Roanoke Comprehensive Services Act Audit

8/6/2019 Roanoke Comprehensive Services Act Audit

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Table of ContentsBackground ."""""'" ..,.,..,.,.,_" ""'_'" ,.,".,.,."" ,._ ,..,.,.,~(.. ,.._ 1Objectives, Scope, and Methodology " 4Observation 1 - Unsupported Billings "" 5Observation 2 - Spending on Empty Beds ,. BObservation 3 - Per Diem Based, Non-Residential Services 10Observation 4 - Case Management. _ " _ 12Observation 5 - Utilization Management.. _ 14Observation 6 - Background Checks 17Observation 7 - Family Assessment & Planning Team 18Observation 8- Vendor Relations _ _ _ _ 19Conclusions , - _., 21Exhibit 1 - Service Provider Contact Log


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BACKGROUND

The Comprehensive Services A ct [G SA ) was established in 1992 with the intent to create acollaborative system of services for troubled and at-risk youth that is child-centered. family-focused and community-based. The Act was created through State Code section 2.2-5200and it encompasses the following goals:1 , Ensure services and funding are consistent with the Commonwealth's policies ofpreserving families and providing appropriate services in the least restrictiveenvironment! while protecting the welfare of children and maintaining the safety of thepublic;2. Identify and intervene early with young children and their families who are at risk ofdeveloping emotional or behavioral problems, or both, due to environmental, physicalpsychological stress;3. Design and provide services that are responsive to the unique and diverse strengths

and needs of troubled youths and families;4. Increase interagency collaboration and family involvement in service delivery andmanagement;5 . Encourage a public and private partnership in the delivery of services to troubled andrisk youths and their families; and6. Allow communities to make decisions and be accountable for providing services inconcert with the goals of the' ActThe Act requires communities to establish a community policy and management team tooversee implementation of comprehensive services. The Roanoke Interagency Council,usually referred to as the RIC, was established to satisfy this mandate.Roanoke Interagenc,Y: Council:The Roanoke Interagency Council includes representatives from the City of Roanoke,Roanoke City Public Schools! the Department of Juvenile Justice) Blue Ridge BehavioralHealthcare, the Health Department, a parent, and a local service provider. The Council isassigned a variety of responsibilities under the Act, including:

Developing interagency processes for coordinating care.Establishing policies for referring children for services.Establishing quality assurance and accountability procedures for program utilization.Identifying and developing community resources for children and families.Authorizing and monitoring expenditures of funds by the family assessment and plannteams.

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The Roanoke Interagency Council essentially serves as a steering committee that establishthe framework for providing coordinated services to at-risk youth and their families, as wellidentifying and developing resources needed to best address local service needs. The Couappoints one or more family assessment and planning teams to work with agency caseworkers in assessing and planning coordinated care for individual youth and their families.Famil~ Assessment and Planning Team:he Family Assessment and Planning Team in Roanoke includes representatives from thefollowing organizations: epartment of Social ServicesBlue Ridge Behavioral HealthcareJuvenile Court ServicesRoanoke City Public SchoolsA local service providerA parent representativeThe duties and powers of the team as specified by State Code section 2.2-5208 includereviewing referrals, developing an individual service-plan, promoting family involvement, andesignating a person to monitor and report on the fulfillment of service plans. The team issupposed to provide regular monitoring and utilization review to determine if the services bprovided continue to be appropriate and effective,

Individual Family Service Plans:Children may be referred for services by a parent, the Department of Social Services, BlueRidge Behavioral Healthcare, Court Services, the Juvenile and Domestic Relations Court, oRoanoke City Public Schools. A case worker develops a service plan for each child andfamily. The plan identifies goals and proposes services that must be reviewed and approveby the Family Assessment and Planning Team [FAPT), The planning team typically approvcommunity based services for a one to three month period. In order to continue services, cworkers must review progress with the planning team and recommend additional services.Provider Paxments:The Department of Social Services uses a case management system, Harmony, to producepurchase of service orders and to process payments to vendors. The system prints monthlinvoices specifying the units of service approved, the unit price, and listing the days of themonth for vendors to record the units of service provided. The vendor must complete theinvoice and submit it to the Social Services Administration Office by the fifth working day offollowing month. Administration forwards the invoices to the associated case workers forapproval; then processes the invoices in the Harmony system to issue payment Harmonyinterfaces with the City's financial system, which prints the checks and passes the paymentinformation back to Harmony. The checks are drawn against the City's consolidated bankaccount. The Department of Finance submits reimbursement requests to the State monthly

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CSA Quality Assurance & Utilization Management:State code requires localities to establish quality assurance and accountability procedures forCSA services and funds. These procedures are to include regular monitoring and utilizattonreview of the services provided to children and their families. Utilization review promotes thequality and efficiency of service delivery.The Act also requires each locality to have a utilization management process. Utilizationmanagement is defined as an evaluation of the appropriateness, medical need and efficiencyof services. The City's Department of Social Services had a full-time coordinator for CSA anda full-time utilization management coordinator in Fiscal Year 2010.

