A R epoRt to the M ontAnA L egisLAtuRe p A eRfoRMAnce udit Montana Developmental Center Closure and Client Transition Department of Public Health and Human Services M 2021 Ay L A egisLAtive udit d ivision 19P-02 Performance Audits Legislative Audit Performance audits conducted by the Legislative Audit Division Committee are designed to assess state government operations. From the Representatives audit work, a determination is made as to whether agencies and Kim Abbott programs are accomplishing their purposes, and whether they [email protected] can do so with greater efficiency and economy. Dan Bartel [email protected] We conducted this performance audit in accordance with Denise Hayman, Chair generally accepted government auditing standards. Those [email protected] standards require that we plan and perform the audit to obtain Emma Kerr-Carpenter sufficient, appropriate evidence to provide a reasonable basis for [email protected] our findings and conclusions based on our audit objectives. We Terry Moore believe that the evidence obtained provides a reasonable basis [email protected] for our findings and conclusions based on our audit objectives. Matt Regier Members of the performance audit staff hold degrees in [email protected] disciplines appropriate to the audit process. Senators Jason Ellsworth, Vice Chair Performance audits are conducted at the request of the Legislative [email protected] Audit Committee, which is a bicameral and bipartisan standing John Esp committee of the Montana Legislature. The committee consists [email protected] of six members of the Senate and six members of the House of Pat Flowers Representatives. [email protected] Tom Jacobson [email protected] Tom McGillvray [email protected] Mary McNally [email protected] Members serve until a member’s legislative term of office ends or until a Audit Staff successor is appointed, whichever occurs first. Julia Connelley Chelsea Rayfield David W. Singer William Soller §5-13-202(2), MCA Fraud Hotline Reports can be found in electronic format at: (Statewide) https://leg.mt.gov/lad/audit-reports 1-800-222-4446 (in Helena) 444-4446 [email protected] www.montanafraud.gov LEGISLATIVE AUDIT DIVISION Angus Maciver, Legislative Auditor Deputy Legislative Auditors: Deborah F. Butler, Legal Counsel Cindy Jorgenson William Soller May 2021 The Legislative Audit Committee of the Montana State Legislature: This is our performance audit of the Montana Developmental Center (MDC) closure managed by the Developmental Services Division of the Department of Public Health and Human Services (DPHHS). This report provides the legislature information about MDC closure activities, former MDC clients, their transition processes and how they are doing now, and the costs of serving former clients in the community compared to MDC. This report includes recommendations for adhering to client monitoring requirements, developing a repurposing plan for the vacant MDC facility, creating a memorandum of understanding with the Department of Justice to clarify Intensive Behavior Center incident reporting processes, improving client plan of care processes, and developing a data management plan for collecting and analyzing client data. A written response from DPHHS is included at the end of the report. We wish to express our appreciation to DPHHS personnel for their cooperation and assistance during the audit. Respectfully submitted, /s/ Angus Maciver Angus Maciver Legislative Auditor Room 160 • State Capitol Building • PO Box 201705 • Helena, MT • 59620-1705 Phone (406) 444-3122 • FAX (406) 444-9784 • E-Mail [email protected] i Table of Contents Figures and Tables ....................................................................................................................iii Appointed and Administrative Officials ...................................................................................v Report Summary ...................................................................................................................S-1 CHAPTER I – INTRODUCTION AND BACKGROUND ����������������������������������������������������������������������1 Introduction ..............................................................................................................................1 Brief History of MDC ..............................................................................................................1 MDC Organization and Funding .............................................................................................2 Legislature Mandated MDC’s Closure .....................................................................................3 Transitioning Clients to Community Providers ........................................................................4 Audit Scope ...............................................................................................................................5 Audit Objectives ........................................................................................................................5 Audit Methodologies .................................................................................................................6 Issue for Further Study ..............................................................................................................7 Report Contents ........................................................................................................................7 CHAPTER II – CLOSURE MILESTONES AND STATUTORY ADHERENCE �����������������������������������9 Introduction ..............................................................................................................................9 MDC Closure