Opinion
Civ. No. 76-293. (SSH).
December 22, 2000.
Joseph Tulman, Esq. and UDC David A. Clarke, School of Law, Washington, DC, Attorneys for Plaintiffs.
Kelly Bagby, Esq., University Legal Services, Washington, DC, Attorney for Plaintiffs.
Richard J. Farano, Esq. U.S. Department of Justice, Civil Rights Division, Special Litigation Section, Washington, DC, Attorney for Plaintiff-Intervenor.
Margaret G. Farrell, Esq., Special Master, Cohen, Milstein, Hausfeld Toll, Washington, DC, and Clarence J. Sundram, Esq., Co-Special Master, Delmar, NY, Attorneys for Plaintiff-Intervenor.
Robert Utiger, Esq. Deputy Corporation Counsel, Maria C. Amato, Esq. Task Force, Major Equity Litigation Office of the Corporation Counsel, Washington, DC, Attorney for Defendants.
PARTIES' JOINT STIPULATED FINDINGS OF FACT
I. Introduction
On February 10, 1999, this Court ordered the Special Master to develop findings of fact with regard to the status of Defendants' compliance with Court Orders in this case. In order to assist the Special Master to comply with this Order, the parties, in order to resolve their differences, avoid costly and unnecessary litigation, and continue their collaborative relationship, have agreed on the following stipulated findings of fact. The stipulations apply to the time period up to and including the date of the statement or report that is the source of the information.
II. Stipulations GENERAL FINDINGS
1. Issues related to the District of Columbia's system of support for individuals with developmental disabilities (hereinafter "District's system") represent one of the most serious breakdowns in the District government over the last two decades. The measure of a society is how it treats its most vulnerable citizens. In this case, the District government failed. Prepared Statement of Anthony A. Williams, Mayor of the District of Columbia (hereinafter "Mayor's Prep. Stmnt."), June 1, 2000 at 1 (Master's Exh. J, June 30, 2000).
2. Mistakes in the District's system of support for individuals with developmental disabilities cover 20 years of neglect and mismanagement. Mayor's Prep. Stmnt. at 1.
3. The District government is seriously broken from years of disinvestment, mismanagement, poor oversight and neglect. Mayor's Prep. Stmnt. at 1.
4. The breakdown in services to clients with developmental disabilities in the District's system had been 19 years in the making. Mayor's Prep. Stmnt. at 1.
5. The Mayor and his administration were aware of problems in the District's Mental Retardation and Developmental Disabilities Administration ("MRDDA") but were not aware that some of the systemic problems could lead to threats to the life and safety of some of the most vulnerable citizens in the District's system. Mayor's Prep. Stmnt. at 2.
6. In spite of some progress in fixing the District's system of support for individuals with developmental disabilities in recent months, much remains to be done. Mayor's Prep. Stmnt. at 2.
7. Two decades of neglect in the District's system has taken a toll on the clients served in the system. Mayor's Prep. Stmnt. at 3.
8. The District government has fundamentally failed its obligation to disabled persons and their families, painful experience has taught that the District's MRDDA system is not a system. Mayor's Prep. Stmnt. at 3.
9. The District's system of support for individuals with developmental disabilities must do a better job assessing risks and being proactive. Mayor's Prep. Stmnt. at 4.
10. The District's support system is a problem that urgently needs to be fixed. Mayor's Prep. Stmnt. at 4.
11. The District government inherited by Mayor Williams was almost completely decimated as a result of years of disinvestment, mismanagement, and poor performance. Prepared Statement of Carolyn N. Graham, Deputy Mayor of the District of Columbia (hereinafter "Deputy Mayor's Prep. Stmnt."), May 22, 2000 at 1 (Master's Exh. K).
12. Problems existed in MRDDA under the present administration. Deputy Mayor's Prep. Stmnt. at 2.
13. The District was aware of problems of poor care provided at group homes, systemic failures and other issues as a result of aWashington Post article in February 1999. Deputy Mayor's Prep. Stmnt. at 3.
14. MRDDA needed legal representation in guardianship hearings that involve citizens with developmental disabilities. Deputy Mayor's Prep. Stmnt. at 4.