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One [1] did not have adequate documentation for us to conclude on thereasonableness of the billing.

Three [3] were found to be appropriate based on our review of other supportindocumentation from the vendor.

Vendor A billed for mentoring services on four [4] separate days, five [5] hours each day, whthe child was confined at the Juvenile Detention Center. At $40 per hour, this resulted in $8in unsupported billings. The daily progress notes were hand written by the mentor, who isalso the owner of the company. The notes listed the service dates, which were consistent wthe invoice. The notes were signed by the owner and dated the same day as service wasprovided. The treatment notes included statements such as: "...went to Vend playedbasketball" and if attended softball toumamenf'for,those dates in question, dates when thchild was confined at the Juvenile Detention Center. The Court Services Case Worker for tyouth marked the invoice to indicate those hours could not have been provided; however, thinvoice was paid by Social Services in full.

Ten [10] invoices clearly showed that services were billed for dates when thechildren were confined and could not have been seen by the vendor.The City's contract with vendors provides that records must be provided to the DepartmentSocial Services upon request The eSA Coordinator requested daily progress notes for thecases on behalf of the Auditing department.

Vendor 8 billed for vocational services on eight [8] separate dates, four [4] hours each day,when the child was confined at the Detention Center. At $25 per hour, this resulted in $800unsupported billings. The owner did not provide daily progress notes and instead providedtyped, monthly summary. The June report stated a significant improvement in attendance,and "... no incidents reported during the month" There was no mention of the child'sconfinement that began June 17 and continued until October 14. The vendor billed a total o72 hours in June.A second client of Vendor B was also invoiced for services on two [2] dates, four [4] hourseach day, when the child was confined at the Detentlon Center. This resulted in $200 inunsupported billings. Again, the notes provided were a monthly summary. The report state"... great attendance, "and IIno incidents reported during the month." There was no mentiof the child having to report to the Detention Center or having to appear in Court.Vendor C billed for counseling services on three [3] dates, one [1 1 hour each day, when thechild was confined at the Juvenile Detention Center. At $70 per hour, this resulted in $210unsupported billings. The progress notes from the vendor were hand written, specified thedate and time the child was seen! persons present, and were signed by the counselor, whothis case was the owner. The notes clearly indicate the child and counselor were togetherthey do not mention the child's confinement. The Juvenile Detention Center confirmed to oudepartment that the child was not seen by a counselor on the dates in question.

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A second client of Vendor C was invoiced for services on six [6] dates, one [1] hour each daywhen the child was confined at the Detention Center. This resulted in unsupported billings of$420. Progress notes from the vendor clearly intended to represent that the child was seen othe dates in question and in no way acknowledged that the child was in the Detention Centerat the time. We confirmed with the Detention Center that the child was not visited by acounselor on these dates.Based on the results noted, we referred the issue to the Roanoke City Police Department. ThPolice Detective verified the dates of confinement with the Juvenile Detention Center. He theinterviewed the owners from the three vendors involved. All three owners were unable toexplain the erroneous billings and attributed the inaccuracies to administrative errors. TheDetective concluded that the evidence did not indicate criminal intent based on his priorexperiences with similar cases and, as a result, did not press criminal charges.Observation 1: Management Response

These invoices should never have been billed or paid. Two of the vendors have made refundto CSA. The third has been referred to Billings and Collections. The number of invoices thatpass through the system numbers in the thousands and while errors are bound to occur ourgoal is 100% accuracy. Since 2009 a number of new processes have been put into place todecrease the likelihood of inaccurate payments. We would also note that the overbillingsresulted in overpayments of $2430 out of total expenditures of about $13,000,000, less than.0002%.O~servation 1: Municipal Auditi~g ClarificationTo state that overbillings represented only .0002% of total expenditures is an inaccurate andmisleading projection, as Municipal Auditing staff did not test 100%, of eSA programexpenditures. We initially attempted to review 70 invoices; however, we could only test 38 asthe remaining invoices were not completed by the vendor.We found exceptions with 10 of the 38 invoices resulting in overpayments totaling $10,744 areflected in Observations 1 through 3. It is more accurate to state that 26% of eSA invoiceswe tested billed for services not provided and 45% were not properly completed by the vendoWhile our sample was not random and does not support statistically valid projections, wewould argue the numbers are disconcerting.

