Foreword – Reaction to Board of Supervisors’ Response to Parts I & II

Recommendations 8

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  The Grand Jury recommends that a task force be formed comprised of expert end users and outside vendors, charging them with the responsibility of streamlining the procurement process and improving the customer service level to all internal departments and external vendors. This end user task force should include members from all major County functions. The BOS should champion this process and assign one of the Supervisors to oversee the progress of this task force, with a monthly update from the leader of this task force to him/her and the CAO. We recommend that this task force start with a “blank page,” and identify an appropriate flow process, effective computer systems’ support and lead times that best serve the needs of the County and outside vendors. Significant progress has already been made in identifying the current process, but the challenge to the team is to identify what changes should be made to improve the procurement process. 2. The completed task force report should be written and submitted to the BOS with all recommended changes no later than the end of fiscal year 2008-2009. 3. No additions to personnel should occur until such time as a full review of the procurement process is completed. RESPONSES Response(s) to this report is required in accordance with California Penal Code §933.05 20 -003 REASON FOR REPORT The El Dorado County Grand Jury received several complaints from citizens of South Lake Tahoe. The complaints centered on the verbally abusive behavior and menacing actions of the South Lake Tahoe Chief of Police. Investigation of these complaints uncovered additional information which prompted the Grand Jury to look further into his managerial and behavioral issues.
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  The State identified issues “that may prove useful when conducting internal reviews” and help the counties “maintain an accountable and effective program.” DHS has applied the information provided by the State to its internal review process. The Program Manager who oversees the The person who oversees the TCM reimbursement claiming TCM and MAA program reimbursement process is actually a Department Analyst, not a Program claiming processes reviews encounter Manager. progress notes before invoicing the State An internal review of TCM encounters is conducted monthly for reimbursement, but does not review by the Analyst. The internal review determines which client files for overall compliance with encounters meet TCM requirements and will be submitted for program requirements. For example, reimbursement. although the progress notes for encounters TCM does not require annual re-assessments. Re-assessments may be reviewed discretely, the entire on an annual basis are a California Department of Aging client file may not reviewed as a whole, program requirement; annual re-assessments are not a TCM and items that are required of the client compliance requirement. file, such as annual Assessments may not be checked for compliance. 5 http://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx. Final Draft Response to the 2007-08 Grand Jury Final Report Part 3 Doc HMR Audit Report Statement DHS Response The Public Guardian provides services that Given that 58.3% of the clients selected by the Auditor were are contingent upon the Office’s representative payees, DHS would expect a statistically appointment as conservator for an significant impact on the results of the audit. While financial individual by the Superior Court or management is mandatory, provision of TCM services requires through its Representative Payee program the cooperation of the client. Representative payee clients for individuals who receive income participate in TCM services but may (and often do) decline through public entitlements, public specific services. Representative payees have the right to benefits programs or other benefits refuse Public Guardian referrals and assistance with any matter programs and voluntarily seek financial that is not financial in nature. management services. For example, although the progress notes for encounters may be reviewed discretely, the entire client file may not reviewed as a whole, and items that are required of the client file, such as annual Assessments may not be checked for compliance. TCM does not require re-assessments. Re-assessments on an 26 The Assessment documentation provided annual basis are a California Department of Aging program by DHS for all but one of the twelve requirement for the Linkages Program (not the Public Public Guardian clients reviewed were Re- Guardian Program). The audit uses the term “re-assessment” assessments rather than the requested to refer to TCM documents that are not utilized by, and are not clients Assessments in effect for the period required to be utilized by, Public Guardian. being reviewed. The Public Guardian’s Re-assessment form contains only four categories: 1) Medical/Mental; 2) Social/Environmental; 3) Financial; and 4) Closing (for comments and summary statements). Most of the Targeted Case Management Due to