15. MRDDA has had trouble getting provider contracts processed in a timely manner. Deputy Mayor's Prep. Stmnt. at 5.
16. The problems in the District's support system for individuals with developmental disabilities were even more egregious than originally and subsequently described. Deputy Mayor's Prep. Stmnt. at 6.
17. The Mayor issued a report that acknowledged that the District's entire mental retardation and developmental disabilities system was fundamentally unable to deliver even the most basic services. It is definitive that the current system failed because of a poor design and years of neglect and disinvestment. The District's system intended to address the needs of those with developmental disabilities suffers from fundamental problems. Examples of such fundamental problems in the District's system include: there are no clearly defined quality service standards; there is no quality improvement process; there are no significant penalties for lack of compliance with existing system's requirements; there is fragmentation and poor coordination in government business processes; there is no investment in technology to augment business processes internal and external to government; there is a poorly trained workforce both in and outside of government; there is a highly inconsistent, underpaid workforce external to government; and there are limited supported employment opportunities. Well over sixty percent of the population in the District's community residential facilities ("CRF's") could benefit from such opportunities. The District's system favors high cost institutional-based care as opposed to a system that supports and encourages independence and inclusion. Deputy Mayor's Prep. Stmnt. at 7-9.
18. The District's support system requires a major overhaul that will not happen overnight. Deputy Mayor's Prep. Stmnt. at 10. While there have been some recent accomplishments, far more remains to be done. Deputy Mayor's Prep. Stmnt. at 14.
19. Painful experience has taught that the District government currently lacks the capacity to adequately deliver the services that the individuals with developmental disabilities in the District's system require. Deputy Mayor's Prep. Stmnt. at 17.
20. The entire mental retardation and developmental disabilities service delivery system is incapable of providing quality service. Preliminary Findings on the Mental Retardation and Developmental Disabilities Service Delivery System, Government of the District of Columbia, Office of the Deputy Mayor for Children and Families, Jan. 18, 2000 (hereinafter "D.C. Prelim. Rep.") at 1 (emphasis in original).
21. The District's mental retardation and developmental disabilities service delivery system is broken. D.C. Prelim. Rep. at 5, 39.
22. The District's system is highly dysfunctional and unable to execute its mission at its most basic level through its current structure and procedures. D.C. Prelim. Rep. at 2.
23. After the closure of Forest Haven, compliance with the Evans v. Williams Court-Ordered mandates began to deteriorate. D.C. Prelim. Rep. at 11 (fn. 5). Many of the requirements of the Evans Court Orders are not being complied with. D.C. Prelim. Rep. at 14. While Court Orders in the Evans case apply only to a portion of the customers served by MRDDA, there is no programmatic or clinical reason to differentiate between class members and other customers. D.C. Prelim. Rep. at 17.
24. The District is mired in a philosophy of service delivery that is reminiscent of approaches that are more than 20 years old and that consequently, neither MRDDA's mission statement nor its operation reflects the most current philosophy demonstrated nationally in best practice models. D.C. Prelim. Rep. at 22.
25. The entire District service delivery system must be redefined and rebuilt. D.C. Prelim. Rep. at 2.
26. The need for reform in the District's system ranges from the broadest to the smallest of issues and simply "tinkering around the edges" will not solve the systemic problems in the system. D.C. Prelim. Rep. at 11.
27. Fixing the District's system requires a combination of short and long-term initiatives that are integrated and coordinated. Previous attempts to analyze and fix problems have been too narrow in scope and did not take into account the overall impact of piecemeal solutions. D.C. Prelim. Rep. at 5, 39.
28. MRDDA does not and cannot meet its stated mission which is to serve individuals with mental retardation and other developmental disabilities. Defendants' staffing pattern and approach has been and still is designed to serve only people with mental retardation. MRDDA is not adequately meeting the needs of people with mental retardation and is not capable of effectively meeting the aspect of its mission to serve people with developmental disabilities other than mental retardation. D.C. Prelim. Rep. at 21.
29. Upon further review of the system, Defendants re-confirmed their earlier conclusion that communication and coordination between departments and even agencies within departments is inadequate. Addendum to Preliminary Findings on the Mental Retardation and Developmental Disabilities Service Delivery System, Government of the District of Columbia, Office of the Deputy Mayor for Children and Families, Mar. 2, 2000 (hereinafter "D.C. Addendum Rep.") at 3.
30. There is no single coordinated plan to ensure lifetime support to individuals with mental retardation and developmental disabilities. D.C. Addendum Rep. at 3.
LEAST RESTRICTIVE COMMUNITY SETTING
31. The District relies on a facility-based model of service delivery that does not lend itself to providing community living and support services that are fully integrated, customer-directed, flexible, cost efficient, and which promote an optimum quality of life. Final Report to the Government of the District of Columbia, Office of the City Administrator, Office of the Deputy Mayor for Operations, Georgetown University Child Development Center, Jan. 18, 2000 (hereinafter "D.C. Georgetown Rep.") at 2.
32. There is a general lack of communication between MRDDA and the Office of Program Operations which results in a lack of coordination in planning to ensure that the appropriate types of facilities are available for the placement of MRDDA clients by MRDDA. D.C. Addendum Rep. at 9. Ultimate decision-making in person centered planning rests with MRDDA even though it is "demonstrably ill-equipped" to carry out this function. D.C. Georgetown Rep. at 15. There are no structural mechanisms within the District system for people with disabilities and their families to select where and with whom they live; participate in the design of services they receive; determine from whom they receive services; and participate in program evaluation including customer satisfaction surveys. D.C. Georgetown Rep. at 15.
33. The District's operating philosophy is the same as it was prior to the closing of Forest Haven resulting in "mini-Forest Havens" rather than a person-centered planning philosophy. D.C. Prelim. Rep. at 2.
34. The District's Medical Assistance Administration ("MAA") and MRDDA have failed to implement an effective Medicaid Home and Community Based Waiver. The District's commitment to self-determination embodied in person centered planning cannot be met without the funding stream provided by an effective waiver. D.C. Prelim. Rep. at 35-36.
35. The lack of an effective home and community based waiver is in itself sufficient to keep the District from effectively implementing person centered planning. D.C. Addendum Rep. at 4.
36. The District does not have a. functioning home and community based waiver program. D.C. Addendum Rep. at 8. Defendants acknowledge that the District has "lagged behind" in instituting a fully functional waiver. D.C. Addendum Rep. at 6.
37. The District's competitive procurement process is not suitable for the procurement of service to the MRDDA population in that awarding the contract to the lowest bidder sometimes results in awards that do not support the goals of person centered planning and respect for individual self-determination. D.C. Prelim. Rep. at 31.
38. MRDDA and provider managers and supervisors may lack sensitivity to the right of persons with mental retardation and developmental disabilities to make choices. D.C. Prelim. Rep. at 16.
STAFF TRAINING
39. Formal training programs and requirements for both District and private sector employees are nearly non-existent in the mental retardation and developmental disabilities service delivery system. D.C. Prelim. Rep. at 3.
40. MRDDA employees have not been provided adequate training for the jobs that they do. D.C. Prelim. Rep. at 17.
41. Residential and transportation provider employees within the District's system have not been provided adequate training for the jobs that they do. D.C. Prelim. Rep. at 17.
42. There has been a lack of appropriate training of MRDDA managers and employees. There is no formal training program in place. D.C. Prelim. Rep. at 18.
PROTECTION FROM HARM/INCIDENT REPORTING/INVESTIGATIONS
43. There is no formal policy or procedure detailing the difference between an unusual incident report and an "alert," that MRDDA staff had different understandings of these two instruments. Defendants acknowledge that more review of the "alert" process is necessary. D.C. Prelim. Rep. at 14.
44. There is a lack of basic policies and procedures in the District system. There was no policy to allow employees to call 911 without first getting a supervisor's approval until December 1999. There was no policy to provide for safe transportation of customers in existence prior to late 1999, and that it was developed only after a customer died after being left unattended in a van. D.C. Prelim. Rep. at 19.
45. Policies and procedures are often not followed in the District's system. For example, many providers do not provide MRDDA with unusual incident reports within 24 hours and do not submit reports on all incidents that should be reported pursuant to current MRDDA policies. D.C. Prelim. Rep. at 19.
46. MRDDA staff do not always track down the outcome of matters referred for action. Once items are referred to other agencies for action, little follow-up is done to determine the status of investigations. This problem is exacerbated by a general failure to share information among involved organizations. D.C. Prelim. Rep, at 20.
47. There is a large backlog of unusual incident reports within the Bureau of Program Operations and Contracts ("BPOC") which is to review them and forward them for appropriate action. D.C. Prelim. Rep. at 24. Since at least November 1, 1999, all unusual incident reports are not sent to the Office of Inspection and Compliance ("OIC") per current policy requirements. D.C. Prelim. Rep. at 25.
48. There has been a lack of appropriate management at the District's Department of Human Services ("DHS") regarding OIC functions. From March to December 1999, more than 600 unusual incident reports were received, yet little action was taken to address workload issues D.C. Prelim. Rep. at 27.
49. The District's Internal Affairs Division ("IAD") has a growing backlog of investigations related to alleged abuses within MRDDA. D.C. Prelim. Rep. at 27.
50. DHS' Policies and procedures for Reporting Unusual Incidents are not always followed with regard to the timely submission of unusual incident reports or currently with the submission of all reports to OIC. The process for submitting incident reports to OIC/IAD is delayed through MRDDA. The delay in receiving notification can hinder an investigation since evidence may be removed or destroyed or persons involved may be moved. D.C. Prelim. Rep. at 28.
51. There is no formal communication structure between the District's Licensing and Regulation Administration ("LRA"), OIC, and MRDDA and that this lack of communication has created gaps in monitoring and handling routine complaints and incident reports. D.C. Prelim. Rep. at 29.
52. There is no formal communication structure that requires providers or clients to report complaints or incidents to LRA. In some cases, complaints and incident reports are never reported to LRA or MRDDA. D.C. Prelim. Rep. at 29.
53. OIC does not adequately coordinate with the District's Department of Health ("DOH"), the District's Metropolitan Police Department ("MPD"), case managers, or others involved in the incident reporting process. The agencies charged with gathering, disseminating, investigating, and reporting on unusual incident reports do not coordinate or communicate on a routine basis. D.C. Prelim. Rep. at 29.
54. MRDDA's unusual incident tracking system does not interface with that of LRA or OIC. D.C. Prelim. Rep. at 29. Information systems between DOH and DHS or that systems within DOH are not standardized. D.C. Prelim. Rep. at 29-30. There is no complete file of the complaints and incidents that occur in an individual facility. D.C. Prelim. Rep. at 30.
55. There is no automated tracking system in place in the District's system to log the unusual incident reports and track action through disposition. It is difficult to track unusual incidents across all involved agencies. D.C. Prelim. Rep. at 30.
56. A lack of investigative powers within OIC and lAD hinders the investigative process. The OIC function is unknown to case managers and vendors who often ask for supervisory clearance before cooperating with an investigation, which delays interviews and document collection and analysis. D.C. Prelim. Rep. at 30.
SAFEGUARDING PERSONAL POSSESSIONS
57. MRDDA lacks sufficient internal procedures and automation to accurately account for all funds allocated to client accounts. Customers in the District's system are entitled to personal care allowance of approximately $70.00 per month. Deposits over $50.00 are to be placed in interest bearing accounts and any interest must be credited to that account. After the cost of care allocation is disbursed to providers, MRDDA has no specific procedures in place to ensure that allocations of funding goes directly to the cost of care and personal care. Evidence set forth by a June 1998 DHS audit indicate that at least $73,000.00 is owed to customers. Audits to identify allocations or misuse of funds are disjointed and funds are tracked through agencies that communicate all information through documentary evidence that does not exist in some cases and is not updated in others. Automation between agencies for audit purposes of funds is nonexistent and therefore allocations of funds are not able to be tracked or monitored. Budgetary and Financial Analysis of MRDDA, Final Report to Government of the District of Columbia, Office of the City Administrator, Management Analysis, Inc., Jan. 13, 2000 (hereinafter "D.C. MAI Budget Rep.") at 3-6, 7.
58. Community bank accounts are not adequately managed by MRDDA. There is no formal control, monitoring or reporting. MRDDA cannot identify how many such accounts exist, or who has them, how much money is in them, or how they are being managed. MRDDA senior staff and case managers do not have the staff to track these accounts down, and are aware that numerous accounts in the community exist outside the knowledge of MRDDA case managers. D.C. MAI Budget Rep. at 3-9.
