Riverside County Grand Jury
2006-2007
From the annual report
The consolidated year-end volume. The individual investigations it contains are listed separately below.
📑 Year-End Report
The full consolidated volume; individual reports are listed below.
Individual reports (15)
Additional Recommendations
2
Not linked to specific findings.
R3:
Larry D. Smith Correctional Facility, Banning: The laundry, kitchen and perimeter fences do not have coverage with cameras. 3
R4:
Indio Jail Facility: There are areas in the jail that have cameras but are not covered by DVR. These 4 include: the kitchen, several cell block locations and some corridors.
Findings and recommendations not yet extracted.
Findings & Recommendations
5 findings
F1:
Southwest Detention Center: The transportation area and C, D, E, and F Pods, do not have cameras.
Related Recommendations (1)
R1:
Southwest Detention Center, Murrieta: Install additional cameras for transportation and C, D, E, and F Pods. Estimated costs: C Pod $34,000, D, E, and F, Pods of $35,000 each.
F2:
Blythe Jail Facility: This facility has an area known as Holding Tank A. This area is currently housing 54 inmates and approximately 2/3 of the area is not observable from the entrance.
Related Recommendations (1)
R2:
Blythe Jail Facility: Install three cameras that cover the areas in Tank A. Estimated Cost: $105,000.
F3:
Larry D. Smith Correctional Facility, Banning: The laundry, kitchen and perimeter fences do not have coverage with cameras.
Related Recommendations (1)
R3:
Larry D. Smith Correctional Facility, Banning: Install cameras in the laundry room to provide coverage of the inmates and deputies. Cameras should be installed during expansion of the kitchen. During design of the new 600-bed facility, plans should include wiring and installation of DVR system. Estimated costs $105,000.
F4:
Indio Jail Facility: There are areas in the jail that have cameras but are not covered by DVR. These include: the kitchen, several cell block locations and some corridors.
Related Recommendations (1)
R4:
Indio Jail Facility: Install DVR capability in the following locations: • Kitchen – Camera 049 • North Jail – Cameras 35 and 052 • Tanks 6/7 – Camera 61 • Corridor South Jail – Camera 046 • Visiting to intake – Camera 038 Estimated cost $70,000. 3
F5:
Robert Presley Detention Center, Riverside: The kitchen, dayroom, and transportation areas do not have sufficient camera coverage. 2
Related Recommendations (1)
R5:
Robert Presley Detention Center, Riverside: Install DVR cameras in the following areas: • Kitchen • Dayrooms • Transportation areas Estimated cost $306,000. Report Issued: 06/27/07 Report Public: 06/29/07 Response Due: 09/26/07 4
Findings & Recommendations
3 findings
F1:
Elsinore Valley Cemetery District board members began an ongoing correspondence with their County Supervisor in August 2004, stating concerns regarding the failure of City and County authorities to address flood control issues in the cemetery area of the city. Copies of these letters were sent to the Lake Elsinore City Council. City and County officials took no documented responsive action to address the concerns of the cemetery district.
Related Recommendations (1)
R1:
The Board of Supervisors (BOS) and the City of Lake Elsinore initiate procedures to ensure that complaints are answered in writing in a timely manner by the appropriate agency or official having direct responsibility.
F2:
Municipal, county, and state agencies (City of Lake Elsinore, Riverside County Flood Control District, and Caltrans) exhibited lack of interagency communication, lack of coordination of responsibilities, and a lack of cooperative corrective action concerning flood mitigation in the Arroyo del Toro area.
Related Recommendations (1)
R2:
County and municipal elected officials develop and enforce policy requiring all agencies/departments subject to their control to communicate, coordinate, and cooperate in areas of mutual concern.
F3:
Proposition F contained an allocation of monies for flood control mitigation in the Arroyo del Toro Channel area immediately adjacent to the Elsinore Valley Cemetery District. During our investigation witnesses stated that the planners of the 1986 Lake Elsinore Flood Control Bond Issue, by deliberately disregarding inflation, substantially underestimated the cost of completing the project. Of the eleven projects authorized, only four were completed at twice the initial estimates for the entire bond issue. Consequently, 18 years later, the taxpayers in Zone 3 are still paying for undelivered flood control improvements. 2
Related Recommendations (1)
R3:
BOS both identify and commit sufficient funds now, or present Zone 3 voters with a bond issue initiative for their consideration, to finish Arroyo Del Toro Channel Flood Control Project. Any action must factor in inflation estimates. Report Issued: 06/11/07 Report Public: 06/13/07 Response Due: 09/10/07 3 4 5
Findings & Recommendations
3 findings
F1:
Elsinore Valley Cemetery District board members began an ongoing correspondence with their County Supervisor in August 2004, stating concerns regarding the failure of City and County authorities to address flood control issues in the cemetery area of the city. Copies of these letters were sent to the Lake Elsinore City Council. City and County officials took no documented responsive action to address the concerns of the cemetery district.
Related Recommendations (1)
R1:
The Board of Supervisors (BOS) and the City of Lake Elsinore initiate procedures to ensure that complaints are answered in writing in a timely manner by the appropriate agency or official having direct responsibility.
F2:
Municipal, county, and state agencies (City of Lake Elsinore, Riverside County Flood Control District, and Caltrans) exhibited lack of interagency communication, lack of coordination of responsibilities, and a lack of cooperative corrective action concerning flood mitigation in the Arroyo del Toro area.
Related Recommendations (1)
R2:
County and municipal elected officials develop and enforce policy requiring all agencies/departments subject to their control to communicate, coordinate, and cooperate in areas of mutual concern.
F3:
Proposition F contained an allocation of monies for flood control mitigation in the Arroyo del Toro Channel area immediately adjacent to the Elsinore Valley Cemetery District. During our investigation witnesses stated that the planners of the 1986 Lake Elsinore Flood Control Bond Issue, by deliberately disregarding inflation, substantially underestimated the cost of completing the project. Of the eleven projects authorized, only four were completed at twice the initial estimates for the entire bond issue. Consequently, 18 years later, the taxpayers in Zone 3 are still paying for undelivered flood control improvements. 2
Related Recommendations (1)
R3:
BOS both identify and commit sufficient funds now, or present Zone 3 voters with a bond issue initiative for their consideration, to finish Arroyo Del Toro Channel Flood Control Project. Any action must factor in inflation estimates. Report Issued: 06/11/07 Report Public: 06/13/07 Response Due: 09/10/07 3 4 5
Findings & Recommendations
6 findings
F1:
The RCHCA did not obtain its own appraisal or conduct an independent review of the buyer’s appraisal. The appraisal report included as comparable property, land that had closed escrow twenty-nine months prior to this sale. It also included another parcel as far away as seven miles from the subject property. During the period of the sale transaction, property values were increasing in the Sage area. Our investigation revealed a 19.05 acre parcel (APN 470-180-028) contiguous to the subject parcel (See Attachment #1) sold for $500,000 in April 2004. This property was within the parameters, though not included, in the comparable property appraisals.
Related Recommendations (1)
R1:
The RCHCA obtain its own appraisal or conduct an independent review of the buyer’s appraisal when selling surplus property.
F2:
RCHCA does not have policy and procedure in place for sale of surplus property or any other operational functions of the Agency. Other than a conflict of interest code, the RCHCA did not produce any other rules and regulations as mandated by the JPA at the time of its creation.
Related Recommendations (1)
R2:
RCHCA develop a comprehensive procedure manual that will instruct the Agency in selling and purchasing land, as well as other operational functions of the Agency.
F3:
On November 10, 2005, Economic Development Agency (EDA) received a Real Property Work Order Request Form to prepare a purchase and sale agreement and open and close escrow to sell the subject land, owned by RCHCA, to a private party. EDA did not follow their own general practice to provide the following services: • Obtain the appraisal and/or conduct an independent review of the buyer’s appraisal to determine “fair market value” • Notify required public entities • Notify adjacent property owners • Post notification to the general public 2
Related Recommendations (1)
R3:
RCHCA coordinate with EDA on all real estate transactions. EDA will provide their full complement of real estate related services, regardless of the point in which the request was received.
F4:
RCHCA did not notify adjacent property owners whose land abutted the subject property (See Attachment #1), denying them the right to purchase the parcel and to participate in competitive bidding in accordance with Government Code §25530.
Related Recommendations (1)
R4:
RCHCA through EDA notify adjacent property owners to allow them the right to purchase the property or engage in competitive bidding to generate increased revenue for the Agency.
F5:
At the request of staff, the General Counsel reviewed the Joint Powers Agreement, Section 3.3.3, to determine whether the Agency had authority to sell the surplus land. General Counsel’s opinion was that the Agreement specifically authorizes the RCHCA to dispose of property it owns, and that the Agency could proceed with the sale. The JPA further requires under Section 3.9 Rules and Governing Law, “This Agreement shall be construed and enforced in accordance with the laws of the State of California. The laws of the State of California applicable to the general law city of Moreno Valley shall govern the Agency in manner of exercising its powers…” General Counsel gave no advice regarding compliance with state laws or county policies.
Related Recommendations (1)
R5:
The Office of the County Counsel replace the General Counsel assigned to RCHCA with an attorney who has experience in real property transactions and knowledge of related laws and policies. Whoever serves as General Counsel advise RCHCA not only the requirements of the Joint Powers Agreement, but of the laws of the State of California and the policies of the County of Riverside.
F6:
The subject property was the first surplus land that was sold by the Agency. Our investigation found that the BOD did not review the transaction of the sale for accuracy and five of the seven directors interviewed were not aware of the transaction, nevertheless they did authorize the executive director of the agency to proceed with the sale. The Board of Directors did not require staff to keep them updated and signed off on incorrect minutes from the meeting on September 29, 2005 regarding the sale of the parcel. The BOD did not require staff to develop a complete policy and procedure manual, including purchase and sale of land. The BOD failed to carry out their fiduciary responsibility to obtain optimal value, therefore depriving the County Agency of significant revenue. 3
Related Recommendations (1)
R6:
The member agencies appoint new representatives to the Board of Directors, as soon as possible, who demonstrate a stronger commitment to their fiduciary responsibility to optimize revenue from the sale of property. Report Issued: 03/20/07 Report Public: 03/22/07 Response Due: 06/18/07 4
Additional Recommendations
1
Not linked to specific findings.
R12:
470180012 47018DD43 . . . . THRAUP SHADOWFAX-TR 470310021 470180037 470180039 470180030 A701B0048 470310020 470180032470180049 470310015 470230015 470230021 470230020 470310016 470230001 =RESEDA=SPRINGS-RD= 470310019 470230023 470230012 470230022 470310017 470310018 470230009470230011: 470230005 470300038 470260004 ....................................... 100 00 0 470240002 470240017 470260005 470240001 1322ft Riverside County GIS 470240003 0 - - . . . . . . . Attachment #1 Bold outline indicates subject property.
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Findings & Recommendations
6 findings
F1:
The RCHCA did not obtain its own appraisal or conduct an independent review of the buyer’s appraisal. The appraisal report included as comparable property, land that had closed escrow twenty-nine months prior to this sale. It also included another parcel as far away as seven miles from the subject property. During the period of the sale transaction, property values were increasing in the Sage area. Our investigation revealed a 19.05 acre parcel (APN 470-180-028) contiguous to the subject parcel (See Attachment #1) sold for $500,000 in April 2004. This property was within the parameters, though not included, in the comparable property appraisals.
Related Recommendations (1)
R1:
The RCHCA obtain its own appraisal or conduct an independent review of the buyer’s appraisal when selling surplus property.
F2:
RCHCA does not have policy and procedure in place for sale of surplus property or any other operational functions of the Agency. Other than a conflict of interest code, the RCHCA did not produce any other rules and regulations as mandated by the JPA at the time of its creation.
Related Recommendations (1)
R2:
RCHCA develop a comprehensive procedure manual that will instruct the Agency in selling and purchasing land, as well as other operational functions of the Agency.
F3:
On November 10, 2005, Economic Development Agency (EDA) received a Real Property Work Order Request Form to prepare a purchase and sale agreement and open and close escrow to sell the subject land, owned by RCHCA, to a private party. EDA did not follow their own general practice to provide the following services: • Obtain the appraisal and/or conduct an independent review of the buyer’s appraisal to determine “fair market value” • Notify required public entities • Notify adjacent property owners • Post notification to the general public 2
Related Recommendations (1)
R3:
RCHCA coordinate with EDA on all real estate transactions. EDA will provide their full complement of real estate related services, regardless of the point in which the request was received.
F4:
RCHCA did not notify adjacent property owners whose land abutted the subject property (See Attachment #1), denying them the right to purchase the parcel and to participate in competitive bidding in accordance with Government Code §25530.
Related Recommendations (1)
R4:
RCHCA through EDA notify adjacent property owners to allow them the right to purchase the property or engage in competitive bidding to generate increased revenue for the Agency.
F5:
At the request of staff, the General Counsel reviewed the Joint Powers Agreement, Section 3.3.3, to determine whether the Agency had authority to sell the surplus land. General Counsel’s opinion was that the Agreement specifically authorizes the RCHCA to dispose of property it owns, and that the Agency could proceed with the sale. The JPA further requires under Section 3.9 Rules and Governing Law, “This Agreement shall be construed and enforced in accordance with the laws of the State of California. The laws of the State of California applicable to the general law city of Moreno Valley shall govern the Agency in manner of exercising its powers…” General Counsel gave no advice regarding compliance with state laws or county policies.
Related Recommendations (1)
R5:
The Office of the County Counsel replace the General Counsel assigned to RCHCA with an attorney who has experience in real property transactions and knowledge of related laws and policies. Whoever serves as General Counsel advise RCHCA not only the requirements of the Joint Powers Agreement, but of the laws of the State of California and the policies of the County of Riverside.
F6:
The subject property was the first surplus land that was sold by the Agency. Our investigation found that the BOD did not review the transaction of the sale for accuracy and five of the seven directors interviewed were not aware of the transaction, nevertheless they did authorize the executive director of the agency to proceed with the sale. The Board of Directors did not require staff to keep them updated and signed off on incorrect minutes from the meeting on September 29, 2005 regarding the sale of the parcel. The BOD did not require staff to develop a complete policy and procedure manual, including purchase and sale of land. The BOD failed to carry out their fiduciary responsibility to obtain optimal value, therefore depriving the County Agency of significant revenue. 3
Related Recommendations (1)
R6:
The member agencies appoint new representatives to the Board of Directors, as soon as possible, who demonstrate a stronger commitment to their fiduciary responsibility to optimize revenue from the sale of property. Report Issued: 03/20/07 Report Public: 03/22/07 Response Due: 06/18/07 4
Findings & Recommendations
8 findings
F1:
Critical elements of the MVUSD implementation plan for financial independence were never implemented: • Disbursing Officer does not currently report to the Superintendent or governing board (Exhibit 2). This reporting relationship was required by RCOE and is critical to establishing independence and integrity from other financial functions such as accounting, purchasing, and to avoid conflict of interest. • The Director of Budget and Finance job description, dated April 2004, was never updated to reflect the new Disbursing Officer duties. • Key managerial personnel were not aware of the requirement or the criticality of the Disbursing Officer position.
Related Recommendations (1)
R1:
The Superintendent, in order to eliminate any conflict of interest: • Implement the functional organization, in accordance with the organization chart, as presented to the auditors, showing the position of the Disbursing Officer reporting directly to the MVUSD Superintendent or governing board (Exhibit #1). • The Superintendent prepare a detailed job description for the Disbursing Officer delineating the supervisory responsibilities and requirements specified by the RCOE. • The Superintendent inform key management personnel of the requirement for and criticality of the Disbursing Officer’s position. 3
F2:
MVUSD did not honor an agreement to give RCOE “view access” to certain screens of the new computer software, Quintessential School Systems (QSS).
Related Recommendations (1)
R2:
MVUSD honor their agreement with RCOE and provide “view access” to the requested screens of the QSS system for financial control.
F3:
The auditor’s report of December 15, 2004, stated that MVUSD did not yet fully comply with the RCOE requirements as follows: • The duties of the Disbursing Officer were never fully defined. • Policies and procedures for the Disbursing Officer were not established.
Related Recommendations (1)
R3:
MVUSD comply with the auditor’s report of December 15, 2004: • Completely define the duties of the Disbursing Officer. • Establish policy and procedures for the Disbursing Officer.
F4:
RCOE did not follow-up on items not completed in the auditor’s report before forwarding it to the state for approval, even after being granted permission to inspect by MVUSD. 2
Related Recommendations (1)
R4:
RCOE conduct an onsite inspection of MVUSD policies and procedures for the Disbursing Officer to ensure they meet the guidelines for financial independence. If MVUSD does not fully comply, then RCOE requests CDE revoke their status for financial independence.
F5:
The Assistant Superintendent for Business Services provided the external auditor with an organization chart (Exhibit #1), and processes and procedures necessary to meet RCOE’s requirements for financial independence. However, the organizational structure and many of the processes and procedures were never implemented.
Related Recommendations (1)
R5:
The Superintendent ensure that the Assistant Superintendent for Business Services fulfill all future agreements made with RCOE.
F6:
There is no requirement for the annual independent auditor to review the operations of the Disbursing Officer or functions relating to financial independence.
Related Recommendations (1)
R6:
RCOE and MVUSD require the annual external auditors to include an evaluation of the organization, job descriptions, and policies and procedures specifically required for complying with financial independence.
F7:
Some managers and subordinate personnel of MVUSD have not received an annual performance evaluation in over two years as required by Business Policy (BP) §4315.
Related Recommendations (1)
R7:
The Superintendent of MVUSD enforces the policy for managerial staff and subordinates to receive annual evaluations, as set forth in MVUSD BP §4315.
F8:
The Director of Budget and Finance/Disbursing Officer, who is a supervisor of personnel, is not authorized to evaluate his/her staff.
Related Recommendations (1)
R8:
The director of budget and finance/disbursing officer be authorized to evaluate subordinates annually. Report Issued: 06/12/07 Report Public: 06/14/07 Response Due: 09/11/07 4
Findings & Recommendations
8 findings
F1:
Critical elements of the MVUSD implementation plan for financial independence were never implemented: • Disbursing Officer does not currently report to the Superintendent or governing board (Exhibit 2). This reporting relationship was required by RCOE and is critical to establishing independence and integrity from other financial functions such as accounting, purchasing, and to avoid conflict of interest. • The Director of Budget and Finance job description, dated April 2004, was never updated to reflect the new Disbursing Officer duties. • Key managerial personnel were not aware of the requirement or the criticality of the Disbursing Officer position.
Related Recommendations (1)
R1:
The Superintendent, in order to eliminate any conflict of interest: • Implement the functional organization, in accordance with the organization chart, as presented to the auditors, showing the position of the Disbursing Officer reporting directly to the MVUSD Superintendent or governing board (Exhibit #1). • The Superintendent prepare a detailed job description for the Disbursing Officer delineating the supervisory responsibilities and requirements specified by the RCOE. • The Superintendent inform key management personnel of the requirement for and criticality of the Disbursing Officer’s position. 3
F2:
MVUSD did not honor an agreement to give RCOE “view access” to certain screens of the new computer software, Quintessential School Systems (QSS).
Related Recommendations (1)
R2:
MVUSD honor their agreement with RCOE and provide “view access” to the requested screens of the QSS system for financial control.
F3:
The auditor’s report of December 15, 2004, stated that MVUSD did not yet fully comply with the RCOE requirements as follows: • The duties of the Disbursing Officer were never fully defined. • Policies and procedures for the Disbursing Officer were not established.
Related Recommendations (1)
R3:
MVUSD comply with the auditor’s report of December 15, 2004: • Completely define the duties of the Disbursing Officer. • Establish policy and procedures for the Disbursing Officer.
F4:
RCOE did not follow-up on items not completed in the auditor’s report before forwarding it to the state for approval, even after being granted permission to inspect by MVUSD. 2
Related Recommendations (1)
R4:
RCOE conduct an onsite inspection of MVUSD policies and procedures for the Disbursing Officer to ensure they meet the guidelines for financial independence. If MVUSD does not fully comply, then RCOE requests CDE revoke their status for financial independence.
F5:
The Assistant Superintendent for Business Services provided the external auditor with an organization chart (Exhibit #1), and processes and procedures necessary to meet RCOE’s requirements for financial independence. However, the organizational structure and many of the processes and procedures were never implemented.
Related Recommendations (1)
R5:
The Superintendent ensure that the Assistant Superintendent for Business Services fulfill all future agreements made with RCOE.
F6:
There is no requirement for the annual independent auditor to review the operations of the Disbursing Officer or functions relating to financial independence.
Related Recommendations (1)
R6:
RCOE and MVUSD require the annual external auditors to include an evaluation of the organization, job descriptions, and policies and procedures specifically required for complying with financial independence.
F7:
Some managers and subordinate personnel of MVUSD have not received an annual performance evaluation in over two years as required by Business Policy (BP) §4315.
Related Recommendations (1)
R7:
The Superintendent of MVUSD enforces the policy for managerial staff and subordinates to receive annual evaluations, as set forth in MVUSD BP §4315.
F8:
The Director of Budget and Finance/Disbursing Officer, who is a supervisor of personnel, is not authorized to evaluate his/her staff.
Related Recommendations (1)
R8:
The director of budget and finance/disbursing officer be authorized to evaluate subordinates annually. Report Issued: 06/12/07 Report Public: 06/14/07 Response Due: 09/11/07 4
Findings & Recommendations
5 findings
F1:
MVUSD is operating 20-22 home-to-school bus routes with Laidlaw without a formal written contract signed by both parties. Instead, they are using a bid proposal document received from Laidlaw as an operational contractual agreement, which is outside the scope of the work to be performed exposing each party to substantial risk, litigation and unlimited cost. This agreement does not meet the requirements of California Public Contracts Codes (CPSS) §20111, §20112 and Moreno Valley Administrative Regulation (AR) §3310. 1
Related Recommendations (1)
R1:
MVUSD comply with the California Code. Specifically, discontinue the practice of using a bid proposal document as a contract and enter into a written contract signed by both parties that defines the scope of the work or services to be performed, pursuant to CPPC §20111, §20112 and AR §3310.
F2:
As of the end of January 2007, Laidlaw has been paid over $700,000 for home-to-school bus service with MVUSD without a contract. MVUSD is non-compliant with state code and its own policy for not advertising for competitive bidding for home-to- school bus service. State code requires advertising for contracts over $65,000 for school year 2006 and $69,000 for 2007, and awarding the contract to the lowest qualified bidder, in accordance with CPPC §20112 and MVUSD Business Policy (BP) §3311.
Related Recommendations (1)
R2:
MVUSD advertise for a home-to-school bus service and award a contract to the lowest qualified bidder in accordance with California Code, and MVUSD regulations in order to award contracts that ensure fair competition, pursuant to CPPC §20110 and §20111.
F3:
MVUSD is not planning to follow the Education Code, as it pertains to contract extension. The code only allows a contract to be extended for a total period of five years. Special provision #3 of MVUSD bid proposal document for charter bus service of 2004 states their agreement ends on June 30, 2005. The time frame of the bid proposal includes an option to extend for up to two additional years; therefore, the duration of the service will end not later than June 30, 2007. MVUSD plans to extend the bid proposal document an additional five years beginning July 1, 2007. This extension will exceed the five-year limitation, in accordance with California Education Code (CEC) §17596.
Related Recommendations (1)
R3:
MVUSD review the requirements of CEC §17596 and consistently comply with the California Code as it applies to contract extensions. Consult with legal counsel before extending any contracts.
F4:
Laidlaw was the low bidder for 84 passenger vehicles in the bid proposal document of 2004. The bid proposal document did not include 22-passenger vehicles, however, MVUSD is using eleven (11) Laidlaw 22-passenger vehicles. Therefore, the district is not in compliance with state code and district policy, CPPC §20111, §20112 and AR §3310.
Related Recommendations (1)
R4:
MVUSD proceed with the competitive bid process for 22- passenger vehicle for home-to-school service contract. The contract be awarded to the lowest qualified bidder, pursuant to CPCC §20111, §20112 and AR §3310.
F5:
In 2006, MVUSD’s governing board (school board) approved the purchase of 10 buses at $150,000 each, without a comprehensive plan, to replace Laidlaw as the bus service provider. As of January 2007, MVUSD has failed to hire a sufficient number of qualified drivers for the new buses; therefore, the governing board approved making this $1.5 million expenditure while also paying for student transportation by Laidlaw. 2
Related Recommendations (1)
R5:
MVUSD governing board must fully research and ensure there is a comprehensive plan for complete implementation for purchases of this magnitude to fulfill their fiduciary responsibilities to the taxpayers. Report Issued: 06/12/07 Report Public: 06/14/07 Response Due: 09/11/07 3
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Findings & Recommendations
5 findings
F1:
MVUSD is operating 20-22 home-to-school bus routes with Laidlaw without a formal written contract signed by both parties. Instead, they are using a bid proposal document received from Laidlaw as an operational contractual agreement, which is outside the scope of the work to be performed exposing each party to substantial risk, litigation and unlimited cost. This agreement does not meet the requirements of California Public Contracts Codes (CPSS) §20111, §20112 and Moreno Valley Administrative Regulation (AR) §3310. 1
Related Recommendations (1)
R1:
MVUSD comply with the California Code. Specifically, discontinue the practice of using a bid proposal document as a contract and enter into a written contract signed by both parties that defines the scope of the work or services to be performed, pursuant to CPPC §20111, §20112 and AR §3310.
F2:
As of the end of January 2007, Laidlaw has been paid over $700,000 for home-to-school bus service with MVUSD without a contract. MVUSD is non-compliant with state code and its own policy for not advertising for competitive bidding for home-to- school bus service. State code requires advertising for contracts over $65,000 for school year 2006 and $69,000 for 2007, and awarding the contract to the lowest qualified bidder, in accordance with CPPC §20112 and MVUSD Business Policy (BP) §3311.
Related Recommendations (1)
R2:
MVUSD advertise for a home-to-school bus service and award a contract to the lowest qualified bidder in accordance with California Code, and MVUSD regulations in order to award contracts that ensure fair competition, pursuant to CPPC §20110 and §20111.
F3:
MVUSD is not planning to follow the Education Code, as it pertains to contract extension. The code only allows a contract to be extended for a total period of five years. Special provision #3 of MVUSD bid proposal document for charter bus service of 2004 states their agreement ends on June 30, 2005. The time frame of the bid proposal includes an option to extend for up to two additional years; therefore, the duration of the service will end not later than June 30, 2007. MVUSD plans to extend the bid proposal document an additional five years beginning July 1, 2007. This extension will exceed the five-year limitation, in accordance with California Education Code (CEC) §17596.
Related Recommendations (1)
R3:
MVUSD review the requirements of CEC §17596 and consistently comply with the California Code as it applies to contract extensions. Consult with legal counsel before extending any contracts.
F4:
Laidlaw was the low bidder for 84 passenger vehicles in the bid proposal document of 2004. The bid proposal document did not include 22-passenger vehicles, however, MVUSD is using eleven (11) Laidlaw 22-passenger vehicles. Therefore, the district is not in compliance with state code and district policy, CPPC §20111, §20112 and AR §3310.
Related Recommendations (1)
R4:
MVUSD proceed with the competitive bid process for 22- passenger vehicle for home-to-school service contract. The contract be awarded to the lowest qualified bidder, pursuant to CPCC §20111, §20112 and AR §3310.
F5:
In 2006, MVUSD’s governing board (school board) approved the purchase of 10 buses at $150,000 each, without a comprehensive plan, to replace Laidlaw as the bus service provider. As of January 2007, MVUSD has failed to hire a sufficient number of qualified drivers for the new buses; therefore, the governing board approved making this $1.5 million expenditure while also paying for student transportation by Laidlaw. 2
Related Recommendations (1)
R5:
MVUSD governing board must fully research and ensure there is a comprehensive plan for complete implementation for purchases of this magnitude to fulfill their fiduciary responsibilities to the taxpayers. Report Issued: 06/12/07 Report Public: 06/14/07 Response Due: 09/11/07 3
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Findings & Recommendations
3 findings
F1:
Jurupa Community Services District (JCSD) managed the sale of The Limonite Property in the timeline as follows: • 08/27/2001 JARPD’s letter formally expressed interest to JCSD in obtaining the Limonite Property for park use. • 09/12/2001 JCSD’s letter replied to JARPD to the effect that if and when the Limonite Property became available, such notification would be provided, as required by California Government Code (GC) §54222. • 11/24/2003 JCSD Board Minutes reveal a unanimous vote declaring the Limonite Property surplus to the district’s needs. JARPD was not advised of this decision, as required by GC §25526, 25528, 25530, and 25531. JCSD did not comply with these provisions. • 03/23/2004 JCSD received an appraisal valuing the Limonite Property at $1,040,000. The appraisal stated, “It is the appraiser’s estimation that both the marketing and exposure time for the Subject Properties would be 12 months or less if placed on the open market in today’s market conditions at the concluded values.” • The Riverside County Economic Development Agency provides expert assistance to agencies having surplus real estate to dispose of. The district did not utilize these services, instead, employed a Ventura, California–based appraisal company. • 05/06/2005 an outside buyer tendered a written offer for the property for $1,200,000. At no time, between the Limonite Property being declared surplus and receipt of the offer to purchase, was public notification made of the availability of the property, as required by GC §54222. 2 • 05/09/2005 At the regularly scheduled JCSD Board Meeting, the minutes show no mention of the availability of the Limonite Property or of the offer to purchase it. • 05/13/2005 JCSD posted notification of a Special Board Meeting to be held the following Monday, May 16, 2005, for the purpose of considering an offer to purchase the Limonite Property. No explanation was given for calling a Special Meeting over the weekend, as opposed to considering the matter at the next regular meeting, one week later. Witnesses testifying concerning the Special Meeting claimed not to remember the reason for the urgency of the meeting. • 05/16/2005 Minutes of the Special Board Meeting reflect the attendance of four of the five directors. Minutes also reflect the absence of the District’s Legal Counsel. A motion to accept the offer to purchase the Limonite Property passed unanimously. The meeting was concluded in about 15 minutes. • 05/15/2006 The land sale transaction culminated with the filing of the Grant Deed transferring title to the new owners.
Related Recommendations (1)
R1:
JCSD comply with GC §54222 by making public notification of the availability of surplus property. The JCSD Board of Directors turn over to JARPD the monies received from the Limonite Property sale ($1,200,000), less the costs of the sale. The JCSD Board of Directors adopt and enforce specific policies requiring that any future sale of district realty utilize the services of the County Economic Development Agency in obtaining appraisal and other real estate services.
F2:
JCSD does not have a Policy and Procedures Manual. Our investigation revealed the following: a. Evidence was received concerning personal use of JCSD credit cards, by district management personnel, in the purchase of clothing and meals. b. Contracts were written with a firm owned by a relative of a district official for billing and printing. The contracts were awarded without competitive bidding, as required by California Public Contract Code §22030-
Related Recommendations (1)
R2:
JCSD prepare and publish a policy and procedures manual. This manual should include provisions for: a. Termination of employment and reference to the District Attorney for prosecution for misuse of District Credit Cards. b. Adherence to California Public Contract Code §22030- 22045 in contracting for goods and services. 4 c. Clear definition of board supervisory authority in relation to hired management. d. Define and require adherence to the requirements of the Brown Act as, it applies to JCSD.
F3:
California State Department of Health and Services (DHS) sent JCSD a Notice of Violation on February 10, 2006, stating that its weekly nitrate sampling requirements had not been met. On April 28, 2006, JCSD received another Notice of Violation from DHS citing the sampling deficiency and ordered Well #17 to be shut down. The public was not initially notified of potable water contamination.
Related Recommendations (1)
R3:
JCSD Directors investigate and immediately notify the public of all potable water-sampling deficiencies. Report Issued: 06/29/07 Report Public: 07/03/07 Response Due: 09/27/07 5
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Findings & Recommendations
3 findings
F1:
Jurupa Community Services District (JCSD) managed the sale of The Limonite Property in the timeline as follows: • 08/27/2001 JARPD’s letter formally expressed interest to JCSD in obtaining the Limonite Property for park use. • 09/12/2001 JCSD’s letter replied to JARPD to the effect that if and when the Limonite Property became available, such notification would be provided, as required by California Government Code (GC) §54222. • 11/24/2003 JCSD Board Minutes reveal a unanimous vote declaring the Limonite Property surplus to the district’s needs. JARPD was not advised of this decision, as required by GC §25526, 25528, 25530, and 25531. JCSD did not comply with these provisions. • 03/23/2004 JCSD received an appraisal valuing the Limonite Property at $1,040,000. The appraisal stated, “It is the appraiser’s estimation that both the marketing and exposure time for the Subject Properties would be 12 months or less if placed on the open market in today’s market conditions at the concluded values.” • The Riverside County Economic Development Agency provides expert assistance to agencies having surplus real estate to dispose of. The district did not utilize these services, instead, employed a Ventura, California–based appraisal company. • 05/06/2005 an outside buyer tendered a written offer for the property for $1,200,000. At no time, between the Limonite Property being declared surplus and receipt of the offer to purchase, was public notification made of the availability of the property, as required by GC §54222. 2 • 05/09/2005 At the regularly scheduled JCSD Board Meeting, the minutes show no mention of the availability of the Limonite Property or of the offer to purchase it. • 05/13/2005 JCSD posted notification of a Special Board Meeting to be held the following Monday, May 16, 2005, for the purpose of considering an offer to purchase the Limonite Property. No explanation was given for calling a Special Meeting over the weekend, as opposed to considering the matter at the next regular meeting, one week later. Witnesses testifying concerning the Special Meeting claimed not to remember the reason for the urgency of the meeting. • 05/16/2005 Minutes of the Special Board Meeting reflect the attendance of four of the five directors. Minutes also reflect the absence of the District’s Legal Counsel. A motion to accept the offer to purchase the Limonite Property passed unanimously. The meeting was concluded in about 15 minutes. • 05/15/2006 The land sale transaction culminated with the filing of the Grant Deed transferring title to the new owners.
Related Recommendations (1)
R1:
JCSD comply with GC §54222 by making public notification of the availability of surplus property. The JCSD Board of Directors turn over to JARPD the monies received from the Limonite Property sale ($1,200,000), less the costs of the sale. The JCSD Board of Directors adopt and enforce specific policies requiring that any future sale of district realty utilize the services of the County Economic Development Agency in obtaining appraisal and other real estate services.
F2:
JCSD does not have a Policy and Procedures Manual. Our investigation revealed the following: a. Evidence was received concerning personal use of JCSD credit cards, by district management personnel, in the purchase of clothing and meals. b. Contracts were written with a firm owned by a relative of a district official for billing and printing. The contracts were awarded without competitive bidding, as required by California Public Contract Code §22030-
Related Recommendations (1)
R2:
JCSD prepare and publish a policy and procedures manual. This manual should include provisions for: a. Termination of employment and reference to the District Attorney for prosecution for misuse of District Credit Cards. b. Adherence to California Public Contract Code §22030- 22045 in contracting for goods and services. 4 c. Clear definition of board supervisory authority in relation to hired management. d. Define and require adherence to the requirements of the Brown Act as, it applies to JCSD.
F3:
California State Department of Health and Services (DHS) sent JCSD a Notice of Violation on February 10, 2006, stating that its weekly nitrate sampling requirements had not been met. On April 28, 2006, JCSD received another Notice of Violation from DHS citing the sampling deficiency and ordered Well #17 to be shut down. The public was not initially notified of potable water contamination.
Related Recommendations (1)
R3:
JCSD Directors investigate and immediately notify the public of all potable water-sampling deficiencies. Report Issued: 06/29/07 Report Public: 07/03/07 Response Due: 09/27/07 5
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Findings & Recommendations
33 findings
F1:
Since the opening of the ITF/ETS facility in the 1980s, an in- depth audit has never been performed by the Riverside County Auditor-Controller or by the Internal Audit Unit, a division of the Auditor-Controller’s Office. Resolution No. 83-338, establishing authority and declaring policy for Internal Audits, “be it resolved by the Board of Supervisors of the County of Riverside in regular session – pursuant to Government Code §26883 the Auditor- Controller is authorized to audit the accounts and records of any department, office, board or institution under control of the Board of Supervisors and any district funds that are kept in the County Treasury.” “Ordinance 442.3 Government Administration items 4(f) and 4(g) authorize the County Executive Officer to conduct comprehensive management reviews and investigations of programs, projects and departments.” The BOS Resolution No. 83-338 establishes authority and declares policy for bi- annual departmental internal audits. The funding and staffing levels are controlled by the BOS and limit the ability of the Office of the Auditor-Controller to comply with this Resolution.
Related Recommendations (1)
R1:
The Board of Supervisors direct an immediate comprehensive administrative and financial audit of ETS and ITF bringing them into compliance with the BOS Resolution 83-338 and Government Code §25250 mandating audits be performed every two years.
F2:
The documents supporting the transfer of costs, licensing, equipment, building leases, and the Memorandum of Understanding written in 1999/2000 are not up to date, lack authorizing signatures, and are contrary to existing practices and operating agreements.
Related Recommendations (1)
R2:
Update interagency agreements including appropriate signatures, detailed operational budget, and cost estimates for expanding ETS/ITF.
F3:
The CEO of RCRMC has not provided a budget to the RCDMH and the Assistant Hospital Administrator of the AC since the 1999 re- alignment. 3
Related Recommendations (1)
R3:
RCRMC Administration forward a detailed annual budget to the Assistant Hospital Administrator at the AC at the same time that they provide RCDMH with a proposed operating budget no later than March 15th of each year, as specified in the Inter-Agency Payor Agreement Amendment signed August 9, 2001.
F4:
The high utilization of registry personnel leads to a lack of continuum of care, poor documentation and an increased burden to the regular staff, therefore, a greater cost to the facility. The daily cost of a registry staff person is almost double the cost of a county staff person. The majority 70 percent of skilled and professional patient care attendants at the AC, are from Staff Registries, which account for 63 percent of the total salaries for daily staffing needs. 2005-2006 NON-ADMINISTRATIVE PROFESSIONAL STAFF SALARIES AND BENEFITS ITF ETS TOTALS % County Staff $2,728,543 $749,158 $3,477,701 37% Registry Staff $4,413,419 $1,407,431 $5,820,850 63% Totals $7,141,962 $2,156,589 $9,298,551 100%
Related Recommendations (1)
R4:
ITF/ETS perform a cost/benefit analysis of registry staff vs. full- time permanent employees to determine and utilize the most cost effective staffing strategy for the facility. 8
F5:
Supervisors and managers at ITF/ETS have not submitted Registry Evaluations (Attachment #1), as requested. Professional Employment Registries request that each employer or supervisor submit a summarized Registry Evaluation of Registry Staff be sent to the site. This enables Registry Agencies to better evaluate their employees.
Related Recommendations (1)
R5:
The ITF/ETS Administration develop and implement a policy that require Nurse Managers to submit “Registry Staff Evaluations” (See Attachment #1) to all their registries.
F6:
There is an absence of continuity of patient care. Due to the extensive use of Per Diem psychiatrist/physicians who do not work a daily schedule, one physician may perform the assessment and develop the treatment plan. Later, another psychiatrist monitors and evaluates the patient and may subsequently make the discharge determination.
Related Recommendations (1)
R6:
The ITF/ETS Administration must schedule psychiatrists so that the same psychiatrist attends a patient for continuity of care during the treatment period.
F7:
ITF/ETS Administration has been unresponsive to complaints by staff psychiatrists regarding: • Nursing Supervisors overturning Doctors’ orders • substandard health and safety conditions adversely affecting patient care, such as patient on patient violence, and patients sleeping on the floor 4
Related Recommendations (1)
R7:
Nurse Managers and non-physician management personnel will not unilaterally overturn medical decisions that are in conflict with the physician’s orders without direct consultation with the attending physician or the physician on duty. This abuse of authority will lead to disciplinary actions up to and including termination of employment. ITF/ETS Administration take steps to immediately correct substandard health and safety conditions at AC.
F8:
The ITF/ETS is violating the RCRMC Department of Psychiatry Policy P.1.18 regarding incident reporting, as well as JCAHO standards PI.1.10, PI.2.20, PI.2.30, and PI.3.10 for sentinel events. “A sentinel event is an occurrence involving death or serious physical or psychological injury, or risk thereof.” “These events are called sentinel because they signal the need for immediate investigation and response.”
Related Recommendations (1)
R8:
The AC Administration amend the Department of Psychiatry Policy P 1.18 to invoke penalties for non-compliance by the administrative and management staff to report all incidents to Quality Improvement Department (QID) and/or Risk Management at RCRMC. These penalties include discipline up to and including termination of employment.
F9:
The Quality Improvement Department (QID) at RCRMC, which is responsible for creating a timely log of all reported incidents, has not maintained this log accurately to reflect the actual dates of reportable incidents. A review of the Incident Report Log reveals entry dates prior to the occurrence of the incidents, evidence of multiple entries with dates out of sequence, and missing data.
Related Recommendations (1)
R9:
QID at RCRMC enforce the policy and procedures for maintaining accurate incident report logs. The logs must reflect actual date of incident and actual date the report was received by QID. All personnel involved in the incident reporting process must take appropriate and timely action.
F10:
All AC incident reports were not submitted to QID and Risk Management. After January 7, 2007, the volume of incidents reported by ITF/ETS changed from 9 percent of total reported incidents in 2006, to 38 percent of the total during the first three months of 2007.
Related Recommendations (1)
R10:
All incident data must be reported accurately and timely to reflect the areas of ITF/ETS that indicate potential for quality improvement.
F11:
Some medical records contained incomplete documentation, including missing signatures on orders, telephone orders, and record of verbal orders.
Related Recommendations (1)
R11:
The Medical Records Department establish an audit team to conduct ongoing record review to ensure that the documentation is completed by validating with a random audit.
F12:
The August 2004 Behavioral Assault Management (BAM) Training Manual presently in use does not reflect the current policies and procedures of the RCRMC Department of Psychiatry.
Related Recommendations (1)
R12:
Update the Department of Psychiatry BAM Training Manual, August 2004, with respect to policies and procedures on seclusion and restraint, reporting assaults to local law enforcement, and the current “CODE GREEN” policy P 1.16f Rev. 10/10/06, which is the Emergency Response to Assault by Patient or Other Individual in the Hospital Environment. 9
F13:
Assembly Bill (AB) 508 passed in 1993 mandates that psychiatric hospital employees receive training and education relating to general safety measures, aggression and violence, verbal and physical maneuvers to diffuse or avoid violent behavior. Based on the training record(s) provided by ITF/ETS Administration in August 2006, it could not be determined that all the staff are in compliance.
Related Recommendations (1)
R13:
Update training documentation related to BAM and implement a procedure that would ensure that staff are kept up to date on BAM and recertified annually, as Psychiatry Department Policy dictates.
F14:
Within the last five (5) years, staff at ITF/ETS have not been given training and drills on Medical Emergency “CODE BLUE” policy and procedure P 1.16 Rev. 4/21/03 and Automated External Defibrillator (AED) policy and procedure P 1.16a Rev. 4/30/03. 5
Related Recommendations (1)
R14:
Institute “CODE BLUE” and “AED” training and drills as a mandatory training program for staff physicians, registered nurses, licensed vocational nurses, licensed psychiatric technicians, and nurses aides, as well as all registry staff, so that all staff are aware of their duties when a “CODE BLUE” is announced.
F15:
Training records covering 234 Riverside County employees at ITF/ETS were found incomplete, disorganized, and not useful with regard to tracking the training of the majority of employees.
Related Recommendations (1)
R15:
Develop and utilize a central database to track mandatory training and specialized supervisory training. Appoint sufficient personnel resources to maintain the training records.
F16:
Insufficient staff coverage on the night shift violates the 4 to 1 and 5 to 1 patient/nurse ratios and has created an unsafe environment at the ITF/ETS facility for patient/clients and staff.
Related Recommendations (1)
R16:
Require administrative supervisory personnel to be available for staffing during periods of personnel shortages.
F17:
The AC facility is being run without adequate general medical staffing. RCRMC provides a primary care physician with an additional duty to attend patients at the AC after working scheduled shift at RCRMC in Moreno Valley.
Related Recommendations (1)
R17:
The Administration hire a full time physician, physician assistant, or a nurse practitioner for ETS/ITF, rather than rely on a physician from RCRMC after working hours as an additional duty.
F18:
Employees who want to work overtime must apply to management. It was found that overtime was often assigned selectively to a small number of employees. Such a practice lends itself to allegations of discrimination based on factors other than competence.
Related Recommendations (1)
R18:
Assign overtime equitably to qualified employees.
F19:
Senior Administration at RCRMC and RCDMH has shown inadequate leadership in making appropriate personnel changes: • leaving funded staff positions unfilled • not reducing the high turnover of professional services of doctors, nurses, and staff • not providing trained professional security staff
Related Recommendations (1)
R19:
Senior administration at RCRMC, RCDMH, and the AC demonstrate leadership by working closely and consistently with Human Resources Director to identify a strategy to fill positions, some of which have not been filled in four years.
F20:
Items such as furniture, are not adequately secured to insure patient and staff safety. At the ITF/ETS facility we observed an agitated patient in a crowded dayroom pick-up a fiberglass chair and throw it across the room, narrowly missing other patients.
Related Recommendations (1)
R20:
The RCRMC Safety Coordinator inspect patient areas at the ITF/ETS facility to ensure that all furniture is either locked together or secured to the floor.
F21:
The indifference displayed by AC Administration has adversely affected employee morale. The mental and physical well-being of employees who have complained of abusive and violent behavior by patients are not supported by AC Administration with a program of follow-up care.
Related Recommendations (1)
R21:
Develop and implement management programs that would give professional support to staff who have experienced physical or psychological abuse or violence.
F22:
The AC administration has not been responsive for ensuring that a system of improved communications is maintained so that no one person can create an environment of fear and intimidation among the staff. 6
Related Recommendations (1)
R22:
The senior administrator establish and ensure open communications with staff and physicians, which will enable all opinions to be heard without fear of intimidation and retaliation. 10
F23:
The current Security Guard Service Contract, “Professional Service Agreement #PUARC690B”, does not meet the unique needs including guard service coverage, emergency codes, and training for that type of facility. 24. “Panic Buttons” are not installed at each reception desk, nurses’ station, and activity room.
Related Recommendations (1)
R23:
Upgrade security service by contracting for sheriff’s deputies, or trained correctional officers, to handle emergency contingencies.
F24:
Install “Panic Buttons” at all reception desks, nurses’ stations, activity rooms, and any other critical areas at ITF/ETS.
Related Recommendations (1)
R24:
Install “Panic Buttons” at all reception desks, nurses’ stations, activity rooms, and any other critical areas at ITF/ETS.
F25:
The planned expansion by RCRMC of the ITF/ETS facility is contingent on the building meeting 1994 seismic standards. The building currently meets the 1973 standards, however, the modifications may reveal needed upgrades to bring the building up to the 1994 Northridge Earthquake Standards.
Related Recommendations (1)
R25:
Expedite plans to expand capacity at ITF/ETS.
F26:
The average daily intake of 27 patients per day at ETS, makes the only existing interview room inadequate to manage the volume of patient interviews and comply with the Welfare and Institutions Code §5325.1(b), related to patient privacy.
Related Recommendations (1)
R26:
Immediately add two (2) additional interview rooms at the ITF/ETS facility.
F27:
Interviews with professional staff and psychiatrists indicate a constant return rate of patients. Some patients have been placed outside of the medical jurisdiction of Riverside County that does not match the level of care needed. The determination of severity of patient’s diagnosis does not match discharge process and placement.
Related Recommendations (1)
R27:
AC Administration provide training for psychiatrists, physicians, psychologists, social workers, nurses, and management to ensure appropriate patient placement at time of discharge.
F28:
Nurses are engaging in unlawful practice by administering medicines to patients without proper documentation on the Medical Administration Record, and requesting other staff members to sign for the administration of the medication.
Related Recommendations (1)
R28:
Update and enforce Policy and Procedures regarding the administration of medication and chart documentation. Impose appropriate disciplinary measures for non-compliance and falsification of documentation.
F29:
During our inquiry we found a clear case where symptoms, and medical description of condition clearly described “schizophrenia with paranoid indications”, in the chart. When describing attempts at outplacement, these symptoms were clearly understated to potential residential placement, such as a board and care, instead of institutional placement, as indicated by a senior administrator.
Related Recommendations (1)
R29:
Find appropriate placement for patients in institutional facilities, licensed residential facilities, or appropriate community sites, based on the actual level of care needed. Do not alter diagnoses to influence placement.
F30:
After hours discharge of patients takes place without appropriate placement planning. Many patients discharged during this timeframe are unable to find shelter or residence of any kind. 7
Related Recommendations (1)
R30:
Develop and implement mandatory procedures, which would allow discharged patients to find shelter or residence.
F31:
ITF does not have qualified professional discharge planners dedicated to discharge placement of patients in California State Mental Hospitals when long-term care is indicated.
Related Recommendations (1)
R31:
Have an experienced discharge professional responsible, as part of the job description, be responsible to coordinate with State Hospitals and ensure proper patient placement.
F32:
Annual Performance Reviews of County Employees at the AC are done on irregular basis, if at all. Therefore, opportunities for constructive criticism and team building are lost.
Related Recommendations (1)
R32:
The AC Administration and Management comply with BOS Policy #C-21 Section 3, regarding performance reviews.
F33:
The Administration at the AC have relinquished their management operational responsibility to lower level managers.
Related Recommendations (1)
R33:
The CEO of RCRMC and the Director of RCDMH initiate a complete review and evaluation of Administrative and Management procedures and responsibilities at the Department of Psychiatry AC, as indicated in the findings of this report, and make appropriate changes. Report Issued: 06/27/07 Report Public: 06/29/07 Response Due: 09/26/07 11 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER REGISTRY EVALUATION Licensed Personnel NAME:______________________________REGISTRY:________________________ DATE:___________________________________UNIT:________________________ RATING N/A
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Findings & Recommendations
33 findings
F1:
Since the opening of the ITF/ETS facility in the 1980s, an in- depth audit has never been performed by the Riverside County Auditor-Controller or by the Internal Audit Unit, a division of the Auditor-Controller’s Office. Resolution No. 83-338, establishing authority and declaring policy for Internal Audits, “be it resolved by the Board of Supervisors of the County of Riverside in regular session – pursuant to Government Code §26883 the Auditor- Controller is authorized to audit the accounts and records of any department, office, board or institution under control of the Board of Supervisors and any district funds that are kept in the County Treasury.” “Ordinance 442.3 Government Administration items 4(f) and 4(g) authorize the County Executive Officer to conduct comprehensive management reviews and investigations of programs, projects and departments.” The BOS Resolution No. 83-338 establishes authority and declares policy for bi- annual departmental internal audits. The funding and staffing levels are controlled by the BOS and limit the ability of the Office of the Auditor-Controller to comply with this Resolution.
Related Recommendations (1)
R1:
The Board of Supervisors direct an immediate comprehensive administrative and financial audit of ETS and ITF bringing them into compliance with the BOS Resolution 83-338 and Government Code §25250 mandating audits be performed every two years.
F2:
The documents supporting the transfer of costs, licensing, equipment, building leases, and the Memorandum of Understanding written in 1999/2000 are not up to date, lack authorizing signatures, and are contrary to existing practices and operating agreements.
Related Recommendations (1)
R2:
Update interagency agreements including appropriate signatures, detailed operational budget, and cost estimates for expanding ETS/ITF.
F3:
The CEO of RCRMC has not provided a budget to the RCDMH and the Assistant Hospital Administrator of the AC since the 1999 re- alignment. 3
Related Recommendations (1)
R3:
RCRMC Administration forward a detailed annual budget to the Assistant Hospital Administrator at the AC at the same time that they provide RCDMH with a proposed operating budget no later than March 15th of each year, as specified in the Inter-Agency Payor Agreement Amendment signed August 9, 2001.
F4:
The high utilization of registry personnel leads to a lack of continuum of care, poor documentation and an increased burden to the regular staff, therefore, a greater cost to the facility. The daily cost of a registry staff person is almost double the cost of a county staff person. The majority 70 percent of skilled and professional patient care attendants at the AC, are from Staff Registries, which account for 63 percent of the total salaries for daily staffing needs. 2005-2006 NON-ADMINISTRATIVE PROFESSIONAL STAFF SALARIES AND BENEFITS ITF ETS TOTALS % County Staff $2,728,543 $749,158 $3,477,701 37% Registry Staff $4,413,419 $1,407,431 $5,820,850 63% Totals $7,141,962 $2,156,589 $9,298,551 100%
Related Recommendations (1)
R4:
ITF/ETS perform a cost/benefit analysis of registry staff vs. full- time permanent employees to determine and utilize the most cost effective staffing strategy for the facility. 8
F5:
Supervisors and managers at ITF/ETS have not submitted Registry Evaluations (Attachment #1), as requested. Professional Employment Registries request that each employer or supervisor submit a summarized Registry Evaluation of Registry Staff be sent to the site. This enables Registry Agencies to better evaluate their employees.
Related Recommendations (1)
R5:
The ITF/ETS Administration develop and implement a policy that require Nurse Managers to submit “Registry Staff Evaluations” (See Attachment #1) to all their registries.
F6:
There is an absence of continuity of patient care. Due to the extensive use of Per Diem psychiatrist/physicians who do not work a daily schedule, one physician may perform the assessment and develop the treatment plan. Later, another psychiatrist monitors and evaluates the patient and may subsequently make the discharge determination.
Related Recommendations (1)
R6:
The ITF/ETS Administration must schedule psychiatrists so that the same psychiatrist attends a patient for continuity of care during the treatment period.
F7:
ITF/ETS Administration has been unresponsive to complaints by staff psychiatrists regarding: • Nursing Supervisors overturning Doctors’ orders • substandard health and safety conditions adversely affecting patient care, such as patient on patient violence, and patients sleeping on the floor 4
Related Recommendations (1)
R7:
Nurse Managers and non-physician management personnel will not unilaterally overturn medical decisions that are in conflict with the physician’s orders without direct consultation with the attending physician or the physician on duty. This abuse of authority will lead to disciplinary actions up to and including termination of employment. ITF/ETS Administration take steps to immediately correct substandard health and safety conditions at AC.
F8:
The ITF/ETS is violating the RCRMC Department of Psychiatry Policy P.1.18 regarding incident reporting, as well as JCAHO standards PI.1.10, PI.2.20, PI.2.30, and PI.3.10 for sentinel events. “A sentinel event is an occurrence involving death or serious physical or psychological injury, or risk thereof.” “These events are called sentinel because they signal the need for immediate investigation and response.”
Related Recommendations (1)
R8:
The AC Administration amend the Department of Psychiatry Policy P 1.18 to invoke penalties for non-compliance by the administrative and management staff to report all incidents to Quality Improvement Department (QID) and/or Risk Management at RCRMC. These penalties include discipline up to and including termination of employment.
F9:
The Quality Improvement Department (QID) at RCRMC, which is responsible for creating a timely log of all reported incidents, has not maintained this log accurately to reflect the actual dates of reportable incidents. A review of the Incident Report Log reveals entry dates prior to the occurrence of the incidents, evidence of multiple entries with dates out of sequence, and missing data.
Related Recommendations (1)
R9:
QID at RCRMC enforce the policy and procedures for maintaining accurate incident report logs. The logs must reflect actual date of incident and actual date the report was received by QID. All personnel involved in the incident reporting process must take appropriate and timely action.
F10:
All AC incident reports were not submitted to QID and Risk Management. After January 7, 2007, the volume of incidents reported by ITF/ETS changed from 9 percent of total reported incidents in 2006, to 38 percent of the total during the first three months of 2007.
Related Recommendations (1)
R10:
All incident data must be reported accurately and timely to reflect the areas of ITF/ETS that indicate potential for quality improvement.
F11:
Some medical records contained incomplete documentation, including missing signatures on orders, telephone orders, and record of verbal orders.
Related Recommendations (1)
R11:
The Medical Records Department establish an audit team to conduct ongoing record review to ensure that the documentation is completed by validating with a random audit.
F12:
The August 2004 Behavioral Assault Management (BAM) Training Manual presently in use does not reflect the current policies and procedures of the RCRMC Department of Psychiatry.
