Summary of Report 08-039

July 2008

Report Number 08-039

The Department of Aging and Disability Services should strengthen certain processes related to mental retardation services.

The Department of Aging and Disability Services (DADS) has taken steps to improve its processes for discussing community living options with state school consumers of mental retardation services. For example:

- DADS now contracts with local mental retardation authorities (MRA). The MRAs conduct discussions of community living options with state school consumers.

- DADS and MRA staff now take consumers, guardians, and state school staff on tours of community facilities to increase awareness of community living options.

There were 4,884 state school consumers at the end of fiscal year 2007. Of those consumers, 644 expressed a preference for alternative living arrangements. DADS did not provide alternative living arrangements to 449 (70 percent) of these 644 state school consumers.

DADS should improve its documentation of required community living options discussions with consumers, as well as its documentation of the reasons for not providing community living arrangements to consumers. DADS's documentation often does not include information about the consumers' awareness of available community living options. Documenting the consumers' awareness of living options is significant given the fact that 52 percent of state school consumers had expressed no preference for specific living arrangements as of the end of fiscal year 2007. In addition, DADS should improve its monitoring to help ensure that (1) it discusses community living options adequately with consumers and (2) it has sound and sufficiently documented reasons for its decisions about consumers' living arrangements. DADS's monitoring efforts also are hindered by weaknesses in the automated case management system that contains information about consumers' needs and preferences. These issues are significant because Texas has the nation's largest population of consumers of mental retardation services living in large, state-run institutions. In fiscal year 2007, DADS began to refer more state school consumers of mental retardation services to community settings. In the last six months of fiscal year 2007, DADS referred 127 state school consumers to community settings, compared with 48 referrals in the first six months of fiscal year 2007. That trend continued in the first six months of fiscal year 2008, when DADS referred 125 state school consumers to community settings.

The Department of Aging and Disability Services also should strengthen its processes for investigating complaints and incidents at state schools and public and private community facilities to identify violations of state rules and Medicaid requirements.

Between September 1, 2005, and December 31, 2007, DADS investigated 99 percent of the highest priority complaints and incidents within one day, as required. However, it did not investigate 41 percent of the second highest priority complaints and incidents within the required timeframe of 14 days.

Auditors identified 10 state school employees who were listed in the Nurses Aide and Employee Misconduct Registries as unemployable due to acts of abuse, neglect, or exploitation that should have disqualified them from their positions. After auditors brought this to DADS's attention, DADS terminated these individuals' employment.

The Department of Family and Protective Services should strengthen its processes for investigating allegations of abuse, neglect, and exploitation.

Texas Human Resources Code, Chapter 48, requires the Department of Family and Protective Services (DFPS) to investigate allegations of abuse, neglect, and exploitation at state schools and government-run community facilities. Between September 1, 2005, and November 30, 2007, DFPS processed 83 percent of allegations accurately. It incorrectly assessed 2 of 21 (10 percent) allegations that auditors reviewed; as a result, DFPS did not investigate these allegations as required.

In addition, DFPS notified facilities of allegations within one hour, as required, 88 percent of the time. DFPS also contacted alleged victims in a timely manner 87 percent of the time, but it should clarify whether contact is required for reports that are referred to the facility and not investigated by DFPS. Lastly, DFPS completed final investigation reports within required timeframes 87 percent of the time.

Various factors lead to higher costs to serve consumers in state schools as compared to community ICF/MR facilities.

The average daily cost to serve a consumer in a state school in fiscal year 2006 was approximately $335. The average daily cost to serve a consumer in a community ICF/MR facility in fiscal year 2006 was approximately $165. Greater costs in state schools are driven by higher costs in direct care staffing, administration, and comprehensive medical care.

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