59. The District has no controls in place to monitor community bank accounts of clients. D.C. Prelim. Rep. at 37.
60. The District has no controls in place to monitor customer burial accounts. MRDDA has neither procedures for the establishment nor the maintenance of burial accounts and similarly lacks procedures for monitoring or administering any existing accounts. D.C. Prelim. Rep. at 37.
61. There is no mechanism in the District's system to effectively monitor the implementation of individual financial plans. providers often fail to get approval from case managers before withdrawing funds from individual accounts. The District rarely insists upon receipts from providers indicating what was actually bought with the funds. There are inadequate asset control mechanisms in place so that case managers and others can determine what property customers own. D.C. Prelim. Rep. at 36.
62. MRDDA does not. enforce penalties or monitor providers' transactions associated with client accounts. MRDDA has no formal procedures for review of the providers' financial statements except upon the case managers' inspection of the providers' residence or if the provider sends MRDDA a copy of the bank statements. Documentation of client accounts, balances and transactions are not systematically tracked and therefore MRDDA is unable to ascertain providers' compliance with Federal and District regulations or whether funds have been commingled or expended on unauthorized allocations. D.C. MAI Budget Rep. at 3-8.
63. Individual Financial Plans ("IFP's") are not used to manage the disbursement of client funds in the District's system. Because the IFP's serve as general guidelines only, they have little or no relevance in monitoring actual customer expenditures. It would be "impossible" for a case manager to manually review all clients' IFP's to ascertain actual expenditures given the lack of automation and lack of records. D.C. MAI Budget Rep. at 3-8.
64. Clients' individual financial plans are not drafted with sufficient or meaningful detail and the monitoring of these plans is inadequate in the District's system. D.C. Prelim. Rep. at 36.
QUALITY ASSURANCE PROGRAMS, MONITORING AND CASE MANAGEMENT
65. Not until December 21, 1999, had the District ever undertaken to conduct an operational review of the entire District system of service delivery to persons with mental retardation and developmental disabilities in an attempt to identify system-wide issues. D.C. Prelim. Rep. at 1.
66. The management and oversight of both District employees and private sector providers has been inadequate. D.C. Prelim. Rep. at 2.
67. Communication and coordination occurs on a limited, ad hoc basis throughout the District's system. D.C. Prelim. Rep. at 2.
68. In most parts of the District's system, there has been and continues to be a lack of managers with solid management skills and recognized expertise in the mental retardation or developmental disabilities field or other related fields. The common use of acting or temporary managers causes uncertainty in the District's system and inhibits change within the organizations cementing in place antiquated practices. The District's system is unable to move forward without permanent managers in key positions. D.C. Prelim. Rep. at 3.
69. Both District and private sector employees lack the updated position descriptions, training, and supervision that is consistent with an effective service delivery system. D.C. Prelim. Rep. at 3.
70. In many cases, policy and procedure statements are not available in the District's system. In some cases, policies and procedures are not circulated to employees or are so out of date, that they are useless. Informal communication of policies and procedures during "on the job training" has served to continue a system of bad habits and poor methods. D.C. Prelim. Rep. at 3-4.
71. All policies and procedures in the District's system are in need of review and revision. Where policies and procedures do not exist, they need to be created in accordance with updated philosophies, processes, and systems. D.C. Prelim. Rep. at 4.
72. One of the most striking findings of the Defendants' own operational review of the District's system was the complete lack of communication and coordination within the mental retardation and developmental disabilities service delivery system. Each organization within the system operates in nearly complete isolation from the other organizations. This has resulted in total dysfunction of the service system and the complete lack of leadership system-wide. D.C. Prelim. Rep. at 4.
73. Automation is lacking throughout the District's service delivery system. D.C. Prelim. Rep. at 4.
74. In addition to failures at MRDDA, a multitude of governmental agencies and various levels of governmental oversight all contribute to the District's broken service delivery system. Bureaucratic processes hinder cross-agency collaboration. D.C. Prelim. Rep. at 10.
75. DHS has failed to take appropriate actions regarding the provision of services to persons with mental retardation and developmental disabilities. D.C. Prelim. Rep. at 14.