limitations in the data reviewed, DHS disagrees with records reviewed for Public Guardian the conclusion that most of the TCM records reviewed for clients were found non-compliant with one Public Guardian were found non-compliant. or more aspects of Program regulations. If this pattern holds true for all Public Guardian clients, a good portion of the Department’s Medi-Cal revenues for this program are at risk of being disallowed for non-compliance with Targeted Case Management regulations. On the other hand, records reviewed for TCM regulations do not specify documentation formats or type Linkages program clients were found to be of forms. Linkages documentation conforms to the substantially compliant. These records requirements of the California Department of Aging. were more thorough and structured consistent with Targeted Case Management requirements. Some areas of the Linkages program billing records, however, were found to be noncompliant with program requirements or determinations of compliance could not be made because of the form in which case file records were provided by DHS. Final Draft Response to the 2007-08 Grand Jury Final Report Part 3 Doc HMR Audit Report Statement DHS Response Assessment and Individual Client Service Plan documents provided by the Department for a number of clients were prepared after the Periodic Reviews provided so it was not possible to determine if service plans and objectives in effect at the time of the Periodic Reviews had been assessed by the case managers. It is true that some of the documents submitted were 25 The second other impairment was that the inadvertently for the most current date and not the encounter Assessment and Individual Client Service date. The Auditor did not communicate to DHS management Plan documents provided for some of the that this was a barrier or work towards resolving the issue. case records were prepared after the Periodic Review documents provided though the request was made for Assessments and Client Service Plans in effect during the review period for each client. Some of the Service Plans provided by DHS were those prepared after the 13 month review period for the case records. Given the rate of non-compliance found The Audit Report does not provide the calculations or define with the sample Targeted Case the methodology substantiating the possible disallowances. Management records reviewed, the DHS disagrees with the audit as to the total number of non- Department of Human Services is at risk compliant TCM encounters and the potential risk of of Medi-Cal disallowances of up to disallowance. $147,747 for Fiscal Year 2006-2007 if the DHS agrees that any amount resulting from potential sample results apply to all Medi-Cal disallowances would be reduced if deficiencies were corrected beneficiary program clients. To the extent to the State’s satisfaction. that deficiencies found can be corrected to the State’s satisfaction, this amount would be reduced. As of January 2008, the Public Guardian It must be clarified that not all Medi-Cal beneficiaries are was serving 327 clients, of which 153 eligible for or receive TCM services. As of February 2008 were Medi-Cal beneficiaries. (not January 2008), the Public Guardian was serving 327 clients, of which 206 were Medi-Cal beneficiaries and of those 206, 153 were eligible for TCM services. Final Draft Response to the 2007-08 Grand Jury Final Report Part 3 Doc HMR Audit Report Statement DHS Response 1. Needs Assessment. The Assessment It appears this information was extrapolated from the TCM documents the conditions of the client and Provider Manual. These statements omit consideration or supports the selection of services for the discussion of relevancy to the individual in assessing the individual. The Assessment should contain client’s needs. at least the following elements: 1) The more detailed discussion of the Assessment within the medical/mental health; 2) training; 3) TCM Provider Manual states: vocational needs; 4) social/emotional “The documented assessment identifies the issues; 5) housing/physical needs; 6) beneficiary's needs. The assessment family/social matters; and, 7) finances. supports the selection of activities and 26 The purpose of the required TCM assistance necessary to meet the Assessment is to document the client’s beneficiary’s assessed needs and must needs in the following areas: 1) include the following, as relevant to each Medical/Mental Health; 2) Training needs individual: for community living; 3) • Medical/mental condition. The Vocational/Education needs; 4) Physical assessment may require obtaining needs, such as food and clothing; 5) evaluations completed by other providers Social/Emotional status; 5) of service. Housing/Physical environment; and, 6) • Training needs for community living. Family/Social Support systems. • Vocational/educational needs. • Physical needs, such as food and 27 The Public Guardian’s Re-assessment clothing. form contains only four categories: 1) • Social/emotional status. Medical/Mental; 2) Social/Environmental; • Housing/physical environment. 