Recipient Rights System of Wayne Community Living Services, Inc.

Michigan Office of the
Auditor General
Thomas H. McTavish, C.P.A.
Auditor General

EXECUTIVE DIGEST #3915297
Recipient Rights System of Wayne Community Living Services, Inc.

INTRODUCTION
This report, issued in August 1998, contains the results of our performance audit of the Recipient Rights System of Wayne Community Living Services, Inc. (WCLS), an agency under contract with the Detroit-Wayne County Community Mental Health Agency (DWCCMHA).

AUDIT PURPOSE
This performance audit was conducted as part of the constitutional responsibility of the Office of the Auditor General. Performance audits are conducted on a priority basis related to the potential for improving effectiveness and efficiency.

BACKGROUND
WCLS, located in Wayne, Michigan, is a nonprofit mental health agency under contract with DWCCMHA to provide mental health services to people with developmental disabilities throughout Wayne County. WCLS provides direct clinical support services and housing development services to recipients and it subcontracts for recipient day program services and residential services. WCLS is governed by a 13-member board of directors selected from Southeastern Michigan.

WCLS's mission is to enable persons with developmental disabilities to experience a full life with dignity, health, opportunity for personal growth, and self-esteem while residing in the community.

As a provider of mental health services, WCLS is required by the Mental Health Code and its contract with DWCCMHA to establish a recipient rights system to protect recipients.

WCLS's operations are funded by State, federal and local funds. As of September 30, 1997, WCLS had 324 authorized positions and was serving approximately 1,680 recipients. For fiscal year 1996-97, WCLS's revenues and expenditures totaled $106,095,891 and $114,055,410, respectively. In addition, WCLS's subcontractors received $7,759,967 in Supplemental Security Income on behalf of recipients that WCLS served for fiscal year 1996-97.

AUDIT OBJECTIVES, CONCLUSIONS, AND NOTEWORTHY ACCOMPLISHMENTS
Audit Objective: To assess the effectiveness of WCLS's efforts to control and prevent recipient abuse and neglect.

Conclusion: We concluded that WCLS was not effective in its efforts to control and prevent recipient abuse and neglect. Our assessment disclosed three material conditions:

WCLS did not establish an effective continuous quality improvement (CQI) process to monitor and improve its Recipient Rights System's performance in protecting recipients from abuse and neglect (Finding 1).

WCLS concurs with the finding. WCLS informed us that it has identified performance indicators and performance goals and is in the process of implementing same in order to monitor and improve its effectiveness in protecting recipients from abuse and neglect.

WCLS did not have an effective quality assurance process for ensuring its compliance with the Mental Health Code and the Michigan Administrative Code requirements for operating a recipient rights system (Finding 2).

WCLS concurs with the finding. WCLS informed us that it has implemented procedural changes as well as a system to monitor performance indicators to ensure its compliance with the Mental Health Code and the Michigan Administrative Code.

WCLS's Office of Recipient Rights (ORR) staffing levels were not sufficient to operate its recipient rights system in accordance with Mental Health Code requirements and its contract with DWCCMHA (Finding 3).

WCLS concurs with the finding and informed us that:
(1)   WCLS has maximized its existing resources
        despite financial constraints. WCLS receives
        funding for 5 positions in ORR and had
        requested additional funding for 4 positions on
        three occasions, the latest in February 1998, that
        were denied by its funding source.
(2)   WCLS has supplemented ORR by an additional
        80% beyond funded staffing with 4 positions from
        WCLS's internal resources, and it continues to
        supplement these 4 positions despite an overall
        employment reduction of 36 (10%) of its total
        workforce.
Our assessment also disclosed reportable conditions related to WCLS recipient rights training, service site rights assessments, and guardianship renewals (Findings 4, 5, and 6).

In addition, our audit disclosed other reportable conditions that may have had an impact on the effectiveness of WCLS's efforts to control and prevent recipient abuse and neglect. These conditions are reported under our second audit objective.