Milestones and Activities ..................................................................................9 Department Focused on Transitioning Clients Out of MDC During Closure ......................10 Department Consolidated Physical Facilities During and After the Closure ..........................11 Department Managed a Declining Workforce .......................................................................11 Department Fulfilled Most Closure Requirements .................................................................12 Department Monitored Some Clients for Incorrect Time Frame ...........................................13 Department Does Not Report Monitoring Results to Family and Guardians ........................14 Department Explained Statutory Noncompliance Was an Administrative Oversight ...15 Department’s Closure Plan Was Not Fully Implemented .......................................................16 Other States Typically Develop Detailed Closure Plans Prior to Closure Activities ................16 MDC Transition Planning Advisory Council Did Not Fulfill All Statutory Expectations.....17 Department Has Not Developed a Boulder Campus Repurposing Plan ................................19 MDC Facilities Idle Since October 2018 ........................................................................19 Lack of Repurposing Plan and Vacant Facilities Lead to Inefficient Use of State Resources .......................................................................................................................20 Other States Addressed Repurposing in Their Formal Closure Plans .............................20 Closure Priorities and Process Complications Extend Repurposing Efforts ...................21 CHAPTER III – STATUS OF FORMER MDC CLIENTS ��������������������������������������������������������������������23 Introduction ............................................................................................................................23 Most MDC Clients Transitioned to Community-Based Placements ......................................23 Community Transition File Review Analysis ..........................................................................26 Community Providers Generally Complimented the Closure Transition Process ..........27 Survey of Former MDC Clients ..............................................................................................28 Most Respondents Indicated Moving from MDC Went Well but Some Miss Friends or Staff ............................................................................................................................29 Freedom, Activities, Friends, and Staff Contribute to Respondents’ Feelings of Safety and Happiness .................................................................................................................29 Survey of Natural Supports .....................................................................................................33 Natural Supports’ Closure Opinions Vary ......................................................................33 19P-02 ii Montana Legislative Audit Division Natural Supports Believe Individuals Are Generally Happy and Providers Contribute to Their Quality of Life �������������������������������������������������������������������������������������������������������35 CHAPTER IV – CLIENT CARE AND SAFETY �������������������������������������������������������������������������������������39 Introduction ����������������������������������������������������������������������������������������������������������������������������39 Statutory Monitoring Data Analysis ���������������������������������������������������������������������������������������39 MDC Incident Reporting Analysis �����������������������������������������������������������������������������������������41 Increase in Incidents and Substantiated Allegations Due Primarily to Policy Change ����41 Department Does Not Coordinate With DOJ on Incident Reporting Changes Over Time �44 Lack of Coordination Impacts Ability to Interpret Incident Data ���������������������������������44 Incident Reporting Process Evolved but Formal Agreement Never Developed ���������������44 Best Practices Surrounding Intra-Agency Controls Include Formal Documentation �����45 MDC and Community Provider Incident Report Analysis ����������������������������������������������������46 MDC and Community Provider Incident Comparison Analysis �����������������������������������46 More Incidents Reported at MDC Than at Community Providers ��������������������������������47 Trend of Increased Incidents for Some Clients Close to Discharge ���������������������������������49 Personal Support Plans: Waiver Plan of Care Analysis ������������������������������������������������������������49 PSPs Not Consistently Maintained or Person-Centered ���������������������������������������������������������50 PSP Quarterly Reports Do Not Always Capture Client Progress �����������������������������������51 Person-Centered Approach Does Not Consistently Guide PSP Development ������������������������52 Outdated, Decentralized PSP Requirements Not Perceived as Meaningful ���������������������������53 MDC/IBC Individual Treatment Plan Analysis ���������������������������������������������������������������������54 Department Could Improve Management Information Availability ��������������������������������������55 Decentralized Data Storage Creates Barriers to Management Information Use �������������56 Department Does Not Have Data Management Plan ����������������������������������������������������56 State Policy Requires Management to Establish Internal Controls to Assess