3) Financial; and 4) Closing (for • Familial/social support system.6 comments and summary statements). [Emphasis added.] While some of the other elements required for TCM Assessments are embedded in the For example, a 90-year old assisted living facility resident is four Re-assessment categories (e.g., unlikely to require a vocational needs assessment. Conversely, Family/Social Support Systems is a a mentally retarded 19 year old representative payee living subsection of the Social/Environmental with his or her parents would be unlikely to need a housing category) or may be addressed in summary assessment. written comments, some of the TCM At the time a Periodic Review is performed, the Public required elements such as Training or Guardian case worker prepares an updated Service Plan, even Vocational/Education needs are simply not if there are no changes to the previous Service Plan. This included and could potentially go prompts the case manager to address 19 distinct areas unaddressed in Re-assessments. The identified on the form to be assessed in terms of meeting the Public Guardian could ensure greater client’s needs. compliance with TCM Assessment requirements and greater continuity in client services by revising its Re- assessment standardized forms to include all required Assessment elements. TCM Provider Manual, Section 2, Targeted Case Management Program Descriptions, page T.2-1-1. Final Draft Response to the 2007-08 Grand Jury Final Report Part 3 Doc HMR Audit Report Statement DHS Response 3. Periodic review. This is an evaluation of the beneficiary’s progress toward achieving goals in Individual Client Service Plans must be assessed at least every six months. The Linkages program requires periodic review at least every 3 months. TCM requirements are for Periodic Reviews at least every six months for the Public Guardian and every three months for the Linkages program. It appears these statements were paraphrased from the TCM 31 The TCM service components and Provider Manual. However, the statements do not fully requirements for the Linkages program is incorporate relevant elements of said document, resulting in a the same as for the Public Guardian with misrepresentation of said facts. The referenced document the exception that Periodic Reviews must actually states: take place at least every three months “The case manager must periodically instead of the Public Guardian requirement reevaluate the beneficiary's progress toward of every six months. achieving the objectives identified in the service plan to determine whether current 33 Though TCM regulations require Periodic services should be continued, modified, or Reviews of program clients at least every discontinued. The review shall be: six months, the Linkages program has a more restrictive requirement that Periodic • Completed at least every six months” 7 Reviews take place at least every three [Emphasis added.] months. There is a separate California Department of Aging requirement for the Linkages Program that a face-to-face 33 As shown in Exhibit 4.7, the majority of contact with the client must occur every three months. This is Linkages Program Period Reviews were a Linkages requirement, not a TCM requirement.8 conducted within the required three month interval requirement. While the case records reviewed showed that most Linkages clients do receive visits from the case managers more frequently than the minimum required four times a year, the fact that certain Linkage and Consultation services are not documented as such has resulted in an absence of TCM required 30 day follow-ups to such services. TCM Provider Manual, Section 2, Targeted Case Management Program Descriptions, page T.2-1-2. Linkages Program Manual, Section 7.E., Monitoring and Follow-Up, . Final Draft Response to the 2007-08 Grand Jury Final Report Part 3 Doc HMR Audit Report Statement DHS Response Page Twenty Medi-Cal eligible clients were The cut-off date was actually July 2007, not August 2007. randomly selected for review from the Documentation was not submitted for 8 clients because: 4 had Public Guardian’s client list. DHS did not not received TCM services prior to July 2007, 3 had not submit documentation for eight of the 20 received billable TCM services within the 13 month time requested sets of records for the following frame, and 1 client was erroneously included in the sample list. stated reasons: three had billings after the The Auditor did not request additional client records to bring August 2007 cutoff date, two were the sample size back up to 20. erroneously attributed to the program sample and three had not received services. Consequently, twelve of the twenty requested Public Guardian Medi- Cal beneficiary client case records were reviewed. Final Draft Response to the 2007-08 Grand Jury Final Report Part 3 Doc HMR Audit Report Statement DHS Response A minority of the twelve randomly DHS disagrees that records that are fully compliant with TCM selected sets of Public Guardian client Program regulations are at risk for Medi-Cal disallowances. records reviewed were found to be fully compliant with TCM program regulations and are thus at risk for Medi-Cal disallowance. The Individual Client Service Plan This statement misquoted the referenced document and did not documents in the sample client records fully incorporate