Noteworthy Accomplishments: WCLS established a CQI committee to provide general education to all WCLS staff on CQI principles and tools. Also, WCLS established three task groups, including a recipient rights task group, to work on issues to help improve recipient rights and the effectiveness of the recipient rights system. Further, during the audit, WCLS assessed ORR's policies and procedures and developed a plan to correct weaknesses identified by the audit.

Audit Objective: To assess the effectiveness of WCLS's efforts to respond to and investigate recipient abuse and neglect complaints.

Conclusion: We concluded that WCLS was often ineffective in its efforts to respond to and investigate recipient abuse and neglect complaints. Our assessment disclosed reportable conditions related to timely reporting and investigation of complaints, timeliness in completing complaint investigations, reporting suspected criminal abuse to law enforcement agencies, and reporting complaint investigation status and results to complainants and recipients, (Findings 7, 8, 9, and 10).

AUDIT SCOPE AND METHODOLOGY
Our audit scope was to examine the program and other records of the Recipient Rights System of Wayne Community Living Services, Inc.. Our audit was conducted in accordance with Government Auditing Standards issued by the Comptroller General of the United States and, accordingly, included such tests of the records and such other auditing procedures as we considered necessary in the circumstances.

We examined WCLS's records and activities for the period October 1, 1994 through October 23, 1997.

To accomplish our audit objectives, we reviewed DWCCMHA's annual contract with WCLS and DWCCMHA's annual assessment of WCLS's Recipient Rights System. We obtained and analyzed WCLS's Management Information System (MIS) database on recipient rights complaints. We reviewed and evaluated WCLS's process for monitoring and improving ORR's effectiveness. We reviewed WCLS's and DWCCMHA's policies and procedures. We examined WCLS's recipient rights training and other program records. We interviewed WCLS and DWCCMHA personnel. We reviewed and evaluated WCLS's quality assurance process for meeting Mental Health Code and Michigan Administrative Code requirements for operating a recipient rights system. We evaluated staffing levels for ORR. We examined select recipient rights abuse and neglect complaint records. We reviewed and evaluated WCLS's process for responding to and investigating recipient abuse and neglect complaints.

AGENCY RESPONSES
Our audit report contains 10 findings and corresponding recommendations. WCLS's preliminary response indicated that it concurs with all 10 findings.

Full Audit Report - #3915297 - Recipient Rights System of Wayne Community Living Services, Inc.

Documents prefaced by require the Adobe Acrobat Reader®, a free application available on the Adobe homepage.

This page was created on 08/24/98.


INTRODUCTION This report, issued in August 1998, contains the results of our performance audit of the Recipient Rights System of Wayne Community Living Services, Inc. (WCLS), an agency under contract with the Detroit-Wayne County Community Mental Health Agency (DWCCMHA).

AUDIT PURPOSE This performance audit was conducted as part of the constitutional responsibility of the Office of the Auditor General. Performance audits are conducted on a priority basis related to the potential for improving effectiveness and efficiency.

BACKGROUND WCLS, located in Wayne, Michigan, is a nonprofit mental health agency under contract with DWCCMHA to provide mental health services to people with developmental disabilities throughout Wayne County. WCLS provides direct clinical support services and housing development services to recipients and it subcontracts for recipient day program services and residential services. WCLS is governed by a 13-member board of directors selected from Southeastern Michigan. WCLS's mission is to enable persons with developmental disabilities to experience a full life with dignity, health, opportunity for personal growth, and self-esteem while residing in the community. As a provider of mental health services, WCLS is required by the Mental Health Code and its contract with DWCCMHA to establish a recipient rights system to protect recipients. WCLS's operations are funded by State, federal and local funds. As of September 30, 1997, WCLS had 324 authorized positions and was serving approximately 1,680 recipients. For fiscal year 1996-97, WCLS's revenues and expenditures totaled $106,095,891 and $114,055,410, respectively. In addition, WCLS's subcontractors received $7,759,967 in Supplemental Security Income on behalf of recipients that WCLS served for fiscal year 1996-97.