Program Effectiveness ��������������������������������������������������������������������������������������������������������������������57 CHAPTER V – COSTS OF SERVING FORMER MDC CLIENTS IN THE COMMUNITY �������������59 Introduction ����������������������������������������������������������������������������������������������������������������������������59 Waiver Cost Plans for Former MDC Clients Significantly Higher Than Average Waiver Recipient ���������������������������������������������������������������������������������������������������������������������������������59 Former MDC Clients Receive Additional Medicaid Covered Services �����������������������������������61 Boulder Campus’ Cost Per Client Has Increased Over Time �������������������������������������������������63 MDC Closure Led to Less Costs to Serve Cohort ������������������������������������������������������������������64 APPENDICES ���������������������������������������������������������������������������������������������������������������������������������������������67 Appendix A - Client Survey Procedures and Potential Limitations �����������������������������������������67 Appendix B - Client Survey Response Rate and Results ���������������������������������������������������������69 Appendix C - Natural Supports Survey Procedures and Potential Limitations �����������������������82 Appendix D - Natural Supports Survey Response Rate and Results ���������������������������������������83 DEPARTMENT RESPONSE Department of Public Health and Human Services��������������������������������������������������������������A-1 iii Montana Legislative Audit Division iii Figures and Tables Figures Figure 1 MDC Total Appropriations Declined Over Time .................................................................2 Figure 2 Client Transition to Community Provider Required Regular Communication.....................4 Figure 3 Twenty-Seven Clients Were Not Monitored After June 30, 2019 (Q8) ................................14 Figure 4 MDC Residential Cottage Boarded Up ...............................................................................19 Figure 5 Sixty-Eight Percent of Cohort Transitioned to Waiver Services With In-State Providers .....24 Figure 6 Most MDC Closure Client Placement Types Have Remained Stable ..................................25 Figure 7 Most Respondents Felt Very Good or Good About Leaving MDC .....................................29 Figure 8 Most Respondents Feel Safe in Their Home All or Most of the Time .................................30 Figure 9 Most Respondents Indicated They are Very Happy or Happy .............................................30 Figure 10 Most Respondents Said Yes When Asked if They/Their… ...................................................32 Figure 11 Natural Supports’ MDC Closure Opinions Vary ................................................................33 Figure 12 Two-Thirds of Respondents Believe the Individual Is Very Happy or Happy ......................35 Figure 13 Most Respondents Said Yes When Asked if They Believe the Individual(’s)… ....................36 Figure 14 Total DOJ Investigations Rose Significantly in Calendar Year 2017 ....................................42 Figure 15 Annual Substantiated Allegations Against Clients Rose Significantly in 2017 .....................43 Figure 16 MDC Incidents Investigated by DOJ Significantly Higher Than Community Provider Incidents Reported During Time Frames Analyzed ............................................................48 Figure 17 Average and Maximum Cohort ICP Expenditures for Cohort Members Exceed Waiver-Wide Average ...........................................................................................................60 Figure 18 Two Average Annual Expenditure Calculations: Cohort Clients With Only Waiver Expenditures and All Cohort Clients With Expenditures ....................................................62 Figure 19 Boulder Campus Cost Per Client and Average Daily Population by Fiscal Year ..................63 Figure 20 Estimated Costs for Cohort and Boulder Over Time ..........................................................65 Tables Table 1 Fiscal Year 2020 Department Operations Expenditures in Boulder ......................................3 Table 2 The Department Fulfilled Most Statutory Closure Requirements .......................................12 Table 3 MDC Transition Planning Advisory Council Fulfilled Half of Its Statutory Requirements 18 Table 4 Costs for Maintaining the Boulder Campus Facilities by Fiscal Year ...................................20 Table 5 Community Provider Transition Files by Process Step.........................................................27 Table 6 Most Clients Who Responded They Are Happy Where They Live Now Were Not Happy at MDC ....................................................................................................31 19P-02 iv Montana Legislative Audit Division Table 7 PSP Actions Did Not Consistently Meet Policy Requirements ............................................50 Table 8 ITP Objectives Met Nearly All Policy Requirements ...........................................................55 Table 9 MDC Closure Has Resulted in Less Costs to the State .......................................................66 v Appointed and Administrative Officials Department of Public Adam Meier, Director (effective January 2021) Health and Human Services Erica Johnston, Acting Director (November 2020 – January 2021) Sheila Hogan, Director (through November 2020) Marie Matthews, Manager, Medicaid and Health Services Branch Rebecca de Camara, Administrator, Developmental Services Division 19P-02