Disease intervention specialists are state or county staff who primarily investigate cases of syphilis and HIV to curb the spread of these sexually transmitted infections. Between 2013 and 2016, cases of sexually transmitted infections increased in Kansas, with syphilis increasing most significantly. Over that same period, we estimated the number of disease intervention specialists working in Kansas did not change. Between these two factors, we estimated the number of syphilis and HIV cases per disease intervention specialists increased about 65% across the state between 2013 and 2016.
Foster Care and Adoption in Kansas: Surveying Guardians Ad Litem on the Treatment of Lesbian, Gay, Bisexual, and Transgender Foster Care and Adoptive Parents
Guardians ad litem are attorneys who have been appointed by a court to represent the best interests of each child in foster care. The 163 Kansas guardians ad litem who responded to our survey had mixed opinions regarding the treatment of lesbian, gay, bisexual, and transgender foster care and adoptive parents. For example, 88 guardians ad litem reported they were not aware of an instance when a parentís sexual orientation negatively affected a childís placement, but 52 reported they were aware of such an instance. Further, 65 guardians ad litem thought the Legislature should conduct a more thorough review of the treatment of these kinds of foster care and adoptive parents, while 40 did not think the Legislature should do this.
The Kansas Eligibility Enforcement System: Evaluating the
Accuracy and Usefulness of KEES Reports and Notices
The KEES notices and reports we reviewed appeared accurate, but were not always easy to understand, complete, or useful. The KEES notices we reviewed were accurate but not always complete. Additionally, several of the notices we reviewed could be improved if they were less duplicative and easier to understand. Finally, the KEES management reports we reviewed appeared accurate, but many were not used.
Medicaid and Medicare Services: Comparing Program Services and Costs in Kansas to Other States
Although Medicaid services in Kansas were similar to those in other states, Medicaid costs varied by state. Kansasí Medicaid servicesóincluding mandatory, optional, and community-based servicesówere similar to those in a sample of other states we reviewed. However, state and federal costs for Medicaid services varied from state to state for two reasons: differences in provider reimbursement rates and federal cost sharing. Additionally, we found that Medicare services and beneficiary costs varied across Medicare plans, but not necessarily from state to state. Medicare consists of four parts, each offering different services to beneficiaries. We found that Medicare covered services and beneficiary out-of-pocket costs varied from plan to plan, but not necessarily from state to state.
Kansas Department of Health and Environment: Evaluating Issues Related to Department Services for Individuals with Phenylketonuria (PKU)
State Law requires the Kanas Department of Health and Environment (KDHE) to provide newborn screening services to detect certain genetic diseases, including Phenylketonuria (PKU). For individuals with PKU, treatment is lifelong and involves a restrictive diet and specialized nutritional products to mitigate increasing damage from the disease. KDHE provides financial assistance to income-eligible individuals to help them purchase a variety of nutritional treatment products and services. We interviewed eight individuals receiving financial assistance through the program and found that most appeared to have no problems purchasing the nutritional formula they needed. However, a couple of individuals reported some difficulty affording low-protein food items and several individuals told us the application and renewal process for the program can be redundant and that it can sometimes be difficult to provide proof of income.
Foster Care and Adoption in Kansas: Reviewing Various Issues Related to the State's Foster Care and Adoption System, Part 3
Kansasí foster care system is administered by the Department for Children and Families (DCF) and is designed to protect children who are victims of abuse or neglect. The system has been privatized since 1997 with two contractorsóKVC Behavioral Healthcare and Saint Francis Community Servicesócurrently providing placement and case management services statewide. As part of this audit, we reviewed the privatized systemís capacity and performance over time, as well as how the costs would compare to a state-run system. We found the stateís foster care system may not have sufficient capacity to provide necessary foster care services, but insufficient data prevented a clear determination. First, the information we reviewed showed both of the stateís case management contractors had challenges employing enough case management staff. Second, while the children in foster care received most of the physical and mental health services they needed, there were exceptions. Third, our analysis showed many Kansas counties and cities appeared to lack enough licensed foster homes. We also found that DCF could be more proactive in monitoring and collecting management information about the foster care system. For example, the information DCF maintained was not adequate to ensure children were placed in appropriate foster homes.
Additionally, we reviewed 11 federal outcomes for children and families and found Kansasí overall performance did not change significantly during federal fiscal years 2000-2013. While these measures may provide useful insights into Kansasí performance, they are self-reported and cannot be compared to other states.
Finally, we estimate the state would incur up to $8 million more in on-going costs as well as significant start-up costs for DCF to provide foster care and adoption services instead of private contractors. Specifically, we estimated DCF would have spent between $164 million and $169 million in on-going costs in fiscal year 2016, compared to the $161 million reported by the contractors. We also found there may be other factors to consider when comparing privatization to a state-run system.
K-12 Health Insurance: Evaluating the Financial Impact of Establishing a Consolidated K-12 Health Insurance Plan
Depending on the plan design, consolidating K-12 health insurance plans for the 101 districts in our sample could save an estimated $63 million a year. Specifically, consolidation would generate an estimated $38 million in annual savings through increased plan efficiencies regardless of plan design. Additionally, consolidation would also generate $25 million a year in savings for districts by shifting costs to employees. Also, we found that joining the state employee health plan is just one of several consolidation options available and that any savings from consolidation would be realized by school districts unless a mechanism is developed to transfer them to the state. The Legislature has several decisions to make regarding the implementation and savings associated with consolidating K-12 health insurance statewide. For example, the Legislature would need to decide whether the state or school districts keep the potential savings from consolidation and would need to make several other key decisions that could affect how much is saved. We also noted that the time needed to implement a consolidated K-12 health insurance plan and several other factors will make it difficult for the state to achieve savings outlined in the Governorís Budget. Finally, we identified two other issues that should be considered if the state decides to consolidate K-12 health insurance.
Foster Care and Adoption in Kansas: Reviewing Various Issues Related to The Stateís Foster Care and Adoption System, Part 2
We assessed DCFís compliance with applicable state and federal laws governing the foster care system. We found that DCF has to meet many state and federal requirements for the foster care program. However, DCF had not followed some of the safety and living condition requirements we reviewed in Part 1 of the audit. Additionally, according to the 2014 and 2015 statewide single audits, DCF materially complied with most, but not all federal requirements. Further, DCF self-reported data shows Kansas met or exceeded about half of the federal outcome requirements for fiscal year 2016, but did not meet the others. Finally, we found DCF must implement a program improvement plan to address issues identified by a 2015 federal review.
KanCare: Reviewing the Timeliness of Medicaid Eligibility Determinations
In July 2015, the state launched the Kansas Eligibility Enforcement System (KEES)óa web-based application intended to help streamline eligibility determination for state medical and social service benefits, including Medicaid. As of June 2016, the state of Kansas had a backlog of 14,000 Medicaid applications. KDHE officials told us implementing the new KEES system and an influx of applications related to the federal Affordable Care Act contributed to the backlog. KDHE has tried to address the backlog by increasing staffing resources and modifying KEES to fix technical glitches. According to KEESí reports, KDHE has reduced the backlog by thousands in recent months and hopes to have it resolved by October 2016. In its efforts to address the backlog, KDHE has stopped reviewing renewal applications. Further, Kansas is not in compliance with federal law related to timely eligibility determinations.
Osawatomie State Hospital: Reviewing the Hospitalís Recent Loss of Federal Funding
Osawatomie State Hospitalís Medicare funding was terminated in December 2015 because it failed to comply with federal regulations related to staff and patient safety. The Kansas Department on Aging and Disability Services (KDADS), which oversees the facility, plans to seek recertification for 60 of the facilityís 206 beds. However, officials from the Centers for Medicare and Medicaid Services (CMS) and KDADS offered significantly different estimates of the time it will take to recertify the 60 beds (9-15 months versus 2-4 months). As of June 2016, the loss of Medicare funding and additional expenses to address the deficiencies have cost an estimated $15 million. Finally, even if the 60 beds are recertified, the hospital will continue to lose significant Medicare funding until the entire facility is recertified.
Foster Care and Adoption in Kansas: Reviewing Various Issues Related to the Stateís Foster Care and Adoption System, Part 1
We reviewed components of the foster care system, including safety of children during the removal and placement process. We found that DCF does not always follow adequate policies to ensure the safety of children during the removal and placement process. DCF has not yet implemented several recommendations from a 2013 evaluation of its child protective services function and has not responded to all report center calls in a timely manner. We also found that DCF does not ensure that required background checks of individuals in foster homes happen as often or as thoroughly as they should. In addition, DCF does not always take steps to ensure that monthly in-person visits happen for children in foster care, adoptive homes, or for children reintegrated with their family. Results from our survey of case-management staff and guardians ad litem also indicate that monthly in-person visits do not always happen. Finally, survey respondents also expressed concerns with staff turnover, morale and training.
As for placement of children, we found DCFís child placement process does not ensure that children are placed in foster care homes with sufficient living and sleeping space and financial resources. That is because DCF allows nearly all requests for exceptions, which results in inadequate sleeping space for some foster children. Our review showed that DCF does not have an adequate process to ensure that licensed foster homes have sufficient financial resources. We also found that despite the lack of DCF requirements related to capacity, living space or financial sources for adoptive placements, few stakeholders had concerns. Finally, we found that child placing agencies both sponsor and regulate foster homes which may create a conflict of interest.
We also found several aspects of the foster care and adoption system are designed to keep family members together. Federal law requires that statesí foster care and adoption programs have a formal preference to keep families together. The majority of stakeholders responding to our survey indicated there was appropriate emphasis placed on keeping families together, with a small portion responding that there was too much emphasis.
Substance Abuse Programs: Evaluating Cost Savings Achieved Through Enhanced Acess to State Substance Abuse Programs
Although substance abuse can result in substantial criminal justice and social service costs, expanding treatment is unlikely to achieve significant savings. We estimated an additional 4,500 to 7,000 individuals are eligible for state-funded treatment and likely to seek it. To provide that treatment, the state would spend between $7 million and $11 million during a three-year period. However, we estimated the state would only reduce spending on other services (i.e. prison, foster care, or state hospitals) by $500,000 to $6 million for those individuals, which would not offset the cost of their treatment. Our results are significantly different from other studies which found greater savings related to providing substance abuse treatment primarily because we focused only on savings to the state and because many of the studies included savings in their estimate that we do not think would be realized.
Kansas State Employee Health Plan: Evaluating the State's Pharmacy Benefits Management System
Since 2006, the Kansas State Employees Health Care Commission has contracted with Caremark to provide pharmacy benefit management services for the prescription drug portion of the Kansas State Employee Health Plan. Because a pharmacy benefit manager controls many aspects of a prescription drug plan, there is a risk that it may not manage the program in the stateís best interest. To mitigate this risk, the commission has negotiated numerous contractual provisions to reduce the risks associated with using a pharmacy benefit manager. However, the Kansas Department of Health and Environment (KDHE) does not routinely take the steps needed to verify that Caremark is complying with the contractual provisions. Specifically, KDHE does not adequately check claims data for spread pricing, does little to ensure it receives its share of drug rebates, and does little to independently verify how the drug formulary is managed. In addition, KDHE does not take steps to ensure it receives all claim recoupments that Caremark collected from pharmacies. We also found that the stateís contract with Caremark includes few controls related to mail-order prescriptions; however state spending for mail-order is minimal. Finally, we found that although specialty drugs comprise 32% of total prescription drug costs for the State Employee Health Plan, we could not verify whether KDHE is proactively monitoring this area.
CDDOs: Reviewing Issues Related to Community Services Provided for Individuals with Disabilities
The Kansas Department for Aging and Disability Services (KDADS) is responsible for administering the developmental disability waiver system. This includes providing oversight of the stateís 27 community developmental disability organizations (CDDOs). CDDOs act as gatekeepers because they are the single point of entry, eligibility determination, and referral for any individual seeking developmental disability waiver services.
In addition to the gatekeeping function, 21 of 27 CDDOs also provide direct services through their own community service provider, which creates an inherent conflict of interest. CDDOs have made some efforts to mitigate this inherent conflict of interest, but stakeholders still cite unfair advantages. For the areas we assessed, we found no direct evidence that CDDOs are taking advantage of this inherent conflict. We did find that the Kansas Department for Aging and Disability Services provides weak oversight for CDDOs in several areas. A bill currently pending would prohibit CDDOs from providing direct services, which could eliminate the inherent conflict of interest. Lastly, the newly implemented KanCare system has added an additional layer to the developmental disability system, but on its own will not address the inherent conflict of interest.
In fiscal year 2014, CDDO regions will receive about $360 million to provide services to about 8,700 individuals with developmental disabilities. We found that consolidating CDDOs could reduce administrative costs by about $500,000 to $800,000 a year. Kansas also could increase federal revenues by up to $6.5 million a year by redirecting $5 million in state aid. However, this policy choice would have significant impact on many Kansans. We found that several CDDOs spend funds on lobbying-related activities, which appears to violate federal and contractual requirements. Finally, KDADS does little to monitor CDDOsí administrative expenditures for the developmental disability waiver.
Larned State Hospital: Reviewing the Operations of the Sexual Predator Treatment Program
The Sexual Predator Treatment Program at Larned State Hospital provides treatment for sex offenders who have completed their prison sentence but who have been determined by the courts to be sexual predators. Overall, the Sexual Predator Treatment Program appears to have done a good job of addressing staff and resident safety and security, although we did identify a few safety and security issues that could affect staff and resident safety. Specifically, the program did not have adequate policies or controls to ensure keys and doors were secure and to prevent and detect prohibited items. Also, despite participating in conflict avoidance training, some staff did not feel adequately prepared for resident altercations. In addition, a significant number of staff positions responsible for ensuring safety, security, and treatment of residents were vacant. Even though program staff worked a significant amount of overtime, the program often failed to meet its internal minimum staffing levels needed to provide safety, security, and treatment.
Foster Care Decisions: Reviewing Decisions To Remove Children from Their Homes
The Department for Children and Families (formerly SRS) serves about 5,200 children a day through foster care. Based on complaints made by foster care families, legislators wanted an independent review of several cases to determine if state officials acted appropriately. For the cases we reviewed, department, law enforcement and court officials had sufficient and convincing reasons for removing children from their parents and not reuniting them. Although our conclusions are based solely on our review of nine cases and cannot be projected to the foster care system as a whole, they are consistent with the findings of a recent internal audit conducted by the department. Although families alleged their cases were mishandled, the allegations we could evaluate were contradicted by the evidence we reviewed, and did not adversely affect case outcomes. In addition, family members consistently expressed concerns about the foster care program for several reasons. Sometimes, parents may not have fully understood all the aspects of their childís case and therefore felt like they had been treated unfairly. Also, parents and relatives often disagreed with key decisions affecting where their child was placed. Lastly, parentsí actions or personal circumstances can further delay or prevent reunification with their children.
Department on Aging: Evaluating the Effect of Increasing Minimum Nursing Hours on Resident Care and State Costs
Although the results are mixed, the most thorough research generally shows a positive relationship between staffing levels and quality of care outcomes in nursing facilities. Further, according to the federal Centers for Medicare and Medicaid Services (CMS), increasing staffing levels up to 4.1 hours of nursing care per resident day improved health outcomes. In addition to staffing levels, researchers also identified a number of other staff-related factors that are important in improving quality of care, such as staffing levels on different shifts or units and staff training. We were unable to detect a clear relationship between nursing hours and quality of care outcomes for Kansasí nursing facilities, though this may be due to limitations in the data we were able to use.
Senate Bill 184, which was introduced but not passed during the 2011 legislative session, would have increased minimum nursing staff requirements in Kansas nursing facilities over a three-year period. However, the billís third year staff level requirements of 4.44 nursing hours per resident day are beyond the level the Centers for Medicare and Medicaid Services identified as leading to improved quality of care. We estimated it would cost the state up to $43 million annually to fully implement Senate Bill 184ís requirements. Although increasing staffing levels may improve health outcomes, better outcomes are unlikely to result in meaningful savings for the state. This is because the most significant costs associated with negative health outcomes are paid for with federal funds. As a result, most savings achieved through better outcomes will benefit the federal government, but not the state.
Kansas Neurological Institute: Evaluating the Efficiency of the Institute's Operations and the Cost and Safety Implications of Moving Its Residents into Local Communities
This audit evaluated both the operational efficiency of the Kansas Neurological Institute, as well as the potential cost and safety implications of moving its residents into a community setting. Our analysis of KNIís operations identified about $550,000 in one-time revenues and almost $270,000 in potential annual cost savings with little or no effect on KNI residents or services. We also identified about $680,000 in unduplicated potential cost savings annually that would change aspects of KNIís service model and could affect the quality of life or safety of KNI residents. We found that the cost and safety implications of closing KNI and serving its residents in a community setting are both complex and far-reaching. Although both settings provide similar core services to individuals with developmental disabilities, they differ in terms of the funding they receive and the specialized medical services they are able to provide. These differences create the potential for about $5 million in annual State savings after all KNI residents were relocated into a community setting. They also raise concerns about the safety and quality of life those individuals would receive in a community setting, specifically the adequacy and availability of medical care, and KNI residentsí ability to adapt to a new environment.
Kansas Commission on Veteransí Affairs: A K-GOAL Audit Reviewing Issues Related to Veteransí Benefits
The Veteransí Claim Assistance Program (VCAP), created in 2006, has not increased the services provided to veterans. Because neither the Commission on Veteransí Affairs nor the veteran service organizations have added significant resources or changed how veterans are served, this is not surprising. In addition, we discovered the Commission does not collect reliable management information about the services provided to veterans, through both VCAP and Commission staff. This severely limits the Commissionís ability to make good management decisions. In an effort to reduce Medicaid costs, several states have started initiatives to transition Medicaid-eligible veterans to U.S. Department of Veterans Affairs health care benefits. We estimate Kansas could save between $1 million to $2 million a year in State funds from a similar initiative. The State may need to add or reprioritize resources to achieve these savings, but these resources may decrease over time. To be successful, the State will also need to establish a structure to better coordinate efforts between several State agencies.
State Benefit Programs: Identifying Disincentives for Marriage
Most of the benefit programs we reviewed have income-based eligibility criteria that could discourage marriage in some situations, or have no effect at all. Thatís because programs vary in how household income is defined. Some programs donít distinguish between the income of married and cohabitating couples. Other programs may consider two unmarried people living together to be two separate households. Very few of the frontline program staff we interviewed think program eligibility rules have a significant effect on clientsí decision to marry. Further, the majority of clients we spoke with told us eligibility criteria have little to no effect on their decision to marry. Lastly, literature acknowledges that programs with income-based eligibility rules have built-in disincentives, but thereís little information about whether those disincentives actually cause people to avoid getting married.
Foster Care: Reviewing Selected Issues Related to Compensation and Oversight of Foster Care Contractors
In December 2007, the Department of Social and Rehabilitation Services (SRS) changed the way it structured foster care contracts to provide more financial stability to contractors. In general, each month, foster care contractorsí costs are less than the monthly payments they receive. However, the payment structure doesnít appear to have affected childrenís length of stay in foster care. We identified many other factors that do seem to affect the length of stay including, judicial discretion and the mental health and behavior problems of the child or the childís family. We also found that increasing the adoption subsidy rate potentially could increase the number of children adopted. Overall, SRS has established a good structure that can help it oversee foster care contractors. However, staff donít always act to correct the problems found while monitoring because the agency has a hands-off approach to overseeing contractors. We also noted that, regardless of SRSí oversight efforts, hundreds of children remain in foster care for a long time. Nevertheless, in taking a hands-off approach following up on problems, SRS increases the risk that children could unnecessarily languish in foster care. Finally, we noted that Kansasí performance on national standards related to length of stay in foster care appears to be about average.
Medicaid: Reviewing the Use of Emergency Room Services By Medicaid Clients (A K-GOAL Audit)
In fiscal year 2010, Kansas spent a total of $2.5 billion on Medicaid, including about $750 million in State funds. In calendar years 2008 and 2009, Kansas paid an average of $2.5 million in State funds for Medicaid emergency room claims. This included 642,000 claims for more than 118,000 individuals. Using a methodology developed by New York University, we estimated that about two-thirds of the emergency room claims were for conditions that didnít require emergency room treatment. Under the most optimistic assumptions, the State could potentially save about $625,000 per year by reducing the number of emergency room visits for non-urgent conditions. Lastly, Kansas already takes many steps to reduce Medicaid non-urgent emergency room use and costs, but we identified seven other strategies, such as operating a 24-7 phone line, that might allow Kansas to make further reductions. We were unable to quantify the potential net savings these strategies might achieve.
Health-Care Related Services: Reviewing Opportunities for Better Coordinating the State's Health-Care Related Programs
By changing Medicaid billing practices, the State could save money spent on inpatient care for Department of Correctionís inmates. Although State agencies could also better coordinate a number of other health-care related programs, service gap issues such as lack of affordable health insurance for low-income single adults can only be addressed through State-level policy decisions. Of more importance is the upcoming federal health care reform, which will greatly affect how health-care related services are provided in Kansas. Its primary goals are to reduce the number of uninsured, slow increases in health care costs, and increase access to health care services and providers. Implementing those reforms will require significant coordination among State agencies. Some State agencies that traditionally have provided health care services will have added responsibilities, while other State agenciesósuch as the Kansas Insurance Departmentówill start having a role. At this point, it is too early to know whether State agencies are on track to implement the various provisions of federal health care reform.
Prescription Drugs: Reviewing What the Kansas Health Policy Authority Is Doing To Control Prescription Drug Costs in the Programs It Oversees
The Health Policy Authority already has implemented several strategies to control prescription drug costs in the Medicaid program and the State Employee Health Plan. We identified five additional strategies for the Medicaid program that could save the Authority between $3.8 million and $4.6 million per year. These include joining a purchasing consortium, regulating mental health prescription drugs, reducing dispensing fees paid to pharmacists, implementing a more aggressive step therapy program, and increasing the maximum amount of certain drugs dispensed at one time. We identified four additional strategies for the Employee Health Plan that could save the State up to $3.0 million per year. These include reducing coverage on some or all prescriptions, increasing the maximum amount of certain drugs dispensed at one time, using a starter dose for new prescriptions, and limiting the number of prescriptions beneficiaries an receive each month.
K-12 Education: Reviewing Issues Related to the Costs of the Health Care Benefits Provided by School Districts (school audit)
Employers join health insurance pools in order to obtain lower and more predictable premiums. Currently there are five such pools available to school districts, including the State Employee Health Plan. We looked but identified only one district that could potentially save money by joining the State plan, primarily because the planís minimum employer contribution requirement is more than most districts currently pay, and because its annual deductible is lower. Because many districts are interested in forming a new Statewide pool of school district employees, we built estimates of what that pool might look like and what it might cost to insure. We looked at a sample of 22 school districts and two service centers and, based on our analysis, it didnít appear that most of them would benefit from joining a Statewide pool, either because they wouldnít save money, or because more out-of-pocket costs would be shifted onto their employees. Finally, if districts were to form a new pool, it would be difficult to sustain without sufficient safeguards, such as screening out districts with less healthy employees, instituting minimum employee participation requirements, or requiring higher employer contributions toward health insurance premiums.
Medicaid: Determining Whether Kansas Could Save Money by Expanding the Use of Managed Care in the Kansas Medicaid Program
Medicaid costs potentially can be reduced by better managing client care and reducing the use of avoidable high-cost services, such as emergency room visits. Kansas and other states have piloted or implemented a number of initiatives aimed at better managing care for high-cost clients, both to improve services to these clients and to reduce costs. Those initiatives often incorporate cost-savings strategies such as improved care coordination, payment incentives, and data management techniques. However, few states, including Kansas, have estimated the dollar savings or effects of these efforts. As a result, itís difficult to know if these initiatives are cost effective, or to estimate what potential cost savings might be possible by further applying these strategies to larger numbers of high-cost clients in Kansas. Regardless, many states we contacted have implemented these strategies on a statewide scale, despite inconclusive evidence that they contain or reduce costs. Thatís likely because the ways in which managed-care systems are supposed to save money are logically intuitive, even if unproven. Kansas has several options for identifying and pursuing cost-savings strategies, including analyses of Statewide medical data and increased use of pilot projects.
Children In Need Of Care: Reviewing Selected Issues Related to Handling Their Cases
Statewide, about 80% of social workers responding to our survey said theyíve never felt unduly pressured by county or district attorneys to include or exclude facts in documents they prepare for attorneys that they felt could distort the circumstances of a case. However, at least one social worker in all six SRS regions told us they had felt unduly pressured at some point to include or exclude information. Responses from social workers in Wichita were more negative, and interviews with social workers and judges revealed several past issues may be largely to blame. Filing a petition to remove a child from the home is decided by the county or district attorneyís office. However, social workers across the State clearly feel frustrated that attorneys donít always respect or follow their recommendations. All SRS social workers we reviewed met the licensure requirements of the State. However, initial and ongoing training social workers receive on writing legal documents, working with attorneys and the courts is sparse and insufficient. On average, social workers were responsible for about 35 open cases during fiscal year 2009. Average caseloads Statewide have remained relatively stable over the last three years, but vary quite a bit among the six SRS regions. Caseloads are somewhat higher than they otherwise would be because of a large number of vacancies that currently exist.
Child-Care Assistance: Determining Whether SRSí Procedures Limit the Risk of Improper Payments
Overall, SRS has reasonable procedures in place to reduce improper payments in the Child-Care Assistance Program, and those procedures caught most of the potentially improper payments we identified. However, we identified a few cases that SRS hadnít found involving clients using their benefits cards to pay themselves. We also identified ten instances in which clients were paying each other to watch each otherís children--something SRS doesnít routinely check for. We also noted some accuracy problems with the data contained in the databases used to manage the program, such as the same social security number being assigned to more than one person, or wrong birth dates. Finally, we noted that 571 families whose incomes appeared to significantly exceed the Programís basic guidelines received $1.8 million in child-care assistance in 2007. Among those 571 were 30 families whose income exceeded $100,000. Certain exceptions in SRSí current eligibility guidelines allowed these families to participate in the Program.
Statewide Medical Expenditures: Reviewing Medicaid Expenditures for Fraud and Abuse
Using data-mining techniques we found almost $13 million in suspicious Medicaid claims for federal fiscal year 2006 (the most recent year for which complete data were available to analyze). The suspicious claims included: more than $10 million in claims for more than 10,000 clients whose income appeared to exceed program limits; almost $700,000 in claims for clients who didnít provide a valid Social Security number, almost $600,000 in potential ďupcodingĒ by doctors for office and emergency room visits, and almost $500,000 in other suspicious claims such as claims filed for deceased individuals and charges for non-hospital services when a client was hospitalized. In addition, we identified 519 clients who received prescriptions for controlled substances, such as heavy painkillers and powerful stimulants, from five or more doctors in one year, which may be indicative of potential abuse.
HealthWave: Determining Whether the Programís Call Center Is Working As It Should
The Kansas Health Policy Authority contracts with a private contractor (MAXIMUS) to operate a Call Center to serve clients from several health insurance programs under the HealthWave umbrella. The Call Center doesnít have a system in place to ensure that all customer voicemail messages are captured and returned, and it didnít meet its standards for returning phone messages for almost one-third of the 100 sample messages we reviewed. In most cases, initial attempts to return calls were only one day late. However, in two cases, we found no documentation that any attempts to return the calls had been made. Contributing factors included poorly documented policies, weaknesses in how the Authority and MAXIMUS monitor or enforce the contract, and the lingering effects from high call volumes brought on by new federal documentation requirements. Those federal documentation requirements likely caused decreases in HealthWave Program enrollments during fiscal year 2007--especially for Title XIX programs. We think itís unlikely that unreturned phone calls had much impact on Program participation, because most individuals whose calls we reviewed were already enrolled in HealthWave, and anyone not enrolled in the Program could phone the Call Center again or receive enrollment information through other sources.
Foster Care: Reviewing Selected Issues Related to State Contracts for Foster Care and Family Preservation Services
SRS and the Division of Purchases didnít follow appropriate procedures during the latest foster care and family preservation contract negotiations in 2004. Late in the negotiations, an SRS employee appears to have inadvertently disclosed information to The Farm Inc., which allowed that organization to raise its bids. That disclosure ended up costing the State an additional $2.9 million during the first two years of the contract. With a few minor exceptions, SRS and the Division of Purchases officials handled other aspects of the negotiated procurement process appropriately.The Farmís outcomes were similar to other contractors in 2006 and 2007. The money the Farm spent from the $23.5 million it received in fiscal year 2007 generally went for items that that seemed reasonably related to providing foster care and family preservation services. In accordance with best practices for non-profits, The Farm didnít directly compensate its board members, its management compensation was in line with other contractors, and we didnít see any extravagant travel expenses. We did identify two issues related to a board member that represent a potential conflict of interest. In addition, The Farm donated $500,000 of its fiscal year 2007 net revenues to one of its affiliates. It reported that donation to SRS as an expense rather than a transfer, which made its financial position appear less positive than it was.
Disability Waiver Programs: Reviewing the Use of Appropriations Intended To Upgrade the Wages of Certain Caregivers
Direct caregivers provide services that help people with developmental and physical disabilities stay in their homes. These services include help with typical life functions such as dressing, feeding, bathing, and shopping. For fiscal years 2007 and 2008, the Legislature provided a combined total of more than $50 million in additional funding to SRS to increase reimbursement rates and decrease the waiting lists for both the developmental and physical disability waivers. The 2007 additional funding was expressly intended for increasing caregiver wages. The 2008 additional funding had no such expressed intent. For developmental disability services, SRS used the additional funding to increase reimbursement rates by about 4% in fiscal year 2007 and by almost 9% in fiscal year 2008. All five developmental disability service providers we sampled increased their direct caregiversí average hourly wages in fiscal years 2007 and 2008. For physical disability services, SRS didnít use the additional funding it received in fiscal year 2007 to increase reimbursement rates. Instead, SRS used the additional funding to eliminate the waiting list. In fiscal year 2008, SRS did use the additional funding to increase the self-directed services reimbursement rate by 3%. For that year, only two of the five physical disability service providers we sampled increased the average hourly wage rate they paid to their direct caregivers. Under both waivers, even when the average hourly rate increased, not all caregivers received an increase.
Childrenís Programs: Reviewing Whether They Are Coordinated To Avoid Duplication and Maximize the Use of Resources
Out of about 220 childrenís programs in Kansas, 20 State-funded and three federally administered programs focus primarily on serving children age five and under. Those 23 programs reported serving more than 500,000 children and spending almost $310 million in fiscal year 2006. At the State level, the risk of duplication comes from having multiple programs offering similar types of services. This risk appears highest in three categoriesĖpreschool services for children, home-based education services to parents of young children, and child-care services to low-income clients. Having multiple agencies involved in administering programs can create administrative duplication. We identified six education-related programs administered by agencies other than the Department of Education and three social services/child safety programs administered by agencies other than SRS. At the local level, where most services actually are provided, the same types of administrative duplication can exist when multiple local agencies administer programs. Efforts to coordinate childrenís programs at both the State and local levels primarily consist of coordinating groups and interagency agreements. A primary example is the Kansas Early Childhood Comprehensive Systems Plan Stakeholders Group, which has worked to develop Statewide strategies for serving young children. Legislation passed in 2007 mandated a plan to bring early childhood education services under a single office in the future, which could have a number of benefits, but issues involving funding and the definition of ďeducationĒ will be need to resolved. At the local level, issues such as community size and competition for funding can affect the extent of coordination that occurs. Finally, consolidating Kansasí programs wonít increase federal funding coming into the State because most federal funding is either fixed or based on formulas.
Kansas Dental Practices Act: Determining the Impact of the 1998 Changes to the Act
Because dental scaling assistants are unlicensed, itís difficult to obtain reliable information on their current employment status. Available information shows that since 1998, 400 dental assistants have completed the training to become scaling assistants, and our survey indicates that at least 158 currently are working, although the majority spend less than half their time scaling and polishing teeth. Thereís no significant evidence to suggest that dental hygienist positions are being replaced by dental scaling assistants.
Health-Care Related Programs in Kansas: Determining What Funding Kansas Receives and Who Administers It
Our inventory focused on three types of government-funded health-care related programs in Kansas--State administered, federally administered, and research--and on programs that were clearly medical in nature or related to substance abuse and mental health. Health-care related programs administered by seven State agencies accounted for about $2.5 billion of the nearly $6 billion in spending we identified for 2006, including $1.6 billion on health care programs and $.8 billion on long-term care. Federally administered health-care related programs accounted for $3.3 billion in spending, nearly all of which was for Medicare. Health-care related research spending totaled about $131 million, with most of that being spent by the University of Kansas.
Foster Care: Reviewing Decisions To Remove Children From Their Homes
Legislators have heard numerous complaints from families who thought there wasnít sufficient reason to remove their children and place them in foster care, or to keep them away once removed. In our review of a small sample of those cases, we concluded that removal and reunification decisions generally were handled reasonably. We did find some problems with other aspects of the cases. Some examples include SRSís contractors not following court orders to obtain drug tests for family members, and not always documenting the results of those tests. Also, in two cases SRS didnít interview individuals who may have been able to provide relevant information about a case. Within the court system, we found several problems or potential problems with the handling of cases in Montgomery County, including the appearance of potential bias in one case, faulty recording devices in a courtroom, and adoption being used as a case goal far more frequently than for all foster care cases Statewide. Finally, we found several instances where there appeared to be deficiencies in the level or quality of legal representation provided to parents. Given everything else that was going on in these cases, for the most part we think it is unlikely that any of these individual problems would have affected the removal and reunification decisions made about these children.
