What We Found
The Intellectual & Developmental Disabilities Services Division (Division) has implemented four recommendations from our 2019 audit of Services for People with Intellectual and Developmental Disabilities, and one is in process.
What the Statuses Mean
Implemented – Auditee has fully implemented, or auditee has resolved the issue to meet the recommendation’s intent.
In Process – Auditee has started implementation.
Not Implemented – Auditee has not implemented, or does not intend to implement.
Why We Did This Evaluation
The Auditor’s Office follows up on audit recommendations to support county government’s accountability. This evaluation focused on all five of the recommendations from the 2019 audit.
About Our Survey
As part of our follow-up procedures, we conducted a survey to help substantiate management’s assertions about the status of the recommendations. We designed the survey to ask questions related to case manager roles within the Division. To encourage participation, our office made the survey anonymous. We emailed the survey to 133 people who work in Division’s case management group, which includes Oregon Needs Assessment assessors, case manager supervisors, program specialists and technicians, and a few others who work in the Division. We received 54 responses for a response rate of 41%.
Status of Recommendations
Recommendation 1: We recommend that between now and the next legislative session, the Board of County Commissioners, county Government Relations, and the Department of County Human Services management continue to work together to keep demonstrating to the state the high risks to clients’ health and safety and negative impacts on the stability of the Division’s program and case managers of rapidly paced, transformative changes.
Auditor’s note: County leadership established a proposal paper with other tri-county partners. The proposal has made its way into a house bill with the Oregon legislature (HB3116) which is currently with the Joint Committee on Ways and Means.
Recommendation 2: Case managers should complete documentation at the time they contact clients or very close to it. Using computers in the field and electronic signatures will help with this effort.
Documentation: The Division developed a procedure to help case managers meet note documentation goals in a timely manner. Supervisors are to meet with case managers who are performing at less than 80% of their required billables on a monthly basis to assist with implementing tools to increase productivity.
In our survey, we found that 98% of the survey respondents were familiar with the procedures and 89% know where to find them if needed. The majority (41% Always/Usually & 31% Sometimes) of those who responded to the survey indicated they are generally getting file documentation competed at the time of contact, or within 1-2 days. Reasons that survey takers provided for not getting notes done sooner related to workload/caseload. Survey respondents appeared to know that documentation procedures and goals are part of their duties. Additionally, 83% of survey respondents noted receiving file documentation training.
We also inquired with case manager supervisors and found that they are meeting with staff.
Computers in the field and electronic signatures: Management indicated that all case managers have been provided with tablets which will allow for electronic signature. Based on our survey, 100% of the survey respondents indicated they have been issued computer/laptop for use in the field. 70% of survey respondents indicated they have the option to use the electronic signatures in the field. For those who indicated they have used the tablet and ability for electronic signatures in the field, 67% found it very helpful or helpful.
Recommendation 4: The Division should strengthen its monitoring over the documentation of client contacts to lower the risk of false case notes. For example a risk based spot-check validation process could be incorporated into the case note audits that the quality and compliance unit already performs.
Auditor’s note: The Division expanded their Quality Assurance procedure to include quality checks and case note review tracking.
In our survey, 96% of those who responded to the survey noted having received case note reviews. Additionally, 94% know how and/or who to contact for training/support related to case notes, and 90% of those who have needed support/training with case notes have had it made available to them.
We also inquired with case manager supervisors and found that they are meeting with staff as it relates to case note productivity.
Recommendation 5: Case managers are still overwhelmed by state-mandated changes and some of the same problems we found at the beginning of the audit will take more time to resolve. The Division should continue its efforts to improve:
a. Funding levels and payment rates with the state as well as capturing indirect billable contacts.
b. Staff retention by hiring case managers with a good mix of people and administrative skills.
c. Morale by building a better connection between upper level management and case managers through better communication and transparency.
d. Training of both new and longer term case managers.
e. Productivity by evaluating best practices among case managers and sharing that information out to all case managers through training opportunities.
f. Case manager documentation and timeliness by examining case notes and providing feedback.
g. Coordination between Oregon Needs Assessments (ONA) assessors and case managers.
h. Case transfer procedures.
i. Case management practices by collaborating with other counties.
a. Funding: There has been an increase in funding levels, including the billable rate allowed. This has allowed the Division to hire additional staff to work on indirect billables.
b. Staff Retention/Hiring: Due to budget increases the Division has been able to hire additional case managers and other support staff. The job profile description includes documentation as part of their duties to support hiring people with administrative skills. The Division is implementing an exit survey with staff who leave the Division in order to gather data for quality improvement purposes. Division leadership holds ‘town hall’ type meetings and ‘listening sessions’ with staff. In our survey, survey respondents acknowledged these meetings exist, but 52% of those responding to the survey indicated they do not attend the meetings. Those indicating they do not attend cited not having the time, with workload/caseload being a reason.
c. Morale: Division leadership holds ‘lunch and learn’ sessions with staff. In our, survey respondents acknowledged these meetings exist. Comments provided by those indicating they do not attend, 67%, once again cited not having the time (workload/caseload being a reason).
d. Training: The Division continues to provide training. In our survey, 100% of those who responded acknowledged attending the ’Wednesday‘ and/or team trainings. The majority (72%) found them very helpful or helpful, while 26% found them somewhat helpful.
Our survey also asked about Program Specialist support. Of those who responded, the majority (86%) know of a Program Specialist assigned to their team, and 94% of the survey respondents acknowledged using a Program Specialist as a resource. Also, 85% of survey respondents reported finding the support very helpful or helpful with only 15% indicating somewhat helpful.
e. Evaluate Best Practices: The Division uses Tableau to capture and report data back to leadership. The Division has and continues to work on trainings and morale initiatives (see above).
f. Documentation and Timeliness of Case Notes: See auditor’s notes above to recommendation #2.
g. Coordination between ONA assessors and case managers: The Division has worked on initiatives to address the coordination between Oregon Needs Assessments (ONA) assessors and case managers. In our survey, 65% of survey respondents said the coordination has improved and 32% said it is about the same, with only 3% noting it as worse.
ONA assessors, who determine level of care requirements as well as functional needs for clients, were included in the invitation to participate in the survey. The survey was anonymous. Therefore, we do not know how many respondents were case managers versus ONA assessors or how the results compared between these two groups.
h. Case transfer procedures: The Division implemented updated procedures. In our survey, 90% of survey respondents are aware of internal case transfer procedures. 88% indicated they have been involved in an internal case transfer recently (since the 2019 audit). Of those involved in a transfer:
52% indicated the process was either very smooth or smooth
20% indicated it was neither smooth nor challenging
27% indicated it was challenging or very challenging
We received several comments for this topic. Survey respondents indicated that there are a lot of transfers happening and that they are having difficulty keeping up, they are overwhelmed, feel a lack of support, and feel there is a lack of communication. They also indicated that there were instances of incomplete transfer files, including missing information, and some noted that clients (and sometimes even the new case manager) were sometimes unaware of a transfer happening until after the new case manager was assigned. Comments also suggested that internal transfer policies are changing often (or are out of date).
While we did not review the root cause to some of the issues identified in case transfers due to the limited scope of this report, we are aware there has been staff turnover within the Division.
Case transfer procedures are only a part of recommendation #5. The Division did update procedures as recommended, and we are considering the overall recommendation as implemented. However, we encourage the Division to continue to look at ways to improve internal case transfers to help ensure success for case managers and clients.
i. Case management practices by collaborating with other counties: The Division indicated they have established metro area meetings with other similarly sized counties to check in about best practices, workload management, and to unite advocacy efforts at the state level. They indicated these meetings are occurring quarterly.
Recommendation 3: The Division should continue to work with the state to develop a process that would allow the Division to upload information to the state’s computer system to free up support staff time.
Auditor’s note: With the help of the County’s IT department, the Division pursued this option with the state. The state responded that it is being worked on. The Division continues to work with the state on this initiative.
Objectives, Scope, & Methodology
The objectives of this evaluation were to determine the status of recommendations from the 2019 audit of Services for People with Intellectual and Developmental Disabilities. Auditors evaluated the status of recommendations based on interviews, documentation, a survey, and other available evidence.
Survey of Case Managers
Our office conducted a survey to help substantiate management’s assertions about the status of the recommendations. We utilized SurveyMonkey, an online survey software that helps create surveys and collect data, as the platform for our survey. To encourage participation, our office made the survey anonymous, and it was not linked to email addresses, name, employee ID, IP address, or any other identifying information. Participation in the survey was voluntary and respondents had the right to withdraw from participation at any time.
We emailed the survey to 133 people who work in the Division’s case management group. We received 54 valid responses for a response rate of 41%.
The survey was designed to ask questions that relate to case manager roles within the Division. However, the link was shared with all staff within the case management group through a group email to help ensure anonymity. This included the ONA assessors, case manager supervisors, program specialists and technicians, and a few others who work within the Division.
Updating the Status of a Recommendation
During each audit our office conducts, we develop recommendations intended to improve government operations, particularly with regard to effectiveness, transparency, accountability, and equity. Our goal for evaluating the status of recommendations is to help ensure management implements these recommendations for improvement.
We recognize that after we publish an evaluation on the status of recommendations, management may fully implement a recommendation that we reported was in process or not implemented. Management can then provide evidence to the Auditor demonstrating why the recommendation’s status should be changed in the Auditor’s future reporting. The final decision on whether to change any recommendation’s status rests with the Auditor.
Annamarie McNiel, CPA, Principal Management Auditor