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Observation 2: Spending on Empty BedsWe identified one child who was required to report to the Juvenile Detention Center onweekends, while also being placed in a residential treatment facility. The City was invoicednormal daily rate [$220] for weekend days when the bed was empty. The standard contractallows the vendor to bill for up to three [3] days when the child is absent without obtainingwritten authorization. We understood that this provision was included in the standard contrato avoid having a child lose his or her bed at a facility when an unexpected absence occurs.The CSA Coordinator stated that there are often waiting lists for residential treatment facilitiIn the case we noted, the child was consistently absent two [2] of every seven [7] days, or 2of the time. We contacted the vendor and discussed the Issue with two of the vendor'srepresentatives. Upon reviewing the case, these representatives concluded that they shoulnot have billed for the weekend absences based on their company's internal policies. Thevendor issued a refund to the City for 30 days at $220 per day, totaling $6,600.

Recommendations:The concept of holding beds for limited, unexpected absences would appear to be reasonaband sound policy. However, the City's application of this policy should be reviewed and refwith the following considerations:

We also identified a treatment foster care service that billed for five [5] consecutive days whthe child was confined at the Juvenile Detention Center. This service costs $109 per day athe contract includes the same three [31day unauthorized absence provision that is appliedresidential treatment centers. There was no written approval on file for holding this placemethe additional days.

1. A hold rate should be established as some percentage of the regular daily fee inrecognition of the vendor's fixed costs that are not reduced during absences.2. The contract should require vendors to contact the child's case manager immediatelyabsences arise. Case managers should evaluate the specific circumstances anddocument the basis for approving the placement hold or terminating the placement.

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Observation 2: Management ResR:onseThe situation which the auditors cite, where a child has spent weekends at the DetentionCenter has occurred only one time. The arrangements were made upon the order of theJuvenile and DomestIc Relations Court.Our contract calls for CSA to pay for an empty bed for up to three days when a child isexpected to return to the placement. This ensures that there will be a bed available when thchild is ready to return. When the contracts are renewed for Fiscal Year 11-12 we will


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The value of expenses paid by advocates were not documented, The reasons for paying expenses were not consistently documented.The case notes and invoices provide the case worker and the Family Assessment andPlanning Team with inadequate information on which to evaluate the cost effectiveness of theservices, the need for additional services, and the conditions that will ultimately enable endingservices.Recommendations:1. The standard agreement should be modified for non-residential services that are perdiem-based to clearly express the scope of services to be provided.2. Case workers should work with the advocates to ensure goals are specific andsubstantive, such that progress towards achieving the goals can be clearly judged.3. Advocates should be required to provide monthly progress reports to case workers.Reports should describe the progress towards goals and also specify the amount,nature, and reason for expenditures made for the benefit of the clientObservation 3: Management ResponseThe use of a per diem service wasnew during the time period cited. Per diem services areused in only a few cases. The number of days paid was based on approval by the CSU casemanager.We concur with these recommendations and have discussed them with the vendor. Analternative to per diem rates is being explored with the vendor and the CSA Coordinator.Recommendations will be made to the RIC for inclusion in the contract for FY 2012.Observation 3: Municipal Auditing ClarificationBased on our review of the payment data from the City's Advantage system, the vendor wasutilized throughout fiscal year 2010 and received payments totaling approximately $196,000.

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Vendors whose fees are based on contact hours with the child are not required to obtaaSign-ature from the parent or guardian to confirm the hours billed.

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4. Specify the information required to be in monthly progress reports.5. Require vendors to submit satisfactory monthly progress reports to case managerswithin 15 days of the end of the month. Subsequent invoices should not be paid untilthe required monthly progress reports have been provided to the case manager.6. Case managers should have the authority and responsibility to reduce the approvedservice units at any point in time based on their review of progress notes andinteractions with the child and provider, This would support greater accountability andmore prudent allocation of resources.7. Invoices should only be paid as approved by case workers.Observation 4: Management Re~ponseWe will recommend to the RIC and to the Roanoke Area Mentoring Standards Committee thathe standard agreement and the mentoring standards be consistent.We do not believe, based on past experience, that having the parent or guardian sIgn a"timesheet" will eliminate fraud. Some of our clients are notably uncooperative and the need tsign a timesheet would lend itself to creating more conflict between the client and the provideIt has also been known to create a situation where other types of fraud can take place.The current contract already requires that vendors submit invoices by the 5th working day ofthe following month. Staff have been diligent in enforcing this standard and have sent lettersto specific vendors reminding them of this requirement.~This item will be referred to the Best Practices Committee of the RIC to determine theinformation that should be included in progress reports.We agree that providers should provide monthly progress reports. We will determine the bestway to ensure that these reports are received timely. It would not be wise to have casemanagers "hold" invoices as this will make monthly expenditure reporting less accurate, aswell as creating an additional burden for case managers.The eSA process requires that the service plan be developed by the FAPT in amultidisciplinary team setting. Changes to service plans or in the services provided must beapproved by the FAPT as soon as possible following any reduction in services, and servicescannot be Increased without the recommendation of the FAPT. Email or telephone votes aretaken in an emergency and then reviewed fully at the next FAPT meeting, Changes inservices require the issuing of a new purchase order and new invoices.CSA procedures require that invoices may be paid only after the approval of and as approvedby the case worker. All incorrect invoices should be returned to the vendor for correction. Anyvariation from this procedure is an anomaly. We will be diligent in ensuring that such an errordoes not recur.

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appropriate vendor is determined when possible. This interdisciplinary approach results ineffective service authorization and utilization.ntil 2009 there were several different FAPTs composed of different members. The RICdetermined that it would be more effective to have consistent membership on the FAPT. Sthat time there has been only one FAPT which meets eight times each month.

Quafterly-the FAPT reserves one of its meetings for a planning meeting in which the FAPTmembers review the process for staffing cases, discuss any issues which may have comelight during the previous quarter. The FAPT may make recommendations to the RIC forprocess or policy changes, and review RIC directives.The Utilization Coordinator has also developed a plan to determine if there are other fundinsources for services that can be used in lieu of CSA. She has secured EPSDT, as well asMedicaid, for funding for those children who are eligible.The CSA program served 620 children in FY 2009 and another 620 in FY 2010. Given thisvolume it is not possible for the Utilization Coordinator to review every case every monthoutside of the FAPT process.

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Observation 7: Family Assessment & Planning TeamThe State code states that localities may include a vendor representative on the FamilyAssessment and Planning Team. There is no compensation for serving on the team andconflict of interest provisions require that vendors abstain from approving cases for which thprovide services to the child.The City's Family Assessment and Planning Team included a vendor representauve.""ln outest work, we noted that the vendor representative did approve one treatment plan thatincluded services to be provided by her own company. Based on our interviews with casemanagers who had presented cases to the Planning Team, their vendor recommendationswere typically approved by the Planning Team without modification.We beHeve that the potential for conflicts of interest, as well as the risk of subduing more opdialogue the Team might have about the effectiveness of treatments and service providers,potentially out weighs the benefits realized from having a vendor representative on the TeamThe vendor community would continue to be represented on the Roanoke Interagency Counas mandated by law, which in our opinion is a more appropriate forum for vendor input.Recommendation:1. The Department of Social Services should not include a vendor representative on theFamily Assessment and Planning Team.Observation 7: Management Response

hile the possibility of conflict on interest issues is always present, the eSA program attempto reduce this possibility. Every new provider member of the FAPT undergoes training whicincludes training on the CSA program's expectations regarding appropriate behavior at FAPother GSA related meetings. This training includes the expectation that members will abstafrom votes involving their own agencies, refrain from advocating for services provided by theown agencies while in FAPT, and identifying themselves as "community partners" whenintroducing themselves to case managers and families. Private providers serving on eitherFAPT or the RIC have limited terms and rotate off those groups regularly. Providers who wto be considered for membership are required to submit applications and those applicationsare reviewed and recommendations made to the appointing body. We would note thatattendance at multiple meetings each month with no compensation is a major commitmentthe part of a provider.It is standard across the state for private providers to serve on FAPT. We believe as do othjurisdictions that they add value to the process by bringing a different perspective to the tablwhen considering the needs of children and families.In spite of our belief that provider representation is valuable, we will recommend to the RICthat provider representation be eliminated from the FAPT and limited to the RIC as requiredlaw.