76. Top level DHS management responses to issues concerning service provision and quality of care of its MRDDA customers has been both reactive and inadequate. D.C. Prelim. Rep. at 14-5. Appropriate DHS leadership has been severely lacking in the District's system. D.C. Prelim. Rep. at 15.
77. There has been a dearth of persons with solid managerial skills in key positions at MRDDA for a number of years which has produced general dysfunction within the entire system. D.C. Prelim. Rep. at 15.
78. MRDDA has not had an Administrator with an appropriate technical background in either mental retardation or developmental disabilities for approximately six years. D.C. Prelim. Rep. at 3, 15.
79. Neither the Bureau of Case Management ("BCM") nor the BPOC has a permanent Bureau Chief. D.C. Prelim. Rep. at 15.
80. In some cases, persons holding management positions regarding the intake and case management functions have not ensured the existence of appropriate procedures or the adherence to existing procedures in the District's system. D.C. Prelim. Rep. at 16.
81. Position descriptions for managers in the District's system are outdated and do not appropriately reflect either the correct tasks or newer philosophies regarding persons with mental retardation and developmental disabilities. D.C. Prelim. Rep. at 16.
82. A significant number of MRDDA employees do not have position descriptions suitable for the jobs they perform. D.C. Prelim. Rep. at 16.
83. MRDDA employees have not had adequate supervision. D.C. Prelim. Rep. at 16. Comments in favorable performance ratings are often inconsistent with such ratings. D.C. Prelim. Rep. at 16-7.
84. There are insufficient numbers of employees to do the work required in the District's system. Monitoring staff is inadequate; there are no staff trained or qualified to create or review draft legislation, procedures or policies; there are no staff specifically charged with tracking compliance with the multiple Court Orders; and there are only two employees charged with making court appearances that occur almost every day. D.C. Prelim. Rep. at 17.
85. There are insufficient numbers of employees in the District's system to do the work required. As an example, a Court Order in the Evans case requires a ratio of case managers of no more than 1:60 for Evans class members. The District has determined that a more appropriate ratio is 1:30 and is attempting to achieve this ratio for all customers. D.C. Prelim. Rep. at 17. Case management position descriptions should be modified to reflect the best and current practices in the coordination of services. D.C. Georgetown Rep. at 4.
86. There are inadequate methods for background checks on providers and the employees of providers in the District's system. D.C. Prelim. Rep. at 18.
87. MRDDA neither has the statutory nor administrative authority to require the interagency coordination and collaboration necessary across District governmental agencies. D.C. Prelim. Rep. at 19.
88. Case managers do not visit all customers on their caseloads at least once per quarter per MRDDA policy. D.C. Prelim. Rep. at 19.
89. There is no document management policy within MRDDA in spite of the fact that all District agencies are to have one. D.C. Prelim. Rep. at 19.
90. There is a lack of adequate communication within sections of MRDDA, as well as with other District organizations. D.C. Prelim. Rep. at 19-20.
91. There is almost no automation used for the intake and case management functions in the District's system. MRDDA as a whole lacks e-mail. Most processes are paper driven. Case managers record their notes by hand. Unusual incident reports are done by hand. A contractor has been hired to develop databases which should allow MRDDA to track such information as demographics of its customer base, the residence of each customer, the status of Individual Habilitation Plans ("IHP's"), incidents involving customers and providers. In addition, this lack of automation contributes to MRDDA failing to comply with Court Orders. D.C. Prelim. Rep. at 20.
92. The District's MRDDA Monitoring Unit had been dismantled for years, and although it has recently been reestablished, no written policies exist for this unit. D.C. Prelim. Rep. at 23.
93. Two positions that directly affect the administration of LRA (the Director and the Director for State Affairs) are not permanently filled. D.C. Prelim. Rep. at 26.
94. District monitoring functions are understaffed. D.C. Prelim. Rep. at 27.
95. LRA only provides monitoring at the minimum level required by the United States Health Care Financing Administration ("HCFA"). This level of monitoring does not support the mission statement of the District's DOH which seeks to assure safe and healthy environments through licensing and regulation, reducing or preventing the risk of disease, dysfunction and premature death. LRA does not perform enough monitoring of facilities to carry out this mission. D.C. Prelim. Rep. at 28.
