of appointment for the Public Administrator and 90 days for the Public Guardian. The PA/PG routinely inventories andprotects assets asmandated by law. Recommendation 06-45: Require thepurchase ofproperty insurance assoon asproperty is acquired. Response: This recommendation will not be implemented since the recommended procedure is already in place. Itisthe policy of the PA/PG to insure real property upon appointment by the court. Recommendation 06-46: Order areview ofthe Cedar Fire case to determine if the estate is entitled to restitution. Response: This recommendation will not be implemented because it is not warranted. The issues have already been thoroughly reviewed. The opening of this estate by the Public Administrator was initiated by apetition filedby the Borrego Springs Bank alleging that the decedent's daughter was defrauding thebank through her cashing of her deceased father's social security checks for aperiod after his death. The daughter was the sole heir. In the final accounting of the estate, she agreed to assign aportion of her total distribution aspayment to satisfy the Bank's claims. She decided not to file an objection to the accounting or aclaim against the County related to the fire loss, andthe matter is closed. The final accounting with proper disclosure was approved by the probate court. By law, since the estate's administration has concluded and the time to appeal has passed, there is no legal means by which the Grand Jury's recommendations can be carried out. SECTION TWO: PA/PG Client Medical Errors FINDINGS:

Public Guardian clients will have to unnecessarily spend their own funds to pay for medical services or prescriptions if Public Guardian employees have insufficient understanding of the extensive State and Federal medical options and regulations. Response: Disagree. There isno basis for this finding.

The staff indicated that the policy and procedures manual gave them little guidance. The Health Insurance employee testified that shewas only given a few hours of medical insurance billing training. Response: Disagree. As stated above, a policy and procedure manual for staff reference is currently available and updated regularly. In addition, staff was provided training/guidance from Social Security and the State Department of Health Services staff, as well as training from the Health Insurance Counseling Advocacy Program (HICAP).

The Grand Jury Audit disclosed that the PAlPG Office in San Diego County has not complied with the law asitpertains to administering estates. Response: Disagree partially. This finding is ambiguous. The PAlPG believes this finding relates to the notification of the State Department of Health Services (DHS) with all PA cases. The Public Administrator routinely notifies DHS regarding the death of a client. The case identified in the audit has been resolved. This practice is overseen by aPAlPG supervisor. RECOMMENDATIONS: The Grand Jury recommends that the San Diego County Board of Supervisors: Recommendation 06-47: Authorize installation of aCounty Meds Computer system in the PAlPG Office. Response: This recommendation will not be implemented because it is not warranted. The PAlPG electronically determines the eligibility status of clients using a County database. The County Meds Computer system would not be of additional benefit to the PAlPG. Recommendation 06-48: Require the PAlPG Office to establish an ongoing Medi- Cal/Medicare Eligibility Training program. Response: This recommendation will be implemented. The PAlPG is developing a training module to provide staff with Medi-Cal, SSI,Medicare andMedicare Part D Prescription information which will also address eligibility issues. This will be implemented by December 2006. Recommendation 06-49: Require case reviews by all PAlPG staff with their supervisors. Response: This recommendation will not be implemented because it is not warranted; The recommended action is already in place. Presently, supervisors meet with deputies to review cases on an ongoing basis and determine the best course of action. The PAlPG has also implemented aprocess to enhance this review. This includes a series ofmeetings to evaluate the sale ofreal property, securities, and medical decisions as well as to make referrals for investment/financial planning. The process also includes individual meetings with County Counsel, as well as Unit meetings to address case management issues. Recommendation 06-50: Require procedures to validate which medical providers were paid with supporting documentation for those payments. Response: This recommendation will not be implemented because it is not warranted; The recommended action is already in place. Procedures are in place to validate payments to medical providers, aswell as supporting documentation. Recommendation 06-51: Require the establishment of a priority for payments to providers based upon legal requirements. Response: This recommendation will not be implemented because it is not warranted; The recommended action is already in place. County Counsel has provided PA/PG staff with direction as it relates to priority of payments, and in accordance with the law. The Public Administrator supervisor currently validates the priority ofpayments. SECTION THREE- PAlPG Management and Personnel Issues FINDINGS: