2001-2002

F1: TCBHS Advisory Board agrees moral was low in the department at the time of the investigation. The TCBHS Advisory Board agrees with the Recommendations (please see enclosed Attachment A).

F2: The Trinity County Board of Supervisors disagrees Responses with Finding #2. The Board does not believe that an independent appraiser could appraise all of the County’s real property for $8,000.00. TO: The Honorable John K. Letton, Presiding Judge of the Superior Court

F3: The Trinity County Board of Supervisors agrees with DATE: May 28, 2002 Finding #3. The Grand Jury Finance and Administration Committee has re- Recommendation #3: The recommendation has been implemented. quested a written response to their final report on the Trinity County The County does review the financial statements and notes for com- Financial Statements and Related Accounting Matters. In my ca- pleteness and accuracy, and we will resolve any inaccuracies with pacity as Auditor-Controller performing the duties of County Ad- the outside auditor. ministrative Officer, my response is a follows:

F4: responsibility for this project for nearly 7 years. I agree, although the county has been coordinating with local fire Finding #3: The Trinity County Board of Supervisors agrees with districts regarding this issue. The county has secured temporary Finding #3. The data bases of the telephone companies and the funding through the Transportation Commission’s Local Transpor- county 911 system need to recognize a single address for each resi- tation Fund to purchase signs for private roads that intersect with dence in the future. At present, the design of the system allows the public roads and the fire districts have provided volunteer labor to dispatcher to have both systems information displayed concurrently install them. It is entirely the responsibility of private property to avoid confusion. owners to purchase and install private road signs when they inter-

F5: management still has much to rectify. The Grand Jury received allegations that the Kings View informa- While the loss of potential revenue is staggering and adds credence tion system failed for a period of four to six months. We also re- to the original allegations, it does not constitute proof as to the ceived allegations that numerous Medi-Cal billings were never sub- remaining allegations. For example, it does not address the asser- mitted, and that the total Medi-Cal reimbursement losses may have tion that a significant number of billings were not submitted that exceeded $100,000. Both the Mental Health Director and the Ex- would add significantly to reimbursement to the County. Because ecutive Director indicated during interviews that some funds may the Grand Jury could not either validate or dismiss all of the allega- have been lost due to errors or late billing, but the amounts were tions, and because the Grand Jury lacks the resources necessary to insignificant in their eyes, and certainly not of this magnitude. conduct thorough financial and management audits, the Grand Jury finds that such audits should be performed to identify and correct Given what the Kings View information management service is to any related problems. provide contractually (refer to the Background section), and in an attempt to shed some light on these allegations, the Grand Jury When the Grand Jury reviewed the State/County contract, we noted initiated a test of the current information system. We requested fi- under Exhibit B - Payments Provisions, section 4 - Amounts Pay- nancial information for fiscal year (FY) 2000-01 and FY 2001-02 able, that the State was to pay TCBHS an allocation amount of to date, broken down by month, and including total revenue, Medi- $126,096 for FY 2001-02. We had not received any documentation Cal billings, and Medi-Cal reimbursements. We also requested, over that modified this allotment, nor assigned it to another source. Since the same time periods, and by month, the total numbers of clients, we had not been provided this figure during our interviews with the and the Medi-Cal client subset. During the same visit, the Grand directors, we asked the Executive Director to explain this omis- Jury also requested copies of all State reviews, inspections, and sion. Initially, he was unable to explain it, and wanted a copy (in audits involving TCBHS, from January 2001 to date. We also re- effect, a copy of a copy originally obtained from TCBHS). Several quested copies of the current State/County mental health provider days later the Executive Director stated he believed this funding contract, including any memorandaof-understanding (MOU), ad- was a portion of the realignment funds listed in the County budget denda, or any other documents that modify the initial contract. associated with Medi-Cal managed care reconciliation. The Grand Jury queried the State contract representative from the Department The Grand Jury did not obtain this information the day it was re- of Mental Health, and he informed us the allocation was direct fund- quested, nor on the following workday when Grand Jury members ing for the contract. Consequently the Grand Jury is still uncertain returned. It was two weeks later before we obtained the bulk of the as to the real funding source and any restrictions associated with material requested. The Grand Jury notes that industry standards this revenue, and just where it resides in the funding explanations normally require audit information be made available by the end of provided to us for the Background section. Examples such as these the workday on which it is requested. tend to erode the Grand Jury’s confidence in the Department’s man- agement. The Grand Jury did eventually receive the monthly Medi-Cal bill- ings and reimbursements for FY 1999-00, 2000-01, and 2001-02 In summary, the Grand Jury finds that the Kings View information through December. Given the Medicare/Medi-Cal reimbursement management system, as implemented at TCBHS, does not measure rate of 51.25 percent and the amounts billed and received, one can up to industry accounting standards. The Grand Jury believes that determine the potential “fully compliant” reimbursements, assum- the type of fiscal information we requested should already have ing no disallowance by the State, and consequently the revenue been available as printed monthly reports, but at the very least, forfeited by the County for a lack of compliance. The following should have been readily available from the computerized infor- table illustrates these results, in which the numbers on the top two mation system. The Grand Jury also finds that any prudent depart- rows were provided by TCBHS, while those figures on the lower ment manager should have had accounting reports provided monthly three rows were derived by the Grand Jury. (as noted above) in order to verify and oversee the client informa- tion and costs being reported to the State, and for comparison with the reimbursements returned from the State. Any disallowance FY 1999-2000 FY 2000-2001 FY 2001- Dec. should have been a flag to management indicating a problem that required inquiry and solution, in order to maximize revenue return. Amount Billed $600,700. $805,856. $430,620. A management information system can be a superb tool for manag- ers to properly execute their managerial duties and responsibilities, tion at the earliest contractual opportunity. but only if properly utilized. B. The Grand Jury has also found a bureaucracy growing within As stated in the opening paragraph of this Finding #5, both the the department, while concurrently, the quality of clinical services Mental Health Director and the Executive Director indicated dur- are deteriorating. Quality medical service to our community must ing interviews that some funds might have been lost due to errors remain a top priority. Consequently, the Grand Jury recommends or late billing, but the amounts were insignificant in their eyes. that the TCBHS organizational structure be streamlined to maxi- This Grand Jury finds that the funds lost due to management negli- mize client services. gence are not insignificant in our eyes, and believes that further investigations are warranted. FINDING #8:

F6: investigation. The Advisory Board has apparently been satisfied by similar assurances. Given the numerous problems that have arisen in the Department during the transition to contract services with Kings View, and The contract with Kings View states that the selection of the Ex- managed care medical delivery service in general, including the ecutive Director shall be subject to the approval of the County. The compliance issues identified during the State audits, the Grand Jury Grand Jury assumes that the “approval of the County” involves finds that the leadership and oversight has not been commensurate review and advice from the Advisory Board. Yet the Advisory Board with the task. We recognize that the Mental Health Director is also was simply informed about Kings View Executive Director appoint- the County Auditor and the interim CAO, in addition to other du- ments after the fact, and was not part of the process. ties that he has been assigned. Overall, he can only devote about 30 percent of his time overseeing the TCBHS Department operations. RECOMMENDATION #8:

F7: B.State statutes and regulations not only require that the County Board of Supervisors establish a mental health board, but consult Throughout most of its history, a single director has headed the with it on any County agreements involving mental health services, County mental health organization. Now, under the Kings View including service or consulting contracts, and director appointments. contract, the organization’s management includes a Mental Health The Grand Jury recommends that the Board of Supervisors and Director, an Executive Director, and a Deputy Director, in addition County Mental Health Director abide by these requirements in the to the section/team leaders. As indicated in the background section future. The Grand Jury also recommends that out of courtesy the and reported findings, both the Mental Health Director and Deputy County consult with the TCBHS Advisory Board about any profes- Director hold other managerial appointments with separate respec- sional appointments within the TCBHS Department. tive duties. The Executive Director, a Kings View employee, re- sides outside of Trinity County. In addition, the team leaders (es- C. The Grand Jury recommends the Board of Supervisors give equal sentially first-line supervision) have reduced some of their clinical if not more credence to the TCBHS Advisory Board’s advice than duties, thus either impacting client services, or adding to the bur- that of the Mental Health Director. The Advisory Board represents den of the remaining clinical staff. the community’s opinion, and the members are serving unselfishly to obtain the best mental health care for the benefit of the County’s The Grand Jury has found that the duties and responsibilities of the citizenry. Mental Health Director and Executive Director are not well delin- eated and are inexorably intertwined. At times they overlap, at times D. The Grand Jury recommends that the County Mental Health they seem not to cover fully all the Department’s requirements, Director attend all of the TCBHS Advisory Board meetings. and, above all, are confusing to both departmental employees and outside observers. CONCLUSIONS: The Grand Jury finds that Kings View has not achieved the original After review of documents and assimilation of numerous interviews, contractual goal of clinical efficacy, cost efficiency, nor full com- it is the Grand Jury’s conclusion that the TCBHS Department is pliance with State requirements. The Grand Jury finds that the post experiencing significant morale problems, especially between man- of Executive Director is extraneous, provided the Board of Super- agement and rank and file employees. It is clear from the inter- visors accepts the previous recommendation for a full-time County views with both management and rank and file employees that the Mental Health Director. transition from a smaller, less bureaucratic department to a larger, more bureaucratic managed care organization has been rocky and

F8: I disagree in part. pressure from the State Department of Mental Health has forced Response: The Chairman of the Advisory Board has been involved the Department into needing to make dramatic changes over a in every interview panel established to review potential executive short period of time. Over the past five months the Department has directors proposed by Kings View. developed a Plan of Correction. That Plan of Correction has been approved by the Department of Mental Health.