Related Recommendations (1)
R12:
Update the Department of Psychiatry BAM Training Manual, August 2004, with respect to policies and procedures on seclusion and restraint, reporting assaults to local law enforcement, and the current “CODE GREEN” policy P 1.16f Rev. 10/10/06, which is the Emergency Response to Assault by Patient or Other Individual in the Hospital Environment. 9
F13:
Assembly Bill (AB) 508 passed in 1993 mandates that psychiatric hospital employees receive training and education relating to general safety measures, aggression and violence, verbal and physical maneuvers to diffuse or avoid violent behavior. Based on the training record(s) provided by ITF/ETS Administration in August 2006, it could not be determined that all the staff are in compliance.
Related Recommendations (1)
R13:
Update training documentation related to BAM and implement a procedure that would ensure that staff are kept up to date on BAM and recertified annually, as Psychiatry Department Policy dictates.
F14:
Within the last five (5) years, staff at ITF/ETS have not been given training and drills on Medical Emergency “CODE BLUE” policy and procedure P 1.16 Rev. 4/21/03 and Automated External Defibrillator (AED) policy and procedure P 1.16a Rev. 4/30/03. 5
Related Recommendations (1)
R14:
Institute “CODE BLUE” and “AED” training and drills as a mandatory training program for staff physicians, registered nurses, licensed vocational nurses, licensed psychiatric technicians, and nurses aides, as well as all registry staff, so that all staff are aware of their duties when a “CODE BLUE” is announced.
F15:
Training records covering 234 Riverside County employees at ITF/ETS were found incomplete, disorganized, and not useful with regard to tracking the training of the majority of employees.
Related Recommendations (1)
R15:
Develop and utilize a central database to track mandatory training and specialized supervisory training. Appoint sufficient personnel resources to maintain the training records.
F16:
Insufficient staff coverage on the night shift violates the 4 to 1 and 5 to 1 patient/nurse ratios and has created an unsafe environment at the ITF/ETS facility for patient/clients and staff.
Related Recommendations (1)
R16:
Require administrative supervisory personnel to be available for staffing during periods of personnel shortages.
F17:
The AC facility is being run without adequate general medical staffing. RCRMC provides a primary care physician with an additional duty to attend patients at the AC after working scheduled shift at RCRMC in Moreno Valley.
Related Recommendations (1)
R17:
The Administration hire a full time physician, physician assistant, or a nurse practitioner for ETS/ITF, rather than rely on a physician from RCRMC after working hours as an additional duty.
F18:
Employees who want to work overtime must apply to management. It was found that overtime was often assigned selectively to a small number of employees. Such a practice lends itself to allegations of discrimination based on factors other than competence.
Related Recommendations (1)
R18:
Assign overtime equitably to qualified employees.
F19:
Senior Administration at RCRMC and RCDMH has shown inadequate leadership in making appropriate personnel changes: • leaving funded staff positions unfilled • not reducing the high turnover of professional services of doctors, nurses, and staff • not providing trained professional security staff
Related Recommendations (1)
R19:
Senior administration at RCRMC, RCDMH, and the AC demonstrate leadership by working closely and consistently with Human Resources Director to identify a strategy to fill positions, some of which have not been filled in four years.
F20:
Items such as furniture, are not adequately secured to insure patient and staff safety. At the ITF/ETS facility we observed an agitated patient in a crowded dayroom pick-up a fiberglass chair and throw it across the room, narrowly missing other patients.
Related Recommendations (1)
R20:
The RCRMC Safety Coordinator inspect patient areas at the ITF/ETS facility to ensure that all furniture is either locked together or secured to the floor.
F21:
The indifference displayed by AC Administration has adversely affected employee morale. The mental and physical well-being of employees who have complained of abusive and violent behavior by patients are not supported by AC Administration with a program of follow-up care.
Related Recommendations (1)
R21:
Develop and implement management programs that would give professional support to staff who have experienced physical or psychological abuse or violence.
F22:
The AC administration has not been responsive for ensuring that a system of improved communications is maintained so that no one person can create an environment of fear and intimidation among the staff. 6
Related Recommendations (1)
R22:
The senior administrator establish and ensure open communications with staff and physicians, which will enable all opinions to be heard without fear of intimidation and retaliation. 10
F23:
The current Security Guard Service Contract, “Professional Service Agreement #PUARC690B”, does not meet the unique needs including guard service coverage, emergency codes, and training for that type of facility. 24. “Panic Buttons” are not installed at each reception desk, nurses’ station, and activity room.
Related Recommendations (1)
R23:
Upgrade security service by contracting for sheriff’s deputies, or trained correctional officers, to handle emergency contingencies.
F24:
"Panic Buttons" are not installed at each reception desk, nurses' station, and activity room.
Related Recommendations (1)
R24:
Install “Panic Buttons” at all reception desks, nurses’ stations, activity rooms, and any other critical areas at ITF/ETS.
F25:
The planned expansion by RCRMC of the ITF/ETS facility is contingent on the building meeting 1994 seismic standards. The building currently meets the 1973 standards, however, the modifications may reveal needed upgrades to bring the building up to the 1994 Northridge Earthquake Standards.
Related Recommendations (1)
R25:
Expedite plans to expand capacity at ITF/ETS.
F26:
The average daily intake of 27 patients per day at ETS, makes the only existing interview room inadequate to manage the volume of patient interviews and comply with the Welfare and Institutions Code §5325.1(b), related to patient privacy.
Related Recommendations (1)
R26:
Immediately add two (2) additional interview rooms at the ITF/ETS facility.
F27:
Interviews with professional staff and psychiatrists indicate a constant return rate of patients. Some patients have been placed outside of the medical jurisdiction of Riverside County that does not match the level of care needed. The determination of severity of patient’s diagnosis does not match discharge process and placement.
Related Recommendations (1)
R27:
AC Administration provide training for psychiatrists, physicians, psychologists, social workers, nurses, and management to ensure appropriate patient placement at time of discharge.
F28:
Nurses are engaging in unlawful practice by administering medicines to patients without proper documentation on the Medical Administration Record, and requesting other staff members to sign for the administration of the medication.
Related Recommendations (1)
R28:
Update and enforce Policy and Procedures regarding the administration of medication and chart documentation. Impose appropriate disciplinary measures for non-compliance and falsification of documentation.
F29:
During our inquiry we found a clear case where symptoms, and medical description of condition clearly described “schizophrenia with paranoid indications”, in the chart. When describing attempts at outplacement, these symptoms were clearly understated to potential residential placement, such as a board and care, instead of institutional placement, as indicated by a senior administrator.
Related Recommendations (1)
R29:
Find appropriate placement for patients in institutional facilities, licensed residential facilities, or appropriate community sites, based on the actual level of care needed. Do not alter diagnoses to influence placement.
F30:
After hours discharge of patients takes place without appropriate placement planning. Many patients discharged during this timeframe are unable to find shelter or residence of any kind. 7
Related Recommendations (1)
R30:
Develop and implement mandatory procedures, which would allow discharged patients to find shelter or residence.
F31:
ITF does not have qualified professional discharge planners dedicated to discharge placement of patients in California State Mental Hospitals when long-term care is indicated.
Related Recommendations (1)
R31:
Have an experienced discharge professional responsible, as part of the job description, be responsible to coordinate with State Hospitals and ensure proper patient placement.
F32:
Annual Performance Reviews of County Employees at the AC are done on irregular basis, if at all. Therefore, opportunities for constructive criticism and team building are lost.
Related Recommendations (1)
R32:
The AC Administration and Management comply with BOS Policy #C-21 Section 3, regarding performance reviews.
F33:
The Administration at the AC have relinquished their management operational responsibility to lower level managers.
Related Recommendations (1)
R33:
The CEO of RCRMC and the Director of RCDMH initiate a complete review and evaluation of Administrative and Management procedures and responsibilities at the Department of Psychiatry AC, as indicated in the findings of this report, and make appropriate changes. Report Issued: 06/27/07 Report Public: 06/29/07 Response Due: 09/26/07 11 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER REGISTRY EVALUATION Licensed Personnel NAME:______________________________REGISTRY:________________________ DATE:___________________________________UNIT:________________________ RATING N/A
* This report's PDF did not contain easily extractable text and required Optical Character Recognition (OCR) for analysis. There may be minor errors in the extracted findings and recommendations due to OCR limitations with scanned documents.