relevant aspects of said document, resulting could be characterized more as checklists in a misrepresentation of facts. The referenced document rather than “written, comprehensive states: individual service plans”2, as required by “written, comprehensive, individualized TCM regulations. Instead of writing, many service plan”9 Plans simply contained checked off boxes All Service Plans are client-specific. The TCM Provider for “Problems or Service Areas” such as Manual actually states that the plan will be individualized to “Financial” with no written commentary or the client. Therefore, some areas may not require written specific objectives or actions to be taken. commentary or specific objectives or actions in need of Many of the Plans reviewed did not attention. For example, a 90-year old assisted living facility identify services the client would be resident is unlikely to require a vocational needs assessment. referred to, as required by TCM Conversely, a mentally retarded 19 year old representative regulations, or were simply comprised of payee living with his or her parents would be unlikely to need notes regarding previous actions taken by a housing assessment. the case manager such as, “Deputy Public Guardian got a temporary card for file.” Checkboxes are a tool used to indicate which areas need attention from the case worker. The Public Guardian case 2 Targeted Case Management Overview, manager prepares the Service Plan, which prompts the case page T-2-1-1, California Department of manager to consider 19 distinct areas identified on the form to Health Care Services. be assessed for meeting the client’s needs. DHS agrees that case notes regarding actions by the case managers could be more directly related to the Service Plan areas and has taken steps to improve both the correlation of the areas and the review by supervisory staff. TCM Service Plans do not have a required format. Service Plans may be designed by each program participating in TCM using the format that works best for them. Check boxes are an acceptable method as evidenced by the State’s use of the forms, which El Dorado County Public Guardian staff participated in the development of, during a Statewide TCM training. In fact, DHS staff informed the Auditor that they had attended Statewide TCM training for Public Guardian providers, that DHS had assisted in the development of the State-accepted forms used during the training, and that DHS staff assisted in training representatives from other Public Guardian offices. TCM Provider Manual, Section 2, Targeted Case Management Program Descriptions, page T.2-1-1. Final Draft Response to the 2007-08 Grand Jury Final Report Part 3 Doc HMR Audit Report Statement DHS Response When such services, called Linkage and Consultation, are provided, TCM regulations require that the initial referral or consultation be documented and that a documented follow-up occurs within a maximum of 30 days to determine whether the services were provided and whether they met the client’s needs. Linkage and This statement did not fully incorporate relevant aspects of Consultation services are not required but said requirements, resulting in a misrepresentation of facts. when they are provided, they must follow The TCM Provider Manual states: the protocols described. “Linkage and Consultation 29 Documentation of required 30 day follow- TCM services provide beneficiaries with ups to the Linkage and Consultation linkage and consultation and with referral to services were not found in any of the service providers and placement activities. The eleven reported incidents. case manager shall follow up with the beneficiary and/or service provider to 34 TCM regulations require that referral to determine whether services were received and such services be followed up within 30 whether the services met the beneficiary’s days to determine if the services were needs. The follow-up shall occur as quickly as received and whether they met the client’s indicated by the assessed need, not to exceed needs thirty (30) days from the scheduled date of the referral service.”10 [Emphasis added.] 34 None of the case records in which such services are recorded contained 30 day Hence, 30-day follow-ups are only required on referrals with follow-up documentation either. specific, scheduled services and must not exceed 30 days from the scheduled date of service. The 30-day follow up is not 34 While the case records reviewed showed required for referrals with open time frames or for referrals that most Linkages clients do receive visits without a scheduled service. from the case managers more frequently than the minimum required four times a year, the fact that certain Linkage and Consultation services are not documented as such has resulted in an absence of TCM required 30 day follow-ups to such services. TCM Provider Manual, Section 2, Targeted Case Management Program Descriptions, page T.2-1-2. Final Draft Response to the 2007-08 Grand Jury Final Report Part 3 Doc HMR Audit Report Statement DHS Response Page Since the TCM program has many It is not clear how the Auditor arrived at the opinion that some requirements, some more significant than TCM requirements are “more