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8: Vendor RelationshiRs' I i) " ~ : ; ' r " ' r " ' , \ . -..~."'.'.".'.' .. :The State code provides exemptions from competitive blddinq and negotiation for publicbodies purchasing services under the Comprehensive Services Act for At-Risk Youth and.u. i. Families. There are substantial public dollars expended on CSA services that are paid to: ~ i .: . private and non-profit entities. The following table lists the top ten cumulative amounts paid t

individual vendors as reported in the City's financial system, from July 1,2006, throughOctober 1,2009:,... '\

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Amount Paid$ 4.169,654. .. ~ 3,915,992$ 3,727,768. .$ 3,545,479$?}17,191$ .?,320,201

.... $. 1,18@,~.6?$ .915,013$ 863,195t _~.. 9 ,? g Q _ . . _ .. '" .$ 2~'!~~~~459 I

Total payments to the three vendors discussed in Observation 1 of this report were as follows. '" 1F ' S ~ 6 I b i ~ ~ r ~~~:~;3~ . 9 0 B . . . " . . . $ j 9 9 ,1 . 4 j . .

2009 . .~256,5?q ...2010 $ 2~~,200 .Totals: l898,237

1 "~~~~i9{....$.l??,722 ..... 1~ 1~.9,308.. $ 210,637: ..

I. . $ 476,958 : .

Vendor C i' " . . . . , . " . . . . . " . . . . . . . . J$ -0-

$ -0-$ 38,770$ 157,960$19'6,'130

The case worker, who would be expected to have the most intimate knowledge of the child'sissues and circumstances, is primarily responsible for identifying an appropriate serviceprovider. Input may be given by co-workers, supervisors, and members of the FamilyAssessment and Planning Team. The collective experiences with providers enable caseworkers to make informed decisions as to which vendor may best serve the specificcircumstances of a given child [age, emotions, family situation, etc.]. This is likely the basis fexempting provider selection from competitive processes. Vendors are required to charge thCity in accordance with rates given to other government programs, such as Medicaid ..1,.-, __------....Over the course of our test work, we noted that case workers, coordinators, and other personinvolved in awarding services sometimes establish close relationships with vendors. This is anatural by-product of collaboration and common professional interests. Public employeesoften have the same professional designations, background and education as serviceproviders. Employees sometimes set up their own businesses or go to work for a vendor afte

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CONCLUSIONSO ur testing focused on ch ildren w ho w ere con fined by the J uv enile D eten tion Center on thetheory that a ch ild cou ld not be in two places at one tim e. Th is a llowed us to base ourconc lus ions on facts , w ithou t hav ing to ask ch ildren and guardIans to tes tify. O ur approachwas in no way based on concerns w ith the Court Serv ices Un it and in fact, we found them anagem ent and em ployees o f the Court Serv ices Unit to be very he lp fu l a nd co ns tru ctiv e inev aluating the is sues w e hav e dis cus sed.W e be liev e that our audit res ults h igh ligh t the fact that b ill ings fo r som e hourly , comm un itybas ed serv ices , s uch as m entoring and v ocational tra in ing , are s usceptib le to erro r and fraudrisks. T he opportun ity to m isrepresen t contact hours fo r such serv ices is ev en greater underc ircum stances In w hich the ch ild is no t sub ject to con finem ent or o ther com m itm ents . It ish op ed tha t im p ro ve d in te rn al c on tro ls wil l help prev en t in fla ted billings as w ell as prov id ingc learer ins igh t in to the effectiv eness o f m entoring, v ocationa l, and o ther comm un ity bas edserv ices"W e wou ld like to thank the em ployees and m anagers in the D epartm ent o f Soc ia l Serv ices , theC ourt S erv ices U nit, the Po lice D epartm ent, the C Ity A ttorney 's O f flce, and the City Manager 'sO ffice for their as sis tance and cooperation during the audit.

D awn Hope M ullins , CPAA ss is ta nt M u nic ip al A ud ito r

~~ -~~ ., = ----D rew Harm on, CPA, CIAMun Ic ip al A u dito r

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EXHIBIT 1

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(ATTACHMJ1.N1')SERV~C'll'.PROVttllmCONTI\CT I"OG~

PROVltJJ! .Jl:O F ( circle): Jan F eb M ar April May June July Aug Sep t O ct Nov Dec

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FORM MUS'l' liE S UDMJ TT ED W lTH MCH MON1HLY INVO lC E . U TIlJS S JG NATUR E A TT ES 1'S T O T lIE A CC URAC Y AND VAumTY O F TO il: CON TACT IN FO R I\IA n ON.

FY 2 01 0 V endor Term s and ConditionsE ffe ctiv e J uty 1 , 2 00 9Page 11 of l l

Roanoke Comprehensive Services Act Audit

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