Board of Healing Arts: Reviewing Issues Related to Complaint Investigations, Background Investigations, and Composition of the Board
The Board of Healing Arts has some elements of a good complaint-handling system, but we identified significant weaknesses in several areas. For example, by policy the Boardís staff donít investigate all allegations of substandard patient care. Board staff also have inadequate processes for tracking and monitoring the progress of complaint investigations, and of investigated cases that have been forwarded to the Boardís Review Committee. In two long-open cases, Board staff failed to obtain expert opinions, which had been recommended, and those cases have languished for years while the doctors in question remain licensed. Disciplinary outcomes for the 30 closed cases we reviewed seemed reasonable. The Board generally collects and verifies the appropriate amount and type of information for medical doctors and osteopaths, but staff donít verify all they could for chiropractors and podiatrists, and arenít authorized to conduct FBI criminal history checks on applicants. The Boardís composition is set in statute and hasnít changed in 20 years, even though many allied health professionsĖ such as physical therapistsĖ have come under its regulatory authority since then. Of 14 professions it regulates, 10 donít have a seat on the Board, but most are represented on advisory councils to the Board. Although other statesí regulatory structures vary in the number of professions regulated or members on the board, their boardsí makeup typically is limited to doctors and members of the public.
Medicaid Waivers: Reviewing Differences in Rates and Hours of Service for Clients Receiving Self-Directed and Agency-Directed Care, Part II: SRSís Physical Disability Waiver
Physically disabled clients with self-directed care cost about $82 per month (7%) more than their counterparts with agency-directed care. That difference is significantly less than the $272 per month difference (41%) we saw in Part I between frail elderly clients with self-directed care and those with agency-directed care. Physically disabled clients who self-direct their care tend to be slightly more disabled and poorer, and to use more of the services (81%) they are authorized than clients with agency-directed service (77%). However, the differences between these two groups arenít great, and likely arenít anything the State can control for. Clients with self-directed care received only about 1 hour less per month in volunteer services than clients with agency-directed care. Had they received the same number of volunteer hours, we estimate the State would have saved about $128,000 in Medicaid costs. In this audit, we saw the same variability in authorized hours of care for physically disabled clients with the same assessed need for service as we did in Part I for frail elderly clients. For example, clients with the same assessed level of need for Ďhygiene and groomingí were authorized anywhere from 2.5 hours to 35 hours per month of assistance. Finally, we found SRS doesnít have readily available basic management information about the waiver, and some existing data are inaccurate and incomplete.
SRS: Reviewing the Recent Restructuring of Area Offices and Its Impact on Employees and Clients
In general, SRS followed a logical and consistent process for reorganizing service areas and determining which local offices should be closed. Some of the conditions staff have reported as leading to low morale have some basis in fact. For example, the process for filling new or vacated positions wasnít always consistent across regions, the reorganization resulted in more management positions and fewer staff who directly serve clients, caseloads have increased significantly in some programs while the number of caseworkers in those programs has been relatively static, the Department has done away with many of the workers who helped caseworkers by filing documents and answering telephones, some job descriptions apparently werenít always finalized before vacancies were posted, and some employees were downgraded or received pay cuts.SRS staff expressed many concerns about the reorganizationís impact on clients, including difficulties accessing services and delays in processing applications for service. Clients responding to a telephone survey SRS commissioned from Fort Hays State University expressed less dissatisfaction. Still, 9 of 13 high-needs clients we spoke with complained about the difficulty in obtaining services. Also, officials from a sample of the new ďaccess pointsĒ across the State reported clients didnít seem to be having much trouble getting materials, but expressed concerns about other access issues related to transportation and clientsí ability to use the computers or fax lines or get their questions answered. We didnít find any evidence of widespread or significant delays in processing applications. Finally, because other budget reductions were happening at the same time, savings from the reorganization are difficult to pinpoint. But theyíre likely to be less than $1.4 million to-date.
Medicaid Waivers: Reviewing Differences in Rates and Hours of Service for Self-Directed and Agency-Directed Care, Part I: The Department on Agingís Frail Elderly Waiver Program
Medicaid is paying more for clients with self-directed care than for clients who choose agency-directed care. From our review of records from January 2005, we estimate that Medicaid will pay about $926 per month for each client with self-directed care and about $654 per month for each client with agency-directed care. This difference in costs is happening for several reasons, including that clients with self-directed care tend to be more disabled and poorer. However, when we compared clients with similar disability scores, the main factor influencing the cost difference is that clients with self-directed care donít rely nearly as much on volunteers to provide help with the services they need. If these clients received about the same number of volunteer hours as clients with agency-directed care (about 17 hours more per client, per month), Kansas would save about $2 million each year in State funding. In addition, we found that other factorsĖincluding whether clients live in rural areas or live aloneĖarenít increasing costs for clients with self-directed care. Finally, we found that Kansas could take additional steps to try to control costs, including not using Medicaid to pay for services when clients turn down voluntarily-provided services, limiting the number of hours family members can be paid to provide services, reducing pay rates to family members, and not allowing payroll agents or attendant care providers to pressure case managers to add service hours to clientsí care plans.
Larned State Hospital: Reviewing the Growth In the Sexual Predator Treatment Program
Since 1998, the number of residents in Kansasí Sexual Predator Treatment Program has increased from 16 to 136. The Program is growing because more sex offenders are being committed (2-3 per month in recent years, compared with about 1 per month in 1999), and few are leaving (some havenít been in the Program long enough to complete it, some arenít progressing, and some never will). Under an optimistic scenario, the population could increase by 100 residents over the next 10 years and nearly triple over the next several decades before leveling off. Under less optimistic assumptions, it could grow to more than 800 residents before leveling off. Staffing and funding for the Program grew by about 340% and 480% over the past 5 years, respectively, to handle the increase in population, but Kansas staffing levels and operating costs seemed reasonable compared with other states. Most comparison statesí programs were similar, but some have more lenient criteria for releasing residents. Options that exist for curbing the Programís growth will require Kansas to accept a higher level of risk.
Foster Care: Determining Whether Adoptions Are Being Finalized As Quickly As Possible, Once An Adoptive Family Is Located
Most children adopted in fiscal year 2004 already had a potential adoptive family identified by the time they were referred to KCSL. On average, these adoptions took the shortest time to complete, but they still took more than a year to finalize. Two-thirds of the adoption cases we reviewed experienced at least one delay in the adoption process that seemed to be unreasonable or unexplained. Adoptive parents appear to have caused most of the unreasonable or unexplained delays. 50% of the unnecessary delays financially benefitted the party that caused the delay. Under the current system, adoptive parents and KCSL can benefit financially from delays in the adoption process. New contracts for adoption and foster care services will reduce contractorsí financial incentives to delay adoptions.
Regulation of Child Care Facilities and Foster Homes: Determining Whether KDHE Is Providing Effective Oversight and Whether KDHE and SRS Provide Duplicate Regulation of These Facilities
Since our 1997 audit, KDHE has made some improvements regarding its oversight of child care providers, but many of the same types of problems persist. This audit identified a number of issues, including: the Department hasn't performed all required background checks, some inspections and complaint investigations weren't conducted in a timely and thorough manner, and it failed to oversee the inspection work performed by child-placing agencies. Also, the Department isn't taking stronger enforcement actions partly because of limitations it perceives in the State's child-care laws and its high threshold for evidence of non-compliance. Kansas generally regulates the same types of child care facilities as the comparison states. Ways that KDHE could increase the efficiency of its regulation include implementing a risk-based inspection system, extending its annual license renewal cycle, and reducing the frequency of background checks. Duplication of regulatory responsibilities is occurring in three areasĖinitial inspections of family foster homes, investigation of child abuse and neglect complaints at child care facilities, and inspections of community mental health centers that provide child care services. SRS and KDHE have formed a working group to reduce the number of conflicting and duplicate regulations affecting mental health centers. Duplication in the other two areas could be eliminated by having KDHE rely on the inspections conducted by child-placing agencies, and by cross-training SRS inspectors to inspect child care facilities.
Medicaid: Reviewing Factors That Affect the Amount of Attendant Care Services Certain Medicaid Clients Receive
Although the opportunity exists for independent living centers and some home health agencies to benefit financially by authorizing more hours of attendant care services for their clients when they also serve as the payroll agent, we found no evidence that was occurring. These agencies actually authorized fewer hours of service for clients in these situations. These clients were more likely to live with someone or have friends or family who could help them out, which could explain why fewer hours of paid services were needed.
West Nile Virus: Reviewing the Department of Health and Environmentís Case Reporting (limited-scope audit)
As of November 2003, the Department of Health and Environment had reported, to the public and to the Centers for Disease Control and Prevention, 90 severe cases of West Nile Virus infection that were confirmed by the State laboratory or the CDC. These were the only types of cases KDHE reported until October 2003, when it decided to add commercial laboratory results to its public reporting of West Nile Virus cases. As of November 2003, KDHE had reported to the public 731 cases that tested positive at commercial laboratories in 2003. The Department hadn't reported 20 unconfirmed but "probable" cases of severe West Nile Virus infection, because Department officials didn't realize the CDC expected them to do so. The number and types of cases reported by Kansas and nearby states varied significantly, due to differences in what types cases are gathered, tested, and reported, and due to differences in the overall presence of West Nile Virus in each state.
Food Safety Programs in Kansas: Evaluating Possible Costs and Efficiencies of Combining Them
Primary responsibility for ensuring food safety in Kansas is divided between the Departments of Agriculture (in the meat and poultry, dairy, and egg inspection programs) and Health and Environment (in the food protection program); together, they spend about $3.2 million for inspection staff. This system is inefficient in some ways, because inspectors from more than one agency or program inspect the same businesses, some businesses are inspected more frequently than they need to be, and similar businesses are regulated inconsistently. In addition, coordination can be improved in situations where the agencies' regulatory authority overlaps. Combining food safety inspection programs could make it more likely similar food businesses and processes would be regulated consistently and that communications would improve. We estimate Kansas can generate about $680,000 in annual savings and improve food safety if certain inspections are combined and if inspections are changed to a risk-based approach. In addition to restructuring the routine food safety inspection system, Kansas needs to continue taking steps to become prepared for intentional threats to food safety.
CDDOs: Reviewing Issues Related to the Funding of Community Services
Public funding for the State's developmental disabilities system has increased 15% over the last 4 years, 82% of which is distributed based on client severity. Over the last 4 years, community service providers' share of the Medicaid waiver increased from 61% to 64%, and the amount of "discretionary" funds CDDOs pass on to them has increased from 21% to 28%. The 2001 Legislature directed SRS to maximize the amount of new federal funds that could be drawn down to help fund direct services. In 2002, 91% of these new moneys were distributed based on client severity; under a new method for 2003, that figure was 22%. CDDOs also got a larger share of these new funds in 2003, mostly because the distribution plans they designed were more favorable to them.Over the last 4 years, CDDO Administration costs have increased by about 17%, and the majority of the funding has shifted from State to federal sources. Although CDDO Administration expenditures have grown faster than spending on direct services, that's due at least in part to CDDOs categorizing more of their expenditures as CDDO Administration, and to the fact that reimbursement rates for Medicaid services weren't increased. CDDO Administration costs vary widely by client. The structure of the current CDDO system creates an inherent conflict of interest for the 22 CDDOs that provide services in competition with the community service providers they contract with. Potential conflicts can arise in the areas of client referrals, contract terms, funding distributions, and quality assurance. Prohibiting CDDOs from providing direct services would address most of these issues. In addition, the discretionary State aid CDDOs receive could be distributed on a different basis, and CDDOs could be made sole providers of targeted case management services. All 3 areas would need further study.
Low-Birthweight and Premature Babies: Reviewing Programs Aimed at Reducing Their Incidence and Associated Costs
Low-birthweight babies cost the State's Medicaid Program about 5 times as much as normal-birthweight babies during their first year of lifeó$16,704 compared with just $3,180. They account for only about 10% of all births, but more than one-third of all payments made. Lack of prenatal care is one of many risk factors that can increase the chance of having a low-birthweight or premature baby. Overall, 72% of Medicaid mothers reported getting adequate or better medical prenatal care. Those who reported getting no or inadequate care generally had a much higher incidence of low-birthweight babies than women who got adequate care. The research on the effectiveness of prenatal care is mixed, but babies whose mothers had no such care cost Medicaid significantly more than those babies whose mothers got even minimal care. Women who had low-birthweight babies also had a higher prevalence of many of the other risk factors associated with poor birth outcomesó including smoking, substance abuse, and low weight gain during pregnancy. Outside of Medicaid, the State spends very little on prenatal care programs. The State's share of the cost for funding prenatal services through Medicaid was almost $15 million in fiscal year 2002. The State also spent $1.4 million on KDHE's Maternal and Infant Program, the State's only program focused primarily on prenatal care. Local health departments cited financial barriers as the primary reason why low-income women don't get prenatal care services, and pointed to a critical gap in the availability of medical services for these women. Neither KDHE nor SRS is doing all it can to educate women about the benefits and availability of prenatal care. KDHE also doesn't collect any information that would allow it to connect the services clients receive with their birth outcomes, but more could be done with existing data.
Medicaid: Assessing the Cost-Effectiveness of Current Procedures for Transporting Medicaid Consumers to the Services They Need (100-hour audit)
SRS' transportation program for Medicaid consumers isn't structured to effectively control costs. For example, there's no incentive for consumers to use lower-cost methods of transportation, providers have an inherent financial conflict of interest when screening consumers' eligibility and determining the necessity of trips, and claims are processed with few controls in place. Kansas has a number of options for setting up a more cost-effective program, including making changes to address the problems identified and carefully considering a different structure to deliver Medicaid-paid transportation, such as a brokerage system adopted by neighboring states. Finally, SRS's new reporting requirements for commercial transportation providers do duplicate information required by the KCC, but only 3 of the 106 commercial transportation providers SRS uses are certified by the KCC and are faced with providing the same information to both agencies.
Medicaid: Reviewing the Compensation of Payroll Agents for Home and Community-Based Waiver Programs (100-hour audit)
Medicaid clients who choose to direct their own attendant care services under the home and community-based service waivers must select a payroll agent (a home health agency or a center for independent living) to process their Medicaid claims. Records reviewed at 5 payroll agents in Kansas showed that they retained an average of $2.14 per hour of service billed, or 18% of the total amounts they bill to Medicaid on the clients behalf. Other states reviewed appear to obtain these services at significantly less cost. In the small sample of other states reviewed, the highest percentage retained by a payroll agent was 12%. A representative from a private company that provides Medicaid billing services in 11 states said that generally 6-10% of the amount billed could be considered a reasonable fee for payroll-related services. Two factors appear to be contributing to Kansas' higher costs. Kansas requires the payroll agents to assume some responsibilities other states don't require and it doesn't solicit competitive bids for these services.
Verifying Information Provided by the SRS on Its Compliance with the Terms of the Foster Care Lawsuit Settlement Agreement: Monitoring Report #15
For the 6-month period generally covered by this audit (January-June 2001), 22 requirements were monitored. Of those, SRS was in compliance with 5 (23%), and wasn't in compliance with 17 (77%). SRS met about one-third of the requirements specifically related to investigating reports of abuse and neglect and managing foster care cases. However, it continued to be out of compliance with 3 requirements related to maintaining data and systems that contribute to the good management of the foster care system. This audit is the last in a series of audits we've conducted since 1993 looking at SRS' compliance with the settlement agreement. The parties have agreed that SRS was in substantial compliance with the agreement, and the agreement expired June 30, 2002. As part of a new quality assurance effort within SRS, the parties have agreed SRS will continue to review any outstanding areas of the agreement that weren't in compliance as of June 30, and will provide an annual report to the Legislature on the results of this monitoring effort.
Medicaid Cost Containment: Controlling Costs of Long-Term Care
Kansas' spending on Medicaid-funded long-term care rose by $157 million between 1998 and 2001, or about 33%. Rising reimbursement rates for nursing facilities-primarily driven by higher direct-care salary costs-accounted for almost $47 million of that increase. Spending for "waiver" services provided in the home or community-primarily driven by significantly more people receiving services-accounted for $110 million of the increase. Factors driving up waiver costs to a lesser extent: relatively small increases in reimbursement rates and in the average amounts of services clients received. Among the reasons why so many more people are getting services in the community: the "woodwork" effect, a change in financial eligibility requirements, the closing of several long-term care institutions for the developmentally disabled, additional funds being provided to serve more people, and a new program for severely emotionally disturbed children.SRS and the Department on Aging need to analyze data already available to them to identify and manage areas where costs need to be controlled. Cost control measures we identified include serving only the neediest by raising the minimum scores required to qualify for the program, tightening financial eligibility requirements, and taking better steps to ensure that people haven't purposefully sheltered assets in order to qualify for Medicaid. The Departments also could limit the number of eligible people who can receive services by using waiting lists, paying less for services by limiting the amount spent per consumer, and stepping-up their efforts to identify and recoup payments that shouldn't have been made. Also, they could roll back or delay nursing home rate increases scheduled to go into effect for fiscal year 2003. Finally, the Departments could work with the Legislature to develop ways to encourage people to pay for their own long-term care.
Regulation of Food Service Establishments: Determining Whether the Department of Health and Environment Is Providing Sufficient Regulatory Oversight
Improvements were needed in many aspects of the State's food service regulatory program. The Department licensed some food service establishments before they'd corrected serious and multiple violations. In calender year 2001, about 30% of the establishments required to be inspected weren't, and complaint and follow-up inspections sometimes weren't timely or weren't done. The Department had limited resources to conduct all the inspections requiredĖthe number of inspections conducted per inspector exceeded FDA standardsĖbut areas were identified where current staff resources could be used more efficiently and effectively. The Department's annual monitoring of county health agencies it contracts with to conduct inspections focused almost exclusively on the number of inspections completed, and in-depth evaluations of these programs were too infrequent to be effective. Also, the Department didn't take appropriate actions against establishments that repeatedly or seriously violated its regulations. It hadn't established clear guidelines for its inspectors as to when enforcement actions should be taken, and left most decisions about initiating actions up to inspectors. Finally, program managers didn't systematically receive or track information about problem establishments to determine whether appropriate actions were being taken.
Medicaid Cost Containment: Controlling Costs of Medical Services - A K-GOAL Audit of the Department of Social and Rehabilitation Services
Costs have increased for regular medical services in the Medicaid Program because of a combination of factors involving the number of people enrolled, the amount of services they use, and the amount paid for those services. More clients who are disabled, aged, or children are enrolled in Medicaid now than in the past, and more of the clients enrolled are receiving services, including costly inpatient services for the disabled and aged. On average, each disabled or aged client uses many more services now than beforeóprimarily in the areas of home health services, certain alcohol and drug therapies or treatments, and special education services. Also, children in State custody (particularly juvenile offenders) now receive many more Medicaid-covered residential and treatment services on average for behavioral, mental health, or alcohol and drug problems. Rates for many services were increased, but the decision to raise rates for physician and outpatient services has cost far more than originally anticipated, largely because of increases in the number of people using those services and increases in the number of services used per person. In some cases, we also saw a number of shifts to using more expensive services once rates were increased or new higher-cost services were offered. Many increases have been the result of legislative or agency decisions to broaden the safety net for low-income adults and children, but some decisions have had unexpected consequences. To control costs in the short run, Kansas could quit serving "optional" populations, reduce the length of time certain groups can use benefits, or reduce or limit coverage for non-mandatory services like dental care and hospice. Over the longer term, SRS needs to reduce errors in the amounts paid to providers, systematically monitor and compare expenditure and usage information against expected outcomes, provide managed care for people with extensive medical needs, and ensure other agencies are claiming all possible federal matching moneys.
Medicaid Cost Containment: Controlling Fraud and Abuse
This audit, conducted by Bland & Associates under contract with Legislative Post Audit, looked at the State's system for controlling Medicaid fraud and abuse. The report noted several positive aspects of that system, but also found a number of serious problems. The part of the system dealing with identification of potential fraud and abuse involves the surveillance and review function, which the Department of Social and Rehabilitation Services has contracted out to Blue Cross/Blue Shield. The effectiveness of that effort is questionable because generally there's no follow-up on information generated by that effort that could point to problems, the focus of the work isn't on the highest risk or most lucrative areas, and there's not much additional analysis outside the standard reports. At least in part, that's because the Department hasn't provided sufficient guidance and direction to that effort, and hasn't followed good contract-management practices. The part of the system dealing with investigation and prosecution of fraud and abuse is handled by the Attorney General's Medicaid Fraud and Abuse Division. Limited to responding only to referrals it gets, that Division is significantly underutilized. This audit didn't attempt to assess the extent to which fraud and abuse is occurring in Kansas. Such an assessment would involve significant effort, but the auditors think that effort would be worth it.
Kansasí Nursing Home Inspections: A K-GOAL Audit Determining Whether Theyíre Carried Out In a Reasonable Manner
For the 16-month period through June 30, 2001, Department inspectors cited more than 5,000 deficiencies in Kansas nursing homes. We saw little evidence indicating Department inspectors were classifying serious deficiencies incorrectly Ėmore than 95% of the serious deficiencies we reviewed appeared to be classified correctly. Although most nursing home administrators think serious deficiencies are classified incorrectly, relatively few appeal the Department's findings. Only about 6% of the deficiencies cited during a recent 8-month period were appealed, and about one-fifth of those were either reduced or dropped altogether. Significant regional differences exist in the number of deficiencies cited at nursing homes, but there's little solid evidence to explain why. Some Department practices may contribute to inconsistencies among inspection teams, or could be changed to better identify and address the inconsistencies that do exist.
Verifying Information Provided by the Department of Social and Rehabilitation Services on Its Compliance With the Terms of the Foster Care Lawsuit Settlement Agreement: Monitoring Report #14
For the six-month period generally covered by this audit (July-December 2000), 25 requirements were monitored. Of those, SRS was in compliance with 6 (24%), and wasn't in compliance with 19 (76%). SRS met about one-third of the requirements specifically related to investigating reports of abuse and neglect and managing foster care cases. However, it continued to be out of compliance with 6 requirements related to maintaining data and systems that contribute to the good management of the foster care system.
The State Health Benefits Program, Part 2: Reviewing the Staffing and Structure of the Current Program
Currently the State Health Benefits Program's structure is appropriate since 98% of the Program's members are active or retired State employees. However, considering the program may be expanded to include other public entities, such as cities and counties, the Legislature and Commission should address how the Program is to be managed in the future. Other states we contacted that, like Kansas, serve only or predominately state employees tend to be located in a multi-function state agency, and are equally likely to be governed either by the head of the agency or by a commission. It also appears that given the new positions added for 2002, the Health Benefits Program has enough staff to handle most of its current workload. Commission staff identified several important responsibilities, such as reconciling insurance carriers' bills, they thought they weren't able to adequately address with their existing staffing levels, but the new positions will help fill these needs. Lastly, we found that Kansas already has enough participants in its health insurance plans to benefit from economies of scale, and lower costs would be unlikely if a plan was eliminated. While Kansas is using most of the strategies that experts mentioned are important in controlling the cost of health insurance, the Commission will have to make tough choices if it is to minimize cost increases in the future because it can no longer rely on money in the reserve fund.
Verifying Information Provided by the Department of Social and Rehabilitation Services on Its Compliance With the Terms of the Foster Care Lawsuit Settlement Agreement, Monitoring Report #13
For the six-month period generally covered by this audit (January-June 2000), 42 requirements were monitored. Of those, SRS was in compliance with 25 (60%), and wasn't in compliance with 17 (40%). SRS met about two-thirds of the requirements specifically related to investigating reports of abuse and neglect, managing foster care cases, and handling adoptions. In addition, SRS was in compliance with 1 of 2 requirements related to ensuring the safety of children. However, it continued to be out of compliance with 5 requirements related to maintaining data and systems that contribute to the good management of the foster care system. We'll follow-up on these requirements next period.
The State Health Benefits Program, Part 1: Reviewing Issues Relating to Premium Costs and Management
Premiums for the Kansas employee health care program are somewhat higher than average when compared to the surrounding states and Iowa, Sedgwick and Shawnee counties, and the Topeka and Wichita school districts, but usually fell well within the middle of the range. Kansas' premiums may be higher than average because Kansas employees pay far less out of pocket for their health care costs than employees in most of those other groups surveyed. No problems were found stemming from specific concerns that the State's self-funded program isn't being properly managed and overseen. The most recent Health Benefits Administrator appeared to be well qualified for the job; the Program's funds are being properly deposited into the State Treasury and the interest being earned on them stays with the Program; and the use of the "incurred cost" method when projecting future program costs is reasonable. In addition, the duties and responsibilities of Blue Cross and Blue Shield as the State's third-party administrator appear to be no different from the responsibilities of contractors in other states that have self-funded plans.
Medicaid for Long-Term Care: Reviewing the Department of Social and Rehabilitation Servicesí Efforts to Identify Inappropriate Means of Sheltering Assets to Qualify for Medicaid
Kansas' eligibility requirements fall within federal guidelines, but give applicants more opportunities to shelter their assets than neighboring states do. As a result, Kansas applicants could become eligible for Medicaid sooner, and the State could end up paying more for their care. In addition, federal regulations have generous provisions which allow applicants to transfer assets to others without incurring meaningful penalties. These same regulations also would allow an applicant's surviving spouse to permanently shelter certain assets. Finally, although SRS follows a number of best practices to ensure that applicants are eligible, the agency could be doing more to ensure that applicants haven't inappropriately sheltered assets before applying for assistance.
The Stateís Adoption and Foster Care Contracts: Reviewing Selected Financial and Service Issues
The size of the State's adoption program and the number of children adopted grew significantly after the program was privatized, but the percent of available children who were adopted decreased from 37% to 26%. Overall, the State has funded a greater portion of agencies' foster care and adoption costs since privatization, but individual agencies' experiences have been very different: some had a greater portion of their costs paid by the State while others had less. On the whole, contractors fared better than subcontractorsĖthe percentage of costs funded by the State for the 4 contractors increased from an average of 79% to 92%, while the percentage for a sample of 6 subcontractors increased from an average of 76% to 83%. For fiscal year 2001, 5 of 6 contractors were projecting that State funding would cover at least 95% of their costs for providing foster care or adoption services. In general, SRS had well-designed procedures for monitoring the financial viability of its contractors, and it also had good procedures for monitoring how well its contractors provide services.
HealthWave: Reviewing the Programís Services and Finances
Horizon Health Plan, Inc., one of the initial contractors for HealthWave, originally was created to operate the State's Medicaid PrimeCare Program. The State's low Medicaid rates, compounded by Horizon's reliance on its Medicaid PrimeCare contract as its sole source of revenue, resulted in the company's severe financial losses. Despite Horizon's financial problems and uncertain future, the Department awarded Horizon the contract for HealthWave because it was the only bidder in 2 of the State's 3 regions, and because Horizon was about to be taken over by a financially secure company. Horizon subsequently was liquidated by the Kansas Insurance Department, and the State has paid nearly $10 million over and above the contract rate since that time. However, only $1 million is directly related to Horizon's liquidation. The current contractors and the HealthWave Program now appear to be financially sound. The Program has been very successful in identifying and insuring previously uninsured children, and in making health care coverage available Statewide. Although information about the number and types of services children have gotten through HealthWave isn't available yet, participants and doctors generally appear to be happy with the Program. To adequately carry out its oversight responsibility, the Department of Social and Rehabilitation Services needs to strengthen its efforts to gather, verify, and analyze data about Program and contractor performance.
Verifying Information Provided by the Department of Social and Rehabilitation Services on Its Compliance With the Terms of the Foster Care Lawsuit Settlement Agreement, Monitoring Report #12
For the six-month period generally covered by this audit (July-December 1999), 49 requirements were monitored. Of those, the Department was in compliance with 7 (14%), and wasn't in compliance with 42 (86%). Monitoring of 5 requirements will stop because the Department demonstrated compliance with them for 2 consecutive monitoring periods. The Department met the requirements specifically related to investigating reports of abuse and neglect, managing foster care cases, and handling adoptions only 18% of the time. In addition, the Department wasn't in compliance with 2 important requirements related to ensuring the safety of children, and it continued to be out of compliance with many requirements related to maintaining data and systems that contribute to the good management of the foster care system. We'll follow-up on these requirements next period.
The audit found that Area Agencies on Aging don't always conduct assessments as timely as called for by Department on Aging guidelines, although elderly clients were satisfied with the timeliness. The Area Agencies do develop service plans that meet the needs identified by their assessments, and make sure that clients either get services called for by their plans or there's a good reason why they don't. In addition, the Area Agencies are effectively coordinating with service providers in administering the programs they're responsible for. Further, several concerns raised about case management done by Area Agencies don't seem to be a problem. The audit also found that new federal reporting and other requirements placed on home health agencies are having a significant fiscal impactĖincreasing the agencies' costs and reducing their revenues. In fact, the new requirements appear to be contributing to a decrease in the number of home health agencies in Kansas.
Reviewing the Medicaid Programís Use of Generic Drugs
The Kansas Medicaid Program spent about $141 million in fiscal year 1999, and about a quarter of that was for prescription drugs. When both name brand and generic versions of drugs were available, Medicaid paid for the generic version 82% of the time, saving $2.2 million. However, drugs available from only one source took 76% of the Medicaid pharmacy dollars in fiscal year 1999. The Department of Social and Rehabilitation Services relies on federal and State caps to limit how much the Program spends for drugs that have generic versions. The Department also has a number of practices to control costs for drugs available from only one source, such as limiting how often it will pay for refills and lowering the reimbursement for specific drugs. Several cost-saving ideas we heard about from other states and from Kansas pharmacists and physicians merit additional research. Some, such as requiring a patient to fail on a generic drug before getting a name brand, would require changes in Kansas law. Others, such as splitting expensive tablets, expanding coverage of over-the-counter drugs and doing more counseling of clients with chronic diseases or conditions, might require only a change in policy.
Reviewing the Implementation of the Mental Health Reform Act
In general, the Department has taken steps to implement the Mental Health Reform Act, but it needs to focus on long-term planning, prioritize needs and goals, and improve monitoring to ensure that centers comply with established standards and definitions. Above all, it needs to improve its information systems to be able to know whether appropriate services are being provided and at what cost. Based on the limited information available, it appears that mental health clients aren't getting all the services they need. Further, case managers and mental health center officials identified specific shortages of services like attendant care, respite care, and case management services Ė often citing a lack of funding or inadequate Medicaid reimbursement rates as the reason. Overall, funding appears to have shifted from State hospitals to the communities. State General Fund spending on hospitals declined by $31 million from fiscal year 1992 to 2000, while spending on community mental health services increased by $34 million. However, about two-thirds of the money mental health centers get through the State is given in the form of grants that aren't necessarily tied to particular services, and those moneys are very unevenly distributed across the State. Significantly more federal money could be made available to fund mental health services at relatively low cost to the State if the Medicaid reimbursement rates were raised. The State currently provides enough funding to match about $73 million in federal Medicaid dollars, but it currently only bills for enough services to draw down about $25 million.
Verifying Information Provided by the Department of Social and Rehabilitation Services on Its Compliance With the Terms of the Foster Care Lawsuit Settlement Agreement: Monitoring Report #11
For the six-month period generally covered by this audit (January-June 1999), only 16 requirements could be monitored. For those 16 requirements, the Department was in compliance with 1 (6%), and wasn't in compliance with 15 (94%). The Department met th
Examining Issues Related to Community Developmental Disability Organizations, Part II: Reviewing Implementation and Funding Issues
The Developmental Disability Reform Act created an inherent conflict of interest by making CDDOs the single point of application, eligibility determination, and service referral for clients seeking services, while at the same time allowing them to continue providing services. Many parents and guardians think they haven't received adequate information from CDDOs about the availability of services in their areas. The law requires the Department to establish an open and equitable contracting process, and some independent service providers are dissatisfied with the process and certain contractual terms. The Act also requires the rates used to reimburse service providers to be independently reviewed every two years. We identified several flaws with the way the Department used cost data in making its 1997 rate recommendations to the Legislature. Developmental disability funds generally are allocated among CDDOs on a reasonable basis, but some moneysĖdiscretionary State aid and fiscal year 2000 waiting list fundsĖmay not have been allocated equitably. The State's system doesn't have enough money to fund all the services eligible people are requesting. The Legislature has increased funding significantly over the last few years, but those funds haven't kept up with the number of clients coming into the system. In addition, some services for existing clients are underfunded. We couldn't tell whether the State could save administrative costs by reducing the system's administrative structure, and most people think there would be more disadvantages than advantages to consolidating CDDO areas.
Examining Issues Related to Community Developmental Disability Organizations, Part I: Assessing Effectiveness and Availability of Services
Most eligible developmentally disabled clients who'd sought services from the State were getting them as of June 1999. However, Statewide nearly 8% of the people who'd sought services (about 600 clients) were waiting for one or more services. About half of those hadn't received any services, and were on the Department's list of clients waiting for services. The other half were considered to be "underserved," and weren't on the Department's list. Most of the clients waiting for services were in the five urban centers of the State, the majority of them were children, and the most common services they were waiting for were in-home services. Lack of funding was the most commonly cited factor for limiting access to disability services. Although a number of factors could limit access to service in rural CDDO areas Ė such as not all services being offered within a CDDO area or services being far away, we found that these factors generally weren't perceived as a significant barrier. Overall, parents and guardians responding to our survey told us that services are better now than before the Reform Act, but respondents from rural areas were more negative in their answers. The Department seems to have a good system in place for monitoring whether developmentally disabled adults are progressing toward broad lifestyle goals such as where they want to live or what work or activities they want to do. However, the Department doesn't measure how well children are meeting their goals, even though nearly half the children in the State's developmental disability system are getting direct services. As for adult clients' progress, the Department's outcome data, our survey responses from parents and guardians and a limited file review at three CDDOs showed that most adult clients had met or were making progress toward their goals.