AUDIT OBJECTIVES, CONCLUSIONS, AND NOTEWORTHY ACCOMPLISHMENTS Audit Objective: To assess the effectiveness of WCLS's efforts to control and prevent recipient abuse and neglect. Conclusion: We concluded that WCLS was not effective in its efforts to control and prevent recipient abuse and neglect. Our assessment disclosed three material conditions: WCLS did not establish an effective continuous quality improvement (CQI) process to monitor and improve its Recipient Rights System's performance in protecting recipients from abuse and neglect (Finding 1). WCLS concurs with the finding. WCLS informed us that it has identified performance indicators and performance goals and is in the process of implementing same in order to monitor and improve its effectiveness in protecting recipients from abuse and neglect. WCLS did not have an effective quality assurance process for ensuring its compliance with the Mental Health Code and the Michigan Administrative Code requirements for operating a recipient rights system (Finding 2). WCLS concurs with the finding. WCLS informed us that it has implemented procedural changes as well as a system to monitor performance indicators to ensure its compliance with the Mental Health Code and the Michigan Administrative Code. WCLS's Office of Recipient Rights (ORR) staffing levels were not sufficient to operate its recipient rights system in accordance with Mental Health Code requirements and its contract with DWCCMHA (Finding 3). WCLS concurs with the finding and informed us that: (1) WCLS has maximized its existing resources despite financial constraints. WCLS receives funding for 5 positions in ORR and had requested additional funding for 4 positions on three occasions, the latest in February 1998, that were denied by its funding source. (2) WCLS has supplemented ORR by an additional 80% beyond funded staffing with 4 positions from WCLS's internal resources, and it continues to supplement these 4 positions despite an overall employment reduction of 36 (10%) of its total workforce. Our assessment also disclosed reportable conditions related to WCLS recipient rights training, service site rights assessments, and guardianship renewals (Findings 4, 5, and 6). In addition, our audit disclosed other reportable conditions that may have had an impact on the effectiveness of WCLS's efforts to control and prevent recipient abuse and neglect. These conditions are reported under our second audit objective. Noteworthy Accomplishments: WCLS established a CQI committee to provide general education to all WCLS staff on CQI principles and tools. Also, WCLS established three task groups, including a recipient rights task group, to work on issues to help improve recipient rights and the effectiveness of the recipient rights system. Further, during the audit, WCLS assessed ORR's policies and procedures and developed a plan to correct weaknesses identified by the audit. Audit Objective: To assess the effectiveness of WCLS's efforts to respond to and investigate recipient abuse and neglect complaints. Conclusion: We concluded that WCLS was often ineffective in its efforts to respond to and investigate recipient abuse and neglect complaints. Our assessment disclosed reportable conditions related to timely reporting and investigation of complaints, timeliness in completing complaint investigations, reporting suspected criminal abuse to law enforcement agencies, and reporting complaint investigation status and results to complainants and recipients, (Findings 7, 8, 9, and 10).

AUDIT SCOPE AND METHODOLOGY Our audit scope was to examine the program and other records of the Recipient Rights System of Wayne Community Living Services, Inc.. Our audit was conducted in accordance with Government Auditing Standards issued by the Comptroller General of the United States and, accordingly, included such tests of the records and such other auditing procedures as we considered necessary in the circumstances. We examined WCLS's records and activities for the period October 1, 1994 through October 23, 1997. To accomplish our audit objectives, we reviewed DWCCMHA's annual contract with WCLS and DWCCMHA's annual assessment of WCLS's Recipient Rights System. We obtained and analyzed WCLS's Management Information System (MIS) database on recipient rights complaints. We reviewed and evaluated WCLS's process for monitoring and improving ORR's effectiveness. We reviewed WCLS's and DWCCMHA's policies and procedures. We examined WCLS's recipient rights training and other program records. We interviewed WCLS and DWCCMHA personnel. We reviewed and evaluated WCLS's quality assurance process for meeting Mental Health Code and Michigan Administrative Code requirements for operating a recipient rights system. We evaluated staffing levels for ORR. We examined select recipient rights abuse and neglect complaint records. We reviewed and evaluated WCLS's process for responding to and investigating recipient abuse and neglect complaints.

AGENCY RESPONSES Our audit report contains 10 findings and corresponding recommendations. WCLS's preliminary response indicated that it concurs with all 10 findings.