96. There is no coordination between the MRDDA monitoring, unit and LRA to ensure that inspections performed complement, as opposed to overlap, each other. D.C. Prelim. Rep. at 29.
97. The MRDDA monitoring unit does not have an automated way to track inspections. D.C. Prelim. Rep. at 29.
98. There have been significant delays in the District's system in negotiating and completing contracts for non-Medicaid services, partly due to significant understaffing. D.C. Prelim. Rep. at 32.
99. Medicaid provider agreements and District contracts with providers lack quality controls, effective monitoring provisions, and incentives or disincentives for superior or substandard service. D.C. Prelim. Rep. at 32.
100. Twenty-seven District employees have been detailed or reassigned from Forest Haven to MRDDA since 1991 with no current position descriptions or any formal determination that they possess the skills and training to perform the tasks to which they are now assigned. D.C. Prelim. Rep. at 32-33.
101. Many, if not most, of the positions at MRDDA lack accurate, up-dated position descriptions. MRDDA supervisors need assistance in proper performance evaluation preparation. D.C. Prelim. Rep. at 33.
102. Defendants acknowledge that there is no true system for providing services to MRDDA customers; rather there are a number of agencies that perform functions that impact the MRDD population in relative isolation from each other. D.C. Addendum Rep. at 4.
103. MAA is currently doing no provider reviews to determine if MRDDA customers are receiving the level of care for which MAA is paying. D.C. Addendum Rep. at 4.
104. There is currently no formal procedure that requires coordination between the District of Columbia's Public Schools ("DCPS") and MRDDA when an individual leaves the DCPS system and enters MRDDA's. D.C. Addendum Rep. at 4.
105. There is insufficient staff assigned to conduct utilization reviews to ensure that the appropriate level of care is being provided to customers within the District's system. D.C. Addendum Rep. at 9.
106. Based on Defendants own review, written policies and procedures are lacking in the District's system. While many policies and procedures are established by HCFA, the Defendants' review indicated that MAA has not formulated or disseminated internal written policies and procedures. D.C. Addendum Rep. at 10.
107. Automation in the system is out-dated in the District's system. D.C. Addendum Rep. at 10.
108. There is a lack of communication between DCPS divisions and between DCPS and MRDDA. D.C. Addendum Rep. at 11.
109. The position description of the Administrator of MRDDA is obsolete and outdated. D.C. Georgetown Rep. at 17.
110. The District's CMD is understaffed to protect the rights of people with mental retardation and other developmental disabilities. D.C. Georgetown Rep. at 19.
111. The position descriptions for non-licensed MRDDA staff do not cite minimum educational requirements. If MRDDA administrative staff were effectively performing the duties and responsibilities as specified in the position descriptions, the agency would not be experiencing multiple and ongoing crises. A significant proportion of MRDDA's staff is former direct care/service personnel. An analysis of the available forms for these personnel fails to demonstrate that re-training or continuing education has occurred to provide personnel with the knowledge and competencies required to fulfill current duties and responsibilities. D.C. Georgetown Rep. at 23.
112. In a recent review of performance ratings for MRDDA personnel a majority had no performance ratings. D.C. Georgetown Rep. at 24.
BUDGET, TIMELY PAYMENT OF VENDORS
113. Since 1995, the District's budget allocation for CRF's and other non-Medicaid supported services has been reduced as a result of fiscal crises. These funds have yet to be restored to meet current demands. Adjusted for inflation, total spending for services for individuals with mental retardation and/or developmental disabilities in the District declined 2 percent during 1991-1996; nationally during the same period, total spending for individuals with mental retardation and/or developmental disabilities advanced 24 percent in inflation adjusted terms. D.C. Georgetown Rep. at 14.
114. The District's budget process is not designed to support MRDDA and customer requirements. There is no effective system in place for identifying MRDDA's actual budgetary requirements in terms of District appropriated funds. MRDDA cannot readily identify its current customer demographics and has no projection of future customer demographics. MRDDA does not track, and is unable to identify costs by customer category. D.C. MAI Budget Rep. at 3-1.
115. IHPs are not used as input to project MRDDA resource requirements. The IHPs document the range of services needed by a current customer, and of course, will change over time. Lack of IHP input tends to understate requirements since MRDDA's population is aging. D.C. MAI Budget Rep. at 3-2.
