FOLLOW-UP SPECIAL REVIEW OF THE PHILADELPHIA PORTION OF THE PENNSYLVANIA CONSOLIDATED 2176 WAIVER WAIVER NUMBER 0147

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1 FOLLOW-UP SPECIAL REVIEW OF THE PHILADELPHIA PORTION OF THE PENNSYLVANIA CONSOLIDATED 2176 WAIVER WAIVER NUMBER 0147 Prepared by: The Health Care Financing Administration Philadelphia Regional Office Joseph Gaffney, Developmental Disabilities Specialist William G. Davis, Medicaid Program Specialist Review Date: February 15, 1989 to March 8, 1989

2 INTRODUCTION Based upon concerns about the quality of care in that part of the Pennsylvania Consolidated 2176 Waiver (0147) serving Philadelphia the Philadelphia Regional Office (RO) of the Health Care Financing Administration (HCFA) conducted a Special Review in July, The review focused on whether the assurances given by Pennsylvania in its waiver request to protect the health and welfare of waiver recipients were being fulfilled. In addition to systemic problems involving the reporting of incidents and injuries, the review disclosed serious deficiencies in the cases of 13 of the 16 recipients included in the review. We, therefore, concluded that Pennsylvania's assurances to protect the recipients' health and welfare were being not fulfilled. As a result, renewal of the waiver, which is expected to entail a commitment of FFP in excess of a half billion dollars over a five year period, was placed in jeopardy. The deficiencies specific to individual clients included a failure to deliver ordered physical, occupational, behavior, and speech therapy, and to implement programmatic goals. Ordered medication reviews, dental, medical, and neurological services were not performed in a number of cases. We found two instances in which the annual plans of care were overdue. Of greatest concern were the five instances of failure to implement needed behavior modification programs and the concomitant use of medication such as Mellaril (thioridazine) with the potential of serious permanent side effects. Also, the failure to implement a behavior modification program in some of these cases created the potential for injuries and the need for excessive restraints. In one case, successful treatment of a behavior problem seemed to have resulted in the possibility that medication could be reduced or eliminated. However, monitoring of the case did not result in the identification of the need for a review of medication in light of the successful reduction of behavior problems. Based on our findings, we directed that the Pennsylvania Department of Public Welfare (DPW) prepare a corrective action plan (CAP) to assure that the standards incorporated into the approved waiver for safeguarding the health and welfare of waiver recipients were met. We requested that the CAP reflect problems in a generic manner rather than in a client specific manner because we were concerned about the care given to all waiver recipients rather than to only those included in the review. We also asked that the CAP be based on the state's analysis of serious problems relevant to the waiver identified by all sources including the Expert Audit Team, the Research and Quality Assurance Group of the Temple University Developmental Disabilities Center, the Special Management Unit and Regional

3 Offices of OMR, county case managers, as well as our own report. We indicated to DPW that we would conduct a follow-up review of the implementation of the CAP in February, The complete CAP was forwarded to HCFA by DPW on December 23, The assignment of tasks was divided between the state and the city with the city, as the operational component, responsible for most of the critical activities. Three primary areas were targeted: county and state administration, case management, and plans of care. The state's response included the assignment of a full time waiver coordinator to work with and monitor the Philadelphia program, bi-monthly meetings between state and city staffs to review progress and outstanding issues, and upgraded licensing regulations and policies for plans of care, psychotropic drugs/ behavior modification, and the reporting of unusual incidents and deaths. The state also took action to submit the HCFA-372 Report (submitted January 18, 1989). The Management Plan submitted by the city administration indicated it had already appointed a Waiver Coordinator reporting directly to the county Administrator, recruited additional case managers, and developed an automated data base and reporting system to track the development of plans of care, the status of clients receiving psychotropic medication, the prescription and rendition of services, and unusual incidents. The city's plan also called for the plans of care to meet the specifications of the waiver and for the case management system to be effective. REVIEW METHODOLOGY The review was conducted by a Developmental Disabilities Specialist with the assistance of a Medicaid Operations Specialist. The review was based on a random sample of 20 Philadelphia waiver clients and one client selected from the previous review. Substitutions were made for two individuals included in the sample who had been discharged from the waiver. The sample was selected from the 341 waiver clients who entered the waiver through June 30, Neither the 17 clients admitted to the waiver between July and September, 1988 nor the 19 clients admitted afterward were included in the universe sampled. Visits to the residences and day program sites were made in seven of the cases included in the review including the case selected from the July review. A second case reviewed in July was also included in the random sample.

4 The review focused on the reporting and resolution of unusual incidents and the actual care given to the clients included in the sample. We enjoyed the full cooperation of city and state staff. Interviews were conducted with all case managers or supervisors serving each client included in the review, the Supervisor of Client Management, the Waiver Coordinators of the state and county, the Medical Director, and the Administrator of OMH/MR. During the site visits, interviews were conducted with both day and residential staff. FINDINGS The review disclosed no problems with the care in any of the cases reviewed. We were very impressed with the progress made and were encouraged to learn that efforts will continue to raise the quality of care even higher. We noted that both city and provider staff displayed better morale as a result of effective leadership establishing a clear mission and purpose. With regard to the administration of the program, we found that improved policy and procedures on the reporting of unusual incidents had been implemented. Accident and injury reports were being monitored on a monthly basis rather than a quarterly basis. A revised computerized tracking system has been instituted to reflect data based on operationally functional definitions, eliminating the confusion caused by the inclusion of events that were not of relevance. Based on trend identification and analysis, actions were being taken to reduce the probability of occurrence of additional accidents and injuries in hazardous situations. Increased protective supervision was being provided when required. Committees have been organized to ensure the protection of the developmentally disabled client's rights with respect to the use of aversive/restrictive programs. In order to facilitate the recruitment of a Mental Retardation Director, the position has been upgraded and the salary increased substantially. We found that case management services were being delivered in an effective manner. The authority necessary for the case managers to accomplish their mission has been extended as a result of the full support of the county Administrator. Case management workloads have been reduced to manageable levels with a staffing margin for reassignment of cases due to absences. Problems were being identified and brought to resolution in a timely manner. All of the individual habilitation plans were current as were all professional evaluations and assessments. The schedules for follow-up have been computerized. Clients were noted receiving

5 all needed medical and programmatic services as determined in the individualized habilitation plans while living and working in a safe environment. Programs were being developed, monitored and modified to meet client needs. Direct care staff were found to be training clients in the areas of self-help, activities of daily living, communication, psycho-social skills, recreation and leisure activity. Adjunctive professional services in areas such as physical, occupational and speech therapy were being delivered to clients both by those professionals and by direct care staff. Overall, we noted an efficient utilization of the resources of the professional therapists. Clients were receiving training in pre-vocational and vocational skill development. Money skills were being taught and clients were paid for their work. Programs were integrated between the day program site and residential site. Clients had needed adaptive equipment. Finally, the review disclosed dramatic improvement in the area of psychotropic drug usage. A Medical Director who specializes in psychiatry was appointed and is overseeing the use of psychotropic medications. Reviews of such medications were occurring. Those medications known to have negative side effects were being monitored and, in some cases, reduced and eliminated. Medications identified as not successfully treating the symptoms for which they were originally prescribed were discontinued. Those clients receiving behavior control medications were also found to be concurrently receiving needed behavior therapy services in order to reduce their need for behavior control medications. The behavior therapy programs were designed and implemented in accordance with the least restrictive, most effective principles of treatment. Clients were noted receiving needed psycho-social skills training in an effort to teach them more appropriate ways of expressing themselves. We were very pleased with the progress made by both the city and state and the high level of service being rendered to waiver clients. We are confident that the commitment to a high quality program will continue in Philadelphia. It appears that the gains were not achieved at the expense of a more costly program.