Verifying Information Provided by the Department of Social and Rehabilitation Services on Its Compliance with the Terms of the Foster Care Lawsuit Settlement Agreement, Monitoring Report #10
In all, 49 of the 67 requirements due for assessment were monitored this period. For those 49 requirements, the Department was in compliance with 17 (35%), and wasn't in compliance with 32 (65%). The Department met the requirements specifically related to investigating reports of abuse and neglect, managing foster care cases, and handling adoptions only 41% of the time. In addition, the Department wasn't in compliance with two important requirements related to ensuring the safety of children, and it continued to be out of compliance with many requirements related to maintaining data and systems that contribute to the good management of the foster care system. We'll follow-up on these requirements next period. Finally, of the 18 requirements that weren't monitored this period, the parties removed two from the settlement agreement, and agreed to suspend monitoring of the other 16 while they negotiated issues related to them.
Evaluating Certain Personnel and Financial Practices at the Kansas Department of Health and Environment (100-hour audit)
For a sample of bills paid in May 1999, about a fourth were paid late, but in many cases the delays were caused by the vendor, not the Department. Based on the same sample, the Department appeared to be purchasing from State contracts when appropriate. In awarding employee bonuses under three different bonus programs, the Department complied with applicable State laws and regulations. However, in the case of the Kansas Savings Incentive Program it didn't follow good management practices in making the awards. Hires and transfers of classified administrative personnel in the last two years were done in accordance with State laws and regulations. Although unclassified positions aren't required to have formal job descriptions, and although qualifications necessary to hold an unclassified job aren't spelled out in State law, unclassified administrative employees hired in the last two years appeared to be qualified for the positions they held.
Reviewing Quarterly Payments Made by Community Developmental Disability Organizations (100-hour audit)
Quarterly, the Department of Social and Rehabilitation Services provides State and federal funding to 28 community developmental disability organizations who pass part of that money on to parents and guardians to help with expenses associated with having a developmentally disabled person living in the home. Some of these parents became concerned and called legislators after a newspaper article reported the Department was freezing payments to CDDOs. Additionally, some CDDOs told parents they might not get their April checks. The Department released about 85 percent of the money it owed CDDOs within 24 hours of deciding to hold up those payments. However, it did hold back about $750,000 until April 12th, when it released that money as well. Of the CDDOs we visited, only one delayed the April checks to parents, and that delay was only a few days. Ultimately, all the CDDOs we visited paid parents the full amounts they were supposed to receive.
Reviewing the Quality of Care and Personnel Management at Kansas Neurological Institute
This audit showed mixed results regarding the quality of care at KNI. On the one hand, recent federally required reviews of KNI's operations show the level of care has improved, surveyed parents generally were satisfied with the level of care being provided, and the number of incidents and injuries at KNI has declined over the past five years. On the other hand, the number of deaths, hospitalizations, and reported instances of abuse or neglect at KNI has increased. Also, many direct-care and medical staff we surveyed thought the level of care had declined. Some direct-care staff think KNI is understaffed because they now must work with clients each day doing shopping, cooking, and laundryĖthings other KNI employees used to do. KNI didn't appear to be understaffed compared to other facilities for the mentally retarded, but at least one Kansas facility we looked at distributes its work among staff somewhat differently. We found that KNI officials generally met all the requirements for handling the personnel transactions we reviewed, but it was clear from survey responses and staff interviews that KNI has a serious morale problem related to perceived unfairness in hiring and promotions. We also found that oversight of time worked by employees is weak and has resulted in some abuses, and a lack of good records in other areas has sometimes hampered abuse investigations. Finally, during this audit we reviewed a number of allegations of mismanagement, misdeeds, and potential conflicts of interest. While some allegations appeared to be basically true, others appeared to be based on a lack of information or misinformation.
Reviewing In-Home Services to Elderly Kansans: A K-GOAL Audit of the Department on Aging
The Department on Aging does a thorough job of evaluating the services provided to elderly Kansans in their own homes when those services are paid for with Medicaid moneys. For in-home services funded through non-Medicaid programs, however, the Department does too little monitoring to provide enough information about the quality of those services. Instead, it relies heavily on the Area Agencies to evaluate the service providers they contract with. Expanded Department oversight would provide more conclusive assurance for these programs that spending is appropriate and that the quality of services is acceptable. Although the State requires most agencies and individuals that provide in-home services to be licensed or certified, some of those agencies aren't being inspected as required by law because of budget shortfalls at the Department of Health and Environment. Further, State law mandates little regulation of the people who provide "hands-on" attendant care services. Finally, two of the three Area Agencies we visited weren't tracking the complaints they received about service quantity and quality, and the Department on Aging's resolution of complaints wasn't well documented. In both situations, there's a greater risk that problems won't be resolved or that patterns of recurring problems won't be identified.
Verifying Information Provided by the Department of Social and Rehabilitation Services on its Compliance With the Terms of the Foster Care Lawsuit Settlement Agreement, Monitoring Report #9
Overall, the Department complied with 21 of the 31 requirements assessed this 9th monitoring period, and didnít comply with 10. Monitoring of an additional 33 requirements related to Case Review #2 (covering the management of foster care cases) was delayed because the Departmentís new information system wasnít accurate enough to identify the cases applicable to these requirements. The Department complied with most requirements related to investigating reports of abuse and neglect and adoption. It also was in compliance with nine long-outstanding requirements related to worker caseloads, the use of paraprofessional staff, and the development and implementation of needed services. However, the Department wasnít in compliance with two important requirements related to ensuring the safety of children, and it continued to be out of compliance with many requirements related to maintaining data and systems that contribute to the good management of the foster care system. A follow-up will be done on these requirements in the next period. In addition, the parties to the settlement agreement agreed to drop formal monitoring for 13 other long-outstanding requirements related to staffing levels, assessments of placement and service needs, case planning, and records of visitation.
Assessing How Well the Foster Care Program in Kansas is Working, Part II: Funding, Staffing, and Monitoring Issues
Original rates paid to the foster care contractors were insufficient because they were based on incomplete information about costs and unrealistic estimates about how long children would remain in foster care. The rates also didnít provide for start-up and ongoing monitoring costs. Since foster care was privatized the Department has provided the contractors with an additional $45.2 million to address funding shortfalls. Limited funding has caused contractors to look for more economical ways to provide services, and has restricted the rates they can pay service providers, which could affect the availability of those services. Some survey respondents complained that services were withheld to save money and that the quality of services provided by the contractorsí staff werenít as good as those provided in the community. Staff werenít able to assess the quality of services, but didnít find any evidence of services being withheld purely for financial reasons. Limited funding also can affect conditions in residential facilities where foster children are placed, and could result in some homes going out of business or refusing to serve foster care clients. Also, thereís a severe shortage of foster homes, and many foster parents complained that the reimbursements they received werenít sufficient to cover their costs. Contractor staff shortages and turnover appear to have stabilized, but those shortages likely were the reasons for delays in services, poor documentation, and other problems noted in the first part of this audit. The Department has designed a comprehensive system to monitor foster care. However, some of the internal reports it produces to assess contractorís achievement of outcomes arenít reliable. Also, it needs to do more to ensure that it doesnít miss out on several million dollars worth of federal reimbursements for services provided to children in foster care. Finally, we found that both the Departments of Social and Rehabilitation Services and Health and Environment needed to better document actions facilities take to address complaints and regulatory violations.
This audit of the Kansas Health Care Data Base is required by statute to look at the programís cost and benefits. The report shows annual costs to the State of about $130,000 to maintain the data base, and estimated annual costs of between $0 and $3,400 for a sample of those who provide data to the program. In addition, the report lists a number of benefits of the program to both the State and to others who use the data compiled. Finally, the report points out that the programís inventory of the Stateís health care resources isnít current.
Assessing How Well the Foster Care Program in Kansas is Working, Part I: Services and Placements
Most foster children and their families in our sample were receiving adequate and timely assessments of their needs. Initially the timeliness of assessments was poor, but it has dramatically improved since the early months of privatization. We found that about 10% of the initial assessments didnít include recommendations for needed services for children or their families, such as sex abuse counseling or parenting training. In addition, the people responsible for making decisions about foster children werenít always involved to the extent they needed to be, and didnít always receive or provide the information they needed. Children received most services recommended for them, but there often were delays in these services starting. Families received only about half the services recommended, generally because they refused to participate. Survey respondents had mixed opinions about the quality of services provided. Children in our sample didnít have a lot of stability. On average, they had been moved every 2-3 months, and had been in 3-4 different placements. Often they were moved because of their behavior. In addition, they sometimes werenít placed in the type of facility they needed to be in, mainly because the right type of facility wasnít available. Few of the children in our sample were abused while in custody, but we did find some safety issues with the system that need to be addressed.
Reviewing Substance Abuse Programs in Kansas, Part II: Assessing the Department of Social and Rehabilitation Servicesí Contracted Managed-Care Program for Substance Abuse Treatment and Prevention
The Commission hasnít adequately monitored substance abuse programs since it implemented managed care for alcohol and drug abuse services. Thatís partly because of bitter disagreements with the management organization it selected to implement the program. Some of those disagreements might have been avoided if the grant agreement had been more carefully reviewed and had clearly spelled out each partyís responsibilities. The Commission planned to resume some monitoring in July 1998, but it has done little to evaluate the success of the program on a Statewide basis, and hasnít used available information to identify areas where additional services are needed. The Commission generally has established adequate procedures for monitoring the programís finances, but it hasnít always made timely payments to the management organization. Thereís little objective data available to assess the effectiveness of managed care because the Commission doesnít have consistent and comparable information about the programís effects on clients. Based on the limited information available, it appears that expenditures for client services are down while administrative costs are up. Fewer clients are being treated on an inpatient basis, and theyíre receiving treatment for shorter periods of time. Also, the number of providers and treatment beds has increased. Treatment providers had mixed views about the system. Some praised it for its accountability, while others didnít think patients were receiving services for long enough periods of time. In addition, treatment providers complained about a poorly functioning computer system, and told us there were shortages of treatment services for adolescents and for mentally ill clients with substance abuse problems.
Verifying Information Provided by the Department of Social and Rehabilitation Serviceson its Compliance With the Terms of the Foster Care Lawsuit Settlement Agreement, Monitoring Report #8
Overall, the Department complied with 8 of the 85 requirements due for assessment this 8th monitoring period, and didnít comply with 61. For the 16 remaining requirements, the parties to the settlement agreement suspended monitoring until a future period because they havenít yet agreed on what the Department must do to comply. More specifically, the Department conceded noncompliance again this period with all requirements related to determining the safety and status of children who reportedly have been abused or neglected, and to appropriately managing the cases of children in its custody. The Department complied with most requirements related to adoption, but inappropriately screened out some bona fide reports of abuse and neglect, which meant those allegations weren't investigated as required. It also was out of compliance with several training requirements, and continued to be out of compliance with many requirements related to maintaining data and systems that contribute to the good management of the foster care system. We'll follow up on these areas in our next report.
Reviewing Substance Abuse Programs in Kansas, Part I: Identifying State Agencies That Receive Substance Abuse Funding, and Reviewing Program Coordination Options
The audit showed that more than 20 State agencies receive funding for substance abuse related programs, most of which are operated at the local level. In 1997, more than $35 million was spent to operate and administer these programs. A few substance abuse programs fund similar services, but there seemed to be good reasons for keeping them separate. Generally these programs were directed at different audiences, or their funding was earmarked only for a specific agency. Although other options exist, a Statewide policy council might be the best way to increase policy coordination among all these agencies.
Assessing Whether State Regulation of Meat Processing Plants is More Stringent and Costly than Federal Regulations Require
New federal regulations adopted in July 1996 are less stringent on meat and poultry plant operators than the draft regulations initially proposed in 1995, and appeared to take small plantsí concerns into account. These new regulations, which the Department of Agriculture incorporated by reference into the Kansas Administrative Regulations, required plant owners to implement sanitary operating procedures and testing requirements by September 1997, and will require them to develop food safety systems by January 2000. A number of factors contributed to the anxiety and uncertainty about these new requirements, including inaccurate and conflicting information about the impact of those new requirements on Kansasí small plants, uncertainty about implementation dates, and meat inspectorsí inability to answer plant ownersí basic questions about some of the new requirements. Itís still difficult to know how these new requirements will affect Kansasí small meat plants. Plant owners will incur some additional costs, and some may choose to go out of business, but the nature and number of such changes is likely to be less significant than the Legislature initially was led to believe. Finally, most plant owners we surveyed said they generally were satisfied with the fairness of their inspectors, but some expressed concerns about inspections being inconsistent across State regions or between inspectors.
Verifying Information Provided by the Department of Social and Rehabilitation Services on its Compliance With the Terms of the Foster Care Lawsuit Settlement Agreement: Report #7
We concluded the Department had complied with 12 of the 82 requirements reviewed during this 7th monitoring period, and hadnít complied with 66. For the 4 remaining requirements, we couldnít assess the Departmentís compliance because the parties involved in the settlement agreement were still negotiating issues related to these requirements. This period, the Department conceded noncompliance with all the requirements related to determining the safety and status of children who reportedly have been abused or neglected (Case Review 1), and to appropriately managing the cases of children in its custody (Case Review 2). The Department was in compliance with most of the requirements related to adoption (Case Review 3). The Department screened out some bona fide reports of abuse and neglect, which meant those allegations werenít investigated as required. It also continues to be out of compliance with many requirements related to maintaining data and systems that contribute to the good management of the foster care system. Weíll follow up on all these areas in our next report.
Reviewing the Department of Health and Environmentís Regulation of Child Care Facilities and Family Day Care Homes
Many of the regulatory activities relating to child care in the State arenít being adequately carried out by the local health departments and private contractors to whom the work has been delegated by the Department. Inadequate staffing and training apparently have contributed to these problems. At the State level, backlogged information within the Department is causing significant delays in getting criminal background checks for staff in larger facilities. The Departmentís enforcement efforts havenít been adequate to ensure that children are sufficiently protected once regulatory violations have been identified. The Departments of Social and Rehabilitation Services and Health and Environment seem to be working together to meet possible demands placed on the Stateís child care system because of welfare reform. However, the Department of Health and Environment (as well as local health departments) may not be positioned to effectively handle any additional work load resulting from welfare reform because of staffing inadequacies. Current child care openings across the State may be adequate to meet the estimated 2,700 additional welfare children who could need child care over the next three years, but those slots may not be available in the right places, or for the types of children who need care.
Verifying Information Provided by the Department of Social and Rehabilitation Services on its Compliance with the Terms of the Foster Care Lawsuit Settlement Agreement, Monitoring Report #6
We concluded the Department had complied with 11 of the 78 requirements reviewed during this sixth monitoring period, and hadnít complied with 60. For the remaining 7 requirements, we couldnít assess the Departmentís compliance because the parties involved in the settlement agreement were still negotiating issues related to these requirements, or the Departmentís Monitoring Unit hadnít completed its work. This period, the Department conceded noncompliance with all the requirements related to determining the safety and status of children who reportedly have been abused or neglected (Case Review 1), and to appropriately managing the cases of children in its custody (Case Review 2). The Department was in compliance with most of the requirements related to adoption (Case Review 3), but it continues to be out of compliance with many requirements related to maintaining information and systems that contribute to the good management of the foster care system. A follow-up on all these areas will be done in the seventh monitoring period.
Assessing the Extent to Which License Applications and Renewals Are Delayed at the Behavioral Sciences Regulatory Board (100-hour audit)
In fiscal year 1996, it took the Behavioral Sciences Regulatory Board an average of 77-197 days to issue a license. Most of the delays were caused by applicants submitting incomplete applications, failing to show up for exams, not passing the exam, not complying with licensing requirements, and the like. We found five cases in which delays occurred because the Boardís staff didnít notify applicants of the Boardís actions regarding their applications in a timely manner. Board staff indicated the Boardís review of several cases occurred during a very busy time, and these cases slipped through the cracks. We also found that the Board has taken several steps to speed up the licensing process including more frequent Board meetings and more frequent testing for social workers. Finally, it appears that the Board could speed up the licensing process if it had better computer capabilities.
Reviewing the Effectiveness of the Domestic Violence Laws in Kansas
A 1991 State law focuses on domestic violence as a crime, and requires law enforcement centers to report all incidents of domestic violence to the Kansas Bureau of Investigation. For a variety of reasons, however, the Bureauís statistics arenít complete. Law enforcement officers, prosecutors, judges, and program directors reported that the number of domestic violence calls hasnít changed since 1991. The number of arrests has risen since then, apparently because of the lawís mandatory arrest provision which has increased the courtsí involvement, and increased the likelihood that abusers will be referred to programs that might help them. People we spoke with pointed out that some judges arenít adapting as well as others to the viewpoint that domestic violence is a crime, and suggested additional training to improve the situation. Program directors report that victims of domestic violence are faring better; however, because of the mandatory arrest requirement, some victims wonít call the police because they donít want the offender arrested. People we talked with offered numerous recommendations and suggestions to help decrease or stop domestic violence in Kansas.