116. The budget process begins with the prior year's baseline as the starting point. However, MRDDA has not been providing a fully satisfactory level of service. There are deficiencies in staff training, quality control, case management, and other areas. Yet baseline budgeting tends to perpetuate existing problems and does not provide management with alternatives and associated costs for addressing these issues. Plus, baseline budgeting does not take into account the differential costs of person centered planning or the changing requirements due to changes in the number or mix of clients. D.C. MAI Budget Rep. at 3-1, 3-2.
117. Financial tracking and reporting are not adequate for program management purposes in the District's system. MRDDA has no timely tracking of expenditures and does not have a precise picture of funds available at any given point during the fiscal year. Despite the existence of many urgent requirements, the agency significantly underspent its FY 1999 general fund budget by $2.6 million. D.C. MAI Budget Rep. at 3-2.
118. MRDDA's appropriated budget is not developed based on any real analysis of the expected expenditures of the agency. Instead, the MRDDA appropriated budget, approximately $24 million per year, is based on no more than guesswork and the use of the prior year's appropriations to estimate budgetary needs. This does not allow for an accurate forecast of expected needs that would support rational policy decisions within the budget development process. D.C. Prelim. Rep. at 34.
119. The District does not know what its true cost is to provide services to individual customers, such that attempts to recover cost of care amounts from individual customers may be inappropriate. D.C. Prelim. Rep. at 36.
120. Fiscal issues have not been appropriately addressed within the District's system. D.C. Prelim. Rep. at 2.
121. The District does not know the total amount expended to operate the MRDDA program and provide services to the client population. D.C. Prelim. Rep. at 34.
122. There is inadequate information exchange between MRDDA and the DHS Chief Financial Officer ("CFO"). D.C. Prelim. Rep. at 34.
123. MRDDA underspent its budget by approximately $2 million or ten percent of MRDDA's appropriated budget (which excluded Medicaid expenses), in part because the DHS CFO and MRDDA failed to communicate about quarterly budgetary forecasts. D.C. Prelim. Rep. at 34.
124. Amounts currently available for case manager trips to visit customers who live outside of the District are insufficient. D.C. Prelim. Rep. at 34.
125. The vendor payment system within the District's system is inadequate and should be redesigned. D.C. Addendum Rep. at 9.
126. Audits of provider cost data are not timely conducted in the District's system. D.C. Addendum Rep. at 9.
127. The total cost of the MRDDA-related programs is not captured by existing financial systems. D.C. MAI Budget Rep. at 3-3.
128. provider contracts in the District's system are vague and overly broad with no uniform provisions governing the maintenance and custodianship over customer accounts and other property. The lack of specific procedural or contractual guidance, either by incorporation or reference, invites all sorts of abuses, and likely preclude the recovery of any misappropriated funds. D.C. MAI Budget Rep. at 3-9, 3-10.
129. Provider contracts in the District's system lack specific guidance for noncompliance with applicable regulations or contractual terms and afford no means of recourse for breach by the provider. D.C. MAI Budget Rep. at 3-10.
The following Defendants' reports are referenced above:
A. Preliminary Findings on the Mental Retardation and Developmental Disabilities Service Delivery System, Government of the District of Columbia, Office of the Deputy Mayor for Children and Families, Jan. 18, 2000 (Master's Exh. F).
B. Addendum to Preliminary Findings on the Mental Retardation and Developmental Disabilities Service Delivery System, Government of the District of Columbia, Office of the Deputy Mayor for Children and Families, Mar. 2, 2000 (Master's Exh. I).
C. Final Report to the Government of the District of Columbia, Office of the City Administratar, Office of the Deputy Mayor for Operations, Georgetown University Child Development Center, Jan. 18, 2000 (Master's Exh. L).
D. Budgetary and Financial Analysis of MRDDA, Final Report to Government of the District of Columbia, Office of the City Administrator, Management Analysis, Inc., Jan. 13, 2000 (Master's Exh. H).
Reference to the reports listed above are solely for the purpose of establishing the effective dates of the stipulations. Defendants assert that the references to any of the above reports or statements are not intended to infer that the reports or statements are admissions of the Defendants.