significant than others” or how others, some judgment was necessary to the Auditor defines “substantial compliance”. define substantial compliance. For The Audit Report acknowledged that the State would likely example, none of the case records offer the Department an opportunity to correct deficiencies reviewed for either the Public Guardian or prior to a finding of disallowance. The Department’s the Linkages program contained the understanding of Medi-Cal programs is that disallowances are frequency or duration of activities not made unless the work was not performed or a duplication recommended for clients in the Individual in services is identified. Client Service Plans, as required by TCM regulations. Using this measure, all encounters billed for during preparation of Client Services Plans are out of compliance with TCM regulations and are therefore subject to Medi-Cal disallowance. A different standard was used though since the absence of frequency and duration of Service Plan activities was not considered as serious a breach of compliance as, for example, lack of compliance with the TCM requirement that a face-to-face Periodic Review of progress be conducted with the client at least every six months. If a case file was found compliant with all Individual billed encounters do not have to contain all TCM TCM requirements except including the components. Only those components specific to the TCM frequency and duration of activities in the encounter being billed are required. Case files typically Individual Client Service Plan, the file was contain additional information relevant to the TCM encounter. considered compliant. If a case file was Full case files were not reviewed by HMR nor were they non-compliant in a variety of areas such requested. as: not specifying activities for the client in Case file compliance cannot be determined based on the the Individual Client Service Plan; not limited number of and types of documents reviewed during the cross-referencing service needs from the Audit. client’s Assessment in the Individual Client Service Plan; and, not specifying the frequency and duration of activities in the Individual Client Service Plan, the case file was considered non-compliant and subject to Medi-Cal disallowance. Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
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  The Grand Jury recommends that both OES and EDCOE, as well as individual school sites and districts, keep emergency response records that include dates of training and practice - to be maintained and supervised by EDCOE. RESPONSES Response(s) to this report is required in accordance with California Penal Code §933.05. 5 -025 REASON FOR REPORT The Fire Protection District Law of 1987, in the State Health and Safety Code §13800, governs all of the Fire Protection Districts (FPDs) in California. Fire protection districts can only provide fire protection and emergency medical services. At the printing of the 3rd edition of “What’s So Special About Special Districts?” there were 386 FPDs in California. El Dorado County has nine FPDs on the West Slope and two FPDs in the Tahoe Basin. The County also has two multi-purpose Community Service Districts (CSDs) that provide fire protection along with other services: Fallen Leaf Lake CSD and Cameron Park CSD. The City of South Lake Tahoe has its own fire department. El Dorado County has a disproportionately high number of fire protection districts compared with the average of other counties in California. El Dorado County would benefit from consolidation. During the Grand Jury investigation, the scope was limited to the West Slope of the County
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  The SLTPD’s Strategic Plan should address clearly defined performance measures that include at a minimum the following areas of concern: • Confidence in Senior Management • Cynicism • Morale • Visions and Values of the Department
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  The Chief of Police should present a written progress report to the City Council and City Manager annually for public review.
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  The City Manager and City Council should maintain an active presence in tracking the Strategic Plan progress.
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  The Chief's annual performance evaluation should include the progress of the goals set in the Strategic Plan. RESPONSES Response(s) to this report is required in accordance with California Penal Code §933.05. 24 -014 REASON FOR REPORT The Grand Jury elected to investigate the County’s Victim Restitution activity to determine if El Dorado County is effectively and efficiently managing victim restitution.
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  Exhibit 4.6 Review of 10 Individual Client Service Plans Linkages Program Plans with activity frequency, duration ------- they were found not fully compliant with TCM regulations in that none of the Service Plans reviewed described the frequency or nature of the activities and specific services to be performed, as required by TCM regulations. 1 http://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx. 25