Reviewing the Department of Social and Rehabilitation Servicesí Efforts to Privatize Government Services (100-hour audit)
State law allows agencies to deny contracts to bidders who have certain criminal convictions. However, federal and State laws and regulations generally only provide an agency with access to in-State conviction information. The Department hasnít established any agency wide procedures for conducting criminal history checks on potential contractors. Although it took reasonable steps to learn about criminal convictions for three or four major contract areas we reviewed, additional steps could have been taken. We also noted that the Division of Purchases needs to issue guidance to agencies regarding what to do to check criminal histories.
Verifying Information Provided by the Department of Social and Rehabilitation Services on its Compliance with the Terms of the Foster Care Lawsuit Settlement Agreement Monitoring Report #5
We concluded the Department had complied with only 8 of the 81 requirements reviewed during this fifth monitoring period, and hadnít complied with 24. For the remaining 49 requirements, we couldnít assess the Departmentís compliance because the parties involved in the settlement agreement generally hadnít resolved their ongoing disagreements about interpretations of the settlement language, or hadnít decided how compliance should be measured. When we looked back at the Departmentís compliance rate over time, we noted it has now complied with most administrative types of requirements, but the Department continues to be out of compliance with almost all requirements related to determining the safety and status of children who reportedly have been abused or neglected. It also continues to be out of compliance with almost all ďfoundationalĒ requirements related to foster care placement and service needs, staffing, and information needs. Finally, because of the problems described earlier, we donít yet know whether the Department has complied with the nearly 40 requirements relating to appropriately managing the cases of children in its custody. Weíll follow up on all these areas in the sixth monitoring period.
Verifying Information Provided by the Department of Social and Rehabilitation Services On Its Compliance With the Terms of the Foster Care Lawsuit Settlement Agreement, Monitoring Report #4
We concluded the Department had complied with 17 of the 47 requirements reviewed during this monitoring period, and had not complied with 23 of those requirements. The areas of noncompliance related to protective services, the assessment of needs for services and placements, information on placement providers, staffing, and information systems. We couldnít determine whether the Department was in compliance with seven additional requirements, related to protective services, assessment of needs for services and placements, information on placement providers, and staffing, because the Department and Childrenís Rights, Inc., havenít yet agreed on what the Department can do in future monitoring periods to resolve the partiesí ongoing disagreement regarding compliance. All of these areas will be followed up during the next monitoring report.
Reviewing the Department of Health and Environmentís Regulation of Nursing Homes
The Departmentís system for handling complaints is well designed. However, we thought about 10% of the complaints we reviewed were more serious, and the Departmentís staff should have given them a higher investigation priority. Given the priorities assigned, the Departmentís staff investigated most complaints on time, and those investigations appeared to be thorough. However, a recent decision to rely on nursing homesí own investigations of certain complaints may not comply with State law. The Departmentís nursing home inspection system also is well designed and should uncover significant violations of laws and regulations. All but a handful of homes were inspected as often as required, and inspections for homes that werenít timely were only a few days late. Inspections we looked at appeared to be complete and comprehensive. The Health Care Financing Administrationís 1995 review of Kansasís inspection program generally was positive, but it noted the Department needed to improve its identification of regulatory violations. The Departmentís efforts to get problem homes to correct deficiencies werenít always effective, in part because it didnít always issue correction orders when it should have, it didnít make full use of the fining authority it has, and it didnít appear to have appropriate remedies to deal with less-serious infractions.
Verifying Information Provided by the Department of Social and Rehabilitation Services on Its Compliance with the Terms of the Foster Care Settlement Agreement: Monitoring Report #3
We concluded the Department had complied with 16 of the 45 areas reviewed during this monitoring period, and had not complied with 18 of those requirements. The areas of non-compliance related to protective services, the assessment of needs for services and placements, staffing, training, and information systems. In addition, the Monitoring Unit reported that the Department wasnít in compliance with six other requirements. However, we concluded the Unitís assessment couldnít be relied on because the reading of case files wasnít accurate enough to determine whether the Department was in compliance or not. Finally, we identified five areas, related to protective/medical services, the revised Family Emergency Assistance Program, Flexible Fund Dollars, equitable workload distribution, and maintaining staffing levels, where we werenít able to determine whether the Department was in compliance, primarily because the Department and Childrenís Rights, Inc., hadnít yet agreed on what the Department was required to do to comply. All of these areas will be followed up during the next monitoring report.
Determining Whether Kansasí Medicaid Program Makes Maximum Use of Third-Party Insurers
The Medicaid computer system has a number of good edits built into the system. Out of about $875 million in claims processed during calendar year 1995, those edits reportedly identified more than $69 million worth of claims that needed to be billed first to other insurance. We looked at a sample of claim where the Medicaid client had other insurance, but the other insurance didnít pay any of the claim. We found a significant number of cases were the health-care providers didnít bill other insurance companies because they werenít aware other coverage existed. In other cases, the providers didnít handle claims according to program regulations. Based on our sample, if other insurance paid only 5% of the estimated number of problem claims, Medicaid might save $10,000-$460,000 during fiscal year 1996. One reason so many claims hadnít been billed to other insurance was that the Department didnít have adequate procedures to identify when Medicaid recipients have other insurance, and didnít always enter insurance information onto the computer system on a timely basis. We also found that EDS hadnít done some of the reviews it was required to do to make sure claims were handled appropriately, and that EDS and the Department havenít aggressively followed up to collect potential overpayments. Finally, we found that Blue Cross and Blue Shield could have a conflict of interest when it takes over as the Departmentís fiscal agent later in 1996.
Examining Child Support Enforcement Activities in Kansas
In fiscal year 1994, Kansas collected about 55% of the current child support owed, about the same as the national average. However, within SRS area offices, this rate varies from 41% to 67%. Shortcomings were identified in about 1 in 5 cases we reviewed, including six that simply ďfell through the cracks.Ē The report identified factors that hamper collection efforts in Kansas, such as high caseloads, lack of equipment, the lack of access to information to locate absent parents, difficulty in getting management information from the Departmentís computer system, and conflicts between the courts and the Department.Kansas spends more than the national average and nearby states for each dollar of child support collected. No comparisons on the cost-efficiency of the various area offices could be made because no data were available. The Department spent about the same per dollar of child support collected as the court trustees on enforcement services, but what it costs the Department to have court trustees handle enforcement services varies significantly. Except for some duplication between the Department and the district court clerks, no inherent inefficiencies in the Programís structure were apparent. Other states contract with private agencies for a more extensive range of child support services than Kansas. It appears Kansas may be able to reduce its expenditures for enforcement services in certain areas of the State where those services arenít being provided as efficiently as they could be.
Verifying Information Provided by the Department of Social and Rehabilitation Services On Its Compliance with the Terms of the Foster Care Lawsuit Settlement Agreement--Monitoring Report #2
We concluded the Department had complied with 17 of the 26 areas reviewed during this monitoring period, and with all four areas we followed-up on from the first monitoring period. The areas of noncompliance included not addressing the effectiveness of the Family Preservation unit, the statewide and regional placement needs, or identifying strategies to assist in the development of resources in the needs assessments for preventive services, placements, and services; not developing caseload guidelines; not evaluating the effectiveness of paraprofessional staff; not maintaining accurate and reliable information on the FAME computer system; and not requesting certain minimum financial resources. We also identified two areas, the maintenance of flexible fund dollars and the determination of youth service workersí caseloads, where we were unable to determine whether the Department was in compliance. All of these areas will be followed-up on in the next monitoring report.
Examining Problems with the University of Kansas Medical Centerís Heart Transplant Program
Four hearts were turned down because of inadequate nurse staffing in May and June 1994, partly because of a shortage of nurses, and partly because the cardiothoracic surgeon had a fundamental disagreement with the nurse manager about the types of nurses who should care for his patients. Between July 1994 and March 1995, 17 hearts were turned down because of a lack of surgeons. Patients who were on, or added to, the waiting list were not informed that hearts were being rejected for non-medical reasons. Top officials of the Medical Center were aware of problems with the heart transplant program, and several knew that donor hearts were being rejected for non-medical reasons. However, these officials failed to recognize how serious the problems were and failed to take appropriate action to deal with them. A total of 14 people were on the waiting list during the period when no heart transplants were being performed. Four were removed from the list, three received transplants at other hospitals, three died, and four are on waiting lists at other hospitals.Similar problems could happen in other departments at the Medical Center because individuals who knew about problems failed to take appropriate steps to ensure the problems were effectively resolved. In addition, the lines of authority and responsibility have not been clearly communicated to Medical Center staff.Finally, heart transplants still would be available at St. Luke's Hospital in Kansas City, Missouri, if the Medical Center permanently closed its heart transplant program, although there would be some financial and other impacts on the Medical Center.
Examining Contract Oversight by the Department of Social and Rehabilitation Services
Most procedures for ensuring that vendors are providing agreed-upon services have been established by individual commissions and divisions, and they vary from one to another. For nearly one-fourth of the 62 contracts and grants we reviewed, it appeared the Department didnít get the services it expected, or it was not possible to tell. Procedural weaknesses we noted that can allow grantees to be paid even though services havenít been provided include the failure to require vendors to submit documentation of the services provided, failure to use that information when it is provided, and failure to make payments contingent on providing a certain level of service for some grants. We also noted that grant expenditures often didnít receive a final review until long after the grants were over, which could make it more difficult to recover moneys that grantees owed the Department.
Reviewing the Department of Health and Environmentís System for Assessing the Impact of Rules and Regulations Mandated by the Federal Government: A K-GOAL Audit of the Department of Health and Environment
In general, the Department did not always accurately and completely assess the economic impact of new regulations. The sample of economic impact statements we reviewed did not always contain the information required by law. For example, the economic impact statement prepared for underground storage tank regulations excluded about $40 million in costs for the federally mandated portion of the regulations. The economic impact statement related to clean water regulations underestimated the impact on industries by at least $10 million. These problems can be attributed to the agencyís lack of standardized procedures, its policy of excluding certain costs from the impact statements, and its failure to involve all those affected by the regulations in the process.
Reviewing the Implementation of Kansasí Waste Tire Disposal Program: A K-GOAL Audit of the Department of Health and Environment
The Department of Health and Environment has established adequate regulations for the Waste Tire Disposal Program. However, the Department issues permits to operators who havenít met all the Stateís requirements, issues permits without inspecting waste tire facilities, allows some facilities to continue operating in apparent violation of State laws and regulations, doesnít routinely inspect facilities or conduct follow-up inspections when problems are identified, and makes no attempt to inspect out-of-State transporters who hold Kansas permits. In addition, the Department needs to improve its handling of permit fees collected from waste tire operators. The Department also provides grant moneys to local units of government to help clean up, dispose of, or recycle waste tires in Kansas. However, the Department has not adequately monitored grants to ensure that grant moneys are being spent according to grant agreements and regulations.
Reviewing the Department of Social and Rehabilitation Servicesí Efforts To Computerize Alcohol and Drug Abuse Treatment Information (100-hour audit)
In 1992, the Department of Social and Rehabilitation Services set out to modernize an existing computer system designed to collect treatment information about alcohol and drug abuse patients. By 1994, the project was not complete, in large part because it was poorly managed. Upper-level management underestimated the complexity of the project, assigned staff to the project on a part-time basis, allowed the project to proceed without an adequate plan or time budget, and exercised little project oversight. The manager assigned to the project was not well organized, did not develop an adequate workplan, and neglected to hire all the staff the Department had authorized. The Department did not violate any purchasing laws in January 1994 when it hired an outside firm to evaluate the project, nor did we find any evidence of favoritism in hiring the same firm to complete the project.
Reviewing Security and Management Issues at the Youth Center at Topeka
Officials in the Department of Social and Rehabilitation Services have made strides in correcting the numerous, major deficiencies identified in our 1989 audit of the Youth Center at Topeka. However, many of those same issues remain as problems in 1994. The existence of a perimeter fence has significantly reduced the number of escapes from the Youth Center, but many other security weaknesses (including staffing shortages) continue to present risks of harm to the staff and students. The Youth Center has given violent offenders various kinds of off-campus passes, a practice that presents undue risks to the public. Our survey of Youth Center staff indicated little confidence in the upper management of the Center. Management officials need to correct problems with criminal record checks on new employees, evaluations of employees, and recordkeeping. We found the Department has not adequately managed a four-year federal grant to ensure that federal moneys were spent properly and that the grantís objectives would be met. Finally, other states have tried various new programs for rehabilitating juvenile offenders, but their effectiveness has not yet been proven.
Verifying Information Provided by the Department of Social and Rehabilitation Services On Its Compliance with the Terms of the Foster Care Lawsuit Settlement Agreement--Monitoring Report #1
We concluded the Department had complied with 13 of the 17 areas reviewed during this monitoring period. The areas of non-compliance included maintaining specified levels of funding for an emergency shelter grant program, for a flexible dollars fund, and for various family services. In these cases, the documentation the Department provided either was insufficient to determine whether these programs and services were being maintained at the levels required by the settlement agreement, or it showed the Department had fallen short of meeting those specified minimums. The Department also was not in compliance with the case-handling requirements related to one of the plaintiffs named in the lawsuit. All of these areas will be followed up on in the next monitoring report.
Reviewing the Department of Social and Rehabilitation Servicesí Procedures for Handling Complaints Against Foster Homes
The Department has not established adequate checks to ensure that licenses are not issued to applicants with past criminal records or other problems that might present risks to foster children. Nearly 20% of the licensing files we reviewed did not contain required assessments of the applicant and his or her family, and many had inadequate character reference checks. About 30% of the abuse and neglect complaints against foster homes we reviewed were not adequately investigated. The most common shortcomings were delays in getting investigations started and failure to interview all appropriate persons. The Department did not always follow up to ensure that foster parents completed additional training or made corrections they agreed to make following an abuse investigation. In nearly half the cases we reviewed, the Department did not take adequate steps to determine whether foster parentsí natural or adopted children were safe. The problems we found stemmed from inadequate Department policies, failure to follow existing policies, and failure to document some actions.
Reviewing the Transfer of Mentally Retarded Patients from State Institutions to Community Living Facilities
The State has established goals to reduce mental retardation hospital resident populations and staffing levels. Although the State has limited admissions and transferred more than 250 hospitals residents to community settings since fiscal year 1991, hospital populations remain higher than planned. One reason is that the Stateís placement approach depends on developing individualized community services and placements, many of which are not readily available. Community centers primarily cite resource inadequacies as the reason why services and placements are not being developed rapidly. Finally, per-person costs for community placements appear to be less than per-person hospital costs. However, even though people are being transferred from hospitals to community settings, total State hospital costs are not going down. In fact, the State will not realize any significant cost savings from transferring individuals to community settings until a hospital is closed.
Reviewing the Contract for the Medicaid Management Information System (100-hour audit)
The Departmentís contract with EDS Federal does not attempt to define specific program modifications that are included within the price of the contract and those that will require additional payment. Any changes that were not agreed to at the time the contract was signed, or that could not be completed in the time available from the 11 on-site systems engineers, have been handled as contract amendments at an additional cost to the Department. The 22 amendments to the current contract have contributed $9.3 million of the total $53 million cost. Because the Department does not have good information about how the systems engineers spend their time, it cannot ensure it is getting what it pays for. Other states we contacted generally carry out more monitoring of their systems than Kansas does.
Examining Potential Duplication and Overlap in Programs for Kansasí Aging Population
The Department on Aging and the Department of Social and Rehabilitation Services fund or provide essentially the same long-term-care services, but offer their programs to different groups of elderly individuals. When more than one agency provides or funds essentially the same services, there is considerable duplication of administrative effort, which can result in client confusion, clients falling through the cracks if coordination is inadequate, and in money being spent for administrative activities that otherwise could be spent for direct services. The State might gain some cost efficiencies from consolidating all its long-term-care programs in one agency, as two comparison states have done, but some disadvantages also would result. For an individual client, the State generally can provide home and community-based long-term-care services at a lower cost than nursing home services. However, the total cost to the State of providing those services may not decrease significantly, particularly in the short-run, because statesí new long-term-care programs tend to expand the number of people eligible for services, and because the Medicaid-Waiver Programs may be serving elderly individuals who would not be getting services in the absence of such Programs.
Reviewing the Process for Providing Health Insurance Benefits for State Employees
Premiums for State employee health insurance in Kansas were generally higher than in nearby states we reviewed. Variations in deductibles and co-insurance amounts employees must pay make it difficult to make blanket statements about how our benefits compare, but generally Kansas' benefits compare favorably. Also, Kansas had the lowest annual maximum out-of-pocket costs for employees who use health insurance a lot. Steps the State Employees Health Care Commission has taken to obtain benefits at the lowest cost include things like soliciting multi-year bids and negotiating rates before signing health insurance contracts. All State employees do not have equal access to the same insurance plans across the State. But employees covered under the State's conventional health insurance plan have access to most general practice doctors, dentists and hospitals in their cities. Finally, if the Regents' employees had been a separate group within the 1993 State employee health insurance plan, that group's claims experience would have resulted in 18 percent lower premiums for that group and 14 percent higher premiums for other employees. When such differences have occurred in the past the Health Care Commission has acted to equalize premiums for all employees.
Reimbursement for Services Provided by the Kansas Bureau of Investigation
In fiscal year 1992, the Bureau provided record checks and laboratory services to local law enforcement and other criminal justice agencies at a cost to the State of about $2.2 million. Like other states, the Bureau has a policy of providing services to these agencies at no charge. The Bureau also provided about 120,000 record checks to non-criminal-justice agencies at a cost of about $650,000. Like other states, the Bureau charges a fee for these services. Because the Department of Health and Environment refuses to pay for its record checks, other agencies end up paying higher fees than necessary and the Bureau still does not collect enough money to fully recover its costs.
Reviewing the Accuracy of Job Placement Information the Department of Human Resources Is Reporting About the Kan Work Program (100-hour audit)
Although the Department of Human Resources records some information about clientsí employment status after-the-fact, it does not appear that those actions were intended to be misleading. In most cases we reviewed, the Department could not have conducted follow-up activities when required because client referrals from the Department of Social and Rehabilitation Services were late. Nevertheless, conducting follow ups late may affect the interpretation of program information, client employment assistance, and program effectiveness. In addition, the Department of Human Resources has job placement follow-up information that the Department of Social and Rehabilitation Services could use to track job-retention rates and provide the Legislature with meaningful program information. However, the Department of Social and Rehabilitation Services does not ask for this information.
Reviewing Selected Issues Related to Workersí Compensation
For the most part, Kansasí workersí compensation benefits are neither high nor low when compared with other states. Based on available information, Kansasí premiums also were slightly below the median for other states and increased at about the same rate as premiums nationally. Over the past few years, laws have been enacted that increased maximum payments for disabilities and death benefits, and required vocational rehabilitation to be provided for many workersí compensation cases. No information exists to determine their exact cost impact. Other states have enacted a number of measures aimed at reducing litigation, controlling medical costs, reducing fraud and improving workplace safety. Those measures include using arbitration services, implementing medical fee schedules, performing utilization and bill reviews, creating fraud hotlines and investigation units, and overseeing workplace safety. Finally, we found that workersí compensation agencies in some states have developed extensive data collection systems that allow them to answer basic questions about workersí compensation, such as which injuries are most frequent or most expensive.
Reviewing Fee-Funded Regulatory Agenciesí Programs for Impaired Licensees
Total expenditures for the programs we reviewed have more than tripled since 1988, primarily because of increases in programs, participants, and in staffing levels and salaries. The licensing boards generally did not have adequate controls to ensure that program funds were spent for the intended purposes. For nearly 80 percent of the cases we reviewed, we determined that the programs were effective. But a significant number of cases, particularly in the physiciansí program, lacked the documentation for us to determine whether they were effective. We found only six cases where we determined that program staff did not take appropriate action. Also, in a few cases, the licensing boards should have taken some action but did not. Finally, the programs that appeared most cost-effective made heavy use of volunteers and did not charge the licensing boards for administrative expenses.
Examining the Effectiveness of the Kan Work Program
Clients in the KanWork Program got more jobs and earned more money than clients who were not participating in the Program, but still did not earn enough to stay off welfare. Over the two-year period we reviewed, KanWork did not appear to make a significant difference in the number of people getting off welfare. However, the Program may need to be viewed over a longer time period to show results. Coordination between the Departments of Social and Rehabilitation Services and Human Resources staff who work with clients is good, but coordination and cooperation between upper-level management of the agencies is poor. The KanWork Program generally conforms to all major federal regulations and State laws. However, Department of Social and Rehabilitation Services staff have not followed all procedures for operating the Program.
Reviewing How the State Supervises Potentially Violent Mental Patients at Topeka State Hospital
The audit found Hospital and Department officials thought that closing the Awl Unit would allow them to reduce patient populations and staff, accommodate budget cuts, and maintain the level of patient care needed to keep the Hospital's federal certification and funding. In fact, anticipated reductions in patient population never materialized because few Awl patients were transferred to Larned State Hospital as originally intended. Instead, most Awl patients were placed in other wards at Topeka State Hospital according to a transfer list prepared by clinical staff. Even though the introduction of these potentially dangerous patients into other wards represented an increased level of risk to Hospital staff and patients, Hospital officials took no immediate actions to lessen that risk. After the murder of a Hospital employee in February 1992, officials sought and received funding for additional security guards, lighting, and equipment. However, critical issues of low staffing, inconsistent compliance with security-related procedures, and an inability to segregate dangerous patients remain to be addressed.
Reviewing State-Funded Medical Scholarships in Kansas
Since the inception of the Kansas Medical Scholarship Program, requirements have become more restrictive regarding designated areas of practice, types of medical specialties, and repayment provisions. In 1986, the emphasis of the Program changed from distributing physicians to underserved areas to placing primary-care physicians into rural areas. Since 1978, more than $36 million in medical scholarships has been awarded to 1,476 students. Approximately 46 percent of those recipients have fulfilled their service obligations. Many graduates are fulfilling their obligations under provisions of the law that allow them to practice in urban areas. The Program appears to be achieving the goals of retaining more Medical Center graduates in Kansas and distributing more doctors to underserved areas. In future years, because fewer than 35 new scholarships are being awarded annually, significantly fewer doctors will be distributed to underserved or rural areas as a result of the Program.
Reviewing Procedures and Staffing for Child Abuse Cases in Douglas County (100-hour audit)
Child abuse and neglect cases handled by the Department of Social and Rehabilitation Services' Douglas County office have increased in recent years, but with the addition of several new social worker positions, individual caseloads have generally remained stable or declined. Douglas County officials told us that the social worker and a supervisor would make the initial decision about removing a child from home, based on a factors such as the child's safety and the parents' ability to protect and care for the child. When families are at-risk of abusing or neglecting their children, social workers in Douglas County assess the specific factors (such as a parent's substance abuse or inappropriate disciplinary methods) that may be contributing to mistreatment of a child, then try to provide services that will help the family address its problems. We did not find any indication that the procedures in place in Douglas County were in conflict with the Department's procedures or with State law.
Kansasí Foster Care Program, Part IV: Summary Report
This report summarizes the findings and recommendations from the series of audits the Division conducted of the State's foster care program, plus an audit of the handling of reports of child abuse and neglect. The latter report was included because children can be placed in the State's custody if there is evidence they have been abused or neglected. This summary report discusses the need to place greater emphasis on preventing children from coming into the overburdened foster care system.
Review of State Grants to the Pittsburg Family Planning Clinic (100-hour audit)
Although State grant moneys were spent for the purposes provided for in the grant contracts, the Clinic's arrangement with Crawford County for the County to process and pay its payroll and other bills resulted in considerable confusion and in a lack of adherence to two provisions of the grant contract. One provision calls for establishing and maintaining an accounting system that records and reports specific financial information, and the other calls for single audit coverage of the organization in accordance with federal requirements. The report recommends that the Department of Health and Environment work with the federal granting agency to ensure that any deficiencies regarding previous audit coverage of grants made to the Family Planning Clinic in Pittsburg are resolved.
Kansasí Foster Care Program, Part III: Staffing and Funding Levels
The number of social workers assigned to foster care has not kept pace with the growing number of children in the Department's custody. Although the Department could not provide information showing changes in caseloads over time, we estimated that average foster care caseloads were more than double the standard proposed by the Child Welfare League of America. It did not appear that funding affected placement and service decisions. The actual limiting factor appeared to be the lack of appropriate placements and services. Most foster care providers we surveyed thought the reimbursements they received from the State did not cover their costs, but this did not appear to be a major reason for them leaving the system.
Kansasí Foster Care Program, Part II: Placements and Delivery of Services
On average, the 200 children in our sample were in the Department's custody for two years and had 4-5 placements each. The majority of these placements lasted six months or less, and were in foster homes or parents' homes. About one-fifth of all placements were not made as recommended, apparently because recommended facilities often were not available. Two-thirds of the children eventually were reunited with their families. Most children and families received services--such as individual or family counseling or clinical evaluations--but the Department did not always recommend services for those who needed them. Also, recommended services often were not started or completed. Many controls and procedures for the foster care system seemed to be adequate, but the Department lacked basic program management information.
Assessing How Effectively the Department of Social and Rehablilitation Services Handles Reports of Child Abuse and Neglect
The number of child abuse or neglect reports investigated by the Department of Social and Rehabilitation Services increased by about 34 percent between fiscal years 1980 and 1990, although the number confirmed declined. Most Department investigations reviewed appeared to be timely and adequate, but about 20 percent were not. Some reports were not investigated at all. Many families that were at risk of abusing or neglecting their children did not receive preventive family services from the Department. Family services were not always successful in preventing out-of-home placements, or in reducing the risk of subsequent abuse or neglect, but in many cases the participating families were uncooperative. Department procedures and management controls were not always effective nor followed. Finally, Department staff surveyed indicated they do not always have adequate resources to do their jobs, which could have contributed to problems noted during the audit.
Kansasí Foster Care Program, Part I: An Overview of the Program
Over the past 10 years, the law has emphasized providing family services to prevent foster care placements rather than maintain children in foster care indefinitely. The number of children in the Department of Social and Rehabilitation Services' custody has risen by more than 20 percent the last three fiscal years. Although the number of people licensed to provide foster care generally has kept up with this increase in children, the number of social workers has not increased correspondingly.The total cost of the foster care program is unknown because the Department's budgeting and accounting system counts only direct payments to foster care providers; it excludes the salaries of social workers who manage the cases. We also noted problems with the accuracy of figures reported by the Department, and cautioned readers accordingly. During the last three years, the amount spent on direct payments to foster care providers increased by about 56 percent (35.2 percent when adjusted for inflation). The amount the Department spends per child varies considerably across the State.
Review of the Department of Social and Rehabilitation Servicesí Grant to Court Appointed Special Advocate of Shawnee County, Inc. (100-hour audit)
The Department of Social and Rehabilitation Services made a grant to Court Appointed Special Advocate of Shawnee County, Inc., to pay travel costs for members of the Permanency Planning Task Force. By making this grant instead of using the normal State expenditure processes, the Department of Social and Rehabilitation Services made State financial information inaccurate and increased the risk of improper use of State moneys in return for questionable savings in processing time. Because the Department did not conduct certain grant oversight procedures, about half of the grant moneys were not handled in accordance with the grant requirements.
Examining Increases in Expenditures for Adult Care Homes
Between 1982 and 1988, Medicaid reimbursements to all adult care homes increased by 46 percent, noticeably less than the 65 percent increase in total reported costs for those homes. The Medicaid reimbursement system has changed in ways that have both increased and decreased State costs. The removal of the limit on total costs by the Department of Social and Rehabilitation Services caused State costs to increase, and a change in the way property costs were reimbursed led to a decrease in State costs. For adult care homes in our sample, increases in health care costs--primarily because of increases in salaries and benefits for nurses and aides--had the largest impact on cost increases.
Comparing Budgeted and Actual Expenditures for Funerals and Burials for Public Assistance Recipients
During the first half of fiscal year 1990, the Department of Social and Rehabilitation Services reduced about one-fourth of its burial assistance payments because the decedent's estate had assets available to help reduce the Department's contribution or because the decedent's family had resources that exceeded the limits established by the Department for full burial assistance. It appears that funeral home and cemetery reimbursements are handled in about the same way as the Department's reimbursements for doctors and similar providers, although other providers may not have to attempt to collect funds from estates as often as funeral homes. The burial assistance program's actual expenditures have exceeded its appropriations each year since fiscal year 1986, and these deficits were always met by transferring funds from other assistance programs to the burial program.
Department of Social and Rehabilitation Servicesí Provision of Alcohol and Drug Abuse Treatment Services
Most facilities provided all or substantially all the alcohol and drug abuse treatment services they proposed to provide with the grant moneys supplied by the Department of Social and Rehabilitation Services' Division of Alcohol and Drug Abuse Services. For five of 27 grants we reviewed, the grantees failed to provide the levels of service they proposed, although each provided some portion of those services. Of those five, the Valley Hope program provided the least service in proportion to its grant objectives. Outpatient programs at these five facilities received only about eight percent of the total funds for the 27 grants. All five facilities have had their grants renewed for the current fiscal year.
Caseload Increases That May Be Attributable to the Department of Social and Rehabilitation Servicesí New Comprehensive Automated Eligibility and Child Support Enforcement System (100-hour audit)
The Department's revised fiscal year 1990 caseload figures for the Aid to Dependent Children Program were primarily based on projected expenditure data, not on caseload information accumulated by the new computer system. Although Department officials initially thought the old and new computer systems may have counted caseloads differently, they later concluded there were no differences between how the two systems accumulated per-month caseload figures. As a result, it appears that the new computer system does not account for any of the increase in caseloads that the Department recently projected for fiscal year 1990.
Comprehensive Automated Eligibility and Child Support Enforcement System (CAECSES)
The Comprehensive Automated Eligibility and Child Support Enforcement System was initially expected to be completed in two years at a cost of $11 - $13 million. The System took an additional year to complete, primarily because the Department of Social and Rehabilitation Services underestimated the amount of time needed to add the medical benefits component to the System. The System cost more than twice as much as expected because early estimates did not include all costs of developing such a system, and underestimated the hardware requirements and the number of State staff involved in the System's development. The State's share of System costs rose because of unanticipated financing costs and the lack of a federally approved link with the judicial branch. The ongoing cost of operating the System will be substantial. Some problems remain with its operation, although the Department is working to resolve them.
Drug Acquisitions Under the Medical Assistance Program
The Department of Social and Rehabilitation Services' contract system for acquiring drugs for the Medical Assistance Program appears to be cost-effective. For seven drugs under the contract system or other limitations during fiscal year 1989, we estimated that drug costs between September 1988 and February 1989 were approximately $230,000 less than they would have been without the system. Three of the seven drugs accounted for about 97 percent of these savings. Medical assistance recipients who had taken the seven drugs, as well as physicians who had prescribed the drugs, generally reported that the drugs were adequate to treat the appropriate medical condition. Finally, pharmacists who dispensed the drugs to recipients generally did not like the system. The pharmacists' concerns, however, were business-related and generally did not involve the quality of patient care.
In general, the audit showed that the Youth Center at Topeka is not equipped to provide the level of security needed for the individuals being placed there. The lack of a fence around the campus as well as weaknesses in the physical facilities and staffing levels may have allowed students to escape rather easily. Also, Youth Center officials do not take into account all available information such as a studentís runaway history when determining the level of supervision a student needs. More importantly, a lack of strong management at the facility has created an atmosphere where poor performance is tolerated, staff morale is low, and overall security is not as strong as it should be.
Improving the System for Providing Mental Health Programs and Services in Kansas
The system in Kansas for providing mental health services anticipates that mentally ill people will be served in the communities when warranted. However, gaps and insufficiencies in community services prevent the system from working as intended. To provide comprehensive, integrated mental health services that minimize use of the State mental health hospitals, the Legislature will need to consider options in the areas of providing additional funding for community services for the seriously mentally ill, shifting resources from the State mental hospitals to community services, and establishing a single authority over the system. The report also makes recommendation to the Department of Social and Rehabilitation Services to improve its screening and aftercare services.
Reviewing the Health Care Plan for State Employees, Part II: Controls and Use
State employees covered by the traditional plan had higher use rates than all Blue Cross subscribers State wide, but when all State employees were recombined into one group (to include those covered by both the traditional plan and a health maintenance organization), their use rate was about the same as all Blue Cross subscribers Statewide. Blue Cross and Blue Shieldís 1987 controls were adequate to ensure that employee claims were processed and paid accurately.
Public Transportation Services for the Elderly and Handicapped in Kansas
Because State agencies do not require local transportation providers to take any specific coordination actions, the current Kansas system results in significant overlap and inefficiency at the local level. All parts of the State apparently have unmet needs for transportation services for the elderly and handicapped. Some Department of Transportation policies are more restrictive than federal requirements, and may limit local agenciesí flexibility to meet the transportation needs of their clients.
Client Abuse Reporting Systems, Part III: Reviewing Implementation of Previous Audit Recommendations (100-hour audit)
The Department of Social and Rehabilitation Services has fully implemented only two of the 11 recommendations made to it in the September 1987 audit report, Client Abuse Reporting Systems, Part II: Parsons and Norton State Hospitals and Neurological Institute. As of January 25, 1988, implementation was planned or had been partially achieved for all but one of the remaining nine recommendations.
Federal Staffing Requirements for Registered Nurses Applicable to Larned State Hospital (100-hour audit)
Federal regulations require adequate nursing staff to provide necessary services to Larned State Hospital patients, but do not specify minimum staffing ratios. The Hospital had been cited for staffing deficiencies in the past, but had not lost its Medicare certification. Following two 1987 federal reviews that threatened the Hospital with decertification, Hospital officials concentrated nursing staff in some units and received certification for those units. Because of this uneven distribution of staff, however, federal funds are now in further jeopardy.
Reviewing the Health Care Plan for State Employees, Part I
Because Blue Cross and Blue Shieldís initial bid for the State employeesí health care plan would have increased the traditional Blue Cross premiums by 40 percent, the Health Care Commission negotiated a different type of plan with Blue Cross. The new Blue Select plan requires employees to choose a primary care physician to coordinate their health care needs. For the first time, State employees will also be required to pay for a portion of their health care coverage. A monthly smokerís charge was also instituted. The Blue Select primary care physicians, selected by Blue Cross, were initially required to serve in HMO Kansas, but that requirement has been dropped. They must still meet the same criteria as HMO Kansas doctors, however. Kansasí State employee health benefits will cost more in 1988 than in 1986, and will cost more than other employersí health benefits.
Kansas provides loans and scholarships to medical, osteopathic, and optometry students. The Medical Scholarship program does not appear to have had an impact on overall retention rates, but does appear to be encouraging a larger proportion of graduates to practice in underserved areas. About 37 percent of Osteopathic Scholarship recipients stayed in Kansas. The Optometry program is too new to determine any impact it has had on retention rates.
Client Abuse Reporting Systems, Part II: Parsons and Norton State Hospitals and Kansas Neurological Institute
Several cases of client neglect were handled outside the established reporting system, staff members accused of abuse or neglect were not always removed from duty, and parents and others were often not properly notified of reported abuse or neglect incidents. In addition, many of the changes the Department has planned or made will still not result in independent and adequate abuse investigations or improved monitoring of the institutions, nor will they address other recommendations made in the March 1987 audit of Winfield State Hospital.
Job Training Programs in Kansas, Part II: Longer-Term Results For Program Participants
The audit shows that the Work Incentive Training program increased the likelihood that successful clients would be working, but it did not improve the wages of those who were employed. Clients who successfully completed the Job Training Partnership Act program were more likely to be employed two years later than individuals who did not successfully complete the program, and they also earned higher wages. Parolees who completed vocational training while they were in prison were no more likely to be employed after two years, and their wages were no higher. And companies that received assistance from the Kansas Industrial Training program were well pleased with its results. Changes can be made to improve the occupational information available to agencies that provide training, and to improve the quality of information those agencies gather to evaluate program results.
Regulation and Operation of Cowley County Developmental Services
The Department of Social and Rehabilitation Services generally enforced its regulations consistently at the six agencies visited. Cowley County Developmental Servicesí handling of client funds was similar to other agenciesí, but the auditors did find several weaknesses. The agency also charged significantly more for vocational services than other agencies. Cowley County Developmental Services had several problems with its financial management procedures, including violations of agency policies and failure to report all unpaid bills. Finally, the auditors investigated numerous complaints concerning the agency; some were apparently true, while others were not substantiated.
Client Abuse Reporting System at Winfield State Hospital
The client abuse reporting system failed to ensure that suspected abuse or neglect of Hospital residents was promptly reported and investigated, and that employees who abused or neglected residents were disciplined appropriately. A number of improvements have been made, but the report contains additional recommendations to address remaining problems.
Between 1980 and 1986, the number of abused or neglected children in the Department of Social and Rehabilitation Servicesí custody declined almost 21 percent. The Department established procedures to ensure that children are placed in the least restrictive setting possible, but did not always follow those procedures or document compliance. The Department needs to improve its foster care allocation formula, compliance, and documentation.
Blind Industries has cost money in recent years because product prices were based on outdated cost estimates. Blind Industries will likely continue to lose money because recently adjusted prices for some products do not cover the actual cost to produce the goods in the most recent year. Blind Industries needs to improve the frequency and quality of accounting reports produced for management, and management needs to make better use of some of the information that is already available.
Cowley County Developmental Services, Inc.(100-hour audit)
Cowley County Development Services is a community-based agency that serves mentally retarded adults. This special audit showed that the agency was serving the required number of clients and was billing correctly for vocational services. However, there was evidence of incorrect payment to client employees, and the agency may not be follwoing accepted practices in determining client pay rates.
Licensing Kansas Drivers with Medical Disabilities
The Division of Vehicles is generally following its established policies and procedures for licensing drivers with medical impairments. These procedures are more stringent than those of other states contacted. Some license applicants expressed dissatisfaction with Division procedures. The Division could minimize such complaints by explaining it policies and procedures more clearly.
In 1985, residents in 170 adult care homes who footed their own bill paid an average of $35. 76 per day for their care, or $6 more per day than Medicaid residents. Data available for 217 homes showed that the average private-pay rate increased by 14.2 percent between 1983 and 1985; Medicaid rates increased by 13.6 percent. The audit examines private-pay rates and rate increases for different types of homes. Chain-owned homes had the highest daily rates. Homes that changed ownership or management had the largest rate increases.
Most of the sample government buildings and private apartment complexes were at least partially accessible to physically handicapped individuals. Despite State and local enforcement efforts, many buildings did not fully comply with the Stateís accessibility requirements. Private apartment buildings had the lowest level of compliance. The audit recommends changes to ensure better enforcement and compliance.
The $25 per month allowance is most often adequate when the resident is severly incapacitated, has no unusually costly personal habits, or has most clothing needs provided by the facility. The allowance is less adequate for active residents. Regulatory agencies find little evidence of mishandling of resident funds. However, guardians and conservators often take a large portion of residentsí allowances for fees.
The Board of Healing Arts and the Health Care Stabilization Fund
Improvements are needed in the procedures for reporting cases of incompetent or impaired practitioners to the Board, and in the Boardís procedures for protecting the public against unprofessional, improper, or unqualified practitioners. This audit also examines recent trends in the balance of the Health Care Stabilization Fund.
Poorly maintained clinical records made health care needs difficult to assess. This audit suggests ways to provide more effective and lower-cost health care services. Decisions on further actions may need to wait on improved information.
Oversight of the Soldiers Home is exercised primarily by the Veterans Commission. Actions are needed to help ensure that current residentsí needs are met and that the quality of care they receive is consistent with State standards. Projected increases in veteran residents can be accommodated in the existing facilities, but capital improvements will be needed.
Although no federal or State laws require State agenices to correct asbestos problems, the Department of Human Resources voluntarily conducts asbestos inspections in public buildings. If the proposed Asbestos Control Program were funded, all asbestos duties would be transferred to the Department of Health and Environment through an agreement between the two agencies.
This report pulls together the main findings in this series of three audits covering property costs, administrative costs, and quality of care. It summarizes recommendations for administrative improvements relating to property and administrative costs. It also presents alternatives for changing the reimbursement system, and outlines the steps needed to bring about these changes.
Little relationship was found between the amount being spent for residents and the quality of care they receive in such areas as staffing, services, food, and the like. Alternatives examined in the report for improving the quality of care are 24-hour licensed nursing care and reimbursement systems that explicitly address residentsí needs.
Regulation of hazardous materials transportation in Kansas has serious gaps. The most serious failing is a lack of adequate inspections. In their absence, insufficient data are collected to estimate the number and volume of shipments in the State. Other problems relate to training deficiencies, the designation of on-scene commanders at accidents, and accident reporting. Efforts are under way to improve the regularty program: the audit makes several additional recommendations.
Northwest Kansas Planning and Development Commissionís Weatherization Program
The agency did not have basic inventory and purchasing controls, causing higher materials costs than necessary and opening the program to abuse. In addition, the agency did not check applicantsí eligibility, and much of the work that was done was substandard. Checkpoints at the local, State, and federal levels to monitor quality control and compliance did not catch the problems. Corrective actions have begun; the report makes recommendations to help ensure these actions are carried out.
The current system for controlling administrative costs has not kept pace with changes in the industry. It unintentionally offers strong financial incentives for chain ownership--primarily in the area of ownerís compensation. Ambiguity in the present system also makes it more difficult to monitor, evaluate, and control administrative office costs, and makes it possible for providers to take advantage of the system.
Court-Ordered Mental Evaluations at State Hospitals
If local funding were available, most competency and presentence evaluations now being done at State hospitals could be performed at much less cost in community mental health centers. Other benefits include faster processing of crimimal cases in district courts, treatment in a less restrictive environment, and better use of State facilities.
Governmental agencies and private organizations that use the services of offenders sentenced by the courts to do community work can be held liable in cases of injury or damages. Community service workers are not covered by workerís compensation. Although liability insurance is available, not all agencies or organizations have it. The audit also discusses other factors that can limit the use of community service programs, and suggests options for dealing with them.
The property report shows that changes of ownership have affected the composition of the industry in Kansas and have placed increasing pressure on property-related costs. The current reimbursement structure for property costs may encourage people to sell adult care homes rather than retain them.
Average charges are more than the average reimbursement rate for medicaid patients in all the categories of homes. They also follow the pattern established with historical costs and reimbursement rates in that they are higher for non-profit homes than for profit homes and higher for homes owned out-of-State than for those owned in-State.
Some improvements are needed in the Stateís administration of the weatherization program, and some local agencies need to press for better quality work. Changes in the program might also expand it to cover more homes.
A Preliminary Analysis of Costs and Charges at Kansas Adult Care Homes
This Post Audit report conducted a performance audit of Kansas program for weatherizing the homes of low income people. The audit examined operations at both the State and Local level, and it addressed two main questions: Do State and local agencies have the ability to effectively use the additional money available? And given the large number of homes yet to be weatherized, what type of weatherization work will porvide the highest benefit and result in weatherizing the greatest number of homes?
This audit concludes that State regulation should be continued because the services performed by both nurses and mental health technicians could result in harm if they are performed improperly. The auditís review of complaints and disciplinary actions against licensed nurses disclosed the potential for physical harm to persons as a result of incompetence. In assessing whether regulation meets the needs of the public, the audit found the following problems with the Boardís complaint investigation function: inadequate reporting of complaints by health care employers, restrictive complaint filing policies, and poor documentation of complaint informatin.
Mental Health and Retardation Services: Part II: Assessing Selected Aspects of Institutional Treatment
The audit disclosed some problems with the way that State mental health and retardation hospitals are carrying out the policies and procedures related to the rights and treatment of institutionalized patients. For example, four of the five hospitals reviewed were not following established policies regarding compensation for patient employees. The auditors also found that the mental health hospitals were using seclusion and restraint measures to excess, and that a number of factors were causing delays in getting mentally retarded patients placed in community facilities when they no longer need institutionalized care and treatment.Recommendations call for the Department to review and reduce the hospitalsí use of seclusion and restraint measures. Also the Department is to ensure that hospital staff refer patients who are ready for community-based treatment to area office social workers for placement on a more timely basis. Other recommendations are intended to ensure that standard patient rights policies are adopted and that patients are treated uniformly and consistently.
Mental Health and Retardation Services: Part I: System-Wide Management
Two sunset performance audits examining the Department of Social and Rehabilitation Servicesí program for providing mental health and retardation services to Kansans were done. Part I addresses concerns about potential duplication and lack of coordination of the programs and services offered at State institutions and at community-based facilities.The audit stated that the Department has not taken an actice enough role in planning, managing, and coordinating the Stateís mental health and retardation system to avoid duplication and to ensure the program is operated efficiently. A number of other findings also illustrate the need for more effective and efficient management.
Controlling Medical Assistance Costs in Kansas, Part III: Improving Controls Over Fraud and Abuse
This performance audit examines the fraud and abuse in the Stateís medical assistance program and assesses the adequacy of efforts to identify and control such fraud and abuse.To detect instances of fraud and abuse, auditors designed computer tests and examined case histories and went through records in physiciansí offices, hospitals, and nursing homes. They found a number of problems. For example, the system often pays medical assistance claims that probably should be paid by third parties such as insurance companies. Also, two payments are sometimes made for the same claim, payments are made for unauthorized services, and providers of medical services are paid for services that are not actually provided.The report makes a number of recommendations to correct the problems that were found and to improve the system.
The audit showed that the regulatory program was a necessary undertaking for the State--some homes donít of their own volition provide residents with a healthy and secure living environment. Moreover, even with regulation residents of a number of homes are not receiving the adequate care they need. The two most frequent problems found were a lack of independent verification of complaint allegations and a lack of final resolution of problems cited in the complaint. The report recommended that a public oversight board--equipped with an ombudsman to handle complaints and a quality control unit to review the entire program--should be established to oversee the program and to ensure that all phases are administered in the best interest of the residents and the public. In conclusion, since the Department may not be able to enforce nursing home regulations vigorously, the report recommended tht the Legislature transfer program responsibility and funding to another agency, such as the Department of Aging.
Physiciansí Corporations at the University of Kansas Medical Center
The audit examined the effectiveness of the relationship between the University of Kansas and the 15 physiciansí corporations operating at the Universityís Medical Center. The current relationship has several advantages. Under the current structure, physicians at the Medical Center provide more money for operating the School of Medicine and have greater incentive to earn higher revenues by working more hours without reducing the time spent on teaching and research. The audit found, however, that a number of issues within the relationship that revolve around a common conclusion: contracting with 15 different corporations poses difficulties for the effective management of the Medical Center. These difficulties range from procedural matters to larger issues as the Medical Centerís ability to shift funds to help meet its goal of supplying more primary care physicians for the State.The audit proposes two major alternatives for improving the relationships: adjusting all 15 contracts with the corporations to make the desired changes when contracts are renegotiated in 1980, or negotiating a single contract with all physicians and departments--in essence, creating a single physiciansí corporation.
Nearly one-third of those receiving general assistance were either ineligible for the program altogether or were receiving incorrect payments, generally overpayments. In fiscal year 1977, these errors cost the State an estimated $2 million, or 17.6 percent of all program expenditures. Errors causing approximately $1.7 million of this amount went undetected. The audit recommended that more strenuous review procedures be applied to the program.
Controlling Medical Assistance Costs in Kansas, Part II: Options for Containing Costs
Between fiscal years 1973 and 1977, total medical assistance expenditures increased from $70.6 million to $146.6 million, an increase of $76 million. The auditors found that the increase was caused by the following: higher medical care prices (49.1 percent of the increase), more people in the program (41.4 percent of the increase), and more services used by those in the program (9.5 percent of the increase). Kansasí efforts to limit services, such as limiting the number of visits to a dentist, address less than 10 percent of increased expenditures. And higher medical care prices, the cause of nearly half the increase, and difficult to contain, especially on a short-term basis. The most significant action appeared to be steps to contain enrollment in medical assistance programs. When the Department of Social and Rehabilitation Services changed the eligibility standards for two State-funded medical assistance programs in 1977, for example, it reduced expenditures for those programs from $35.5 million to $19.6 million.The audit recommended ways to address all three reasons for cost increases.
Security Policies and Procedures at Larned State Hospital and Osawatomie State Hospital
The primary concerns of both Larned State Hospital and Osawatomie State Hospital are the care and safety of patients, staff, and the community-at-large. It is important that these hospitalsí security control systems are adequate to meet and balance all these concerns. In general, this review seemed to indicate that there are some serious deficiencies in the security systems at both hospitals.
Controlling Medical Assistance Costs in Kansas, Part I: Improved Accountability Through Better Program Information and More Effective Budget Review
Auditors attempted to determine the reasons for rising costs in medical assistance programs, and particularly the reasons for a supplemental appropriation of $14.5 million in State funds for fiscal year 1977. They found that certain actions in the budget process, and not unforeseen medical assistance costs, led to the need for the supplemental appropriation. The analysis showed that when budget cuts have been made at the start of the budget process, they have not been accompanied by corresponding cuts in the kinds or levels of service. This finding led to recommendations to help ensure that the Legislature receives more accurate and reliable medical assistance budget estimates, to encourage better documentation for what is intended by changes in the level of funding for medical assistance programs, to clarify the intent of the Legislature when it makes appropriations for these programs, and to provide more meaningful legislative oversight of medical assistance programs. Auditors also found that information about particular medical assistance programs was inadequate for determining precislely why medical assistance costs rose. The report recommends that the Department of Social and Rehabilitation Services establish a system that will provide more useful information about the programs. This system will allow the Department to identify expenditures and services by program, to identify the reasons for cost increases, and to assess the impact of possible changes in medical assistance programs.
Management Audit of State Funded Pharmacies and Drug Rooms
Due to concerns that a number of the laboratories in the state are not operating to full capacity there is to be a review of the operations and fee schedules of state operated laboratories. Major state laboratories were identified from statutory and budget research prior audits, Budget Division, Legislative Research and other pertinent sources, including telephone interviews. The audit of the laboratories will follow the patterns of the audit of state operated pharmacies and drug rooms. This audit excluded such labs as those at state colleges and universities and labs operated by hospitals which serve the single institutionís needs.
Unclassified Personnel Positions at the University of Kansas Medical Center
This audit comes as a direct request from the Legislative Coordinating Council. The request directed Legislative Post Audit to study why there are 2,200 unclassified positions at the University of Kansas Medical Center. Based on the initial study it was decided to concentrate detailed analysis on research associates and assistant positions.